CORRUPT DEFEAT OF NEW JERSEY'S CONSCIENTIOUS EMPLOYEE PROTECTION ACT

Colloquy 10

demonstrated on the witness stand or through the other witnesses. I understand that. And that's always the problem when you have a litigant who is representing himself; there's a line. It's a bright line. What's done in closing and openings are not evidence. It's only when you're under oath on the witness stand.

So the motion is denied and we're going to go forward with his case now. Yes?

MR. MILLER: I'm wondering, Your Honor, when you instruct the jury, when you give them their charge, perhaps you could just instruct them to decide whether or not I was qualified to form a reasonable belief that the application of diapers to incontinent bedridden patients was detrimental to their health.

THE COURT: Well, there will be a point when we get to the charge when we will talk about that, and you will both know the jury charge before you sum up. So you'll understand that. There is a suggested charge that is written by a committee for jury charges, and we'11 be going through them.

All right. Are you ready with your case?

MR. THIBAULT: I am ready.

THE COURT: Jury out, please. (Continuing in the presence and hearing of the jury.)

THE COURT: Please be seated. Good morning. Welcome back. The plaintiff has rested and now the defendant may call witnesses at this point.

MR. THIBAULT: Thank you, Your Honor. The defendants call Dr. Douglas Ratner to the stand. DOUGLAS RATNER, M. D., DEFENDANT'S WITNESS, SWORN

THE CLERK: Would you please state your name for the record.

THE WITNESS: Dr. Douglas Ratner.

VOIR DIRE EXAMINATION BY MR. THIBAULT:

Q Good morning, Dr. Ratner.

A Good morning.

Q Dr. Ratner, where are you employed?

A Presently at Overlook Hospital in Summit, New Jersey.

Q And is that part of any particular health care system?

A It's part of the Atlantic Health System which is composed of Morristown Hospital, Mountainside, and Overlook.

Q Okay. Have you ever been employed by Community Medical Center?

A No.

Q Have you ever been employed by any of the

entities within the Saint Barnabas Health Care System?

A No.

Q What is your position at Overlook Hospital?

A I'm the Chairman of Medicine, Internal Medicine at Overlook Hospital.

Q And how long have you been the Chairman of Internal Medicine at Overlook?

A About five years.

Q Doctor, do you have any Board certifications?

A I'm Board certified in internal medicine and preventive medicine.

Q Okay. And how long have you held that Board certification?

A Twenty years.

Q Can you explain to the jury how one becomes a Board certified physician in internal medicine?

A You study. Actually, you go through your residency and at the end of the residency you are to sit for this exam. It's a very long exam. And you pass it, hopefully, and you get your Board certification.

Q Are there any periodic updates to your certification?

A Well, actually I was grandfathered in. Now you have to recertify every ten years. But I'm also – I have been the Director of the internal medicine residency. And so I stay very current with the residents and the new cases that come in constantly.

Q Doctor, where did you go to college?

A I went to college at Hofstra University.

Q And what year did you graduate?

A 1974.

Q Received a Bachelor's degree?

A Hmm-hmm.

Q What was your undergraduate study?

A Pre-med.

Q Where did you go to medical school?

A Hahnemann Medical College in.Philadelphia. Now it's Drexel.

Q And what did year did you graduate from Hahnemann? A I graduated in 1981.

Q Did you do any residency?

A I did a three year internal medicine residency which is the time that you have to complete that.

Q Okay.

A At Danbury Hospital in Danbury, Connecticut.

Q Now, Doctor, do you have any experience in teaching?

A Yeah, I've been teaching now for about 17 or 18 years, first as an Associate Director of a residency program in Westchester County, and then I came over to Overlook twelve years ago and was an associate for a few years and then I was promoted to the Director of the internal medicine program. And then it was a few years into that they established the Chairman of Medicine position and put me into that position.

Q Do you teach at any medical schools?

A Well, I have appointments at Columbia, UMDNJ, and in the past New York Medical College. And I have taught a great deal at these schools.

Q Are you presently teaching at UMDNJ?

A Hmm-hmm. We get students coming over on a daily basis. So actually we have students with us all the time and I go on chief rounds with them and meet with them individually and go over cases because I feel that that's the most interesting way for them to learn medicine. I think these kids get a great deal of pleasure out of coming over to a real hospital and to talk about real cases because they never follow a book.

