been
the sole criteria for certifying as an expert before the courts of the state
of Tennessee. I don't know where
counsel gets that as a criteria. I
don't believe that's the test and I don't believe it's the basis for basic
criteria. He practices pediatric
gastroenterology. He has 17
years. We can go through all --
THE
COURT: Go ahead and ask him the questions.
Ms. Luster, with the time left you can ask on cross, I don't know what
records he's reviewed, don't know what information he's had.
We very carefully went through that with Dr. Polk, so go ahead with
your questions, which is whether I think he believes this mother has that
diagnosis. Is that correct?
Is that the question.
MR.
FRIEDMAN: I asked if he ever considered --
THE
COURT: Did you ever consider that diagnosis for Mrs. Patrick?
THE
WITNESS: Yes, ma'am.
THE
COURT: Did you decide that was the case or not?
THE
WITNESS: I decided against it.
THE
COURT: And why was that?
THE
WITNESS: Because I had inaccurate records which led me to that diagnosis, and
once I got adequate and appropriate information, then I did not feel that I
need to entertain the possibility of Munchausen's by Proxy.
DIRECT
EXAMINATION RESUMED
QUESTIONS
BY MR. FRIEDMAN:
Q.
Tell the Court about the inaccurate records that you're referring to
that led you to initially consider whether this woman had this syndrome?
A.
I received a child who had severe diarrhea.
In the previous hospital the work-up which was done had excluded
infectious causes. In the
previous hospital an endoscopy done also showed apparently that the intestinal
lining was intact. Under those
circumstances, it was very difficult for me to explain why the child is having
ongoing, severe diarrhea. So the
possibilities at that stage were does he have any hormonal problems, any
endocrine problems leading to diarrhea or is Munchausen's by Proxy an issue.
Q.
Explain what endoscopy is.
A.
Endoscopy is when you take a flexible lighted tube and go down the
child's mouth all through the gastrostomy site and go into the small intestine
and take biopsies, take a look and take biopsies.
Q.
Explain what the medical records that you had originally been provided
on this child said in regard to the findings of a previous -- or the previous
endoscopy.
A.
They said that the esophagus, which is the food tube, the
stomach and the first part of the duodenum were normal.
MS.
LUSTER: Your Honor, if I can just
clarify
which medical records he's referring to.
MR.
FRIEDMAN: I was about to do that.
BY
MR. FRIEDMAN:
Q.
What records were you -- did you refer to all the records that Dr. Polk
said he referred to? Did you look through those, the medical records?
A.
Most of them.
Q.
I
didn't hear.
A.
Most of them.
Q.
Which record in particular --
A.
From LeBonheur.
Q.
What was it that LeBonheur said?
A.
They said that the biopsies of the esophagus, which is the food tube,
the stomach and the duodenum were normal.
Q.
What did you find, sir?
A.
What I found was that beyond the second part of duodenum there was
complete denudation of the lining of the intestine.
Q.
What does that mean?
A.
That means that he had no intestinal lining.
Q.
And what effect does that have on the results of the
tests you had done previous to that?
A.
That gave me a reason why the child was having diarrhea so severe and
that fit in nicely with the clinical impression and the other investigations,
so at that stage I felt Munchausen's by Proxy was not something to be
entertained.
Q.
You have reviewed each and every record of this youngster
since he was taken at 6:00 p.m. on September the 6th, 1996, by Dr. Polk
and by the Department of Human Services.
Is that correct?
A.
I have reviewed records. I
don't know if
Q.
Do they presume -- do they appear to be records from the date of
September 6th, 1996, through, I believe, yesterday?
A.
That is correct.
Q.
Today. Excuse me, through today.
I'm sorry. I'll pass you
forward those paper documents if I may. Please,
sir, and I want you --
MR.
FRIEDMAN: May I approach, Your
Honor?
May I approach the witness?
THE
COURT: Certainly.
MR.
