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39 West 37th Street * New York, New York 10018 (800) NYC-FINK * (212) 869-3063

Fink & Carney Reporting and Video Services

STATE OF MICHIGAN

IN THE CIRCUIT COURT FOR THE COUNTY OF WAYNE

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RUTH SMITH, PersonalRepresentative of the Estateof Quintella Smith, Deceased,

Plaintiff,Case No.

vs15-015180-NH

MAROUN NURSING CENTER OFDETROIT, LLC, a domesticlimited liability company,d/b/a AMBASSADOR NURSING ANDREHABILITATION CENTER, OLYMPIAGROUP, LLC, a foreign limitedliability company, and DANIELS. MIZRAHI, D.O.,

Defendants.

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DEPOSITION of ALEXANDER McMEEKING, M.D., taken

by Defendants at the offices of Fink & Carney

Reporting and Video Services, 39 West 37th Street,

Sixth Floor, New York, New York, on Monday,

September 11, 2017, commencing at 9:54 a.m ., before

Karen Ann Carney, CSR, RPR, CMRS, and Notary Public

within and for the State of New York.



2 (Pages 2 to 5)

(1)(2) A P P E A R A N C E S:(3)(4) (Via Telephone)

HERTZ SCHRAM, P.C.(5) Attorneys for Plaintiff

1760 South Telegraph Road, Suite 310(6) Bloomfield Hills, MI 48302-0183(7) BY: STEVEN P. JENKINS, ESQ.(8)(9)

FOLEY, BARON, METZGER & JUIP, PLLC(10) Attorneys for Defendant

Daniel S. Mizrahi, D.O.(11) 38777 Six Mile Road, Suite 300

Livonia, MI 48152(12)

BY: KIM J. SVESKA, ESQ.(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)

Page 3

(1) A. McMeeking, M.D.

(2) (Handwritten notes of Dr.

(3) McMeeking, consisting of six pages,

(4) were premarked as McMeeking Exhibit

(5) No. 1 for identification, as of this

(6) date.)

(7) A L E X A N D E R M c M E E K I N G , M.D.,

(8) called as a witness, having been first

(9) duly sworn by KAREN ANN CARNEY, a Notary

(10) Public within and for the State of New

(11) York, was examined and testified as

(12) follows:

(13) EXAMINATION

(14) BY MR. SVESKA:

(15) Q Doctor, would you state your name

(16) for the record, please.

(17) A Alexander McMeeking,

(18) M-c-M-E-E-K-I-N-G.

(19) Q Doctor, as you know, we are here

(20) in the Quintella Smith case. I'm here

(21) representing Dr. Mizrahi --

(22) A Yes, sir.

(23) Q -- the attending at the nursing

(24) home.

(25) I'm going to be asking you

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(1) A. McMeeking, M.D.(2) questions, and Mr. Jenkins may follow up, as you(3) know. This is a process I'm sure you've been(4) through many times.(5) A I have, sir.(6) Q The only thing I would suggest is(7) sometimes I may not ask the perfect question and(8) you may not understand it. Feel free to let me(9) know and I will do my best to make sure you

(10) understand it.(11) A Yes, sir. I understand.(12) Q Let's start with some background.(13) I have your CV, and I'll use it.(14) And if you need me to hand it to you, let me(15) know. I'll be happy to do that.(16) A Very good.(17) Q Medical school was at New Jersey(18) Medical School in Newark?(19) A Yes, sir.(20) Q Graduating in 1982 with an M.D.(21) degree?(22) A Yes, sir.(23) Q And then you went to(24) St. Luke's-Roosevelt Hospital Center here in(25) New York and completed presumably an internal

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(1) A. McMeeking, M.D.(2) medicine internship and residency?(3) A I did.(4) Q And it looks like you completed(5) the residency in '85, right?(6) A Yes, sir.(7) Q And then you progressed to an(8) infectious disease fellowship at New York(9) University-Bellevue Medical Center, graduating(10) from that program in '87?(11) A Yes, sir.(12) Q Did you then sit for both boards(13) at some point?(14) A Yes; the internal medicine boards(15) in 1985. I passed that board exam that year.(16) And the infectious disease boards were only(17) offered every other year, so I took those and(18) passed those in 1988.(19) Q Given the age of those certs, I'm(20) going to guess that you're fortunate enough to(21) be grandfathered?(22) A I am, sir. Yes.(23) Q The issues that we're going to be(24) discussing today, as you probably are very well(25) aware of, deal with decubitus ulcers and



3 (Pages 6 to 9)

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(1) A. McMeeking, M.D.(2) possible infections thereof, right?(3) A Yes, sir.(4) Q Have you published anything, done(5) any research regarding those topics?(6) A The only article that may come in(7) is near the end. I work closely with the wound(8) healing service at NYU, and we published an(9) article on wound care in HIV patients.(10) It wasn't specifically bed(11) sores/decubitus ulcers. More to do with chronic(12) venous leg ulcers. Things of that nature.(13) So I don't think any of those(14) patients -- they were not hospital-bound, so I(15) doubt they had any decubitus ulcers.(16) Q What would the nature of their(17) wounds be?(18) A In people with HIV? They get(19) things everyone else gets nowadays, since they(20) don't die anymore. They can get venous(21) insufficiency with chronic leg ulcers, they can(22) get diabetic-related feet ulcers, vascular(23) disease-related ulcers.(24) So it wasn't per se to do with(25) HIV. The reason we published it is it turns out

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(1) A. McMeeking, M.D.(2) there was no data on wound care in HIV patients(3) since the mid-1980s, and the data in those days(4) was dreadful because everyone died of AIDS. So(5) it looked like if you got a wound you died;(6) whereas, it turns out now you do just as well as(7) everybody else does if you get appropriate wound(8) care.(9) Q Got it. I assume these were

(10) ambulatory patients and these were not typical(11) pressure-related?(12) A Correct, sir. They were all(13) ambulatory, seen through the wound healing(14) clinic.(15) Q Just for context, I'll read -- and(16) then I'll pass it over to you so you can confirm(17) it. The cite is "Wounds in Patients with HIV.(18) Advances in Skin Care," 2014, Volume 27, No. 9,(19) Pages 396 to 399 (handing).(20) A (Perusing document.) That's it,(21) sir. Yes.(22) Q And it appears you were the lead(23) author?(24) A I had that honor. Yes.(25) Q I started that series of questions

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(1) A. McMeeking, M.D.(2) with research and publications.(3) Is there anything else relative to(4) pressure --(5) A That's the only one I can think(6) of, sir.(7) Q I don't see a listing of(8) presentations. I assume you do speak on a(9) frequent basis?(10) A I do. Mostly at the medical(11) center. I'll give grand round talks. I'll give(12) lectures to the doctors, the fellows in(13) training, the medical house staff. And, of(14) course, a great deal of bedside teaching also(15) goes into my responsibilities there.(16) Q Sure. We'll get into that in more(17) detail.(18) Is there anything that you have(19) got canned, shall we say, like in a PowerPoint(20) presentation, that would be used to discuss some(21) of the things that we're going to be dealing(22) with here today, pressure sores --(23) A Not that I'm aware of; no, sir.(24) Q Let's talk about your practice(25) next.

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(1) A. McMeeking, M.D.(2) A Yes, sir.(3) Q Would you consider your practice(4) to be that of a general infectious disease(5) physician?(6) A I believe so. I spend half of my(7) day at the hospital seeing various infectious(8) disease consultations. I spend the other half(9) in my office.

(10) In the hospital side, as I say, I(11) see a number of people with the wound care --(12) wound healing service, and anyone else who calls(13) me: Critical care, OB/GYN. I do not do(14) pediatrics. Orthopedics, I may see patients.(15) Any service -- occasionally I'll be asked to see(16) patients in the emergency room who are being(17) admitted, or there is a consideration for an(18) admission.(19) And then the other half of my(20) practice in the office, I take care of between(21) four and 500 people with HIV infection where I(22) serve as their general practitioner as well as(23) their HIV infectious disease specialist.(24) I do travel-related medicine:(25) Vaccinations, prophylaxis for malaria -- things



4 (Pages 10 to 13)

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(1) A. McMeeking, M.D.(2) of that nature.(3) I also see people with viral(4) hepatitis, though fortunately most of those are(5) cured now. So the hepatitis part of my practice(6) is dropping off on an almost daily basis(7) nowadays.(8) And then I do some general(9) internal medicine in my office. Maybe of my

(10) office practice, of that 50 percent of the day I(11) spend there, a third of that is the patients who(12) I'm their primary care provider. These tend to(13) be people who have been with me for many years.(14) Q I was going to make that(15) assumption.(16) A Yes.(17) Q So, it sounds like you do the full(18) gamut of what a typical ID physician would do,(19) except for pedes?(20) A Yes, sir. Everything except(21) pediatrics.(22) Q And then add on top of that, you(23) have probably a fairly large HIV-related(24) practice, which some ID docs don't have?(25) A Correct. Yes.