Q Do you teach anywhere else other than UMDNJ?

A Well, I do teach at the osteopathic schools, NYCOM in New York as well as Kirksville; they come to us in Missouri. That's a lot of teaching.

Q And when you say the students come to Overlook Hospital and you're teaching, what do you mean? Explain what you do as part of that teaching?

A Well, most students get a lot of book knowledge, but one of the things that you learn as you go further into this career of medicine is that most of the time cases have strange nuances. And what we try to teach young doctors are how to pick up small, little signs of a disease and how it manifests itself so that you catch things early. And there are so many different ways that this happens. After 25 years of taking care of patients, I've seen a lot, and so I like to teach in that way so that they can — it keeps their interest and they realize that what they're learning now has value. So if, for example, you learn twenty different aspects of pneumonia, pneumococci pneumonia, it's rare when a patient presents with all twenty aspects. So it's learning nuances and how to pick up on it early on in the process.

Q Doctor, do you hold any certifications with respect to medications, prescriptions, things of that nature?

A Well, I have besides my license I have a CDC, a controlled substance license, as well as a DEA which is every couple years you have to fill out forms to update as to whether you're still prescribing these drugs. And unless they have some reason why they would choose not to allow you to do that, usually always gets passed and you get your license.

Q And, Doctor, when you referenced the DEA, you're referring to the Drug Enforcement Agency, the federal agency; correct?

A Mostly narcotic controlled substances.

Q All right. Now, Doctor, are you on any committees at Overlook Hospital?

A More than you can count. I mean, I feel like I'm on every committee.

Q Can you tell us some of those committees that you're on?

A Well, I'm on the Safety Committee which is a committee that is — it's a newly formed committee to try to reduce the number of medical errors that occur. I'm on the Performance Improvement Committee which deals with actually developing programs for this aim to improve the quality in the hospital. I'm on the P&T Committee which is the Pharmacy and Therapeutics Committee which hears all cases for putting medications on the form and also about medication errors and what we need to do to change them. I'm on a number of other committees.

One of the committees that I soon will be on and I'm very proud of is I went to the State Legislatures, Tom King, Jr., and we got a Bill passed, which was no small task, to seat a commission to look at disease management, how to bring that into the health care field. I've developed my own programs. And basically it's charge is to look at these programs for New Jersey. Some of the programs are how to reduce medication errors. So I'm very proud that we got it as far as we did so far.

Q And, Doctor, am I correct that you also sit on the Medical Care Review Committee at Overlook Hospital?

A Yeah. Medical Care Review is a very important committee. The others are, too. But this one actually hears cases that perhaps where there was negligence or oversight or education is needed to give to the docs that were involved or sometimes not. But those cases all come to Medical Care Review. It's for quality assurance and essentially at this point I bring in the docs in and find out whether there was a class one or class two error, or just a reprimand, or in this case — not really reprimand; just to teach them how to maybe do better.

MR. THIBAULT: Your Honor, at this time we'd move to qualify Dr. Ratner as an expert to give expert opinion in this case.

THE COURT: Do you have any questions on the doctor's qualifications?

MR. MILLER: May I have sidebar, Your Honor?

THE COURT: Yes. (The following discussion was held at sidebar.)

THE COURT: You're going to be asking opinions?

MR. THIBAULT: With respect to documentation errors.

MR. MILLER: If he says serious, I'm going to ask him why unless he breaks him down.

MR. THIBAULT: I will ask him the why. So we'll get that out.

MR. MILLER: So unless he's an expert in pharmacology, you know, I don't want him testifying. He can talk about standards.

MR. THIBAULT: Pharmacology is irrelevant. It has no basis.

MR. MILLER: It absolutely does.

THE COURT: There is certain medical knowledge a doctor would have on the effects of medication on a patient. So I'll permit that.

MR. MILLER: Yeah, but I have, too.

THE COURT: But he's been qualified as expert. You're not. Do you have any questions on his qualifications?

MR. MILLER: No.

THE COURT: All right.

(Sidebar concluded.)

THE COURT: I'm satisfied based on the witness' testimony that he should be certified as an expert in his field of internal medicine and may offer his expert opinion to the jury in that vein. Go ahead.

