# T H E 

# K L E I N 

# L A W 

# F I R M

2000 T HE L YRI C C ENTRE 440 L OUI SI

A NA S TREET H OUSTON, T EXAS 7700 2 ( 7 1 3 ) 6 5 0

- 1 1 1 1 F A CSI M I L E ( 7 1 3 ) 2 2 7

- 1 1 2 1 M Y R IA M K

. L E G G E

OF COUNSEL A LE X ANDER B

. K

LE IN III

BOA RD CERTIFIED PERSONAL

I NJUR Y T RIA L LA

W TE XA S BOA RD OF LEGAL SPE CIA LIZA TION

A LSO LICENSED IN COLORA DO

Mar ch 4, 2 01 5

Mr. Ch ris to ph er A. Pri ne V ia eFi li ng Cl erk , 14 Co ur t o f App eal s

th 30 1 F an ni n S tre et , Sui te 24 5 Hou st on , Texa s 7 70 02

Re: App el la te Cau se No. 14 -1 4- 00 11 2- CV ; Deb ra C. Gu n n , M .D., Obs te tr ic al an d Gynec ol og ic al As so ci at

es , P.A., a n d Obs te tr ic al an d Gynec ol og ic al As so ci at

es , P.L.L. C. vs . And

re McC oy , as Perm an ent Gua rd ia n of Sha nno n Mi le s McCo y, an In ca

pa ci ta te d Pers on ; In th e Fo ur te en th Co ur t o f App eal s, Ho us to n, Tex as

Dear M r. Pri ne :

I am writ in g to pr ov id e t h e McC oy fa m il y ’s r es po ns e to th e po st -s ub m is si on le tt er b rie f su bm it te d b y

Debr a C. Gun n, M .D.

I. Dr. Brew er’s ca us at io n tes timony is leg al ly suf fic ie nt.

The po si ti on ta ke n by Dr. Gun n in he r le tt er br ie f is cu rio us gi ve n th e fact th at sh e to ld th e jury th at sh e ha d “ no op in io ns ” ab ou t th e to pi c of pr ox i mat e c a us e , o r 1 th e accu racy of Dr. Brewe r’s bl oo d lo ss cal cu la ti on s

. Dr. Gun n te st ifi ed at tri al th at 2 sh e no t on ly la ck ed th e “ ex pe rti se ” to te st ify ab ou t th e cau se of Sh an no n’s co de an d br ai n da m ag e, sh e al so to ld th e jury th at , if so m eo ne wan te d to cal cu la te Sh an no n’s

3 bl oo d l os s o n t he 14
, th ey n eed ed to as k Dr. Br ewe r : th

RR. Vol. 10, 28:4- 15. 1

RR. Vol. 10, 151:7- 152:4. 2

RR. Vol. 10, 123:9- 16. 3Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2

Q: Did y ou do th es e cal cu la ti on s?

A: I di dn' t do tho se ex ac t ca lc ul at io ns . No, si r, I di d no t.

Q: I se e. So if we ba ck up to aro un d 7: 27 in th e m or ni ng whe re Dr. Brewe r ha d sa id ab o u t 2 5 pe rcen t of th e bl oo d vo lu m e was lo st whe n he r he m og lo bi n was 5.5 . Do y ou ag ree o r di sa gr ee wi th th at nu m be r?

A: You w ou ld ha ve to a sk Dr. Brew er.

RR. Vol. 9 , 27 7: 4- 11 (em ph as is ad de d)

.

Des pi te th es e co nc es si on s, Dr. Gun n’s rece nt co rres po nd en ce read s m or e li ke

a pr e-t ria l rep or t fro m a de fen s e ex pe rt ex pl ai ni ng he r reb ut ta l po in ts on cau sa ti on rat he r th an a le tt er b rie f on leg al su ffi ci en cy . Alth ou gh Dr. Gun n h as ad m it te d t ha t sh e is un qu al ifi ed to ad dr es s th e is su e, he r le tt er b rie f ex pl or es th e fact ua l m in ut ia e of Dr. Brewe r’s te st im on y in at te m pt to co nv in ce th is Co ur t th at Dr. Brewe r an d th e jury go t it wro ng on cau sa ti on , bu t he r ex pe rts go t it rig ht

. And
, as a res ul t, th is Co ur t sh ou ld fin d t ha t Dr. Bre wer’s cau sa ti on tes ti m on y am ou nt s t o n o e vi de nc e at all

.

Dr. Gun n’s arg um en t ig no res th e fu nd am en ta l te ne t of rev ie win g a no ev id en ce po in t on ap pe al –wh en cau sa ti on ev id en ce (e.g
., ev id en ce ab ou t a di sp ut ed fact ) fal ls wit hi n th e zo ne of re a s o n a b l e di sa gr eem en t, th e rev ie win g ap pe ll at e co ur t is
pr oh ib it ed fro m in va di ng th e fact f in di ng ro le of th e jury to su st ai n a no -ev id en ce ch al le ng e. Ci ty of Kel le r v. W il so n , 16 8 S.W .3d 80 2
, 8 2 2 ( Te x. 20 05 ); Mor re ll v. Fin ke , 18 4 S .W .3d 25 7, 2 72 (Tex .App .–F or t Wort h 2 00 5, pet

. de ni ed ). Dr. Brewe r pr ov id ed le ga ll y su ffi ci en t ev id en ce on th e is su e of pr ox im at e cau se , an d App el la nt s lo st th e “ ba tt le of th e ex pe rts ” at tri al

. W hi le Dr. Gun n in vi te s th is Co ur t to si t as th e th irt een th juro r an d re-t ry th is cas e on cau sa ti on , th e in vi ta ti on to su bs ti tu te a di ffer en t de ci si on for th e o ne reac he d b y th e jury in t hi s ca se sh ou ld be de cl in ed

.

In a ba tt le of co m

pe ti ng ex pe rts , th e jury ha s th e so le res po n s i b i l i t y t o de te rm in e th e c red ib il it y of th e wit ne ss es an d th e weig ht to be gi ve n to th ei r te st im on y

. Mor re ll v. Fin ke
, 18 4 S.W .3d 25 7, 27 2 (Tex .App .–F or t W or th 20 05
, pe t. de ni ed ). The jury al on e ge ts to de ci de whi ch ex pe rt’s te st im on y on cau sa ti on sh ou ld be acce pt ed or reject ed in reac hi ng it s ve rd ic t. Mor re ll
, 18 4 S.W .3d at 27 2; W il so n ,Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 3

16 8 S.W .3d at 82 2. On ap pe al
, whe n th e lo si ng pa rty co m pl ai ns th at t h e ex pe rt te st im on y th e jury rel ie d on to reac h it s verd ic t is le ga ll y in su ffi ci en t, th e rev ie win g

co u r t i s n o t f

r e e to re-we ig h th e ev id en ce, re-t ry th e cas e, an d se t as id e th e jury’ s

ve rd ic t. Mor re ll , 1 84 S.W .3d at 27 2. Thi s is tru e ev e n i f t h e rev ie win g co ur t feel s th at a di ffer en t resu lt ba se d on th e sa m e ev id en ce is m or e reas on ab le

. Mor re ll
, 18 4 S.W .3d at 2 72

.

If Tex as la w real ly m ean s wha t it sa y s, e.g ., th at al l ev id en ce in su pp or t of th e jury’ s fi nd in g o n p ro xi m at e cau se m us t be con si de red in th e li gh t m os t favo rab le to th e ve rd ic t; an d, al l reas on ab le in fere nc es to be dr awn fro m th e ev id en ce co nc ern in g pr ox im at e c a u s e , in cl ud in g Dr. Brewe r’s te st im on y , m us t be m ad e in fav or of

su pp or ti ng th e ju r y’s ve rd ic t, th e le ga l su ffi ci en cy ch al le ng e to Dr. Brewe r’s
te st im on y sh ou ld be ov erru le d. W il so n , 16 8 S.W .3d at 82 1. Nearl y twen ty-fiv e y ears ag o, th is Co ur t m ad e th e fo ll owi ng ob se rv at io n th at pr ov id es an en du rin g ba ck dr op ag ai ns t wh ic h Dr. Gu nn ’s leg al su ffi ci en cy ch al le ng e sh ou ld be vi ewed :

Eve n if we as th e rev ie win g co ur t m ig ht vi ew th e ci rcu m st an ces of th is
tra gi c cas e co nt rary to t h e w a y t h e jury di d, we can no t be co m e a th irt een th juro r an d su bs t i t ut e ou r jud gm en t fo r th ei rs

. In a ba tt le of

co m pe ti ng ev id en ce, it is th e so le ob li ga ti on of th e jury to de te rm in e th e cred ib il it y of th e wit ne ss es an d to weig h th ei r te st im on y

. ... And it is ou r ob li ga ti on to see th at th e pr oc es s was fai r an d carr ie d ou t acco rd in g to th e ru le s. We cann ot un de r an y cir cu m st an ces re-t ry

th e cas e.

W ar ne r v. Hur t, 83 4 S.W .2d 40 4, 40 8– 09 (Tex .App .–Ho us to n [1 4t h Dis t.] 19 92
, no writ ); se e al

so Mor re ll
, 18 4 S.W .3d at 27 2. Here, th e jury was free to be li ev e Dr. Brewe r’s cau sa ti on te st im on y ov er th e op in io ns ex pr es se d by th e de fen se ex p ert s. The jury was free to acce pt th e McC oy’ s th eo ry of th e cas e, an d to reject App el la nt s’ th eo ry of th e cas e. In cas es li ke t h i s o n e , whe re reas on ab le juro rs co ul d res ol ve

co nf li ct in g cau sa ti on ev id en ce ei th er way , a rev ie win g co ur t m us t pr es um e th ey di d

so in fav or of th e pr ev ai li ng pa rty. W il so n , 16 8 S.W .3d at 82 2. Turn in g no w to th e sp eci fic po in ts arg ue d by Dr. G u nn , th e br ie fin g be lo w sh ows th at he r no ev id en ce ch al le ng e to Dr. Brewer ’s tes ti m on y sh ou ld be ov erru le d.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 4

II

. Dr. Gunn ’s at tempt t o es ta bl is h the in co rrec tnes s of Dr. Brew er’s bl oo d lo ss ca lc u l a t i on s fo r the jury m is se s the m ar k on pro xi m at e

ca us e.

Co nt rary to Dr. Gu nn ’s co nt en ti on , th e an swe r to Ju st ic e Bo y ce’s q ue st io n i s

“ y es ;” th e re was ev id en ce pr es en te d to th e jury sh owi ng a m ech an is m of in jury in de pe nd en t of Sh an no n’s bl oo d lo ss

. Tha t m ech an is m was two fo ld : (1 ) Dr. Gun n’s

ne gl ig en t fai lu re to or de r an d ad m in is te r fres h fro zen pl as m a (“ FFP” ) to Sh an no n on th e 14 , a nd ( 2 ) t h e n e gl ig en t or de rin g an d ad m in is tra ti on of Lasi x– a di ur et ic dr ug

th th at cau se d Sh an no n to ex pe rie nc e flu id vo lu m e lo ss in de pe nd en t of th e bl oo d lo ss sh e was ex pe rie nc in g fro m th e DIC. Each of th es e cau sa ti on m ech an is m s is di sc us se d be lo w.

A. If Sha nno n ha d bee n a dminis tere d FFP on the 14 , a s requ ir ed by t h the sta nda rd of care, her bloo d w ou ld ha ve been ab le to effe cti ve ly

co ag ul at e o r cl ot , sto ppi ng the bl oo d lo ss fro m the DI C.

Sev eral un di sp ut ed fact s are relev an t to th is as pe ct of Dr. Brewe r’s cau sa ti on te st im on y . They are a s fo ll ows :

1. Sh an no n was su ffer in g fr om DIC an d a ct iv el y

bl eed in g a t t he ti m e Dr. Gun n was cari ng for he r on Sep te m be r 14 , 20 04

.

