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COURT OF COMMON PLEAS OF LEHIGH COUNTY
CIVIL DIVISION
SHARLEE ANN SMOYER, :Plaintiff :
:v : No. 2010-C-2071
:JOSE R GARCIA MD GNANAPRAKASH :GOPAL, MD LEHIGH VALLEY :PHYSICIAN GROUP GARCIA AND :POWERS ASSOCIATES MUHLENBERG :PRIMARY CARE PC LEHIGH VALLEY :PHYSICIAN PRACTICE LEHIGH VALLEY :PHYSICIAN GROUP AFFILIATED WITH :THE LEHIGH VALLEY HEALTH NETWORK :LEHIGH VALLEY PHYSICIAN-HOSPITAL :ORGANIZATION INC FREDERIC A :STELZER MD EASTERN PENNSYLVANIA :GASTROENTEROLOGY AND LIVER :SPECIALISTS PC JOLYNN YURCHAK RN :CARBON SCHUYLKILL COMMUNITY HOSPITAL :INC DOING BUSINESS AS ST LUKES MINERS :MEMORIAL HOME CARE JOSE R GARCIA MD PC :Defendants :
NOTES OF TESTIMONY OF MARK C. POZNANSKY(ROUGH DRAFT DAILY COPY)
BEFORE THE HONORABLE CAROL K. McGINLEYSEPTEMBER 9TH, 2011Courtroom No. 2A
Lehigh County CourthouseAllentown, Pennsylvania
APPEARANCES:
MATTHEW CASEY, ESQUIREFor the Plaintiff
PAUL LAUGHLIN, ESQUIREFor the Defendant
COURT REPORTER: CARA HARRIS, OCR
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INDEX TO WITNESSES
PLAINTIFF'S WITNESSES PAGE
MARK C. POZNANSKY
Direct-Examination on Qualifications 3By Mr. CaseyCross-Examination on Qualifications 16By Mr. LaughlinDirect-Examination by Mr. Casey - 25Cross-Examination by Mr. Laughlin - 94Redirect-Examination by Mr. Casey - 128Recross-Examination by Mr. Laughlin - 133
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MR. CASEY: At this time, the plaintiff
calls Dr. Mark C. Poznansky to testify as an expert on
the causation issue in this case.
* * *
MARK C. POZNANSKY, having been duly sworn,
was examined and testified as follows:
* * *
DIRECT-EXAMINATION ON QUALIFICATIONS
BY MR. CASEY:
Q. Good morning, sir.
A. Good morning.
Q. Sir, what line of work -- what is your
profession?
A. I'm an infectious disease physician and scientist
at Massachusetts General Hospital.
Q. Can you tell the jury a little bit about your
educational background? Before I do that, I'll mark as
plaintiff's next exhibit, which is plaintiff's 9, a copy
of Dr. Poznansky's resume or curriculum vitae, and I'll
show you a copy of it, if you need it for reference.
MR. CASEY: May I approach, Your Honor?
THE COURT: Go ahead.
MR. POZNANSKY: I was educated, I went to
medical school at Edinburgh University in Scotland. I
then did a Ph.D in Cambridge University and did my
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scientific studies I returned back to the UK to do
infectious disease fellowship in London the main
hospital in London, and then I was invited back to
Massachusetts General Hospital and completed further
infectious diseases fellowship training and became an
attending infectious disease physician at the Dana
Farber Cancer to Massachusetts General Hospital.
BY MR. CASEY:
Q. And I was guilty of it earlier, can you just slow
down just a little bit, Dr. Poznansky. On your CV, and
I just, I want to have you explain, so the jury
understands, your post doctoral training, in addition to
graduating from medical school, can you take the jury
through the steps of your training? Your resume
indicates you did an internship in Medicine and Surgery
at the Royal Infirmary in Edinburgh Scotland, right?
A. Yes.
Q. And that was in 1985, correct?
A. Correct.
Q. You then did a residency in Clinical Immunology
at Addenbroooke's Hospital in Cambridge?
A. That is correct.
Q. That was followed by a fellowship, correct? As
research fellow?
A. That's correct.
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Q. Immunology, is that, what I just referenced --
and I might be saying it too generally, correct me if
I'm wrong, but is that the study of infectious diseases?
A. It's the study of how the body responds to
infectious diseases and fights infection.
Q. You did a fellowship from 1989 to 1992 at Dana
Farber Cancer Institute; is that correct?
A. That's correct.
Q. Explain to the jury first, Dana Farber Cancer
Institute, one might think, well, you're a cancer
specialist, an oncologist. Tell the jury about the Dana
Farber Cancer Institute and the work you were doing in
your fellowship between '89 and '92?
A. A Cancer Institute like Dana Farber, many of the
patients are on treatment immune suppression, either
like chemotherapy drugs to treat that cancer, and as a
result of that, they're often very vulnerable to
infections and many of the patients we see that are
coming into the hospital actually have infections and
require infectious disease specialists to treatment them
for those infections.
The other point pertinent to the case, is
many, many of these patients have indwelling catheters
like the Hickman catheter in this case and we're very
vigilant in that context, and we learn a lot about how
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to manage the infections associated with those
catheters.
Q. The next question on that point was, can you
describe to the jury what a fellowship is? You're
described on your CV as doing a fellowship between '89
and '92, and there are others on your CV that I'm going
to ask you about. So the jury understands what it is,
what is a fellowship?
A. There are 2 types of fellowships; one involving
clinical work where you specialize the entire time on
seeing patients and being trained and the kind of more
advanced level of infectious disease care, and there's a
fellowship where you're spending time concentrating on
research on specific aspects of infectious diseases. In
'89 and '92 I was at the Dana Farber Cancer Institute
doing a research fellowship.
Q. Yes, and I'll move through this a little bit
quicker, but I wanted to understand what a fellowship
was. From '92 to '94 you were a resident in internal
medicine in the Internal Medicine Residency Program at
St. Mary's Hospital, Imperial College and Central
Middlesex Hospital in London in the United Kingdom,
right?
A. That is correct.
Q. From 94 to 95 you did another fellowship with the
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Department of Genito-Urinary Medicine and Communicable
Diseases at the Imperial College of Medicine in London,
correct?
A. Yes. And communicable diseases in England is the
same as infectious diseases in America. It's just
different terms.
Q. You did another one of those fellowships the
following year; is that just a continuation -- you did a
research fellowship and clinical fellowship in the same
place, correct?
A. That's correct.
Q. In 1996 and until 1998, you did a clinical
fellowship on infectious diseases at Harvard Medical
School in Boston Massachusetts, correct?
A. That's correct. That involved this very intense
infectious disease fellowship training at the clinical
level in Massachusetts General Hospital.
Q. Your licensure and certification, I see that it's
referenced from coming from the United Kingdom and Royal
College of Physicians in United Kingdom?
A. I have licensure in the UK for role college of
physician, which is the way you get licensed, and in
Massachusetts, I have a medical license that allows me
to practice in Massachusetts.
Q. In terms of your certification, is there any
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means by which a certification like a board
certification in infectious diseases obtained in the
United Kingdom is recognized, during your work at
Harvard, which we'll get to, as a functional equivalent?
A. When I joined the staff at the Dana Farber Cancer
Institute, hospital, they considered my credentials in
the UK to be equivalent and the term they use to be
grandfathered into the infectious diseases at the this
hospitals and in Massachusetts and so the was a vigorous
assessment of whether the credentials I have from UK
were equivalent to the credentials I have in the U.S.
Q. That was found to be the case?
A. That was found to be the case.
Q. The hospitals that you mentioned in the United
States regarding Farber Cancer Institute, you mentioned
Massachusetts General Hospital, and you've mentioned a
hospital called Brigham and Women's Hospital?
A. That's right.
Q. Are any one of them or all of them affiliated
with Harvard?
A. They're all affiliated with Harvard.
Q. Your academic points, sir, I'd like to talk to
you about those now so the jury understands sometimes we
who are not in the practice of medical might think of
academic points as simply being a teacher somewhere and
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not having to do with the practice of medicine. Can you
explain before you tell the jury about your academic
appointments, the interplay between clinical medicine
and your academic points?
A. I don't both clinical work for up to 9 weeks a
year. I see patient on a regular basis and for the rest
of the time I do research associated with infectious
diseases.
Q. You understand that your testimony here today as
to do with the causation issues involved in Ms. Sharlee
Smoyer's case right?
A. Absolutely.
Q. You're not here to talk about standard of care
issues per se?
A. Correct.
Q. Can you tell the jury and I'm sorry, I was
telling you to slow down before, but just in summary
fashion, because I'm actually saying maybe you should
speed up, your academic appointments and you can
reference your CV if you want?
A. My academic appointments contained within my
appointment to Massachusetts General Hospital. I'm
Associate Professor of Medicine and Associate Physician.
These are two ranking positions within the hospital that
allowed me to and to see patients.
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Q. The professional associates your resume is a lot
of pages. It's 23 pages long, and I'm know it's single
spaced, and I'm not going to go through all of it. Very
briefly, some of the professional societies you're a
member of Royal College of Physicians in United Kingdom?
A. Right.
Q. You're a member of the American Association of
Immunologists?
A. Correct.
Q. You're a member of the Infectious Diseases
Society of America?
A. Correct.
Q. Some of the awards and honors, not all of them,
1983, Victor-Wallace Travel Scholarship from Edinburgh
University?
A. Correct.
Q. In 1983, you were -- the award says First Class
-BSc(hons) degree in pathology, Edinburgh University?
A. Correct.
Q. 1983, Cappell Award for Original Research in
Edinburgh University?
A. Correct.
Q. 1984, you won Gunning Prize for Original Research
at that same university?
A. Correct.
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Q. From 1986 to 1989, Medical Research Counsel
Training Fellowship at Cambridge University?
A. Correct.
Q. Harvard University?
A. That's correct.
Q. What is Harkness Fellow?
A. It's an eminent US based award for visiting
scholars from the UK.
Q. From 1995 to 1996, you were you won an award
Governor's Lecturer, Imperial College of Medicine in
London?
A. That's correct.
Q. How long, sir I know you described how during the
course of your career and training you went from United
Kingdom back to Massachusetts and then back to the
United Kingdom and subsequently, back here, right?
A. This is my home. Boston is my home. I've been
14 years now in Boston work at Massachusetts General
Hospital.
Q. Are you on the faculty at Harvard Medical School?
A. I am.
Q. And in what regard are you on the faculty at
Harvard Medical School?
A. As an Associate Professor.
Q. What do you teach in that capacity there, sir?
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A. I teach medical students on bedside teaching. I
also supervise exams for medical students with regards
to performing history and exams on patients. So, there
are teaching tools that are involved in that process.
Q. Entire section of your resume devoted to research
and the funded research that you have right?
A. Right.
Q. And in terms of what can you describe for us what
does that mean? What does it mean to have that he's
funds?
A. It's a very competitive process to get US
Government National Type Health Funding and funds from
private foundations discussions improving care for
patients with infectious disease new ways of treating
infectious diseases. It's a very competitive process to
get that funding. I had successfully competitively
funded Massachusetts General Hospital for the last
12 years.
Q. There were various things under that and I just
don't want to go through all of them of course, but I'm
going to move actually to your presentations you've been
teaching at Harvard Medical School for the past
11 years?
A. Yes 11 years.
Q. Your presentation to some of them infectious
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diseases medicine seminars in 1997?
A. Correct.
Q. Harvard Medical School Immunology Seminar Series?
A. Yes.
Q. Harvard Institutes of Medicine Seminar also in
2000?
A. Yep.
Q. Harvard 2003 Biomedical Science and Engineering
Seminar?
A. Correct.
Q. You had various invited presentations in
conjunction if you work at Harvard?
A. That's right.
Q. You've done a lot of work trying to find
treatments and cures for incurable diseases.
A. Absolutely for infectious diseases.
Q. Under the continuing medical education course in
1998, it says 1988 to the present, Post Graduate Course
Clinical Rounds - Infectious Diseases of Adults Harvard
Medical School, Massachusetts General Hospital, right?
A. Yes.
Q. And again, I'm skipping ahead. These are
advisory and supervisor responsibilities and clinical
laboratory settings 97, 2003 you did work entitled
Supervision and consultancy on the development for
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treatment of breast cancer?
A. That's correct.
Q. That was in conjunction with your work at Dana
Farber?
A. That's correct.
Q. From 2006 to the present, you're been involved
with supervision of research work on novel and
therapeutic approaches for cancer and infectious
decides?
A. That's correct.
Q. From 2009 to present, you've been the Director of
Vaccine and Immunotherapy Center, and that's at
Massachusetts General Hospital?
A. That's correct.
Q. What is immunotherapy?
A. Immunotherapy is using your -- making your immune
system work better to fight infections or cancer.
Q. In terms of your research, I know there are a lot
of fancy medical terms like T cells and other things in
your CV that I'm not going to try to explain, but what
is then the generally speaking, the primary focus of
your research, sir?
A. The primary focus of research being able to
understand how the body fights infection how we can in
certain circumstances make it fight better, and how to
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prevent infectious diseases.
Q. On page 11, I don't have much more. I'm trying
to move thru it. Under Regional National or
International Contributions, you have invited
presentations -- there are many, actually -- both
nationally and internationally?
A. That is correct.
Q. And you're given presentations in United States
in the United Kingdom and any other countries?
A. In Europe.
Q. I see -- well, United Kingdom, we covered. I see
Italy. I see London, and I see Poland. I see London
again, anyway, throughout the United Kingdom?
A. Yes.
Q. Also on your CV, it's indicated you have a
bibliography. These are published by you?
A. That's correct.
Q. In various areas of infectious disease?
A. That's correct.
Q. That goes to the end of your 23 page resume.
MR. CASEY: Your Honor, at this time, I
would move the Court to recognize Dr. Mark Poznansky as
an expert on the causation issues in this case to
testify. I'm sorry, as expert in infectious diseases to
testify causation expert in this case?
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THE COURT: Mr. Laughlin?
MR. LAUGHLIN: I have a couple questions.
* * *
CROSS-EXAMINATION ON QUALIFICATIONS
BY MR. LAUGHLIN:
Q. Go good morning. According to my catch watch
there briefly Dr. Poznansky look at your CV and your
hospital positions and appointments you've indicated
staff grade physician assistant medicine and from 2008
to the present associate physician in medicine
Massachusetts General, I don't see on your CV, have you
ever been Chief of the Infectious Diseases?
A. No, I have not.
Q. You talk about certification the board
certification here the membership of the royal college
of physicians?
A. That is correct.
Q. In the UK, correct?
A. That's correct.
Q. I don't see that you have specific
subspecialties, board certification in the subspeciality
area of the infectious diseases?
A. That's correct.
Q. At we sit here today, in terms of infectious
diseases, you're not specifically board certified in
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infectious diseases?
A. That is correct.
MR. LAUGHLIN: That's all I have at this
juncture, Your Honor.
THE COURT: I think this is a good time to
take a break. You can step down, Doctor. We'll begin
your testimony this afternoon at 1:30.
* * *
(Whereupon, a lunch recess was taken, and
the jury exits the courtroom at 11:58 a.m.)
* * *
THE COURT: Do we expect any issues this
afternoon?
MR. CASEY: Yes, Your Honor. Your Honor,
the testimony uncontroverted on the part of the
defendant in this case, as to what she would have done
or whom she would have been looking to followup with
care for this patient -- Ms. Smoyer -- I'm talking about
physician with whom she would follow up, was Dr. Garcia
and Dr. Gopal.
Now, Mr. Laughlin went into questions with
Nurse Gorski with the deposition of Dr. Powers because
it has been established that Dr. Powers was in the
office covering for Dr. Garcia during that week. So, I
understand as it related to Dr. Gopal and Dr. Garcia
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that, you know, that there maybe some relevance
arguably, -- I'm not saying I agree with that, but there
may be some arguments with relevance to what Dr. Power's
has to say, but we've gone back and forth now with
snipits of depositions of Dr. Powers.
But the defendant has admitted that her
faxing the labs to Dr. Stelzer had nothing to do with
anticipation of contacting him about problems, but
rather had to do with an appointment in the future, and
given Ms. Yurchak admissions on that issue, I would
object to the use of any testimony from Dr. Stelzer's
deposition that, in the form of opinions, as to what he
might have done in the event that he had been contacted
or anything of the kind because it would be
impermissible testimony.
It would not meet the standards set forth
under the case law and the rules as to the testimony of
the treating physician because anything of this time
that he would say would not be in the course, in the
scope, even conceivably, given the defendant's
admittance on issues care and treatment on this patient
between October 13th and October 15th, 2008.
There may be some basic facts he was faxed
the information but anything beyond that would be
speculation and impermissible given what the defendant
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has admitted.
THE COURT: So, you're asking that Mr.
Laughlin be precluded from introducing Dr. Stelzer's
deposition to this witness or comment?
MR. CASEY: Yes. For this witness, and I'm
just anticipating that or with any witness provided --
THE COURT: With any witness?
MR. CASEY: With any witness.
THE COURT: I understand.
MR CASEY: Yes. Thank you, Your Honor.
THE COURT: Mr. Laughlin?
MR. LAUGHLIN: Your Honor, it appears that
this witness included in number 2 of his report that he
reviewed Dr. Stelzer's deposition transcript. I believe
that it is appropriate, and it's permissible for me, and
I'm entitled to question the witnesses who testify, the
experts with regard to the materials that they reviewed
in reaching their conclusions number one, and number 2,
to the extent that Dr. Stelzer was a physician involved
in the care and information was provided to him, he's
part of the fabric of this case.
You know, I don't think it's appropriate to
just sort of strike bits and pieces out of the things
that the experts have reviewed and prevent me from
inquiring.
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MR. CASEY: May I just add one thing to
that, Your Honor?
THE COURT: No. The Motion To Preclude the
use of Dr. Stelzer's deposition testimony is granted in
that it has been established that the defendant did not
the defendant did not consider his involvement in the
case to be concurrent with the events at hand.
MR. LAUGHLIN: Just to make sure I
understand. Am I not permitted to inquire of this
witness as to his review of Dr. Stelzer's deposition and
whether or not he agrees or disagrees with certain
aspects of it and whether or not it played a role in any
of his opinions?
THE COURT: That's correct.
MR. LAUGHLIN: Thank you.
THE COURT: Dr. Stelzer is essentially a
legal stranger to where we are in this, and I'm sure you
have plenty of other doctors you can ask them about.
MR. LAUGHLIN: Please note my exception.
THE COURT: All right, thank you. We'll see
you. Please be back about 1:20. I do have one argument
scheduled for one 1:30. Unfortunately, it involves some
pro se litigants, so we're not able to reach them. I
was trying to advance them to come at 1:15, but we'll
try to keep that argument as brief as possible. We'll
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see you at 1:20, please.
* * *
(Whereupon, a recess was taken at 12:04
p.m.)
* * *
(Court proceedings resumed at 1:25 p.m.)
* * *
THE COURT: Counsel, while I'm waiting to
see if I'm going have someone the other side of the
argument, can we see if there's other issues we need to
address this afternoon?
MR. CASEY: I don't believe so Your Honor.
MR. LAUGHLIN: No, Your Honor.
THE COURT: I have had a chance to give
further thought to Mr. Laughlin's request with regard to
whether or not this witness can be impeached with the
deposition of Frederic Stelzer, and I continue to rule
that he may not be impeached by that. However, I do
think somebody needs to establish whether or not the
inclusion or exclusion of that deposition would change
his opinion.
So, you're free to do that, Mr. Casey or Mr.
Laughlin is free to do that, but since it is one of the
reviewed materials just to being removed -- and it's
just one question. That's all I would permit on that,
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and that is, if, you know, whether or not that
deposition would change his conclusions.
MR. CASEY: Your Honor, if I may, I think I
would submit the issue is consistent with Your Honor's
ruling, whether or not a witness relies on something
simply because they reviewed it doesn't make it
admissible. The deposition, we already argued to the
Court. The Court heard my argument on it, and there is
inadmissible things in it anyway, but I think -- are you
suggesting -- and I would, of course, be guided by what
Your Honor does by establishing whether it was something
he relied on for his opinion.
THE COURT: Yes. I think that would be a
more precise way to address the issue is to establish
that he did not rely on it.
MR. CASEY: I understand, Your Honor.
THE COURT: But that is the only thing that
-- but then once he established that he didn't rely on
it, there will be no further inquiry on it.
MR. LAUGHLIN: Just for the record, I
believe the witness has been in the room during this
colloquy.
THE COURT: I think he was in the room in
the colloquy before that.
MR. LAUGHLIN: Well, I know, but I guess my
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concern is, the suggestion is now that he's --
essentially, it's been -- he's now aware of something
that he put in his report that he reviewed didn't
indicate in the report that he had relied on it, and now
he's in the room, and is now aware that all he has to do
is say he didn't rely on it, and then I can't ask him
about something that he reviewed.
THE COURT: Okay. Well, we can go back to
the other way, Mr. Laughlin, where nobody asked him
whether or not he relied on it.
MR. LAUGHLIN: I'm not trying to be
difficult, Your Honor. I'm just asserting that I
believe --
THE COURT: Well, what your asserting is
that because you think the witness is in the room and
heard an evidentiary issue here that now he's going be
change his testimony.
MR. LAUGHLIN: I don't know what his
testimony is going to be. All I'm asking, Your Honor,
is I want to be clear, assuming he answers that he did
not rely upon it, then I'm still precluded from testing
him on it?
THE COURT: Absolutely, and I would expect
him to testify truthfully if he did rely on it, that he
would say so. And then we might be in a different
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situation, but I don't really see how.
MR. LAUGHLIN: Am I permitted to ask him if
he considered the particular portions of the testimony
of Dr. Stelzer for his factual knowledge and opinions
for his testimony?
THE COURT: No. Let me rephrase the way I'm
thinking about it to clarify it for both counsel.
Somebody, I don't care whether it's the plaintiff or the
defendant needs to establish the degree to which he
relied -- whether or not he relied on Dr. Stelzer's
deposition in reaching his opinions.
And then -- but what I don't want to get to
is using this witness as a way to put Dr. Stelzer's
deposition up on the board for the jury to read because
it would be irrelevant. So, if we run into issues on
this, we're going to have to take a break, excuse the
jury and address them, but I don't think this is that
big an issue that it should cause a problem.
* * *
(Whereupon, the jury returns to the
courtroom at 1:34 p.m.)
* * *
THE COURT: Good afternoon, ladies and
gentlemen. We're ready to resume and we can ask the
doctor to return to the stand.
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* * *
DIRECT-EXAMINATION
BY MR. CASEY:
Q. Good afternoon, Dr. Poznansky.
A. Good afternoon.
Q. Just to go back on something you were asked just
before the break, and I touched on it in the midst of
going thru your 23 page resume but on the board
certification issue, can you explain in response to the
question Mr. Laughlin asked whether the certification
you have to teach and care for patients at Harvard on
infectious disease is the functional equivalent what
he's referring to as board certification?
A. Absolutely. Without -- I wouldn't be able to
practice in the hospitals.
Q. At my law firms request did you review medical
records for a patient named Sharlee Smoyer and
specifically, I'm referring to medical records for the
moment I'm referring to medical records that document
Ms. Smoyer's care from approximately March of 2008, to
the end of November of 2008?
A. I did.
Q. And did you consider in reviewing the medical
records whether let me back up a second the jury has
already heard testimony regarding standard of care
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issues in the case. And, sir do you understand you're
not here to testify on those issues?
A. I do.
Q. I just want you for the purposes of your
testimony to presume that between October 13th, and
October 15th, 2008, that there was a delay in picking up
and reporting and following up on signs and symptoms
risk factors for infection and for the purposes of your
testimony on the causation issues of the case just
presume that as a foundation okay?
A. I understand.
Q. There is perhaps in terms of the factual
predicate the factual baseline some over lap of course
between what was happening according to the Miner's
Memorial home care records on the 13th and the early
part of October up to the 15th of October when I think
which I'll get to a minute the records indicate the
patient was one sent to one hospital and transferred to
Lehigh Valley Hospital. Do you understand what I'm
saying?
A. I do.
Q. So, I'm not suggesting that I don't expect you to
refer to those records, but the focus of your testimony
is going to be the causative factors in Ms. Smoyer's
injuries, particularly, her bilateral below the knee
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amputation and left pinky amputation in the resulting
problems okay?
A. Okay.
Q. Sir, in addition to the records that we've
identified, did you also have a large volume of records
going back years and years for Ms. Smoyer that detailed
basically the history of her Chrohn's illness?
A. I did and I was beyond November 2008 I also had
files beyond November, 2008.
Q. In terms of the testimonial record in the case,
did you review Ms. Yurchak's deposition, sir?
A. Yes, I did.
Q. And did you review Ms. Smoyer's deposition?
A. I did.
Q. Did you review depositions of Dr. Garcia, Gopal
and Powers?
A. I reviewed them, yes.
Q. Now, were you present in the courtroom yesterday
when and I believe it was yesterday I can't say for sure
-- were you present in the courtroom to hear testimony
from the defendant as to whom the defendant would have
contacted or followed up with had she followed up on the
clinically facts and circumstances she found on the 13th
of October?
A. I had the impression she would followup with a
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doctor. I'm not sure I remember the specific doctor she
had she would followup.
Q. The record would reflect I'll represent to you
Ms. Yurchak testified that --
MR. LAUGHLIN: Objection, Your Honor.
THE COURT: Overruled. Continue.
BY MR. CASEY:
Q. She would followup with doctor Garcia and Gopal.
Will you accept that as a premise for your testimony,
sir?
A. I do.
Q. Were you here this morning when Mr. Laughlin
pointed out that while those 2 physicians were her
primary care physicians, that is Garcia and Gopal, in
following this central line TPN (Total Parenteral
Nutrition) that on October 13th, 2008, Dr. Powers was a
partner in his practice with Dr. Garcia was covering for
Dr. Garcia were you here for that?
A. I was.
Q. Were you here for the testimony of Ms. Yurchak
she indicated as far as Dr. Stelzer was concerned she
simply faxed him the she simply faxed him the labs in
anticipation for an appointment the following week, but
was not anticipating in any regard following up with him
as to management issues with the central line?
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A. I was.
Q. Accordingly, in terms of your causation opinions
in the case, which you're here to testify about, did you
rely upon did you rely upon Dr. Stelzer's deposition in
terms of reaching your causation opinion?
A. No. Could I clarify that? I referred to it, but
I didn't rely on it.
Q. I understand. And for that matter, in terms of
what were the key factors for you in analyzing the
causation issues in the case as an infectious disease
specialist, what role did the medical records play in
March of 2008 and November of 2008?
A. They set the scene and described the clinical
events.
Q. Would you not, sir have been able looking at the
just the records themselves and an lying the medical
facts in the records just those alone have been able to
reach your opinion as to the positive factors for Ms.
Smoyer's amputation?
A. There were certain points in the depositions
where I could refer to relating to issues in the history
and examinations they could get a little bit more detail
what besides what was in the written record what was
sort of being talked about.
Q. In terms of the history?
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A. In terms of the history.
Q. All right. Now, earlier this morning, during
Nurse Gorski's deposition, there was reference page to a
page in the Lehigh Valley Hospital record from the
history the H and P as it's protocol history and
physical what is that in terms of chronology records the
H and P?
A. History and protocol on what's done on admission
to the hospital, detail what has just happened to the
patient and when the patient's examined, what are the
physical findings.
Q. Now, on the morning of October 15th, 2008, did
you see in the records and did you see did you hear in
any of the testimony so far in the case basically what
transpired if you can describe for the jury generally
speaking what Ms. Yurchak documents that she found when
she arrived at Sharlee Smoyer's house and take the jury
through chronology so we can pick up that point the
chronology up to hen Ms. Smoyer is admitted to the
Lehigh Valley Hospital?
A. On the 15th of August -- and from reading the
written note on this, Nurse Yurchak reported finding the
patient in a distressed state breathing very rapidly and
her nose and fingers were purplish, blue, and the
patient was in quite a bit of distress. The exact
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wording -- I would have to see it up on the screen to
remind myself of exactly the words we used in that and
the purpose of the time that she was with the patient on
that instant was to rapidly as possible get the transfer
to the hospital she recognized the patient was in acute
distress.
Q. Based upon your review of the -- not only that
record but if records that followed what was happening
physiologically to Ms. Smoyer what was happening to her
body on the morning of October 15th?
A. This is where if I could beg a little patience on
this because this is quite complicated medical setting,
one I would take quite a big bit of time to explain to
residents in a hospital residents. When a patient is in
this level of distress, the patient is basically either
in shock or about to go into shock.
There are specific aspects of shock that
imminent when this patient is breathing that rapidly and
also has purple fingers and nose. It's quite a shocking
thing to see going to see a patient who looks like that,
and I'm sure none of us would like to see that sight.
What is happening physiologically and the
way to explain that to a quite complicated to bear with
me and Ia hope I can do justice to the situation,
basically, as a person has an infection that is
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overwhelming their body. They've been fighting it and
now it's overwhelming their body. Bacteria in the
bloodstream subsequently demonstrated at hospital are
producing poisons and the poisons are damaging the
organs in the patient.
In this case most evidently clinically look
at her and remarkable finding was write of 60 that was
60 if that if any of us try to breathe at one breath
sitting there even if we felt healthy so what that tells
us is the patients lungs were being damaged by the
toxins, number one. Number 2, the organ that makes the
lungs function appropriately, the heart, was also being
damaged. At that time the heart was being poisoned by
these bacterial poisons and it was causing the heart to
work less well.
So the lungs weren't working well. So, at
that particular time, the response that the body has to
that effect of the heart having trouble pumping enough
and not getting enough breathe in, you need oxygen to
live is that you is that right start shutting down your
blood supply to most of your body except to your central
organs. So the most important things in your body are
your heart, lungs, brain and kidneys. I say, of course,
but these are all sit in the center of your body and the
little that there is concentrated to keep the basic core
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functions of your body going through this extreme time,
and it is extreme. 60 breathes a minute is extreme and
body is basically trying to compensate for all the
damage that's happening.
It doesn't -- the body -- the person does
not want to die, so there are mechanisms within your
body that adapt to this terrible insult that's going on
in the body and consequence have visible as you walk
into a room and see a patient like this their nose is
purple fingertips are purple that's because very, very
cold day restricted to little blood.
They're able to circulate into the core
functions to keep you alive at that point you don't
really, you know, you jeopardize your skin to save your
heart because if your heart's not pumping it doesn't
matter whether you've got good skin to put it in a very
simple terms and the right thing to do at that point is
assess the patient rapidly and get them emergently where
they can be resuscitated.
That vision of that patient should fix in
your mind because it is a very traumatic example. It
seems to me a patient about to become close to death.
Not dying, but these are very core hours that we now the
to be resuscitated.
Q. Thank you, Dr. Poznansky. Do you have any
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opinion we have other records to get to it we'll take
the jury through many details as you believe are
relevant in terms of your opinion there are a lot of
records from that admission, sir?
A. There are.
Q. We'll go through some of them as a threshold
matter before we do you have an opinion, sir as to what
was happening with Ms. Smoyer on October 15th to cause
the process that you just described what was it?
A. It was bacteria replicating or dividing, growing
in the blood and producing poisons.
Q. Having reviewed the records, do you have an
opinion, sir as to where whether there was infection
present in Ms. Smoyer's body on October 13th, 2008, on
the morning when Ms. Yurchak was there caring for her?
A. I do have an opinion.
Q. What is that opinion?
A. The opinion there was an next her body at that
time.
Q. Is there any doubt in your mind about that?
A. No.
Q. And do you have any opinion as to whether the
infection that you say was present on October 13th,
2008, was the cause of what was happening when Ms.
Yurchak arrived back to Ms. Smoyer's back on
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October 13th?
A. Yes, I do have an opinion. That there was an
/EUPB /EURBLTs possess.
Q. And in terms of the admission at Lehigh Valley
Hospital from October 15th, 2008, to 'til the end of
November 2008, do you have an opinion as to what it was
that caused Ms. Smoyer's amputations that are documented
in that record and the complications the pain and
associated with it and the complications that are
associated with those amputations at that time?
A. I do.
Q. What is that opinion?
A. The opinion is that the overwhelming bacteria
infection in the blood led to the subsequent
catastrophic injuries that the patient experienced.
Q. Do you have an opinion where the infection
originated?
A. Yes, I do.
Q. Where -- what is your opinion?
A. The left hick catheter the surrounding tissue
around it is where the infection initiated.
Q. Reviewing the records themselves including
October 13th, 2008, thru the Lehigh Valley admission can
you explain to the jury the basis for your opinion that
there was infection present on October 13th, 2008, in
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that Hickman catheter?
A. If you could repeat that question again.
Q. I'd like you to explain to the jury using the
medical records and your analysis of them from
October 13th to the Lehigh Valley admission, I'd like
you to explain the basis for your opinion that the
Hickman catheter the left hick catheter was the source
for the infection that you say was present on
October 13th, 2008?
A. So since this is -- and I'm going to ask for an
opportunity to explain this if I could with a picture?
I can draw because again, this is a complicated process
that I would take time with my own team when I see
patients to explain this is not quick answer can rattle
off this is a process --
Q. You say you want to address something now?
A. I'll demonstrate very quickly. I'm used to
drawing.
Q. Before you do that, in terms of the clinical
bases for your opinion of the Hickman catheter on the
left, just using the record and the testimony you've
heard so far, generally speaking, just explain it, and
you can follow up as you see fit.
A. Very good. So, I saw as I reviewed the chart was
a patient and this is being referred to before as a high
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risk for an infection associated with a line. This is a
patient who had chronic illness. Patients who have
chronic illness, like Chrohn's Disease, are at a high
risk for infections. She also had diabetes.
People who have diabetes are at a higher
risk for infection. She also had -- was on steroids for
a long period of time, either intravenously or orally.
Steroids have, especially 5 milligrams a day, can, in a
patient, cause suppression of the inflammatory response.
So, that was her core status going into the time when
the line was placed. She was already vulnerable to the
infection. There were other historical components in
the record.
The fact that she had previous line
infections make you a higher risk for current further
infections. The finding that the line had become
contaminated, that the dressing, the protection of the
line, has become broken in the context of a shower is a
significant finding medically, and therefore, putting
the actual line itself at risk for infection. Although
the exact timing of isn't known how long, in a sense
isn't known it's my understanding from the record that
anytime a line is exposed like that in the context of
water present is concerning.
So she has all of these things stacked up
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and then on the 30th of October, she seen by Nurse
Yurchak and that story is reported, but then there are
both history which was the fact that Ms. Yurchak dutily
told Ms. Smoyer that the dressing had fallen off and in
the shower, and it got wet, that was her duty to report
that in a sense.