MR. THIBAULT: Thank you, Your Honor.

I'd like to mark this D-19.

(D-19 marked for identification.) DIRECT EXAMINATION BY MR. THIBAULT:

Q Dr. Ratner, I'm showing you a document that's been identified as D-19 for the record. Is that your report you did in this case?

A Yes.

Q And that report contains your opinions with regard to David Miller and the charts that you reviewed?

A Yes, it does.

Q All right. Now, Doctor, are you familiar with a nurse's obligation to chart the medication that she gives her patient?

A Absolutely.

Q Is that a requirement at Overlook Hospital?

A It's a requirement at Overlook and it's a requirement elsewhere, I understand, as well.

Q I'm sorry. Elsewhere, what?

A The senior — I forget the name of the — I have it my records — senior — the State Senior & Health Services also requires that you do that.

Q Are doctors required to chart the treatments and care that they give to their patients?

A Everything has to go on the chart. The chart is the method by which we communicate. The hospital has numerous people at any given time walking around the hallways and treating the patient, walking into rooms. It is the only real method to date, short of electronic medical records, which hasn't come yet in the hospital to communicate. So we need to look at the charts both at patient's bedside and otherwise to know what is going on, what has transpired in the case.

Q Now, Doctor, as part of developing your opinion in this case did you review Community Medical Center's policy with regard to the requirement to chart medications in a patient's medical record?

A Hmm-hmm. Yes.

Q And you saw that nurses are required to chart the drugs they give a patient?

A No question. No question.

Q Does Overlook Hospital have a similar policy?

A It does. In fact, we have not only the policy which I have furnished to you but also what we call an MAR which is Medication Administration Record where all medications given, doses and the route that they' re given, whether i.m., i.v., or by mouth, all the dates, the times, everything is to be charted. And if they're not, there is a list of about ten different items that they have to — the nurse or whoever is writing in that med card, mostly the nurse, has to indicate as to why they were unable to give the medication; the patient has a nasal gastric tube or is on a ventilator and the medicine was by mouth. So they have to document if they don't give the medication, why that didn't happen.

Q Okay. Now, has this requirement of nurses to chart the medications that they give to their patients, has that been a requirement at other hospitals that you've worked at?

A Every hospital, every hospital.

Q And, Doctor, can you explain to us why it's important for doctors and nurses to chart medications that they give to their patients?

A Well, as I mentioned, it's our only way to know exactly what happened. For example, there are shifts at every hospital, and now with the duty hour legislation, the residents themselves, medical residents do not stay overnight that often. There are shifts now so that they don't get more than ten or twelve hours per day. And so when they chart something, often times they're not going to be around to even answer a question. But even if that were not the case, when you look at the chart, when I round on the chart, I look exactly as to whether or not the medications were given so that I know what exactly is going on accurately with my patient. I can give you some examples, if you'd like.

Q Well, let me ask the question. From your experience, can you tell us the types of things that can happen to a patient if that chart doesn't reflect the medication that's been given to that patient?

A Okay. Let's say you ordered a narcotic for somebody and it wasn't given. That patient, if they have mental status changes -- or you ordered it and you assumed it was given and then they have mental status changes, you may just ascribe them to the medication, which is quite often, but they may be having something else going on, a meningitis, a sepsis, other things, renal failure, that can give you a change in mental status. And your first thought would be that the medication is doing this. So it's absolutely -- when we look at the chart, I'll look and see, well, did the patient get any medication that can get into the central nervous system to cause these changes because the person you look for would be a medicinal cause for the problem. Now, if there is no medicine charted, then you may very well start a workup as to whether or not this patient is suffering from some of these other entities. Some of them, if you don't make the diagnosis very quickly, you can lose the patient. I speak particularly of meningitis or sepsis, especially with older patients.

Now, another case could simply be someone who has a dissecting triple — we call it triplopia (phonetic) — an aortic aneurism where the pain in unremitting, generally. We never say always in medicine. If the patient does or does not get the medication and you assume the patient got the medication and is still in excruciating pain, you may feel as if something else may be going on that you have to move on. Or in the opposite, if the patient didn't get the medication, then you may not know how to interpret those physical findings. So it's absolutely crucial that everything you do to that patient is documented, so the people who come in contact with that patient can factor in this information with the case at hand. This is, by the way, one of the reasons why the Institute of Medicine published their report, 100,000 lives, which I'm sure many of you have read. And it pretty much talks about medical errors that are committed in hospitals. And those of us who work in hospitals were taken back by it, but in further looking at it we realized a lot of the mistakes are real and many of them are medication induced.