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(1) A. McMeeking, M.D.(2) Q Is there anything that you don't(3) do that you can think of that other ID(4) physicians would typically do? So this is the(5) reverse -- the negative of the prior question.(6) A Correct.(7) You know, I can't think of(8) anything. I can't think of anything we don't(9) take care of related to infectious diseases.(10) Q Of the internal medicine(11) patients -- I know you mentioned that they have(12) been with you for quite awhile, which begs the(13) question: I assume you are not actively seeking(14) new internal medicine patients to take, to be(15) their primary care doc?(16) A That is correct. At this point,(17) if one of my patients says "My husband or my(18) wife or my dear cousin or friend," sometimes(19) we'll make an exception. But, in general, if(20) someone were to call our office de novo asking(21) to become a general internal medicine patient,(22) we have a list of several excellent people on(23) the NYU faculty I would refer them to.(24) Q Have you been in a situation where(25) you've had a nursing home practice?

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(1) A. McMeeking, M.D.(2) A No, I've never worked at a nursing(3) home.(4) Q And I've got to believe in your(5) current role as an ID doc, you're typically not(6) asked to go see patients in the nursing home(7) setting?(8) A No, that would not happen. No.(9) Q Let's talk about what you reviewed(10) in this case.(11) A Yes.(12) (Perusing documents.) So this is(13) just the first note from Mr. Jenkins that came(14) with the actual medical records which I'll show(15) you in a second.(16) Q Let's do these seriatim.(17) A Okay. Let me give you those.(18) (Perusing documents.) The records(19) I have: I have the Ambassador Nursing Home;(20) then back to the Ambassador again after the stay(21) for the GI bleed at St. John's (handing). I(22) don't have the St. John's record in between(23) those.(24) Then the first Detroit Receiving,(25) October 3rd to the 14th (handing).

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(1) A. McMeeking, M.D.(2) Back to the Ambassador,(3) October 14th to the 30th of October (handing).(4) Detroit Receiving, October 30th(5) (handing).(6) Q Through November 7th?(7) A Yes.(8) Then Ambassador, November 7th to(9) the 16th (handing).

(10) And then the final,(11) November 6th -- that's the last page of that --(12) Detroit (handing).(13) Then this is the affidavit from(14) Dr. Homa; the death certificate (handing).(15) Q Just so we have this on the(16) record. You've highlighted the cause of death(17) section, and the primary is listed as sepsis;(18) secondary is listed as end-stage renal disease,(19) and tertiary is diabetes mellitus, Type 2?(20) A Yes, sir.(21) Q And those go in the sequence of(22) days, years, and years?(23) A Yes, sir.(24) Q Did I get that right?(25) A Yes, sir.



5 (Pages 14 to 17)

Page 14

(1) A. McMeeking, M.D.(2) (Perusing documents.) I have two(3) depositions; one is Ruth Smith, and the second(4) is Dr. Homa's deposition (handing).(5) This is the cover letter for the(6) depositions (handing).(7) Q Provided to you on September 7th(8) of this month?(9) A Yes. Those I reviewed over this

(10) weekend when I got back from vacation.(11) Q I don't see much in the way of(12) highlighting or any type of marking on these.(13) Did you do such?(14) A Just the yellow marker would be(15) the only ones. They were fairly(16) self-explanatory, I thought.(17) Q I know that you provided me a copy(18) of your notes.(19) A Yes.(20) Q Did anything from those(21) depositions make their way into your notes?(22) A No.(23) Q The medical records -- I believe(24) most of them to be partial?(25) A That is correct.

Page 15

(1) A. McMeeking, M.D.(2) Q Is that your understanding, as(3) well?(4) A Yes. Yes.(5) Q Do you have an understanding as to(6) what it was that you were provided? And let's(7) take it nursing home, hospital.(8) A Sure. For the nursing home, it(9) would be the admission and discharge summaries

(10) with notes related to any kind of wound care(11) that occurred, or significant notes such as the(12) patient getting ill.(13) And also in the hospital records,(14) I think again it was admission summaries,(15) discharge summaries, and also things like(16) microbiology-related laboratory data and(17) progress notes of significance from(18) Dr. McArthur, the infectious disease specialist.(19) Things like that.(20) But, yes, these are far from,(21) obviously, complete records of every single(22) page.(23) Q Did you identify during your(24) review any omissions that would be important?(25) A I asked a couple of questions.

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(1) A. McMeeking, M.D.(2) One question I asked was never -- I think for(3) some reason it was never done -- but there was a(4) decubitus ulcer culture collected on(5) October 5th, according to the surgeon, when they(6) did an incision and drainage at Detroit(7) Receiving, and it says culture sent from the(8) operating room. But I could never find that(9) wound culture.

(10) That was really the only thing I(11) asked Mr. Jenkins for. And, as I say, I don't(12) think it exists. Maybe it got lost in the way(13) from the operating room to the microbiology lab.(14) But they did document they were sending it, but(15) no one could ever find it.(16) Q And the reason that you would be(17) requesting that is that it would be helpful to(18) you to understand what, if any, bacteria has(19) colonized that particular wound?(20) A Well, yes. What the culprit was(21) in the wound infection in the second admission(22) to Detroit when the blood cultures show up an(23) E. coli bacteremia, it would have been helpful(24) had a wound culture been taken at that point to(25) try and correlate that.

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(1) A. McMeeking, M.D.(2) Q Did you see any wound cultures?(3) A I did not. I did not.(4) Q Can you identify anything else(5) that you did not receive or that might exist(6) that you made any request for?(7) A Not that I'm aware of.(8) Q Did you do any research relative(9) to your preparation for rendering any opinions(10) in this case?(11) A No, sir. This is kind of what I(12) do.(13) Q Bread and butter?(14) A Exactly. That's a good word for(15) it.(16) Q The notes, which our court(17) reporter has kindly already premarked as Exhibit(18) No. 1, were these generated as you reviewed the(19) materials?(20) A Exactly. Exactly.(21) The way Mr. Jenkins -- he called(22) me and asked me would I be willing to look at(23) the case, with no pre, "This is what we think."(24) Just, "If you could take a look at it."(25) So I generated these records from



6 (Pages 18 to 21)

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(1) A. McMeeking, M.D.(2) a review of these -- the data I have here today,(3) as I read them. And then we spoke on the phone(4) and I gave Mr. Jenkins my thoughts on the case,(5) and he explained a little bit more about the(6) case at that point. But I read it in kind of a(7) blinded fashion without any predetermined(8) thoughts, shall we say.(9) Q Let me ask you what is it that you(10) were asked to do? Were you asked -- and I can(11) make this maybe as clean as possible for you.(12) Were you asked to deal with only infectious(13) disease-related issues or were you asked to deal(14) with broader internal medicine-related issues?(15) A Right. So when I first got the(16) records, there was no "Please look at this just(17) from" -- I always assume it's an infectious(18) disease aspect. But because I'm also an(19) internist, I tend to look at the whole record.(20) So it was only after I spoke with(21) Mr. Jenkins that he said "I have an internal(22) medicine wound care," and I suspected that from(23) the fact that I had read Dr. Homa's affidavit,(24) if that's what you call it.(25) So I suspected they had a wound

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(1) A. McMeeking, M.D.(2) care specialist -- a hospitalist involved. But(3) it was only after I spoke with Mr. Jenkins that(4) he said "I just want you to look at the(5) infectious disease aspects of the cause of the(6) sepsis in this lady."(7) MR. JENKINS: We can(8) stipulate that he is being used for(9) causation only, not standard of care(10) testimony.(11) MR. SVESKA: Thank you,(12) Steve. That will make this go(13) faster. But I think the doctor was(14) just getting ready to tell me,(15) because I was going to ask him that(16) question next.(17) MR. JENKINS: And under(18) Michigan law --(19) (Telephone connection(20) interruption.)(21) MR. SVESKA: Steve, for(22) whatever reason, you are coming(23) through quite poorly and our court(24) reporter is having difficulty(25) hearing you. Could you say what you

