UNITED STATES DISTRICT COURT

DISTRICT OF NEW HAMPSHIRE

Karen L. Bartlett

v. Civil No. 08-cv-00358-JL

Mutual Pharmaceutical

Company, Inc.

SUMMARY ORDER

Attached are the court’s rulings on Mutual’s objections to

the deposition testimony of two of Bartlett’s potential

witnesses, Drs. Claes Dohlman and Nam Heui Kim, who have been

deemed unavailable to testify at trial under Rule 32(a)(4) of the

Federal Rules of Civil Procedure (see doc. 275).

SO ORDERED.

____________________________

Joseph N. Laplante

United States District Judge

Dated: August 10, 2010

cc: Keith M. Jensen, Esq.

Bryan Ballew, Esq.

Patrick J. O’Neal, Esq.

Eric Roberson, Esq.

Christine M. Craig, Esq.

Timothy P. Beaupre, Esq.

Joseph P. Thomas, Esq.

Paul J. Cosgrove, Esq.

Jeffrey D. Geoppinger, Esq.

Linda E. Maichl, Esq.

Stephen J. Judge, Esq.

Pierre A. Chabot, Esq.

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Witness_ Claes Dohlman, M.D., Ph.D. -: 1:4 - 1:19

UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF NEW HAMPSHIRE

5 

6 CIVIL ACTION NO. 08-CV-358-JL

7 - - - - - - - - - - - - - -

KAREN L. BARTLETT and

8 GREGORY S. BARTLETT,

Plaintiffs

9 

v.

10 

MUTUAL PHARMACEUTICAL

11 COMPANY, INC., and UNITED

RESEARCH LABORATORIES, INC.,

12 Defendants

- - - - - - - - - - - - - -

13 

14 VIDEOTAPE DEPOSITION OF CLAES DOHLMAN,

M.D., Ph.D., taken on behalf of the

15 Plaintiffs, taken pursuant to the

applicable provisions of the Federal Rules

16 of Civil Procedure, before Carol A.

Fierimonte, Certified Shorthand Reporter

17 and Notary Public within and for the

Commonwealth of Massachusetts, (#134693),

18 at the Massachusetts Eye and Ear Infirmary,

Howe Laboratory, 243 Charles Street,

19 Boston, Massachusetts, on Thursday,

September 10, 2009, commencing at 9:20 a.m.

Witness_ Claes Dohlman, M.D., Ph.D. -: 6:8 - 6:20

8 Q. Please state your name for the record.

9 A. Claes Dohlman.

10 Q. And are you a doctor?

11 A. Yes.

12 Q. Okay. As we sit here now, Doctor Dohlman,

13 are we at both Harvard Medical School and

14 the Massachusetts Eye and Ear Infirmary?

15 A. If I'm what?

16 Q. Yes, sir. As we sit here now, are we at

17 both Harvard Medical School --

18 A. Yes, that is correct.

19 Q. -- as well as Mass. Eye and Ear Infirmary?

20 A. Correct.

Witness_ Claes Dohlman, M.D., Ph.D. -: 7:2 - 10:10

2 Q. Thank you, sir. Are you an

3 ophthalmologist, Doctor Dohlman?

4 A. Yes.

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5 Q. Are you an eye surgeon?

6 A. Yes.

7 Q. Are you a Harvard Medical School professor?

8 A. Yes.

9 Q. Do you hold any board certifications?

10 A. Yes.

11 Q. How many?

12 A. In Ophthalmology only.

13 Q. Okay. Are you licensed to practice

14 medicine in one or more states?

15 A. In Massachusetts, yes.

16 Q. Thank you. Are you an -- is there an

17 endowed chair or professorship here at

18 Harvard in your name?

19 A. Yes.

20 Q. Is that endowed chair or professorship in

21 your name designed to last in perpetuity,

22 also known as forever, hopefully?

23 A. That is correct. It's a hope.

24 Q. Tell us about the endowed chair or

25 professorship in your name here at Harvard, 

00008

1 please, sir.

2 A. Oh, when I retired as Chief here, the

3 Former Dean Tosterson at Harvard announced

4 that the chair in my name, the Chair in

5 Ophthalmology in my name would be created.

6 It took a number of years before the

7 necessary funding could be accomplished and

8 finalized, but now it is in place and the

9 incumbent is Dr. Reisa Dana.