2. DIC i s a b l o od cl ot ti ng di so rd er th at co m pr om is es th e hu m an bo dy’ s

co ag ul at io n m ech an is m th at na tu ral ly oc cu rs as a de fen si ve res po ns e to bl eed in g b y

de st ro y in g t he clo tt in g fa ct or s i n t he bl oo d. 4

3. Sh an no n’s bl oo d was no t co ag ul at in g on th e 14 be cau se th e DIC ha d th de pl et ed or de st ro y ed he r cl ot ti ng fact or s as ev id en ced by th e ab no rm al

RR. Vol. 8, 160:8-16, 162:7-13, 163:4-15, 164:1-7 (Dr. Bre wer ’s t est i m o n y ab o u t how 4 DI C c auses the body to c onsume, not pr oduce, blood c lotting fac tors); RR. Vol. 13, 219:7-10 (Dr. Alexander, Appellants’ materna l feta l medicine expert, testified that DI C cause s the destruction of
coag ulation fac tors in the blood).Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 5

ch an ge s in he r PT, PTT, FSP, pl at el et , an d fib rin og en la b va lu es on th e

14 th

. 5

4. To fix th e co ag ul at i o n p ro bl em , fres h fro zen pl as m a or “ FFP” is ad m in is te red to th e pa ti en t to gi ve th e hu m an bo dy wha t it ne ed s (p la s ma) to m ak e th e co ag ul at io n fact or s th at en ab le th e bl oo d to cl ot

an d s to p t he pa ti en t’s b lo od lo ss

. 6

5. Sh an no n “ ne ed ed ” FFP on th e 14 be cau se it was “ vi ta l” to he r th

co nd it io n. 7

6. W he n cari ng fo r a DIC pa ti en t, su ch as Sh an n o n, th e ap pr op ria te st an da rd of m ed ic al care req ui res th e tre at i n g ph y si ci an to or de r an d ad m in is te r FFP to th e pa ti en t so th at th e pa ti en t’s bl oo d m ay co ag ul at e effe ct iv el y

to st op th e p at ie nt ’s bl oo d l os s fr om th e DIC. 8

RR. Vol. 12, 230:5-9 (Dr. Aubuchon’ s testimony ); RR. Vol. 8, 160:8-16, 162:7-13, 163:4- 5 15, 164:1-7 (Dr. Br ewe r’s testimony ). Dr. Br ew er relied on objective foundational data (the abnorma l chang es in Shannon’s PT, PTT, FSP, and fibrinog en) to explain to the jury how and why Shannon’s blood had lost the abili t y to eff ectively clot. Vol. 8, 160:8-16, 162:7-13, 166:11-15, 184:1-21; see also RR. Vol. 16B, 109-10:M cCoy 0 2 7 3 -74 (P laintif f’s Exhi bit 7)

. Dr. Br ewe r explained that Shannon’s PT level chang ed in response to rec eiving the FF P order ed by Dr. J acobs; howeve r, it never normalized on the 14

. RR. Vol. 8, 184:1-21; see also RR. Vol. 16 B , 109- t h 10:Mc Coy 0273-74 (P laintif f’s Exhi bit 7)

. Also, Shannon’s FSP and fibrinog en levels rema ined abnorma l on all of the labs draw n on the 14
, further indicating that Shannon’s inability to clot was t h

never corr ecte d to nor

mal. RR. Vol. 16B, 109-10:Mc Coy 0273-74 (P laintif f’s Exh ibit 7)

. RR. 164:12-23, 167:16-24 (Dr. B rew er’ s testimony about how and why FF P is g iven t o 6

a DI C patient to repla ce clotting fac tors); RR. Vol. 9, 257:4-10 (Dr. Gunn testified that FF P is g iven
to the patient to repla ce the clotting fac tors that are lost from bleeding ); RR. Vol. 12, 221:12-15 (Dr. Aubuchon testified that plasma contains proteins that ca use or pr omote normal coag ulation of t he blood); RR. Vol. 13, 26:15- 16 (Dr. A ubuchon testified that plasma is “FF P.”).

RR. Vol. 13, 251:24-253: 2 (Dr. Alexander testified that Shannon neede d FF P a nd that it 7 was vital to her c ondition).

RR. Vol. 9, 257:4-10, 257:19-24 (Dr. Gunn testified that it was her re s ponsibili ty to 8 administer FF P to S hannon to re place the clotting f actor s she had lost due to blee ding)

.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 6

7. Dr. Gun n was 10 0% ne gl ig en t in fai li ng to or de r or ad m in is te r an y FFP
to Sh an no n o n t he 14

. th

Non e of th es e fact s ha ve be en ch al le ng ed on ap pe al

. The fact ua l fin di ng App el la nt s

are a tt em pt in g t o re -arr an ge on ap pe al (gu is ed in th e p arl an ce o f a l eg al su ffi ci en cy ch al le ng e) is whe th er Dr. Gun n’s ne gl ig en ce in th is reg ard m ad e a di ffer en ce in te rm s of pr ev en ti ng Sh an no n’s ul ti m at e ou tc om e. The an swe r is –o f co ur se it di d– be cau se th e jury had leg al ly suf

fic ie nt ev id en ce u po n wh ic h t o b as e th is co nc lu si on at t ria l.

As Dr. Brewe r ex pl ai ne d to th e jury, wha t Sh an no n ne ed ed to tre a t h e r DIC (in de pe nd en t of gi vi ng he r a m as si ve bl oo d tra ns fu si on to rep la ce red bl oo d cel ls ) was

a m ech an is m to m ak e he r bl oo d co ag ul at e to st op th e bl oo d lo ss sh e was ex pe rie nc in g

on th e 14

. Tha t m ech an is m , wh ic h Dr. Gun n was ne gl ig e n t i n fai li ng to pr ov id e,

th 9

was th e ad m in is tra ti on of fres h fro zen pl as m a or “ FFP.” In de pe nd en t of rep la ci ng 1 0 Sh an no n’s lo st bl oo d vo lu m e wit h pa c k ed red bl oo d cel ls
, Sh an no n’s bo dy ne ed ed
to rece iv e FFP so th at he r bl oo d co ul d effe ct iv el y cl ot to o v e r c om e th e bl oo d lo ss

cau se d b y th e DIC. Dr. Brewer e xp la in ed as f ol lo ws: 1 1

Q: And tel l us , is the purp os e of the FFP to repl ac e tho se c l o tti ng fa cto rs so tha t yo u ca n co rrec t the DIC so the p a t i e n t st op s bl eedi ng ?

A: Tha t's co rrec t.

RR. Vol. 9 , 19 0: 17 -2 0 (em ph as is ad de d)

.

RR. Vol. 8, 205:11-206: 17, 223:15-225: 12, 214:9-215: 8, 282:9-15, 282:17-19, 282:25- 9 283:3, 225:1-12, 223:10-12 (Dr. Br ewe r’s direc t ex am); RR. Vol. 9, 190:5-20 (Dr. Br ewe r’s redirec t exam); see also RR. Vol. 9, 257:4-10
, 257:19-24 (Dr. Gunn’s testimony that Shannon neede d FF P and i t wa s h er responsibility to g ive it to her) ; RR. Vol. 13, 251:24-253: 2 (Dr. Alexander testified that Shannon nee ded F FP and that it was vital to her condition).

Id . at Footnote 9. 1 0

See Footnote 9. 1 1Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 7

Q: Ass um e wit h m e hypo th et ic al ly th at th e de fen da nt wan ts to co m e in he re

an d sa y no , I ve rb al ly or de red FFP, we do n't se e an y ev id en ce of th at in th e nu rs in g no te s o r t h e bl oo d ba nk reco rd s or th e ad m in is tra ti on

reco rd s, d o we?

A: No, w e do n' t an d in ad di tio n to tha t, ac tua ll y ther e w as a lo t of st uff bei ng do ne. And it w as al l do cumented , A, B, C, D, E, F. And the FFP w as the o nl y th in g th at w as m is si ng .
Q: And was FFP, an act ua l or de r fo r FFP th at Sh an no n ge t th e FFP, cri ti cal th at m or ni ng ?

A: It w as cri tic al tha t m or ni ng .

RR. Vol. 9 , 19 0: 5- 16 (em ph as is ad de d)

. Q: In y ou r op in io n, was it cri ti cal th at Sh an no n re cei ve th e FFP?

A: Abso lu tel y cri tic al

. Bec au se yo u ca n repl ac e bl oo d unti l the co w s

co m e ho m e, but i f yo u ca n’t cl ot an d yo u ha ve an op en w ou nd li k e in si de the uter us , they ’re go in g to co nti nue to bl eed. And so yo u 1 2 ba si ca ll y pu t t h e b lo od in an d the bl oo d co m es ou t, an d w ith ou t cl ot tin g fa cto rs , yo u ca nno t co ntro l th e co ag ul at io n di so rder

.
Q: Did it rep res en t a br each in th e st an da rd of care to fai l to or de r th e FFP?

A: I be li ev e it did

.
Q: Did Sh an no n n eed th e FFP?

A: She a bs ol utel y n eede d it

.

Dr. Br ewe r explained that when the place nta separ ates awa y from the wall of the uterus, 1 2 it lea ves a big are a that bleeds like a big scab, and the patient’s clotting fac tors have to be repla ced so that this area

can c lot properly

. RR. Vol. 8, 223:15- 225:12.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 8

Q: Did Sh an no n con ti nu e to lo se bl oo d vo lu m e be cau se sh e di dn ’t ge t th e FFP?

A: At le as t pa rti al ly beca us e sh e di dn’t ge t the FFP.

RR. Vol. 8 , 20 5: 11 - 20 6: 17 (em ph as is ad de d)

. Q: W he n y ou lo ok ed at th e in fu si on reco rd s[ ,] bl o o d b a n k reco rd s[ ,] an d

nu rs in g reco rd s, was th ere an y FFP in fu si ng aro un d 10 :0 0 o’cl oc k in th e

m or ni ng ...[? ]

A: Ther e w as no t.

Q: The y

were n ev er o rd ered were t he y ?

A: They co ul dn’t ha ve been or dere d or the bl oo d ba nk w ou ld ha ve rel ea se d them.

Q: Acco rd in g to th e m ed ic al reco rd
, th e la st un it of FFP was i nf us ed

aro un d 3: 51 in th e m or ni ng , an d th at was th e un it or de red –e ss en ti al ly,

or de red by D r. Ja co bs , cor rect ?

A: Tha t’s m y u nder st an di ng .
Q: Now, is th ere an y way to de fen d Dr. Gun n’s m an ag em en t of Sh an no n wit h a co m

pl et e ab se nc e of FFP, fres h fro zen pl as m a, be twee n th e ti m e sh e cam e on bo ard an d th e ti m e s he to ok Sh an no n to th e op erat in g

ro om ?

A: Ther e is no defe ns e o f tha t in m y o pi ni on .
Q: W as FFP ab so lu te ly crit ic al to tak in g c are o f th is lad y ?

A: It w as ab so lu tel y c ri tic al

.

RR. Vol. 8 , 21 4: 9 - 2 15 :8

.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 9

Dr. Brewe r al so te st ifi ed th at , if Sh an no n ha d be en pr op erl y res us ci ta te d wit h FFP, bl oo d, an d pl at el et s, Sh an no n’s ou tc om e wou ld ha ve be en co m pl et el y di ffer en t:

A: If sh e h a d been ad equa tel y res us ci ta ted [w ith bl oo d, pl at el ets an d FFP] an d sh e ha d bl ed the amoun t tha t sh e bl ed fro m 11 :0 0 o' cl oc k to 2: 00 o' cl oc k an d ha d been ta k en to the op era tin g ro om, I bel ie ve

w ith rea so na bl e cert ai nty tha t they w ou l d ha ve put her to sl eep, in tuba ted her, ta k en he r ute rus ou t, an d sh e w ou ld ha ve w ok en up in ta ct, ex cept m is si ng her ut erus .

RR. Vol. 8 , 28 2: 9- 15 (em ph as is ad de d)

.

A: As yo u lo ok thro ug h w here al l thi s bl oo d lo ss oc curr ed, it w as al l cumula tiv e. And I thi nk I' ve st at ed se ve ra l times tha t sh e di dn' t ge t

eno ug h cl ot tin g fa cto rs . You ca n po re the bl oo d in , b u t the bl oo d jus t k eeps co m in g o ut i f yo u ca n' t cl ot it.

RR. Vol. 8 , 28 2: 17 -1 9, 2 82 :2 5- 28 3: 3 (em ph as is ad de d)

.
Q: W ha t do es th at m ean : Fu nd us is bo gg y an d th at whe n th ey m as sa ge d it
, th ere was a la rg e am ou nt of b le ed in g?

A: So the w ay I re ad thi s i s, i t's k in d o f w ha t I w as des cri bi ng ea rl ie r, if yo u do n' t -- if yo u do n' t repl ac e the cl ot tin g fa cto rs , yo u put bl oo d i n an d bl oo d co m es ou t beca us e sh e ha d a ra w bed w he r e t h e pl ac enta w as deta ched

.

RR. Vol. 8 , 22 3: 10 -2 2 (em ph as is ad de d)

. Q: W h e n it go t to th e po in t th at th e ut eru s be ga n to be co m e un ab le to

co nt ract ba ck d o w n , i s it fo res eeab le to ge t ev en m or e bl eed in g whe n y ou 've go t u nc on tro ll ed DIC?

A: Tha t's co rrec t ex ac tly w ha t ha ppen s.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 0

Q: Is th at ex act ly th e po si ti on th e de fen da nt pu t he rs el f in by no t ta ki ng th e rig ht st ep s t hr ou gh ou t t he earl ie r pa rt o f th e d ay ?

A: I thi nk no t r e p l a ci ng the cl ot tin g fa cto rs ha s a lo t to do w ith the uter in e a to ny .
Q: Tha t m ean s n ot ge tt in g t he FFP?

A: Tha t's rig ht.

RR. Vol. 8 , 22 5: 1- 12 (em ph as is ad de d)

.