MR. LAUGHLIN: Objection, Your Honor.
MR. CASEY: Objection. Move to strike. I
agree.
MR. POZNANSKY: She reported it, and the
next thing was the site was looked at, and there was a
description the description was redness around the site,
if I'm correct, redness around the site. That is
another, now physical evidence. So you have the risk
factors likely to be infected and the visual physical
evidence that is consistent with an infection.
Furthermore, on the 13th, blood samples are
sent in that context, and there are what were described
previously as abnormal, not critical, but abnormal
results, which would be consistent with an infection
with a raised white count of neutrophil. Neutrophil are
cells that fight bacteria in your body. Neutrophils
react in minutes. If you have any infection,
neutrophils are ready to defend you. And so when you
see an increase, or in medical terms, we call it a bump
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in the white count occur, you -- it raises your
awareness that there may be an infection.
So, those aspects of the 13th are where you
describe that the infection has started in the Hickman
line site. The subsequent events are the natural
progression of a bacterial infection in the context
having breached one of your main skin completely intact
and the causitive role here break in the skin and
bacteria greeting thru the bacteria that pass through
your defenses, and over time, while you're attempting to
combat, fight back bacteria, it is getting a lead on you
and again, this is where the patient's previous health
matters.
She has less defenses once the wall is being
breached then the average healthy individual who doesn't
have diabetes and Chrohn's disease and is on steroids.
Your defenses just aren't as good so you become more
vulnerable between the 13th and the 14th to progressive
infection. And therefore --
Q. I can go to the records if it might be easier to
get thru it a little bit quicker.
A. Sorry.
Q. It's okay. I know you do want to explain.
That's fine, but I'd like to just establish using the
records first, I want to show you the admission note
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from Lehigh Valley Hospital. It's page 499 this is 3 of
4 of the Lehigh Valley Hospital admission and Mr.
Heilman, this sentence beginning with we, and take it
down to admitted to.
You need to go up a little bit. Okay. I
just want to take it to administer, and then end it if
you can do that. Dr. Poznansky, I'm going to -- after
we quickly look at this record, I'm going to go back to
the ambulance records from Gnaden Huetten Hospital, the
transfer from that hospital to the Lehigh Valley
Hospital, okay? But first I want to just establish in
the admission H and P at Lehigh Valley Hospital, it
reads, we will have interventional radiology remove that
left IJ Hickman, as I believe is a source of the
infection, and we will culture the catheter tip. We
sent for a blood culture and urine culture -- and this
is the word I want to focus on now -- before her
antibiotics were administered; do you see that?
A. I do.
Q. This is a hospital, Lehigh Valley Hospital
receiving a critically ill patient, right?
A. Right.
Q. And they're trying to assess the situation and
get to the bottom of what's going on, right?
A. Right.
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Q. But they note, as I just earlier had on the
screen from the same note a few minutes earlier, that
they noted that there was -- maybe I haven't put it up
yet. Let me put it up, 04017, it's from the same page,
page 1, just the bottom, please. They noted in the same
record that it was, there was positive left IJ Hickman
with purulent exudate and erythema, right?
A. Right.
Q. What is erythema.
A. Redness.
Q. And the note I just referred to indicated that
the physician admitting Ms. Smoyer to the hospital
believed that the catheter, the Hickman catheter was the
source of the infection according to that note, right?
A. That is correct.
Q. Now, what I also highlighted on that page was, at
Lehigh Valley Hospital, they said, we sent for the blood
cultures before we gave antibiotics, right?
A. Right.
Q. Now, why would you want to do that? Why would
you want to send for the blood cultures before you give
the patient antibiotics?
A. Because if you give antibiotics before you see
the cultures you'll disturb the diagnosis of the
bacterial infection if there is one. So, it will change
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the pattern of what was actually growing in the
patient's body. You have to make a clear diagnosis.
Q. Does it make it -- although it makes it not as
clear, is it still possible to make a diagnosis?
A. It is possible, yes.
Q. And did in fact, did in fact after those cultures
were back, did this hospital make a diagnosis
unmistakably as to whether the source for this sepsis
and infection was that internal Hickman catheter?
MR. LAUGHLIN: Objection.
THE COURT: Sustained.
BY MR. CASEY:
Q. What was the diagnosis at this hospital for the
source for Ms. Smoyer's sepsis?
A. It was gram negative catheter related sepsis.
Q. Now, back to the issue of antibiotics and blood
cultures, were you here for the opening speeches where
Mr. Laughlin talked about well, there was one organism
found on the tip and another organism found in the
blood; were you here for that or not?
A. I was not.
Q. I thought you might have been here. I wasn't
sure. Let's put up Bates 18962. For identification
purposes, this is the Medevac record from the first
hospital to Lehigh Valley Hospital, right?
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A. Correct.
Q. The ambulance records?
A. That's correct.
Q. If we could page ahead to 18964, I want to
highlight right here Mr. Heilman, the Rocephin. This
record indicates what medication Ms. Smoyer was getting
either while she was at Gnaden Huetten or on the way to
Lehigh Valley Hospital or both right?
A. Correct.
Q. Just to establish a context. And it indicates
that she received into her IV that was placed Rocephin,
right?
A. That is correct.
Q. What is Rocephin?
A. It's what's called the third generation
cephalosporin. It's a particular type of antibiotics.
Q. And the cultures that grew out, which we'll get
to also, the cultures that grew out from the blood
sample that was drawn, grew out what organism?
A. It grew out a gram negative bacteria, called
enterobacter.
Q. Were there other gram negative bacteria found in
that blood, but they were unable to identify this
specific -- would it be species? Or --
A. Yes. It would be species -- Enterobacter
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cloacae. The cloacae is the species name.
Q. Let me put up the record. Sorry. I was
referring to the catheter, and I'll get to that now.
A. Yes.
Q. What did the cultures of the catheter grow out?
A. The catheter tip, which is the final, sort of,
piece of the tip line in the blood vessel itself sitting
right in the blood flow, grew out another gram negative
called Klebsiella, and that species name is pneumoniae,
but it is a ground negative organism.
Q. Did the cultures of the catheter grow out
additional gram negative bacteria that couldn't be
precisely identified?
MR. LAUGHLIN: Objection to the form. Well,
I'll withdraw it.
THE COURT: You can answer the question.
MR. POZNANSKY: I would have to -- I looked
through this, but I did not see additional gram
negatives identified.
MR. CASEY: Okay, let me put it up. It's
18531 please. I'm referring to the bottom of the page,
Mr. Heilman, right here.
BY MR. CASEY:
Q. This is the culture result of the Klebsiella
pneumonia, and what is the second finding?
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A. There's three colonies of gram negative rods.
Can I explain?
Q. Yes.
A. Let me explain a little bit more about that type
of reporting. The colonies a lit /SPOL you can see with
the naked eye. When there's initial reports like this,
it maybe evident that some colonies are clearly one type
of species of bacteria. In this case they were both
gram negatives. One could be clearly identified, and
one that wasn't identified, but sometimes by the time
the final report comes back in and all of the colonies
have grown up to an identifiable size, Klebsiella or
maybe the additional colony of something else. So,
generally, this is sort of a preliminary type of
reporting before the final report, which gives you the
sensitivities.
Q. What does it mean to say that -- did you say
whether each of these bacteria, Klebsiella and
enterobacter are gram negative?
A. Yes. I can explain that?
Q. Yes, briefly.
A. They are stained. In order to find out what type
of bacteria, you stain them with a particular purplish
stain. If they don't stain up purple, they're gram
negative. If they do stain up purple, they're gram
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positive. They're 2 different grounds of bacteria.
Q. The Rocephin that Ms. Smoyer was given on the way
to Lehigh Valley Hospital, is there a phrase in the -- a
term of art in medicine as to whether a particular
antibiotic can kill a particular bug?
A. Yes.
Q. Is there a term of art? A word that can be used?
MR. LAUGHLIN: Objection to the scope.
THE COURT: The objection is overruled.
BY MR. CASEY:
Q. The word I'm looking for is what, sir?
A. Sensitive.
Q. Or susceptible?
A. Sensitive or susceptible.
Q. One of the things when antibiotics are being
administered -- well, I'll ask it more directly.
Rocephin, what bug of the ones we've identified, what
bacteria would Rocephin expected to kill? Or put it
another way, to what antibiotic is -- well, I'll ask it
the first way. I'm sorry. My colleague's telling me
how I missed that question. To what bacteria can
Rocephin be directed?
A. Rocephin can be directed to some gram positive
bacteria and some gram negative bacteria.
Q. Is Klebsiella susceptible to Rocephin?
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A. It can be.
Q. And did the medical records here indicate that
the Klebsiella found in Ms. Smoyer's body was in fact
susceptible to a third generation cephalosporin?
A. Exactly, and indeed the Klebsiella was sensitive
to third generation cephalosporin.
Q. And what impact in this case did the Rocephin
have on the blood culture that was done later at Lehigh
Valley Hospital but was given before the blood cultures
were drawn?
MR. LAUGHLIN: Objection, beyond the scope.
THE COURT: Overruled.
MR. POZNANSKY: The single dose of
intravenous antibiotic Rocephin -- the other name is
Ceftriaxone -- would kill the Klebsiella in the blood,
and it would be very hard to culture if you took a blood
culture after the Rocephin was given.
Q. Okay. Now, there was, as depicted -- and I've
marked it, this sketch, for demonstrative purposes as
plaintiff's 10 -- there was enterobacter found in the
blood flow, correct?
A. Correct.
Q. Now is enterobacter susceptible to Rocephin?
A. It could be susceptible, but the enterobacter
that was identified in this patient was not susceptible.
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It was resistant to the Rocephin.
Q. Do you have any opinion as to whether that is why
the enterobacter was found in the blood and not the
enterobacter together with the Klebsiella?
A. Well, the Rocephin basically selectively killed
the Klebsiella in the bloodstream floating in the
bloodstream, but left the enterobacter intact as it was
resistant to that antibiotic.
Q. Now, I want to move ahead to -- and just for
purposes of clarity or context, when were the blood
cultures drawn? The original -- upon -- after she was
admitted to the hospital, was it on October 15th?
A. It was on October 15th.
Q. And then it takes sometime, does it, for the
cultures to kind of grow out?
A. Yes.
Q. Now, if we can put up Bates 2970. I want to
highlight -- this is a central catheter procedural
checklist dated 10-15-08. It's at 10:25 at night, and
do these records document -- and I'm going to go through
others a diagnosis of left subclavian site infected
Hickman catheter?
A. They do.
Q. Let's go to the next page I want to talk about,
Bates 02974. This is a central catheter procedural
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checklist. This is from the following day, 10-16-08. I
guess later that night, 1 o'clock in the morning, right
here. Left subclavian infected Hickman, right?
A. Correct.
Q. Okay. By the way, has anybody at this point in
the records, said that this was a, this was an
enterobacter from Crohn's disease that was from a flair
up of Crohn's that was causing this problem?
A. No.
Q. Some floating fistula or mysterious fistula, has
anybody talked about that in the records at this point?
A. No.
Q. Let's put up 04025. This is from the Critical
Care Service at Lehigh Valley Hospital here in
Allentown. What is a Critical Care Service? What do
they do?
A. They look after patients who are critically ill.
A patient such as this, who was in shock, would be a
classical example of a patient they would look after.
Q. And the top of the note says impression. What
does the word impression mean in medical terms?
A. In medical terms, it generally means after
assessment of the history and the exam the findings or
the x-ray finding, an impression was made based on all
of those findings. It's not their first impression.
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It's the impression at the end of gathering all of that
data.
Q. And this is from the Critical Care Service at
Lehigh Valley Hospital, impression; septic shock, likely
infected indwelling catheter, correct?
A. Correct.
Q. If we could move down the page, Mr. Heilman. It
says to interventional radiology -- that's what IR
means, right?
A. Correct.
Q. For removal of infected line and placement of
triple lumen HD catheter, correct?
A. Correct.
Q. At this point -- I know you described for the
jury what was happening to her body on the morning of
October 15th, but the jury has heard the term -- well, I
don't know if they've heard it at this point -- but why
was this patient now being put on hemodialysis?
A. In order to support the kidney function of a
patient, who is otherwise in shock as a result of the
sepsis.
Q. Are her organs -- were her organs shutting down?
A. They were.
Q. This catheter here, being put in, this was for
her kidneys, correct?
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A. It was to support kidney function.
Q. Let's move to Bates 04031. This is from the
Critical Care Service the following day. Go down to the
bottom of the page. The impression from the Critical
Care Service says gram negative sepsis, right?
A. Correct.
Q. Enterobacter and Klebsiella are gram negative
organisms, correct?
A. Correct.
Q. And then it says, underneath there, secondary to
line, correct?
A. Correct.
Q. Let's move to the next page, 04036. This is the
next day, 10-17. By the way, let's go back to the next
-- let's go back to the last page. I want to highlight
-- I'm sorry, Mr. Heilman. The IV section right here,
infectious disease. Now, this is 10-16, October 16th.
At this point, the blood cultures had already come back
and said, or partially, positive gram negative rod,
right?
A. Correct.
Q. And the catheter culture was pending, right?
A. That is correct. That's what that reeds.
Q. Let's move to the next page. The top of this
page, it says septic shock secondary to gram rod
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bacteria, right?
A. Correct.
Q. Let's move to 04037. Same date from the same
service. Infectious disease, right here. Gram negative
rod in blood cultures x2, line culture, continue -- what
is that? Cefepime?
A. Cefepime, yes.
Q. And what's the other thing?
A. Fluconazole.
Q. To what organisms are bugs are those antibiotics
directed?
A. The Cefepime fights the infection gram negative
organism antibiotic, and the Fluconazole is an antiyeast
antibiotic.
Q. And if we can go down the page under impression,
it says, gram negative sepsis, and then, what's it say
underneath there, Dr. Poznansky?
A. It says catheter related.
Q. Then, we'll go to the next day, October 18th.
04041. Same thing, infectious disease. Gram negative
rods and blood cultures continue Cefepime. And this
indicates it's going through an IV, right?
A. Yes.
Q. And then it says positive Klebsiella pneumoniae
in catheter culture, right?
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A. Correct.
Q. At this point, did they have the basic
information back on both their blood and the --
A. Yes.
Q. -- and the catheter?
A. By the 18th, yes.
Q. Now, there are some -- to the extent there's
records on the blood culture results that say final --
are the cultures allowed to just continue to grow?
A. Yes, and there are various checks that are done
to make sure, to confirm the initial diagnosis and tests
and so forth that are done -- I guess each
microbiological lab is different, but they'll eventually
write a final point.
Q. But at this point, do the clinicians have the
results of the blood cultures on the 18th?
A. They do.
Q. Let's move to the bottom of the page, under
impression. Septic shock secondary to Klebsiella
bacteriemia catheter related, right?
A. Correct.
Q. Now, would it be just as accurate at that point
to say enterobacter sepsis?
A. Yes. In addition to Klebsiella sepsis.
Q. Can you explain, to the extent there's a
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contention, well, we have 2 different organisms here,
they must come from 2 different places. Can you assess
that, please?
A. Yes. These bacteria cohabit together in the
mixture generally on your mouth or it can be on the
skin, and they exist together. They're not really
separable in this particular patient because they work
together.
Q. Okay. There's been testimony in the case about
the fact that this Hickman catheter was -- and I guess
you would know from the records -- did Ms. Smoyer have a
colostomy on that side -- on the same side of her
abdomen as the catheter?
A. The Hickman was actually on the left side, and
the colostomy was on the left side. So, so, it would be
--
Q. Right. I'm sorry. This side -- where would,
approximately, the stoma be for the colostomy? In this
area?
A. A little bit lower.
Q. Right here?
A. Exactly.
Q. And if hit were on this side it would be right
here?
A. Yes. Just under the rib cage.
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Q. Okay, now, we're going to get to it at some
point, but there's been a contention made -- and it will
be made in this courtroom -- and this is discussed in
your report, that this was enterobacter in the blood,
and that must have come from inside her body, inside her
bowel. It can't come through the catheter. It can't be
a catheter infection because it's enterobacter. Can you
assess that, Dr. Poznansky?
A. Well, there's specific aspects of this patient,
which is, there was a colostomy site, which was emptying
stool into a bag, her bowel motions into a bag, at the
specific distance below the Hickman site of entry. So,
it's imminently possible that there was enterobacter
around and on the skin associated with contamination
from that colostomy site.
Q. Okay. I want to talk about something in relation
to that. Were you here in the courtroom when Mr.
Laughlin was talking about the fact that, well, on the
evening going into the morning of the 15th, some point
there, this bag opened up. Do you remember that
testimony?
A. I do, yes.
Q. And do you remember him asking Ms. Yurchak, was
that colostomy bag intact on the 2nd and the 6th and the
13th; do you remember him asking her that?
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A. I do.
Q. Well, devil's advocate here, if the colostomy bag
is intact isn't that stoma free of bacteria?
A. No.
Q. And again, is it your opinion -- I'm not asking
you exactly where it came from, but is it your opinion
-- do you have any opinion whether the enterobacter
found in her blood came from something on her skin?
A. I do have an opinion on that, yes.
Q. What is your opinion?
A. That it came from the skin around the colostomy
site that was adjacent to the Hickman catheter site
entry point.
Q. Now, this may be a -- the word uncomfortable is
not the right word. It may be indelicate or disgusting,
perhaps, but can you discuss as an infectious disease
specialist with this jury that phenomenon in a way that
we all can relate to from our everyday lives?
A. It is indelicate, but doctors talk about a lot of
things that are indelicate, so I will talk to you as I
would talk to you as I talk to my colleagues. The point
is this, that when you, say you go to the bathroom and
have a bowel motion, and you clean yourself up
afterwards, for example, and you clean yourself
extremely well. If a biologist swabbed the skin around
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your anus, they would find evidence of the bacteria. In
other words, you cannot clean bacteria a hundred percent
from the skin surface.
Now, in the case of the colostomy, when the
bag is changed or even if the seal is not a hundred
percent tight, and if even if there's no physical -- you
must remember, the bacteria are microscopic organisms,
and they can leak in a way that you couldn't possibly
see them, in the same way that you can clean a surface
as well as you possibly can, and you can still find
bacteria on the surface. And for this reason, the skin
is accepted -- in the context of a Hickman line and
colostomy and the home setting as being potentially a
source of bacteria.
Q. Okay, and just to further that point, but not too
much, but when you said that there's bacteria there,
what kind of bacteria from your vantage point as an
infectious disease specialist would you except to find?
What's it called?
A. So, in the context of this patient, it would be
potential stool organisms on the skin, like gram
negative organisms that were found in the blood.
Q. Is Klebsiella something that would commonly be
found in this context of microscopic bacteria from
stool?
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A. Yes.
Q. And same thing for enterobacter?
A. Yes.
Q. Again, I said -- one point further to this, but
not too much, when -- and I'm sorry, but when someone
flushes a toilet even, and you would think that the
toilet is relatively clean at that point. And again,
this is fairly disgusting in this -- I don't mean
disgusting -- you know what I mean.
A. Yes.
Q. Sorry. Sorry. Can you describe even in that
context where this kind of bacteria would be expected to
be found and why?
A. So, when you flush the toilet or the combination
of water with bacteria causes the bacteria to actually
aerosolize into the area as a very, very, fine mist.
You can't see it, but it's there when you -- it's almost
like you splash water and there would be droplets that
you can see, but there will be droplets that you can't.
They're very small. The bacteria actually showered onto
the toilet seat, and the area around it.
Q. Okay, and --
A. I just want to clarify one point.
Q. Yes?
A. In the context of a normal healthy person going
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into that bathroom, they're not at risk. You can go to
a public bathroom without, you know, assuring you that
they be cleaned every 20 minutes as a public health
safety.
Q. But if you have an indwelling Hickman catheter
that goes directly into your blood stream, is there some
risk?
A. There is if it is exposed.
Q. Okay. If we could continue, Bates 04045. This
is October 19th, under infectious disease, positive
Klebsiella on catheter culture, susceptible to Cefepime,
right?
A. Correct.
Q. It says continue Cefepime, right?
A. Correct.
Q. And then, start Vancomycin?
A. That's correct.
Q. The Cefepime that they're continuing the patient
on, are both Klebsiella and enterobacter -- would they
be expected to respond to it, in this patient?
A. In this patient, yes. They are sensitive -- both
of them are sensitive to Cefepime.
Q. At the bottom of this page on the 19th,
continuing diagnosis, the very bottom of the page.
Impression, this is, again, from the critical care
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service at Lehigh Valley Hospital, septic shock
Klebsiella catheter infection, right?
A. Correct.
Q. Let's move ahead to 04055 continuing critical
care notes, and there's notes every day, but under
GI/Hepatic, this is an analysis of the gastrointestinal
issues, right?
A. Um-hmm.
Q. Yes?
A. Yes.
Q. It says Crohn's status/ post ileostomy, sepsis,
secondary to catheter feeding, right?
A. Correct.
Q. Patient improved, continue Cefepime, right?
A. Correct.
Q. Now, again, is there anybody at Lehigh Valley
Hospital that -- we're now -- we're now 6 days into the
hospitalization -- who is treating this patient for a
mysterious burrowing hidden Crohn's fistula that's
causing an infection?
A. No.
Q. The next few records I want to ask you about
relate to what was going on with Ms. Smoyer's legs
during these initial few days, and what it looked like.
All right? I'm going to go back to some of those other
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records I was just going through in a minute, but Bates
04042, down here. If we could just highlight this
entire section at the bottom. This is from October 19th
from the Vascular Surgery Service, right?
A. Yes.
Q. It says bilateral lower extremity ischemia,
right?
A. Yes.
Q. Both feet remain cyanotic and marginally viable,
right?
A. Yes.
Q. I'm not sure what that last word is?
A. Skin.
Q. With marginally viable skin, right?
A. Correct.
Q. Palpable, arterial tibular pulse at angle level,
right?
A. Correct.
Q. Distal arterial thrombosis related to gram
negative sepsis, right?
A. Correct.
Q. Just describe to the jury what these physicians
are saying in regards to her legs, and how it's related
based upon your review of the records, this record, to
this infection?
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A. So, when bacteria progressed to this stage where
they multiply in your blood and culture them and so
forth, and they're producing these poisons, there are
two things that happens. One is the poisons themselves
damage directly the blood vessels in your periphery.
They actually injure them. They're very toxic
substances they go there and they damage.
In addition, you are reacting as well by
shutting down your circulation, so that during sepsis of
this type, your whole blood supply to your periphery;
your nose, fingers, feet are being shut down. So that
the tissue that is causing oxygen and blood supply are
gone, and those tissues are dying. And this is why
depending on the severity of the shock or the septic
shock in this case, you could lose toes, a foot. You
could lose a whole leg. In this case, she lost her
legs, and she lost a pinky. This is classical for
severe septic shock.
Q. If we could go 04047. This is the following day.
Vascular surgery -stable, bilateral lower extremity
ischemia palpable distal at pulses, feet warmer, skin
remains cyanotic; right?
A. Right.
Q. What does cyanotic mean?
A. Blue.
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Q. Heparin is no contraindication. That's a blood
thinner, right?
A. Right.
Q. Does that say heart stable? No. I'm sorry.
What does it say?
A. Hands stable, I think.
Q. Hands stable. Can you read the rest of the note?
With marginal viability left fifth finger, right?
A. Right.
Q. Small vessel thrombosis related to gram negative
sepsis, right?
A. Correct.
Q. And in terms of the progression of this, is this
note essentially describing how the infection resulted
in a systemic body response, sepsis, then causes further
vascular damage that is resulting in the problems
identified here?
A. Correct.
Q. Let's move down that very same page while we're
at it, right here. Gram negative rod sepsis Klebsiella,
that's the note from the service on October 20th at
roughly 9 o'clock in the morning, correct?
A. Yes.
Q. Now, again, a devil's advocate question -- well,
if the Rocephin that Ms. Smoyer got on the way to the
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hospital kills the Klebsiella in the blood, well, why
didn't it kill the Klebsiella in the catheter? Why
didn't it eradicate that?
A. It's another point -- little bit more detail.
Q. Sure. Sure.
A. Certain bacteria have an ability to stick onto
basically the plastic that exists when you put in a
line. They actually have an ability to stick to
plastic, like, bacteria in your mouth are able to stick
to your teeth. They create a substance that allows them
to stick on. And interestingly, when they're stuck on,
they have, sort of like, glue-like material. They are
more resistant to the antibiotics. Then, when they're
just floating free in the blood, this -- kind of the
best way to describe it is like a glue they make. If
you can think about bacteria sticking to your teeth,
that's a pretty hard job. They can stick to plastic so
the antibiotics didn't actually penetrate them.
Q. All right. Continue. I apologize. I thought
you were done.
A. I am finished.
Q. 04058, this is October 22nd, now, from Vascular
Surgery, and it says, bilateral lower extremity ischemia
left hand ischemia feet stable with severe cyanosis --
they're blue, right?
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A. Yes.
Q. Some gangrenous changes distal toe, right?
A. Right.
Q. Palpable pulses and fibial pulses, and there's a
reference about the hands at the moment. We can read
it, but I don't need to ask you about it. What's
happening physiologically -- this cyanosis in the feet
is starting to become what's described as gangrenous?
A. The tissue is now dead or very close to being
dead. It will go from a bluish color to a black color.
And at that point, the tissue that is black is not
salvageable.
Q. Let's go to 04080. This is October 24th.
Patient with severe ischemia, changes to her feet, right
greater than left, plantar third, fourth, fifth toes,
now appear darker, pregangrenous today gauze placed
between toes of both feet, nursing changed leaking
pouch, will change again on 10-28. Did I read that
correctly?
A. Yes. That's correct.
Q. And I'm just trying to establish with you the
progression of this process. Now, does it continue?
There are other records that I don't need to go through,
but -- at the moment at least -- does this process
continue despite what's happening in the hospital and
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best efforts that they can't salvage Ms. Smoyer's --
first, her left pinky; right?
A. That's correct.
Q. And then does that -- over the course of, I think
it's the next 2-weeks or so from there -- and the jury
will see these records in this case. Does it continue
to the point where she learns she's going to lose one
leg, and then the other, below the knee amputations, as
a result of this infection?
A. Correct.
Q. Does that also occur -- I asked you that, I'm
sorry. Now, I want to go back to some of the records I
was asking you about before. Does the medical record
from Lehigh Valley Hospital indicate that the diagnosis
as to the source for this infection, their assessment of
it, over the next several days and weeks, and even when
she's -- well, I'll get to the discharge. Does it
continue to be, and did it always remain that it was
from the catheter?
A. Yes.
Q. Are there times in the record where someone,
instead of saying Klebsiella sepsis or gram negative rod
sepsis, calls it an enterobacter sepsis?
MR. LAUGHLIN: Objection, Your Honor.
THE COURT: Overruled.
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MR. POZNANSKY: Correct.
BY MR. CASEY:
Q. Let's pull it up 04086. This is from the
Nephrology Service on October 26th, assessment in plan.
What is AKI? If it is AKI? Above the -- let's move to
the next page. Enterobacter line sepsis, correct?
A. Correct.
Q. That's one of those things that can't happen
because enterobacter is inside your body. It seems to
be on this date that somebody at Lehigh Valley Hospital
thinks it's an enterobacter or gram negative sepsis from
the line, right?
A. Correct.
Q. Just go thru a few more. 04116 this is
October 30th. I just want to go down to the assessment
of plan, Mr. Heilman. Sepsis Klebsiella related, right?
A. Yes.
Q. Ischemia gangrene or next week, right?
A. Correct.
Q. Here it says, Crohn's with fistula appeared
today, correct?
A. I think --
Q. Opened today. GI consultant, right?
A. Yes, correct.
Q. Now, go to 04122. This is after GI is consulted
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about a fistula that is documented there. A couple
days, actually. Let's go under assessments and plans.
Sepsis with Klebsiella gangrene is secondary to above,
right?
A. Correct.
Q. Does the fact that during her hospitalization --
well, I'll ask you more directly. After a documentation
of this fistula in late October, between then and when
she's sent home, does the diagnosis as to what brought
her there and resulted in all these problems to her
extremities change?
A. No.
Q. Let's pull up 00494. This is the discharge
summary. This was after the patient -- I have it dated
as 10-30-2008. Was the patient at some point discharged
from the ICU out to, I guess it would be a general
medical floor?
A. Right.
Q. So, there's a discharge in the records for that,
and there's a discharge summary for when the patient is
sent home?
A. Correct.
Q. This is when she was discharged from the ICU.
It's the in summary paragraph, if you want to highlight
it, Mr. Heilman. In summary, this is a 52-year-old
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female with severe sepsis related to klebsiella
bacteremia, who developed small vessel thrombosis and
ischemic changes in her digits related to gram negative
septicemia. Did I read that correctly?
A. Yes.
Q. The patient was started on hemodialysis for her
worsening renal failure. Right?
A. Correct.
Q. Let's go to the other discharge summary. This is
a discharge summary from when she was -- I want to make
sure I'm right about this. I'll have to track it down,
but, this is another discharge summary. Page 04285.
Admitting diagnosis; severe septic shock, correct?
A. Correct.
Q. Respiratory failure?
A. Correct.
Q. Metabolic acidosis?
A. Correct.
Q. Acute renal failure?
A. Yes.
Q. Are all those related to the infection that
becomes sepsis that's a result in multi-organs systems
failure?
A. Yes.
Q. Discharge Diagnosis: Number 1. Gram-negative
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septicemia causing septic shock, right?
A. Correct.
Q. Ventilator-dependent respiratory failure
extubated October 22nd, right?
A. Correct.
Q. Okay. And then, there are other things there
about the treatment she was getting. Let's go to 04286.
It's part of the same -- the following page. Under, the
patient had initial blood cultures. This is part of the
same discharge summary, correct?
A. Correct.
Q. The patient had initial blood cultures which grew
an Enterobacter cloacae left indwelling CVP line grew
Klebsiella, and then -- this is the point I wanted to
get to -- and a femoral catheter placed later grew VRE;
right?
A. Correct.
Q. Now, later on in the hospitalization, are there
records that indicate other line infections while she
was in the hospital?
A. Yes, there are.
Q. Okay?
A. Can I just correct one thing? CVP, should be
CVC, central venous catheter.
Q. Right. That's what I thought. Okay. Now, when
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-- at the time that the other -- the femoral line was
placed later, what is femoral line?
MR. LAUGHLIN: Judge, I object.
THE COURT: Sustained. Beyond the scope.
MR. CASEY: I want to pull up 19020.
BY MR. CASEY:
Q. This is a consultation with the Gastroenterology
Service from 10-29-08. That was the front page. If we
go to 19022, which is the last page of this note, the
assessment, right here. Assessment. It says, the
patient is a 52 year old woman with a known history of
Crohn's Disease, status quo, post ileostomy who remains
quite stable from the Crohn's standpoint. We recommend
the patient remain under current residence including
atrocal would continue low revenue diet will follow
along with you; right?
A. Yes.
Q. And it was that note, October 30th, 2008 -- at
least it's stated that way -- I showed it to you. It
says date dictated, 29th of October, but I showed you
earlier the note that talks about the fistula that
opened, and I believe it was the day before right?
Either the day before or the day of. It's hard to tell
from the record, but it's in conjunction with that
fistula opening, right?
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A. Correct.
Q. Now, Dr. Poznansky, the later records that the
jury may see between the records that I've showed you
about the changes that started to appear in Ms. Smoyer's
lower extremities to the point where she has those
amputations, did you read those records?
A. I did.
Q. And we have them here. If we have to go through
them, we will, but to try to speed things up, did the
line infection that you indicated was present on
October 13th, 2008, cause the progression of this
infection and sepsis and multi-organs systems failure in
resulting vascular changes in Ms. Smoyer's extremities,
and did it result in the her bilateral below the knee
amputation and her left finger amputated?
A. Yes, it did.
Q. Had the infection been treated and dealt with on
October 13th, or October 14th, 2008, was this patient's
condition salvageable?
A. It was.
Q. Can you explain?
A. The best way to explain, is that the infection
started on the 13th, bacteria had breached the defenses
of that patient with regard to where the line was in the
chest, and they had established a foot hole in the body.
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At that point, if the infection would be recognized, it
could have been treated with antibiotics and the
infection could been curtailed at a very early time
point.
MR. CASEY: Can I have that answer read
back, please?
* * *
(RECESS AT 3:04 P.M.)
* * *
(PROCEEDINGS RESUMED AT 3:28 P.M.)
* * *
THE COURT: All right. The witness can
return to the stand.
MR. CASEY: May I, Your Honor?
THE COURT: Go ahead.
BY MR. CASEY:
Q. Dr. Poznansky, I know you don't have the chart
with you up there. At this point, Your Honor, I'll mark
as plaintiff's, it will be 12 actually, the entire chart
from the October 15th, 2008, admission to Lehigh Valley
Hospital the Bates numbers are 02360 thru 02491, and
Bates 18432 thru 19083.
Dr. Poznansky, before we took a break and I
asked that testimony be read back because I got
distracted, I was asking you about whether -- had the
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patient's condition been worked-up and evaluated on
either the 13th or the 14th of October, her condition
would have been salvageable, and you talked about
antibiotics earlier on the 13th or 14th, would have
prevented these injuries. Do I have -- have I
summarized where we were at the break?
A. Correct.
Q. Is that your opinion?
A. That is my opinion.
Q. The -- I know you're not here to testify about
standard of care. I want to clarify that for you for
the purposes of the foundation for my question, okay?
But with the presumption that they were deviations from
the standard of care on the part of Nurse Yurchak in
failing to work-up and reassess this line on the 13th,
failure to come back on the 14th, and the testimony for
which you were present from Ms. Gorski, with that as a
foundation, can you tell us whether those deviations
from the standard of care increased the risk of harm to
Ms. Smoyer for exactly the kind of injuries that she
suffered from?
A. Yes, they did.
Q. And would earlier antibiotic administration on
either the 13th or the 14th enabled Ms. Smoyer to avoid
the injuries, the bilateral amputations and the left
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pinky amputation from which she suffers today?
A. They would.
Q. I think next week a physician by the name of Dr.
Nieman -- I don't recall his first name, I honestly
don't remember -- but Dr. Nieman is going to testify in
the defense case. He's an infectious disease
specialist. Did you review his report?
A. I did.
Q. Did you see where Dr. Nieman says, well, even if
there was an assessment of things on the 13th and before
they were ended up being assessed for Ms. Smoyer, you
know, this whole outcome would have been the same
because there wouldn't have been time to get this
worked-up or words to that effect; did you see that in
his report?