FRIEDMAN: Thank you.
BY
MR. FRIEDMAN:
Q.
I want you to tell the Court, if you will, based upon your review of
these records, if the child's medical condition has improved or worsened since
Dr. Polk and DHS took this child from his mother on September 6th?
MS.
LUSTER: Objection, Your Honor.. Unless he's reviewed all the Vanderbilt
records prior to that, he's got no way of knowing what the condition was prior
to September 6th, I don't think he has a basis to make that opinion.
THE COURT: I sustain that unless you can show that he has seen the other records.
MR.
FRIEDMAN: Your Honor please, I think I asked him on the limited period of time
from the time that they took him has his condition improved or gotten worse.
THE
COURT: I think the objection is there would be no way to know that if he had
not reviewed the records prior to that time.
BY
MR. FRIEDMAN:
Q.
Have you reviewed the previous records in regard to this child?
A.
I have had conversations with the treating physician, so I'm aware of
what his clinical status was, but I have not reviewed the records.
Q.
They consulted with you in regard to this child prior to taking the
child away from the mother. Is
that true?
A.
I don't know if consulted is the right word.
Yes, I have had several conversations.
Q.
With whom?
A.
With Dr. Barnard and Dr. Crissinger.
THE
COURT: Dr. who?
THE
WITNESS: Dr. Crissinger and Dr. Hummell and someone else from immunology.
BY
MR. FRIEDMAN:
Q.
I'll ask you if based on your conversations with
those physicians who contacted you discussing the present condition of young
Mr. Patrick, and based upon your observations of the medical records, has this
child improved, worsened or stayed the same since he was taken by the
Department of Human Services and Dr. Polk?
A.
I think in some aspects he has deteriorated.
Specifically, he was never intubated, he was never on a respirator, and
now he's on a respirator. His
diarrhea, as per the records, he's still having 12 to 13 stools a day which
are loose and copious, leading to a fluid imbalance.
He is still having trouble with maintaining hydration status, and he is
either getting dehydrated which needs aggressive fluid management which is
being done or he's getting overhydrated which is leading to compromise of his
respiratory status, which is, again, being dealt with appropriately.
Q.
Let me ask you this, sir. In
regard to -you heard Dr. Polk talk about the investigation he had made into
organisms that had been grown and his statement about how he believes that
that supports his diagnosis of Munchausen's Syndrome by Proxy, did you not?
A.
Yes, I did hear.
Q.
Would you explain to the Court, please, sir, in regard to those
particular gross, why -- first of all, is it your opinion that those assist in
this Court, or any
A.
Only if someone can show me evidence that they saw someone actually
injecting them into the central line.
Q.
How else could they have gotten -- could this child have gotten this
infection based upon your medical experience?
Is there another explanation?
A.
There is.
Q.
What is it?
A.
When a child has diarrhea, it's extremely, extremely difficult to
maintain a hundred percent sterility of the central line.
It's a known fact that kids with explosive diarrhea will have very
often contamination of the central line at some stage.
Q.
If there was a contamination -- is it a reasonable medical opinion that
contamination described by Dr. Polk could have originated from the diarrhea
that this child was experiencing based on the medical records?
A.
That is correct.
Q.
Is that, at least in your opinion, as reasonable a conclusion, based
upon medical certainty, as that someone, in particular the mother, somehow
inserted foreign substances or fecal matter into the central tube?
A.
That is correct.
Q.
Let me ask you this in regard to attempting
to
confirm the exact type of organism
in the stool and correlate that with
the organism in the blood. Would
that be something a doctor should
do in considering the testimony of Dr. Polk?
And, if so, why?
A.
The purpose of doing such a test would be to show that the organisms in
the blood are identical to the organisms in the stool.
Q.
Could that be accomplished by serotyping or DNA fingerprinting
techniques?
A.
Yes.
Q.
Are those readily available?
A.