Dr. B r e w e r ’s cau sa ti on te st im on y su ffi ci en tl y es ta bl is he d th at th e ne gl ig en t fai lu re to p r o v i de Sh an no n wit h FFP was a su bs ta nt ia l fact or in br in gi ng ab ou t he r br ai n dam ag e an d wi th ou t t hi s n eg li ge nc e Sh an no n’s b rai n d am ag e wou ld no t hav e

oc cu rred

. RR. Vol

. 8, 20 5: 11 -2 06 :1 7, 22 3: 15 -2 25 :1 2, 21 4: 9- 21 5: 8, 28 2: 9- 15 , 28 2: 17 -1 9, 2 82 :2 5- 28 3: 3, 2 25 :1 -1 2, 2 23 :1 0- 12 ; RR. Vol. 9 , 19 0: 5- 20

.

Dr. Brewe r es ta bl is he d th at , if Dr. Gun n ha d act ua ll y or de red an d ad m in is te red th e 4 un it s of FFP to Sh an no n th at sh e cl ai m ed to ha ve ve rb al ly or de red on th e 14
, th it wou ld ha ve m ad e a d iff eren ce i n p rev en ti ng Sh an no n’s b rai n d am ag e b ecau se , in

reas o n a b l e m ed ic al pr ob ab il it y , th e FFP ad m in is tra ti on wou ld ha ve en ab le d Sh an no n’s bl oo d to co ag ul at e an d st op th e bl oo d lo ss sh e ha d ex pe rie nc ed be fo re 1: 00 p.m

. on th e 14

. Id

. Sh an no n ne ve r go t th e FFP th at s h e ne ed ed to m ak e he r th bl oo d cl ot effe ct iv el y be cau se Dr. Gun n ne ve r or de red it

. Acco rd in g to Dr. Brewe r, th is ne gl ig en ce in fai li ng to or de r an d ad m in is te r t h e F F P pr ox im at el y cau se d Sh an no n’s br ai n da m ag e be cau se S h an no n co nt in ue d to bl eed (b ecau se he r bl oo d

co ul dn ’t co ag ul at e), res ul ti ng in he r ul ti m at e card i o v a s c ul ar de -co m pe ns at io n in to he m or rh ag ic sh oc k, ca rd ia c arr es t an d b rai n d am ag e:

1. Dr. Brewe r te st ifi ed th at Sh an no n’s la ck of bl oo d, la ck of ci rcu la ti ng bl oo d vo lu m e, pr ox im at el y cau se d he r br ai n da m ag e be cau se sh e di dn ’t ha ve ad eq ua te bl oo d flo w a n d ox y ge n de li ve ry to he r br ai n. RR. 8: 25 8: 16 -2 5; RR. 8:2 61 :9 -1 7

.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 1

2. Dr. Brewe r te st ifi ed th at it was Dr. Gun n’s res po ns ib il it y to ke ep th is fro m ha pp en in g by or de rin g th e ad m in is tra ti on of m or e bl oo d an d bl oo d
pr od uc ts , es pe ci al ly FFP, to kee p th is fro m ha pp en in g. RR. 8: 26 1: 18

- 22

.

3. Dr. Brewe r te st ifi ed th at , g iv en Sh an no n’s pr of ou nd bl oo d l os s, i t was fo re s e e a bl e th at Sh an no n wou ld go in to V-fi b. RR. 8 :2 48 :1 4- 19 ; RR. 8: 24 5: 1- 5; 8:2 59 :8 -2 3.

4. Dr. Brewe r te st ifi ed th at , a s a res ul t of t h e V

- f ib , S ha nn on ’s h eart was

no t be at in g pr op erl y , res ul ti ng in in ad eq ua te bl oo d flo w an d ox y ge n to he r br ai n. RR. 8:2 47 :1 2- 24 8: 4

.

5. Dr. Brewe r te st ifi ed th at , whe n Sh an no n wen t in to V-fi b, sh e was do wn fo r ab ou t 11 m in ut es ; an d, du rin g CPR, sh e was do wn fo r an ad di ti on al 20 m in ut es

. RR. 8:2 48 :4 -1 3

.

6. Dr. Brewe r te st ifi ed th at th e V-fi b was ba si cal ly a card ia c arre st be cau se Sh an no n’s h eart st op pe d p um pi ng pro pe rly. RR. 8:2 52 :7 -1 0

.

7. Dr. Brewe r t e s ti fie d th at th e V-fi b res ul te d in la ck of ox y ge n to Sh an no n’s b rai n. RR. 8:2 56 :8 -1 2.

8. Dr. Brewe r te st ifi ed th at Sh an no n’s la ck of bl oo d, la ck of ci rcu la ti ng bl oo d v ol um e cau se d h er h eart to go in to V-fib

. RR. 8:2 58 :2 4- 25 9: 1

.

9. The art eri al bl oo d ga se s ta ke n fro m Sh an no n aft er sh e wen t in to V-fi b sh owe d m et ab ol ic aci do si s, e.g

. a pH of 6.9 (7 .35 -7 .40 no rm al )
, a ba se

ex ces s o f -2 4. RR. 8:2 52 :1 3- 25 3: 14

.

10

. Sh an no n’s bl oo d ga se s were co ns is te nt wit h so m eo ne who ha s su ffer ed gl ob al br ai n da m ag e fro m ox y ge n de pr iv at io n; an d, th at th e EEG st ud y

was co ns is te nt wit h t hi s an al y si s. 8: 25 9: 24 -2 60 :2

.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 2

11

. The ev id en ce of

m et ab ol ic /l act ic aci do si s pr ov es th at al l of Sh an no n’s ti ss ue s, in cl ud in g he r br ai n, wer e e x t rem el y lo w in ox y ge n. RR 8: 25 4: 16 -1 9

.

12

. Dr. Brewe r te st ifie d tha t, in re as on ab le m ed ic al pr ob ab il it y , if Sh an no n’s D I C ha d be en co rrec tl y (n on -n eg li ge nt ly) tre at ed by Dr. Gu n n , Sh an no n’s br ai n da m ag e wou ld no t hav e oc cu rred

. RR. 8: 25 0: 13 -1 8.

13

. Dr. Brewe r te st ifi ed th at he r op in io n co nc ern in g th e cau se of Sh an no n’s br ai n da m ag e was m ed ic al ly su pe rio r to th e ot he r po ss ib l e c a u s es th at sh e ex cl ud ed

. RR. 8:2 79 :1 8- 28 0: 5

.

Dr. Brewe r al so te st ifi ed th at he r cau sa ti on an al ys i s w a s c on fir m ed by th e fo ll owi ng m ed ic al ev id en ce re ga rd in g t he eti ol og y of S ha nn on ’s bra in da m ag e:

1. Dr. Brewe r te st ifi ed th at th e ne ur ol og i c al as se ss m en t of Sh an no n pe rfo rm ed by t he tre at in g ne ur ol og is t at W om en ’s Ho sp i t a l co nf irmed he r cau sa ti on an al y si s; an d, Dr. Brewe r de sc rib ed he r caus at ion op in io ns in th e co nt ex t of th e cau sa ti on di ag ram th e tre at in g ne ur ol og is t in cl ud ed in Sh an no n’s m ed ic al reco rd s (RR 8: 26 1: 23 -2 62 :1 5; RR. 8: 26 3: 6- 20 ; Pla in tif fs ’ Ex hi bi t 5 );

2. Dr. Brewe r te st ifi ed th at he r cau sa ti on an al y si s was co ns is te nt wit h an d

co nf irmed by th e se ve nt een (1 7) n e u r o l og y co ns ul ts fro m St

. Luk e’s Hos pi ta l (th e ho sp it al whe re Sh an no n was ta ke n to tre at he r br ai n in jury) al l of whi ch ag reed th at Sh an no n su ffer ed pe rm an en t br ai n da m ag e fro m la ck of bl oo d flo w an d ox y ge n to th e br ai n ( R R

. 8 : 26 3: 21 -2 64 :1 6; Pla in tif fs ’ Ex hi bi t 8A- 8Q );

3. Dr. Brewe r te st ifi ed th at he r cau sa ti on an al y si s was co nf irmed by Sh an no n’s ab no rm al EEG res ul ts th at sh owe d ev id en ce of an ox ic br ai n in jury ( RR 8:2 57 :1 9- 25 );

4. Dr. Brewe r te st ifi ed th at he r cau sa ti on an al y si s was co nf irmed by Sh an no n’s art eri al bl oo d ga s r es ul ts , sh owi ng ev id en ce of pr of ou ndMr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 3

m et ab ol ic aci do si s co ns is te nt wit h ox y ge n de pr iv at io n fro m bl oo d lo ss

( RR 8:2 54 :1 6- 19 ); a nd
,

5. Dr. Bre wer te st ifi ed th at he r cau sa ti on an al y si s was co nf irmed by th e rad io lo gy repo rt d is cu ss in g t he he ad CT res ul ts at S t. Lu ke ’s Hos pi ta l, sh owi ng rad io lo gi cal ev id en ce th at Sh an no n ha d su ffer ed se ve re is ch em ic bra in da m ag e ( RR. 8:2 66 :2 0- 23 ).

Dr. Brewer als o t es ti fie d t ha t he r cau sa ti on an al y si s was co nf irmed by rul in g

ou t o r ex cl ud in g o th er p la us ib le cau se s fo r Sh an no n’s b rai n d am ag e:

1. Dr. Brewe r te st ifi ed ab ou t ho w an d w h y th e CT of th e he ad an d

ne ur ol og y rep or ts fro m St

. Lu k e ’s Hos pi ta l ru le d ou t in tra cran ia l bl eed in g an d CVA or st ro ke as a po ss ib le cau se fo r Sh an no n’s br ai n da m ag e ( RR. 8:2 66 :1 3- 16 ); ( RR. 8:2 70 :1 9- 27 1: 22 );

2. Dr. Brewe r te st ifi ed ab ou t ho w an d why sh e ru l ed ou t a pu lm on ary

em bo li sm as a po ss ib le cau se fo r Sh an no n’s br ai n da m ag e ( RR. 8: 27 1: 15 -2 72 :2 );

3. Dr. Brewe r te st ifi ed ab ou t ho w an d why sh e ru le d ou t am ni ot ic flu id

em bo li sm as a po ss ib le cau se fo r S ha nn on ’s br ai n da m ag e ( RR. 8: 27 2: 7- 19 );

4. Dr. Brewe r te st ifi ed a b o ut ho w an d why sh e ru le d ou t in fect io n as a po ss ib le cau se fo r Sh an no n’s br ai n da m ag e ( RR. 8: 27 2: 20 -2 73 :7 ); an d,

5. Dr. Brewer tes ti fie d a bo ut ho w and why sh e ru le d ou t Dr. Alex an de r’s
ut eri ne at on y th eo ry ( RR. 8: 28 1: 21 -2 8 3 :5 ), an d Dr. St ei ne r’s m ic ro

th ro m bi t h e or y as po ss ib le cau se s fo r Sh an no n’s br ai n da m ag e. RR. 8: 28 4: 14 -2 92 :1 4

.

In th is cas e, Sh an no n’s bl oo d cl ot ti ng syste m was de act iv at ed by th e DIC an d

no t wor ki ng an y

m or e. R R

. Vol

. 8, 16 3: 4- 15 , 16 4: 1- 7

. To fix th is pr ob le m , Dr. Brewe r te st ifi ed th at Sh an no n ne ed ed to rece iv e FFP so th at th e cl ot ti ng fact or s an d cel ls th at en ab le th e bl oo d t o c oa gu la te co ul d b e rep la ced , pre ve nt in g fu rth er b lo odMr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 4

lo ss an d per m an en t in

jury to Sh an no n. RR. Vol . 8, 164 :1 2- 23 , 16 7: 16 -2 4, 20 5: 11

- 206:17 , 223: 15- 225: 12, 214: 9- 215: 8, 282: 9- 15 , 28 2: 17 -1 9, 28 2: 25 -2 83 :3 , 22 5: 1- 12 , 22 3: 10 -1 2 ; RR. Vol. 9 , 19 0: 5- 20

.

The fact th at Sh an no n ne ed ed FFP to en ab le he r b l o o d t o cl ot was ne it he r

co nt es te d at tri al
, no r on ap pe al

. In fact
, Dr. Alex an de r te st ifi ed th at FFP was “ vi ta l” fo r Sh an no n an d th at sh e “ ne ed ed ” it on th e 14

. RR. Vol

. 13 , 25 1 : 2 4

- 2 5 3 :2

. Dr. th Gun n te st ifi ed th at Sh an no n ne ed ed FFP an d it was he r res po ns ib il it y to gi ve it to he r

on th e 14

. RR. Vol

. 9, 25 7: 4- 10
, 25 7: 19 -2 4

. As Dr. Gun n po in te d ou t, Sh an no n’s

th

co m pl et e in ab il it y to co ag ul at e pr ev en te d he r fro m rece iv in g an ep id ur al be cau se , if sh e bl ed in th e sm al l sp ace aro un d her sp in al co rd fro m th e in se rti on of th e ep id ur al

ne ed le
, sh ou ld co ul d be co m e pa ral y zed

. RR. Vol

. 10 , 69 :6 -1 6

. The se fact s are al so

un di sp ut ed on ap pe al

.