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(1) A. McMeeking, M.D.(2) just said again, slowly.(3) MR. JENKINS: I wish to say(4) additionally --(5) (Telephone connection(6) interruption.)(7) MR. SVESKA: We're getting(8) about 20 percent of your content,(9) Steve, so our court reporter has

(10) requested that we try to reconnect.(11) (Whereupon, at 10:11 a.m., a(12) recess was taken to 10:17 a.m.)(13) (The deposition resumed with(14) all parties present.)(15) A L E X A N D E R M c M E E K I N G , M.D.,(16) resumed and testified further as follows:(17) MR. JENKINS: When we had(18) left, I had stipulated that we are(19) offering him for causation only, not(20) standard of care testimony.(21) MR. SVESKA: Yes. Thank(22) you.(23) MR. JENKINS: And that the(24) percentage of his practice would(25) preclude him from giving standard of

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(1) A. McMeeking, M.D.(2) care testimony under Michigan law(3) anyway.(4) MR. SVESKA: Thank you for(5) that.(6) BY MR. SVESKA:(7) Q But just to be clean on the(8) record, Doctor, I'm going to follow up on that.(9) Obviously you haven't looked at a(10) number of things that will be necessary for you(11) to offer any opinions relative to Dr. Mizrahi;(12) for example, you haven't looked at the complete(13) records, right?(14) A That is correct, sir.(15) Q You haven't looked at his(16) deposition transcript?(17) A I have not.(18) Q And at this moment, you have no(19) intention whatsoever to give any testimony(20) relative to anything that he did or didn't do in(21) this case, right?(22) A As far as the wound care, no, sir;(23) no testimony whatsoever.(24) Q Your litigation consulting(25) experience is the next topic.



7 (Pages 22 to 25)

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(1) A. McMeeking, M.D.(2) A Yes, sir.(3) Q Let me ask questions.(4) A Sorry.(5) Q I appreciate that you are very --(6) you've done this enough. You know exactly what(7) I'm going to ask. You're anticipating things(8) very well, which is fine. But in order to get a(9) good, clean record from our court reporter's

(10) perspective and my perspective, I'll take the(11) lead.(12) When did you first start doing any(13) litigation consulting work?(14) A Twenty years ago. In 1997.(15) Q How was it you got into litigation(16) consulting?(17) A I had a patient who had an(18) infected breast implant, and her attorney(19) approached me about possibly serving as their(20) expert since I had taken care of her after the(21) infection occurred. And so that was the first(22) time I testified. It was here in(23) New York State, in Manhattan.(24) Then he referred me a couple of(25) other cases over the next two or three years

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(1) A. McMeeking, M.D.(2) and -- I guess word of mouth.(3) And then about twelve years ago I(4) got approached by a medical defense organization(5) here in New York, a malpractice carrier. And(6) for two or three years I did only in-house work(7) for them, where they would call me if they had a(8) case they wanted me to review.(9) And more recently, over the last

(10) four or five years, I started to do(11) out-of-state -- I'll do either plaintiff or(12) defense work. Though, to be honest, I rarely(13) get defense work out of state. Maybe one or two(14) a year. Most of what I get out of state is(15) plaintiff work.(16) And then in-state, because I do(17) this work for the malpractice carrier, I only do(18) defense work in New York State. That way it's(19) cleaner. And, again, I always make sure they(20) are not the malpractice carrier for the(21) physician.(22) Q I'm presuming that when we talk(23) about litigation consulting, you are discussing(24) that it's malpractice-related and infectious(25) disease-related?

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(1) A. McMeeking, M.D.(2) A All cases, infectious disease.(3) I have in a non-malpractice(4) situation done some defense work for the City of(5) New York Police Department. Every once in a(6) great while -- what would you say -- a prisoner(7) or somebody who has been arrested has some(8) infectious disease issue that they are claiming(9) are related to their being incarcerated. So

(10) that maybe comes up every other year. But(11) that's, of course, not malpractice.(12) Q Are you able to tell me the name(13) of the carrier?(14) A It's Medical Liability Mutual(15) Insurance. I know in some states you are not(16) supposed to mention that.(17) Q You might have some sort of a(18) confidentiality agreement, which is why --(19) MR. JENKINS: And I would(20) object to that for purposes of the(21) trial.(22) MR. SVESKA: Sure. Sure.(23) Q When you were doing the two to(24) three a year in-house work with them, were you(25) required to exclusively work with them and not

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(1) A. McMeeking, M.D.(2) take any other assignments?(3) A Well, initially when I started(4) working with the carrier, they didn't want me to(5) do any outside malpractice work. So after two(6) or three years, I would get calls and I would(7) say, "Sorry, I can't really do it."(8) Then one day I just approached(9) them and said, "Look, if I'm doing cases out of(10) state, be they defense, be they plaintiff work,(11) what difference does it make to you?"(12) And actually, quite frankly, I(13) think it makes me a better reviewer because I(14) can see both sides of the case. For example,(15) when I review a record, I'll always look at,(16) well, how would I defend this, or how would I(17) criticize this if I think there were criticisms(18) to be made.(19) So they agreed and then, as I say,(20) I every now and again get a call.(21) Maybe -- I would say in defense(22) work in New York, there is maybe five or six(23) cases over the last two years that are still(24) active. And out of state, there's maybe ten or(25) twelve that are still active. So it's maybe



8 (Pages 26 to 29)

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(1) A. McMeeking, M.D.(2) something I will get a call once a month from(3) somebody.(4) Q Have you ever, to your knowledge,(5) been listed by any of the expert witness(6) services?(7) A Not that I'm aware of. And I've(8) been approached by a couple, and I've said(9) "Thanks, but no thanks."

(10) Q Guy Saponaro here in New York?(11) A You know, I heard his name in the(12) deposition. I've never heard of him.(13) There is something called the(14) Expert Institute that will send me e-mails, and(15) I just hit delete.(16) And I have done a couple of cases(17) for a company called medQuest, where again they(18) do some of both. But I think maybe two or three(19) cases in the last couple of years. But to the(20) best of my knowledge, they don't -- first of(21) all, I'm not their only infectious disease(22) expert, because I've told them sometimes I can't(23) do it at the time or whatever, and they say "Oh,(24) that's okay. We'll use somebody else."(25) And I hope they don't advertise my

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(1) A. McMeeking, M.D.(2) name. I don't think they do. I've never had it(3) pointed out to me by a plaintiff or defense(4) attorney that my name is on a list somewhere.(5) Q What's your split currently(6) between plaintiff and defense work?(7) A It comes down to roughly -- not(8) including the in-house work I do, which(9) obviously is purely defense, it's about 50-50.(10) Q Lifetime depositions in litigation(11) consulted cases?(12) A Both testimony and depositions(13) combined?(14) Q Deps. Just depositions.(15) A Just depositions. Probably(16) roughly fifteen depositions. And I've testified(17) about twenty times.(18) Q I'm going to have to figure that(19) out. Twenty times, does that include trial?(20) A That's the trials. Twenty trials.(21) Q So fifteen depositions --(22) A Yes.(23) Q -- and five trials?(24) A Yes -- no, no, no. Twenty trials.(25) Sorry. Twenty trials. And some of the fifteen

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(1) A. McMeeking, M.D.(2) depositions did lead to a trial. So I would say(3) three or four of those are kind of a(4) combination; deposition leading to trial(5) testimony.(6) Q Just so I'm clear --(7) A Yes, sir.(8) Q -- it sounds like you have been(9) involved with, in terms of litigated cases, a(10) much larger number than fifteen or twenty.(11) Fifty, a hundred?(12) A Oh. Cases I've looked at over the(13) years?(14) Q Cases that have become litigated(15) cases that you have worked on.(16) A Probably a hundred, I would say.(17) Q So do you know how it is that you(18) have only given fifteen depositions?(19) A Well, some of the states don't(20) require depositions; like Massachusetts, for(21) example. I've testified a number of times(22) there. And let's see. And also in New York,(23) there is not a need for a deposition before(24) trial.(25) Q Got it. In terms of your charges,