A. I did.
Q. What is your response to that, sir?
MR. LAUGHLIN: Objection.
THE COURT: Overruled.
MR. POZNANSKY: I disagree.
BY MR. CASEY:
Q. Why?
A. Because it ignores the fact there was evidence of
an infection on the 13th.
Q. Well, I'm just taking about from a causation
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point of view, just hypothetically, as Dr. Nieman is, I
guess prepared to say this, that had this been worked-up
on the 13th or 14th, that -- I think you said something
-- and you can tell me if I'm wrong, because you wrote a
report in response to it; did you not, sir?
A. I did.
Q. It takes 48-hours for cultures to come back and
if that had been done on the 13th, you know, that would
take til the 15th for culture results to come back, so,
this would be the same outcome. Can you respond to
that?
MR. LAUGHLIN: Objection, Your Honor.
Leading and scope.
THE COURT: There's a second report?
MR. CASEY: Just a responsive report to Dr.
Nieman.
THE COURT: I need to have that. I don't
have that. The objection is overruled. You may answer
the question, if you remember it.
MR. POZNANSKY: May I see my report?
MR. CASEY: Yes. May I approach, Your
Honor?
THE COURT: Yes.
MR. POZNANSKY: I don't remember it
verbatim.
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THE COURT: Well, why don't you ask it
again.
MR. CASEY: Yes, Your Honor.
BY MR. CASEY:
Q. Just to draw your attention to what I'm talking
about, Dr. Poznansky, did you respond to Dr. Nieman's
opinion that if Ms. Smoyer presented to the hospital for
evaluation on 10-13 no action to address her developing
infection would have been taken until Ms. Smoyer
deteriorated beyond healthy. Did you evaluate that
assertion by Dr. Nieman?
A. I did evaluate that.
Q. Can you please assess it?
A. So, it's incorrect.
Q. Why?
A. It would be a rapid assessment and action taken.
The culture would not be waited -- you would not wait
for cultures to come back before starting to treat.
Q. Yeah, on the 15th, did the antibiotics start
right away?
A. They probably started on the 15th -- the first
antibiotics, as we discussed, Rocephin was given because
the patient was critically ill and was given before
blood cultures were taken.
Q. Let's go to Bates 18962. These are back to the
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ambulance records. These are records we used to
establish the administration of the Rocephin. The trip
covered between 11:27 a.m. that morning and 12:45 p.m.
that afternoon, just a few hours after Ms. Yurchak was
in Ms. Smoyer's home, right?
A. Correct.
Q. Now, have you been present in the courtroom for
the testimony regarding the documentation of redness --
I'm sorry -- of no redness -- in the medical record on
the morning of 10-15-08?
A. I was.
Q. And were you present when relatedly -- well, I'll
stay on that point. Earlier in your examination, do you
recall my showing you the record from Lehigh Valley
Hospital from early in the afternoon that documented
positive redness and discharge from the site of the
catheter?
A. Correct, I did.
Q. And how do you reconcile, in terms of your
causation, how this progressed the documentation of no
redness in the morning with the positive of redness in
the afternoon?
A. Because the patient's clinical condition was
different between the time that she was first seen that
morning on the 15th, and when the reporting was done
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subsequently at Lehigh Valley hospital.
Q. And explain what you mean in terms of the finding
of redness or less redness, I guess, or no redness on
the morning of the 15th, as documented by Nurse Yurchak?
A. The description of the patient on the morning,
the first time the patient was seen by health care
professionals in the morning of the 15th of October, she
was described as pale, with multiple skin appearance and
blue nose and blue fingertips, all evidence of
uncontrolled sepsis and circulatory shut down, shock.
When that happens, as I explained to you earlier, you
take the blood out of the skin and you put it into the
/SPH-R as if you were very cold you're keeping
everything going, keeping your engine going, and
consequently what makes your skin red at that time is
that there's actually blood going through your skin,
you're seeing the results of your blood going thru your
skin when something is red, so when she shuts down, her
circulating system, septic shock, all of that blood can
drain away it appears to be red can be much less red
when that patient is in that critically ill state.
Q. Right. And then, again, how does that reconcile
with the few hours later where it's found to be then
documented to having redness and positive drainage?
A. This is a very important clinical point here
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because we can get misled here about these things but
changes, but she that appearance her pale, multiple blue
fingertips and nose, she goes to a Gnaden Huetten
Hospital, and they start to resuscitate her.
The resuscitation gets her circulation going,
supporting her in whatever way they can. They
resuscitate her, and she sort of stabilizes so to a
level they can Medevac her to another hospital, and
another hospital, they continue to resuscitation. One
of the primary things you do when you resuscitate state
a person like this besides giving oxygen is to make sure
circulation fills out their body again. And you do that
by putting more fluids in the body.
The word resuscitate, they kind of, come
back from this pale blue state to a pinker state, and
the pink state is associated with the appearance of some
of these clinical signs, like the arithema, and there's
evidence in, clinical evidence, as this process you can
always watch this process go on as you follow the chart
reporting of a patient is actually resuscitated.
So this is how we explain the less redness
when the patient is basically in septic shock, and then
it reappears when the patient is being resuscitated.
These are important clinical science that we watch when
we're treating patients with sepsis.
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Q. And also on that point, were you here, were you
in court to hear the testimony this morning where Mr.
Laughlin pointed out in the morning when Ms. Yurchak was
there, there was a normal temperature. Then, as you got
-- later in the day, on the 15th, the temperature went
up. Did you hear that?
A. I did.
Q. Well then, why is it -- why then isn't it so that
this infection couldn't have been on the 13th if the
temperature was normal on the morning of the 15th and
then got worse on the 15th? How do you reconcile those
things as an infectious disease specialist?
A. Again, it has to do with the clinical condition.
When a patient is in the state that Ms. Smoyer was --
clinically, on the morning of the 15th, she would have
felt cold, not warm because she had shut down the body
barely keeping going at that particular point, unable
because of her critically ill state to even make a
fever. This is an aspect of sepsis.
Again, as you resuscitate a patient, they're
able to bring back that response that they had. This is
a natural response when you or I have an infection, we
get a fever, but if you were very, very severely ill, we
would not be able to maintain a fever. What you see in
the reports is the tempore of time of day, hour by hour
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changes, she's sort of resuscitating and getting her
reaction back to her infection.
Q. Well, Ms. Smoyer -- I misspoke a moment ago --
Sharlee Smoyer didn't have a fever when Ms. Yurchak was
in her home on the 13th, why does that not mean well she
must not have had an infection if she didn't have a
fever?
A. Again in detail here, on the 13th she had an
infection what would be considered the beginning of
infection at a line site, but she was immunosuppressed
by the presence of medications at that particular time,
which was steroids, which if patients take steroids,
they can mask a fever and that -- it is complicated.
It's a different clinical condition on the 13th then it
is on morning of the 13th, and the afternoon of the
13th. On the 13th, it's the beginning of the infection
and she's not generating that level of fever because
she's suppressed by steroids.
Q. A few other points. If we can pull up Bates
19056. This is from plaintiff's 12. This is a day or
so after the note from the gastroenterologist when there
was an opening of the fistula. Just to reorient you to
the point where I am in this medical record, okay?
Okay, Dr. Poznansky?
A. Yes, okay.
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Q. It indicates, there's a question asked by the
caregivers whether this mid abdominal fistula was
present on admission; do you see that?
A. Yes.
Q. What is recorded by the medical providers?
A. No.
Q. It has date of onset, 10-30; right?
A. Correct.
Q. The record that I showed you earlier will speak
for itself as to what date it was when the fistula
actually opened in the records, but is there any
evidence in the chart as of the end of October here
2008, that the medical providers at Lehigh Valley
Hospital were treating a sepsis in connection with the
lower extremity problems that they believed in any way
was associated with this -- a Crohn's fistula infection
that went to the blood?
A. No.
Q. And did -- I know you told the jury how sick Ms.
Smoyer was on the 15th of October, were the organisms
that I had marked on the plaintiff's 10, were those
organisms, the Klebsiella and the enterobacter, did they
respond? Did they resolve with the administration of
gram-negative rod antibiotics?
A. They did.
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Q. Was the line removed on the 15th?
A. Yes. It was removed on the afternoon of the
15th.
Q. I want to get to that in one second, but I'm
coming to the end. Now, in terms of this infection
being a catheter-related bloodstream infection, which I
know we talked about as being your opinion. Given that
the results of the cultures of the catheter tip and the
culture of the blood -- and I know we've gone over this
a little bit -- they have 2 different words on the
culture results, Klebsiella and enterobacter. How is it
then that you can say that this was a catheter-related
blood infection? Don't they always have to match up?
The same organism in the catheter? Different organism
in the blood?
A. The answer to that is based on the actual
clinical presentation and this case, the explanation for
the difference is the use of the antibiotic prior to the
blood cultures and the catheter tip being sampled.
Q. It appears later on in the hospitalization
towards the end of October -- and I'm trying to avoid
putting on more records up because I'm trying to move
through it -- do you see there being a reference to it
being a serratia related sepsis? And I could put the
record up for you.
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A. You know, in my recollection, that does -- it
rings a bell in amongst all of the charts.
Q. Let me put it up. 04184. Just so there's no
confusion. 04184. The very top, and this is towards
the end of the hospitalization. Just so -- before I get
there -- the dates of the amputation; 11-4-08, finger;
11-7-08, right foot, lower leg; 11-10, this is just for
the sake of going a little bit faster. I'll represent
that these are the dates of the amputations in the
records; okay, sir?
A. Yes.
BY MR. CASEY:
Q. Left foot, lower leg, and this we marked as
plaintiff's 11, November 4th, November 7th and
November 10th. Toward the end of the hospitalization,
there are records now reflecting back to what had
transpired to the whole hospitalization, and they say,
status quo septic shock secondary to serratia septicemia
resolved; right?
A. Correct.
Q. Is serratia in the same family as Klebsiella and
enterobacter?
A. It is a gram-negative organism.
Q. And are there references throughout the record
before this to gram-negative sepsis?
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A. There are.
Q. Okay. And is there any indication in the records
as to -- well, was there any serratia found in any of
the cultures?
A. No. I reviewed the microbiology that was sent to
me, and I could not find the serratia in the culture.
Q. But again, nonetheless, is there -- serratia and
Klebsiella and enterobacter all part of the -- they have
in the other -- P10 -- gram-negative rods?
A. They are.
Q. The last point I wanted to make with you, Dr.
Poznansky, is I stopped you earlier. You were going to
come down and draw something, and I don't -- I think I
interrupted you, but going back to this October 13th,
2008, and October 15th, 2008, is there any way that you
can describe, using your assessment of the progression
of this infection, how it started and how it got into
the bloodstream that you think might be helpful to the
jury?
A. Yes. I could do quite a simple diagram.
Q. Sure. Go ahead.
MR. CASEY: Your Honor, may I -- may I --
THE COURT: You can do it, but it's the same
thing. My stenographer has to be able to hear him or
else he goes right back on the stand.
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MR. POZNANSKY: I'll do my best.
MR. CASEY: May I move this over here?
MS. LEVIN: Your Honor, may I approach the
witness with some markers?
THE COURT: Yes. That's fine.
MR. CASEY: And just speak up, Dr.
Poznansky, if you can.
MR. POZNANSKY: Okay. I have to do 2
pictures.
MR. CASEY: Speak up just like that.
MR. POZNANSKY: I have to draw two pictures
to explain this process by which the line got infected.
First of all, I'm just going to draw a body. That's the
neck, chest, arms abdomen, legs will be down here. This
is the form of a human. The head is off the top and the
hands and so forth. We're talking about the chest and
the abdomen. The Hickman line entry site is around
about there, approximately. That's where the Hickman
catheter line goes into the skin, thru the tissues
underneath the skin, into a blood vessel and then traps
the plastic tube along the blood vessel until it reaches
the superior vena cava, which is a one of the big
vessels draining blood. I'm going to put left and
right.
On the left side, this is where the Hickman
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line enters the left chest. It's a plastic tube. It
goes through the chest wall, thru the skin and the
tissue underneath it thru towards and into a blood
vessel that out into the arm. It's fed into that vessel
and fed down, and I could sort of drop it down just into
a vessel, but running right inside you, a big vessel. A
big vein. And it's sitting there. The plastic is
sitting there in the flow of blood flowing process.
This is what you see on the skit. It's a
hole with a plastic tube, and then you got, like in the
model, tubing around here, tape down, so forth. This is
going inside to your blood vessel system from the
outside sticking to the outside of your skin. Below
that on the abdomen -- the abdomen is actually correctly
called the biliary tube -- which is the place where the
bowel is brought out of the skin, the whole bowel, the
whole tubing of the bowel comes out there, and it's
sitting there with a bag over it -- and I'll just draw
around it like that. They are proximal to each other on
the same side of the body, so I have to draw that first.
BY MR. CASEY:
Q. What does the word proximal mean?
A. That's close to each other. And in fact, as you
can see on this one, the tubing can come down quite a
bit. You know, bacteria can stick to the tubing --
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they'll grow on whatever is out there. So that's
looking at the patient. What I'm going to do, and I
hope you can go with me on this. I am going to make a
section into this body thru both the catheter line and
the line, the ileotomy side.
So, I'm going to show you what that looks
like, and I'm going to rotate this so the person's lying
on their back. So, you have here, I'm going to draw the
skin first, and I'm going to give it some sort of
thickness because skin actually does have thickness.
MR. CASEY: Dr. Poznansky, I'm just trying
to make sure that everybody can see, and I know that
it's difficult, but is there any way, that in addition
to keeping your voice up high, just to try to stand
back, and do your best.
MR. POZNANSKY: I'm drawing the layer of
skin now that is penetrated by both the Hickman catheter
and by the ileostomy. Now, I'm going to put (I( for
ileostomy. Basically, you have bowels -- this is coming
down, and then that would control the bowel if you
imagine, like that, and this is where your bowel motion
comes out, like that into a bag. There's a sort of
sealant and a bag over it. And it collects in the bag.
We're looking at the patient laying flat here.
Now, here, on this side where there's the
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Hickman, is a break in the skin, and there's actually a
tunnel, sort of a channel, that has been artificially
created going through the skin and popping into a blood
vessel. So, I'm going to a blood vessel and sort of
taking the blood vessel with a tube and cut it down
here, and the tube actually sits in that canal like
this. These 2 lines are the Hickman catheter. This is
the channel which consists of human tissue thru which
that line goes and it sort of leaks off, and if you
imagine, this vessel is going -- this tubing loops down
to the correct vessel.
So you have 2 breaches of the skin.
Effectively, effectively, this is what could be called,
it's a medically induced enterocutaneous fistula. It's
therapeutic. It's draining bowel motions into the bag.
It goes from the bowel to the skin. And then, next to
it, you actually got a vascular cutaneous fistula going
from the skin to the blood supply.
BY MR. CASEY:
Q. What is a fistula?
A. A fistula is an abnormal trap. They don't occur
cur in naturally, healthy people. So, you already have
2 sites that are abnormal break in what I described
before as your main defense system, which is your skin.
You got holes in your skin. One with bowel coming thru
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it and one with a tube going through it, and what I'm
talking about, Mr. Casey, is how does this interact with
each other?
You got 2 breaks next to each other into a
major organ system. One into the bowel and one into the
major blood vessel. And what I'm saying, I'm drawing
this as dots, and I'm not drawing many dots. I'm
drawing dots, and what bacteria, if we could see them as
dots, would appear like on the skin. Scattered across
the skin.
They exist on you. They exist on me. They
exist on Ms. Smoyer, but because of the proximity of the
bowels, that this bacteria would -- because of the fact
you have bowels coming up -- it is not normal for the
front of your abdomen. And although this distance here
looks sort of large for us maybe, or maybe it looks
large for a tiny, minute bacteria, it's not very far.
Bacteria transfer across distances -- you wouldn't
believe how they're transferred. They're transferred
with a finger, and maybe and just by chance here, there
would be a bacteria there.
THE COURT: Excuse me. I need to remind the
witness that you are talking 360 degrees, okay?
MR. POZNANSKY: Okay. Sorry.
THE COURT: We need you to talk 360 degrees.
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MR. POZNANSKY: But the point about transfer
of bacteria, it's a very well-established component for
our understanding of how bacteria exists. They exist at
one site. They multiple at that site and they spread by
contact. They actually -- some of them -- bacteria have
little things that make them move as well, and what I'm
saying is eventually, they get into this site. It's not
a stretch of the imagination that there's 2 big defects
in your skin, that that could happen.
BY MR. CASEY:
Q. Well, setting aside whether it's a stretch of the
imagination, is it -- do you have -- can you explain
your opinion here that you've given that the culture
results and the organisms found resulted from this
interplay?
A. Yes. So, the bacteria that would be rarely but
present scattered around the ileostomy side would be
gram-negative rods that we're talking about, Klebsiella
an enterobacter, as part of what would exist of stool
coming out of here and of presentation of contamination
of the skin that is unavoidable in the context of the
ileostomy and then tracking to this place. Now this, as
you remember, I mentioned that the tubing drapes down.
Let's say the tubing drapes a little closer, and there
was maybe the port at the end, which is where you
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actually inject things into it.
Bacteria live on plastic. As I mentioned,
Klebsiella, you found them on the tip of the catheter.
That's because they actually live on plastic. So this
represents another risk. Even if you have this taped
down, you know, with tape the way that Ms. Yurchak
showed, you know, she taped down. It's now closer to
the skin. So, this is why this particular -- coming
back to the causation -- this catheter site was at high
risk for infection and vigilance was required to watch
that like a hawk because of that.
MR. CASEY: I'll move to strike that last
sentence, Your Honor.
THE COURT: I take it you have no opposition
to that.
MR. LAUGHLIN: No.
BY MR. CASEY:
Q. I just want you to stay focused on -- is there
anything else from the causation point of view you want
to add?
A. Just one thing. The first sign that bacteria
were invading is that this skin around here gets
inflamed, that's your alarm that something has happened
here with regards to infection, and this is the
beginning of the first -- that ultimately led the
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bacteria trapping down into the blood system colonizing
the, or living on the plastic and appearing in the
bloodstream, ultimately, being the sepsis.
Q. One question before you go. I'm pointing to this
circle that you have under the h, is that actually the
bloodstream?
A. That is the bloodstream. These vessels are big,
and the lumen of the catheter is small compared to the
vessel. It's actually in the bloodstream itself.
Q. Thank you, Dr. Poznansky. I'll mark Dr.
Poznansky's 2 diagrams as plaintiff's 13 and plaintiff
plaintiff's 14. Dr. Poznansky, have all your opinions
today been stated with a reasonable degree of medical
certainty?
A. They have.
MR. CASEY: Cross-examine.
* * *
CROSS-EXAMINATION
BY MR. LAUGHLIN:
Q. Good afternoon, Doctor.
A. Good afternoon.
Q. First of all with regard to the serratia that was
mentioned, you acknowledge that although it looks like
some of the doctors were referring to serratia, there
was no serratia, correct?
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A. From my review of microbiology reports that I
saw, there was no mention of positive serratia culture.
Q. When you say the microbiology records, you're
talking about the culture from the lab, correct?
A. Exactly.
Q. And serratia, it's not just a name, it's an
actual organism?
A. It is.
Q. So, when you're talking about various different
organisms, they're not just names. They are actually
different organisms, correct?
A. Correct.
Q. Such as the Klebsiella?
A. Correct.
Q. Such as the enterobacter?
A. Correct.
Q. And serratia, all three are different organisms,
correct?
A. Correct.
Q. They may be gram-negative rods, but they are
indeed different?
A. Correct.
Q. So to the extent they were mentioned by some of
the doctors in terms of the serratia -- well, let me
back up -- in terms of identifying organisms, the way
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that they are identified is thru culture, correct?
A. Correct.
Q. And that's how they were identified in this
hospitalization, correct?
A. Correct.
Q. There was no other means for them to identify
organisms other than the cultures, correct?
A. Correct.
Q. So in terms of the reference to serratia you
would acknowledge there were doctors during the
hospitalization who were, perhaps, loosely and
incorrectly characterizing the organisms involved
correct?
A. You used the terms doctors. I'm not sure that it
was more than one doctor.
Q. Well, somebody was, correct?
A. Somebody was.
Q. And you don't know who it was?
A. No.
Q. It was typed in one of the -- can you put up
4184, please Mr. Heilman? Serratia discipline ID; what
does ID stand for?
A. Infectious disease.
Q. Does this appear to be an infectious disease
note?
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A. It does.
Q. It appears likely to -- it's not in the nurses
notes; correct?
A. Correct.
Q. Progress record is where physicians document,
correct?
A. Correct.
Q. Do you find that that happens from time to time
in records that you review? Have you ever seen that
before?
THE COURT: Perhaps, you've seen what
before?
MR. LAUGHLIN: Yes, I apologize.
BY MR. LAUGHLIN:
Q. Have you, in records that you reviewed before,
seen physicians reference perhaps using a term
incorrectly, in terms of labeling an organism?
A. I've seen it once before on a dictated note where
one could think that maybe the dictation machine or
whatever had interpreted the word incorrectly.
Q. It's possible that somebody could be thinking one
thing and saying another thing and writing another thing
correct?
A. Correct in this case.
Q. Now, getting back to the blood work. So we were
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talking about cultures, and the way you identify the
bacteria, specific organisms, is through cultures,
correct?
A. Correct.
Q. And there are -- in this case, we've done blood
cultures but there are also catheter cultures, correct?
A. Correct.
Q. In terms of the lab at Lehigh Valley Hospital, by
looking at the lab records, were you able to determine
the type of culture that was performed on the catheter?
A. Yes. It was a catheter tip culture.
Q. Right. In terms of the method, the method they
used, was the semiquantitative catheter culture;
correct?
A. I'm not sure of that, no.
Q. Are you familiar with the semiquantitative
culture method?
A. I'm familiar with the particular method they use
in my hospital.
Q. Do they use that method?
A. I don't know whether they define it in exactly
the same.
Q. Let me ask you this question, as I -- did you
notice how when ever they were testing a catheter in the
hospital they distinguished as to whether it was greater
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than 15 colonies to one unit?
A. I did.
Q. Is that done at your hospital?
A. It is, and it is greater than a 150 or greater
than 300, it's also noted in our hospital.
Q. Okay, but in -- are you familiar with the method
that the delineation of greater than 15 colonies forming
unit is the delineation that separates colonization with
organisms from what would be less and presumed to be
perhaps contamination upon removal of the catheter?
A. No.
Q. You're not familiar with that?
A. I'm familiar in terms of the distinction between
contamination and colonization or infection of the
catheter by the fact that the colonies themselves are
much fewer than that, one colony, 2 colonies, maybe at
the most, 2 colonies, but often just one colloquy, and
then the species of the colony being a very specific
type of bacteria that lives on the skin is that is very
very rarely pathogenic or the cause of disease.
So, in fact there is a report, there is one
biological report in this whole record where they
identified hysteroids, which is another type of bacteria
on the line tip, but they consider it to be a
contaminate rather than an infection. That's because
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hysteroids are red and pathogenic all cause disease in
that particular setting. So, finding 15 colonies of
Klebsiella on the culture tip, which would be the tip,
right down there in the superior vena cava is a
significant finding clinically.
Q. When they found the 15th culture they went onto
type it and determined it was Klebsiella correct?
A. Correct and due to the sensitivities on that.
Q. Okay. In terms of what was evaluated there, the
Klebsiella was -- when they did the culture -- if we can
put up 18531, please. This is the culture results from
the catheter, correct?
A. Correct.
Q. Klebsiella pneumoniae, correct?
A. Greater than 15 colonies.
Q. And that was the significant number such that, it
was then characterized further and determined to be a
Klebsiella, correct?
A. Correct.
Q. There were no other organisms that were
identified in that culture, correct?
A. That is correct.
Q. So, the only the only organism identified on the
catheter was Klebsiella, correct?
A. Correct.
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Q. Now, this culture was done and the results were
final on October 17th, correct?
A. Yes, correct.
Q. In terms of this culture, this culture does not
demonstrate the presence of enterobacter?
A. That is correct.
Q. The blood was cultured twice, correct? Let me --
On the 15th?
A. Yes.
Q. And that is standard protocol?
A. Correct.
Q. You draw 2 samples to compare them, correct?
A. Correct.
Q. And Mr. Heilman, if we can have 18528? We have a
time here 1330, correct?
A. Correct.
Q. On October 15th?
A. Yes.
Q. One of the blood draws was at that time, correct?
A. Correct.
Q. And just -- we'll come back to that, Mr. Heilman.
If we go below, there was another draw previously
basically, 13 and 3 correct?
A. Correct and reported final on the 19th.
Q. Exactly. So, I think there was some questions
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before as to the information available on the 18th, and
I think you had indicated that all the information was
available, you will agree that this information was not
final until the 19th, correct?
A. Correct.
Q. So, it may not have been this information was
available on the 18th, correct?
A. Correct.
Q. In reality, in terms of the culture of the blood,
it came back with enterobacter, correct?
A. Correct. Can I clarify one thing because a
preliminary report would have been issued before the
19th, which we're not privy to because these things are
changed and updated, but the preliminary report may have
reported enterobacter without those certainties yet.
Q. Well, we have gram negative rods results
previously, so it could have been also that they just
simply said gram-negative rods, correct?
A. It's possible.
Q. So you don't know, correct?
A. No.
Q. So, that information is not something which you
can bring to bear here, correct?
A. That's correct. In my experience of seeing
multiple microbiological reports, you can get a species
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announced before you get anything else in the sense to
make it final.
Q. Did you see anything in the records indicating
that anybody was aware it was enterobacter prior to the
19th?
A. I do not recall.
Q. Specifically, if we could go to -- Mr. Casey
walked thru a number of the notes with ID. Let's show
another one from October 20th, 04049. This is from
October 20th, correct? It's a little small.
A. Yeah, I see it. That's correct.
Q. So this is the day after the final results,
correct?
A. Correct.
Q. And without going through what you went thru on
direct, now we have under ID positive Klebsiella on
catheter -- CX, is that culture?
A. Culture, yes.
Q. Now they're distinguishing positive enterobacter
in the blood cultures, correct?
A. Correct.
Q. Just if we could going forward, 4106. We have
another one of these notes. This is later in the week,
a week later, October 20th, to be exact. If we could
move down. We have ID. Does that appear to say
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enterobacter sepsis?
A. It does.
Q. So again, are you aware of anything in here that
indicated knowledge of enterobacter in the blood culture
prior to the 19th, specifically?
A. Not that I can recall. Can I clarify one point?
Because all of these culture were drawn at the same
time, and they were all processed, and some of their
speciation or the determination of the species, can take
different lengths of time for different species. So,
it's a technical process.
Q. Sure. But that's what we have in terms of the
timing, correct?
A. Correct, and they're all gram-negative organisms.
Q. But different?
A. Different species, yes.
Q. Different organisms?
A. Different species.
Q. When we talked about it before, when I asked you
about serratia and enterobacter and the klebsiella, I
asked you if they were different organisms, and you said
yes. Were you wrong?
A. I would like to clarify that the first name
serratia, is the family name, and we don't know what the
species name is. So it's just listed as serratia in
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that particular -- here, we do know enterobacter, so we
do know what the species is.
Q. And we know Klebsiella pneumoniae, and they are
different species, correct?
A. They're different species, that's right.
Q. So, just to be sure, Klebsiella and enterobacter
are not the same?
A. Not the same species.
Q. In terms of the culture, and again, if we could
go back to 18528, Mr. Heilman? In both of the results
from the blood cultures, the one at 1303 the culture
result was enterobacter, and the culture result from
1330 above, enterobacter, correct?
A. Correct.
Q. There were no other organisms or species
identified in the blood culture, correct?
A. There was no --
THE COURT: I'm sorry, I couldn't hear. Can
you repeat your answer?
MR. POZNANSKY: Yes. Can you repeat the
question?
BY MR. LAUGHLIN:
Q. There was no Klebsiella in the blood culture
results from the blood at 1303?
A. That is correct.
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Q. And there was no Klebsiella from the 1330 one?
A. That's correct. The --
Q. These cultures --
MR. CASEY: Objection, Your Honor. He was
explaining --
MR. POZNANSKY: I just wanted to explain
that the catheter tip is sitting in the blood. So, the
bacteria of -- sitting on the catheter -- but they are
-- they have the capability of moving on and off that
catheter, and as we explained before, the single dose of
Cephalosporin could have been given, it would have
killed the Klebsiella in the hospital. If you take
blood out of a patient that has an antibiotic in it that
is capable of killing a specific bacteria, you will not
be able to grow it.
BY MR. LAUGHLIN:
Q. In terms of what was put up there, you will
acknowledge that you can have a colonized catheter that
does not involve and is not associated with or cause a
bloodstream infection, correct?
A. In this particular case, I don't think that that
is the case.
Q. Sir, I'm asking you in general, will you
acknowledge that you can have a colonized catheter that
does not cause a bloodstream infection?
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A. That's correct.
Q. So, you can have -- without or without
antibiotics given -- you can have a catheter that's
cultured and positive that grows out of bacteria and no
infection in the blood whatsoever, correct?
A. That is correct.
Q. In terms of -- you have talked about the bacteria
and the different multiple types, have you -- are you
familiar with studies and definitions of catheter
related bloodstream infections that have defined it as
identifying the same organism in the blood and in the
catheter?
A. It is defined in general, but not for the
specific case.
Q. I understand we're here for this specific case,
but do you agree that the definition of a
catheter-related bloodstream infection involves the
identification of the same organism in the blood and in
the catheter?
A. No. The term definition, I'm not comfortable
with a greater definition. I think I'm comfortable with
the term guideline.
Q. Criteria?
A. Not criteria. Guideline.
Q. You have indicated that you have published
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materials, correct?
A. Correct.
Q. When you review some of the literature and
whatnot, what do you review? What types of journals do
you review to keep up with the literature?
MR. CASEY: Objection, Your Honor.
THE COURT: Sustained.
BY MR. CASEY:
Q. Are you familiar with the New England Journal of
Medicine?
A. Yes.
Q. Do you read that from time to time?
A. Yes.
Q. Is it one of the more respective journals around?
A. It is.
Q. Have you published in it?
A. A letter, yes.
Q. Do you consider it one of the standard journals
that many physicians will refer to from time to time?
A. Yes.
Q. In connection with this case, have you ever
looked to see if, in the New England Journal of
Medicine, if there has ever been a definition of
catheter-related sepsis?
MR. CASEY: Objection, Your Honor.
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THE COURT: Grounds and one word.
MR. CASEY: If he's ever looked to see
whether there's --
THE COURT: Objection sustained to the form
of the question.
BY MR. LAUGHLIN:
Q. Did you perform any research in the connection
with preparing this report?
A. I had previously looked at guidelines CDC
guidelines on catheter line related infections.
Q. All right. You didn't mention them in your
report did you?
A. No.
Q. You wrote 2 reports in this case, correct?
A. Correct.
Q. You didn't mention them in the first report?
A. No.
Q. Didn't mention them in the second report?
A. No.
Q. When were those guidelines prepared? Do they go
back to 2001?
A. 2002, I think.
Q. 2002?
A. But these are guidelines not defined for this
specific case.
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Q. Did the guidelines in the CDC going back to 2002,
basically include a definition of catheter related
bloodstream infections as being bacteria in a patient
with an intravascular catheter with at least one
positive blood culture obtained from a peripheral vein
clinical manifestations of infection and no apparent
source from the bloodstream infection except the
catheter. That's part of it. Does that sound familiar?
A. That sounds familiar.
Q. Beyond that, one of the following should be
present positive semiquantitative, meaning, greater than
15 colonies forming a unit or quantitative greater than
10 colonies for a unit culture whereby the name
organisms, species and anti diagram is isolated from the
catheter segment and peripheral blood; does that sound
familiar?
A. It sounds familiar, but it doesn't include this
prior use of antibiotics.
Q. I understand your position, sir, but is that the
guideline that you referenced that you reviewed in
connection with your preparation of this case?
A. Yes.
Q. Is that the guideline that you elected not to put
in either of your reports?
A. No. I looked at the guidelines after I had
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written the reports.
Q. The first report?
A. The second report.
Q. I see. So, before you wrote your second report,
you had looked at Dr. Nieman's report; correct?
A. That is correct.
Q. You were asked about Dr. Nieman's report,
correct?
A. Is that correct.
Q. Dr. Nieman, his opinion in this case, is that
this was not catheter related bloodstream infection in
part because there was not the isolation of the same
organism in both the catheter and the bloodstream,
correct?
A. Can I have his report?
Q. Well, do you now not -- let me ask you this --
MR. CASEY: Your Honor, he asked for his
report.
THE COURT: Yes.
MR. LAUGHLIN: I thought he remembered it on
direct, but I will --
BY MR. LAUGHLIN:
Q. Let me first ask, do you have that recollection
or no?
THE COURT: He's asked to see the report.
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MR. LAUGHLIN: Okay.
BY MR. LAUGHLIN:
Q. Did you have a chance to look at that?
A. I'm reading Dr. Nieman's writing on the subject
of the Hickman catheter was removed and the tip of the
catheter intra Klebsiella an entirely different
organism.
Q. And you see he criticized your report for
ignoring the distinction?
A. Enterobacter cannot be in any way shape or form
be ascribed to the presence of Klebsiella on a Hickman
catheter tip.
Q. What he's focusing on there clearly, is the
distinction between the enterobacter and the Klebsiella
insofar as they are not both found in the bloodstream,
correct?
A. Well it's the relationship between the presence
of the enterobacter in the blood cannot be ascribed to
the presence of the klebsiella on the Hickman catheter.
That's different --
Q. He will describe what he means by that, but --
MR. CASEY: Objection, Your Honor.
THE COURT: Objection sustained.
MR. CASEY: Can he finish his answer?
MR. LAUGHLIN: Sure. Sure.
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MR. POZNANSKY: I mean that's -- what you
asked me, I didn't completely understand in relation to
what Dr. Nieman had written.
BY MR. LAUGHLIN:
Q. All right. So after -- he did indicate that you
essentially did not address the distinction in the
bacteria, correct?
A. Well, he's describing a relationship between
enterobacter and Klebsiella.
Q. I'll ask a new question. So, after you looked at
Dr. Nieman's report, you did not go and review any of
the literature concerning the guidelines and the
identification of catheter related bloodstream
infection, correct?
A. Because of the specifics of this case.
Q. But after you wrote your report, you -- I take it
you then went to check and see what the CDC Guidelines
indicated, correct?
A. Correct.
Q. And we discussed what that is?
A. Correct.
Q. You did not write a third report, you've only
written 2 reports correct?