Q Doctor, following up on your testimony about mental change in status, if I understand your testimony, if a patient is complaining of pain, is a doctor's first look to see what types of drugs the patient has been given?

A Well, today you've got so many people that work on a patient, you even have a pain medicine service which in our hospitals become the fifth vital sign. And what we mean by that is for years in hospitals we probably didn't give much credence to pain, and we realized that we were under-treating it. So we actually at Overlook took the step of making this a fifth sign so that when a nurse goes in and monitors your blood pressure, weight, and so forth, they will put on a pain scale on one of these drawings, whether it's a face or a body, and you will try to get an estimation of how much pain that patient is having. And so you see whether or not after you've given medication the patient will be given the drawing again and see whether or not you've made some improvement in the amount of pain that they have. If it was a scale of one to ten, that would be an eight or a six.

So it is crucial to know what has been given and what hasn't so that you either will move quickly to adjust the medication because everybody is different. People metabolize the medications differently. It's not just enough to know the dose and the half life, but it is just as important to know what their kidneys and livers are doing because they will metabolize it differently. And then again everyone has a different tolerance for pain and a different tolerance for these medications.

Q Doctor, other than change of status, are there other issues that may arise with a patient if a drug that may or may not have been given is not charted in a patient's medical record?

A I'm sorry. Would you repeat that one more time?

Q Other than a mental change of status —

A Right.

Q — are there other things that may flow to the patient if a drug that was supposed to be given is not charted in the patient's medical record as having been given?

A Well, it may set up a very dangerous cascade of evaluation. For example, if, for example, we wanted to know whether X, Y, and Z medications were given or not given, we may start to think, well, geez, we've given all this medication but it's not having any effect. I'd really have to start looking further as to why this patient is complaining. And it may lead to everything from a needle being put into different systems, to various tests, to a whole host of lab work that may generate an abnormality and then that abnormality has to be followed up. So that there's a whole cascade of possibilities that can occur, and I've seen everything — that may occur if things are not done correctly, if the protocol is not followed. And plus not to mention, if for whatever reason a nurse chooses not to chart and the doctors -- and this becomes something for common knowledge -- you will lose total faith in an entire group of professionals because you'll be looking over your shoulder, knowing whether or not this has been done, whether or not they've followed your orders, whether or not you obviously sit there and do it yourself. I mean, the possibilities are tremendous because if not for anything else, a hospital's function with numerous rules that were put there for a purpose and it's kind of a large family of orchestrated orchestra, so to speak, where everything has to be done in an optimum fashion so that we can get the best results for the patients.

So if I were on a case and I did not know because that nurse was choosing for whatever reason not to document what they're doing, I would be very uneasy managing that case, and this would go throughout the hospital. I am sure of that.

Q Doctor, might you send a patient for tests, as you mentioned, or procedures that could be harmful if that may have been avoided had medication been charted accurately in a patient?

A Yeah. Let's take the case of someone who's on Heparin. This actually happened a few years ago. I had a case of a resident not charting whether or not the initial — Heparin is a blood thinner given in certain cases like fibrillation where the heart beats abnormal, a clot can go to the brain, and you've got a stroke. So one of the treatments is to give Heparin first which is an iv drug to thin the blood so to prevent that. But we in medicine know that every medication has toxicity, and you're always weighing the advantage versus the disadvantage. But in this case it's much more advantageous. But in this case someone did not document what they had done. And when someone came to follow up, they did not know that a bolos of the Heparin had already been given, and so they went and bolos again in my patient, which meant that they were so thin, they would bleed just by nature because they had no ability to clot. And we almost lost that patient, but we were able to salvage the situation.

But there's got to be a lot of examples. It follows — and we don't do this willy-nilly — but it follows that if, in fact, you see an abnormality, you are going to try to figure out what is causing it. And tests that are done, especially in the hospital can be very invasive. The more invasive, the more toxicity. And so, let's say, in a case where a patient has mental status changes and you don't know whether or not what's going on with the medications if there's no note that you gave these medications, you may start to put together with other findings that this patient has meningitis. You'll do a lumbar puncture which is not a totally benign process, and things follow.