10 Q. Okay. Are endowed chairs or professorships

11 here at Harvard in part to pay honor to or

12 to pay tribute to the medical contributions

13 or work of those whom they're named after,

14 sir?

15 A. Yes, that is the principle.

16 Q. Okay. And is there specific areas that the

17 endowed professorship in your name here is

18 supposed to be dedicated to, specific areas

19 of eye surgery or ophthalmology?

20 A. It is understood that the incumbent of the

21 chair should be a person with a specialty,

22 subspecialty in corneal diseases and,

23 ideally, the Director of our Corneal

24 Service here. And this is the case right

25 now. 

00009

1 Q. Okay. Have you also -- how long have you

2 been an eye surgeon, Doctor Dohlman?

3 A. How long?

4 Q. Yes, sir.

5 A. I graduated from the University of Lund

6 with my M.D., 1950. And I was trained in

7 Lund for a couple of years. I have my

8 Ph.D. in biochemistry. And then in 1958, I

9 was invited to come here for to do corneal

10 work for three years.

11 Q. Thank you, sir. In addition to your work

12 as a surgeon, is it true that you've also

13 published a great deal about eye surgery?

14 A. That is correct.

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15 Q. Is it true that many of your publications

16 involve how, when, or why eye surgery

17 should be done?

18 A. Yes.

19 Q. Okay. And you just provided me a copy of

20 your Curriculum Vitae, which I'll place on

21 the screen here.

22 And is this Exhibit No. 128 a copy

23 of it, sir? Is this it?

24 A. Yes.

25 Q. Okay. 

00010

1 A. Yes, it is.

2 Q. Thank you, sir. And I see that you've

3 published some 290 different publications

4 either as original research or as book

5 chapters or that you co-authored. Correct?

6 A. Correct.

7 Q. Okay. And your name would be in bold as

8 one of the co-authors of each of these 290

9 publications?

10 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 10:11 - 10:15

Is

12 the best way to sum up these 290

13 approximate publications is pertaining to

14 how, when, and why eye surgery should be

15 done?

Witness_ Claes Dohlman, M.D., Ph.D. -: 10:18 - 11:5

18 A. It is not all surgery.

19 Q. Okay.

20 A. It -- in the beginning it was biochemistry

21 of the cornea of the eye, and then more

22 physiology of the cornea of the eye, and

23 then, then more surgery, corneal

24 transplantation. And then for the last 20

25 years, particularly surgery pertaining to 

00011

1 artificial corneas, which has been my

2 interest.

3 Q. What is your best estimate, sir, of how

4 many eye surgeries of any type you've done

5 in your career?

Witness_ Claes Dohlman, M.D., Ph.D. -: 11:8 - 11:12

8 A. Maybe 5,000.

9 Q. Okay. And what's your best estimate of

10 those approximate 5,000 eye surgeries have

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11 involved something called a

12 keratoprosthesis?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 11, Line 15

15 A. About 500.

Witness_ Claes Dohlman, M.D., Ph.D. -: 11:24 - 13:2

24 A. About, about 500.

25 Q. Thank you, sir. 

00012

1 A. Keratoprosthesis, yes.

2 Q. Okay. Do you -- did you or do you have a

3 patient named Karen Bartlett?

4 A. Yes.

5 Q. Okay. And were you the lead surgeon on a

6 number of eye operations on Karen

7 Bartlett's left eye?

8 A. Yes. I may have done, and I will have to

9 check that, I think, three surgeries on her

10 left eye.

11 Q. Okay. Have you reviewed the chart recently

12 or -- this is not a memory test.

13 A. Yes, this morning.

14 Q. Okay. Thank you.

15 A. Yes.

16 Q. And of the approximate 500 surgeries you've

17 done involving a keratoprosthesis, how many

18 of those have involved something called the

19 Boston or Dohlman Keratoprosthesis?

20 A. All.

21 Q. All. Okay.

22 A. Yes.

23 Q. And can we use the term "K-Pro" as short

24 for keratoprosthesis?

25 A. Yes, correct. 

00013

1 Q. Is that how you refer to it?

2 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 13:10 - 13:19

10 Q. Is a K-Pro, a Boston Dohlman K-Pro, is that

11 a device that's used in an eye surgery?

12 A. Yes.

13 Q. Okay. Who is the principal pioneer or

14 inventor of the medical device now known as

15 the Boston K-Pro?