A. Correct.
Q. In addition to that, in terms of -- I think I
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mentioned the New England Journal of Medicine -- may I
approach Your Honor?
MR. CASEY: Your Honor I don't -- objection
as to foundation.
THE COURT: I think it's permissible for him
to hand him the document, and let him see it and we'll.
MR. CASEY: I understand, Your Honor.
BY MR. LAUGHLIN:
Q. By the way, Doctor, a few minute ago, before we
-- you had mentioned you looked at the CDC Guidelines?
A. Yes.
Q. Before we talked about the CDC Guidelines, I had
asked you about the New England Journal of Medicine,
correct?
A. Correct.
Q. And you had acknowledged that you published in
it?
A. Yes.
Q. And you had acknowledged that it was a standard
work in the medical field, correct?
A. In the medical journals, yes.
Q. Yes. I've handed you the CDC Guidelines for the
ones you looked at were 2002. We already discussed
this. This is an article in the New England Journal of
Medicine --
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THE COURT: No. No.
MR. CASEY: Objection, Your Honor.
BY MR. LAUGHLIN:
Q. Let me ask this, are you aware -- we talked about
a definition. Are you aware of a definition of catheter
--
MR. CASEY: Objection, Your Honor. He's
reading.
THE COURT: The objection is sustained to
the form of the question.
BY MR. LAUGHLIN:
Q. Doctor, before, when we were discussing, and I
asked you whether the definition involved, with catheter
related bloodstream infections, involved the same
organisms in both?
A. I had talked about that I had not seen
definitions. I had seen guidelines.
Q. Right, and -- but you're familiar with the New
England Journal of Medicine text?
A. It's a standard medical journal.
Q. It's a journal not a textbook. Would you look,
sir, at page 1306 of that? Is there a section,
definitions?
A. There is.
Q. Does it include, in the New England Journal of
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Medicine, a definition of catheter related septicemia?
A. It does.
Q. Is it labeled definition?
A. It's labeled definitions.
Q. Does the definition indicate isolation of the
same organism from a catheter and from blood clinical or
autopsy and microbiological data disclosing no other
source of the septicemia and clinical features of
bloodstream infections?
A. It does. It was a definition published from
1977. That explains the situation in the 70s.
Q. And the guidelines from the CDC that we already
discussed, that talked about isolated the same organisms
addresses the situation in the 2000s, correct?
A. In the 2000s, but not in this specific case.
Q. I understand your position, sir. In this case --
MR. CASEY: Objection. Move to strike the
commentary about, I understand your --
THE COURT: Yes. That's stricken.
BY MR. LAUGHLIN:
Q. In terms of -- we have in your diagram here, you
reference that the ileostomy and the Hickman were sort
of like manmade enterocutaneous fistulas, correct?
A. Correct.
Q. There are also biological enterocutaneous
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fistulas as well, correct?
A. Correct. Could I just correct one thing?
Q. Yes.
A. The Hickman line is a vascular cutaneous.
Q. Okay. You did say that. Point taken. In terms,
however, you can have -- a patient can have fistulas
within the abdomen, correct?
A. Correct.
Q. And in addition to enterocutaneous fistulas,
which could be a fistula come from the bowel and then
exit to the skin, there are other fistulas that don't
necessarily exit through the skin, correct?
A. Correct.
Q. At some point, I think you indicated, burrowing,
you have can have a fistula that sort of opens up and
burrows, and it takes awhile to burrow to the skin,
correct?
A. Correct.
Q. And you can have other fistulas that go elsewhere
to other organs, correct?
A. Correct.
Q. Fistulas can be a source and lead to abdominal
infections, correct?
A. Correct.
Q. Abscesses, correct?
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A. Correct.
Q. Sepsis?
A. Correct.
Q. In the present case, you said you reviewed
records going back well before October of 2008, correct?
A. Correct.
Q. In terms of your report, it appears only that you
mentioned -- let me ask you this, do you recall
referencing any records or discussing history going back
before August 28th of 2008?
A. I talked about past medical history of a patient,
but I, you know, again, I don't remember my report
verbatim.
Q. Do you have a copy of it there?
A. I don't.
MR. CASEY: I think he just has the second
report.
MR. LAUGHLIN: May I approach, Your Honor?
MR. POZNANSKY: Thank you.
MR. LAUGHLIN: You're welcome.
MR. POZNANSKY: Yes. I referred to the past
medical history significant for Crohn's Disease.
BY MR. LAUGHLIN:
Q. That's in the first paragraph?
A. That's correct.
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Q. You said she'd been treated and, you know, you
referenced, August. Did you reference any of her past
problems with fistula?
A. I didn't because I didn't feel it was relevant to
this specific presentation of this patient. On the
period between the 9th, between the first of October and
the 9th, both small bowel follow thru and knows that,
documented that stabilization of the patient's Crohn's
Disease, and subsequently after that, up until the 30th
of October, which was 2-weeks or more past, the acute
septic event that there had not been an issue with, an
acute issue with the Crohn's Disease, that seems that
you could attribute sepsis too.
Q. The report you were shown on direct referenced
Crohn's Disease stable was dated October 29th; do you
recall that?
A. Yes.
Q. It was the very next day, the 30th, that that
fistula came out of the skin, correct?
A. That is correct, but otherwise, the patient had
also been stable.
Q. But we know the fistula broke through the skin as
of the 30th?
A. Correct.
Q. Now, if we could -- bear with me please, for a
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moment -- go back as early as March, she had problems
with abscesses and fistula, correct?
A. Correct.
Q. She had had an operative procedure, correct?
A. Correct.
Q. In the discharge from that hospitalization, do
you recall -- and we can put it up if need be -- she had
both abscesses and fistula?
A. Correct.
Q. And if we can, Mr. Heilman, put up 4853, she had
-- these are cultures that were done back at the time of
surgery, correct?
A. Correct.
Q. And she had enterobacter and Klebsiella during
the time of that March hospitalization, correct?
MR. CASEY: Objection, Your Honor. Are
these blood cultures?
THE COURT: Just don't answer the question
yet. There's an objection, and I don't understand the
objection.
MR. CASEY: It just -- objection misleading,
Your Honor. I'll withdraw it. I'll withdraw it.
THE COURT: All right. You can answer the
question.
MR. POZNANSKY: I'm aware that both cultures
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of abscess material and intracutaneous fistula were done
March, April of 2008. I'm not sure which ones these are
whether they are the intracutaneous fistula leakage, or
when they go in and they take out a sample.
BY MR. LAUGHLIN:
Q. But just to be clear, we're not talking about
blood cultures here. We're talking about leakage from
the abdominal cavity, correct?
A. Correct. Intracutaneous fistula or they do
surgery, and they have to take abscess materials. Those
are two different things.
Q. Can we go back one page, Mr. Heilman? This is an
earlier page abdomen incision and surgical site wound
culture, correct?
A. Right. I'm not sure that this is evident of this
occurring in March or April, but the period that we were
focusing on was around the time of October.
Q. Okay. I'm asking you now to move back a little
bit with me, okay?
A. I understand.
Q. So, we do have -- she's had a history -- she had
an incision. Does it refresh your recollection that
there was some drainage from her incision during that
period of time?
A. Yes.
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Q. She had a intracutaneous fistula, correct?
A. Correct.
Q. And we know that the drainage cultured positive
for Klebsiella and on the next page enterobacter,
correct?
A. That's right. On 2 occasions, the enterobacter
and Klebsiella from the stool that was coming out of the
fistula and from the abdominal contents. Those
organisms were together.
Q. That occurred in April as well, correct?
A. Yes.
Q. In June, this intracutaneous fistula recurred,
correct? Or persisted? Do you recall?
A. I don't recall whether it persisted.
Q. That's okay. Let me, Mr. Heilman -- do you see
that up there?
A. I do see it. It says areas and intracutaneous
draining stool.
Q. Okay. Thank you. Are you aware in July -- let's
put 11708, please. This is the report of a CT?
A. Yes.
Q. Reflects inter-abdominal wall abscess?
A. Correct.
Q. She's continuing to have problems with
infections, correct?
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A. Yes. At this time she has active Crohn's
disease.
Q. And does it refresh your recollection -- if we
could move down, Mr. Heilman -- intracutaneous fistula
appears slightly smaller in caliber compared to prior
exam. It's still there, correct?
A. Correct.
Q. Do you know, was it present in September as well?
The fistula -- excuse me?
A. It was resolving in September.
Q. If we could go to 4296, please? I guess -- I
apologize. We should probably go back to get the date
the page before. The page before that was
September 11th, 2008?
A. Correct.
Q. And then, Mr. Heilman, 2 pages hence, please.
Clinical oppression acute intracutaneous fistula?
A. Correct.
Q. 4298 please, Mr. Heilman. Let's go back one
page. Okay. That's okay. We have a date down here,
9-11, same hospitalization?
A. Right.
Q. And we have from her abdominal scars open and
she's drainage purulent drainage at that point, correct?
A. Correct.
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Q. Purulent drainage is that there is some
potentially infected fluid seeping through there and
coming out thru the incision, correct?
A. Correct. At that time.
Q. I believe you discussed some testimony about the
white blood count, and the white blood count up to 10.9?
A. Correct.
Q. Mr. Heilman, if you could put up 18433, please?
This is from Health Newtork Laboratories, correct?
A. Correct.
Q. You know that to be affiliated with Lehigh Valley
Hospital?
A. No.
Q. In terms of this lab record, in terms of the
range for the white blood count, the reference range of
normal goes up to 11, correct?
A. Correct.
Q. If we could go to 4840, please. This is Sacred
Heart Hospital in Allentown. Did you review those
records?
A. This is from which date?
Q. Allentown, Pennsylvania, where we are here.
THE COURT: No. He asked the date.
MR. POZNANSKY: The date?
BY MR. LAUGHLIN:
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Q. The date? I apologize --
A. No, I didn't specifically look at that.
Q. The reference range for Sacred Heart in terms of
the white blood count goes up to 11, correct?
A. Correct.
Q. Can steroids contribute to the raising of a white
blood count?
A. Yes, but only temporarily.
Q. In terms of, she was put on a new steroid
October 9th, correct?
A. Correct.
Q. Can smoking cause an elevation in white blood
count?
A. I'm not aware of that.
Q. In your report, I believe it was your initial
report, do you see on the top of page 2, your discussing
the white count? Let me know -- are you with me?
A. Yes.
Q. Top of page 2, your April 14th, report?
A. April 14th, yes, top of page 2, yes.
Q. Your referencing the lab results, correct?
A. Correct.
Q. Those are the lab results from which date that
you're referencing?
A. That was from the 10-13.
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Q. And you referenced the white count of 10.9,
correct?
A. Correct.
Q. And you also state here that there were 88%
neutrophils?
A. Correct.
Q. Segmented neutrophils?
A. I think it's segments plus bands.
Q. Do they call them segs sometimes?
A. Yes.
Q. Mr. Heilman, if we could put up 1422, please?
Segs, they're right here, correct?
A. Correct.
Q. They're not 88, correct?
A. No, but with the bands, which are the immature
form, it is 88, yes.
Q. Well, 8 here and the bands are within normal,
correct?
A. No, 42 to 75 is the range. 80 would be high.
Q. The bands, excuse me, sir?
A. Sorry. I apologize. 8 is of normal.
Q. Mr. Heilman, if we could go back to the 1416,
please?
A. Could I just clarify part of my discussion of
this?
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Q. Sure.
A. Because previously blood tests of this patient
were lower than this, and the patient did not have bands
present in her blood at that time.
Q. Okay. Well, let me ask you this though, about
the segs. This is from October 6th, correct?
A. Correct.
Q. This is -- these are the previous labs, correct?
A. Correct, with a lower white count.
Q. Right, but segs, 88, correct?
A. Correct.
Q. 88 is higher than 80, correct?
A. It is correct.
Q. So, in terms of the segs -- I know you're talking
about bands were 4 -- the bands went up, segs came down;
correct?
A. Correct.
THE COURT: May I see counsel at sidebar off
the record, please?
* * *
(Whereupon, the following discussion took
place at sidebar off the record:)
* * *
THE COURT: All right. Ladies and
gentlemen, I know it's 5:00, and I know it's Friday, but
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I would like to finish this witness up because if I let
the lawyers go home and rest, they're just going to
think up more questions. So, they promised me that it's
going to be very brief, and so we're just going to
finish up this witness, and thank you so much for your
cooperation.
MR. LAUGHLIN: Judge, as I indicated, I am
finished.
THE COURT: You are?
MR. LAUGHLIN: Yes.
THE COURT: All right. I'm not cutting you
off.
MR. LAUGHLIN: I understand.
THE COURT: I just wanted to be sure. Mr.
Casey?
MR. CASEY: Thank you, Your Honor.
* * *
REDIRECT-EXAMINATION
BY MR. CASEY:
Q. Very briefly, Dr. Poznansky, if we could put
those labs back up again. The last one on the 6th, and
the 13th, just quickly. What happened to the white
blood cell counts between the 6th and 13th?
A. It went up.
Q. From what to what?
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A. It went up from 8.5 to 10.9.
Q. And let me just see, whose lab is this? Whose
lab is doing this work at the top?
A. St. Luke's.
Q. This is St. Luke's Lab, and what's they're
reference range for the white count and their samples?
A. It's 42 to 75.
Q. On the white count?
A. Oh, on the white count, 3.9 to 9.5.
Q. So 9.5, and that's on 10-6, and the white count
was?
A. 8.5.
Q. And let's go now to the one week later on the
13th. That was normal on the 6th?
A. Correct.
Q. According to St. Luke's lab -- now, according to
St. Luke's lab on the 13th, let's look at the white
count and the reference range again. The white blood
cell count and then go over to the reference range,
please. That's fine. Thank you. Okay.
A. White count of 10.9 with a range of 3.9 to 9.5.
Q. It's still St. Luke's lab, correct?
A. Correct.
Q. Mr. Laughlin showed you records from September
and earlier actually of 2008 regarding the fistula. Can
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3
4
5
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7
8
9
10
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12
13
14
15
16
17
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19
20
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we pull up 01348. This is the small bowel series done
on October 7th, about 6 days before Ms. Yurchak was at
Ms. Smoyer's house. And can we go down to the bottom
just so we can go quickly to the impression section.
What does that say?
A. It says postsurgical changes, no fixed stricture
or filling defect seen of small bowel loops. No bowel
obstruction. No enterocutaneous fistula seen.
Q. What is a small bowel seen, very briefly?
A. A die is placed into the bowel and it runs
through the bowel and takes a of different images that
would make you able to see if there was a fistula or
adhesion or scripture or any of these things, really
what we -- by x-ray.
Q. Do you they actually look -- just drawing your
eye up to the middle -- it's actually, it's the mucosal
of the bowel, correct?
A. That's very important with Crohn's disease, that
it appears to be within normal limits.
Q. And 13864, please. This is an October 9th note
from Dr. Garcia's chart, says, she had enterocutaneous
fistulas -- and then I'm skipping ahead -- a barium
shall bowel follow thru was performed, which amazingly
shows post surgical changes, no fixed strictures or
filling defect seen, no bowel obstruction, no
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2
3
4
5
6
7
8
9
10
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12
13
14
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enterocutaneous fistulas, and what is the last sentence
in this section? I know there's more on the page.
A. She is totally healed.
Q. This note is written 4 days before October 13th?
A. Correct.
Q. May I see that 1970s article? Do you have a copy
of it?
MR. CASEY: May I approach, Your Honor?
THE COURT: Go ahead.
BY MR. CASEY:
Q. Next brief set of questions I have, doesn't have
to do with the 1970s. It has to do with some of the
medical records for Sharlee Smoyer in 2009 and 2010.
We'll start with 2008, 04243. It says from the actual
hospitalization, October, 2008, it's a radiology note,
and it says, History: Infected left tunneled infusion
catheter, right?
A. Correct.
Q. And if we can pull up 0068. This is a colon
rectum surgery note from December 29th, 2009, by a
gentleman named -- his last name is Bub. David Bub, and
I'd just like to point out, do you see in the record,
Dr. Bub associated with St. Luke's Hospital?
A. I recall the name. I can't remember the
association.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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Q. Okay. In the middle it says, he's now had the
opportunity to see Sharlee Smoyer in the office, as well
as review her operative history at Sacred Heart and
Lehigh Valley Hospitals. And page up. He says, as you
are aware, this letter says to Dr. Garcia, I have
managed her several times at St. Luke's Hospital for
recurrent parastomal abscesses. He says, toward the end
of the first paragraph, as a result -- I'm sorry. I
better back up. Referring back to the hospitalizations
where his records he reviewed, he said she required an
emergent exploration several days later for a leakage
from the small bowel repair. He's referring to the
spring of 2008. Are you with me, Doctor?
A. I am.
Q. This was re-repaired and unfortunately the
patient went on to develop an enterocutaneous fistula.
This was treated non-operatively, and the patient was
managed with TPN. And then, here's the next sentence.
As a result of the long indwelling catheter, she
developed a line sepsis and was admitted to the Lehigh
Valley Hospital. Due to the severe nature of this
episode she developed ischemia to her legs and other
extremities requiring bilateral below the knee
amputations? Did I read that correctly?
A. I did.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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22
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24
25
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THE COURT: Mr. Casey, you really have to
limit it because we still need to have recross.
MR. CASEY: I understand. Dr. Poznansky,
those are all the questions I have. Thank you.
* * *
RECROSS-EXAMINATION
BY MR. LAUGHLIN:
Q. We don't know whether or not this doctor actually
looked at the actual cultures though, correct?
A. We don't know.
Q. And in terms of enterocutaneous fistula,
unfortunately, the reality is, they can reemerge,
correct?
A. Correct.
MR. LAUGHLIN: That's all I have.
THE COURT: Thank you doctor. You can step
down, and you're free to go.
* * *
(Whereupon, the witness stepped down from
the witness stand and exited the courtroom.)
* * *
THE COURT: Ladies and gentlemen, we hope
you have a pleasant weekend. I'd like you to stay in
the jury room for just one minute because I need to talk
to counsel about our starting time for Monday.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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* * *
(Whereupon, the jury exits the courtroom at
5:08 p.m.)
* * *
THE COURT: All right. Since we're holding
the jurors for this, I'm having inquires made of the
jurors to see if they'll be able to start at 8:30 on
Monday. I am extremely, extremely concerned because we
just keep falling further behind. We don't ever seem to
-- I mean, sometimes in a long trial, we can run into a
stall, and then make up ground elsewhere, but that
doesn't seem to be happening here. So, if the jurors
are available to start at 8:30 on Monday, is everybody
available to do that?
MR. CASEY: Yes, Your Honor.
MR. LAUGHLIN: Yes.
THE COURT: Let's just wait, and then we'll
take up some other issues.
TIP STAFF: Yes. Yes.
THE COURT: Ask them to be here for an 8:30
start on Monday.
THE COURT: Counsel, I ask you to be here at
8:00 on Monday so that we can take care of issues. All
I can ask you, Counsel, is please -- I think it's easier
in a way for lawyers to do cross-examination because you
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2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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know that you're looking for a yes or a no. I think
sometimes on direct-examination -- and I'm going to
scold you today, Mr. Casey, because you're doing the
direct, and then I'll scold Mr. Laughlin when he's doing
his direct, but please try to laser, focus your
questions so we can move these witnesses.
MR. CASEY: I understand, Your Honor.
THE COURT: And it's -- I know everybody --
it's the end of a long week, and I think everybody's
getting fatigued by the end of today, and so, get a good
rest over the weekend everybody.
MR. CASEY: Was it that obvious?
THE COURT: Everybody. Not just -- I wasn't
just referring to the direct examiner, the cross
examiner, the Judge, the stenographer, everybody.
MR. CASEY: I understand the Court's
instruction. I will.
THE COURT: It's an encouragement, please,
because I really -- these poor jurors are giving up a
lot to be here, and I want to be sure that we don't have
to keep them longer than I promised. All right, any
other issues that we can do, take care of today quickly
or anything we need to take care of before we get into
Monday?
MR. CASEY: I don't believe so, Your Honor.
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We're off to do a videotaped deposition.
THE COURT: Have a good weekend everybody.
We'll see you at 8:00 Monday morning then. Thank you.
* * *
(Whereupon, Court adjourned at 5:11 p.m.)
'
'89 [3] - 5:13, 6:5,
6:15
'92 [4] - 5:13, 6:6,
6:15, 6:19
'94 [1] - 6:19
/
/EUPB [1] - 35:3
/EURBLTs [1] - 35:3
/SPH-R [1] - 79:13
/SPOL [1] - 45:5
0
00494 [1] - 68:13
0068 [1] - 131:19
01348 [1] - 130:1
02360 [1] - 73:21
02491 [1] - 73:21
02974 [1] - 48:25
04017 [1] - 41:4
04025 [1] - 49:13
04031 [1] - 51:2
04036 [1] - 51:13
04037 [1] - 52:3
04041 [1] - 52:20
04042 [1] - 61:2
04045 [1] - 59:9
04047 [1] - 62:19
04049 [1] - 103:9
04055 [1] - 60:4
04058 [1] - 64:22
04080 [1] - 65:13
04086 [1] - 67:3
04116 [1] - 67:14
04122 [1] - 67:25
04184 [2] - 85:3, 85:4
04243 [1] - 131:14
04285 [1] - 69:12
04286 [1] - 70:7
1
1 [3] - 41:5, 49:2,
69:25
10 [3] - 47:20, 83:21,
110:13
10-13 [2] - 77:8,
125:25
10-15-08 [2] - 48:19,