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(1) A. McMeeking, M.D.(2) what's your hourly?(3) A Usually $500 an hour for anything,(4) be it record review, today, testimony time.(5) From the time I go on the witness stand until(6) the time I step down, $500 an hour.(7) Q If you are asked to travel to(8) Michigan to attend a trial in this case, how(9) would you charge for that?(10) A I'd probably charge roughly(11) between three and $4,000 for the day, since I(12) would have to be out of my office for the entire(13) day. And I sat down and calculated it. That's(14) roughly what we would bill for a day in the(15) office.(16) Q Have you had discussions yet with(17) any lawyers from the Hertz Schram firm,(18) including Mr. Jenkins, about coming to trial in(19) Michigan?(20) A I would be willing to come, sure,(21) if I have to.(22) Q I think the way most people do it(23) is, assuming there is not something else that is(24) significant and important in their practice or(25) in their personal life, you would be willing to



9 (Pages 30 to 33)

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(1) A. McMeeking, M.D.(2) attend?(3) A Yes. Yes, sir. That's exactly(4) right.(5) Q In the Federal Court system, and(6) in some states, experts are required to create(7) lists of depositions and trials that they have(8) been involved with for a five-year time span.(9) A Yes.(10) Q Have you ever been asked to do one(11) of those?(12) A Yes, I have.(13) Q When is the last time?(14) A About a year ago.(15) Q Is that still available --(16) A I can provide that.(17) Q -- that listing?(18) A Yes.(19) Q Would you be willing to provide(20) that to Mr. Jenkins?(21) A Yes, sir.(22) Q Thank you for that.(23) Is it up to date or is it about a(24) year out of date?(25) A Oh, no. It's up to date.

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(1) A. McMeeking, M.D.(2) Q You maintain it?(3) A Exactly. Yes.(4) Q What does the list have in it?(5) A It's any, in the last four or five(6) years, trials or testimony -- depositions I've(7) given.(8) Q Well, let me be more specific.(9) A Sure.(10) Q Does it have, for example, the(11) jurisdiction, the case name, the date, the basic(12) facts in the case -- things like that?(13) A Well, I was asked to make it a(14) little over a year ago for a case in St. Louis(15) for the Veterans Administration. So the prior(16) four years I did from memory. And what I did(17) was if I remembered the law firm, I called them(18) and asked for the name of the plaintiff and the(19) defendant. And so I have the name of the(20) plaintiff, the defendant, the date I testified(21) or was deposed, and the name of the attorney's(22) office and where they are located.(23) But I don't have things like trial(24) date numbers, or stuff like that. I guess that(25) could be generated if I called them back.

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(1) A. McMeeking, M.D.(2) Q I would not ask you to do any(3) additional work. Just to give Mr. Jenkins the(4) list.(5) A Sure.(6) Q I just wanted to make sure I(7) understood what I will be receiving.(8) A Yes.(9) Q Do you know how it is that Hertz(10) Schram, in general, or Mr. Jenkins specifically(11) became aware of your availability for a case(12) like this?(13) A You know, I'm really not. I got(14) kind of a cold call about a different case a(15) couple of years back. And I looked at the data,(16) and since then they have called me on four or(17) five occasions.(18) I think there were two cases where(19) I told them no, I don't see a case here. And(20) besides this one, I believe there are two other(21) cases that are still active with the company,(22) that I'm aware of.(23) Q Are any of those other cases(24) active with the Hertz Schram firm decubitus(25) ulcer-related cases?

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(1) A. McMeeking, M.D.(2) A No, sir.(3) Q More of a straight infectious(4) disease kind of case?(5) A Right. One is necrotizing(6) fasciitis. Another is a urinary tract(7) infection, as I recall.(8) Q Have you done litigation(9) consulting work for other Michigan law firms?(10) A No, not that I recall.(11) Q Anything else in the region; Ohio,(12) Illinois?(13) A Chicago. I did a deposition for a(14) company on a herpes simplex encephalitis case(15) where I was deposed. That should be on my list(16) that Mr. Jenkins will send you. That settled.(17) It did not go to trial, so I didn't have to go(18) to Chicago. That was the only case in the area.(19) Q Let's go back to your notes.(20) A Yes, sir.(21) Q Feel free -- I'm going to ask you(22) some general questions, and feel free to refer(23) to your notes or the medical records.(24) A Very well.(25) Q Quintella Smith at the time of her



10 (Pages 34 to 37)

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(1) A. McMeeking, M.D.(2) death was 76 years old and had a number of(3) underlying co-morbid conditions, right?(4) A That is correct.(5) Q Can you create a list --(6) A I have it.(7) Q -- of her co-morbid conditions?(8) A Sure. (Perusing document.) It's(9) in about the middle of the page. The sentence(10) starts "Failed to prevent."(11) Q Okay.(12) A So, she had a history of(13) depression, diabetes mellitus.(14) She had peripheral vascular(15) disease, which led to a below-the-knee(16) amputation on her left leg.(17) She had chronic renal failure, for(18) which she was on hemodialysis three times a(19) week.(20) She had a history of hypertension,(21) and a history of congestive heart failure.(22) Now, I did not pick up a history(23) of dementia, but I got some information(24) suggesting mild dementia from Dr. Homa's(25) deposition, the plaintiff expert. But I did not

Page 35

(1) A. McMeeking, M.D.(2) see that in my initial -- it's not in my notes.(3) Q Would the term poor protoplasm(4) and/or vasculopath fit Ms. Quintella Smith's(5) underlying disorders?(6) A It would.(7) Q It's the kind of patient -- I know(8) you don't treat patients in the nursing home(9) setting, but it's the kind of patient that may(10) be more of a, quote, sitting duck, end quote,(11) for the development of pressure ulcers, right?(12) A Certainly at risk; yes, sir.(13) Q Even with appropriate care?(14) A It can sometimes happen even with(15) appropriate care. And I think from reading(16) Dr. Homa's deposition, I think he made a very(17) nice outline of ulcers that could not be(18) prevented.(19) Q Her decline significantly(20) decreased or, rather, increased after a left(21) below-knee amputation, right?(22) A Yes. That was the --(23) MR. JENKINS: Objection to(24) form.(25) A Yes. That was the first kind

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(1) A. McMeeking, M.D.(2) of -- she had a leg injury which did not heal(3) and led to a below-the-knee amputation at(4) St. John's Hospital.(5) Q And thereafter, pretty much she(6) developed some level of sacral decubitus ulcers(7) which pretty much didn't heal from that point(8) forward?(9) A Correct. She initially, that I(10) could see, came to Ambassador with a Stage 3(11) ulcer on her sacrum and buttocks. After her(12) return to St. John's and her readmission to(13) Ambassador on September 12th, it was now a(14) Stage 2 ulcer, which was going in the right(15) direction.(16) But unfortunately it progressed,(17) as far as I could see, to a Stage 4 by her first(18) admission to Detroit Receiving on October 3rd.(19) Q Might I see the original of yours,(20) sir?(21) A Sure (handing). I can show you(22) where those notes are, if you would like.(23) Q No. That's not the purpose for me(24) looking at these.(25) I'm taking your cue, which you

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(1) A. McMeeking, M.D.(2) told me off the record, that some of the items(3) are underlined in red.(4) A Yes.(5) Q Is that just --(6) A It's primarily so I can separate(7) each, you know -- Ambassador versus Detroit(8) Receiving and the dates that she would have been(9) transferred or readmitted.