W hi le th e is su e of whe th er Dr. Gun n ev er m ad e a “ ve rb al ” or “ te le ph on e” or de r fo r FFP was di sp ut ed at tri al
, th e jury res ol ve d th e co nf li ct in g ev id en ce on th is is su e in fav or of Sh an no n, fin di ng Dr. Gun n ne gl ig en t, i n p a r t, fo r fai li ng to or de r an d ad m in is te r FFP. The jury al so fo un d th at Dr. Gun n’s ne gl ig en ce in th is r e ga rd
pr ox im at el y cau se d Sh an no n’s pe rm an en t br a i n da m ag e. Thro ug h th e ab ov erefe ren ced te st im on y of Dr. Brewe r, al on g wit h th e cau sa ti on fin di ng s do cu m en te d by th e tre at in g ne ur ol og is ts in Sh an no n’s m ed ic al reco rd s, th e jury was pr ov id ed wit h

m or e th an a sc in ti l l a o f ev id en ce to es ta bl is h th at Dr. Gun n’s ne gl ig en t fai lu re to

or de r an d a dm in is te r FFP t o S ha nn on pro xi m at el y cau se d h er b rai n d am ag e.

Dr. Brewe r ex pl ai ne d to th e jury th at th e ad m in is tra ti on of FFP wou ld ha ve , in

reas on ab le m ed ic al pr o b ab il it y , m ad e a cri ti cal di ffer en ce in en ab li ng Sh an no n’s bl oo d to co ag ul at e effe ct iv el y th ereb y st em m in g an d st op pi ng th e bl o o d lo ss an d
pr ev en ti ng Sh an no n’s br ai n da m a g e

. Th e t es ti m on y by Dr. Brewe r was ba se d on rel ia bl e fo un da ti o n a l da ta an d m ed ic al sc ie nc e, no t ip se di xi t co nc lu si on s or

un fo un de d a ss um

pt io ns

.

D r

. Brewe r es ta bl is he d fo r th e jury th at Sh an no n ne ed ed to rece iv e FFP t o

m ak e he r bl oo d c lo t an d t o o ve rco m e th e DIC. Sh an no n di dn ’t r ecei ve an y FFP on S e p t e m be r 14
, 20 04 be cau se Dr. Gun n ne ve r or de red it
, ne gl ig en tl y vi ol at in g th e st an da rd of care in th is cas e. Thi s ne gl ig en ce was a su bs ta nt ia l fact or in br in gi ng ab ou t Sh an no n’s br ai n da m ag e in th is cas e be cau se , i n t h e a b s e n ce of th e FFP,Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 5

Sh an no n’s bl oo d was un ab le to co ag ul at e, re s ul ti ng in Sh an no n’s co nt in ue d bl oo d lo ss fo ll owe d by he m od y na m ic in st ab il it y , card io v as cu la r co ll ap se , hypo vo le m ic

s h o c k
, card ia c arre st , an d hypo xi c en cep ha lo pa th y

. At le as t th at ’s wha t th e jur y

co nc lu de d aft er he ari ng al l th e ev id en ce pr es en te d by bo th si de s, in cl ud in g Dr. Brewe r’s te st im on y an d th e cau sa ti on fin di ng s do cu m en te d in th e m ed ic al reco rd s by Sh an no n’s t reat in g n eu ro lo gi st s.

Thi nk ab ou t it th is way , if th e co m pl et e fai lu re to adm in is te r FFP to Sh an no n

on th e 14 was no t a pr ox im at e cau se of Sh an no n’s br ai n da m ag e, why di d App el la nt s

th

so fero ci ou sl y at te m

pt to es ta bl is h (b ut co ul dn ’t) t h a t t h e tre at in g nu rs es were al le ge dl y res po ns ib le fo r fai li ng to fo ll ow Dr. Gun n’s al le ge d “ te le ph on e or de r” fo r 4 un it s of FFP on th e 14 ? App el la nt s’ no ev id en ce/ le ga l su ffi ci en cy po in t on th 1 3

cau sa ti on sh ou ld be ov erru le d.

B. The neg li ge nt or deri ng and ad m in ist ra tio n of La si x ca us ed Sha nno n to ex peri ence flu id vo lu m e lo ss in depe nden t of the bl oo d lo ss sh e

w as ex peri enci ng fro m the DI C.

Lasi x is a di ur et ic dr ug th at cau se s t he pa ti en t t o u rin at e. Urin at io n, in tu rn , res ul ts in flu id lo s s fro m th e bo dy. Dr. Brewe r te st ifi ed th at Lasi x was

co n t r a i n di cat ed fo r Sh an no n be cau se sh e was bl eed in g, an d th at th e Lasi x ad m in is tra ti on m ad e Sh an no n’s co nd it io n “ wor se .” R R

. Vol

. 8, 21 8: 1- 22 0: 2, RR. Vol . 8,2 20 :1 8- 22 , RR. V ol . 8,2 20 :2 3- 22 2: 12 , RR. Vol

. 8, 27 0: 11 -1 6. Co nt rary to Dr. Gun n’s as se rti on in he r le tt er br ie f, Dr. Brewe r te st if i e d th at Dr. Gun n was

ne gl ig en t in gi vi ng Sh an no n Lasi x, an d th at th is ne g l i g e n c e was a pr ox im at e cau se of Sh an no n’s br ai n da m ag e. RR. Vo l. 8, 21 8: 1- 22 0: 2, RR. Vol . 8,2 20 :1 8- 22 , RR. Vol . 8,2 20 :2 3- 22 2: 12 , RR. V ol . 8, 2 70 :1 1- 16

.

The evidenc e showed (which the jury believed) that Dr. Gunn never wrote any order s for 1 3 FFP o n t h e 1 4

. RR. Vol. 8, 214:9 - 215:8. (Dr. Br ewe r’s testimony ); RR. Vol. 9, 259:16-21, t h 261:11-13, 261:14-19 (Dr. Gunn’s testimony ); RR. Vol. 13, 253:5-8 (Dr. Alexander’s testimony ). Whil e Dr . Gunn claimed to have issued a te lephone or der f or FF P, ther e was no documentation in
any of Shannon’s medical rec ords of any written order or telephone order being made by Dr. Gunn for fresh frozen plasma. I ndeed, the hospital bloo d bank employ ee, Ms. Fowle r, t estified that she thawed o u t 2 u n i t s of FF P on her own to be “proa ctive;” howeve r, she did not have any documentation to prove that the FF P had been order ed by Dr. Gunn. RR. Vol. 14, 93:8-94: 16, 97:2- 6, 105:18-19

.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 6

So why is it th at th e tre at in g ph y si ci a n sh ou ld n’t do wha t Dr. Gun n di d wit h

res pe ct to th e Lasi x ad m in is tra ti on i n a pa ti en t si tu at ed li ke Sh an no n? Dr. Co ll in s, Sh an no n’s t reat in g c ard io lo gi st , per ha ps sai d i t b es t:

Q: Our bo di es , y ou rs , m in e, an d Sh an no n's
, al l hav e a bu il t in ph y si ol og ic

res po ns e to bl eed in g; is n't th at rig ht ?

A: Yes

.
Q: And whe n we be gi n to bl eed an d ou r bo dy se ns es th at we're l os in g o ur

vo lu m e of f

l u i d s, ou r bo dy co m

pe ns at es by st op pi ng th e ur in e pr od uc ti on , cor rect ?

A: Yes

.
Q: Bec au se ou r bo dy wan ts to sa ve i t s f lu id s an d do es n't wan t to

un ne ces sa ril y

ex pe l an y

in th e fo rm

of u rin e, co rrec t?

A: Yes

.

RR. Vol. 1 4, 6 5: 25 -6 6: 11

.
Q: So whe n y ou ha ve th es e pa ti en ts who ha ve DIC an d are bl eed in g, wha t th e do ct or s are tryin g to do an d th e nu rs es are tryin g to do is to in crea se th ei r vo lu m e wit h b lo od , bl oo d p ro du ct s an d IV's , cor rect ?

A: Yes

.
Q: Su re. W he n y ou ha ve a pa ti en t th at is bl eed in g fro m , fo r ex am pl e DIC, wha t y ou se e is th e pa ti en t's bo dy tri es to co m pe ns at e f o r th at lo ss of flu id vo lu m e by ei th er ha lt in g th e pr od uc ti on of ur in e or cu tt in g it ba ck si gn ifi can tl y , cor rect ?

A: Yes

.

RR. Vol. 1 4, 6 5: 14 -2 4.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 7

Q: Did y ou ev er o rd er Las ix for Sh an no n?

A: No, s ir

.
Q: You un de rs ta nd ho w Lasi x wo rk s, co rrec t?

A: Yes

.
Q: W ou ld y ou wan t to gi ve La si x to a pa ti en t si tu at ed li ke Sh an no n who

was bl eed in g wi th DIC?

A: I w ou ld n' t ha ve gi ve n it

.
Q: W hy is it th at y ou wou ld no t ha ve gi ve n Lasi x to a pa ti en t li ke Sh an no n who ha d DIC an d was bl eed in g?

A: Wel l, i t w ou ld n' t do an y g oo d.

RR. Vol. 1 4, 6 4: 16 -2 5.

Dr. Co ll in s’ te st im on y co rro bo rat ed wha t Dr. Brewe r ha d ex pl ai ne d to th e jury in he r te st im on y , e.g

. , t h e La si x ad m in is tra ti on wou ld n’t do an y go od be cau se it

wou ld cau se Sh an no n to ur in at e , c o mp o u nd in g th e bl oo d lo ss pr ob le m by fu rth er de pl et in g h er fl ui d v ol um e an d m ak in g S ha nn on ’s con di ti on “ wor se ”:

Q: At 10 :1 5, wha t in fo rm at io n di d th e nu rs es rev eal ab ou t Sh a nn on 's

co nd it io n?

A: At 10 :1 5, they sa id tha t -- there w as a repo rt of a decr ea se in ur in e

ou tput

.
Q: Now, wha t do es th a t t e ll so m eo ne who kn ows wha t th ey 're do in g who is m an ag in g a pa ti en t l ik e Sh an no n?

A: Par t of w ha t uri ne ou tput tel ls yo u in , es peci al ly in a yo ung , hea lth y pa tie nt, is it tel ls yo u ho w w el l her k id ney s ar e bei ng pro fus ed. AndMr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 8

t h a t's k

in d of a fa ncy w ay of jus t ba si ca ll y sa yi ng : Is ther e b l o o d flo w to the ki dney s? Are they ge tti ng eno ug h? Bec au se w ha t ha ppen s is the bl oo d go es thro ug h the k id ney s an d ge ts fil tere d ou t,

an d it pro duce s uri ne as a res ul t of tha t. So if yo ur uri n e o u t p ut is do w n, is decr ea se d, tha t m ea ns tha t yo ur bl oo d fl ow to t he k id ney , pa rti cul ar ly in thi s k

in d o f si tua tio n, is pro ba bl y d ecre as ed. So it' s

rea ll y a n impor ta nt thi ng to b e fo ll ow ed.

Q: Is it a warn in g s ig n?

A: It ab so lu tel y is a w ar ni ng si gn , pa rti cul ar ly in the co n t e x t o f thi s pa tie nt.

RR. Vol. 8 ,21 8: 2- 25

.
Q: How d id th e d efen da nt res po nd to th is warn in g s ig n?

A: She ga ve her drug ca ll ed La si x. And La si x is a di uret ic w hi ch m ea ns it mak es yo u uri na te more.

Q: Is th at th e ri gh t t hi ng to do ?

A: Not in the sc ena ri o w here her vo lu m e w as do w n so fa r. We us e La si x fo r flu id ov erl oa d; in ot her w or ds , to o m uch flu id , w e need to ge t ri d of so m e w at er. We us e La s i x fo r peo pl e w ith co ng es tiv e hea rt fa il ure, w here ther e is too m uch flu id in thei r hea rt. In the co ntex t of ble edi ng , it' s co ntra in di ca ted.

Q: Did ord eri ng th e Las ix m ak e it wors e fo r Sh an no n?

A: Pro ba bl y.

Q: W as th e Las ix ex act ly w ha t you d id n't want to ord er?

A: It w as on e o f the t hi ng s y ou did n' t w an t to or der.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 1 9

Q: W ha t di d it te ll y ou ab ou t th e de fen da nt 's un de rs ta nd in g of wha t sh e was do in g whe n s h e o r d e r ed Lasi x aro un d 10 :1 5 in th e m or ni ng whe n th e

nu rs es to ld he r th e u rin ary ou tp ut was d own ?

A: Wel l, the w ay I l oo k ed a t tha t is she did n' t rea ll y u nder st an d w ha t

w as ha ppen in g to the pa tie nt.

RR. Vol. 8 ,21 9: 1- 22 0: 2.

Q: W as it ne gl ig en t of th e de fen da nt to or de r Lasi x th at m or ni ng , fai li ng to act reas on ab ly and pru de nt ?

A: It w as fai li ng to a ct re as on ab ly an d prud entl y, y es .

RR. Vol. 8 ,22 0: 18 -2 2.

Q: Now, a t a r o un d 10 :5 0 in th e m or ni ng , wha t, in fact
, was rel at ed to th e de fen da nt fro m

th e n ur se s?