Not readily available, but you can get them done.
Q.
Is that something that -- well, I don't think that's a proper question.
Let me ask you this. You
heard the doctor say another big thing that he saw and observed was this
chromium level of the child. Did
you hear him say that?
A.
Yes.
Q.
Would you explain to me about whether the TPN had any chromium.
He said the TPN did have chromium.
Would you explain what that means for this record?
What does that mean?
A.
What exactly?
Q.
What is TPN and why would it have chromium in it?
A.
Chromium is an essential element which is an integral part of total parenteral
nutrition, and it is also a contaminant in total parenteral nutrition, and
extremely difficult to exclude that from TPN solutions.
And, in addition, we do add chromium to the TPN to make it more
wholesome. The level of chromium
will increase if there is liver damage or any liver disease.
It becomes extremely difficult to correlate chromium toxicity from the
urine sample in a child who's acutely ill who is on chromium in the TPN.
It becomes very difficult to make that judgment.
Q.
And without knowing the blood chromium level, you couldn't judge, based
on toxicological guidelines, whether there was chromium toxicity.
Is that correct?
A.
I'm not aware of what the exact diagnostic guidelines are for chromium
toxicity. But one of the things I would certainly would like to check
is what exactly was the chromium level in the TPN. It is possible the pharmacy could have accidentally put in
extra chromium.
Q.
That's not unusual?
A.
That is not unusual.
Q.
That certainly is a reasonable medical possibility other than the
mother did something to inject
A.
That is possible.
Q.
Let me ask you this so that we have a picture of this lady who you said
spent almost every day with you for three months.
Was this lady docile, quiet, as Dr. Polk said he saw and observed?
MS.
LUSTER: Objection. That's not -
THE
COURT: Sustained. I never heard
Dr. Polk say she was docile and quiet.
MR.
FRIEDMAN: Let me try again.
BY
MR. FRIEDMAN:
Q.
Describe Ms. Patrick's approach to interact to treatment of her child
-- her son as you saw and observed and experienced, of course, during your
course of treatment of him this year.
MS.
LUSTER: Your Honor, I think we've got to kind of limit that to the
circumstances. I know Dr. Polk
discussed her appearance when he said your child is gravely ill.
Other than that --
THE
COURT: I'm not sure her approach to getting treatment for her son -- I think
with the letters and everything else was aggressive and -- I mean, if there's
something else, Doctor, tell me what her
THE
WITNESS: I think she's a very demanding mom.
She is not just happy with good quality care.
She constantly gives you the impression that there is something more
which can be done for the child and she's constantly pushing the medical
system to seek more answers. And
I did encourage that to the point that I offered her free access to the
library and instructed the librarian to let her Xerox whatever material she
wanted at my business expense. I
gave her two textbooks of pediatric gastroenterology and nutrition in her room
so she would not leave the child's bedside to read, and I also offered that I
would give her a free modem for Medline search if she so desired, and she
declined that.
THE
COURT: Why did Phillip leave the hospital, your clinic?
THE
WITNESS: He was sick but stable and mom really wanted to go home.
She felt the best place for him was at home because she has three other
children. And she struggled with
me for three weeks and I
THE
COURT: And did you discharge him to her home?
THE
WITNESS: That is correct.
THE
COURT: And are you aware if that's what occurred?
THE
WITNESS: That is correct.
THE
COURT: And how long did that go on, if you know?
THE
WITNESS: A few days. THE COURT:
Two?
THE
WITNESS: Maybe three days.
THE
COURT: Three days?
THE
WITNESS: Yes.
THE
COURT: And then what happened?
THE
WITNESS: And then the mother called me and said that he had some
respiratory distress so I referred her to the pediatrician who felt the child
may have
THE
COURT: Thank you, Doctor. I
wanted to get that straight in my mind. I
had not been sure who had been treating this children when.
Do you have any other questions?
MR.
FRIEDMAN: I do.