(10) Q Got it. So it's underlining the(11) next change in status, essentially --(12) A Essentially.(13) Q -- as she went from the nursing(14) home to the hospital or whatever?(15) A Exactly. So that way I don't lose(16) my place.(17) Q (Handing.)(18) A Thank you.(19) Q She would be in the nursing home(20) setting and then develop some problem, be it a(21) UTI, urinary tract infection, or sepsis or low(22) blood pressure or something that would trigger(23) her readmission?(24) A She would get sepsis with signs(25) of --



11 (Pages 38 to 41)

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(1) A. McMeeking, M.D.(2) MR. JENKINS: I object to(3) form and foundation. Go ahead.(4) A She would get a sepsis with(5) potentially septic shock, with low blood(6) pressure, which is advanced sepsis, and get(7) readmitted to -- or be admitted and then(8) readmitted to Detroit Receiving with a diagnosis(9) of sepsis.(10) Q Now, you understand that she(11) was -- I think it was nine years out end-stage(12) renal failure on dialysis; does that sound(13) right?(14) A Yes, sir.(15) Q Having that in her co-morbid(16) conditions, does that change anything from your(17) perspective relative to her susceptibility to(18) either urinary tract or sepsis?(19) A Well, having co-morbidities does(20) put you at high risk of getting infections and(21) sepsis.(22) Q Yes. But I was specific to the(23) end-stage renal failure.(24) A In and of itself, yes. You can,(25) for example, get skin infections where your

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(1) A. McMeeking, M.D.(2) dialysis catheter is. And, again, if you have(3) vascular disease, you can get wound(4) infections -- you know, leg infections from(5) ulcers from diabetes and peripheral vascular(6) disease. Those are classically what one sees(7) with a patient with renal failure.(8) Q There are sporadic notes from some(9) of the nursing notes -- for example, on the(10) middle to lower section of Page 2, it says(11) Nursing Notes.(12) Note 10/3: "Confused. BP 68/36.(13) Temp 99.9. Transfer for hypotension." I(14) believe that must say "Change MS."(15) A (Perusing document.) Change in(16) mental status.(17) Q "Change in mental status. 68/40."(18) A (Perusing document.) Yes.(19) Q "DX septic shock."(20) So is that a note just basically(21) describing -- it appeared in the nurse's notes,(22) but describing what happened?(23) A Exactly. Yes.(24) Essentially, in my review, I did(25) everything as it was given to me in the record.

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(1) A. McMeeking, M.D.(2) So this came out in nursing notes in that(3) chronology. So some of the nursing notes came(4) before, say, some of the -- for example, those(5) came before the Wound Care Clinics of America(6) consult notes.(7) So that's why they are there, even(8) though it looks like they're a little out of(9) place, because it's essentially a note from

(10) October 3rd.(11) Q It looks like the basic mission(12) here in your notes is to make it easier for you(13) to sit here today or in another setting and(14) recall things and not have to go back to the(15) records to pull things out; is that accurate?(16) A That's correct, sir. Yes.(17) Q While I see at the back page(18) something in parentheses which could be part of(19) an opinion, is basically the purpose for this(20) document again what I just stated?(21) A That's it. Just so I can remember(22) things and we don't spend fifteen minutes with(23) me digging through the records to find some(24) point I wanted to make.(25) Q When you reviewed the records --

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(1) A. McMeeking, M.D.(2) and I know this may not have been your(3) assignment, but did you see any deficiencies(4) relative to how the infectious disease care was(5) provided?(6) A At Detroit Receiving?(7) Q Anywhere.(8) MR. JENKINS: I object to(9) relevance, but go ahead.

(10) A No, not that I'm aware of.(11) Nothing comes to mind. No comments about the(12) antibiotic choices or what the infectious(13) disease people at Detroit did.(14) And I didn't have really, quite(15) frankly, enough notes to say one way or the(16) other. It didn't seem she was showing signs of(17) sepsis before the day of transfer from(18) Ambassador.(19) Q I was just wanting to see -- I(20) mean from my review of the records -- and I'm(21) not an infectious disease physician, obviously.(22) But from my review of the records, it looked to(23) me like the hospital care and treatment,(24) especially as it pertains to the ID portion, was(25) all very appropriate?



12 (Pages 42 to 45)

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(1) A. McMeeking, M.D.(2) A I believe so. I would agree.(3) Q Let's hone in on the -- strike(4) that. Let me start over again.(5) Not only did this patient have all(6) of the co-morbid conditions that we have talked(7) about, she also in the nursing home setting had(8) significant bouts of bowel and bladder(9) incontinence?(10) A Yes, sir.(11) Q Which certainly can aggravate the(12) situation?(13) A Absolutely.(14) Q And it would make it even more(15) difficult to maintain a clear healing sacral(16) decubitus under those circumstances?(17) A Yes. I mean, one does the best(18) they can nursing-wise to clean the patient up as(19) rapidly as possible because the longer one is(20) wet or lying in their feces, the more likely(21) there will be skin breakdown. So one tries to(22) rapidly take care of that when it happens.(23) Q Have you ever heard the term(24) "Kennedy ulcer"?(25) A Actually, I heard that for the

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(1) A. McMeeking, M.D.(2) first time when I -- or read it the first time(3) in Dr. Homa's deposition. I had never come(4) across that before.(5) Q I guess I should go back to your(6) wound care experience. In terms of your wound(7) care consults in the inpatient setting, are you(8) there primarily to deal with antibiotic(9) selection?(10) A That is correct, sir.(11) Q So, for example, when you go see a(12) patient, do you take down their dressing and(13) observe, for example, a sacral wound, or do you(14) make assumptions relative to that?(15) A Well, I try to round with the(16) staff, the nurse practitioners who are doing the(17) actual wound care dressings in the morning and(18) will round on the patients. I always like to(19) see the wounds myself, though I'm not going to(20) be the one making recommendations on using(21) collagenase, or what kind of dressing to use, or(22) when it's time to go to the operating room.(23) We'll look at the wounds together.(24) We'll go over the microbiology, laboratory data,(25) what is growing, and we'll go over the

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(1) A. McMeeking, M.D.(2) antibiotic selection; continue this, change to(3) that, switch to oral this because they are going(4) home.(5) So I'm not making any decisions as(6) to the actual wound care, other than the(7) antibiotics.(8) Q Do you have a routine relative to(9) whether or not you do cultures?

(10) A We try to always do cultures.(11) Cultures are always a good thing, in my opinion,(12) because it helps me decide which antibiotics,(13) are they the right antibiotics, how long do we(14) have to give them, when can we switch to(15) something -- narrow the spectrum of coverage.(16) So I'm always -- and I've kind of(17) trained the wound care staff to do that; to(18) always do cultures.(19) Q In a patient like this, isn't(20) there a high degree of colonization of those(21) wounds?(22) A There can be. So wounds -- a swab(23) taken off a surface of a wound like this would(24) not be very helpful, which is why when you take(25) somebody to the operating room and you get into

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(1) A. McMeeking, M.D.(2) deeper tissues below the surface, the cultures(3) become very relevant, which is why I was looking(4) for the culture from the operating room at(5) Detroit Receiving, which we couldn't find. That(6) would have been a very helpful culture to me.(7) But you're correct. Things just(8) taken off surfaces don't mean an awful lot.(9) Q What would you expect to see or

(10) what would the range of possibilities be that(11) you would expect for that wound culture that we(12) can't find?(13) A Usually a combination of bacteria,(14) especially something at the sacrum, near the --(15) where one could get some fecal contamination.(16) It could be what they call Gram-negative(17) bacteria. It could be sometimes what are called(18) anaerobes. And, of course, regular skin(19) bacteria like staphylococcus is often involved.(20) So a wound culture is often(21) polymicrobial; hence you start with broad(22) spectrum antibiotics, as they did in this lady's(23) case, and then you try to narrow, if one can.(24) Q At some point there was a question(25) of osteomyelitis, based on either the wound



13 (Pages 46 to 49)

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(1) A. McMeeking, M.D.(2) description or based on an x-ray or something.(3) But apparently it was determined that there was(4) not active osteo; is that your recollection?(5) A That is correct, yes. Because she(6) had a Stage 4 ulcer, which can go all the way(7) into muscle, and possibly to bone -- and, of(8) course, your coccyx, your tailbone is right(9) there -- it's not uncommon in that area for(10) Stage 4 ulcers to go to bone.(11) And if bone is involved, by(12) definition, you have osteomyelitis. So that was(13) a reasonable thing for them to think about.(14) Q And had she had osteo, the(15) antibiotics that they were using would have been(16) covering for that?(17) A Yes. The difference would be the(18) duration. You would have to treat her for a(19) period of six weeks to sometimes several months(20) to potentially cure an osteomyelitis. They are(21) cured very slowly.(22) Q In a patient who has a history of(23) urinary tract infections and has significant(24) sacral decubitus and they come in with SIRS,(25) S-I-R-S, or what appears to be sepsis, in that