Q Doctor, is the failure to chart a medication a problem even if no direct harm comes to the patient?

A Totally. You know, I say to my residents that if they fail to put something in their differential and the patient lived and got away and they did fine doesn't mean that they did well. What it means is you got lucky. And so it does not matter one iota whether these patients suffered any harm. Sometime it will happen. It is totally unacceptable. I've heard that argument; it doesn't wash.

Q Is it appropriate at any time for a nurse to decide that he or she is not going to chart a medication for any given reason?

A Absolutely not. There is appropriate if the nurse says, "I think this drug is — I think the patient has too much medication," and they want to bring this to the attention of the doctor all the time. I consider nurses so valuable, I think they're so under appreciated by the general public. But they will tell me things because they're at bedside, they'll tell me things that they've noticed, and I absolutely take that into consideration. But never is it a case of them deciding on their own not to chart something. Never.

Q Doctor, I know we talked about this. But why is the charting of pain medication, specifically pain medications, important? In this case there's been evidence of Percocets, and Valium, and Xanax, and morphine. But why is it important that those controlled substances are charted in the patient's record?

A Well, they all have toxicity, and added together they can be very toxic. There is no non-toxic medication, you know. Let's be real about it. Unfortunately, when you're watching television commercial they give you -- the second part of the commercial is all the toxicity, and that can make people think that that's what's going to happen. Those are rare, but they're real. And so in the case of narcotics, they can lead to everything from ataxia, which can make someone, the doctor think there's a cerebella or a problem, there can be a problem with dystaxia and not being able to swallow, and that could lead to someone to think there's a gastrointestinal problem. They have caused low blood pressure and in significant dosages can kill a patient.

And then it raises another spector of why we are in such a highly controlled atmosphere that it is absolutely mandatory that any narcotic be documented because of the possibility of abuse, because of the possibility that they'd be used for other reasons. So this is something that is -- this is just well known in a hospital.

Q Doctor, earlier you had mentioned a report or a study by the Institute of Medicine and you mentioned something about statistics for medical errors. Could you explain that? Can you share with the jury what —

A Well, they came to — this is a respectable organization run by Donald Berwin (phonetic) which is an international person who's devoted his adult life to rooting out errors in medicine. It's interesting, he gives the example of you have a plane crash with two hundred people and there's years of investigation. If you had planes that carried 100,000 people, you can imagine the amount of investigations that would go on. But in that 100,000, you can argue whether it's 190,000 but still the point is well taken. Medication errors are no doubt a part of the mix here.

And I would also want to tell you in some studies, people over the age of 60, when they get hospitalized, 60 percent of the time it's due to medication errors. So I teach the residents that you must rule that out first because statistically medications can do this.

Q Now, the Institute of Medicine reported in their quality report the effects of medical errors on the delivery of patient care and the delivery of health care. Could you tell the jury what they reported as to the costs and effects to patients for these medical errors?

A The costs are in the billions. But they reported very succinctly that the hospitals in the country, despite the fact that they teach the methods, have contributed to many deaths. Very, very disconcerting to those of who work in the hospitals, but it's also a real eye opener. So we are even more diligent today than ever before, and that needs to be taken into account. There cannot be anybody in the system knowing this where various rules are not followed such as charting, such as doing things on your own.

Q Did the Institute of Medicine report how many patients die each year from medical errors?

A They do talk about, yeah, the number.

Q Why don't you take a look at your report that you identified on page two, the third full paragraph.

A I'm sorry. Page two?

Q . Page two, third full paragraph.

A Okay. They mention in Institute reports that between 44,000 and 98,000 Americans die from medical errors annually, and medication related errors for hospitalized patients cost roughly $2 billion annually; that medical errors kill more people per year than breast cancer, AIDS, or motor vehicle accidents.

Q And your source for that was this Institute of Medicine?

A Institute of Medicine, the quality report of 2000, Center for Disease Control and Prevention, and the National Center for Health Statistics.

Q Thank you, Doctor. Now, in this particular case you reviewed the medical records of individuals who were at Community Medical Center; is that correct?

A Yes.