16 A. I was.

17 Q. Okay. Is that why in the literature you

18 frequently see it referred to as the either

19 the Boston or just the Dohlman K-Pro?

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Witness_ Claes Dohlman, M.D., Ph.D. -: 13:22 - 14:25

22 A. Some people call it the Dohlman

23 Keratoprosthesis. But I did not like that,

24 so I invented the name Boston

25 Keratoprosthesis. 

00014

1 Q. And why did --

2 A. And that --

3 Q. Thank you, sir. And why did you choose to,

4 for lack of a better word, donate, if you

5 will, instead of calling it the Dohlman

6 Keratoprosthesis, to the Boston K-Pro?

7 A. Well, in our circles it does not look good

8 if you put your own name on something and

9 --

10 Q. Okay.

11 A. And the more -- the lesser of that, the

12 better.

13 Q. Okay. And is there another type of eye

14 surgery called a keratoplasty?

15 A. Yes. That is standard corneal

16 transplantation.

17 Q. Okay. And is a standard corneal

18 transplantation also called a penetrating

19 keratoplasty?

20 A. Yes.

21 Q. Okay. A kerato -- is it correct to state

22 that your medical device in the surgery

23 called the Boston K-Pro involves both a

24 medical device as well as human tissue both

25 implanted in a person's eye? 

Witness_ Claes Dohlman, M.D., Ph.D. -: 15:3 - 15:11

3 A. Yes. That is the way we do it here. It is

4 not always absolutely necessary to use a

5 donor corneal graft as a carrier for the

6 plastic device.

7 Many times, especially in

8 developing countries where resources are

9 scarce, they often can use the patient's

10 own cornea and then implant the plastic

11 device and then suture it back.

Witness_ Claes Dohlman, M.D., Ph.D. -: 15:16 - 15:19

16 Q. Do you agree, sir, that all the testimony

17 you will provide today will be based upon a

18 reasonable degree of medical certainty or

19 probability?

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Witness_ Claes Dohlman, M.D., Ph.D. -: 15:22 - 16:2

22 A. That, I hope. I will certainly do my best.

23 Q. Thank you, sir. What is your best

24 estimate, Doctor Dohlman, of how many

25 patients you've treated or consulted or 

00016

1 operated on in your career who had SJS or

2 TEN at one time?

Witness_ Claes Dohlman, M.D., Ph.D. -: 16:5 - 17:3

5 A. I cannot say with certainty. I believe

6 that -- I cannot say with certainty but it

7 is probably in the range only of about 50.

8 Q. Okay.

9 A. And the reason for that is that the

10 Stevens-Johnson are so difficult and, with

11 standard corneal transplantation, virtually

12 hopeless. And with keratoprosthesis, our

13 keratoprosthesis, in the beginning the

14 results were terrible. And they were so

15 bad so that I had a self-declared

16 moratorium in the sometime in the mid

17 '90's. Then we improved a number of things

18 and I started again. And now it's much

19 better, but still it is our worst category.

20 Maybe it will come to that, but this is our

21 worst category. And we have now in a small

22 series reached an outcome of about

23 50-percent survival or reasonable vision

24 after five years.

25 Q. And that small series you just referred to 

00017

1 was a 2008 publication that you were a

2 co-author of?

3 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 17:6 - 17:8

6 A. Yes. Together with Sayegh, Ang.

7 Q. Sayegh, Ang was the lead author?

8 A. Sayegh, yes, sir.

Witness_ Claes Dohlman, M.D., Ph.D. -: 17:17 - 17:25

17 Q. And you understand, of course, that SJS and

18 TEN are acronyms for Stevens-Johnson

19 syndrome and toxic epidermal necrolysis,

20 correct?

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21 A. Yes.

22 Q. Okay. Do you understand that the word or

23 the term "TEN" is reserved by doctors for

24 the more severe form of SJS but that it is

25 the same disease process? 

Witness_ Claes Dohlman, M.D., Ph.D. -: 18:2 - 18:20

2 A. Whether it is exactly the same disease

3 process, I don't know. But it certainly

4 behaves like Stevens-Johnson, only, only

5 worse, and the matter of quibbling among

6 the dermatologists what should be called

7 erythema multiforme and what should be

8 called Stevens-Johnson and what should be

9 called TEN, and but it's probably a

10 spectrum of the same type of disease.