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(1) A. McMeeking, M.D.(2) patient, the consideration -- the most likely(3) considerations for the source of their infection(4) would be either the urinary tract or a wound(5) seeding the blood directly?(6) A That is correct. Those would be(7) the commonest: Urinary tract infections and(8) infected ulcers.(9) Q And in order to accurately(10) determine the source, you would have to really(11) have more information such as a culture, which(12) would give you better ideas on where the source(13) was?(14) A Well, what I can say for sure in(15) this case is they did do urine cultures --(16) Q Hang on.(17) A Sorry.(18) Q I'm asking generally.(19) A Oh, in general.(20) In general, cultures are always(21) helpful. I mean --(22) MR. JENKINS: I object to(23) the form.(24) A You can tell if a wound is(25) infected from looking at it. It's just the

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(1) A. McMeeking, M.D.(2) information you're looking for then is what are(3) the bugs causing the infection and, therefore,(4) are we giving the right antibiotic therapy?(5) Q So, for example, if a patient --(6) again, this is not this case specifically.(7) A Yes, sir.(8) Q If a patient has a history of(9) urinary tract infections and either has an(10) indwelling Foley catheter or is incontinent, and(11) they also have decubitus ulcers which appear to(12) be infected, if you had a positive culture(13) with -- blood culture with a Gram-negative, you(14) would probably suspect that it was from the(15) urinary tract?(16) MR. JENKINS: Objection;(17) form, foundation, relevance.(18) A You're half right.(19) Q Okay. Fix it.(20) A It could be indeed a urinary tract(21) infection. But because of the location by the(22) sacrum next to the -- with fecal contamination,(23) the vast majority of bacteria in our stools are(24) Gram-negatives. So it's just as likely it could(25) be from a wound infection. It's hard to -- you

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(1) A. McMeeking, M.D.(2) can't tell.(3) Q Sure. And in order to sort that(4) out, you would really want to have cultures of(5) the blood, you would want to have cultures of(6) the wound, and you would want to have cultures(7) of the urinary tract?(8) A Correct.(9) MR. JENKINS: Same(10) objection.(11) Q And that would give you the(12) most -- the highest level of precision relative(13) to what the source was?(14) A Exactly.(15) MR. JENKINS: Same(16) objection.(17) Q And it would really require a(18) guess or speculation, if a physician didn't have(19) that data, to make the call on where the source(20) was for sepsis?(21) MR. JENKINS: Objection;(22) form, foundation, relevance.(23) A Okay. What I would say is this:(24) So you have a patient, and say they have(25) positive blood cultures, especially with a



14 (Pages 50 to 53)

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(1) A. McMeeking, M.D.(2) Gram-negative bacteria. If you have a potential(3) urinary tract infection and you have a potential(4) infected wound, it's a coin toss as to where the(5) blood infection is coming from.(6) Q So you can't say one more than the(7) other?(8) A In the general sense, yes.(9) Correct.(10) MR. JENKINS: Same(11) objection.(12) Q As this lady progressively -- her(13) condition worsens, she has several(14) hospitalizations where she has sepsis, right?(15) A Yes, sir.(16) Q The last one being -- apparently(17) she was in dialysis --(18) A Correct.(19) Q -- and her blood pressure was(20) noted to be low, and so she was admitted to(21) Detroit Receiving Hospital and worked up for(22) sepsis?(23) A That is correct.(24) Q During that hospitalization, the(25) blood cultures were drawn but didn't come back

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(1) A. McMeeking, M.D.(2) with any identification of any bacteria, right?(3) A That is correct.(4) Q And the urine culture that was(5) done came back as polymicrobial, and they didn't(6) do any further testing because they thought it(7) was a contaminant; did I get that right?(8) A That is correct, sir. That would(9) be standard.

(10) Q And as far as you know, neither(11) the blood cultures or the urinary tract cultures(12) were ever repeated?(13) A I couldn't see that. (Perusing(14) document.) The suggestion was if the urine was(15) consistent with contamination -- "repeat if(16) indicated" was what I have written down here for(17) the urine culture from the microbiology lab.(18) Q But you didn't see it repeated?(19) A No, they never repeated it.(20) Q So we don't have specific(21) information on that last admission relative to(22) what bacteria was present in the wound, what(23) bacteria was present in the blood, or what(24) bacteria was present in the urine?(25) A That is correct.

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(1) A. McMeeking, M.D.(2) MR. JENKINS: Relevance(3) objection.(4) Q The antibiotics they provided her(5) at that last hospitalization were appropriate?(6) A Yes, sir.(7) Q They were giving her presumptive(8) treatment?(9) A Yes. Empiric antibiotics.

(10) Q That's the term I was looking for.(11) Thank you.(12) A Yes.(13) Q The last notation on Page 6 --(14) A Yes.(15) Q "Three hours beyond first hours,"(16) is that what that says?(17) A (Perusing document.) That's my(18) billing, so I remember what to ask Mr. Jenkins(19) for.(20) Q What was your first?(21) A They sent me a retainer for $500,(22) which is in the (indicating), and then -- so I(23) spent all together four hours. So I had the(24) retainer, then three hours beyond the first(25) hour.

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(1) A. McMeeking, M.D.(2) Q Gotcha. Without speciating the(3) bacteria, the statement "polymicrobial in the(4) urine" really doesn't give you a lot of(5) information, right?(6) A Actually, you're --(7) MR. JENKINS: Object to the(8) form.(9) A -- you're wrong.

(10) Q Okay.(11) A I'll tell you why. Because that's(12) a common -- everyone does that.(13) Urinary tract infections are(14) classically caused by one or, at the most, two(15) organisms. So when I was in training, the(16) golden rule was if you have more than one(17) bacteria in the urine, it was a contaminant.(18) It turns out now, sometimes you(19) can get a co-infection with maybe two organisms.(20) But when you have polymicrobial -- and I don't(21) know what their -- is it four or is it five?(22) The cutoff varies hospital to hospital. But(23) when you have more than two bacteria in the(24) urine, it's not considered a urinary tract(25) infection. It's what they call colonization,



15 (Pages 54 to 57)

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(1) A. McMeeking, M.D.(2) which is why they said this is consistent with(3) colonization, repeat the culture and see on(4) regrowth if you get a one- or two-bug(5) predominance which we could say is our organism.(6) But in and of itself, this to me(7) suggested just a colonization and not a true(8) urinary tract infection.(9) Q But really to be definitive on

(10) that, you would need to reculture and see what(11) it grew?(12) A You would. And, of course, I'm(13) reading into their heads here as to what I would(14) do.(15) In this situation, the infectious(16) disease specialist -- if they really thought it(17) was a urinary tract infection, they would(18) definitely have said no, we have to repeat that,(19) and they didn't.(20) So, I think -- again, this is just(21) what I would think. If I were Dr. McArthur and(22) the service, I would say, "Well, it's(23) polymicrobial. We're giving her the(24) antibiotics. We know she has an infected(25) decubitus, by physical experience. We're going

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(1) A. McMeeking, M.D.(2) to use the same antibiotics anyway, so it's not(3) going to change our treatment."(4) So I'm assuming they didn't think(5) it was a true urinary tract infection; hence,(6) they never repeated it.(7) Q Sure. And while all this is going(8) on, the daughter is making the decision to put(9) her on comfort care --(10) A That is correct.(11) Q -- right?(12) A On this last admission, yes.(13) Q So wouldn't that maybe alter the(14) aggressiveness with which the infectious disease(15) physician would be going after the source here?(16) A Possibly.(17) Q You don't know for sure, but that(18) could have been in play?(19) A It could be.(20) Q So in the end when it comes down(21) to determining a source for Ms. Smith's sepsis(22) and what bacteria, really it's the same(23) situation we were in: It's a coin toss? You(24) really can't tell the source because we don't(25) have the data to support it?

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(1) A. McMeeking, M.D.(2) A Well, no, I would --(3) MR. JENKINS: Object to(4) form.(5) A I would say this: We definitively(6) have -- though they didn't take a culture, which(7) they should have, she definitively had a(8) severely infected decubitus ulcer.(9) The thing we can't really tell,

(10) based on the data we do have from the urine(11) culture, is this was not consistent with a(12) urinary tract infection.(13) So that was why I made that next(14) to last statement at the bottom of Page 6 that(15) (reading) urine is polymicrobial, would be(16) expected in a debilitated patient. That was to(17) remind me to say it's not clear to me she ever(18) had a true urinary tract infection in any of the(19) three admissions.(20) Q In the prior admission, she grew(21) out E. coli?(22) A In her blood, but not from her(23) urine.(24) Q Didn't they draw the conclusion(25) that it was from urine?