A: 1 0: 50 pho ne repo rt: Urin ar y ou tput of 35 in 1 the la st ho ur. T h a t

w as af ter La si x. And ho w I in terp ret tha t is if sh e ha d ha d to o m uch flu id , she w ou ld ha ve m ad e a lo t of uri ne. But it s ay s to m e tha t, in fa ct, sh e w as flu id lo w ; in ot her w or ds , sh e di dn' t ha ve eno ug h flu id in her v ei ns to a ctua ll y i ncre as e her uri ne o utpu t.

Q: Let's ba ck up

. The re is th is do se of Lasi x gi ve n th at is su pp os ed to cau se

so m eo ne to m ak e a lo t of uri ne , co rrec t? Yet, af te r th e d os e was gi ve n, th e n ur se s ca ll ed up an d re po rte d t ha t t he re was on ly, wha t?

A: 35 Mls

.
Q: 35 MLs. Th at 's?

A: It 's li k e tha t.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 0

Q: A th ird of a cu p?

A: (The w itn es s no ds .)

Q: W ha t s ho ul d th at te ll a ph y si ci an who kn ows wha t th ey 're do in g whe n th ey gi ve a do sa ge of Lasi x li ke th at an d ge t a th ird of Dix ie cu p of ur in e aft erwar d?

A: I thi nk it tel ls a rea so na bl e phy si ci an tha t tha t's no t the ap pro pri at e trea tm ent, th at tha t's no t go in g to fix the pr ob le m .
Q: Bu t wh at di d t he de fen da nt do in res po ns e to th at ?

A: Ev entu al ly , she ga ve her a sec on d do se .
Q: W as it ne gl ig en t to gi ve th e se co nd do se of Lasi x; th at is
, fai li ng to act

reas on ab ly and pru de nt ly?

A: I be li ev e it w as .
Q: Is th at th e o pp os it e o f wha t Sh an no n n eed ed ?

A: Tha t is the o ppo si te o f w ha t Sha nno n nee ded.

Q: Is th ere a nyway

to de fen d g iv in g t he se two do se s o f Las ix ?

A: I thi nk the on ly defe ns e of tha t i s s h e di dn' t unde rs ta nd w ha t w as go in g, w ha t w as ha ppen in g w ith the pa tie nt.

RR. Vol. 8 ,22 0: 23 -2 22 :1 2.

Afte r b e i n g pr ov id ed wit h th e de fin it io n of pr ox im at e cau se , Dr. Brewe r te st ifi ed th at th e ne gl ig en ce of Dr. Gun n, in cl ud in g th e Lasi x ad m in is tra ti on , pr ox im at el y

cau se d S ha nn on ’s bra in da m ag e:Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 1

Q: And was th e ne gl ig en ce of th es e th in gs we'v e ou tl in ed
, w a s t h a t a pr ox im at e cau se of wh at we se e h ere?

A: I be li ev e it is

.
Q: Or th e p ro xi m at e cau se ?

A: It is the pr ox imate c au se , yes .

RR. Vol. 8 , 27 0: 11 -1 6.

In su m , Dr. Brewe r’s te st im on y co nc ern in g th e ne gl ig en t Lasi x ad m in is tra ti on

an d ho w th e ad m in is tra ti on of a di ur et ic to a bl eed in g pa ti en t mak i n g a th ird of a D i x i e c up of ur in e was cau sa ll y li nk ed to Sh an no n’s br ai n da m ag e in th is cas e was le ga ll y su ffi ci en t. App el la nt s’ no ev id en ce/ le ga l su ffi c ie nc y po in t on cau sa ti on sh ou ld be ov erru le d.

II I. The le tter bri ef po in ts ra is ed by Dr. Gunn do no t es ta bl is h tha t Dr. Bre w er’s ca us at io n tes timony w as leg al ly ins uffi ci ent.

A. The bl oo d lo ss “r e-ca lc ul at io ns ” perf or m ed by Dr. Gunn i n h er le tter bri ef do no t pro ve tha t Dr. Bre w er’s ca us at io n tes timony w as le ga ll y i ns uffi ci ent.

The fal la cy of Dr. Gun n’s at ta ck on Dr. Brewe r’s bl oo d l o s s an al y si s by
at te m pt in g to re-c al cu la te it on ap pe al is th at Dr. Gun n to ld th e jury th at , if so m eo ne

wan te d to cal cu la te Sh an no n’s bl oo d lo ss on th e 14
, th ey ne ed ed to as k Dr. Brew er , th

no t he r. RR. Vol

. 9, 27 7: 4- 11

. Dr. Gun n to ld th e jury th at sh e ha d no ba si s to di sp ut e th e bl oo d lo ss cal cu la ti on s p erfo rm ed by Dr. Brewe r; and
, th at , ev en th ou gh sh e sa t in th e co ur tro om an d watc he d Dr. Brewe r cal cu la te Sh an no n’s bl oo d lo ss fo r th e jury, sh e n ev er wen t b ack to re-c al cu la te th em :

Q: Do y ou ag ree o r d i s a g ree wit h Dr. Brewe r th at aro un d 8: 00 o'c lo ck in th e mo r n i n g th at Sh an no n ha d lo st 25 pe rcen t of he r bl oo d vo lu m e, or y ou jus t d on 't h av e an op in io n?Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 2

A: I do n' t ha ve an op in io n.

Q: W he n i t co m es to th e he m og lo bi n th at cam e ba ck at 7.5 , I be li ev e, th at aft ern oo n, Dr. Brewe r m ad e t h e ad jus tm en ts an d cal cu la ti on s an d sa id
at th at po in t Sh an no n was do wn 22 pe rcen t in he r bl oo d vo lu m e. Do y ou ag ree wi th th at , di sa gr ee o r jus t n ot ha ve an op in io n?

A: I do n' t ha ve an op in io n.

Q: And th e n at aro un d 1: 00 o'c lo ck -- ex cu se m e. I m is sp ok e ab ou t th e he m og lo bi n. Thi s cam e ba ck at 1: 00 o'c lo ck
, bu t sh e di d th e cal cu la ti on s of in pu t an d o ut pu t an d a ro un d 1 1: 00 , sh e sa id 22 pe rcen t?

A: No o pi ni on .
Q: So th en aro un d a li tt l e a f t e r 1 : 00 o'c lo ck
, we se e a he m og lo bi n of 7.5
, bu t whe n y ou al lo w fo r th e bl eed in g an d wha t was rep la ced
, Dr. Brewe r

sa id 33 to 44 pe rcen t of Sh an no n's bl oo d vo lu m e was go ne

. Do y ou ag ree wit h th os e cal cu la ti on s, di sa gr ee w i th th em , or do y ou jus t no t ha ve an op in io n?

A: I do n' t ha ve an op in io n.

Q: Do you be li ev e th at if y ou 're go in g to un de rta ke th e se rio us job of

m an ag in g a pa ti en t th at y ou kn ow ha s DIC th at pa rt o f yo u r jo b is to pe rfo rm cal cu la ti on s to kn ow whe re sh e is in t e rm s of he r bl oo d

vo lu m e?

A: Yes

.
Q: Yet, whe n we lo ok at th is ch art , we do n' t s e e a ny cal cu la ti on s wha ts oe ve r, do we?Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 3

A: My c al cul at io ns w ere n ot pa rt o f the medic al cha rt, no

. 1 4

RR. Vol. 1 0: 15 1: 7- 15 2: 13

.
Q: And ha ve y ou red on e th os e cal cu la ti on s to gi ve us op in io ns as to whe re y ou th ou gh t Sh an no n was at 8: 00 o'c lo ck in th e m or ni ng or 11 :0 0 in th e

m or ni ng or 1 :0 0 i n t he aft ern oo n?

A: I' ve no t red on e tho se ca lc ul at io ns , no.

RR. Vol. 1 0: 15 2: 14 -1 8. 1 5

How can App el la nt s cred ib ly arg ue on ap pe al th at Dr. Brewe r ’s bl oo d lo ss cal cu la ti on s are ip se di

xi t co nc lu s i o n s w i t h no fact ua l ba si s wha ts oe ve r, whe n Dr. Gun n her se lf di dn ’t di sa gr ee with th em at tri al , di dn ’t re-ca lc ul at e th em for th e jury
to de m on st rat e th ei r al le ge d in accu racy, an d to ld th e jury th at , if th ey wan te d to kn ow ho w m uc h b lo od Sh an no n l os t, th ey ne ed ed to as k Dr. Brewe r? Dr. Aub uc ho n, t he de fen s e tra ns fu si on m ed ic in e ex pe rt, ne ve r di sp ut ed th e bl oo d lo ss cal cu la ti on s pe rf o r med fo r th e jury by Dr. Brewe r. RR. Vol

. 12 , 53 :3 -5

. Neit he r di d Dr. Alex an de r, th e de fen se m at ern al fet al m ed ic in e ex pe rt. RR. Vol

. 13 , 24 0: 4- 10

. On

cro ss -ex am in at io n, Dr. Brewe r of fere d to re-c al cu l at e th e bl oo d lo ss fo r de fen se

co un se l b y g o in g ba ck th ro ug h th e in pu t an d ou tp ut reco rd s (“ I’s an d O’ s” ), bu t de fen se co un se l refu se d. RR. Vol

. 9, 21 9: 9- 12

. So
, at th e en d of th e da y , th e jury was le ft wit h th e un co nt es te d ev id en ce pr ov id ed by D r

. B r e w e r ab ou t Sh an no n’s bl oo d lo ss . Dr. Gun n’s l et te r br ie f on th is is su e sh ou ld be ov erru le d.

Dr. Gunn testified that she perf ormed blood loss calc ulations simil ar t h o s e which Dr. 1 4 Br ewe r perf

ormed in front of the jury at the time she was car ing for Shannon, but she never produce d them, or made them a par t of the medica l rec ords. RR. Vol. 9, 277:13- 18; Vol. 10, 34:16- 24

.
Neither Dr. Aubuchon, nor Dr. Alexander, disputed the blood loss calc ulations perf ormed 1 5 for the jur y by Dr. B rew er. RR. Vol. 12, 53:3- 5; RR. V ol. 13, 240:4-10

.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 4

B. Dr. Bre w er’s bl oo d lo ss ca lc ul at io ns w ere su ppo rted by the rel ia bl e fo unda tio na l da ta co nta in ed i n Sha nno n’s m edi ca l re co rds

.

The po in t of th e bl oo d lo ss an al y si s pe rfo rm ed by Dr. Brewe r was to sh ow th e jury th at Dr. Gun n ha d pl en ty of warn in g si gn s to te ll he r w h a t w as go in g on wit h S ha nn on an d th at sh e ne ed ed to st op Sh an no n’s bl eed in g by do in g so m et hi n g di ffer en t w it h res pe ct to he r tre at m en t of Sh an no n, in cl ud in g gi vi ng Sh an no n FFP
to en ab le he r bl oo d to cl ot effe ct iv el y an d to no t m ak e he r flu id v o l u me l o s s an d hypo vo le m ia wor se by ad m in is te rin g a di ur et ic

. W hi le Dr. Gun n al le ge s on ap pe al

1 6 th at Dr. Brewe r’s bl oo d lo ss cal cu la ti on s are “ un su pp or te d es ti m at es ,” th e real it y of wha t Dr. Brewe r di d to es ta bl is h th is po in t fo r th e jury is an ch or ed in th e rel ia bl e, ob jecti ve fou nd at io na l d at a co nt ai ne d i n t he m ed ic al reco rd s.

Thi s d at a in cl ud ed Sh an no n’s to ta l bl oo d vo lu m e on ad m is si on , ch an ge s in 1 7 Sh an no n’s la b va lu es (e.g
., he r he m og lo bi n, he m at oc rit
, pl at el et , PT, PTT, FSP, an d 1 8 f i b r i n o g en le ve ls ), Sh an no n’s vi ta l si gn s (e.g
., ag e, weig ht
, pr eg na nc y st at us , he art rat e, br eat hi ng rat e, an d bl oo d pr es su re), Sh an no n’s flu id in ta ke (e.g
., IV flu id s, red bl oo d cel ls , a nd pl a t e l e t s) , a nd Sh an no n’s flu id ou tp ut (e.g ., b lo od lo ss an d ur in ary

ou tp ut ). RR. Vol

. 8 8: 18 7: 22 -1 91 :3 , 19 1: 2 0

- 1 9 2 : 10 , 19 3: 7- 19 4: 8, 19 8: 11 -1 99 :3 , 19 9: 11 -2 00 :2 2, 20 1: 4- 7, 20 3: 13 -2 5, 21 0: 18 -2 13 :1 , 21 3: 4- 18 , 21 8: 2- 22 0: 2, 22 0: 23

- 22 2: 12 , 2 4 8: 20 -2 49 :6 ; RR. Vol

. 9, 19 6: 14 -2 5, RR. Vol

. 9, 19 7: 1- 17 , RR. Vol

. 9, 20 7: 7- 208: 15; se e als o R R

. V ol. 16B 109- 111: M cC oy 0273-2 75 (Pla in tif fs ’ Ex hi bi t 7)

.