Q And they were identified for the purposes of your review as Patients C, D, E, F, and G?

A Right.

Q Do you recall reviewing those?

A Yes, I do.

Q Now, based on your review of those records can you tell us what your understanding, what you found that David Miller had failed to do with respect to those patients?

A Well, the charting, the failure to chart is again the theme for this whole thing. To me, right off the bat, that is a practice that can't be condoned. I did write — can I read to you what I wrote?

Q Yeah, I believe it's on the first page. Take a look at that just to refresh your recollection.

A "Community Medical Center's policy M-03 requires a nurse to," quote, "immediately chart in the MIS system all medications as given or not given after administering the medications. My comparison of the patients' records set forth above and Mr. Miller's withdrawal of narcotics for those particular patients reveals that several of the narcotic withdrawals were never entered into the patients' record either as having been given to the patient or not having been given to the patient or the actual time of the administration was erroneous. In my opinion, these are serious medication errors which can adversely affect patient care."

Q Doctor, have you ever heard the adage, "If it isn't documented, it isn't done"?

A Yeah, I've heard it, particularly by the third-party people. I also in the position advise for case management, which means I have the wonderful role of dealing with the insurance to make sure the hospital gets paid. And they always fall back on if it's not documented, it never happened. And that really when it comes to medications, it's so true. When it comes to reimbursing care, their natural stance is to give you as little as possible. So they love to revert back to that phrase.

Q Doctor, in your opinion, based on your review of the medical records, were David Miller's charting omissions and discrepancies with regards to the narcotics administration in those five patient records, were they serious?

A Yes.

Q And in your opinion, did those errors, those discrepancies and omissions, did they detrimentally affect patient care?

A Yes.

Q And is that for all the reasons that you've expressed during your testimony?

A For all the reasons that I've expressed.

Q Would your opinion that these were serious errors and that it detrimentally affected patient care, would that opinion change if you learned that the patients at issue, those five patients, C, D, E, F, and G, did not suffer any actual harm?

A Absolutely not. Absolutely not. Doesn't matter.

MR. THIBAULT: I have nothing further, Your Honor.

THE COURT: I'm going to let you cross-examine, but I'm going to give about a five-minute break. Then I'll be back out and we'll start with your cross-examination. This is really not your mid morning break. It's going to be relatively long when that happens. So let me give you five minutes or so and then I'll have you back out.

(Recess from 10:04 a.m. to 10:13 a.m.) (Continuing out of the presence and hearing of the jury.)

THE COURT: Jury out.

(Continuing in the presence and hearing of the jury.) THE COURT: Please be seated. All right. You may cross-examine the witness.

DOUGLAS RATNER, M. D., DEFENDANT'S WITNESS, PREVIOUSLY SWORN CROSS-EXAMINATION BY MR. MILLER:

Q Good morning. Doctor.

A Good morning.

Q Are you being paid to testify here today?

A Yes, I am.

Q How much?

A Well, I guess 2,000 for the day.

Q Pardon me?

A Two thousand dollars for the day.

Q Is that the total that you've been paid for this case?

A No.

Q How much total?

A I've gotten 1600 already.

Q So $3600 total?

A I believe that's what it's going to be.

MR. MILLER: No further questions.

THE COURT: Any guestions?

MR. THIBAULT: I have no questions, Your Honor.

THE COURT: Members of the jury, you may ask the witness questions if you like. Put it in writing.

(After a pause)

THE COURT: If there were no notes on a chart, would you ask why?

THE WITNESS: If there were no notes by?

THE COURT: By a nurse, on the chart.

THE WITNESS: Yes. Actually, I have in cases, various cases where a doctor has come in and I see four notes in a row. Very unusual as to why that would be the case in a hospital where so many people enter data on a chart. And so I've got to ask myself and ask the doctors some very serious questions when usually you see a large number of notes in between your own notes.

THE COURT: If drugs are not documented and not given to the patient, what procedure do you follow before you order tests for other causes for the patient's discomfort or pain or change in physical status?

THE WITNESS: That's a good question. I will go ask the nurse who's working with the patient. I may even go to the supervisor to find out why a medication wasn't given after I've ordered it. So I will do a number of things to try to weed out as to why a medication wasn't given.