11 Q. Yes, sir. And have you gained the

12 understanding, oh, within the last ten

13 years since it occurred that dermatologists

14 as you referenced now define SJS as up to

15 ten percent of your total body surface area

16 being involved sluffing off or exfoliating;

17 between 11 and 29 percent as SJS TEN

18 overlap; and 30 percent and above they

19 reserve for the definition TEN?

20 A. I have heard that definition.

Witness_ Claes Dohlman, M.D., Ph.D. -: 18:23 - 19:16

23 A. Okay. I have heard that definition. I

24 cannot vouch for how reasonable it is.

25 Q. When ophthalmologists like you refer to 

00019

1 Stevens-Johnson syndrome, in your mind,

2 sir, are you referring to the entire

3 spectrum of the disease, whether it is SJS

4 or TEN?

5 A. Correct, yes. We, we lump it altogether.

6 We only see it as a gradient in terms of

7 severity.

8 Q. Okay.

9 A. And we don't have -- I don't use personally

10 any other name than Stevens-Johnson

11 syndrome.

12 Q. Thank you, sir. Are you aware that Karen

13 Bartlett, when she was at Mass. General,

14 not too far from where we are here today,

15 that they diagnosed her with the more

16 severe form called TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 19:19 - 20:18

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19 A. I was not aware of that.

20 Q. Okay. Fair to say that you never went back

21 and looked at her, I will represent to you,

22 over 1,000 page medical record from Mass.

23 General?

24 A. No. It doesn't matter from, from our point

25 of view what they call it. It is just the 

00020

1 degree of severity that we can then see in

2 front of us that matters.

3 Q. Okay. And when you say the degree of

4 severity, sir, are you referring to the

5 amount of eye damage caused?

6 A. Yes.

7 Q. Okay. Of the approximate 50 SJS or TEN

8 patients you have treated in your career,

9 sir --

10 A. It must be more.

11 Q. Okay.

12 A. It must be at least, I think, at least a

13 hundred.

14 Q. Okay. Of the approximate hundred SJS TEN

15 patients you have treated in your career,

16 sir, what is your best estimate of how many

17 of those hundred were legally blind in one

18 or both eyes from SJS or TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 20:22 - 20:25

22 A. I cannot remember in detail. But if I

23 operate on such a patient, they must be so

24 severe that they are bilaterally blind --

25 Q. And when you say -- 

Witness_ Claes Dohlman, M.D., Ph.D. -: 21:3 - 21:24

3 THE WITNESS: Bilaterally blind

4 according to definitions.

5 Q. And when you say by definition, when you

6 operate on an SJS TEN patient they are, by

7 definition, bilaterally blind, does that

8 mean that they are legally blind in both

9 eyes or worse?

10 A. Correct.

11 Q. Okay. Right.

12 A. What is worse?

13 Q. Yes. Well, and let me ask you. 20 -- is

14 2200 the accepted definition of what is

15 legally blind?

16 A. In this country it is, yes.

17 Q. Okay. And vision does get worse than that,

18 correct?

19 A. Yes.

20 Q. Okay. For -- and please explain what it

21 means when we see a recordation like

22 counting figures or hand motion.

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23 First of all, are both those worse

24 than legally blind, 2200?

Witness_ Claes Dohlman, M.D., Ph.D. -: 22:2 - 23:1

2 A. Well, anything below 2200's in this country

3 is legally blind. And you can go down to

4 2400's, you can go down to finger counting

5 in front of the eye, you can go down to

6 even worse, just hand movements, detecting

7 the hand movements in front of the eye.

8 Worse than that is just mere light

9 perception where you cannot even see the

10 hand but just see the light. And then of

11 course, there is total blindness when there

12 is no light perception.

13 Q. Okay. Let me see if I have the order

14 correct from best to worse. Best would be

15 legally blind at 2200; then it would get

16 worst at 2400; then it would get worse at

17 counting fingers; then it would get worse

18 at hand motion; and then it would get worse

19 at light perception only.

20 A. Correct.

21 Q. Do I have the order correct?

22 A. Correct.

23 Q. Okay. And anything in the question I just

24 gave beyond 2200 is also legally blind,

25 it's just worse, meeting the threshold of 

00023

1 legally blind, correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 23:6 - 23:8

6 A. Correct.

7 Q. Thank you. Do SJS and TEN cause legal

8 blindness?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 23, Line 11

11 A. It certainly can, and those are the

Witness_ Claes Dohlman, M.D., Ph.D. -: 23:16 - 24:10

16 Is what I just handed you, marked

17 Exhibit No. 134, sir, is that the 2008

18 publication that you just referenced that

19 you were one of the authors of?