Dr. Brewer cal cu la te d th at Sh an no n’s to ta l bl oo d v ol um e was ap pr ox im at el y 6.7 li te rs of bl oo d (1 8 un it s) whe n sh e arri ve d at th e ho sp it al

. RR. Vol

. 8, 18 7: 4- 21 ; RR. Vol

. 9, 19 7: 13 -1 7, 20 7: 7- 20 8: 15

. App el la nt s ne ve r di sp ut ed th is te st im on y at tri al

. Dr. Brewe r te st ifi ed t h a t , a c c o r di ng to th e ch an ge s in Sh an no n’s la b res ul ts

co nc ern in g he r he m og lo bi n, pl at el et , FSP, an d fib rin og en le ve ls
, as well as th e flu id in pu t an d ou tp ut da ta co nt ai ne d m ed ic al reco rd s, Sh an no n lo st ap pr ox im at el y 1,4 00

Dr. Gunn testified that the term “hy povolemia” means that the pati en t ’s “cir culatory 1 6
sy stem did not have enoug h fluid and blood to support bodily functions.” RR. Vol. 10, 92:12-17

.

RR. Vol. 9, 197:13- 17, 207:7-208: 15

. 1 7

RR. Vol. 9, 196:14- 25. 1 8Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 5

m L of bl oo d ( 1 .4 li te rs /4 -5 un it s) be fo re th e de li ve ry of he r da ug ht er. RR. Vol

. 9, 19 6 : 1 4 -2 5

. Dr. Brewe r te st ifi ed th at , acco rd in g to th is sa m e fo un da ti on al da ta , Sh an no n lo st an ot he r 1,6 00 m L of bl oo d in th e ICU, to ta li ng ap pr ox im at el y 3,0 00 m L of bl oo d lo ss

. RR. Vol

. 9, 19 7: 1- 12

. Dr. Brewe r’s te st im on y ab ou t Sh an no n’s bl oo d lo ss was ba se d on Sh an no n’s to ta l es ti m at ed bl oo d vo lu m e, th e ch an ge s in Sh an no n’s la b va lu e s, as well as th e in fo rm at io n co nc ern in g Sh an no n’s flu id in pu t an d ou tp ut d o c u m en te d in th e m ed ic al reco rd s. RR. Vol

. 8 8: 18 7: 22 -1 91 :3 , 19 1: 20 -1 92 :1 0, 19 3: 7- 19 4: 8, 19 8: 11 -1 99 :3 , 19 9: 11 -2 00 :2 2, 20 1: 4- 7, 20 3: 13 -2 5, 21 0: 18 -2 13 :1 , 21 3: 4- 18 , 21 8: 2- 22 0: 2, 22 0: 23 -2 22 :1 2, 24 8: 20 -2 49 :6 ; RR. Vol

. 9, 19 6: 14 -2 5, RR. Vol

. 9, 19 7: 1- 17 , RR. Vol

. 9, 20 7: 7- 20 8: 15 ; se e al so RR. Vol

. 16 B 10 9- 11 1: McCo y 02 73 -2 75 (Pla in tif

fs ’ Ex hi bi t 7)

.

All o f t h is da ta was an al y zed an d synth es iz ed fo r th e jury by Dr. Brewe r to pr ov id e th em wit h an un de rs ta nd in g ab ou t ho w an d why Sh an no n was bl eed in g, ho w

m uc h bl oo d Sh an no n ha d lo st an d was co nt in ui ng to lo os e be fo re 1: 00 p.m

. (d es pi te be in g tra ns fu se d w i t h b l o o d an d pl at el et s)
, wha t Sh an no n’s bo dy was do in g ph y si ol og ic al ly to co m

pe ns at e fo r th e bl oo d lo ss (e.g
., in crea se d he art rat e, in crea se d b r e a t h i n g rat e, dr op in ur in e ou tp ut , dr op in bl oo d pr es su re), an d why Sh an n o n

ne ed ed to rece iv e FFP to st op he r bl oo d lo ss an d pr e v e nt th e m on um en ta l di sa st er th at Dr. Gun n c au se d b y

he r own ne gl ig en ce. Id

.

The m ed ic al reco rd s sh ow th at Sh an no n was ad m in is te red 3,4 00 m L of bl oo d

an d bl oo d pr od uc ts in th e op erat in g ro om (1 5 un it s of pa ck ed red bl oo d cel ls
, 16 un it s of FFP, an d 8 un it s of pl at el et s) to rep la ce th e cl ot ti ng fact or s an d bl oo d vo lu m e th at Dr. Gun n ne gl ig en tl y al lo wed Sh an no n to lo se on th e 14

. RR. 16 A, 1 31 :McCo y th 01 21 , 13 7: McCo y 01 27 (Pla in tif f’s Ex hi bi t 7)

. If Dr. Brewe r’s b lo od lo ss cal cu la ti on s fo r th e jury were real ly “ un su pp or te d es ti m at es ,” why is it th at he r

es ti m at io n of Sh an no n’s bl oo d lo ss be fo re 2: 10 p.m

. on th e 14 (3 ,00 0 m L) is so cl os e th
to th e do cu m en te d am ou nt of bl o o d v o l u m e rep la ced in th e op erat in g ro om (3 ,40 0

m L)? RR. 16 A, 13 1: McCo y 0 12 1, 1 37 :McCo y 0 12 7 (Pl ai nti ff’s Ex hi bi t 7) . Dr. Brew e r ’s b l o od lo ss cal cu la ti on s were su pp or te d by th e rel ia bl e fo un da ti on al da ta

co nt ai ne d in Sh an no n’s m ed ic al reco rd s, an d th is le tt er b r i e f p oi nt sh ou ld be

ov erru le d.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 6

C. Dr. Gunn ’s ar gu m ent ab ou t the rel at io ns hi p betw een Sha nno n’s bl eedi ng an d uter in e a to ny is sup po rted by the medica l re co rds

.

Dr. Br ew er te sti fi ed th at Sh an no n’s ut eri ne at on y ha d to be an al y zed in co nt ex t. RR. Vol

. 8, 28 1: 21 -2 83 :5

. Dr. Brewe r te st ifi ed th at th e ut eri ne at on y was a bypr od uc t of th e m as si ve bl oo d lo ss Sh an no n ex pe rie nc ed pr io r to 1: 00 p.m

. on th e 14

. th RR. Vol

. 8, 28 1: 21 -2 83 :5

. Dr. Brewe r te st ifi ed th at , if Sh an no n ha d be en ad eq ua te ly

res us ci ta te d, bu t ex pe rie nc ed th e sa m e am ou nt of bl eed in g sh e di d be twee n 1: 00 p.m

. to 2: 00 p.m

. on th e 14
, sh e wou ld ha ve co m e ou t of th e su rg ery “ in ta ct ,” in di cat in g th th at ut eri ne at on y was no t th e cau se of Sh an no n’s br ai n da m ag e. RR. Vol

. 8, 28 1: 21

- 28 3: 5

. Dr. Brewe r al so te st ifi ed th at he r op in io ns reg ard in g Sh an no n’s ut eri ne at on y

were ba se d, in pa rt, on he r ex pe rie nc e as qu al ifi ed ex pe rt in cari ng fo r th es e pa ti en ts , as well as th e ev id en ce co nc ern in g Sh an no n’s en or m ou s bl oo d lo ss pr io r to 1: 00 p.m .;

an d, th e fact th at no ne of Sh an no n’s cl ot ti ng fact or s were rep la ced th ro ug h th e ad mi n i s t r a t io n of FFP. RR. Vol

. 8, 24 9: 11 -2 50 :2 5, 22 5: 6- 12 , 28 1: 21 -2 83 :5

. Dr. Brewe r’s te st im on y co nc ern in g th e ex cl us io n of ut eri ne at on y as a po ss ib le cau se fo r Sh an no n’s ou tc o me w a s su pp or te d by th e rel ia bl e fo un da ti on al da ta co nt ai ne d in Sh an no n’s m ed ic al reco rd s. Th is let te r br ie f po in t s ho ul d b e o ve rru le d.

D. Dr

. B r ew er’s tes timony ab ou t Sha nno n’s in tern al bl eedi ng w as ba se d o n the e vi denc e co nta in ed i n the medic al reco rds

.

W hi le Dr. Brewer sai d t ha t Shan no n had bl oo d “ po ur in g ou t,” s he ne ve r sa id th at al l of Sh an no n’s bl oo d lo ss cam e ou t of he r va gi na

. RR. Vol

. 8, 24 9: 2- 6

. Dr. Brewe r te st ifi ed th at Sh an no n ha d vi si bl e bl oo d lo ss fro m th e va gi na , as well as 1 9 in te rn al bl eed in g in to th e wall of th e ut eru s. RR. Vol

. 8, 22 3: 10 -2 24 :1 8, 22 5: 1- 20

. Thi s te st im on y is ba se d on th e do cu m en te d fin di ng s co nt ai ne d in th e m ed ic al reco rd s.

Dr. Br ewe r testified that, acc ording to the medical rec ords, Shannon had a larg e amount 1 9 of bleeding at 12:00 p.m. on the 14
, and expelled a larg e amount of blood from the vag ina at 12:45 t h
p.m. on the 14

. RR. Vol. 8, 223:10 -1 4 , 2 2 9 :2 -6

. Acc ording to Dr. Gunn’s discharg e sum mary ,

t h Shannon had approximately 800 to 1,000 cc’ s of blood and clots at the perine um at 1:28 p.m. RR. Vol. 16A, 42:Mc Coy 0032 (P laintif f’s Exhi bit 7)

. The intensive medicine phy sician called by Dr. Gunn, Nanc y J

. Esper, M.D., documented in her note that Shannon’s vag in al bleeding was “uncontr ollable” on the 14 and that the same level of blood loss was prese nt at the time of surg ery

. t h RR. Vol. 16A, 85: McC oy 0075 (P laintif f’s Exh ibit 7)

.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 7

The m ed ic al reco rd s s ho wed (an d Dr. Gu nn ag reed in he r te st im on y ) th at th e ul tra so un d pe rfo rm ed at 5: 25 a.m

. sh owe d ret ro -p la cen ta l bl eed in g (b le ed in g be hi nd th e pl acen ta ), an d th at al l th e bl oo d ve ss el s in th e ut eru s were co m pl et el y fil le d wit h cl ot te d bl oo d. RR. Vol

. 10 , 67 :1 6- 22 , 12 0: 1 1 -1 9

. Dr. Gun n do cu m en te d in he r di sc ha rg e su m

m ary th at Sh a nn on ’s ut eru s was “ en go rg ed ” wit h bl oo d “ th ro ug ho ut th e m us cl e la y ers [,]” an d th at th e va gi na l va ul t was “ fil le d” wit h bl oo d cl ot s. R R

. 1 6 A , 42 -4 3: McCo y 00 32 -3 3 (Pla in tif f’s Ex hi bi t 7)

. Dr. Gun n do cu m en te d in h e r op erat iv e rep or t fro m th e hyste rect om y su rg ery th at Sh an no n ha d “ ob vi ou s bl eed in g in to th e ut eri ne m

us cu la tu re.” RR. 16 A, 13 1: McCo y 01 21 (Pla in tif f’s Ex hi bi t 7)

. Dr. Gun n al so do cu m en te d in he r op erat iv e rep or t th at “ [t]he ICU b e d h a d b lo od th ro ug ho ut fro m th e he ad o f t h e b e d to th e fo ot .” RR. 16 A, 13 2: McCo y 01 22 (Pla in tif f’s Ex hi bi t 7)

. If Sh an no n was n’t real ly lo si ng th at mu c h b l o o d
, an d he r bl eed in g was real ly im

pr ov in g, as Dr. G u n n c l a i m s in he r le tt er br ie f, why was it

ne ces sa ry to gi ve Sh an no n 3
, 40 0 m L of bl oo d an d bl oo d pr od uc ts in th e op erat in g

ro om ? Dr. Brewe r’s te st im on y ab ou t Shan no n’s in te rn al bl oo d lo ss is su pp or te d by th e rel ia bl e fo un da ti on al da t a c o nt ai ne d in Sh an no n’s m ed ic al reco rd s. Thi s le tt er br ie f po in t s ho ul d b e o ve rru le d.

E. The la b res ul ts do no t neg at e Dr. Bre w er’s tes timony ab ou t Sha nno n’s blo od lo ss .

Dr. Gun n cl ai m s th at Sh an no n’s la b res ul ts ne ga te Dr. Brewe r’s te st im on y th at Sh an no n c on ti nu ed to bl eed aft er d el iv ery, bu t t hi s p oi nt m ak es no sen se in li gh t o f th e do cu m en te d fact s co nt ai ne d in th e m ed ic al reco rd s. Sh an no n’s he m og lo bi n le ve l

on th e fir st se t o f l a b s o r d ered by Dr. Ja co bs was ab no rm al ly lo w at 8.6 (1 0.2 -1 4.9

no rm al ). RR. Vol

. 16 B, 11 1: McCo y 02 75 (Pla in tif f’s Ex hi bi t 7)

. At 7: 20 a.m

. on th e 14
, Sh an no n’s he m og lo bi n le ve l dr op pe d fro m 8.6 to 5.5 –a cri ti cal ly lo w le ve l.

th 2 0 RR. Vol. 1 6B , 11 1: McCo y 0 27 5 (Pl ai nti ff’s Ex hi bi t 7)

.