78:10
10-16 [1] - 51:17
10-16-08 [1] - 49:1
10-17 [1] - 51:14
10-28 [1] - 65:18
10-29-08 [1] - 71:8
10-30 [1] - 83:7
10-30-2008 [1] - 68:15
10-6 [1] - 129:10
10.9 [4] - 124:6,
126:1, 129:1,
129:21
10:25 [1] - 48:19
10th [1] - 85:15
11 [6] - 12:23, 12:24,
15:2, 85:14, 124:16,
125:4
11-10 [1] - 85:7
11-4-08 [1] - 85:6
11-7-08 [1] - 85:7
11708 [1] - 122:20
11:27 [1] - 78:3
11:58 [1] - 17:10
11th [1] - 123:14
12 [3] - 12:18, 73:19,
82:20
128 [1] - 2:8
12:04 [1] - 21:3
12:45 [1] - 78:3
13 [2] - 94:11, 101:23
1303 [2] - 105:11,
105:24
1306 [1] - 115:22
133 [1] - 2:9
1330 [3] - 101:15,
105:13, 106:1
13864 [1] - 130:20
13th [40] - 18:22,
26:5, 26:15, 27:23,
28:16, 34:14, 34:23,
35:1, 35:23, 35:25,
36:5, 36:9, 38:17,
39:3, 39:18, 55:25,
72:11, 72:18, 72:23,
74:2, 74:4, 74:15,
74:24, 75:10, 75:24,
76:3, 76:8, 81:9,
82:5, 82:8, 82:14,
82:15, 82:16, 86:14,
128:22, 128:23,
129:14, 129:17,
131:4
14 [2] - 11:18, 94:12
1416 [1] - 126:22
1422 [1] - 126:11
14th [9] - 39:18,
72:18, 74:2, 74:4,
74:16, 74:24, 76:3,
125:19, 125:20
15 [5] - 99:1, 99:7,
100:2, 100:15,
110:12
150 [1] - 99:4
15th [30] - 18:22,
26:6, 26:16, 30:12,
30:21, 31:10, 34:8,
35:5, 48:12, 48:13,
50:16, 55:19, 73:20,
76:9, 77:19, 77:21,
78:25, 79:4, 79:7,
81:5, 81:10, 81:11,
81:15, 83:20, 84:1,
84:3, 86:15, 100:6,
101:8, 101:17
16 [1] - 2:6
16th [1] - 51:17
17th [1] - 101:2
18432 [1] - 73:22
18433 [1] - 124:8
18528 [2] - 101:14,
105:10
18531 [2] - 44:21,
100:11
18962 [2] - 42:23,
77:25
18964 [1] - 43:4
18th [5] - 52:19, 53:6,
53:16, 102:1, 102:7
19020 [1] - 71:5
19022 [1] - 71:9
19056 [1] - 82:20
19083 [1] - 73:22
1970s [2] - 131:6,
131:12
1977 [1] - 116:11
1983 [3] - 10:14,
10:17, 10:20
1984 [1] - 10:23
1985 [1] - 4:18
1986 [1] - 11:1
1988 [1] - 13:18
1989 [2] - 5:6, 11:1
1992 [1] - 5:6
1995 [1] - 11:9
1996 [2] - 7:12, 11:9
1997 [1] - 13:1
1998 [2] - 7:12, 13:18
19th [8] - 59:10,
59:23, 61:3, 101:24,
102:4, 102:13,
103:5, 104:5
1:15 [1] - 20:24
1:20 [2] - 20:21, 21:1
1:25 [1] - 21:6
1:30 [2] - 17:7, 20:22
1:34 [1] - 24:21
2
2 [26] - 6:9, 19:13,
19:18, 28:13, 32:11,
46:1, 54:1, 54:2,
84:10, 87:8, 90:7,
90:12, 90:23, 91:4,
92:8, 94:11, 99:16,
99:17, 101:12,
109:14, 113:23,
122:6, 123:16,
125:16, 125:19,
125:20
2-weeks [2] - 66:5,
119:10
20 [1] - 59:3
2000 [1] - 13:6
2000s [2] - 116:14,
116:15
2001 [1] - 109:21
2002 [4] - 109:22,
109:23, 110:1,
114:23
2003 [2] - 13:8, 13:24
2006 [1] - 14:6
2008 [33] - 16:9,
18:22, 25:20, 25:21,
26:6, 27:8, 27:9,
28:16, 29:12, 30:12,
34:14, 34:24, 35:5,
35:6, 35:23, 35:25,
36:9, 71:18, 72:11,
72:18, 73:20, 83:13,
86:15, 118:5,
118:10, 121:2,
123:14, 129:25,
131:14, 131:15,
132:13
2009 [3] - 14:11,
131:13, 131:20
2010 [1] - 131:13
2010-C-2071 [1] - 1:4
2011 [1] - 1:17
20th [4] - 63:21,
103:9, 103:10,
103:24
22nd [2] - 64:22, 70:4
23 [3] - 10:2, 15:20,
25:8
24th [1] - 65:13
25 [1] - 2:7
26th [1] - 67:4
28th [1] - 118:10
2970 [1] - 48:17
29th [3] - 71:20,
119:15, 131:20
2A [1] - 1:18
2nd [1] - 55:24
3
3 [3] - 2:5, 40:1,
101:23
3.9 [2] - 129:9, 129:21
300 [1] - 99:5
1
ROUGH DRAFT DAILY COPY
30th [6] - 38:1, 67:15,
71:18, 119:9,
119:18, 119:23
360 [2] - 91:23, 91:25
3:04 [1] - 73:8
3:28 [1] - 73:10
4
4 [3] - 40:2, 127:15,
131:4
4106 [1] - 103:22
4184 [1] - 96:21
42 [2] - 126:19, 129:7
4296 [1] - 123:11
4298 [1] - 123:19
48-hours [1] - 76:7
4840 [1] - 124:18
4853 [1] - 120:10
499 [1] - 40:1
4th [1] - 85:14
5
5 [1] - 37:8
52 [1] - 71:11
52-year-old [1] -
68:25
5:00 [1] - 127:25
5:08 [1] - 134:3
5:11 [1] - 136:5
6
6 [2] - 60:17, 130:2
60 [3] - 32:7, 32:8,
33:2
6th [5] - 55:24, 127:6,
128:21, 128:23,
129:14
7
70s [1] - 116:11
75 [2] - 126:19, 129:7
7th [2] - 85:14, 130:2
8
8 [2] - 126:17, 126:21
8.5 [2] - 129:1, 129:12
80 [2] - 126:19,
127:12
88 [4] - 126:14,
126:16, 127:10,
127:12
88% [1] - 126:4
8:00 [2] - 134:23,
136:3
8:30 [3] - 134:7,
134:13, 134:20
9
9 [3] - 3:18, 9:5, 63:22
9-11 [1] - 123:21
9.5 [3] - 129:9,
129:10, 129:21
94 [2] - 2:8, 6:25
95 [1] - 6:25
97 [1] - 13:24
9th [4] - 119:6, 119:7,
125:10, 130:20
9TH [1] - 1:17
A
a.m [2] - 17:10, 78:3
abdomen [8] - 54:13,
87:14, 87:17, 88:14,
91:15, 117:7,
121:13
abdominal [6] - 83:2,
117:22, 121:8,
122:8, 122:22,
123:23
ability [2] - 64:6, 64:8
able [14] - 14:23,
20:23, 25:14, 29:15,
29:17, 33:12, 64:9,
81:21, 81:24, 86:24,
98:9, 106:15,
130:12, 134:7
abnormal [4] - 38:19,
90:21, 90:23
abscess [3] - 121:1,
121:10, 122:22
abscesses [4] -
117:25, 120:2,
120:8, 132:7
absolutely [4] - 9:12,
13:16, 23:23, 25:14
academic [6] - 8:22,
8:25, 9:2, 9:4, 9:19,
9:21
accept [1] - 28:9
accepted [1] - 57:12
according [5] - 16:6,
26:14, 41:14,
129:16
accordingly [1] - 29:2
accurate [1] - 53:22
acidosis [1] - 69:17
acknowledge [4] -
94:23, 96:10,
106:18, 106:24
acknowledged [2] -
114:16, 114:19
action [2] - 77:8,
77:16
active [1] - 123:1
actual [5] - 37:20,
84:16, 95:7, 131:14,
133:9
acute [5] - 31:5,
69:19, 119:10,
119:12, 123:17
adapt [1] - 33:7
add [2] - 20:1, 93:20
Addenbroooke's [1] -
4:21
addition [7] - 4:12,
27:4, 53:24, 62:8,
89:13, 113:25,
117:9
additional [3] - 44:12,
44:18, 45:13
address [6] - 21:11,
22:14, 24:17, 36:16,
77:8, 113:6
addresses [1] -
116:14
adhesion [1] - 130:13
adjacent [1] - 56:12
adjourned [1] - 136:5
administer [1] - 40:6
administered [2] -
40:18, 46:16
administration [3] -
74:23, 78:2, 83:23
admissible [1] - 22:7
admission [10] - 30:8,
34:4, 35:4, 35:23,
36:5, 39:25, 40:2,
40:12, 73:20, 83:3
admissions [1] -
18:10
admittance [1] -
18:21
admitted [6] - 18:6,
19:1, 30:19, 40:4,
48:12, 132:20
admitting [2] - 41:12,
69:13
Adults [1] - 13:19
advance [1] - 20:24
advanced [1] - 6:12
advisory [1] - 13:23
advocate [2] - 56:2,
63:24
aerosolize [1] - 58:16
AFFILIATED [1] - 1:8
affiliated [3] - 8:19,
8:21, 124:11
afternoon [13] - 17:7,
17:13, 21:11, 24:23,
25:4, 25:5, 78:4,
78:15, 78:22, 82:15,
84:2, 94:20, 94:21
afterwards [1] - 56:24
ago [2] - 82:3, 114:9
agree [4] - 18:2, 38:9,
102:3, 107:16
agrees [1] - 20:11
ahead [9] - 3:22,
13:22, 43:4, 48:9,
60:4, 73:15, 86:21,
130:22, 131:9
AKI [2] - 67:5
alarm [1] - 93:23
alive [1] - 33:13
Allentown [4] - 1:19,
49:15, 124:19,
124:22
allowed [2] - 9:25,
53:9
allows [2] - 7:23,
64:10
almost [1] - 58:17
alone [1] - 29:17
amazingly [1] -
130:23
ambulance [3] - 40:9,
43:2, 78:1
America [2] - 7:5,
10:11
American [1] - 10:7
amputated [1] - 72:15
amputation [6] - 27:1,
29:19, 72:15, 75:1,
85:6
amputations [7] -
35:7, 35:10, 66:8,
72:6, 74:25, 85:9,
132:24
analysis [2] - 36:4,
60:6
analyzing [1] - 29:9
AND [2] - 1:6, 1:11
angle [1] - 61:16
ANN [1] - 1:3
announced [1] -
103:1
answer [9] - 36:14,
44:16, 73:5, 76:18,
84:16, 105:19,
112:24, 120:18,
120:23
answers [1] - 23:20
anti [1] - 110:14
antibiotic [9] - 46:5,
46:19, 47:14, 48:8,
52:13, 52:14, 74:23,
84:18, 106:13
antibiotics [17] -
40:18, 41:18, 41:22,
41:23, 42:16, 43:16,
46:15, 52:10, 64:13,
64:18, 73:2, 74:4,
77:19, 77:22, 83:24,
107:3, 110:18
anticipating [2] -
19:6, 28:24
anticipation [2] -
18:8, 28:23
antiyeast [1] - 52:13
anus [1] - 57:1
anytime [1] - 37:23
anyway [2] - 15:13,
22:9
apologize [5] - 64:19,
97:13, 123:12,
125:1, 126:21
apparent [1] - 110:6
appear [5] - 65:16,
72:4, 91:9, 96:24,
103:25
appearance [3] -
79:8, 80:2, 80:16
APPEARANCES [1] -
1:20
appeared [1] - 67:20
appearing [1] - 94:2
appointment [3] -
9:22, 18:9, 28:23
appointments [4] -
9:3, 9:19, 9:21, 16:8
approach [6] - 3:21,
76:21, 87:3, 114:2,
118:18, 131:8
approaches [1] - 14:8
appropriate [2] -
19:15, 19:22
appropriately [1] -
32:12
April [5] - 121:2,
121:16, 122:10,
125:19, 125:20
area [4] - 16:22,
54:19, 58:16, 58:21
areas [2] - 15:18,
122:17
arguably [1] - 18:2
argued [1] - 22:7
argument [4] - 20:21,
20:25, 21:10, 22:8
arguments [1] - 18:3
arithema [1] - 80:17
arm [1] - 88:4
arms [1] - 87:14
arrived [2] - 30:17,
34:25
art [2] - 46:4, 46:7
arterial [2] - 61:16,
61:19
2
ROUGH DRAFT DAILY COPY
article [2] - 114:24,
131:6
artificially [1] - 90:2
AS [1] - 1:12
ascribed [2] - 112:11,
112:18
aside [1] - 92:11
aspect [1] - 81:19
aspects [5] - 6:14,
20:12, 31:17, 39:3,
55:9
asserting [2] - 23:12,
23:14
assertion [1] - 77:11
assess [5] - 33:18,
40:23, 54:2, 55:8,
77:13
assessed [1] - 75:11
assessment [10] -
8:10, 49:23, 66:15,
67:4, 67:15, 71:10,
75:10, 77:16, 86:16
assessments [1] -
68:2
assistant [1] - 16:9
Associate [3] - 9:23,
11:24
associate [1] - 16:10
associated [10] - 6:1,
9:7, 35:9, 35:10,
37:1, 55:14, 80:16,
83:16, 106:19,
131:23
associates [1] - 10:1
ASSOCIATES [1] -
1:7
association [1] -
131:25
Association [1] - 10:7
assuming [1] - 23:20
assuring [1] - 59:2
AT [2] - 73:8, 73:10
atrocal [1] - 71:15
attempting [1] - 39:10
attending [1] - 4:6
attention [1] - 77:5
attribute [1] - 119:13
August [3] - 30:21,
118:10, 119:2
autopsy [1] - 116:7
available [5] - 102:1,
102:3, 102:7,
134:13, 134:14
average [1] - 39:15
avoid [2] - 74:24,
84:21
award [3] - 10:17,
11:7, 11:9
Award [1] - 10:20
awards [1] - 10:13
aware [10] - 23:2,
23:5, 103:4, 104:3,
115:4, 115:5,
120:25, 122:19,
125:14, 132:5
awareness [1] - 39:2
awhile [1] - 117:16
B
background [1] -
3:17
bacteremia [1] - 69:2
bacteria [60] - 32:2,
34:10, 35:13, 38:22,
39:9, 39:11, 43:20,
43:22, 44:12, 45:8,
45:18, 45:23, 46:1,
46:18, 46:21, 46:24,
52:1, 54:4, 56:3,
57:1, 57:2, 57:7,
57:11, 57:14, 57:16,
57:17, 57:24, 58:12,
58:15, 58:20, 62:1,
64:6, 64:9, 64:16,
72:23, 88:25, 91:8,
91:13, 91:17, 91:18,
91:21, 92:2, 92:3,
92:5, 92:16, 93:2,
93:21, 94:1, 98:2,
99:19, 99:23, 106:8,
106:14, 107:4,
107:7, 110:3, 113:7
bacterial [3] - 32:14,
39:6, 41:25
bacteriemia [1] -
53:20
bag [11] - 55:11,
55:20, 55:24, 56:2,
57:5, 88:18, 89:22,
89:23, 90:15
bands [7] - 126:8,
126:15, 126:17,
126:20, 127:3,
127:15
barely [1] - 81:17
barium [1] - 130:22
based [5] - 11:7, 31:7,
49:24, 61:24, 84:16
baseline [1] - 26:13
bases [1] - 36:20
basic [3] - 18:23,
32:25, 53:2
basis [3] - 9:6, 35:24,
36:6
Bates [10] - 42:23,
48:17, 48:25, 51:2,
59:9, 61:1, 73:21,
73:22, 77:25, 82:19
bathroom [3] - 56:22,
59:1, 59:2
bear [3] - 31:23,
102:23, 119:25
became [1] - 4:5
become [5] - 33:22,
37:16, 37:18, 39:17,
65:8
becomes [1] - 69:22
bedside [1] - 12:1
BEFORE [1] - 1:17
beg [1] - 31:11
begin [1] - 17:6
beginning [4] - 40:3,
82:9, 82:16, 93:25
behind [1] - 134:9
bell [1] - 85:2
below [7] - 26:25,
55:12, 66:8, 72:14,
88:13, 101:22,
132:23
best [5] - 64:15, 66:1,
72:22, 87:1, 89:15
better [3] - 14:17,
14:25, 132:9
between [19] - 5:13,
6:5, 9:3, 18:22,
26:5, 26:14, 39:18,
65:17, 68:8, 72:3,
78:3, 78:24, 99:13,
112:14, 112:17,
113:8, 119:6,
128:23
beyond [7] - 18:24,
27:8, 27:9, 47:11,
71:4, 77:10, 110:10
bibliography [1] -
15:16
big [7] - 24:18, 31:13,
87:22, 88:6, 88:7,
92:8, 94:7
bilateral [7] - 26:25,
61:6, 62:20, 64:23,
72:14, 74:25,
132:23
biliary [1] - 88:15
biological [2] - 99:22,
116:25
biologist [1] - 56:25
Biomedical [1] - 13:8
bit [15] - 3:16, 4:10,
6:17, 29:22, 30:25,
31:13, 39:21, 40:5,
45:4, 54:20, 64:4,
84:10, 85:8, 88:25,
121:19
bits [1] - 19:23
black [2] - 65:10,
65:11
blood [94] - 32:21,
33:11, 34:11, 35:14,
38:17, 40:16, 41:17,
41:21, 42:16, 42:20,
43:18, 43:23, 44:7,
44:8, 47:8, 47:9,
47:15, 47:16, 47:21,
48:3, 48:10, 51:18,
52:5, 52:21, 53:3,
53:8, 53:16, 55:4,
56:8, 57:22, 59:6,
62:2, 62:5, 62:10,
62:12, 63:1, 64:1,
64:14, 70:9, 70:12,
77:24, 79:12, 79:16,
79:17, 79:19, 83:17,
84:9, 84:13, 84:15,
84:19, 87:20, 87:21,
87:23, 88:3, 88:8,
88:12, 90:3, 90:4,
90:5, 90:18, 91:6,
94:1, 97:25, 98:5,
101:7, 101:19,
102:9, 103:20,
104:4, 105:11,
105:16, 105:23,
105:24, 106:7,
106:13, 107:5,
107:11, 107:18,
110:5, 110:15,
112:18, 116:6,
120:17, 121:7,
124:6, 124:15,
125:4, 125:7,
125:12, 127:2,
127:4, 128:23,
129:18
bloodstream [21] -
32:3, 48:6, 48:7,
84:6, 86:18, 94:3,
94:6, 94:7, 94:9,
106:20, 106:25,
107:10, 107:17,
110:3, 110:7,
111:11, 111:13,
112:15, 113:13,
115:14, 116:9
blue [7] - 30:24,
62:25, 64:25, 79:9,
80:2, 80:15
bluish [1] - 65:10
board [7] - 8:1, 16:14,
16:21, 16:25, 24:14,
25:8, 25:13
body [30] - 5:4, 14:24,
31:10, 32:1, 32:2,
32:17, 32:21, 32:22,
32:24, 33:1, 33:3,
33:5, 33:7, 33:8,
34:14, 34:18, 38:22,
42:2, 47:3, 50:15,
55:5, 63:15, 67:9,
72:25, 80:12, 80:13,
81:16, 87:13, 88:20,
89:4
Boston [3] - 7:14,
11:17, 11:18
bottom [9] - 40:24,
41:5, 44:21, 51:4,
53:18, 59:23, 59:24,
61:3, 130:3
bowel [24] - 55:6,
55:11, 56:23, 88:16,
88:17, 89:20, 89:21,
90:15, 90:16, 90:25,
91:5, 117:10, 119:7,
130:1, 130:7, 130:9,
130:10, 130:11,
130:17, 130:23,
130:25, 132:12
bowels [3] - 89:19,
91:13, 91:14
brain [1] - 32:23
breached [3] - 39:7,
39:15, 72:23
breaches [1] - 90:12
break [8] - 17:6,
24:16, 25:7, 39:8,
73:23, 74:6, 90:1,
90:23
breaks [1] - 91:4
breast [1] - 14:1
breath [1] - 32:8
breathe [2] - 32:8,
32:19
breathes [1] - 33:2
breathing [2] - 30:23,
31:18
brief [3] - 20:25,
128:4, 131:11
briefly [5] - 10:4,
16:7, 45:21, 128:20,
130:9
Brigham [1] - 8:17
bring [2] - 81:21,
102:23
broke [1] - 119:22
broken [1] - 37:18
brought [2] - 68:9,
88:16
BSc(hons [1] - 10:18
Bub [2] - 131:21
bub [1] - 131:23
bug [2] - 46:5, 46:17
bugs [1] - 52:10
bump [1] - 38:25
burrow [1] - 117:16
burrowing [2] -
60:19, 117:14
burrows [1] - 117:16
BUSINESS [1] - 1:12
3
ROUGH DRAFT DAILY COPY
BY [37] - 3:9, 4:8,
16:5, 25:3, 28:7,
42:12, 44:23, 46:10,
67:2, 71:6, 73:16,
75:21, 77:4, 85:12,
88:21, 90:19, 92:10,
93:17, 94:19, 97:14,
105:22, 106:16,
108:8, 109:6,
111:22, 112:2,
113:4, 114:8, 115:3,
115:11, 116:20,
118:23, 121:5,
124:25, 128:19,
131:10, 133:7
C
cage [1] - 54:25
caliber [1] - 123:5
Cambridge [3] - 3:25,
4:21, 11:2
canal [1] - 90:6
Cancer [8] - 4:7, 5:7,
5:9, 5:12, 5:14,
6:15, 8:5, 8:15
cancer [5] - 5:10,
5:16, 14:1, 14:8,
14:17
cannot [3] - 57:2,
112:10, 112:18
capability [1] - 106:9
capable [1] - 106:14
capacity [1] - 11:25
Cappell [1] - 10:20
CARA [1] - 1:25
CARBON [1] - 1:12
care [21] - 6:12, 9:13,
12:13, 17:18, 18:21,
19:20, 24:8, 25:11,
25:20, 25:25, 26:15,
28:14, 59:25, 60:5,
74:11, 74:14, 74:19,
79:6, 134:23,
135:22, 135:23
CARE [2] - 1:7, 1:13
Care [5] - 49:14,
49:15, 50:3, 51:3,
51:5
career [1] - 11:14
caregivers [1] - 83:2
caring [1] - 34:15
CAROL [1] - 1:17
case [43] - 3:3, 5:22,
5:24, 8:12, 8:13,
9:11, 15:23, 15:25,
17:16, 18:17, 19:21,
20:7, 26:1, 26:9,
27:10, 29:3, 29:10,
30:14, 32:6, 45:8,
47:7, 54:9, 57:4,
62:15, 62:16, 66:6,
75:6, 84:17, 97:24,
98:5, 106:21,
106:22, 107:14,
107:15, 108:21,
109:14, 109:25,
110:21, 111:10,
113:15, 116:15,
116:16, 118:4
casey [1] - 103:7
CASEY [70] - 1:21,
3:1, 3:9, 3:21, 4:8,
15:21, 17:14, 19:5,
19:8, 19:10, 20:1,
21:12, 22:3, 22:16,
25:3, 28:7, 38:8,
42:12, 44:20, 44:23,
46:10, 67:2, 71:5,
71:6, 73:5, 73:14,
73:16, 75:21, 76:15,
76:21, 77:3, 77:4,
85:12, 86:22, 87:2,
87:6, 87:10, 88:21,
89:11, 90:19, 92:10,
93:12, 93:17, 94:16,
106:4, 108:6, 108:8,
108:25, 109:2,
111:17, 112:22,
112:24, 114:3,
114:7, 115:2, 115:7,
116:17, 118:16,
120:16, 120:21,
128:16, 128:19,
131:8, 131:10,
133:3, 134:15,
135:7, 135:12,
135:16, 135:25
Casey [8] - 2:6, 2:7,
2:8, 21:22, 91:2,
128:15, 133:1,
135:3
catastrophic [1] -
35:15
catch [1] - 16:6
catheter [91] - 5:24,
35:20, 36:1, 36:7,
36:20, 40:15, 41:13,
42:9, 42:15, 44:3,
44:5, 44:6, 44:11,
48:18, 48:22, 48:25,
50:5, 50:12, 50:24,
51:22, 52:18, 52:25,
53:5, 53:20, 54:10,
54:13, 55:6, 55:7,
56:12, 59:5, 59:11,
60:2, 60:12, 64:2,
66:19, 70:15, 70:24,
78:17, 84:6, 84:8,
84:12, 84:14, 84:19,
87:19, 89:4, 89:17,
90:7, 93:3, 93:9,
94:8, 98:6, 98:10,
98:11, 98:13, 98:24,
99:10, 99:15,
100:12, 100:24,
103:17, 106:7,
106:8, 106:10,
106:18, 106:24,
107:3, 107:9,
107:12, 107:17,
107:19, 108:24,
109:10, 110:2,
110:4, 110:8,
110:15, 111:11,
111:13, 112:5,
112:6, 112:12,
112:19, 113:13,
115:5, 115:13,
116:1, 116:6,
131:17, 132:19
catheter-related [4] -
84:6, 84:12, 107:17,
108:24
catheters [2] - 5:23,
6:2
causation [12] - 3:3,
9:10, 15:23, 15:25,
26:9, 29:2, 29:5,
29:10, 75:25, 78:20,
93:9, 93:19
causative [1] - 26:24
caused [1] - 35:7
causes [2] - 58:15,
63:15
causing [5] - 32:14,
49:8, 60:20, 62:12,
70:1
causitive [1] - 39:8
cava [2] - 87:22,
100:4
cavity [1] - 121:8
CDC [7] - 109:9,
110:1, 113:17,
114:10, 114:12,
114:22, 116:12
Cefepime [9] - 52:6,
52:7, 52:12, 52:21,
59:11, 59:14, 59:18,
59:22, 60:14
ceftriaxone [1] -
47:15
cell [2] - 128:23,
129:19
cells [2] - 14:19,
38:22
center [1] - 32:24
Center [1] - 14:12
Central [1] - 6:21
central [6] - 28:15,
28:25, 32:21, 48:18,
48:25, 70:24
Cephalosporin [1] -
106:11
cephalosporin [3] -
43:16, 47:4, 47:6
certain [4] - 14:25,
20:11, 29:20, 64:6
certainties [1] -
102:15
certainty [1] - 94:14
certification [10] -
7:18, 7:25, 8:1, 8:2,
16:14, 16:15, 16:21,
25:9, 25:10, 25:13
certified [1] - 16:25
chance [3] - 21:14,
91:20, 112:3
change [6] - 21:20,
22:2, 23:17, 41:25,
65:18, 68:11
changed [3] - 57:5,
65:17, 102:14
changes [9] - 65:2,
65:14, 69:3, 72:4,
72:13, 80:2, 82:1,
130:6, 130:24
channel [2] - 90:2,
90:8
characterized [1] -
100:17
characterizing [1] -
96:12
chart [6] - 36:24,
73:17, 73:19, 80:19,
83:12, 130:21
charts [1] - 85:2
check [1] - 113:17
checklist [2] - 48:19,
49:1
checks [1] - 53:10
chemotherapy [1] -
5:16
chest [5] - 72:25,
87:14, 87:16, 88:1,
88:2
Chief [1] - 16:12
Chrohn's [3] - 27:7,
37:3, 39:16
chronic [2] - 37:2,
37:3
chronology [3] -
30:6, 30:18, 30:19
circle [1] - 94:5
circulate [1] - 33:12
circulating [1] - 79:19
circulation [3] - 62:9,
80:5, 80:12
circulatory [1] - 79:10
circumstances [2] -
14:25, 27:23
CIVIL [1] - 1:2
clarify [8] - 24:7, 29:6,
58:23, 74:11,
102:11, 104:6,
104:23, 126:24
clarity [1] - 48:10
Class [1] - 10:17
classical [2] - 49:19,
62:17
clean [5] - 56:23,
56:24, 57:2, 57:9,
58:7
cleaned [1] - 59:3
clear [4] - 23:20, 42:2,
42:4, 121:6
clearly [3] - 45:7,
45:9, 112:13
Clinical [2] - 4:20,
13:19
clinical [21] - 6:10,
7:9, 7:12, 7:16, 9:3,
9:5, 13:23, 29:13,
36:19, 78:23, 79:25,
80:17, 80:18, 80:24,
81:13, 82:14, 84:17,
110:6, 116:6, 116:8,
123:17
clinically [4] - 27:23,
32:6, 81:15, 100:5
clinicians [1] - 53:15
cloacae [3] - 44:1,
70:13
close [3] - 33:22,
65:9, 88:23
closer [2] - 92:24,
93:7
cohabit [1] - 54:4
cold [3] - 33:11,
79:13, 81:16
colleague's [1] -
46:20
colleagues [1] -
56:21
collects [1] - 89:23
college [2] - 7:21,
16:15
College [5] - 6:21,
7:2, 7:20, 10:5,
11:10
colloquy [3] - 22:22,
22:24, 99:17
colon [1] - 131:19
colonies [13] - 45:1,
45:5, 45:7, 45:11,
99:1, 99:7, 99:15,
99:16, 99:17, 100:2,
100:15, 110:12,
110:13
4
ROUGH DRAFT DAILY COPY
colonization [2] -
99:8, 99:14
colonized [2] -
106:18, 106:24
colonizing [1] - 94:1
colony [3] - 45:13,
99:16, 99:18
color [2] - 65:10
colostomy [10] -
54:12, 54:15, 54:18,
55:10, 55:15, 55:24,
56:2, 56:11, 57:4,
57:13
combat [1] - 39:11
combination [1] -
58:14
comfortable [2] -
107:20, 107:21
coming [10] - 5:19,
7:19, 84:5, 89:19,
90:25, 91:14, 92:20,
93:8, 122:7, 124:3
comment [1] - 19:4
commentary [1] -
116:18
COMMON [1] - 1:1
commonly [1] - 57:23
Communicable [1] -
7:1
communicable [1] -
7:4
COMMUNITY [1] -
1:12
compare [1] - 101:12
compared [2] - 94:8,
123:5
compensate [1] -
33:3
competitive [2] -
12:11, 12:15
competitively [1] -
12:16
completed [1] - 4:4
completely [2] - 39:7,
113:2
complicated [4] -
31:12, 31:23, 36:12,
82:13
complications [2] -
35:8, 35:9
component [1] - 92:2
components [1] -
37:12
conceivably [1] -
18:20
concentrated [1] -
32:25
concentrating [1] -
6:13
concern [1] - 23:1
concerned [2] -
28:21, 134:8
concerning [2] -
37:24, 113:12
conclusions [2] -
19:18, 22:2
concurrent [1] - 20:7
condition [6] - 72:19,
74:1, 74:2, 78:23,
81:13, 82:14
confirm [1] - 53:11
confusion [1] - 85:4
conjunction [3] -
13:12, 14:3, 71:24
connection [4] -
83:14, 108:21,
109:7, 110:21
consequence [1] -
33:8
consequently [1] -
79:15
consider [4] - 20:6,
25:23, 99:24,
108:18
considered [3] - 8:6,
24:3, 82:9
consistent [3] - 22:4,
38:16, 38:20
consists [1] - 90:8
consultancy [1] -
13:25
consultant [1] - 67:23
consultation [1] -
71:7
consulted [1] - 67:25
contact [1] - 92:5
contacted [2] - 18:13,
27:22
contacting [1] - 18:8
contained [1] - 9:21
contaminate [1] -
99:25
contaminated [1] -
37:17
contamination [4] -
55:14, 92:20, 99:10,
99:14
contention [2] - 54:1,
55:2
contents [1] - 122:8
context [13] - 5:25,
37:18, 37:23, 38:18,
39:6, 43:10, 48:10,
57:12, 57:20, 57:24,
58:12, 58:25, 92:21
continuation [1] - 7:8
continue [15] - 21:17,
28:6, 52:5, 52:21,
53:9, 59:9, 59:14,
60:14, 64:19, 65:22,
65:25, 66:6, 66:18,
71:15, 80:9
continuing [5] -
13:17, 59:18, 59:24,
60:4, 122:24
contraindication [1] -
63:1
contribute [1] - 125:6
Contributions [1] -
15:4
control [1] - 89:20
cooperation [1] -
128:6
copy [4] - 3:18, 3:20,
118:14, 131:6
COPY [1] - 1:16
core [4] - 32:25,
33:12, 33:23, 37:10
correct [294] - 4:18,
4:19, 4:22, 4:23,
4:25, 5:2, 5:7, 5:8,
6:24, 7:3, 7:10,
7:11, 7:14, 7:15,
9:15, 10:9, 10:12,
10:16, 10:19, 10:22,
10:25, 11:3, 11:5,
11:12, 13:2, 13:10,
14:2, 14:5, 14:10,
14:14, 15:7, 15:17,
15:19, 16:17, 16:18,
16:19, 16:23, 17:2,
20:14, 38:13, 41:15,
43:1, 43:3, 43:9,
43:13, 47:21, 47:22,
49:4, 50:5, 50:6,
50:10, 50:12, 50:13,
50:25, 51:6, 51:8,
51:9, 51:11, 51:12,
51:21, 51:23, 52:2,
53:1, 53:21, 59:13,
59:15, 59:17, 60:3,
60:13, 60:15, 61:15,
61:18, 61:21, 63:12,
63:18, 63:22, 65:20,
66:3, 66:10, 67:1,
67:6, 67:7, 67:13,
67:19, 67:21, 67:24,
68:5, 68:22, 69:8,
69:13, 69:14, 69:16,
69:18, 70:2, 70:5,
70:10, 70:11, 70:17,
70:23, 72:1, 74:7,
78:6, 78:18, 83:8,
85:20, 90:11, 94:25,
95:4, 95:11, 95:12,
95:14, 95:16, 95:18,
95:19, 95:22, 96:1,
96:2, 96:4, 96:5,
96:7, 96:8, 96:13,
96:16, 97:3, 97:4,
97:6, 97:7, 97:23,
97:24, 98:3, 98:4,
98:6, 98:7, 98:14,
100:7, 100:8,
100:12, 100:13,
100:14, 100:18,
100:19, 100:21,
100:22, 100:24,
100:25, 101:2,
101:3, 101:6, 101:7,
101:11, 101:12,
101:13, 101:15,
101:16, 101:19,
101:20, 101:23,
101:24, 102:4,
102:5, 102:7, 102:8,
102:10, 102:11,
102:18, 102:20,
102:23, 102:24,
103:10, 103:11,
103:13, 103:14,
103:20, 103:21,
104:13, 104:14,
105:4, 105:13,
105:14, 105:16,
105:25, 106:2,
106:20, 107:1,
107:5, 107:6, 108:1,
108:2, 109:14,
109:15, 111:5,
111:6, 111:8, 111:9,
111:14, 112:16,
113:7, 113:14,
113:18, 113:19,
113:21, 113:23,
113:24, 114:14,
114:15, 114:20,
116:14, 116:23,
116:24, 117:1,
117:2, 117:7, 117:8,
117:12, 117:13,
117:17, 117:18,
117:20, 117:21,
117:23, 117:24,
117:25, 118:1,
118:3, 118:5, 118:6,
118:25, 119:19,
119:20, 119:24,
120:2, 120:3, 120:4,
120:5, 120:9,
120:12, 120:13,
120:15, 121:8,
121:9, 121:14,
122:1, 122:2, 122:5,
122:10, 122:13,
122:23, 122:25,
123:6, 123:7,
123:15, 123:18,
123:24, 123:25,
124:3, 124:4, 124:7,
124:9, 124:10,
124:16, 124:17,
125:4, 125:5,
125:10, 125:11,
125:21, 125:22,
126:2, 126:3, 126:6,
126:12, 126:13,
126:14, 126:18,
127:6, 127:7, 127:8,
127:9, 127:10,
127:11, 127:12,
127:13, 127:16,
127:17, 129:15,
129:22, 129:23,
130:17, 131:5,
131:18, 133:9,
133:13, 133:14
correctly [4] - 65:19,
69:4, 88:14, 132:24
counsel [4] - 21:8,
24:7, 127:18,
133:25
Counsel [3] - 11:1,
134:22, 134:24
count [18] - 38:21,
39:1, 124:6, 124:15,
125:4, 125:7,
125:13, 125:17,
126:1, 127:9, 129:6,
129:8, 129:9,
129:10, 129:18,
129:19, 129:21
countries [1] - 15:9
counts [1] - 128:23
County [1] - 1:18
COUNTY [1] - 1:1
couple [2] - 16:2,
68:1
course [8] - 11:14,
12:20, 13:17, 18:19,
22:10, 26:13, 32:23,
66:4
Course [1] - 13:18
court [1] - 81:2
COURT [75] - 1:1,
1:25, 3:22, 16:1,
17:5, 17:12, 19:2,
19:7, 19:9, 19:11,
20:3, 20:14, 20:16,
20:20, 21:8, 21:14,
22:13, 22:17, 22:23,
23:8, 23:14, 23:23,
24:6, 24:23, 28:6,
42:11, 44:16, 46:9,
47:12, 66:25, 71:4,
73:12, 73:15, 75:19,
76:14, 76:17, 76:23,
77:1, 86:23, 87:5,
91:22, 91:25, 93:14,
97:11, 105:18,
108:7, 109:1, 109:4,
5
ROUGH DRAFT DAILY COPY
111:19, 111:25,
112:23, 114:5,
115:1, 115:9,
116:19, 120:18,
120:23, 124:23,
127:18, 127:24,
128:9, 128:11,
128:14, 131:9,
133:1, 133:16,
133:22, 134:5,
134:17, 134:20,
134:22, 135:8,
135:13, 135:18,
136:2
Court [5] - 15:22,
21:6, 22:8, 136:5
Court's [1] - 135:16
Courthouse [1] - 1:18
courtroom [9] -
17:10, 24:21, 27:18,
27:20, 55:3, 55:17,