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(1) A. McMeeking, M.D.(2) A All I saw was E. coli bacteremia(3) and sepsis. I don't know that I saw they said(4) that came from the urine. I didn't see a(5) statement in the ID consultant's note saying(6) that.(7) Q I believe it says most likely(8) urinary tract is the source.(9) A Yes. And I'll tell you why that(10) is.(11) When this lady came in -- all(12) three admissions, as we discussed, she could(13) have had a urinary tract infection, and she did(14) have an infected decubitus.(15) So correctly on their admission(16) notes they put down possible urinary tract(17) infection, rule out pneumonia -- hence they did(18) chest x-rays -- and infected decubitus ulcer.(19) So that was appropriate, to have a broad(20) differential as to where the sepsis was coming(21) out.(22) But, as you know, on the first(23) admission, the urine culture was sterile. So(24) that obviously wasn't the source. And her chest(25) x-ray was normal, so she didn't have pneumonia.



16 (Pages 58 to 61)

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(1) A. McMeeking, M.D.(2) And then both of the other(3) admissions, the urine was polymicrobial. The(4) microbiology lab said "This is a contaminate.(5) Please resubmit."(6) So that's why I was saying maybe(7) there was a urinary tract infection, but I can't(8) say that. Whereas, I know for a fact there was(9) an infected decubitus based on the presentation

(10) each time.(11) It would have been nice if they(12) had done cultures. It would have been very(13) nice, but they didn't. But nonetheless, I'm a(14) hundred percent sure that these decubiti were(15) infected -- her decubitus was infected.(16) Q Right. But you really can't be(17) sure that the source of the sepsis came from the(18) decubiti --(19) MR. JENKINS: Object to(20) form.(21) Q -- that's a long shot?(22) A Well, I would say that the(23) decubitus played a major role in the absence of(24) another obvious source.(25) I mean, if you had a nice clean

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(1) A. McMeeking, M.D.(2) urine culture with just E. coli, I would agree(3) with you a hundred percent. But with the urine(4) culture data being the first time no growth and(5) the other two, polymicrobial, probable(6) colonization, I would have trouble saying that(7) that was the obvious source of her sepsis.(8) I think more likely than not it(9) was her -- the one constant you have is the(10) decubitus which is infected in all three(11) admissions. That's why I would say that was the(12) more likely culprit of the two.(13) Q And in terms of any resources that(14) would support that, you're basically relying on(15) your experience?(16) A Oh, and that's basically -- you(17) can go to any infectious disease textbook -- you(18) may do that later today -- and look up urinary(19) tract infections. And when you have more than(20) two organisms in a urine culture, the answer is(21) it's a colonization or a contamination. Please(22) repeat if clinically appropriate.(23) But a true urinary tract infection(24) is going to be one or, at the most, two(25) organisms. It's not going to be polymicrobial.

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(1) A. McMeeking, M.D.(2) And, again, in a lady like this(3) who is incontinent, it's not uncommon for her(4) bladder -- urinary bladder to be colonized. In(5) fact, it would be --(6) Q It would be unusual for it not to(7) be?(8) A Exactly. If it came back sterile,(9) I would say "Please repeat. I don't believe(10) that."(11) So you're always going to have(12) bacteria in the bladder. The question is the(13) correlation between -- is it an infection or is(14) it colonization is sometimes difficult to make.(15) Q Sure. What I was asking about and(16) what I want to get to is drawing the conclusions(17) that you are drawing relative to the(18) polymicrobial urine suggesting that maybe that(19) was the cause of the sepsis in this lady, I'm(20) just saying the resources you're using to make(21) that call are basically your experience?(22) A And my training, yes. And the(23) literature.(24) Q Well, that's where I'm going next.(25) Obviously, you understand this process.

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(1) A. McMeeking, M.D.(2) A Yes.(3) Q If I look or if you look, are we(4) going to find in Kousar's or Mandell's or some(5) other infectious disease textbook that you(6) should interpret a polymicrobial urine as you're(7) doing here?(8) A Yes, sir. Most definitely.(9) Q You would find that?(10) A A hundred percent.(11) Q That would suggest that the wound(12) was the source as opposed to the urinary tract?(13) A Well, what it would suggest is the(14) urine is not truly infected. If you have a(15) polymicrobial culture, that would suggest to a(16) doctor that this is not a urinary tract(17) infection; it's a colonization. Because a true(18) infection is going to be one or two species of(19) bacteria, not several. That's a basic(20) infectious disease --(21) Q Okay. All right. The other(22) factor here that we haven't talked about is the(23) urine itself had four-plus bacteria; meaning a(24) large volume, a large quantity --(25) A Correct. Correct.



17 (Pages 62 to 65)

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(1) A. McMeeking, M.D.(2) Q -- of bacteria.(3) Does that add to this(4) polymicrobial thing that we're discussing?(5) A It doesn't one way or the other.(6) And I'll tell you why. And, again, it goes back(7) to when this lady was admitted and they did the(8) urinalysis, that urinalysis shows white blood(9) cells, it shows bacteria.(10) That in and of itself is quite(11) consistent with either a urinary tract infection(12) or a colonization, and that's why I think again(13) the doctors put down urinary tract infection, as(14) they should have, as part of the differential on(15) the admission diagnosis all three times, I(16) believe.(17) And that's why you do the culture:(18) To see is it just bacteria in the bladder or is(19) it a true infection. Because the urinalysis,(20) unfortunately, can't tell you the --(21) differentiate between the two.(22) Q If you were to go look this up(23) this afternoon, or if you were to direct me to(24) go look this up this afternoon, where would you(25) go?

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(1) A. McMeeking, M.D.(2) A You could look in Mandell's(3) textbook, as you mentioned. That's probably the(4) most widely read and respected textbook on(5) infectious diseases. Just the general chapter(6) on urinary tract infections.(7) Q You would consider, I assume,(8) Mandell's to be a reliable source?(9) A It's reliable. And I've been

(10) asked many times if things are authoritative,(11) and I think the answer there is, if you are(12) going to ask me -- is because the data is at(13) publication at least two or three years old,(14) nothing per se is ever authoritative in a(15) textbook.(16) Q But you would consider Mandell's a(17) good place to go to help answer this question?(18) A Absolutely. Absolutely.(19) Q So your basic opinion here is that(20) Ms. Smith developed sepsis which was caused by(21) bacteria that was residing in the wounds(22) somewhere, and that at least partially led to(23) her demise?(24) A I would say it played a major(25) role, yes.

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(1) A. McMeeking, M.D.(2) Q Well, the other issue there is,(3) you know, she was put on comfort care?(4) A That is correct -- ultimately.(5) Q And the antibiotics were stopped?(6) A You're absolutely correct.(7) MR. JENKINS: Objection.(8) Q So in terms of the actual -- the(9) death itself, it was probably more related to(10) that at that point in time?(11) A And that's why the death(12) certificate --(13) MR. JENKINS: Objection,(14) form and foundation.(15) A That's why the death --(16) THE WITNESS: Sorry, Steve.(17) MR. JENKINS: Go ahead.(18) A That's why the death certificate(19) correctly outlines the underlying major(20) morbidities: Renal failure, and due to diabetes(21) and hypertension, probably; that she died of a(22) combination of sepsis and these -- they probably(23) stopped her dialysis, I'm sure. And people with(24) renal failure can't live without dialysis.(25) Q Did you form any opinions relative

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(1) A. McMeeking, M.D.(2) to her life expectancy had she survived this(3) last hospitalization?(4) A That's always such a tricky(5) question. People ask me how long somebody has,(6) and I would say --(7) Q Well, first off, you don't have to(8) have an opinion there. I'm asking you do you(9) have an opinion there?