20 A. Correct.

21 Q. Okay. And in fact --

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22 A. I was the senior author.

23 Q. Yes, sir. And there you are. And it's

24 published in 2008.

25 And the very first sentence says, 

00024

1 "Stevens-Johnson syndrome often causes

2 severe ocular surface disease and

3 impairment of vision." Correct?

4 A. Correct.

5 Q. Okay. And when you published just last

6 year that SJS often causes severe ocular

7 surface disease and impairment of vision,

8 were you including in that legal blindness

9 or worse?

10 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 24:13 - 24:15

13 Is there a relationship between

14 counting fingers at any feet and a

15 numerical value like 2500 or 21,000?

Witness_ Claes Dohlman, M.D., Ph.D. -: 24:18 - 25:7

18 A. There is, although we don't use that.

19 Below 2400, we don't use that. We don't

20 use in our parlance here 2800 or less.

21 Q. Why not?

22 A. We -- custom.

23 Q. Okay.

24 A. And there is another system of measuring

25 vision more exactly with the Logmar system. 

00025

1 And there is a correlation table there and

2 we use that Logmar in scientific studies

3 sometimes. But it has no particular

4 meaning here, what we call it.

5 Q. Is 2400 the last numerical value and also

6 the worst vision that doctors generally put

7 by numerical value?

Witness_ Claes Dohlman, M.D., Ph.D. -: 25:9 - 25:10

9 A. Correct. That is the standard use of the

10 word.

Witness_ Claes Dohlman, M.D., Ph.D. -: 26:8 - 26:10

8 Q. How certain are you, Doctor Dohlman, that

9 SJS and TEN can and do cause legal

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10 blindness or worse?

Witness_ Claes Dohlman, M.D., Ph.D. -: 26:16 - 27:7

16 A. Okay. Because we, we see these patients

17 here often referred to us and with that

18 history.

19 Q. Mm-hmm.

20 A. And we often have records from the

21 referring hospitals and/or MGH or

22 elsewhere, clearly spelling out the

23 diagnosis and the history. So there is no

24 question that that episode of

25 Stevens-Johnson episode and the sequels is 

00027

1 what causes the blindness and not

2 necessarily anything else.

3 Q. Okay. And if you can, Doctor, can you put

4 a number on that? When you say there is no

5 question, does that mean in your mind that

6 it's 100 percent certainty that SJS and TEN

7 can and, in fact, do cause legal blindness?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 27, Line 10

10 A. 100 percent certain.

Witness_ Claes Dohlman, M.D., Ph.D. -: 28:9 - 29:17

9 Can you do us a favor, Doctor

10 Dohlman, and with this eye model, perhaps,

11 tell us how the human eye works in a

12 healthy adult or child?

13 A. Okay. We have a cross section of the eye

14 here. And let's see now. A cross section

15 of the eye, and this is the front part.

16 Here is the cornea, which is normally in

17 you and me so transparent so that we don't

18 see it. We can see the blue or brown iris

19 and the pupil through it, but normally we

20 don't see it.

21 But if the cornea is opaque, then

22 we see it as a white scar often

23 vascularized with blood vessels, and then

24 the cornea becomes visible and often white,

25 grayish or white. 

00029

1 Now, the clear cornea is necessary

2 for the image formation on the retina back

3 here. So that light comes in through the

4 cornea and it is refracted, meaning that it

5 is bent by the curve here, it is bent

6 towards the retina. There is more bending

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Page 12

7 necessary, and that is done by the

8 crystalline lens behind, behind the iris,

9 and then it is focused on the retina and

10 the image is then formed on the retina.

11 And the message from there goes to the

12 brain.

13 Q. Thank you, Doctor. Now, if you could keep

14 the model in your hand and tell us when you

15 are presented with a person who has SJS or

16 TEN and they are legally blind or worse,

17 what is different about the eye?

Witness_ Claes Dohlman, M.D., Ph.D. -: 29:22 - 30:6

22 A. The difference is that, as I mentioned, the

23 cornea is very scarred. The surface is

24 irregular and there are blood vessels in

25 the cornea. 