78:7, 133:20, 134:2
Courtroom [1] - 1:18
covered [2] - 15:11,
78:3
covering [2] - 17:24,
28:17
create [1] - 64:10
created [1] - 90:3
credentials [3] - 8:6,
8:10, 8:11
criteria [2] - 107:23,
107:24
critical [3] - 38:19,
59:25, 60:4
Critical [5] - 49:13,
49:15, 50:3, 51:3,
51:4
critically [5] - 40:21,
49:17, 77:23, 79:21,
81:18
criticized [1] - 112:8
Crohn's [14] - 49:7,
49:8, 60:11, 60:19,
67:20, 71:12, 71:13,
83:16, 118:22,
119:8, 119:12,
119:15, 123:1,
130:18
CROSS [2] - 16:4,
94:18
Cross [2] - 2:6, 2:8
cross [3] - 94:16,
134:25, 135:14
cross-examination
[1] - 134:25
CROSS-
EXAMINATION [2] -
16:4, 94:18
Cross-Examination
[2] - 2:6, 2:8
cross-examine [1] -
94:16
CT [1] - 122:20
culture [47] - 40:15,
40:16, 44:24, 47:8,
47:16, 47:17, 51:22,
52:5, 52:25, 53:8,
59:11, 62:2, 76:9,
77:17, 84:9, 84:11,
86:6, 92:13, 95:2,
95:4, 96:1, 98:10,
98:11, 98:13, 98:17,
100:3, 100:6,
100:10, 100:11,
100:21, 101:1,
101:4, 102:9,
103:17, 103:18,
104:4, 104:7, 105:9,
105:11, 105:12,
105:16, 105:23,
110:5, 110:13,
121:14
cultured [3] - 101:7,
107:4, 122:3
cultures [38] - 41:18,
41:21, 41:24, 42:6,
42:17, 43:17, 43:18,
44:5, 44:11, 47:9,
48:11, 48:15, 51:18,
52:5, 52:21, 53:9,
53:16, 70:9, 70:12,
76:7, 77:18, 77:24,
84:8, 84:19, 86:4,
96:7, 98:1, 98:2,
98:6, 103:20,
105:11, 106:3,
120:11, 120:17,
120:25, 121:7,
133:9
cur [1] - 90:22
cures [1] - 13:15
current [2] - 37:15,
71:14
curriculum [1] - 3:19
curtailed [1] - 73:3
cut [1] - 90:5
cutaneous [2] -
90:17, 117:4
cutting [1] - 128:11
CV [8] - 4:10, 6:5, 6:6,
9:20, 14:20, 15:15,
16:7, 16:11
CVC [1] - 70:24
CVP [2] - 70:13, 70:23
CX [1] - 103:17
cyanosis [2] - 64:24,
65:7
cyanotic [3] - 61:9,
62:22, 62:24
D
DAILY [1] - 1:16
damage [4] - 33:4,
62:5, 62:7, 63:16
damaged [2] - 32:10,
32:13
damaging [1] - 32:4
Dana [8] - 4:6, 5:6,
5:9, 5:11, 5:14,
6:15, 8:5, 14:3
darker [1] - 65:16
data [2] - 50:2, 116:7
date [12] - 52:3,
67:10, 71:20, 83:7,
83:10, 123:12,
123:20, 124:21,
124:23, 124:24,
125:1, 125:23
dated [3] - 48:19,
68:14, 119:15
dates [2] - 85:6, 85:9
David [1] - 131:21
days [7] - 60:17,
60:24, 66:16, 68:2,
130:2, 131:4,
132:11
dead [2] - 65:9, 65:10
dealt [1] - 72:17
death [1] - 33:22
December [1] -
131:20
decides [1] - 14:9
defect [2] - 130:7,
130:25
defects [1] - 92:8
defend [1] - 38:24
Defendant [1] - 1:23
defendant [8] - 17:16,
18:6, 18:25, 20:5,
20:6, 24:9, 27:21
defendant's [1] -
18:20
Defendants [1] - 1:13
defense [2] - 75:6,
90:24
defenses [4] - 39:10,
39:14, 39:17, 72:23
define [1] - 98:21
defined [3] - 107:10,
107:13, 109:24
definition [12] -
107:16, 107:20,
107:21, 108:23,
110:2, 115:5,
115:13, 116:1,
116:3, 116:5,
116:10
definitions [4] -
107:9, 115:17,
115:23, 116:4
degree [3] - 10:18,
24:9, 94:13
degrees [2] - 91:23,
91:25
delay [1] - 26:6
delineation [2] - 99:7,
99:8
demonstrate [2] -
36:17, 101:5
demonstrated [1] -
32:3
demonstrative [1] -
47:19
Department [1] - 7:1
dependent [1] - 70:3
depicted [1] - 47:18
deposition [17] -
17:22, 18:12, 19:4,
19:14, 20:4, 20:10,
21:17, 21:20, 22:2,
22:7, 24:11, 24:14,
27:11, 27:13, 29:4,
30:3, 136:1
depositions [3] -
18:5, 27:15, 29:20
describe [9] - 6:4,
12:8, 30:15, 39:4,
58:11, 61:22, 64:15,
86:16, 112:21
described [9] - 6:5,
11:13, 29:13, 34:9,
38:18, 50:14, 65:8,
79:8, 90:23
describing [2] -
63:14, 113:8
description [3] -
38:12, 79:5
despite [1] - 65:25
detail [4] - 29:22,
30:9, 64:4, 82:8
detailed [1] - 27:6
details [1] - 34:2
deteriorated [1] -
77:10
determination [1] -
104:9
determine [1] - 98:9
determined [2] -
100:7, 100:17
develop [1] - 132:16
developed [3] - 69:2,
132:20, 132:22
developing [1] - 77:8
development [1] -
13:25
deviations [2] -
74:13, 74:18
devil's [2] - 56:2,
63:24
devoted [1] - 12:5
diabetes [3] - 37:4,
37:5, 39:16
Diagnosis [1] - 69:25
diagnosis [11] -
41:24, 42:2, 42:4,
42:7, 42:13, 48:21,
53:11, 59:24, 66:14,
68:9, 69:13
diagram [3] - 86:20,
110:14, 116:21
diagrams [1] - 94:11
dictated [2] - 71:20,
97:18
dictation [1] - 97:19
die [2] - 33:6, 130:10
diet [1] - 71:15
difference [1] - 84:18
different [28] - 7:6,
23:25, 46:1, 53:13,
54:1, 54:2, 78:24,
82:14, 84:10, 84:14,
95:9, 95:11, 95:17,
95:21, 104:10,
104:15, 104:16,
104:17, 104:18,
104:21, 105:4,
105:5, 107:8, 112:6,
112:20, 121:11,
130:11
difficult [2] - 23:12,
89:13
digits [1] - 69:3
DIRECT [2] - 3:8, 25:2
Direct [2] - 2:5, 2:7
direct [7] - 103:16,
111:21, 119:14,
135:2, 135:4, 135:5,
135:14
direct-examination
[1] - 135:2
DIRECT-
EXAMINATION [2] -
3:8, 25:2
Direct-Examination
[2] - 2:5, 2:7
directed [3] - 46:22,
46:23, 52:11
directly [4] - 46:16,
59:6, 62:5, 68:7
Director [1] - 14:11
disagree [1] - 75:20
disagrees [1] - 20:11
discharge [10] -
66:17, 68:13, 68:19,
68:20, 69:9, 69:10,
69:12, 70:10, 78:16,
120:6
Discharge [1] - 69:25
6
ROUGH DRAFT DAILY COPY
discharged [2] -
68:15, 68:23
discipline [1] - 96:21
disclosing [1] - 116:7
discuss [1] - 56:16
discussed [6] - 55:3,
77:22, 113:20,
114:23, 116:13,
124:5
discussing [3] -
115:12, 118:9,
125:16
discussion [2] -
126:24, 127:21
discussions [1] -
12:13
Disease [6] - 37:3,
71:12, 118:22,
119:9, 119:12,
119:15
disease [26] - 3:14,
4:2, 4:6, 5:20, 6:12,
7:16, 12:14, 15:18,
25:12, 29:10, 39:16,
49:7, 51:17, 52:4,
52:20, 56:16, 57:18,
59:10, 75:6, 81:12,
96:23, 96:24, 99:20,
100:1, 123:2,
130:18
Diseases [4] - 7:2,
10:10, 13:19, 16:12
diseases [19] - 4:5,
5:3, 5:5, 6:14, 7:4,
7:5, 7:13, 8:2, 8:8,
9:8, 12:15, 13:1,
13:15, 13:16, 15:1,
15:24, 16:22, 16:25,
17:1
disgusting [3] -
56:15, 58:8, 58:9
distal [3] - 61:19,
62:21, 65:2
distance [2] - 55:12,
91:15
distances [1] - 91:18
distinction [4] -
99:13, 112:9,
112:14, 113:6
distinguished [1] -
98:25
distinguishing [1] -
103:19
distracted [1] - 73:25
distress [3] - 30:25,
31:6, 31:15
distressed [1] - 30:23
disturb [1] - 41:24
dividing [1] - 34:10
DIVISION [1] - 1:2
doctor [8] - 24:25,
28:1, 28:8, 96:15,
115:12, 133:8,
133:16
Doctor [4] - 17:6,
94:20, 114:9,
132:13
doctoral [1] - 4:12
doctors [6] - 20:18,
56:19, 94:24, 95:24,
96:10, 96:14
document [4] - 25:19,
48:20, 97:5, 114:6
documentation [3] -
68:7, 78:8, 78:20
documented [6] -
35:7, 68:1, 78:15,
79:4, 79:24, 119:8
documents [1] -
30:16
DOING [1] - 1:12
done [16] - 13:14,
17:16, 18:13, 30:8,
47:8, 53:10, 53:12,
64:20, 76:8, 78:25,
98:5, 99:3, 101:1,
120:11, 121:1,
130:1
dose [2] - 47:13,
106:10
dots [4] - 91:7, 91:8,
91:9
doubt [1] - 34:20
down [39] - 4:10,
9:17, 17:6, 32:20,
40:4, 50:7, 50:22,
51:3, 52:15, 61:2,
62:9, 62:11, 63:19,
67:15, 69:11, 79:10,
79:18, 81:16, 86:13,
87:14, 88:5, 88:11,
88:24, 89:20, 90:5,
90:10, 92:23, 93:6,
93:7, 94:1, 100:4,
103:25, 123:4,
123:20, 127:15,
130:3, 133:17,
133:19
Dr [65] - 3:2, 3:19,
4:10, 15:22, 16:7,
17:19, 17:20, 17:22,
17:23, 17:24, 17:25,
18:3, 18:5, 18:7,
18:11, 19:3, 19:14,
19:19, 20:4, 20:10,
20:16, 24:4, 24:10,
24:13, 25:4, 27:15,
28:16, 28:17, 28:18,
28:21, 29:4, 33:25,
40:7, 52:17, 55:8,
72:2, 73:17, 73:23,
75:3, 75:5, 75:9,
76:1, 76:15, 77:6,
77:11, 82:24, 86:11,
87:6, 89:11, 94:10,
94:12, 111:5, 111:7,
111:10, 112:4,
113:3, 113:11,
128:20, 130:21,
131:23, 132:5,
133:3
DRAFT [1] - 1:16
drain [1] - 79:20
drainage [6] - 79:24,
121:23, 122:3,
123:24, 124:1
draining [3] - 87:23,
90:15, 122:18
drapes [2] - 92:23,
92:24
draw [10] - 36:12,
77:5, 86:13, 87:11,
87:13, 88:18, 88:20,
89:8, 101:12,
101:22
drawing [6] - 36:18,
89:16, 91:6, 91:7,
91:8, 130:15
drawn [4] - 43:19,
47:10, 48:11, 104:7
draws [1] - 101:19
dressing [2] - 37:17,
38:4
drop [1] - 88:5
droplets [2] - 58:18,
58:19
drugs [1] - 5:16
due [2] - 100:8,
132:21
duly [1] - 3:5
during [11] - 8:3,
11:13, 17:24, 22:21,
30:2, 60:24, 62:9,
68:6, 96:10, 120:14,
121:23
dutily [1] - 38:3
duty [1] - 38:5
dying [2] - 33:23,
62:13
E
early [4] - 26:15, 73:3,
78:15, 120:1
easier [2] - 39:20,
134:24
EASTERN [1] - 1:10
Edinburgh [5] - 3:24,
4:16, 10:14, 10:18,
10:21
educated [1] - 3:23
education [1] - 13:17
educational [1] - 3:17
effect [2] - 32:18,
75:14
effectively [2] - 90:13
efforts [1] - 66:1
either [8] - 5:15,
31:15, 37:7, 43:7,
71:23, 74:2, 74:24,
110:24
elected [1] - 110:23
elevation [1] - 125:12
elsewhere [2] -
117:19, 134:11
emergent [1] - 132:11
emergently [1] -
33:18
eminent [1] - 11:7
emptying [1] - 55:10
enabled [1] - 74:24
encouragement [1] -
135:18
end [14] - 15:20,
25:21, 35:5, 40:6,
50:1, 83:12, 84:5,
84:21, 85:5, 85:15,
92:25, 132:7, 135:9,
135:10
ended [1] - 75:11
engine [1] - 79:14
Engineering [1] -
13:8
England [8] - 7:4,
108:9, 108:22,
114:1, 114:13,
114:24, 115:19,
115:25
enterobacter [46] -
43:21, 45:19, 47:20,
47:23, 47:24, 48:3,
48:4, 48:7, 49:7,
51:7, 53:23, 55:4,
55:7, 55:13, 56:7,
58:2, 59:19, 66:23,
67:6, 67:9, 67:11,
83:22, 84:11, 85:22,
86:8, 92:19, 95:15,
101:5, 102:10,
102:15, 103:4,
103:19, 104:1,
104:4, 104:20,
105:1, 105:6,
105:12, 105:13,
112:10, 112:14,
112:18, 113:9,
120:14, 122:4,
122:6
Enterobacter [2] -
43:25, 70:13
enterocutaneous [9]
- 90:14, 116:23,
116:25, 117:9,
130:8, 130:21,
131:1, 132:16,
133:11
enters [1] - 88:1
entire [4] - 6:10, 12:5,
61:3, 73:19
entirely [1] - 112:6
entitled [2] - 13:24,
19:16
entry [3] - 55:12,
56:13, 87:17
episode [1] - 132:22
equivalent [4] - 8:4,
8:7, 8:11, 25:12
eradicate [1] - 64:3
erythema [2] - 41:7,
41:9
especially [1] - 37:8
ESQUIRE [2] - 1:21,
1:23
essentially [4] -
20:16, 23:2, 63:14,
113:6
establish [8] - 21:19,
22:14, 24:9, 39:24,
40:11, 43:10, 65:21,
78:2
established [5] -
17:23, 20:5, 22:18,
72:25, 92:2
establishing [1] -
22:11
Europe [1] - 15:10
evaluate [2] - 77:10,
77:12
evaluated [2] - 74:1,
100:9
evaluation [1] - 77:8
evening [1] - 55:19
event [2] - 18:13,
119:11
events [3] - 20:7,
29:14, 39:5
eventually [2] - 53:13,
92:7
everyday [1] - 56:18
evidence [8] - 38:14,
38:16, 57:1, 75:23,
79:9, 80:18, 83:12
evident [2] - 45:7,
121:15
evidentiary [1] -
23:16
evidently [1] - 32:6
exact [3] - 30:25,
37:21, 103:24
7
ROUGH DRAFT DAILY COPY
exactly [8] - 31:2,
47:5, 54:22, 56:6,
74:20, 95:5, 98:21,
101:25
exam [2] - 49:23,
123:6
examination [3] -
78:13, 134:25,
135:2
EXAMINATION [6] -
3:8, 16:4, 25:2,
94:18, 128:18,
133:6
Examination [6] - 2:5,
2:6, 2:7, 2:8, 2:8,
2:9
examinations [1] -
29:22
examine [1] - 94:16
examined [2] - 3:6,
30:10
examiner [2] -
135:14, 135:15
example [3] - 33:21,
49:19, 56:24
exams [2] - 12:2, 12:3
except [3] - 32:21,
57:18, 110:7
exception [1] - 20:19
exclusion [1] - 21:20
excuse [4] - 24:16,
91:22, 123:9,
126:20
exhibit [1] - 3:18
exist [6] - 54:6, 91:11,
91:12, 92:3, 92:19
exists [2] - 64:7, 92:3
exit [2] - 117:11,
117:12
exited [1] - 133:20
exits [2] - 17:10,
134:2
expect [3] - 17:12,
23:23, 26:22
expected [3] - 46:18,
58:12, 59:20
experience [1] -
102:24
experienced [1] -
35:15
expert [4] - 3:2,
15:23, 15:24, 15:25
experts [2] - 19:17,
19:24
explain [25] - 4:11,
5:9, 9:2, 14:20,
25:9, 31:13, 31:23,
35:24, 36:3, 36:6,
36:11, 36:14, 36:22,
39:23, 45:2, 45:4,
45:20, 53:25, 72:21,
72:22, 79:2, 80:21,
87:12, 92:12, 106:6
explained [2] - 79:11,
106:10
explaining [1] - 106:5
explains [1] - 116:11
explanation [1] -
84:17
exploration [1] -
132:11
exposed [2] - 37:23,
59:8
extent [4] - 19:19,
53:7, 53:25, 95:23
extreme [3] - 33:1,
33:2
extremely [3] - 56:25,
134:8
extremities [4] -
68:11, 72:5, 72:13,
132:23
extremity [4] - 61:6,
62:20, 64:23, 83:15
extubated [1] - 70:4
exudate [1] - 41:7
eye [2] - 45:6, 130:16
F
fabric [1] - 19:21
fact [13] - 37:14, 38:3,
42:6, 47:3, 54:10,
55:18, 68:6, 75:23,
88:23, 91:13, 99:15,
99:21
factors [5] - 26:8,
26:24, 29:9, 29:18,
38:15
facts [3] - 18:23,
27:23, 29:17
factual [3] - 24:4,
26:12, 26:13
faculty [2] - 11:20,
11:22
failing [1] - 74:15
failure [7] - 69:7,
69:15, 69:19, 69:23,
70:3, 72:12, 74:16
fairly [1] - 58:8
fallen [1] - 38:4
falling [1] - 134:9
familiar [12] - 98:16,
98:18, 99:6, 99:12,
99:13, 107:9, 108:9,
110:8, 110:9,
110:16, 110:17,
115:18
family [2] - 85:21,
104:24
fancy [1] - 14:19
far [4] - 28:21, 30:14,
36:22, 91:17
Farber [9] - 4:7, 5:7,
5:9, 5:12, 5:14,
6:15, 8:5, 8:15, 14:4
fashion [1] - 9:18
faster [1] - 85:8
fatigued [1] - 135:10
faxed [3] - 18:23,
28:22
faxing [1] - 18:7
features [1] - 116:8
fed [2] - 88:4, 88:5
feeding [1] - 60:12
feet [7] - 61:9, 62:11,
62:21, 64:24, 65:7,
65:14, 65:17
fellow [1] - 4:24
Fellow [1] - 11:6
fellowship [16] - 4:2,
4:5, 4:23, 5:6, 5:13,
6:4, 6:5, 6:8, 6:13,
6:16, 6:18, 6:25,
7:9, 7:13, 7:16
Fellowship [1] - 11:2
fellowships [2] - 6:9,
7:7
felt [2] - 32:9, 81:16
female [1] - 69:1
femoral [3] - 70:15,
71:1, 71:2
fever [7] - 81:19,
81:23, 81:24, 82:4,
82:7, 82:13, 82:17
few [8] - 41:2, 60:22,
60:24, 67:14, 78:4,
79:23, 82:19, 114:9
fewer [1] - 99:16
fibial [1] - 65:4
field [1] - 114:20
fifth [2] - 63:8, 65:15
fight [4] - 14:17,
14:25, 38:22, 39:11
fighting [1] - 32:1
fights [3] - 5:5, 14:24,
52:12
files [1] - 27:9
filling [2] - 130:7,
130:25
fills [1] - 80:12
final [10] - 44:6,
45:11, 45:15, 53:8,
53:14, 101:2,
101:24, 102:4,
103:2, 103:12
findings [3] - 30:11,
49:23, 49:25
fine [4] - 39:24, 58:16,
87:5, 129:20
finger [4] - 63:8,
72:15, 85:6, 91:20
fingers [3] - 30:24,
31:19, 62:11
fingertips [3] - 33:10,
79:9, 80:3
finish [3] - 112:24,
128:1, 128:5
finished [2] - 64:21,
128:8
firms [1] - 25:16
first [24] - 5:9, 39:25,
40:11, 42:24, 46:20,
49:25, 66:2, 75:4,
77:21, 78:24, 79:6,
87:13, 88:20, 89:9,
93:21, 93:25, 94:22,
104:23, 109:16,
111:2, 111:23,
118:24, 119:6,
132:8
First [1] - 10:17
fistula [37] - 49:10,
60:19, 67:20, 68:1,
68:8, 71:21, 71:25,
82:22, 83:2, 83:10,
83:16, 90:14, 90:17,
90:20, 90:21,
117:10, 117:15,
119:3, 119:19,
119:22, 120:2,
120:8, 121:1, 121:3,
121:9, 122:1, 122:8,
122:12, 123:4,
123:9, 123:17,
129:25, 130:8,
130:12, 132:16,
133:11
fistulas [9] - 116:23,
117:1, 117:6, 117:9,
117:11, 117:19,
117:22, 130:22,
131:1
fit [1] - 36:23
fix [1] - 33:20
fixed [2] - 130:6,
130:24
flair [1] - 49:7
flat [1] - 89:24
floating [3] - 48:6,
49:10, 64:14
floor [1] - 68:17
flow [3] - 44:8, 47:21,
88:8
flowing [1] - 88:8
Fluconazole [2] -
52:9, 52:13
fluid [1] - 124:2
fluids [1] - 80:13
flush [1] - 58:14
flushes [1] - 58:6
focus [5] - 14:21,
14:23, 26:23, 40:17,
135:5
focused [1] - 93:18
focusing [2] - 112:13,
121:17
follow [6] - 17:19,
36:23, 71:15, 80:19,
119:7, 130:23
followed [4] - 4:23,
27:22, 31:8
following [11] - 7:8,
26:7, 28:15, 28:23,
28:24, 49:1, 51:3,
62:19, 70:8, 110:10,
127:21
follows [1] - 3:6
followup [4] - 17:17,
27:25, 28:2, 28:8
foot [4] - 62:15,
72:25, 85:7, 85:13
form [7] - 18:12,
44:14, 87:15, 109:4,
112:10, 115:10,
126:16
forming [2] - 99:7,
110:12
forth [6] - 18:4, 18:16,
53:12, 62:3, 87:16,
88:11
forward [1] - 103:22
foundation [4] -
26:10, 74:12, 74:18,
114:4
foundations [1] -
12:13
fourth [1] - 65:15
FREDERIC [1] - 1:10
Frederic [1] - 21:17
free [5] - 21:22, 21:23,
56:3, 64:14, 133:17
Friday [1] - 127:25
front [2] - 71:8, 91:15
function [3] - 32:12,
50:19, 51:1
functional [2] - 8:4,
25:12
functions [2] - 33:1,
33:13
funded [2] - 12:6,
12:17
Funding [1] - 12:12
funding [1] - 12:16
funds [2] - 12:10,
12:12
furthermore [1] -
38:17
future [1] - 18:9
8
ROUGH DRAFT DAILY COPY
G
gangrene [2] - 67:18,
68:3
gangrenous [2] -
65:2, 65:8
GARCIA [3] - 1:5, 1:6,
1:13
Garcia [9] - 17:19,
17:24, 17:25, 27:15,
28:8, 28:14, 28:17,
28:18, 132:5
Garcia's [1] - 130:21
gastroenterologist
[1] - 82:21
Gastroenterology [1]
- 71:7
GASTROENTEROL
OGY [1] - 1:11
gastrointestinal [1] -
60:6
gathering [1] - 50:1
gauze [1] - 65:16
General [11] - 3:15,
4:4, 4:7, 7:17, 8:16,
9:22, 11:18, 12:17,
13:20, 14:13, 16:11
general [3] - 68:16,
106:23, 107:13
generally [7] - 5:2,
14:21, 30:15, 36:22,
45:14, 49:22, 54:5
generating [1] - 82:17
generation [3] -
43:15, 47:4, 47:6
Genito [1] - 7:1
Genito-Urinary [1] -
7:1
gentleman [1] -
131:21
gentlemen [3] -
24:24, 127:25,
133:22
GI [2] - 67:23, 67:25
GI/Hepatic [1] - 60:6
given [13] - 15:8,
18:10, 18:20, 18:25,
46:2, 47:9, 47:17,
77:22, 77:23, 84:7,
92:13, 106:11,
107:3
glue [2] - 64:12, 64:15
glue-like [1] - 64:12
Gnaden [3] - 40:9,
43:7, 80:3
GNANAPRAKASH [1]
- 1:5
Gopal [5] - 17:20,
17:25, 27:15, 28:8,
28:14
GOPAL [1] - 1:6
Gorski [2] - 17:22,
74:17
Gorski's [1] - 30:3
Government [1] -
12:12
Governor's [1] -
11:10
grade [1] - 16:9
Graduate [1] - 13:18
graduating [1] - 4:13
gram [38] - 42:15,
43:20, 43:22, 44:8,
44:12, 44:18, 45:1,
45:9, 45:19, 45:24,
45:25, 46:23, 46:24,
51:5, 51:7, 51:19,
51:25, 52:4, 52:12,
52:16, 52:20, 57:21,
61:19, 63:10, 63:20,
66:22, 67:11, 69:3,
69:25, 83:24, 85:23,
85:25, 86:9, 92:18,
95:20, 102:16,
102:18, 104:14
gram-negative [9] -
69:25, 83:24, 85:23,
85:25, 86:9, 92:18,
95:20, 102:18,
104:14
grandfathered [1] -
8:8
granted [1] - 20:4
greater [9] - 65:15,
98:25, 99:4, 99:7,
100:15, 107:21,
110:11, 110:12
greeting [1] - 39:9
grew [8] - 43:17,
43:18, 43:19, 43:20,
44:8, 70:12, 70:13,
70:15
ground [2] - 44:10,
134:11
grounds [2] - 46:1,
109:1
GROUP [2] - 1:6, 1:8
grow [6] - 44:5,
44:11, 48:15, 53:9,
89:1, 106:15
growing [2] - 34:10,
42:1
grown [1] - 45:12
grows [1] - 107:4
guess [8] - 22:25,
49:2, 53:12, 54:10,
68:16, 76:2, 79:3,
123:11
guided [1] - 22:10
guideline [4] -
107:22, 107:24,
110:20, 110:23
Guidelines [4] -
113:17, 114:10,
114:12, 114:22
guidelines [9] -
109:9, 109:10,
109:20, 109:24,
110:1, 110:25,
113:12, 115:17,
116:12
guilty [1] - 4:9
Gunning [1] - 10:23
H
hand [3] - 20:7,
64:24, 114:6
handed [1] - 114:22
hands [4] - 63:6,
63:7, 65:5, 87:16
hard [3] - 47:16,
64:17, 71:23
Harkness [1] - 11:6
harm [1] - 74:19
HARRIS [1] - 1:25
Harvard [14] - 7:13,
8:4, 8:20, 8:21,
11:4, 11:20, 11:23,
12:22, 13:3, 13:5,
13:8, 13:12, 13:19,
25:11
hawk [1] - 93:11
HD [1] - 50:12
head [1] - 87:15
healed [1] - 131:3
HEALTH [1] - 1:9
Health [2] - 12:12,
124:9
health [3] - 39:12,
59:3, 79:6
healthy [5] - 32:9,
39:15, 58:25, 77:10,
90:22
hear [6] - 27:20,
30:13, 81:2, 81:6,
86:24, 105:18
heard [6] - 22:8,
23:16, 25:25, 36:22,
50:16, 50:17
Heart [3] - 124:19,
125:3, 132:3
heart [7] - 32:12,
32:13, 32:14, 32:18,
32:23, 33:15, 63:4
heart's [1] - 33:15
Heilman [20] - 40:3,
43:5, 44:22, 50:7,
51:16, 67:16, 68:25,
96:21, 101:14,
101:21, 105:10,
120:10, 121:12,
122:15, 123:4,
123:16, 123:19,
124:8, 126:11,
126:22
helpful [1] - 86:18
hemodialysis [2] -
50:18, 69:6
hen [1] - 30:19
hence [1] - 123:16
heparin [1] - 63:1
hick [2] - 35:20, 36:7
Hickman [28] - 5:24,
36:1, 36:7, 36:20,
39:4, 40:14, 41:6,
41:13, 42:9, 48:22,
49:3, 54:10, 54:14,
55:12, 56:12, 57:12,
59:5, 87:17, 87:18,
87:25, 89:17, 90:1,
90:7, 112:5, 112:11,
112:19, 116:22,
117:4
hidden [1] - 60:19
high [5] - 36:25, 37:3,
89:14, 93:9, 126:19
higher [3] - 37:5,
37:15, 127:12
highlight [5] - 43:5,
48:18, 51:15, 61:2,
68:24
highlighted [1] -
41:16
historical [1] - 37:12
History [1] - 131:16
history [16] - 12:3,
27:7, 29:21, 29:25,
30:1, 30:5, 30:8,
38:3, 49:23, 71:11,
118:9, 118:11,
118:22, 121:21,
132:3
hit [1] - 54:23
hmm [1] - 60:8
holding [1] - 134:5
hole [2] - 72:25, 88:10
holes [1] - 90:25
home [9] - 11:17,
26:15, 57:13, 68:9,
68:21, 78:5, 82:5,
128:2
HOME [1] - 1:13
honestly [1] - 75:4
Honor [44] - 3:21,
15:21, 17:4, 17:14,
19:10, 19:12, 20:2,
21:12, 21:13, 22:3,
22:11, 22:16, 23:12,
23:19, 28:5, 38:7,
66:24, 73:14, 73:18,
76:12, 76:22, 77:3,
86:22, 87:3, 93:13,
106:4, 108:6,
108:25, 111:17,
112:22, 114:2,
114:3, 114:7, 115:2,
115:7, 118:18,
120:16, 120:22,
128:16, 131:8,
134:15, 135:7,
135:25
Honor's [1] - 22:4
HONORABLE [1] -
1:17
honors [1] - 10:13
hope [3] - 31:24,
89:3, 133:22
HOSPITAL [2] - 1:9,
1:12
Hospital [45] - 3:15,
4:4, 4:7, 4:21, 6:21,
6:22, 7:17, 8:16,
8:17, 9:22, 11:19,
12:17, 13:20, 14:13,
26:19, 30:4, 30:20,
35:5, 40:1, 40:2,
40:9, 40:11, 40:12,
40:20, 41:17, 42:25,
43:8, 46:3, 47:9,
49:14, 50:4, 60:1,
60:17, 66:14, 67:10,
73:21, 78:15, 80:4,
83:14, 98:8, 124:12,
124:19, 131:23,
132:6, 132:21
hospital [30] - 4:3,
5:19, 8:6, 8:17,
9:24, 16:8, 26:18,
30:9, 31:5, 31:14,
32:3, 40:10, 40:20,
41:12, 42:7, 42:13,
42:25, 48:12, 64:1,
65:25, 70:20, 77:7,
79:1, 80:8, 80:9,
98:19, 98:25, 99:3,
99:5, 106:12
hospitalization [13] -
60:18, 68:6, 70:18,
84:20, 85:5, 85:15,
85:17, 96:4, 96:11,
120:6, 120:15,
123:21, 131:15
hospitalizations [1] -
132:9
hospitals [3] - 8:9,
8:14, 25:15
Hospitals [1] - 132:4
9
ROUGH DRAFT DAILY COPY
hour [2] - 81:25
hours [3] - 33:23,
78:4, 79:23
house [2] - 30:17,
130:3
Huetten [3] - 40:9,
43:7, 80:3
human [2] - 87:15,
90:8
hundred [2] - 57:2,
57:5
hypothetically [1] -
76:1
hysteroids [2] -
99:23, 100:1
I
Ia [1] - 31:24
ICU [2] - 68:16, 68:23
ID [5] - 96:21, 96:22,
103:8, 103:16,
103:25
identifiable [1] -
45:12
identification [3] -
42:23, 107:18,
113:13
identified [14] - 27:5,
44:13, 44:19, 45:9,
45:10, 46:17, 47:25,
63:17, 96:1, 96:3,
99:23, 100:21,
100:23, 105:16
identify [3] - 43:23,
96:6, 98:1
identifying [2] -
95:25, 107:11
ignores [1] - 75:23
ignoring [1] - 112:9
IJ [2] - 40:14, 41:6
ileostomy [7] - 60:11,
71:12, 89:18, 89:19,
92:17, 92:22,
116:22
ileotomy [1] - 89:5
ill [6] - 40:21, 49:17,
77:23, 79:21, 81:18,
81:23
illness [3] - 27:7,
37:2, 37:3
images [1] - 130:11
imagination [2] -
92:8, 92:12
imagine [2] - 89:21,
90:10
immature [1] - 126:15
imminent [1] - 31:18
imminently [1] -
55:13
immune [2] - 5:15,
14:16
Immunologists [1] -
10:8
Immunology [2] -
4:20, 13:3
immunology [1] - 5:1
immunosuppressed
[1] - 82:10
Immunotherapy [1] -
14:12
immunotherapy [2] -
14:15, 14:16
impact [1] - 47:7
impeached [2] -
21:16, 21:18
Imperial [3] - 6:21,
7:2, 11:10
impermissible [2] -
18:15, 18:25
important [4] - 32:22,
79:25, 80:24,
130:18
impression [12] -
27:25, 49:20, 49:21,
49:24, 49:25, 50:1,
50:4, 51:4, 52:15,
53:19, 59:25, 130:4
improved [1] - 60:14
improving [1] - 12:13
inadmissible [1] -
22:9
INC [2] - 1:10, 1:12
incision [4] - 121:13,
121:22, 121:23,
124:3
include [3] - 110:2,
110:17, 115:25
included [1] - 19:13
including [2] - 35:22,
71:14
inclusion [1] - 21:20
incorrect [1] - 77:14
incorrectly [3] -
96:12, 97:17, 97:20
increase [1] - 38:25
increased [1] - 74:19
incurable [1] - 13:15
indeed [2] - 47:5,
95:21
indelicate [3] - 56:15,
56:19, 56:20
INDEX [1] - 2:1
indicate [7] - 23:4,
26:17, 47:2, 66:14,
70:19, 113:5, 116:5
indicated [11] - 15:15,
16:8, 28:21, 41:11,
72:10, 102:2, 104:4,
107:25, 113:18,
117:14, 128:7
indicates [5] - 4:15,
43:6, 43:10, 52:22,
83:1
indicating [1] - 103:3
indication [1] - 86:2
individual [1] - 39:15
induced [1] - 90:14
indwelling [5] - 5:23,
50:5, 59:5, 70:13,
132:19
infected [7] - 38:15,
48:21, 49:3, 50:5,
50:11, 87:12, 124:2
Infected [1] - 131:16
infection [67] - 5:5,
14:24, 26:8, 31:25,
34:13, 34:23, 35:14,
35:16, 35:21, 35:25,
36:8, 37:1, 37:6,
37:12, 37:20, 38:16,
38:20, 38:23, 39:2,
39:4, 39:6, 39:19,
40:15, 41:14, 41:25,
42:9, 52:12, 55:7,
60:2, 60:20, 61:25,
63:14, 66:9, 66:15,
69:21, 72:10, 72:12,
72:17, 72:22, 73:1,
73:3, 75:24, 77:9,
81:9, 81:22, 82:2,
82:6, 82:9, 82:10,
82:16, 83:16, 84:5,
84:6, 84:13, 86:17,
93:10, 93:24, 99:14,
99:25, 106:20,
106:25, 107:5,
107:17, 110:6,
110:7, 111:11,
113:14
infections [16] - 5:18,
5:19, 5:21, 6:1,
14:17, 37:4, 37:15,
37:16, 70:19,
107:10, 109:10,
110:3, 115:14,
116:9, 117:23,
122:25
Infectious [3] - 10:10,
13:19, 16:12
infectious [38] - 3:14,
4:2, 4:5, 4:6, 5:3,
5:5, 5:20, 6:12,
6:14, 7:5, 7:13,
7:16, 8:2, 8:8, 9:7,
12:14, 12:15, 12:25,
13:16, 14:8, 15:1,
15:18, 15:24, 16:22,
16:24, 17:1, 25:12,
29:10, 51:17, 52:4,
52:20, 56:16, 57:18,
59:10, 75:6, 81:12,
96:23, 96:24
Infirmary [1] - 4:16
inflamed [1] - 93:23
inflammatory [1] -
37:9
information [8] -
18:24, 19:20, 53:3,
102:1, 102:2, 102:3,
102:6, 102:22
infusion [1] - 131:16
initial [6] - 45:6,
53:11, 60:24, 70:9,
70:12, 125:15
initiated [1] - 35:21
inject [1] - 93:1
injure [1] - 62:6
injuries [5] - 26:25,
35:15, 74:5, 74:20,
74:25
inquire [1] - 20:9
inquires [1] - 134:6
inquiring [1] - 19:25
inquiry [1] - 22:19
inside [5] - 55:5, 67:9,
88:6, 88:12
insofar [1] - 112:15
instant [1] - 31:4
instead [1] - 66:22
Institute [7] - 5:7,
5:10, 5:12, 5:14,
6:15, 8:6, 8:15
Institutes [1] - 13:5
instruction [1] -
135:17