THE
COURT: Well, we're going to adjourn. We
will start back at nine in the morning. Counsel
can consult as to how you want to proceed.
(WHEREUPON,
Court was adjourned at this time.)
THE
COURT: Are we ready to start? We
were in the middle of two doctors' testimonies.
MR.
FRIEDMAN: Yes, Your Honor. May
I,, please the Court --
THE
COURT: Yes, sir,
MR.
FRIEDMAN: I don't know if Your Honor's court officer advised her, after we
concluded yesterday, while we were still in Your Honor's courtroom, Dr.
Khoshoo, the witness who was testifying advised me when the Court respited
this case until this morning that he could not remain here to testify, that he
had a number of matters, one of which he advised was an emergency matter that
he had to return to New Orleans for. I
advised counsel and I also asked Your Honor's court officer if I could address
the Court on that when he advised me that was the situation.
Your Honor had apparently exited the building, we were advised by Your
Honor's court officer. This was
approximately, I suppose, five minutes after we had concluded --
THE
COURT: I had left the courtroom.
MR.
FRIEDMAN: Yes, ma'am. I tell the
Court this most respectfully. In
an abundance of precaution, (a) I did advise opposing counsel there was little
we could do, I did also serve -- this doctor was appearing pursuant to a
subpoena that we had sent down there which probably didn't have the ability to
compel him before this Court, but he appeared -- based on that he appeared
without fee. The only concession
or consideration which was paid was air transportation which, in fact, my
clients were able to do.
In
an abundance of precaution so that I could look Your Honor in the eye and so
that my client could, we did issue a second subpoena here in the courthouse
for Dr. Khoshoo because I had to advise him because I could not release him
from this Court, He was in the process of testifying and he appeared before
the Court, and I might tell the Court I don't know if that subpoena has
reached the jacket because the jacket was still apparently up here in the
courtroom when we went down to the clerk's office.
THE
COURT: I don't believe I have any jurisdiction whatsoever, that I'm aware of,
to do anything about an out-of-state witness.
And I am not unsympathetic, but I also said at the beginning of this
case that these are the timetables. He
could have gone first. I
cautioned everyone all throughout yesterday afternoon that I had to leave at
4:00, and that's what I did. And,
actually we went to eight minutes after four, So you can call another witness,
you can take a deposition, we can adjourn this preliminary hearing so that you
can call another expert, I'm willing to do whatever you want to do, I have no
jurisdiction that I'm aware of to do anything with Dr. Khoshoo.
MR.
FRIEDMAN: I
don't take exception, I might tell you that Dr. Khoshoo did fax back to my
client last night from New Orleans a fax saying -- and I'll be glad to share
this with counsel, this fax from the Kinko=s on Causeway Boulevard in New
Orleans that he had to leave Nashville today and fly
THE
COURT: Oh, don't
even start that. Your co-counsel
was here.
MR.
FRIEDMAN: But I
was about to say that my co-counsel advised me, I knew what Your Honor had
said. No. I'm not trying to
challenge what the Court said, I wanted the Court to know that we, on behalf
of our client, and our client made every effort to keep this physician here,
and I felt that I owed that responsibility as an officer of the court and also
to counsel and my client, I was not challenging what the Court said nor
challenging the way the Court's
Your
Honor please, as to seeking a continuance, if Your Honor would indulge me for
a moment, all I can advise my clients last night and this morning is the Court
had a number of options that it considered.
Under this unusual predicament, I did not predict what Your Honor might
consider doing. If Your Honor
will indulge me for about two minutes, I'll give the Court an answer.
I'd like to consult with my clients,
THE
COURT: Well, there are several things that everyone needs to be aware of.
From the beginning, the two lawyers that have been involved for the
parents, and I trust and I'm very confident, that the lawyer that represented
the three lawyers at the hearing was well aware of all the possibilities in
this case. We set a very early
hearing for the trial, October the 22nd and 24th, Is that correct?