(10) A I really don't. I really don't.(11) I'm certainly not an expert on all these other(12) aspects of her care, her kidney failure and(13) things like that.(14) Q Sir, I think I'm done. So let me(15) ask you this: Is there anything that I missed(16) in terms of an opinion that you might provide us(17) with at the time of trial in this case? And I(18) know --(19) MR. JENKINS: Objection to(20) the form.(21) Q -- it does to some extent relate(22) to the questions you're asked, obviously. But(23) you're here, you're prepared. I assume if you(24) have anything else, you will tell me.(25) A No, I think we covered it. I



18 (Pages 66 to 69)

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(1) A. McMeeking, M.D.(2) just -- it was never clear to me that this lady(3) had a true urinary tract infection, so I(4) couldn't honestly say that that played a major(5) role in her sepsis.(6) I think more likely than not the(7) decubitus ulcer, because it was infected and it(8) was the one thing that was there in all three(9) admissions, played the major role.

(10) Q Sure. And I got that. So let's(11) just do a little hypothetical.(12) Let's say hypothetically that the(13) wound culture that we can't find surfaces --(14) A Okay.(15) Q -- and it's a bacteria that you(16) would expect from a skin wound, you know, maybe(17) staph, maybe some other Gram-positive bacteria.(18) Will that change anything that you(19) talked about today?(20) A No. Again --(21) MR. JENKINS: Form(22) objection.(23) A The bacteria one finds in a(24) wound -- they don't always lead to bloodstream(25) infections, as far as causing sepsis. Sepsis

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(1) A. McMeeking, M.D.(2) could be also caused by toxins being released(3) into the blood by the bacteria, and also the(4) person's own immunologic response to the(5) infection sometimes is a double-edged sword and(6) leads to complications of the sepsis syndrome,(7) which is kind of a cascade.(8) So you can have severe sepsis,(9) septic shock. You can die of sepsis with

(10) negative blood cultures. Not everyone develops(11) positive blood cultures.(12) So the wound culture -- again,(13) maybe I'm looking at it from the point of view(14) of the more information I have as to the(15) culture, but the absence of it doesn't change my(16) opinion.(17) Q Well, I'm asking the reverse of(18) that.(19) A Oh.(20) Q If it becomes present --(21) A Yes, sir.(22) Q -- and it's a Gram-positive, which(23) is what you probably see in let's say a Stage 3(24) wound, right?(25) A You certainly would expect to see

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(1) A. McMeeking, M.D.(2) some Gram-positives in there. Absolutely.(3) Q Let's say all that is true --(4) A Yes.(5) Q -- does that change anything(6) relative to what we've discussed here today?(7) A No, sir.(8) MR. SVESKA: That's all I(9) have.(10) THE WITNESS: Okay. Thank(11) you very much.(12) MR. JENKINS: I have some(13) follow-up questions.(14) THE WITNESS: Okay.(15) EXAMINATION(16) BY MR. JENKINS:(17) Q Dr. McMeeking, based on your(18) knowledge, training, education, and experience,(19) do you have an opinion more likely than not that(20) the infected decubitus ulcers on Ms. Smith's(21) sacrum caused her premature death?(22) A Yes. My opinion is more likely(23) than not, because it was the one thing that was(24) a constant in all the admissions, it was the(25) infected sacral decubitus that led to her sepsis

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(1) A. McMeeking, M.D.(2) and death.(3) Q And when you used the term "major(4) role" in response to Mr. Sveska's questioning --(5) "major role," do you interpret that to be more(6) likely than not?(7) A Yes, sir; more likely than not.(8) Q What is the basis for your opinion(9) that the infected decubitus ulcers on(10) Ms. Smith's sacrum more likely than not led to(11) her premature death?(12) A We know this lady had sepsis. She(13) had all the cardinal signs: The fever, the low(14) blood pressure, the high white blood cell count.(15) And as I was explaining, the only(16) constant through each admission between(17) Ambassador and the hospital was an infected(18) decubitus ulcer.(19) The urine culture -- the initial(20) one was negative. The next two were(21) polymicrobial, probably contaminants. She had(22) negative chest x-rays, so she didn't have(23) pneumonia. So there was nothing else that I(24) found in the records that could be a potential(25) source that was anywhere near as likely or at



19 (Pages 70 to 73)

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(1) A. McMeeking, M.D.(2) all, quite frankly, other than the infected(3) decubitus. It was the only source that seemed(4) to make sense to me as a source of her sepsis.(5) Q Is your opinion that she had --(6) that the cause of death was more likely than not(7) infected decubitus ulcers leading to her(8) premature death supported by the lack of(9) evidence in the medical records to support a UTI

(10) or a pneumonia or other sources of infection?(11) MR. SVESKA: Form. Boy,(12) that's convoluted. Go ahead.(13) A That would be correct. Yes, the(14) sepsis caused her death, and the sepsis was(15) caused more likely than not by the infected(16) decubitus ulcer.(17) Q And do you have an opinion more(18) likely than not that had the ulcers not(19) developed to Stage 4, with respect to the(20) presentation to Detroit Receiving Hospital on(21) October 3rd, that her premature death could have(22) been prevented?(23) MR. SVESKA: Foundation. It(24) requires other expertise.(25) THE WITNESS: Can I answer?

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(1) A. McMeeking, M.D.(2) MR. SVESKA: Yes.(3) MR. JENKINS: Go ahead.(4) Yes.(5) A So, yes, I have an opinion. The(6) opinion is this:(7) If you don't have a large ulcer, a(8) Stage 4, which is all the way through the skin,(9) you wouldn't -- you don't develop infections

(10) usually.(11) It's classically, when you have a(12) Stage 4 ulcer which is down into the muscle,(13) sometimes all the way to the bone, that an(14) infection tends to be more serious and leads to(15) sepsis.(16) So had this lady stayed at a(17) Stage 2, which is essentially just skin(18) thickness and nothing below the skin, more(19) likely than not she wouldn't have gone on to(20) develop sepsis and die.(21) Q Given her underlying(22) co-morbidities and the condition of the wound on(23) October 3rd and the infectious process that had(24) begun, do you have an opinion that it would have(25) been difficult to prevent her premature death

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(1)(2) after October 3rd?(3) MR. SVESKA: Foundation.(4) A Well, I have an opinion.(5) I think, again, with good wound(6) care to -- I mean, the infections were treated(7) appropriately by Dr. McArthur and the service at(8) Detroit Receiving. With good wound care, there(9) would be a possibility for the wounds to heal to

(10) prevent recurrent sepsis, which -- the problem(11) here was the wound never got better once it(12) developed, as far as I could tell. So she was(13) at risk again and again of getting sepsis from(14) infection from her wound.(15) Had it been treated appropriately(16) and resolved, then she wouldn't have gotten(17) sepsis and she wouldn't have died.(18) MR. JENKINS: I don't have(19) any other questions.(20) MR. SVESKA: We're set.(21) THE WITNESS: Okay. Thank(22) you very much.(23) (Time noted: 11:11 a.m.)(24)(25)

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(1)(2) I N D E X(3) WITNESS: ALEXANDER McMEEKING, M.D.(4) Examination By Page(5) Mr. Sveska 3(6) Mr. Jenkins 68(7)(8) E X H I B I T S(9)

McMeeking Description Page(10) For Ident.(11) 1 Handwritten notes of Dr. McMeeking, 3

consisting of six pages(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)



20 (Page 74)

Page 74

(1)

(2) C E R T I F I C A T E

(3) STATE OF NEW YORK )

(4) ) ss.

(5) COUNTY OF NEW YORK )

(6) I, KAREN ANN CARNEY, CSR,

(7) RPR, CMRS, a Shorthand (Stenotype)

(8) Reporter and Notary Public of the

(9) State of New York, do hereby certify

(10) that the foregoing Deposition, of

(11) the witness, ALEXANDER MCMEEKING,

(12) M.D., taken at the time and place

(13) aforesaid, is a true and correct

(14) transcription of my shorthand notes.

(15) I further certify that I am

(16) neither counsel for nor related to

(17) any party to said action, nor in any

(18) wise interested in the result or

(19) outcome thereof.

(20) IN WITNESS WHEREOF, I have

(21) hereunto set my hand this 18th day

(22) of September, 2017.

(23)

(24) ________________________________

KAREN ANN CARNEY, CSR, RPR, CMRS

(25)


Fink & Carney Reporting and Video Services39 West 37th Street * New York, New York 10018 (800) NYC-FINK * (212) 869-3063


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