Acc ording to Shannon’s lab rec ords, a hemog lob i n o f 6

. 9 0 is a critica lly low level; 2 0

acc ording ly
, a 5.5 level and a 4.0 level are obviously critica l l y low. RR. Vol. 16B, 111:Mc Coy 00275 (P laintif

f’s Exhi bit 7)

. The lab results are highlig hted and attached to this response along with D r. Esper’ s documentation that Shannon’s hemog lobin level was 4.0 be fore she was taken to surg ery

.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 8

Im po rta nt ly, whi le th e la b res ul ts sh ow th at Sh an no n’s he m og lo bi n le ve l was 7.8 at 1: 15 p.m ., Dr. Esp er do cu m en te d in he r no te th at , acco rd in g to a “ st at ” bl oo d 2 1 dr aw in th e ICU, Sh an no n’s he m og l ob in le ve l ha d dro pped to 4.0 at th e ti m e sh e

was ta ke n to th e op e rat in g ro om at 2: 10 p.m

. RR. Vol

. 16 A, 88 :McCo y 00 78 (Pla in tif f’s Ex h i bi t 7) (em

ph as is ad de d)

. The ot he r la b va lu es di sc us se d by Dr. Brewe r were eq ua ll y co ns is t e nt wit h he r cau sa ti on op in io ns co nc ern in g Sh an no n’s bl oo d l os s. RR. Vol. 1 6B , 10 9- 10 :McCo y 0 02 73 -7 4 (Pl ai nti ff’s Ex hi bi t 7)

. Sp eci fic al l y, Sh an no n’s PT, FSP, an d fib rin og en le ve ls (in di cat or s of Sh an no n’s bl oo d cl ot ti ng ab il it y ) ne ve r no rm al iz ed be twee n th e fir st la b res ul ts ob ta in ed at 10 :1 5 p.m . o n th e 13 an d th e la s t l a bs th at were dr awn at 1: 16 p.m . o n th
t h e 14 be fo re Sh an no n was ta ke n to th e op erat in g ro om

. RR. Vol

. 16 B, 1 0 9

-

th 10 :McCo y 00 27 3- 74 (Pla in tif f’s Ex hi bi t 7)

. Sh an no n’s PT le ve l wen t up fro m 17 .2 (1 0.8 -1 3.5 n o r mal ) at 7: 27 a.m

. on th e 14 to 18 .2 at 1: 16 p.m ., in di cat in g th at th Sh an no n’s bl oo d clo tt in g m ech an is m was ne ve r co rrec te d to no rm al be fo re she was ta ke n to th e op erat in g ro om

. RR. Vo l

. 1 6 B , 10 9- 10 :McCo y 00 27 3- 74 (Pla in tif f’s Ex hi bi t 7)

. Sh an no n’s FSP an d fib rin og en le ve ls ne ve r im pr ov ed an d wer e al way s ab no rm al fro m 7: 27 a.m

. to 1: 16 p.m ., fu rth er in di cat in g th at Sh an no n’s ab il it y to cl ot

ne ve r ch an ge d fro m ab no rm al to no rm al be fo re sh e was ta ke n to th e op erat in g ro om

. RR. Vol

. 16 B, 10 9- 10 :McCo y 00 27 3- 74 (Pla in tif f’s Ex hi bi t 7)

. Sh an no n’s cl ot ti ng fact or s wer e so ab no rm al sh e was m ed ic al ly dep riv ed of e pi du ral an es th es ia du rin g de li ve ry so th at sh e wou ld av oi d th e pr ob ab le ris k of be co m in g pa ral y zed

. RR. Vol

. 8, 18 0: 3- 22

. Not on ly di d Dr. Brewe r di sc us s th is fact wit h th e jury, so di d Dr. Gun n. RR. Vol

. 10 , 69 :6 -1 6

. Non e of th e s e l ab va lu es ne ga te Dr. Brewe r’s op in io ns

co nc ern in g Sh an no n’s bl oo d lo ss or cau sa ti on

. Thi s le tt er br ie f p o i n t s ho ul d be

ov erru le d.

Dr. Gunn relies on this hemog lobin value to arg ue that Shannon’s condition was 2 1 “improving ;” this arg ument ignor es the fac t that Shanno n ’ s h e moglobin level never normalized. The hemog lobin level of 7.8 is abnorma lly low and Dr. Br ewe r acc ounted for this rise in hemog lobin in her c ausation ana ly sis by

explaining to the jury

that Shannon’s hemog lobin leve l w ent up bec ause of the pa cked r ed blood ce lls that were a dminist ere d to her prior to 1:15 p.m.Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 2 9

F. Dr. Bre w er’s ca us at io n tes timony w as no t ba se d on ip se di xi t

as su m pti on s.

Ip se di xi t m ean s: “ I sa y

it is so ; t he refo re, s o i t i s.” Acc or di ng to Dr. Gun n, Dr. Brewe r ex pe ct ed th e jury to acce pt he r cau sa ti on op in io ns as va li d si m pl y be cau se sh e sa id th ey were. Seri ou sl y , is th at real ly wha t Dr. Brewe r di d? The to ta li ty of Dr. Brewe r’s cau sa ti on an al y si s sh ows th at th is ch arac te riz at io n is way of f ba se , an d th at he r te st im on y

was l eg al ly suf

fic ie nt to li nk -u p Dr. Gun n’s neg li ge nc e to Sh an no n’s br ai n d am ag e.

Abr ah am Lin co ln was o nc e si m il arl y accu se d o f su ch hi gh -h an de dn es s. In

res po ns e, th is is what he ha d t o s ay :

I w a n t t o sa y th at , i n th e fir st pl ace, I ha ve m ad e no ch arg e of an y so r t up on m y ip se di xi t

. I ha ve on ly arra y ed th e ev id en ce ten di ng to pro ve it
, an d pr es en te d it to th e un de rs ta nd in g of ot he rs , sa y in g wha t I th in k it
pr ov es , bu t gi vi ng y ou th e m ean s of jud gi ng whe th er it pr ov es it or no t. Thi s is pr eci se ly wh a t I ha ve do ne

. I ha ve no t pl aced it up on m y ip se di xi t at a ll

. 2 2

Dr. Brewe r’s te st im on y on cau sa ti on was de ta il ed an d co m pr eh en si ve , no t ip se di

xi t

. Dr. Gun n cit es to th e Pol lo ck an d W il so n op in io ns to ass ert he r arg um en t, b ut th es e de ci si on s are un av ai li ng

. A cu rs or y co m pa ris on of th e ex pe rt cau sa ti on op in io ns in Pol lo ck an d t h os e ex pr es se d by Dr. Brewe r rev eal s th at Dr. Brewe r’s cau sa ti on

an al y si s pa ss es m

us te r. W he n it co m es to W il so n , Dr. Brewe r’s cau sa ti on te st im on y fal ls sq ua rel y wit hi n th e le ga l su ffi ci en cy req ui rem en ts s e t f o r th in th is cas e. Dr. Gun n’s l et te r br ie f po in t o n t hi s i ss ue sh ou ld be ov erru le d.

Abra ham L incoln, Political Debates Between Lincoln and Douglas 38-39 (Cleveland: 2 2 Bur rows B ros. Co. 1897).Mr. Ch ris to ph er A. Pri ne , Cle rk

Mar ch 4, 2 01 5 Pag e 3 0

G. The s umm ar y ju dg m ent w as pro perl y g ra nted beca us e Appel la nts fa il ed to in tro duce an y ev id ence to es ta bl is h a fa ct is su e on nurs in g neg li ge nce.

As Ju st ic e Bo y ce’s co m m en ts at or al arg um en t m ad e cl ear, App el la nt s

su bm it te d no ev id en ce in res po ns e to th e M c C o y fam il y ’s m ot io n fo r su m m ary jud gm en t to es ta bl is h a fact is su e on whe th er an y th in g th e nu rs es di d, or fai le d to do
, in th is cas e pr ox im at el y cau se d Sh an no n’s br ai n da m ag e. Dr. Gun n’s le tt er br ie fin g

on th is po in t s ho ul d b e o ve rru le d.

In c l o s i ng , on e fin al th ou gh t is wor th m en ti on in g he re. If Dr. Gun n ha d de vo te d as m

uc h ti me t o c a r i n g fo r Sh an no n on Sep te m be r 14
, 20 04 as sh e ha s in
at te m pt in g to ex pl ai n in he r ap pe ll at e br ie fin g why th e jury a nd Dr. Brewe r go t it

wro ng on th e is su e of pr o x i mat e c a u se , im ag in e wha t wou ld ha ve ha pp en ed to Sh an no n? The McC oy fam il y res pe ct fu ll y req ue st s th at th e po in ts rai se d by Dr. Gun n in he r le tt er br ie fin g be ov erru le d, an d th e tri al co ur t’s jud gm en t sh ou ld be affi rm ed

.
Very tru ly y ou rs ,

J. To dd Trom

bl ey

JTT: pe b Enc lo su res

cc: Mr. J im

Hun d V ia Fa cs im il

e No. (8 06

) 78 3- 87 10

an d e Ser vi ce Mr. J effe ry

T. Nobl es V ia Fa cs im il

e No. (7 13 ) 96 0- 15 27

an d e Ser vi ce Ms . Barb ara Hi lb ur n V ia Fa cs im il

e No. (7 13 ) 22 4- 53 58

an d e Ser vi ce Mr. Mi ch ael C. Feeh an V ia Fa cs im il

e No. (7 13 ) 65 2- 60 00

an d e Ser vi ce

# EXHIBI T 710122104 0620 MEDICAL DIRECTOR: Bradley Wertman. H.D. The Woman's Hospital of Texas Laborator-Y 7800 Fannin, Houston. TX 77054 3

*** INPATIENT DISCHARGE SUMMARY REPORT ***

Patient: MCCOY.SHANNON IF00019169487 (Continued)



### I

. . *** COAGULATlDN *** (continued)

Date

------------------------------------- SEP/14104----------------------------

--------- Time 2330 1810 1502 1316 0727 0727 Reference Units

F'SP**1~5<20** ***~5<20"'** E2o<ab> ***~20** * I r20(ac ) * I (<5) ug/!IL RVVT PATIENT I I I I**~** II1.4Cadl If I (0

. 0-1.1) RATIO DVVTC I I

. I I 10.9<ael I I (0.8-1.2} RATIO STACLOT LA I

### ~71Cahl H · 

# I I j5.5(ad) I I (0.0-8.0) RATIO 0-DiMER ll775(ag) H I I I I (<248) ng/ml F'AC V MUT I I I I I (ail I mn TiiR()otBI N 3 I I I I II6H ad) L I (89-120} l PROTEIN C FUNC I I I I li49(ad) L · I (60-140) s PROT C ANTIGENC I I

.. .. I I 163<ad)

. I PROTEIN S TOTAL I I I I 1142(adJ L I (70-140) s

. PROTEIN S FREE

. I I

. I I ll25<adl L I <58-113} l ACA IGG l I

. I I 16

. 1Cadl I I

. (<•15) GPL

. Ad. IGA I : I I

. I 11.5<ad) I I (<-12} APL

ACA IGM I I I I 16.6Cadl I I (<•12.5) MPL

Date SEP/14/04 SEP/13/04 Time 0020 2215 Reference Units

Pt PATIENT 1120.0 ( akl '*li 17

. 3<all H t I I I Cl() B-13 Sl SECONDS PTI 1139

. 8< am> tt 35. 7Canl H I I I I (23 .7-34 2) SECONDS F!BRINOGEN · . lll93Cao l L I I I I (351-773) rrg/dl FSP I 1 1> 20 * I I I I (<5) ug/ITL R- TIME.