MR.
HIRSH: It was
the 23rd, Your Honor.
THE
COURT: There may be many doctors. I
don't know what you'll decide to do about that, But there is ample time. We'll have a pre-trial conference that we are going to end up
this morning, You are absolutely entitled to a preliminary hearing, which I
have given you, I believe, every opportunity to present whoever you want to
present, whether it's a local doctor that's available, Your clients can
testify today. What I would like
to do is go on. I think Dr. Polk
is here, I want for you to con -if you have any other cross of Dr. Polk, and
Ms, Miller to be able to finish if we need to do that.
You know, for the purpose of a preliminary hearing, if we need to do
that, I want everyone to have an opportunity to do it, If you plan to present
your clients or any other witnesses that are here, I want you to have an
opportunity to do that,
MR.
FRIEDMAN: Your
Honor please, I have no problem with that, I do have a few further questions
for Dr. Polk, and I think what -- I don't think there's any reason for
THE
COURT: I would like to complete the preliminary hearing, but I'm also very
willing to adjourn if you need to get some other witnesses here.
If you want Dr. Khoshoo to come back on, what, September the 26th, you
know, we can do that if you think that is helpful and that's going to provide
any light on the reasonable belief standard that I use in a preliminary
hearing. I have cases scheduled,
I could see if I could get a special, I want them to have a preliminary
hearing, I think my concern is that they understand that this has been set
very quickly for trial and that we will have a full trial where we hear
everything.
At
this point, having heard Dr. Polk's testimony, before you finish the cross,
before I've heard from the guardian ad litem, I believe the State has carried
their burden, but I'm very willing, obviously, to hear whatever you want to
offer in opposition to that, I've heard Dr. Khoshoo's
testimony, Although you did not finish, I'm assuming you asked him the most
important things first, which I have heard.
And, again, you can call someone else if you want to do that. So why
don't we -- Dr. Polk's here.
Let's
finish that and then talk again.
MR.
FRIEDMAN: Very well.
THE
COURT: Dr. Polk, thank you for rearranging your schedule.
MR.
FRIEDMAN: Thank you, Your Honor.
DAVID
BRENT POLK, M.D.
was
recalled as a witness, and after having been previously sworn, continued to
testify as follows:
CONTINUING
CROSS-EXAMINATION
QUESTIONS
BY MR. FRIEDMAN:
Q.
Dr. Polk, I have just a few more questions for you in regard to this
matter. I believe that you
advised us yesterday that no one, no medical personnel, no doctor, to the best
of your knowledge based on your review of the records, had made any
accusations concerning Munchausen's Syndrome by Proxy concerning Ms, Patrick
or any of the Patricks prior to your consideration and your diagnosis, Is that
what you said?
A.
Yes,
according to my reading of the record,
Q.
You have reviewed all those records that you had available --
A.
Yes,
Q.
-- as you described. And please, sir, you said that one of the things that
concerned you, I believe, was that Ms, Patrick said something about an
accusation of Munchausen which you found not to be correct from the medical
records; that somebody had accused her of Munchausen, excuse me.
A.
on nine separate occasions, she informed -medical personnel documented
that she had been accused by all three facilities that she'd previously been
accused of Munchausen's by Proxy Syndrome.
Q.
But, in fact, to the best of your knowledge, information and belief,
none of the medical personnel, nursing staff, technicians, anything else at
any of the other three hospitals had ever made such an accusation, and that
bothered you?
A.
Yes.
Q.
Now, let me also be certain I understand. You first came
to meet Ms, Patrick on what date?
What was the first date you ever came to meet her in regard to this
case, I don't presume you ever met her before,
A.
I'll have to look at a calendar.
Q.
Would you
do so?
A.
I was on call, as I indicated in my testimony yesterday, on the 23rd
and 24th and 25th of August of
1996.
Q.
Yes, sir.