THE COURT: Have you been —

THE WITNESS: Can I — I just want to say something. There are — you know, this is a very busy world in medicine as it is elsewhere, and there are doctors who especially today with managed care, they come at six a.m., seven a.m. to get back to their office, so that rounding on their own patients, so that they can see the maximum number of patients to make the same living that they made five, ten years ago. This is reality. And so they are in the hospital very quickly, in and out. They may not ask all the appropriate questions. They may not even realize until much later that those things aren't being done.

THE COURT: Have you ever been called to testify as a witness before this on issues regarding non-charting of medications?

THE WITNESS: This is the first time. This is the first time I've ever been doing this.

THE COURT: As an expert witness?

THE WITNESS: Yes.

THE COURT: Do you understand the term, "half life"?

THE WITNESS: Yes, I do.

THE COURT: All right. How is it that you understand that term?

THE WITNESS: Well, we were taught that in pharmacology.

THE COURT: You took a course in pharmacology?

THE WITNESS: Took a course. You have to go -- pharmacology is part of a medical school curriculum.

THE COURT: Can you define half life for the jury?

THE WITNESS: Well, half life is the —

THE COURT: Can't hear him? The mike went off?

THE WITNESS: All right. The question again is? Let me get the question again.

THE COURT: Can you define half life for the jury?

THE WITNESS: Well, it's the amount of time that it takes for half of that substance to be out of the body. That's the best way to word it. So —

THE COURT: I'm sorry. I didn't mean to cut you off. Is there anything else?

THE WITNESS: Well, it's important. It's one factor in determining the dose that that patient may have in their system, but it's not the only factor. I alluded to before the kidneys and the liver, liver in most cases, detoxifies these medications. There's a whole host of reasons that have nothing to do with the half life of that drug that may lead to the drug staying longer in the body or being excreted quicker. So it's -- that's a case of learning something in medical school but seeing how it works in real life. Everyone metabolizes these medications different.

THE COURT: All right. I'm going to --there's another question I'm going to permit to be asked, but I need to have the jury leave the courtroom for just a second so I can explain it to the parties. (Continuing out of the presence and hearing of the jury.)

THE COURT: The question is, "How did you come to be involved in this case or this investigation?"

I want to hear what your answer is on that. How did you become involved?

THE WITNESS: To tell you straight up, we interviewed for a Chairman of Medicine for the entire Atlantic Health System three years ago, and I interviewed all of the three candidates that came to the end of the interview process. And one of them apparently gave my name to this legal firm because I got a call from them.

THE COURT: All right. The reason I asked the witness first outside the presence of the jury is sometimes a witness is retained by a specific insurance carrier, and I didn't want the issue of insurance being sent to the jury because you're not allowed to do that. So I just wanted to make sure that was it.

Now, I will permit you to answer that question in front of the jury. I just wanted to make sure there was no involvement with a particular insurance carrier.

THE WITNESS: Very quickly, I am going to submit additional bills to this firm. So I don't know if it's going to be just at that level. So I didn't want to be incorrect.

THE COURT: I'll permit you to clarify that before that jury. In light of that statement, that's fine. We'll let the jury know that. That's fine.

Jury out, please. (Continuing in the presence and hearing of the jury.)

THE COURT: All right. You may be seated.

Doctor, outside the presence of the jury you asked permission to clarify a response on the amount of compensation you may receive in connection with this case, and I said it was fine to tell the jury.

THE WITNESS: Yeah. I'm going to submit some additional bills because I've been told to bill for every hour that I prepared for this. Last night I did some summary work. So I just wanted you to know that.

THE COURT: All right. And how is it that you came to be involved in this investigation or this lawsuit?

THE WITNESS: Okay. Atlantic Health System interviewed for a Chairman of Medicine for the entire system about three years ago. I'm the Chairman of Medicine at Overlook. And apparently one of the candidates who didn't get the job — they were all very nice men -- he apparently gave my name to the firm because I got a call asking if I would be interested in coming in as an expert witness. And I asked about the case because I don't do this — this is the first time I've ever done this — but I wanted to know the specifics because I'm not for hire.

THE COURT: All right. Any other follow-up questions?

MR. MILLER: No, Your Honor.

THE COURT: Any questions?

MR. THIBAULT: I have no other questions.

THE COURT: Very well. Doctor, you may step down.

(The witness was excused.)

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