insult [1] - 33:7
intact [4] - 39:7, 48:7,
55:24, 56:3
intense [1] - 7:15
inter [1] - 122:22
inter-abdominal [1] -
122:22
interact [1] - 91:2
interestingly [1] -
64:11
internal [2] - 6:19,
42:9
Internal [1] - 6:20
International [1] -
15:4
internationally [1] -
15:6
internship [1] - 4:15
interplay [2] - 9:3,
92:15
interpreted [1] -
97:20
interrupted [1] -
86:14
interventional [2] -
40:13, 50:8
intra [1] - 112:6
intracutaneous [8] -
121:1, 121:3, 121:9,
122:1, 122:12,
122:17, 123:4,
123:17
intravascular [1] -
110:4
intravenous [1] -
47:14
intravenously [1] -
37:7
introducing [1] - 19:3
invading [1] - 93:22
invited [3] - 4:3,
13:11, 15:4
involve [1] - 106:19
involved [8] - 7:15,
9:10, 12:4, 14:6,
19:19, 96:12,
115:13, 115:14
involvement [1] -
20:6
involves [2] - 20:22,
107:17
involving [1] - 6:9
IR [1] - 50:8
irrelevant [1] - 24:15
ischemia [7] - 61:6,
62:21, 64:23, 64:24,
65:14, 67:18,
132:22
ischemic [1] - 69:3
isolated [2] - 110:14,
116:13
isolation [2] - 111:12,
116:5
issue [10] - 3:3,
18:10, 22:4, 22:14,
23:16, 24:18, 25:9,
42:16, 119:11,
119:12
issued [1] - 102:12
issues [17] - 9:10,
9:14, 15:23, 17:12,
18:21, 21:10, 24:15,
26:1, 26:2, 26:9,
28:25, 29:10, 29:21,
60:7, 134:18,
134:23, 135:22
Italy [1] - 15:12
itself [4] - 37:20, 44:7,
83:10, 94:9
IV [3] - 43:11, 51:16,
52:22
10
ROUGH DRAFT DAILY COPY
J
jeopardize [1] - 33:14
job [1] - 64:17
joined [1] - 8:5
JOLYNN [1] - 1:11
JOSE [2] - 1:5, 1:13
Journal [7] - 108:9,
108:22, 114:1,
114:13, 114:24,
115:19, 115:25
journal [2] - 115:20,
115:21
journals [4] - 108:4,
108:14, 108:18,
114:21
judge [1] - 71:3
Judge [2] - 128:7,
135:15
July [1] - 122:19
juncture [1] - 17:4
June [1] - 122:12
jurors [4] - 134:6,
134:7, 134:12,
135:19
jury [30] - 3:16, 4:11,
4:13, 5:9, 5:11, 6:4,
6:7, 8:23, 9:2, 9:16,
17:10, 24:14, 24:17,
24:20, 25:24, 30:15,
30:17, 34:2, 35:24,
36:3, 50:15, 50:16,
56:17, 61:22, 66:5,
72:3, 83:19, 86:19,
133:24, 134:2
justice [1] - 31:24
K
keep [6] - 20:25,
32:25, 33:13, 108:5,
134:9, 135:21
keeping [4] - 79:13,
79:14, 81:17, 89:14
key [1] - 29:9
kidney [2] - 50:19,
51:1
kidneys [2] - 32:23,
50:25
kill [4] - 46:5, 46:18,
47:15, 64:2
killed [2] - 48:5,
106:12
killing [1] - 106:14
kills [1] - 64:1
kind [8] - 6:11, 18:14,
48:15, 57:17, 58:12,
64:14, 74:20, 80:14
Kingdom [10] - 6:22,
7:19, 7:20, 8:3,
10:5, 11:15, 11:16,
15:9, 15:11, 15:13
klebsiella [3] - 69:1,
104:20, 112:19
Klebsiella [51] - 44:9,
44:24, 45:12, 45:18,
46:25, 47:3, 47:5,
47:15, 48:4, 48:6,
51:7, 52:24, 53:19,
53:24, 57:23, 59:11,
59:19, 60:2, 63:20,
64:1, 64:2, 66:22,
67:16, 68:3, 70:14,
83:22, 84:11, 85:21,
86:8, 92:18, 93:3,
95:13, 100:3, 100:7,
100:10, 100:14,
100:18, 100:24,
103:16, 105:3,
105:6, 105:23,
106:1, 106:12,
112:6, 112:11,
112:14, 113:9,
120:14, 122:4,
122:7
knee [4] - 26:25, 66:8,
72:14, 132:23
knowledge [2] - 24:4,
104:4
known [3] - 37:21,
37:22, 71:11
knows [1] - 119:7
L
Lab [1] - 129:5
lab [12] - 53:13, 95:4,
98:8, 98:9, 124:14,
125:21, 125:23,
129:2, 129:3,
129:16, 129:17,
129:22
labeled [2] - 116:3,
116:4
labeling [1] - 97:17
Laboratories [1] -
124:9
laboratory [1] - 13:24
labs [4] - 18:7, 28:22,
127:8, 128:21
ladies [3] - 24:23,
127:24, 133:22
lap [1] - 26:13
large [3] - 27:5,
91:16, 91:17
laser [1] - 135:5
last [9] - 12:17, 51:15,
61:12, 71:9, 86:11,
93:12, 128:21,
131:1, 131:21
late [1] - 68:8
LAUGHLIN [52] -
1:23, 16:2, 16:5,
17:3, 19:12, 20:8,
20:15, 20:19, 21:13,
22:20, 22:25, 23:11,
23:18, 24:2, 28:5,
38:7, 42:10, 44:14,
46:8, 47:11, 66:24,
71:3, 75:18, 76:12,
93:16, 94:19, 97:13,
97:14, 105:22,
106:16, 109:6,
111:20, 111:22,
112:1, 112:2,
112:25, 113:4,
114:8, 115:3,
115:11, 116:20,
118:18, 118:20,
118:23, 121:5,
124:25, 128:7,
128:10, 128:13,
133:7, 133:15,
134:16
Laughlin [16] - 2:7,
2:8, 2:9, 16:1,
17:21, 19:3, 19:11,
21:23, 23:9, 25:10,
28:12, 42:18, 55:18,
81:3, 129:24, 135:4
Laughlin's [1] - 21:15
law [2] - 18:17, 25:16
lawyers [2] - 128:2,
134:25
layer [1] - 89:16
laying [1] - 89:24
lead [2] - 39:11,
117:22
leading [1] - 76:13
leak [1] - 57:8
leakage [3] - 121:3,
121:7, 132:11
leaking [1] - 65:17
leaks [1] - 90:9
learn [1] - 5:25
learns [1] - 66:7
least [3] - 65:24,
71:19, 110:4
Lecturer [1] - 11:10
led [2] - 35:14, 93:25
left [23] - 27:1, 35:20,
36:7, 36:21, 40:14,
41:6, 48:7, 48:21,
49:3, 54:14, 54:15,
63:8, 64:24, 65:15,
66:2, 70:13, 72:15,
74:25, 85:13, 87:23,
87:25, 88:1, 131:16
leg [4] - 62:16, 66:8,
85:7, 85:13
legal [1] - 20:17
legs [5] - 60:23,
61:23, 62:17, 87:14,
132:22
LEHIGH [6] - 1:1, 1:6,
1:7, 1:8, 1:9, 1:9
Lehigh [31] - 1:18,
26:19, 30:4, 30:20,
35:4, 35:23, 36:5,
40:1, 40:2, 40:10,
40:12, 40:20, 41:17,
42:25, 43:8, 46:3,
47:8, 49:14, 50:4,
60:1, 60:16, 66:14,
67:10, 73:20, 78:14,
79:1, 83:13, 98:8,
124:11, 132:4,
132:20
lengths [1] - 104:10
less [6] - 32:15,
39:14, 79:3, 79:20,
80:21, 99:9
letter [2] - 108:17,
132:5
level [6] - 6:12, 7:17,
31:15, 61:16, 80:8,
82:17
LEVIN [1] - 87:3
license [1] - 7:23
licensed [1] - 7:22
licensure [2] - 7:18,
7:21
likely [3] - 38:15,
50:4, 97:2
limit [1] - 133:2
limits [1] - 130:19
line [39] - 3:12, 28:15,
28:25, 37:1, 37:11,
37:14, 37:16, 37:18,
37:20, 37:23, 39:5,
44:7, 50:11, 51:11,
52:5, 57:12, 64:8,
67:6, 67:12, 70:13,
70:19, 71:1, 71:2,
72:10, 72:24, 74:15,
82:10, 84:1, 87:12,
87:17, 87:19, 88:1,
89:4, 89:5, 90:9,
99:24, 109:10,
117:4, 132:20
lines [1] - 90:7
listed [1] - 104:25
lit [1] - 45:5
literature [3] - 108:3,
108:5, 113:12
litigants [1] - 20:23
live [3] - 32:20, 93:2,
93:4
LIVER [1] - 1:11
lives [2] - 56:18,
99:19
living [1] - 94:2
London [7] - 4:2, 4:3,
6:22, 7:2, 11:11,
15:12
look [10] - 16:7, 32:6,
40:8, 49:17, 49:19,
112:3, 115:21,
125:2, 129:17,
130:15
looked [12] - 38:11,
44:17, 60:24,
108:22, 109:2,
109:9, 110:25,
111:5, 113:10,
114:10, 114:23,
133:9
looking [7] - 17:17,
29:15, 46:11, 89:2,
89:24, 98:9, 135:1
looks [5] - 31:20,
89:6, 91:16, 94:23
loops [2] - 90:10,
130:7
loosely [1] - 96:11
lose [3] - 62:15,
62:16, 66:7
lost [2] - 62:16, 62:17
low [1] - 71:15
lower [10] - 54:20,
61:6, 62:20, 64:23,
72:5, 83:15, 85:7,
85:13, 127:3, 127:9
Luke's [7] - 129:4,
129:5, 129:16,
129:17, 129:22,
131:23, 132:6
LUKES [1] - 1:12
lumen [2] - 50:12,
94:8
lunch [1] - 17:9
lungs [4] - 32:10,
32:12, 32:16, 32:23
lying [2] - 29:16, 89:7
M
machine [1] - 97:19
main [3] - 4:2, 39:7,
90:24
maintain [1] - 81:24
major [2] - 91:5, 91:6
manage [1] - 6:1
managed [2] - 132:6,
132:18
management [1] -
11
ROUGH DRAFT DAILY COPY
28:25
manifestations [1] -
110:6
manmade [1] -
116:23
March [6] - 25:20,
29:12, 120:1,
120:15, 121:2,
121:16
marginal [1] - 63:8
marginally [2] - 61:9,
61:14
mark [5] - 3:2, 3:17,
15:22, 73:18, 94:10
MARK [3] - 1:15, 2:4,
3:5
marked [3] - 47:19,
83:21, 85:13
markers [1] - 87:4
Mary's [1] - 6:21
mask [1] - 82:13
Massachusetts [16] -
3:15, 4:4, 4:7, 7:14,
7:17, 7:23, 7:24,
8:9, 8:16, 9:22,
11:15, 11:18, 12:17,
13:20, 14:13, 16:11
match [1] - 84:13
material [2] - 64:12,
121:1
materials [4] - 19:17,
21:24, 108:1,
121:10
matter [3] - 29:8,
33:16, 34:7
matters [1] - 39:13
MATTHEW [1] - 1:21
McGINLEY [1] - 1:17
MD [4] - 1:5, 1:6,
1:10, 1:13
mean [12] - 12:9,
45:17, 49:21, 58:8,
58:9, 62:24, 79:2,
82:5, 88:22, 113:1,
134:10
meaning [1] - 110:11
means [5] - 8:1,
49:22, 50:9, 96:6,
112:21
mechanisms [1] -
33:6
Medevac [2] - 42:24,
80:8
medical [33] - 3:24,
4:13, 7:23, 8:24,
12:1, 12:2, 13:17,
14:19, 25:16, 25:18,
25:19, 25:23, 29:11,
29:16, 31:12, 36:4,
38:25, 47:2, 49:21,
49:22, 66:13, 68:17,
78:9, 82:23, 83:5,
83:13, 94:13,
114:20, 114:21,
115:20, 118:11,
118:22, 131:13
Medical [7] - 7:13,
11:1, 11:20, 11:23,
12:22, 13:3, 13:20
medically [2] - 37:19,
90:14
medication [1] - 43:6
medications [1] -
82:11
medicine [7] - 6:20,
9:1, 9:3, 13:1, 16:9,
16:10, 46:4
Medicine [14] - 4:15,
6:20, 7:1, 7:2, 9:23,
11:10, 13:5, 108:10,
108:23, 114:1,
114:13, 114:25,
115:19, 116:1
meet [1] - 18:16
member [3] - 10:5,
10:7, 10:10
membership [1] -
16:15
Memorial [1] - 26:15
MEMORIAL [1] - 1:13
mention [4] - 95:2,
109:11, 109:16,
109:18
mentioned [10] -
8:14, 8:15, 8:16,
92:23, 93:2, 94:23,
95:23, 114:1,
114:10, 118:8
metabolic [1] - 69:17
method [6] - 98:12,
98:17, 98:18, 98:20,
99:6
microbiological [3] -
53:13, 102:25,
116:7
microbiology [3] -
86:5, 95:1, 95:3
microscopic [2] -
57:7, 57:24
mid [1] - 83:2
middle [2] - 130:16,
132:1
Middlesex [1] - 6:22
midst [1] - 25:7
might [8] - 5:2, 5:10,
8:24, 18:13, 23:25,
39:20, 42:22, 86:18
milligrams [1] - 37:8
mind [2] - 33:21,
34:20
Miner's [1] - 26:14
MINERS [1] - 1:12
minute [6] - 26:17,
33:2, 61:1, 91:17,
114:9, 133:24
minutes [3] - 38:23,
41:2, 59:3
misleading [1] -
120:21
misled [1] - 80:1
missed [1] - 46:21
misspoke [1] - 82:3
mist [1] - 58:16
mixture [1] - 54:5
model [1] - 88:11
moment [5] - 25:19,
65:5, 65:24, 82:3,
120:1
Monday [7] - 133:25,
134:8, 134:13,
134:21, 134:23,
135:24, 136:3
morning [25] - 3:10,
3:11, 16:6, 28:12,
30:2, 30:12, 31:10,
34:15, 49:2, 50:15,
55:19, 63:22, 78:3,
78:10, 78:21, 78:25,
79:4, 79:5, 79:7,
81:2, 81:3, 81:10,
81:15, 82:15, 136:3
most [4] - 32:6,
32:21, 32:22, 99:17
motion [2] - 56:23,
89:21
Motion [1] - 20:3
motions [2] - 55:11,
90:15
mouth [2] - 54:5, 64:9
move [24] - 6:17,
12:21, 15:3, 15:22,
38:8, 48:9, 50:7,
51:2, 51:13, 51:24,
52:3, 53:18, 60:4,
63:19, 67:5, 84:22,
87:2, 92:6, 93:12,
103:25, 116:17,
121:18, 123:4,
135:6
moving [1] - 106:9
MR [139] - 3:1, 3:9,
3:21, 3:23, 4:8,
15:21, 16:2, 16:5,
17:3, 17:14, 19:5,
19:8, 19:10, 19:12,
20:1, 20:8, 20:15,
20:19, 21:12, 21:13,
22:3, 22:16, 22:20,
22:25, 23:11, 23:18,
24:2, 25:3, 28:5,
28:7, 38:7, 38:8,
38:10, 42:10, 42:12,
44:14, 44:17, 44:20,
44:23, 46:8, 46:10,
47:11, 47:13, 66:24,
67:1, 67:2, 71:3,
71:5, 71:6, 73:5,
73:14, 73:16, 75:20,
75:21, 76:12, 76:15,
76:20, 76:21, 76:24,
77:3, 77:4, 85:12,
86:22, 87:1, 87:2,
87:6, 87:8, 87:10,
87:11, 88:21, 89:11,
89:16, 90:19, 91:24,
92:1, 92:10, 93:12,
93:16, 93:17, 94:16,
94:19, 97:13, 97:14,
105:20, 105:22,
106:4, 106:6,
106:16, 108:6,
108:8, 108:25,
109:2, 109:6,
111:17, 111:20,
111:22, 112:1,
112:2, 112:22,
112:24, 112:25,
113:1, 113:4, 114:3,
114:7, 114:8, 115:2,
115:3, 115:7,
115:11, 116:17,
116:20, 118:16,
118:18, 118:19,
118:21, 118:23,
120:16, 120:21,
120:25, 121:5,
124:24, 124:25,
128:7, 128:10,
128:13, 128:16,
128:19, 131:8,
131:10, 133:3,
133:7, 133:15,
134:15, 134:16,
135:7, 135:12,
135:16, 135:25
MS [1] - 87:3
mucosal [1] - 130:16
MUHLENBERG [1] -
1:7
multi [2] - 69:22,
72:12
multi-organs [2] -
69:22, 72:12
multiple [5] - 79:8,
80:2, 92:4, 102:25,
107:8
multiply [1] - 62:2
must [4] - 54:2, 55:5,
57:7, 82:6
mysterious [2] -
49:10, 60:19
N
naked [1] - 45:6
name [12] - 44:1,
44:9, 47:14, 75:3,
75:4, 95:6, 104:23,
104:24, 104:25,
110:13, 131:21,
131:24
named [2] - 25:17,
131:21
names [1] - 95:10
National [2] - 12:12,
15:3
nationally [1] - 15:6
natural [2] - 39:5,
81:22
naturally [1] - 90:22
nature [1] - 132:21
necessarily [1] -
117:12
neck [1] - 87:14
need [13] - 3:20,
21:10, 32:19, 40:5,
65:6, 65:23, 76:17,
91:22, 91:25, 120:7,
133:2, 133:24,
135:23
needs [2] - 21:19,
24:9
negative [34] - 42:15,
43:20, 43:22, 44:8,
44:10, 44:12, 45:1,
45:19, 45:25, 46:24,
51:5, 51:7, 51:19,
52:4, 52:12, 52:16,
52:20, 57:22, 61:20,
63:10, 63:20, 66:22,
67:11, 69:3, 69:25,
83:24, 85:23, 85:25,
86:9, 92:18, 95:20,
102:16, 102:18,
104:14
negatives [2] - 44:19,
45:9
Nephrology [1] - 67:4
NETWORK [1] - 1:9
neutrophil [2] - 38:21
neutrophils [4] -
38:22, 38:24, 126:5,
126:7
New [7] - 108:9,
108:22, 114:1,
114:13, 114:24,
115:18, 115:25
new [3] - 12:14,
113:10, 125:9
12
ROUGH DRAFT DAILY COPY
Newtork [1] - 124:9
next [22] - 3:18, 6:3,
34:18, 38:11, 48:24,
51:13, 51:14, 51:24,
52:19, 60:22, 66:5,
66:16, 67:6, 67:18,
75:3, 90:16, 91:4,
119:18, 122:4,
131:11, 132:18
Nieman [7] - 75:4,
75:5, 75:9, 76:1,
76:16, 77:11, 113:3
nieman [1] - 111:10
Nieman's [5] - 77:6,
111:5, 111:7, 112:4,
113:11
night [2] - 48:19, 49:2
nobody [1] - 23:9
non [1] - 132:17
non-operatively [1] -
132:17
none [1] - 31:21
nonetheless [1] -
86:7
normal [9] - 58:25,
81:4, 81:10, 91:14,
124:16, 126:17,
126:21, 129:14,
130:19
nose [6] - 30:24,
31:19, 33:9, 62:11,
79:9, 80:3
note [21] - 20:19,
30:22, 39:25, 41:1,
41:2, 41:11, 41:14,
49:20, 63:7, 63:14,
63:21, 71:9, 71:18,
71:21, 82:21, 96:25,
97:18, 130:20,
131:4, 131:15,
131:20
noted [3] - 41:3, 41:5,
99:5
notes [5] - 60:5, 97:3,
103:8, 103:23
NOTES [1] - 1:15
nothing [1] - 18:7
notice [1] - 98:24
novel [1] - 14:7
November [8] - 25:21,
27:8, 27:9, 29:12,
35:6, 85:14, 85:15
Number [1] - 69:25
number [7] - 19:13,
19:18, 32:11,
100:16, 103:8
numbers [1] - 73:21
Nurse [6] - 17:22,
30:3, 30:22, 38:1,
74:14, 79:4
nurses [1] - 97:2
nursing [1] - 65:17
Nutrition [1] - 28:16
O
o'clock [2] - 49:2,
63:22
object [2] - 18:11,
71:3
Objection [1] - 66:24
objection [26] - 28:5,
38:7, 38:8, 42:10,
44:14, 46:8, 46:9,
47:11, 75:18, 76:12,
76:18, 106:4, 108:6,
108:25, 109:4,
112:22, 112:23,
114:3, 115:2, 115:7,
115:9, 116:17,
120:16, 120:19,
120:20, 120:21
obstruction [2] -
130:8, 130:25
obtained [2] - 8:2,
110:5
obvious [1] - 135:12
occasions [1] - 122:6
occur [3] - 39:1,
66:11, 90:21
occurred [1] - 122:10
occurring [1] -
121:16
OCR [1] - 1:25
October [63] - 18:22,
26:5, 26:6, 26:16,
27:24, 28:16, 30:12,
31:10, 34:8, 34:14,
34:23, 35:1, 35:5,
35:23, 35:25, 36:5,
36:9, 38:1, 48:12,
48:13, 50:16, 51:17,
52:19, 59:10, 61:3,
63:21, 64:22, 65:13,
67:4, 67:15, 68:8,
70:4, 71:18, 71:20,
72:11, 72:18, 73:20,
74:2, 79:7, 83:12,
83:20, 84:21, 86:14,
86:15, 101:2,
101:17, 103:9,
103:10, 103:24,
118:5, 119:6,
119:10, 119:15,
121:17, 125:10,
127:6, 130:2,
130:20, 131:4,
131:15
OF [4] - 1:1, 1:15
office [2] - 17:24,
132:2
often [2] - 5:17, 99:17
old [1] - 71:11
ON [2] - 3:8, 16:4
once [3] - 22:18,
39:14, 97:18
oncologist [1] - 5:11
one [65] - 5:10, 6:9,
7:7, 8:19, 19:18,
20:1, 20:21, 20:22,
21:23, 21:25, 26:18,
31:13, 32:8, 32:11,
39:7, 41:25, 42:18,
45:7, 45:9, 45:10,
46:15, 58:4, 58:23,
62:4, 66:7, 67:8,
70:23, 80:9, 84:4,
87:22, 88:24, 90:25,
91:1, 91:5, 92:4,
93:21, 94:4, 96:15,
96:20, 97:19, 97:21,
99:1, 99:16, 99:17,
99:21, 101:19,
102:11, 103:9,
103:23, 104:6,
105:11, 106:1,
108:14, 108:18,
109:1, 110:4,
110:10, 117:2,
121:12, 123:19,
128:21, 129:13,
133:24
ones [3] - 46:17,
114:23, 121:2
onset [1] - 83:7
open [1] - 123:23
opened [4] - 55:20,
67:23, 71:22, 83:11
opening [3] - 42:17,
71:25, 82:22
opens [1] - 117:15
operative [2] - 120:4,
132:3
operatively [1] -
132:17
opinion [33] - 21:21,
22:12, 29:5, 29:18,
34:1, 34:3, 34:7,
34:13, 34:16, 34:17,
34:18, 34:22, 35:2,
35:6, 35:12, 35:13,
35:16, 35:19, 35:24,
36:6, 36:20, 48:2,
56:5, 56:6, 56:7,
56:9, 56:10, 74:8,
74:9, 77:7, 84:7,
92:13, 111:10
opinions [6] - 18:12,
20:13, 24:4, 24:11,
29:2, 94:12
opportunity [2] -
36:11, 132:2
opposition [1] - 93:14
oppression [1] -
123:17
orally [1] - 37:7
order [2] - 45:22,
50:19
organ [2] - 32:11,
91:5
organism [16] -
42:18, 42:19, 43:19,
44:10, 52:13, 84:14,
85:23, 95:7, 97:17,
100:23, 107:11,
107:18, 111:13,
112:7, 116:6
organisms [26] -
51:8, 52:10, 54:1,
57:7, 57:21, 57:22,
83:20, 83:22, 92:14,
95:10, 95:11, 95:17,
95:25, 96:7, 96:12,
98:2, 99:9, 100:20,
104:14, 104:17,
104:21, 105:15,
110:14, 115:15,
116:13, 122:9
ORGANIZATION [1] -
1:10
organs [7] - 32:5,
32:22, 50:22, 69:22,
72:12, 117:20
original [1] - 48:11
Original [2] - 10:20,
10:23
originated [1] - 35:17
otherwise [2] - 50:20,
119:20
outcome [2] - 75:12,
76:10
outside [2] - 88:13
overruled [6] - 28:6,
46:9, 47:12, 66:25,
75:19, 76:18
overwhelming [3] -
32:1, 32:2, 35:13
own [1] - 36:13
oxygen [3] - 32:19,
62:12, 80:11
P
P.M [2] - 73:8, 73:10
p.m [6] - 21:4, 21:6,
24:21, 78:3, 134:3,
136:5
P10 [1] - 86:9
page [40] - 15:2,
15:20, 25:8, 30:3,
30:4, 40:1, 41:4,
41:5, 41:16, 43:4,
44:21, 48:24, 50:7,
51:4, 51:13, 51:15,
51:24, 51:25, 52:15,
53:18, 59:23, 59:24,
63:19, 67:6, 69:12,
70:8, 71:8, 71:9,
115:22, 121:12,
121:13, 122:4,
123:13, 123:20,
125:16, 125:19,
125:20, 131:2,
132:4
PAGE [1] - 2:3
pages [3] - 10:2,
123:16
pain [1] - 35:8
pale [3] - 79:8, 80:2,
80:15
palpable [3] - 61:16,
62:21, 65:4
paragraph [3] -
68:24, 118:24,
132:8
parastomal [1] -
132:7
Parenteral [1] - 28:15
part [11] - 17:15,
19:21, 26:16, 70:8,
70:9, 74:14, 86:8,
92:19, 110:8,
111:12, 126:24
partially [1] - 51:19
particular [14] - 24:3,
32:17, 43:16, 45:23,
46:4, 46:5, 54:7,
81:17, 82:11, 93:8,
98:18, 100:2, 105:1,
106:21
particularly [1] -
26:25
partner [1] - 28:17
pass [1] - 39:9
past [5] - 12:22,
118:11, 118:21,
119:2, 119:10
pathogenic [2] -
99:20, 100:1
pathology [1] - 10:18
patience [1] - 31:11
patient [69] - 9:6,
17:18, 18:21, 25:17,
26:18, 30:10, 30:23,
30:25, 31:3, 31:5,
31:14, 31:15, 31:18,
31:20, 32:5, 33:9,
33:18, 33:20, 33:22,
13
ROUGH DRAFT DAILY COPY
35:15, 36:25, 37:2,
37:9, 40:21, 41:22,
47:25, 49:18, 49:19,
50:18, 50:20, 54:7,
55:9, 57:20, 59:18,
59:20, 59:21, 60:14,
60:18, 65:14, 68:14,
68:15, 68:20, 69:6,
70:9, 70:12, 71:11,
71:14, 72:24, 77:23,
79:5, 79:6, 79:21,
80:20, 80:22, 80:23,
81:14, 81:20, 89:2,
89:24, 106:13,
110:3, 117:6,
118:11, 119:5,
119:20, 127:2,
127:3, 132:16,
132:17
patient's [7] - 30:10,
39:12, 42:2, 72:18,
74:1, 78:23, 119:8
patients [14] - 5:15,
5:18, 5:23, 6:11,
9:25, 12:3, 12:14,
25:11, 32:10, 36:14,
37:2, 49:17, 80:25,
82:12
pattern [1] - 42:1
PAUL [1] - 1:23
PC [3] - 1:7, 1:11,
1:13
pending [1] - 51:22
penetrate [1] - 64:18
penetrated [1] - 89:17
PENNSYLVANIA [1] -
1:10
Pennsylvania [2] -
1:19, 124:22
people [2] - 37:5,
90:22
per [1] - 9:14
percent [2] - 57:2,
57:6
perform [1] - 109:7
performed [2] -
98:10, 130:23
performing [1] - 12:3
perhaps [6] - 26:12,
56:16, 96:11, 97:11,
97:16, 99:10
period [4] - 37:7,
119:6, 121:16,
121:24
peripheral [2] - 110:5,
110:15
periphery [2] - 62:5,
62:10
permissible [2] -
19:15, 114:5
permit [1] - 21:25
permitted [2] - 20:9,
24:2
persisted [2] -
122:13, 122:14
person [4] - 31:25,
33:5, 58:25, 80:11
person's [1] - 89:7
pertinent [1] - 5:22
Ph.D [1] - 3:25
phenomenon [1] -
56:17
phrase [1] - 46:3
physical [5] - 30:6,
30:11, 38:14, 38:15,
57:6
Physician [1] - 9:23
physician [10] - 3:14,
4:6, 7:22, 16:9,
16:10, 17:19, 18:18,
19:19, 41:12, 75:3
PHYSICIAN [4] - 1:6,
1:8, 1:8, 1:9
PHYSICIAN-
HOSPITAL [1] - 1:9
Physicians [2] - 7:20,
10:5
physicians [7] -
16:16, 28:13, 28:14,
61:22, 97:5, 97:16,
108:19
physiologically [3] -
31:9, 31:22, 65:7
pick [1] - 30:18
picking [1] - 26:6
picture [1] - 36:11
pictures [2] - 87:9,
87:11
piece [1] - 44:7
pieces [1] - 19:23
pink [1] - 80:16
pinker [1] - 80:15
pinky [4] - 27:1,
62:17, 66:2, 75:1
place [4] - 7:10,
88:15, 92:22,
127:22
placed [6] - 37:11,
43:11, 65:16, 70:15,
71:2, 130:10
placement [1] - 50:11
places [1] - 54:2
plaintiff [3] - 3:1,
24:8, 94:11
Plaintiff [2] - 1:3, 1:22
PLAINTIFF'S [1] - 2:3
plaintiff's [9] - 3:18,
47:20, 73:19, 82:20,
83:21, 85:14, 94:11,
94:12
plan [2] - 67:4, 67:16
plans [1] - 68:2
plantar [1] - 65:15
plastic [10] - 64:7,
64:9, 64:17, 87:21,
88:1, 88:7, 88:10,
93:2, 93:4, 94:2
play [1] - 29:11
played [1] - 20:12
PLEAS [1] - 1:1
pleasant [1] - 133:23
plenty [1] - 20:18
plus [1] - 126:8
pneumonia [1] -
44:25
pneumoniae [4] -
44:9, 52:24, 100:14,
105:3
point [46] - 5:22, 6:3,
30:18, 33:13, 33:17,
49:5, 49:11, 50:14,
50:17, 51:18, 53:2,
53:14, 53:15, 53:22,
55:2, 55:19, 56:13,
56:21, 57:15, 57:17,
58:4, 58:7, 58:23,
64:4, 65:11, 66:7,
68:15, 70:14, 72:5,
73:1, 73:4, 73:18,
76:1, 78:13, 79:25,
81:1, 81:17, 82:23,
86:11, 92:1, 93:19,
104:6, 117:5,
117:14, 123:24,
131:22
pointed [2] - 28:13,
81:3
pointing [1] - 94:4
points [5] - 8:22,
8:25, 9:4, 29:20,
82:19
poisoned [1] - 32:13
poisons [6] - 32:4,
32:14, 34:11, 62:3,
62:4
Poland [1] - 15:12
poor [1] - 135:19
popping [1] - 90:3
port [1] - 92:25
portions [1] - 24:3
position [2] - 110:19,
116:16
positions [2] - 9:24,
16:8
positive [17] - 29:18,
41:6, 46:1, 46:23,
51:19, 52:24, 59:10,
78:16, 78:21, 79:24,
95:2, 103:16,
103:19, 107:4,
110:5, 110:11,
122:3
possess [1] - 35:3
possible [7] - 20:25,
31:4, 42:4, 42:5,
55:13, 97:21,
102:19
possibly [2] - 57:8,
57:10
Post [1] - 13:18
post [4] - 4:12, 60:11,
71:12, 130:24
postsurgical [1] -
130:6
potential [1] - 57:21
potentially [2] -
57:13, 124:2
pouch [1] - 65:18
Power's [1] - 18:3
Powers [1] - 27:16
POWERS [1] - 1:7
powers [4] - 17:22,
17:23, 18:5, 28:16
POZNANSKY [24] -
1:15, 2:4, 3:5, 3:23,
38:10, 44:17, 47:13,
67:1, 75:20, 76:20,
76:24, 87:1, 87:8,
87:11, 89:16, 91:24,
92:1, 105:20, 106:6,
113:1, 118:19,
118:21, 120:25,
124:24
Poznansky [21] - 3:2,
4:10, 15:22, 16:7,
25:4, 33:25, 40:7,
52:17, 55:8, 72:2,
73:17, 73:23, 77:6,
82:24, 86:12, 87:7,
89:11, 94:10, 94:12,
128:20, 133:3
Poznansky's [2] -
3:19, 94:11
practice [5] - 7:24,
8:24, 9:1, 25:15,
28:17
PRACTICE [1] - 1:8
precise [1] - 22:14
precisely [1] - 44:13
Preclude [1] - 20:3
precluded [2] - 19:3,
23:21
predicate [1] - 26:13
pregangrenous [1] -
65:16
preliminary [3] -
45:14, 102:12,
102:14
premise [1] - 28:9
preparation [1] -
110:21
prepared [2] - 76:2,
109:20
preparing [1] - 109:8
presence [5] - 82:11,
101:5, 112:11,
112:17, 112:19
present [21] - 13:18,
14:6, 14:11, 16:10,
27:18, 27:20, 34:14,
34:23, 35:25, 36:8,
37:24, 72:10, 74:17,
78:7, 78:12, 83:3,
92:17, 110:11,
118:4, 123:8, 127:4
presentation [4] -
12:25, 84:17, 92:20,
119:5
presentations [4] -
12:21, 13:11, 15:5,
15:8
presented [1] - 77:7
presume [2] - 26:5,
26:10
presumed [1] - 99:9
presumption [1] -
74:13
pretty [1] - 64:17
prevent [2] - 15:1,
19:24
prevented [1] - 74:5
previous [3] - 37:14,
39:12, 127:8
previously [5] -
38:19, 101:22,
102:17, 109:9,
127:2
primary [4] - 14:21,
14:23, 28:14, 80:10
PRIMARY [1] - 1:7
private [1] - 12:13
privy [1] - 102:13
Prize [1] - 10:23
pro [1] - 20:23
problem [2] - 24:18,
49:8
problems [8] - 18:8,
27:2, 63:16, 68:10,
83:15, 119:3, 120:1,
122:24
procedural [2] -
48:18, 48:25
procedure [1] - 120:4
proceedings [1] -
21:6
PROCEEDINGS [1] -
73:10
process [13] - 12:4,
12:11, 12:15, 34:9,
36:12, 36:15, 65:22,
14
ROUGH DRAFT DAILY COPY
65:24, 80:18, 80:19,
87:12, 88:8, 104:11
processed [1] - 104:8
producing [3] - 32:4,
34:11, 62:3
profession [1] - 3:13
professional [2] -
10:1, 10:4
professionals [1] -
79:7
Professor [2] - 9:23,
11:24
Program [1] - 6:20
progress [1] - 97:5
progressed [2] -
62:1, 78:20
progression [5] -
39:6, 63:13, 65:22,
72:11, 86:16
progressive [1] -
39:18
promised [2] - 128:3,
135:21
protection [1] - 37:17
protocol [3] - 30:5,
30:8, 101:10
provided [2] - 19:6,
19:20
providers [2] - 83:5,
83:13
proximal [2] - 88:19,
88:22
proximity [1] - 91:12
public [2] - 59:2, 59:3
published [5] - 15:16,
107:25, 108:16,
114:16, 116:10
pull [6] - 67:3, 68:13,
71:5, 82:19, 130:1,
131:19
pulse [1] - 61:16
pulses [3] - 62:21,
65:4
pumping [2] - 32:18,
33:15
purple [5] - 31:19,
33:10, 45:24, 45:25
purplish [2] - 30:24,
45:23
purpose [1] - 31:3
purposes [6] - 26:4,
26:8, 42:24, 47:19,
48:10, 74:12
purulent [3] - 41:7,
123:24, 124:1
put [30] - 23:3, 24:13,
33:16, 41:3, 41:4,
42:23, 44:2, 44:20,
46:18, 48:17, 49:13,
50:18, 50:24, 64:7,
79:12, 84:24, 85:3,
87:23, 89:18, 96:20,
100:11, 106:17,
110:23, 120:7,
120:10, 122:20,
124:8, 125:9,
126:11, 128:20
putting [3] - 37:19,
80:13, 84:22
Q
Qualifications [2] -
2:5, 2:6
QUALIFICATIONS [2]
- 3:8, 16:4
quantitative [1] -
110:12
questions [7] - 16:2,
17:21, 101:25,
128:3, 131:11,
133:4, 135:6
quick [1] - 36:14
quicker [2] - 6:18,
39:21
quickly [5] - 36:17,
40:8, 128:22, 130:4,
135:22
quite [8] - 30:25,
31:12, 31:13, 31:19,
31:23, 71:13, 86:20,
88:24
quo [2] - 71:12, 85:18
R
radiology [3] - 40:13,
50:8, 131:15
raised [1] - 38:21
raises [1] - 39:1
raising [1] - 125:6
range [8] - 124:15,
125:3, 126:19,
129:6, 129:18,
129:19, 129:21
ranking [1] - 9:24
rapid [1] - 77:16
rapidly [4] - 30:23,
31:4, 31:18, 33:18
rarely [2] - 92:16,
99:20
rather [2] - 18:9,
99:25
rattle [1] - 36:14
ray [2] - 49:24, 130:14
re [1] - 132:15
re-repaired [1] -
132:15
reach [2] - 20:23,
29:18
reaches [1] - 87:21
reaching [3] - 19:18,