A.
And that was when I had occasion to meet her.
Q.
Did you meet her on each of those dates, sir?
A.
On the 23rd and 24th, Saturday and Sunday. Actually, I did not see her
on Sunday, I only saw her on Saturday.
Q.
You met her on one date, the 24th, Is that now correct?
I'm not trying to put words --
A.
Saturday.
THE
COURT: Saturday was on the 24th.
MR.
FRIEDMAN: Thank you,
BY
MR. FRIEDMAN:
Q.
How long did you spend with Ms. Patrick on the 24th?
A.
On that date, 30 minutes,
Q.
Thirty minutes. Was anyone else present with you other than yourself
and Ms, Patrick?
A.
Dr. Acra, who is a pediatric gastroenterology Fellow and the nurse.
Q.
Do you know the nurse's name, by any chance?
A.
No, I do not.
Q.
At that time, did you render any care or treatment to her son?
A.
I'll have to look at the record.
Q.
Can you do so, sir?
A.
Yes. My purpose in being
on call was to make sure there had been no significant changes in him over the
weekend,
THE
COURT: Doctor, while you are looking -- I may have just forgotten -- did you
give me an admission date? Do you
have that in your record?
THE
WITNESS: July the lst of 1996.
THE
COURT: He came to Vanderbilt on July the 1st, but this is your first time to
have provided him with any care or had met his mother, Is that correct?
THE
WITNESS: Yes.
THE
COURT: Was your group covering Phillip prior to that?
THE
WITNESS: Yes. From July the lst,
they covered Phillip until the current -THE COURT: Was there a primary
physician? I don't know if that's
how you
THE
WITNESS: The attending on service is the primary physician, so for the month
of July it was Dr. John Barnard, The month of August it was Dr. Karen
Crissinger, and then I came on in September,
THE
COURT: Okay. Thank you.
THE
WITNESS: On August the 24th there was a bacterial organism culture, That was
the first indication that we had the blood infection, and he was started on
Ampicillin at that time for the assumption of the treatment of leuconostoc,
the bacterial organism which he was growing.
So, yes, I did institute therapy.
THE
COURT: Doctor, what date? I'm
sorry,
THE
WITNESS: August the 24th of 1996,
THE
COURT: Thank you,
BY
MR. FRIEDMAN:
Q.
And that would have been the first day you would have seen the child?
A.
Yes,
Q. And I presume the order to start that substance was your order. Is that correct?
A.
No.
it would not have been written by me, It was my recommendation, The orders are
written by the house officers in the chart,
Q.
At that juncture, do you recall conducting any physical examination or
visual examination of the child?
A. Yes,.
Q.
And you had a conversation with the mother as well and the entirety of
that was approximately 30 minutes?
A.
Yes.
Q.
When was the next time that you saw her?
A.
The next time I saw Mrs. Patrick was on Tuesday, the 3rd of September,
the Tuesday after Labor Day.
Q.
Right, That was the second time you had seen Phillip or his mother;
correct?
A.
Yes.
Q.
And how long did you spend on that occasion with Phillip and his
mother?
A.
I spent over the course of the day more than
Q.
Ten minutes with Ms, Patrick and about -- I presume an hour fifty, if
my math is correct, with the child; correct?
A.
Yes. But the child was
present when I was with Mrs. Patrick, So that would have been a two-hour -
Q.
So you -- the 10 minutes you spent with Ms. Patrick was in the room
with the child?
A.
At the patient's bedside,
yes.
Q.
I understand. When was the next time that you spent time with Ms. Patrick,
if you know?
A.
I'm not certain, It was either Wednesday or Thursday afternoon, the 4th
or 5th of September,
Q.
Would your record --
A.
Yes, my record would reflect that.
Q.
Refer to your record so that we're accurate.
A.
(Witness complies,) That would have been September the 5th,
Q.
What
time did that take place?
A.