. 17.3 I I I · . . I I I K- TIME 17.9 I I I I I I
NOTES: (abl RESULTS CALLED TO FELICIA AT 1539 09/14/04 BY F.LAB

. IZD. EXT 3203 <acl ABOUT THE COAG PANEL Cad) TESTING PERFORMED Ai SPRING BRANCH MEDICAL CENTER LABORATORY 8850 LONG POINT ROAD. HOUSTON. TX 77055 <ae) See (a f). (ad) <afl This final result is expressed as the normalized ratio: Ratio greater than 2

. 0 LA is strongly present Ratio between 1.5 and 2

. 0 LA is moderately present Ratio between 1.2 and 1.5 LA is weakly present (ag) RESULTS CALLED TO WYNDE READ BACK & CONFIRMED? YES BY F.LAB.KAI 09/15/04 0431 See also (ad) (ah) RESULTS CALLED TO ELEANOR READ BACK & CONFIRMED? Y BY F.LAB.ELH 09/14/04 2144 See also (ad) (ai) NO MATION See also (aj). Cad} (ajl Testing perfonned at: Spring Branch Medical Center 8850 Longpoint Houston. TX 77055 (ak) RESULTS VERIFIED BY REPEAT ANALYSIS RESULTS CALLED TO AMBER "c•n I>Arv

.... ,. ...... u

.. ,. ..

v**-~- ·~**  89114/64 8118 - - · -- Cal) RESULTS VERIFIED BY REPEAT ANALYSIS Cam) RESULTS VERIFIED BY REPEAT ANALYSIS/ RESULTS CALLED TO AMBER READ BACK &**C~FIRMED?** Y BY F.LAB.YMC 09/14/04 0118 (an) RESULTS VERIFIED BY REPEAT ANALYSIS Cao) RESULTS VERIFIED BY REPEAT ANALYSIS

Patient: MCCOY,SHANNON Age/Sex: 35/F Acct#f00019169487 Un1t#f000435351

Miles-l\,1cCoy 000273 

### I

-10/22/04 0620 

# C)

The Woman's Hospital of Texas Laboratory 7800 Fannin. Houston, TX 77054 2
MEDICAL**DIRE~TOR:** Bradley Wertman. H.D. *** INPATIENT DISCHARGE SUMMARY REPORT ***

Patient: MCCOY .SHA!iNON

. . #F00019169487 (Continued} :



### I

.. *** HEMATOLOJY *****~cont inued2**  

### I

Date ----------------SEP/14104---------

------- SEP/13/04 Time 1 316 0727 0017 2215 R eference Units

· · Mrnc ' 1 133.8

ko6<ol L 

### lijl. 7 l 

# I 1 1 <32-35} !1T1/dl RD.ol I**~H** 

# pa.s H I I (11

. 8-14.8) s PLt 1 189 *l 150 I I I <1 35-380) Klrnn3 MPV I 17.8 I J8.4 

# I I I <7.0-10.1) fL NEUT t ' I

. I I**1~1.1** H I I {51.5-79.7} l LYMPH S I I I 1 .o l I I 04-40) l**~t** I

. I I**{4.~** I I I {4.0-10.2} l EOS t I I

. I 10.1 I I (0-4.1) s BASO f I I

- I IKl. 0 L I l (0.1-0.7) % NEUT t I I I 121.7 H I I (2.5-8.6) K/rrm3

· LYMPH# I
.. I

. . I**~-9** l I I 0.1-3

. 6) K/111113

liJNO# l I.



## · I l.lH I I (Q 3-0.9) K/Tm'J

. · · EOS #

· I

. I

. •,• • I D.(}Q

. t I I (0.0-0.4} I
" BASO 11 I I I 10.0 I I I (0.0-0.0) K/rrm3 MAN DIFF NEEDED I •. ' JYES I I I I I RSC MORPH REV I I <p> I l<ql I I I <NORMAL> PlT liJRPH REV I l<r) I I (S) I I I (NQRtoW.. l CELLS COUNTED I 

# I§ I I I I #CELS

. SEGS I I 2 H 1 I I I <55-BO) l

BAND I I H I I I I (0-5) % LYMPH I 15 l l I l I (20-40) :c MONOCYTE I 14 I I I I I (Q-8) % HYPO 1 12+ 

# l I I I I ANI SO I 11+

. I I 

# I I MICRO I 12+ I I I PL T ESTIMATE I ll0£CREASED * I I I I I CADEOl 

### I *** COAGULA Tl ON 

### '*

- I

Date

··················-·-······-··------ -SEP/14/04--------------

- ----- - ---------------- Time 2330 1810 1502 1316 0727 0727 Reference Units

PT PATIENT 113

. 5 1114.4 H ll9

. 7(t) '*H 118

. 2( U ) "H 117

. 2(v) H 121. 5{w) *1-i J 00

. 8-13 5) SECONDS PTI J33

. 2 133.2 1!44. 4( X) '*H 32.0 j34.Q(y) !136.3 H I (23.7-34.2) SECONDS PT 1 :3 MiX I 11214 L

. 

## EI l h slCaa2 L**~12.** 9(Z) I 

# I SECS

- FIBRINCGEN 11331 l 11 118 l ( 351-773) nv;/ ell

NOTES: (O) RESULTS VERIFIED BY REPEAT ANALYSIS (p) RBC HORPH ABNORMAL (q) RBC HORPH ABNORMAL HYPOCHRC11IA 1 + (r} NORMAL PLT MORPH. (S) NORI"AL PL T MORPH. (t) RESULTS CALLED TO FELICIA READ BACK & CONFIRMED? Y BY F

. LAB.IZD 09/14/04 1539 (U) RESULTS CALLED TO VICKY READ BACK & CONFIRMED? YES BY F.LAB.EDA 09/14/04 1422 (v) INR•2.4

,\ l"lCC"III TC" UCDTt:CTCn**D~** DCI"l!:"AT \Lt. VC"!C" (X) RESULTS CALLED TO FELICIA 

## - -

.. -- READ BACK &**~FIRMED?** Y BY F.LAB.IZD 09/14/04 1539 (y) TESTING PERFORMED AT SPRING BRANCH MEDICAL CENTER LABORATORY B850 LONG POINT ROAD. HOUSTON. TX 77055 (Z) PT MIX 1:1• 11.9 See also (y) Caa) RESULTS CALLED TO SANDY AT 1446 09/14/04 BY F.LAB.EDA.

Patient: MCCOY,SHANNON Age/Sex: 35/F Acct#F00019169487 Un1tiF000435351

!vfiles-o\kCoy**000~-::-4**- 

## (**~** 

## J .::___)

- ..__) _j 10i22!04 0620 MEDICAL DIRECTOR: Bradley Wertman. M.D. The Woman's Hospital of Texas laboratory 7800 Fannin, Houston, TX 77054



# . . *** INPATIENT DISCHARGE**Su~Y** REPORT **Y

PATIENT: MCCOY .SHANNON ACCT #: F00019169487 LOC: F

. ICU

. . U #: FD00435351 Afi..iSXi 35/F · RCDt: F. IC4 REG: 09/la/04 REG OR: Gunn. Debra Clark STAl\.IS: DIS IN BED: A DIS: 09/lS/04 

### I *** HEW>.TOL<XlY

_.
Date ---------SEP/15/04---------

---------- - ---------- --SEP/14/04---

·- -- ------ ------- ·-- Time 1744 0530 2330 1810 1455 1316 Reference

. wBC tna.7 H n6A H 112.4 H 115

. 4 [}I 6.8 H 

# I (4

. 5,11.2)

RBC [3.64 j3. 71 13

. 70 14

. 14 D I .36 *l (3.42-5.20) HGB !10.7 111.0 110

. 9 !12.2<al D

. 9(b) l [7 .5 DL I (10

. 2-14. 9) HCT**13~.9** 132.2 iJ2.5 135

. 9 D I 0.3 L 122.3 Q l (31

. 3-44.8) MCV 188 187 188 87 186 I I (81-95) MCH 129.4 129.5 129.6 129

. 6 129

. 1 I I (27-34) MCHC 133.6 34.1 j33.8 134.2 133

. 8 I I (32-35) ROW iil5.1 H 14.5 14.5 i14.8 14.7 I I m.8-14.8J PLT 1175 *l 175Ccl *l f74(d) *L 181(e) *L 161 *l I l (135-380} MPV )9.8 8.9 8

. 8 18.4 8

. 1 I I (7.0-10.1) NM% · 1!92 .5 H 185

. 6 H 180.9 H 183.9 H 79.5 I I (51.5-79.7) LYMPH % 113

. 6 L 15,9 l

. 19.6 l 10.9 l 15.5 I I ( 14-40) i-KJNo t 113

. 7 l 8.3 19

. 5 19.2 14

. .7 I I (4 0-10.2) EOS l 10.1 10.0 jO

. O 0.0 10

. 3 I (0-4 1) BASO i 10.1 0

. 2 JQ.O L 0.0 L l(l.O l I (0.1-0.7) NEUT ff jll7 .3 H 14.0 H no.o H 12.9 H 21.3 H I (2.5-8

. 6) LYMPH II !10.7 L l.Ol 1.2 1.1 14.2 H · f (1.1-3.6} t-()NO # 10.7 11.4 H 1.2H 1.4 H 1.2H I (Q 3-0

. 9)

· EOS I !0- 00

. !0.00 10.00 10.00 10.10 I I (0.0-0.4}

BASO I jO.O

. · . jO.O 10

. 0 10.0 jO.O I l (0.0-0

. 0) RBC HORPH REV I <n l (g) I I <h> I <n I I (NORMAL) PLT t-()RPH REV I <j > I <k > I j(l} I (m) I I (NORHAL>

Date

--------------- -SEP/14/04----·-···------- SEP/13104 Time 1316 0727 0017 2215 Reference

lolBC I 129-

. 7 H 1123

. 8 H I I I (4.5

- 11.2) RBC I 1 2 14 D'*l !3

. 67 I I (3.42-5.20) H68 I l 5.5(n ) O'*L 1 18

. 6 L I I (10

. 2-14.9} HCT I

... 1 16

. 3 D'*t. 1 127

. 2 L I I (Jl.3·4A 8) MCV ' I I 6 L 174 l I I (81-95) MCH I 1 2 5

. 8 l 123

. 4 L I I (27-34)

NOTES : (a) RESULTS CALLED TO KASSANDRA AT 1831 09114/04 BY F.LAB

. IZD. (b) CRITICAL VALUE CALLED TO TROY RN AT 1457 ON 09/14/04 BY F .LAB.EOA. (C) RESULTS VERIFIED BY REPEAT ANALYSIS NOTIFICATION OF RESULTS BROADCAST TO ELENOIR BY F.LAB.TTT AT 0609. 09/15/04. (d) NOTIFICATION OF RESULTS BROADCAST TO SELENA BY F.LAB.KAI AT 0210. 09/15/04. (e) RESULTS CALLED TO KASSANDRA AT 1830 09/14/04 BY F.LAB

. IZO. (f) RBC MORPH NORMAL (g) RBC t-'IJRPH NORMAL (h) RBC MORPH NORMAL (i) RBC HORPH NORMAL ""'' no T U'\nn' (lc) NORMAL PLT HORPH.

... .. · - - - -- {1) NORMAL PLT MORPH. Sl. DECREASE <ml NORMAL PLT MORPH. <nl RESULTS CALLED TO MAGGIE READ BACK & CONFIRMED? YES BY F.LAB

. EDA 09/14/04 0850 RESULTS VERIFIED BY REPEAT ANALYSIS

Patient: MCCOY,SHANNON Age-/Sex: 35/F Acct#F00019169487 Un1tlf000435351 Units

Klnm3 M/rrm3 gm/L 1 fL P9 gm/dl 1 K/mn3 fL

I l % % % K/nm3 K/rrm3 K/flll'J I Klnm3

Units

K/nm3 M / flll'J gm/L % f1. pg 

# -

I

-- -

;\tile s -McCoy 00027.5f ( d.

. I

... _.,**A.~"** 

### v ;

. i

PATIENT NAME: MCCOY, SHANNON ( . ,

. ... · . ,**~·** ; 1 

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MR NUMBER: OOOOOOF000435351 ACCOUNT NUMBER: F00019169487 '·•

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150 later on. EKG was reviewed, no acute changes were noted, but there was diffuse nonspecific ST-T changes.

ASSESSMENT: 1. Seizure activity. could be multifactorial, possibly eclampsia related, versus secondary to hypocalcemia versus secondary to anoxic seizure secondary to anoxic encephalopathy since the patient had cardiopulmonary resuscitation for te n minutes

, an a she was hypotensive prior to that, and**he~** hemoglobin was 4 at the time of admissi-on to the operating room for a dilatation and curettage and hysterectomy. 2. Status post disseminated intravascular coagulation, secondary to fetal demise, secondary to placenta abruptio. 3. Mild renal insufficiency, secondary mostly to hypovolemia. 4. Hypocalcemia, secondary to Valium and blood products replacement. 5. Hypertension, possibly preeclampsia related. 6. Hyperglycemia, possibly related to intravenous fluid replacement with OS half normal saline versus gestational diabetes. 7. Elevated troponin level, most likely related to cardiopulmonary resuscitation rather than an myocardial infarction in the absence of signs of myocardial infarction on the electrocardiogram.

PLANS: 1. The patient will be kept on magnesium loading and intravenous infusion, fosphenytoin loading dose and maintenance therapy, Versed or Ativan p.r.n. Close monitoring of electrolytes with replacement will be done and also close monitoring of DIC profile. Parameters of blood pressure will be given and possibly beta blockers or hydralazine will be started for a systolic blood pressure more than 170 or diastolic blood pressure more than 110. STAT neurology consult was ordered and requested for possible EEG and further management. 2. The case was discussed in very great details with Dr. Gunn and Dr Shearer-Poor, they agreed with the above plan, also the family was informed about the condition and the progress, and all their questions were answered. We spoke with, Dr. Shearer-Poor and I, with the husband, the brother, the sisters, and the father, and they all seemed to be understanding the situation. The patient's poor prognosis was also explained to them and unstable status at this time.

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Chart Copy

Miles-McCoy 000078