24:11, 29:5
react [1] - 38:23
reacting [1] - 62:8
reaction [1] - 82:2
read [10] - 24:14,
63:7, 65:5, 65:18,
69:4, 72:6, 73:5,
73:24, 108:12,
132:24
reading [3] - 30:21,
112:4, 115:8
reads [1] - 40:13
ready [2] - 24:24,
38:24
reality [2] - 102:9,
133:12
really [6] - 24:1,
33:14, 54:6, 130:13,
133:1, 135:19
reappears [1] - 80:23
reason [1] - 57:11
reasonable [1] -
94:13
reassess [1] - 74:15
received [1] - 43:11
receiving [1] - 40:21
recess [2] - 17:9, 21:3
RECESS [1] - 73:8
recognize [1] - 15:22
recognized [3] - 8:3,
31:5, 73:1
recollection [4] -
85:1, 111:23,
121:22, 123:3
recommend [1] -
71:13
reconcile [3] - 78:19,
79:22, 81:11
record [31] - 22:20,
27:10, 28:3, 29:23,
30:4, 31:8, 35:8,
36:21, 37:13, 37:22,
40:8, 41:6, 42:24,
43:6, 44:2, 61:24,
66:13, 66:21, 71:24,
78:9, 78:14, 82:23,
83:9, 84:25, 85:24,
97:5, 99:22, 124:14,
127:19, 127:22,
131:22
recorded [1] - 83:5
records [59] - 25:17,
25:18, 25:19, 25:24,
26:15, 26:17, 26:23,
27:4, 27:5, 29:11,
29:16, 29:17, 30:6,
30:13, 31:8, 34:1,
34:4, 34:12, 35:22,
36:4, 39:20, 39:25,
40:9, 43:2, 47:2,
48:20, 49:6, 49:11,
53:8, 54:11, 60:22,
61:1, 61:24, 65:23,
66:6, 66:12, 68:19,
70:19, 72:2, 72:3,
72:6, 78:1, 83:11,
84:22, 85:10, 85:16,
86:2, 95:3, 97:9,
97:15, 98:9, 103:3,
118:5, 118:9,
124:20, 129:24,
131:13, 132:10
recross [1] - 133:2
Recross [1] - 2:9
RECROSS [1] - 133:6
Recross-
Examination [1] -
2:9
RECROSS-
EXAMINATION [1] -
133:6
rectum [1] - 131:20
recurred [1] - 122:12
recurrent [1] - 132:7
red [5] - 79:15, 79:18,
79:20, 100:1
REDIRECT [1] -
128:18
Redirect [1] - 2:8
REDIRECT-
EXAMINATION [1] -
128:18
Redirect-
Examination [1] -
2:8
redness [13] - 38:12,
38:13, 41:10, 78:8,
78:9, 78:16, 78:21,
79:3, 79:24, 80:21
reeds [1] - 51:23
reemerge [1] - 133:12
refer [3] - 26:23,
29:21, 108:19
reference [14] - 3:20,
9:20, 30:3, 65:5,
84:23, 96:9, 97:16,
116:22, 119:2,
124:15, 125:3,
129:6, 129:18,
129:19
referenced [6] - 5:1,
7:19, 110:20, 119:2,
119:14, 126:1
references [1] - 85:24
referencing [3] -
118:9, 125:21,
125:24
referred [4] - 29:6,
36:25, 41:11,
118:21
referring [9] - 25:13,
25:18, 25:19, 44:3,
44:21, 94:24, 132:9,
132:12, 135:14
reflect [1] - 28:3
reflecting [1] - 85:16
reflects [1] - 122:22
refresh [2] - 121:22,
123:3
regard [6] - 11:22,
19:17, 21:15, 28:24,
72:24, 94:22
regarding [4] - 8:15,
25:25, 78:8, 129:25
regards [3] - 12:2,
61:23, 93:24
Regional [1] - 15:3
regular [1] - 9:6
relate [2] - 56:18,
60:23
related [23] - 17:25,
42:15, 52:18, 53:20,
61:19, 61:23, 63:10,
67:16, 69:1, 69:3,
69:21, 84:6, 84:12,
84:24, 107:10,
107:17, 108:24,
109:10, 110:2,
111:11, 113:13,
115:14, 116:1
relatedly [1] - 78:12
relating [1] - 29:21
relation [2] - 55:16,
113:2
relationship [2] -
112:17, 113:8
relatively [1] - 58:7
relevance [2] - 18:1,
18:3
relevant [2] - 34:3,
119:4
relied [5] - 22:12,
23:4, 23:10, 24:10
relies [1] - 22:5
rely [8] - 22:15, 22:18,
23:6, 23:21, 23:24,
29:4, 29:7
remain [3] - 61:9,
66:18, 71:14
remains [2] - 62:22,
71:12
remarkable [1] - 32:7
remember [11] - 28:1,
55:20, 55:23, 55:25,
57:7, 75:5, 76:19,
76:24, 92:23,
118:12, 131:24
15
ROUGH DRAFT DAILY COPY
remembered [1] -
111:20
remind [2] - 31:2,
91:22
removal [2] - 50:11,
99:10
remove [1] - 40:13
removed [4] - 21:24,
84:1, 84:2, 112:5
renal [2] - 69:7, 69:19
reorient [1] - 82:22
repair [1] - 132:12
repaired [1] - 132:15
repeat [3] - 36:2,
105:19, 105:20
rephrase [1] - 24:6
replicating [1] - 34:10
report [41] - 19:13,
23:3, 23:4, 38:5,
45:11, 45:15, 55:4,
75:7, 75:15, 76:5,
76:14, 76:15, 76:20,
99:21, 99:22,
102:12, 102:14,
109:8, 109:12,
109:16, 109:18,
111:2, 111:3, 111:4,
111:5, 111:7,
111:15, 111:18,
111:25, 112:8,
113:11, 113:16,
113:22, 118:7,
118:12, 118:17,
119:14, 122:20,
125:15, 125:16,
125:19
reported [5] - 30:22,
38:2, 38:10, 101:24,
102:15
REPORTER [1] - 1:25
reporting [5] - 26:7,
45:5, 45:15, 78:25,
80:20
reports [8] - 45:6,
81:25, 95:1, 102:25,
109:14, 110:24,
111:1, 113:23
represent [2] - 28:3,
85:8
represents [1] - 93:5
request [2] - 21:15,
25:16
require [1] - 5:20
required [2] - 93:10,
132:10
requiring [1] - 132:23
Research [3] - 10:20,
10:23, 11:1
research [12] - 4:24,
6:14, 6:16, 7:9, 9:7,
12:5, 12:6, 14:7,
14:18, 14:22, 14:23,
109:7
residence [1] - 71:14
Residency [1] - 6:20
residency [1] - 4:20
resident [1] - 6:19
residents [2] - 31:14
resistant [3] - 48:1,
48:8, 64:13
resolve [1] - 83:23
resolved [1] - 85:19
resolving [1] - 123:10
respective [1] -
108:14
respiratory [2] -
69:15, 70:3
respond [4] - 59:20,
76:10, 77:6, 83:23
responds [1] - 5:4
response [8] - 25:9,
32:17, 37:9, 63:15,
75:17, 76:5, 81:21,
81:22
responsibilities [1] -
13:23
responsive [1] -
76:15
rest [4] - 9:6, 63:7,
128:2, 135:11
restricted [1] - 33:11
result [10] - 5:17,
44:24, 50:20, 66:9,
69:22, 72:14,
105:12, 132:8,
132:19
resulted [3] - 63:14,
68:10, 92:14
resulting [3] - 27:1,
63:16, 72:13
results [16] - 38:20,
53:8, 53:16, 76:9,
79:17, 84:8, 84:11,
92:14, 100:11,
101:1, 102:16,
103:12, 105:10,
105:24, 125:21,
125:23
resume [7] - 3:19,
4:14, 10:1, 12:5,
15:20, 24:24, 25:8
resumed [1] - 21:6
RESUMED [1] - 73:10
resuscitate [5] - 80:4,
80:7, 80:10, 80:14,
81:20
resuscitated [4] -
33:19, 33:24, 80:20,
80:23
resuscitating [1] -
82:1
resuscitation [2] -
80:5, 80:9
return [2] - 24:25,
73:13
returned [1] - 4:1
returns [1] - 24:20
revenue [1] - 71:15
review [16] - 20:10,
25:16, 27:11, 27:13,
27:15, 31:7, 61:24,
75:7, 95:1, 97:9,
108:3, 108:4, 108:5,
113:11, 124:19,
132:3
reviewed [15] - 19:14,
19:17, 19:24, 21:24,
22:6, 23:3, 23:7,
27:17, 34:12, 36:24,
86:5, 97:15, 110:20,
118:4, 132:10
reviewing [2] - 25:23,
35:22
rib [1] - 54:25
rings [1] - 85:2
risk [12] - 26:8, 37:1,
37:4, 37:6, 37:15,
37:20, 38:14, 59:1,
59:7, 74:19, 93:5,
93:10
RN [1] - 1:11
Rocephin [16] - 43:5,
43:11, 43:14, 46:2,
46:18, 46:22, 46:25,
47:7, 47:14, 47:17,
47:23, 48:1, 48:5,
63:25, 77:22, 78:2
rocephin [2] - 46:17,
46:23
rod [6] - 51:19, 51:25,
52:5, 63:20, 66:22,
83:24
rods [7] - 45:1, 52:21,
86:9, 92:18, 95:20,
102:16, 102:18
role [4] - 7:21, 20:12,
29:11, 39:8
room [6] - 22:21,
22:23, 23:5, 23:15,
33:9, 133:24
rotate [1] - 89:7
ROUGH [1] - 1:16
roughly [1] - 63:22
Rounds [1] - 13:19
royal [1] - 16:15
Royal [3] - 4:16, 7:19,
10:5
rule [1] - 21:17
rules [1] - 18:17
ruling [1] - 22:5
run [2] - 24:15,
134:10
running [1] - 88:6
runs [1] - 130:10
S
Sacred [3] - 124:18,
125:3, 132:3
safety [1] - 59:4
sake [1] - 85:8
salvage [1] - 66:1
salvageable [3] -
65:12, 72:19, 74:3
sample [2] - 43:19,
121:4
sampled [1] - 84:19
samples [3] - 38:17,
101:12, 129:6
save [1] - 33:14
saw [2] - 36:24, 95:2
scars [1] - 123:23
scattered [2] - 91:9,
92:17
scene [1] - 29:13
scheduled [1] - 20:22
scholars [1] - 11:8
Scholarship [1] -
10:14
school [2] - 3:24,
4:13
School [6] - 7:14,
11:20, 11:23, 12:22,
13:3, 13:20
SCHUYLKILL [1] -
1:12
science [1] - 80:24
Science [1] - 13:8
scientific [1] - 4:1
scientist [1] - 3:14
scold [2] - 135:3,
135:4
scope [5] - 18:20,
46:8, 47:11, 71:4,
76:13
Scotland [2] - 3:24,
4:16
screen [2] - 31:1, 41:2
scripture [1] - 130:13
se [2] - 9:14, 20:23
seal [1] - 57:5
sealant [1] - 89:23
seat [1] - 58:21
second [8] - 25:24,
44:25, 76:14, 84:4,
109:18, 111:3,
111:4, 118:16
secondary [6] -
51:10, 51:25, 53:19,
60:12, 68:3, 85:18
section [7] - 12:5,
51:16, 61:3, 89:4,
115:22, 130:4,
131:2
see [65] - 5:18, 7:18,
9:6, 9:25, 15:11,
15:12, 16:11, 16:20,
20:20, 21:1, 21:9,
21:10, 24:1, 30:13,
31:1, 31:20, 31:21,
33:9, 36:13, 36:23,
38:25, 40:18, 41:23,
44:18, 45:5, 57:9,
58:17, 58:19, 66:6,
72:3, 75:9, 75:14,
76:20, 81:24, 83:3,
84:23, 88:9, 88:24,
89:12, 91:8, 103:3,
103:11, 108:22,
109:2, 111:4,
111:25, 112:8,
113:17, 114:6,
122:15, 122:17,
125:16, 127:18,
129:2, 130:12,
131:6, 131:22,
132:2, 134:7, 136:3
seeing [3] - 6:11,
79:17, 102:24
seem [2] - 134:9,
134:12
seeping [1] - 124:2
segment [1] - 110:15
segmented [1] -
126:7
segments [1] - 126:8
segs [6] - 126:9,
126:12, 127:6,
127:10, 127:14,
127:15
selectively [1] - 48:5
Seminar [3] - 13:3,
13:5, 13:9
seminars [1] - 13:1
semiquantitative [3] -
98:13, 98:16,
110:11
send [1] - 41:21
sense [3] - 37:21,
38:6, 103:1
sensitive [5] - 46:12,
46:14, 47:5, 59:21,
59:22
sensitivities [2] -
45:16, 100:8
sent [7] - 26:18,
38:18, 40:16, 41:17,
68:9, 68:21, 86:5
sentence [4] - 40:3,
16
ROUGH DRAFT DAILY COPY
93:13, 131:1,
132:18
separable [1] - 54:7
separates [1] - 99:8
sepsis [36] - 42:8,
42:14, 42:15, 50:21,
51:5, 52:16, 53:23,
53:24, 60:11, 61:20,
62:9, 63:11, 63:15,
63:20, 66:22, 66:23,
67:6, 67:11, 67:16,
68:3, 69:1, 69:22,
72:12, 79:10, 80:25,
81:19, 83:14, 84:24,
85:25, 94:3, 104:1,
108:24, 118:2,
119:13, 132:20
SEPTEMBER [1] -
1:17
September [4] -
123:8, 123:10,
123:14, 129:24
septic [12] - 50:4,
51:25, 53:19, 60:1,
62:14, 62:18, 69:13,
70:1, 79:19, 80:22,
85:18, 119:11
septicemia [5] - 69:4,
70:1, 85:18, 116:1,
116:8
series [1] - 130:1
Series [1] - 13:3
serratia [18] - 84:24,
85:18, 85:21, 86:3,
86:6, 86:7, 94:22,
94:24, 94:25, 95:2,
95:6, 95:17, 95:24,
96:9, 96:21, 104:20,
104:24, 104:25
service [3] - 52:4,
60:1, 63:21
Service [8] - 49:14,
49:15, 50:3, 51:3,
51:5, 61:4, 67:4,
71:8
set [3] - 18:16, 29:13,
131:11
setting [4] - 31:12,
57:13, 92:11, 100:2
settings [1] - 13:24
several [3] - 66:16,
132:6, 132:11
severe [6] - 62:18,
64:24, 65:14, 69:1,
69:13, 132:21
severely [1] - 81:23
severity [1] - 62:14
shall [1] - 130:23
shape [1] - 112:10
SHARLEE [1] - 1:3
Sharlee [6] - 9:10,
25:17, 30:17, 82:4,
131:13, 132:2
shock [18] - 31:16,
31:17, 49:18, 50:4,
50:20, 51:25, 53:19,
60:1, 62:14, 62:15,
62:18, 69:13, 70:1,
79:10, 79:19, 80:22,
85:18
shocking [1] - 31:19
show [4] - 3:20,
39:25, 89:6, 103:8
showed [6] - 71:19,
71:20, 72:3, 83:9,
93:7, 129:24
shower [2] - 37:18,
38:5
showered [1] - 58:20
showing [1] - 78:14
shown [1] - 119:14
shows [1] - 130:24
shut [3] - 62:11,
79:10, 81:16
shuts [1] - 79:18
shutting [3] - 32:20,
50:22, 62:9
sick [1] - 83:19
side [12] - 21:9,
54:12, 54:14, 54:15,
54:17, 54:23, 87:25,
88:20, 89:5, 89:25,
92:17
sidebar [2] - 127:18,
127:22
sight [1] - 31:21
sign [1] - 93:21
significant [4] -
37:19, 100:5,
100:16, 118:22
signs [2] - 26:7, 80:17
simple [2] - 33:17,
86:20
simply [5] - 8:25,
22:6, 28:22, 102:18
single [3] - 10:2,
47:13, 106:10
sit [2] - 16:24, 32:24
site [18] - 38:11,
38:12, 38:13, 39:5,
48:21, 55:10, 55:12,
55:15, 56:12, 78:16,
82:10, 87:17, 92:4,
92:7, 93:9, 121:13
sites [1] - 90:23
sits [1] - 90:6
sitting [7] - 32:9,
44:7, 88:7, 88:8,
88:18, 106:7, 106:8
situation [5] - 24:1,
31:24, 40:23,
116:11, 116:14
size [1] - 45:12
sketch [1] - 47:19
skin [47] - 33:14,
33:16, 39:7, 39:8,
54:6, 55:14, 56:8,
56:11, 56:25, 57:3,
57:11, 57:21, 61:13,
61:14, 62:21, 79:8,
79:12, 79:15, 79:16,
79:18, 87:19, 87:20,
88:2, 88:13, 88:16,
89:9, 89:10, 89:17,
90:1, 90:3, 90:12,
90:16, 90:18, 90:24,
90:25, 91:9, 91:10,
92:9, 92:21, 93:8,
93:22, 99:19,
117:11, 117:12,
117:16, 119:19,
119:22
skipping [2] - 13:22,
130:22
skit [1] - 88:9
slightly [1] - 123:5
slow [2] - 4:9, 9:17
small [10] - 58:20,
63:10, 69:2, 94:8,
103:10, 119:7,
130:1, 130:7, 130:9,
132:12
smaller [1] - 123:5
smoking [1] - 125:12
SMOYER [1] - 1:3
Smoyer [24] - 17:18,
25:17, 27:6, 30:19,
31:9, 34:8, 38:4,
41:12, 43:6, 46:2,
54:11, 63:25, 74:20,
74:24, 75:11, 77:7,
77:9, 81:14, 82:3,
82:4, 83:20, 91:12,
131:13, 132:2
Smoyer's [17] - 9:11,
25:20, 26:24, 27:13,
29:19, 30:17, 34:14,
34:25, 35:7, 42:14,
47:3, 60:23, 66:1,
72:4, 72:13, 78:5,
130:3
snipits [1] - 18:5
societies [1] - 10:4
Society [1] - 10:11
someone [3] - 21:9,
58:5, 66:21
sometime [1] - 48:14
sometimes [5] - 8:23,
45:10, 126:9,
134:10, 135:2
somewhere [1] - 8:25
sorry [17] - 9:16,
15:24, 39:22, 44:2,
46:20, 51:16, 54:17,
58:5, 58:11, 63:4,
66:12, 78:9, 91:24,
105:18, 126:21,
132:8
sort [16] - 19:23,
29:24, 44:6, 45:14,
64:12, 80:7, 82:1,
88:5, 89:9, 89:22,
90:2, 90:4, 90:9,
91:16, 116:22,
117:15
sound [2] - 110:8,
110:15
sounds [2] - 110:9,
110:17
source [10] - 36:7,
40:14, 41:14, 42:8,
42:14, 57:14, 66:15,
110:7, 116:8,
117:22
spaced [1] - 10:3
speaking [3] - 14:21,
30:16, 36:22
specialist [6] - 5:11,
29:11, 56:17, 57:18,
75:7, 81:12
SPECIALISTS [1] -
1:11
specialists [1] - 5:20
specialize [1] - 6:10
speciation [1] - 104:9
species [18] - 43:24,
43:25, 44:1, 44:9,
45:8, 99:18, 102:25,
104:9, 104:10,
104:16, 104:18,
104:25, 105:2,
105:4, 105:5, 105:8,
105:15, 110:14
specific [15] - 6:14,
16:20, 28:1, 31:17,
43:24, 55:9, 55:12,
98:2, 99:18, 106:14,
107:14, 107:15,
109:25, 116:15,
119:5
specifically [5] -
16:25, 25:18, 103:7,
104:5, 125:2
specifics [1] - 113:15
speculation [1] -
18:25
speeches [1] - 42:17
speed [2] - 9:19, 72:9
spending [1] - 6:13
splash [1] - 58:18
spread [1] - 92:4
spring [1] - 132:13
ST [1] - 1:12
St [8] - 6:21, 129:4,
129:5, 129:16,
129:17, 129:22,
131:23, 132:6
stabilization [1] -
119:8
stabilizes [1] - 80:7
stable [8] - 62:20,
63:4, 63:6, 63:7,
64:24, 71:13,
119:15, 119:21
stacked [1] - 37:25
STAFF [1] - 134:19
staff [2] - 8:5, 16:9
stage [1] - 62:1
stain [4] - 45:23,
45:24, 45:25
stained [1] - 45:22
stall [1] - 134:11
stand [6] - 24:25,
73:13, 86:25, 89:14,
96:22, 133:20
standard [9] - 9:13,
25:25, 74:11, 74:14,
74:19, 101:10,
108:18, 114:19,
115:20
standards [1] - 18:16
standpoint [1] - 71:13
start [8] - 32:20,
59:16, 77:19, 80:4,
131:14, 134:7,
134:13, 134:21
started [6] - 39:4,
69:6, 72:4, 72:23,
77:21, 86:17
starting [3] - 65:8,
77:18, 133:25
state [9] - 30:23,
79:21, 80:10, 80:15,
80:16, 81:14, 81:18,
126:4
States [2] - 8:15, 15:8
status [4] - 37:10,
60:11, 71:12, 85:18
stay [3] - 78:13,
93:18, 133:23
STELZER [1] - 1:10
Stelzer [6] - 18:7,
19:19, 20:16, 21:17,
24:4, 28:21
Stelzer's [8] - 18:11,
19:3, 19:14, 20:4,
20:10, 24:10, 24:13,
29:4
stenographer [2] -
86:24, 135:15
17
ROUGH DRAFT DAILY COPY
step [2] - 17:6, 133:16
stepped [1] - 133:19
steps [1] - 4:14
steroid [1] - 125:9
steroids [7] - 37:6,
37:8, 39:16, 82:12,
82:18, 125:6
stick [6] - 64:6, 64:8,
64:9, 64:11, 64:17,
88:25
sticking [2] - 64:16,
88:13
still [6] - 23:21, 42:4,
57:10, 123:6,
129:22, 133:2
stoma [2] - 54:18,
56:3
stool [6] - 55:11,
57:21, 57:25, 92:19,
122:7, 122:18
stopped [1] - 86:12
story [1] - 38:2
stranger [1] - 20:17
stream [1] - 59:6
stretch [2] - 92:8,
92:11
stricken [1] - 116:19
stricture [1] - 130:6
strictures [1] - 130:24
strike [4] - 19:23,
38:8, 93:12, 116:17
stuck [1] - 64:11
students [2] - 12:1,
12:2
studies [2] - 4:1,
107:9
study [2] - 5:3, 5:4
subclavian [2] -
48:21, 49:3
subject [1] - 112:4
submit [1] - 22:4
subsequent [2] -
35:14, 39:5
subsequently [4] -
11:16, 32:3, 79:1,
119:9
subspeciality [1] -
16:21
subspecialties [1] -
16:21
substance [1] - 64:10
substances [1] - 62:7
successfully [1] -
12:16
suffered [1] - 74:21
suffers [1] - 75:1
suggesting [2] -
22:10, 26:22
suggestion [1] - 23:1
summarized [1] -
74:6
summary [9] - 9:17,
68:14, 68:20, 68:24,
68:25, 69:9, 69:10,
69:12, 70:10
superior [2] - 87:22,
100:4
supervise [1] - 12:2
Supervision [1] -
13:25
supervision [1] - 14:7
supervisor [1] - 13:23
supply [4] - 32:21,
62:10, 62:12, 90:18
support [2] - 50:19,
51:1
supporting [1] - 80:6
suppressed [1] -
82:18
suppression [2] -
5:15, 37:9
surface [3] - 57:3,
57:9, 57:11
surgery [4] - 62:20,
120:12, 121:10,
131:20
Surgery [3] - 4:15,
61:4, 64:23
surgical [2] - 121:13,
130:24
surrounding [1] -
35:20
susceptible [8] -
46:13, 46:14, 46:25,
47:4, 47:23, 47:24,
47:25, 59:11
sustained [6] - 42:11,
71:4, 108:7, 109:4,
112:23, 115:9
swabbed [1] - 56:25
sworn [1] - 3:5
symptoms [1] - 26:7
system [6] - 14:17,
79:19, 88:12, 90:24,
91:5, 94:1
systemic [1] - 63:15
systems [2] - 69:22,
72:12
T
talks [1] - 71:21
tape [2] - 88:11, 93:6
taped [2] - 93:5, 93:7
teach [3] - 11:25,
12:1, 25:11
teacher [1] - 8:25
teaching [3] - 12:1,
12:4, 12:22
team [1] - 36:13
technical [1] - 104:11
teeth [2] - 64:10,
64:16
temperature [3] -
81:4, 81:5, 81:10
temporarily [1] -
125:8
tempore [1] - 81:25
term [7] - 8:7, 46:4,
46:7, 50:16, 97:16,
107:20, 107:22
terms [50] - 7:6, 7:25,
12:8, 14:18, 14:19,
16:24, 26:12, 27:10,
29:2, 29:5, 29:8,
29:25, 30:1, 30:6,
33:17, 34:3, 35:4,
36:19, 38:25, 49:21,
49:22, 63:13, 78:19,
79:2, 84:5, 95:24,
95:25, 96:9, 96:14,
97:17, 98:8, 98:12,
99:13, 100:9, 101:4,
102:9, 104:12,
105:9, 106:17,
107:7, 113:25,
116:21, 117:5,
118:7, 124:14,
125:3, 125:9,
127:14, 133:11
terrible [1] - 33:7
testified [2] - 3:6,
28:4
testify [9] - 3:2, 15:24,
15:25, 19:16, 23:24,
26:2, 29:3, 74:10,
75:5
testimonial [1] -
27:10
testimony [27] - 9:9,
17:7, 17:15, 18:11,
18:15, 18:17, 20:4,
23:17, 23:19, 24:3,
24:5, 25:25, 26:5,
26:9, 26:23, 27:20,
28:9, 28:20, 30:14,
36:21, 54:9, 55:21,
73:24, 74:16, 78:8,
81:2, 124:5
TESTIMONY [1] -
1:15
testing [2] - 23:21,
98:24
tests [2] - 53:11,
127:2
text [1] - 115:19
textbook [1] - 115:21
THE [75] - 1:9, 1:17,
3:22, 16:1, 17:5,
17:12, 19:2, 19:7,
19:9, 19:11, 20:3,
20:14, 20:16, 20:20,
21:8, 21:14, 22:13,
22:17, 22:23, 23:8,
23:14, 23:23, 24:6,
24:23, 28:6, 42:11,
44:16, 46:9, 47:12,
66:25, 71:4, 73:12,
73:15, 75:19, 76:14,
76:17, 76:23, 77:1,
86:23, 87:5, 91:22,
91:25, 93:14, 97:11,
105:18, 108:7,
109:1, 109:4,
111:19, 111:25,
112:23, 114:5,
115:1, 115:9,
116:19, 120:18,
120:23, 124:23,
127:18, 127:24,
128:9, 128:11,
128:14, 131:9,
133:1, 133:16,
133:22, 134:5,
134:17, 134:20,
134:22, 135:8,
135:13, 135:18,
136:2
themselves [4] -
29:16, 35:22, 62:4,
99:15
therapeutic [2] - 14:8,
90:15
therefore [2] - 37:19,
39:19
they've [2] - 32:1,
50:17
thickness [2] - 89:10
thinking [2] - 24:7,
97:21
thinks [1] - 67:11
thinner [1] - 63:2
third [5] - 43:15, 47:4,
47:6, 65:15, 113:22
three [2] - 45:1, 95:17
threshold [1] - 34:6
thrombosis [3] -
61:19, 63:10, 69:2
throughout [2] -
15:13, 85:24
tibular [1] - 61:16
tight [1] - 57:6
til [1] - 76:9
timing [2] - 37:21,
104:13
tiny [1] - 91:17
TIP [1] - 134:19
tip [14] - 40:15, 42:19,
44:6, 44:7, 84:8,
84:19, 93:3, 98:11,
99:24, 100:3, 106:7,
112:5, 112:12
tissue [6] - 35:20,
62:12, 65:9, 65:11,
88:3, 90:8
tissues [2] - 62:13,
87:19
TO [1] - 2:1
today [10] - 9:9,
16:24, 65:16, 67:21,
67:23, 75:1, 94:13,
135:3, 135:10,
135:22
toe [1] - 65:2
toes [3] - 62:15,
65:15, 65:17
together [5] - 48:4,
54:4, 54:6, 54:8,
122:9
toilet [4] - 58:6, 58:7,
58:14, 58:21
took [3] - 47:16,
73:23, 127:21
tools [1] - 12:4
top [8] - 49:20, 51:24,
85:4, 87:15, 125:16,
125:19, 125:20,
129:3
Total [1] - 28:15
totally [1] - 131:3
touched [1] - 25:7
toward [2] - 85:15,
132:7
towards [3] - 84:21,
85:4, 88:3
toxic [1] - 62:6
toxins [1] - 32:11
TPN [2] - 28:15,
132:18
track [1] - 69:11
tracking [1] - 92:22
trained [1] - 6:11
training [5] - 4:5,
4:12, 4:14, 7:16,
11:14
Training [1] - 11:2
transcript [1] - 19:14
transfer [4] - 31:4,
40:10, 91:18, 92:1
transferred [3] -
26:18, 91:19
transpired [2] -
30:15, 85:17
trap [1] - 90:21
trapping [1] - 94:1
traps [1] - 87:20
traumatic [1] - 33:21
Travel [1] - 10:14
treat [2] - 5:16, 77:18
18
ROUGH DRAFT DAILY COPY
treated [4] - 72:17,
73:2, 119:1, 132:17
treating [5] - 12:14,
18:18, 60:18, 80:25,
83:14
treatment [5] - 5:15,
5:20, 14:1, 18:21,
70:7
treatments [1] - 13:15
trial [1] - 134:10
trip [1] - 78:2
triple [1] - 50:12
trouble [1] - 32:18
truthfully [1] - 23:24
try [6] - 14:20, 20:25,
32:8, 72:9, 89:14,
135:5
trying [10] - 13:14,
15:2, 20:24, 23:11,
33:3, 40:23, 65:21,
84:21, 84:22, 89:11
tube [7] - 87:21, 88:1,
88:10, 88:15, 90:5,
90:6, 91:1
tubing [7] - 88:11,
88:17, 88:24, 88:25,
90:10, 92:23, 92:24
tunnel [1] - 90:2
tunneled [1] - 131:16
twice [1] - 101:7
two [4] - 9:24, 62:4,
87:11, 121:11
type [10] - 43:16,
45:4, 45:7, 45:14,
45:22, 62:10, 98:10,
99:19, 99:23, 100:7
Type [1] - 12:12
typed [1] - 96:20
types [3] - 6:9, 107:8,
108:4
U
U.S [1] - 8:11
UK [6] - 4:1, 7:21, 8:7,
8:10, 11:8, 16:18
ultimately [2] - 93:25,
94:3
um-hmm [1] - 60:8
unable [2] - 43:23,
81:17
unavoidable [1] -
92:21
uncomfortable [1] -
56:14
uncontrolled [1] -
79:10
uncontroverted [1] -
17:15
under [14] - 12:19,
13:17, 15:3, 18:17,
52:15, 53:18, 54:25,
59:10, 60:5, 68:2,
70:8, 71:14, 94:5,
103:16
underneath [4] -
51:10, 52:17, 87:20,
88:3
unfortunately [3] -
20:22, 132:15,
133:12
unit [4] - 99:1, 99:8,
110:12, 110:13
United [12] - 6:22,
7:19, 7:20, 8:3,
8:14, 10:5, 11:14,
11:16, 15:8, 15:9,
15:11, 15:13
university [1] - 10:24
University [7] - 3:24,
3:25, 10:15, 10:18,
10:21, 11:2, 11:4
unmistakably [1] -
42:8
up [80] - 9:5, 9:19,
17:19, 24:14, 25:24,
26:6, 26:7, 26:16,
27:22, 28:24, 30:18,
30:19, 31:1, 36:23,
37:25, 40:5, 41:3,
41:4, 42:23, 44:2,
44:20, 45:12, 45:24,
45:25, 48:17, 49:8,
49:13, 55:20, 56:23,
67:3, 68:13, 71:5,
72:9, 73:18, 74:1,
74:15, 75:11, 75:14,
76:2, 81:6, 82:19,
84:13, 84:22, 84:25,
85:3, 87:6, 87:10,
89:14, 91:14, 95:25,
96:20, 100:11,
106:17, 108:5,
117:15, 119:9,
120:7, 120:10,
122:16, 124:6,
124:8, 124:16,
125:4, 126:11,
127:15, 128:1,
128:3, 128:5,
128:21, 128:24,
129:1, 130:1,
130:16, 131:19,
132:4, 132:9,
134:11, 134:18,
135:19
updated [1] - 102:14
Urinary [1] - 7:1
urine [1] - 40:16
US [2] - 11:7, 12:11
V
Vaccine [1] - 14:12
Valley [30] - 26:19,
30:4, 30:20, 35:4,
35:23, 36:5, 40:1,
40:2, 40:10, 40:12,
40:20, 41:17, 42:25,
43:8, 46:3, 47:9,
49:14, 50:4, 60:1,
60:16, 66:14, 67:10,
73:20, 78:14, 79:1,
83:13, 98:8, 124:11,
132:4, 132:21
VALLEY [5] - 1:6, 1:7,
1:8, 1:9, 1:9
Vancomycin [1] -
59:16
vantage [1] - 57:17
various [5] - 12:19,
13:11, 15:18, 53:10,
95:9
Vascular [2] - 61:4,
64:22
vascular [5] - 62:20,
63:16, 72:13, 90:17,
117:4
vein [2] - 88:7, 110:5
vena [2] - 87:22,
100:4
venous [1] - 70:24
ventilator [1] - 70:3
ventilator-
dependent [1] - 70:3
verbatim [2] - 76:25,
118:13
vessel [17] - 44:7,
63:10, 69:2, 87:20,
87:21, 88:4, 88:6,
88:12, 90:4, 90:5,
90:10, 90:11, 91:6,
94:9
vessels [3] - 62:5,
87:23, 94:7
viability [1] - 63:8
viable [2] - 61:9,
61:14
Victor [1] - 10:14
Victor-Wallace [1] -
10:14
videotaped [1] -
136:1
view [2] - 76:1, 93:19
vigilance [1] - 93:10
vigilant [1] - 5:25
vigorous [1] - 8:9
visible [1] - 33:8
vision [1] - 33:20
visiting [1] - 11:7
visual [1] - 38:15
vitae [1] - 3:19
voice [1] - 89:14
volume [1] - 27:5
VRE [1] - 70:15
vulnerable [3] - 5:17,
37:11, 39:18
W
wait [2] - 77:17,
134:17
waited [1] - 77:17
waiting [1] - 21:8
walk [1] - 33:8
walked [1] - 103:8
wall [3] - 39:14, 88:2,
122:22
Wallace [1] - 10:14
warm [1] - 81:16
warmer [1] - 62:21
watch [4] - 16:6,
80:19, 80:24, 93:10
water [3] - 37:24,
58:15, 58:18
ways [1] - 12:14
week [8] - 17:24,
28:23, 67:18, 75:3,
103:23, 103:24,
129:13, 135:9
weekend [3] - 133:23,
135:11, 136:2
weeks [2] - 9:5, 66:16
welcome [1] - 118:20
well-established [1] -
92:2
wet [1] - 38:5
whatnot [1] - 108:4
whatsoever [1] -
107:5
whereby [1] - 110:13
white [19] - 38:21,
39:1, 124:6, 124:15,
125:4, 125:6,
125:12, 125:17,
126:1, 127:9,
128:22, 129:6,
129:8, 129:9,
129:10, 129:17,
129:18, 129:21
whole [7] - 62:10,
62:16, 75:12, 85:17,
88:16, 88:17, 99:22
WITH [1] - 1:8
withdraw [3] - 44:15,
120:22
witness [19] - 19:4,
19:5, 19:6, 19:7,
19:8, 19:13, 20:10,
21:16, 22:5, 22:21,
23:15, 24:13, 73:12,
87:4, 91:23, 128:1,
128:5, 133:19,
133:20
WITNESSES [2] - 2:1,
2:3
witnesses [2] - 19:16,
135:6
woman [1] - 71:11
Women's [1] - 8:17
won [2] - 10:23, 11:9
word [11] - 40:17,
46:7, 46:11, 49:21,
56:14, 56:15, 61:12,
80:14, 88:22, 97:20,
109:1
wording [1] - 31:1
words [4] - 31:2,
57:2, 75:14, 84:10
work-up [1] - 74:15
worked-up [3] - 74:1,
75:14, 76:2
worse [1] - 81:11
worsening [1] - 69:7
wound [1] - 121:13
write [3] - 32:7, 53:14,
113:22
writing [2] - 97:22,
112:4
written [6] - 29:23,
30:22, 111:1, 113:3,
113:23, 131:4
wrote [4] - 76:4,
109:14, 111:4,
113:16
X
x-ray [2] - 49:24,
130:14
x2 [1] - 52:5
Y
year [3] - 7:8, 9:6,
71:11
years [6] - 11:18,
12:18, 12:23, 12:24,
27:6
yesterday [2] - 27:18,
27:19
yourself [2] - 56:23,
56:24
YURCHAK [1] - 1:11
Yurchak [17] - 18:10,
28:4, 28:20, 30:16,
19
ROUGH DRAFT DAILY COPY
30:22, 34:15, 34:25,
38:2, 38:3, 55:23,
74:14, 78:4, 79:4,
81:3, 82:4, 93:6,
130:2
Yurchak's [1] - 27:11