I don't have the exact time documented, I have clinic in the morning on
that day and so it would have been in the afternoon most likely.
Q.
You did not -- and, again, I'm not saying--
A. I did not document the time that I spent with her,
Q. You did not document or log in the time?
A.
No.
Q.
Approximately, to the best of your knowledge, not
based on the records, how long did you spend
A.
About 20
minutes.
Q.
Was this also in the room with Phillip?
A.
Yes, at the bedside,
Q.
Was this part of the --
A.
This was the intensive care unit where I was seeing him.
It was not a private room and we could have been alone.
Q.
This was the intensive care unit.
Look on this date, this third date of the 5th when you spent
approximately 20 minutes with Ms, Patrick, did you include in that physical
observation a review or a check of the child?
Was that part of the 20 minutes?
A.
Yes -- no, I came back at a different time and examined him.
Q.
Came back at a different time for examination.
So you spent 20 minutes --
A.
At the bedside, I just held his hand, touched his abdomen, looked at
him,
Q.
Let me ask you --
A.
And I did spend time with
the medical record at the end of the bed.
Q.
If I can, I'd like to pass you forward a couple
of pictures and ask you if you can identify them and in particular I want to
talk to you about some things that are depicted if I may first pass these over
to counsel. Thank you,
MR.
FRIEDMAN: I'll bring them back to the Court.
I didn't mean to pick apposing counsel first,
THE
COURT: No. We just need a court officer.
MR.
FRIEDMAN: These are pictures that were taken at Vanderbilt, Let me show them
to you. If I may approach the
witness and hand him the pictures.
THE
COURT: You may.
BY
MR. FRIEDMAN:
Q.
If I may, let me pass you these pictures and ask you, first, if you can
identify who that is.
A.
That's
Phillip Patrick.
Q.
Can you identify that as being, as a matter of fact, in Vanderbilt
Hospital?
A.
I can not.
Q.
I don't know if you can tell from the decor or not because there's not
--
A.
There's not really anything visible for me to answer that question.
Q.
Yes, sir. Let me ask you
this, if I may. We talked
yesterday briefly about various, I'll call them in lay terms, tubes that are
being -- were being utilized or are being utilized for the care and treatment
of this child, Are some of them depicted in those pictures?
A.
Yes, one of them is, The gastrostomy tube is clearly visible coming out
of the side of his stomach.
Q.
All right, Let me do this, if I may.
Could you please, sir --
MR.
FRIEDMAN: May I approach, Your Honor?
THE
COURT: Yes.
MR.
FRIEDMAN: Thank you.
THE
COURT: Go ahead, please.
BY
MR. FRIEDMAN:
Q.
Would you please take this blue pen, and if you'll draw a pretty good
line to show what is depicted as what you're saying is the gas -- what did you
call it, a gas --
A.
Gastrostomy tube. This pen is not working.
Q.
Right. Let me try --
A.
Can I use mine?
Q.
Sure, if your pen works better, that'd be great.
A. (Witness drawing on picture.)
Q.
Now, that was one tube.
Could you state medically and physiologically, if you will, where that
tube is located because our record will include the pictures but won't show --
A.
It's in his left mid-axillary line, which is a line, imaginary line,
drawn from under the armpit down to the hip just below his rib cage, which is
referred to as the costal margin is how I'd refer to it in medical terms,
Q.
In lay terminology, it's just above where his diaper is, isn't it?
Is that true?
A.
It looks about an inch and-a-half above where his diaper is.
Q.
Now, there was another tube that -- what's the purpose of that tube you
just described?
A.
The purpose that it was originally placed, as best I can tell from the
records, was that in order to maintain good calorie intake for this patient
who had a failure to thrive or had not gained weight well at the time that he
arrived at Children's Hospital of Philadelphia, they're used frequently for
that purpose of maintaining calories and providing calories.
Q.
So you feed him, you feed the body through that tube, Is that true?