00030

1 In addition, there are other

2 problems. As a rule, they often have

3 glaucoma, meaning high pressure, and they

4 often have cataracts, meaning that the

5 normal crystalline lens behind here becomes

6 cloudy as well.

Witness_ Claes Dohlman, M.D., Ph.D. -: 30:9 - 30:14

9 When you estimated that you

10 treated about 100 people with SJS and TEN

11 in your career and you said by definition

12 they were bilaterally legally blind, does

13 that mean that you operated on every one of

14 the SJS TEN patients that you saw?

Witness_ Claes Dohlman, M.D., Ph.D. -: 30:17 - 31:7

17 A. I probably have operated on about a

18 hundred. And that means that they are so

19 bad that nothing, nothing else can help.

20 In addition, I am sure that I have seen a

21 number of lighter cases that have come for

22 consultation and so on where I've deemed

23 that surgery would be too risky or not

24 needed at all.

25 Q. Okay. 

00031

1 A. And how many of those, I don't remember.

2 Q. Fair enough. Have SJS and TEN patients

3 generally been referred to you because your

4 ophthalmology colleagues here at Harvard or

5 elsewhere in the country or the world

6 believe that they should be evaluated for

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7 surgery?

Witness_ Claes Dohlman, M.D., Ph.D. -: 31:10 - 31:25

10 A. Yes. We have a corneal service here which

11 I started in 1958. And that has developed

12 into a large referral service for not only

13 local but also national and international

14 patients. And but that doesn't mean that

15 we see them all in the country, of course

16 not. There are many other good cornea

17 surgeons around that are also consulted.

18 But most of them do not operate on

19 Stevens-Johnson because of the bad outcome

20 with standard corneal transplantation.

21 Q. Okay. Please tell us how bad the outcome

22 presently is, as understood by medicine

23 today in 2009, for using a traditional

24 standard corneal replacement in a blind eye

25 from SJS or TEN. 

Witness_ Claes Dohlman, M.D., Ph.D. -: 32:4 - 32:24

4 A. It is hard to say because of the

5 differences in severity. You can have less

6 than 2200's and still be a reasonably wet

7 that is reasonably wet and reasonably

8 comfortable and gives a little bit of

9 vision, and we turn them down for any

10 surgery. And then that is on one end.

11 And the other end, when they have

12 totally dried up so that the whole surface

13 of the cornea in the eye is like leather

14 and there is no wetness at all. Under

15 those harsh circumstances, a standard

16 corneal transplant is absolutely 100

17 percent hopeless.

18 Q. You just said the eye looks like leather.

19 I'm showing you now, Doctor

20 Dohlman, you have a copy of it there,

21 pictures from your 2008 publication. Tell

22 us what these pictures depict and how that

23 might help you explain what you just

24 testified to.

Witness_ Claes Dohlman, M.D., Ph.D. -: 33:4 - 35:20

4 MR. JENSEN: Yes. And here,

5 here's a copy.

6 A. Okay. The upper left depicts a patient

7 with Stevens-Johnson and shrinkage and

8 swelling of the conjunctiva outside the

9 cornea. The cornea is moderately hazy.

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10 The surface is irregular, as you can see

11 from the light reflex that is broken up,

12 and it is fairly dry and there have been

13 forming, there are, there have been formed

14 symblephara. That is shrinkage of the fold

15 between the lid and the eye.

16 Q. You are still on the top left picture, sir?

17 A. That is the top left, yes.

18 Q. Thank you, sir.

19 A. And in the top right, there is an even

20 worse situation. There, the -- it has

21 become so dry so that the surface of the

22 cornea is completely dry.

23 Q. Okay.

24 A. There are no tears any longer.

25 Q. Okay. And before we go to the next images, 

00034

1 sir, is what I'm showing you now and what

2 I'm showing on the screen, is that, sir,

3 your invention?

4 A. Yes.

5 Q. And for the record, that is the Boston

6 K-Pro?

7 A. Yes.

8 Q. Okay. And are there two different types of

9 the Boston K-Pro shown on Exhibit No. 127?

10 A. Yes. And the left one is one, the one we

11 are using in 98 percent of our cases or so.

12 And that is for the usually normally wet

13 eye and not autoimmune diseases.

14 But in the extremely dry eye, then

15 we -- there is no conjunctiva left. We

16 remove --

17 Q. What is conjunctiva, please?

18 A. Conjunctiva is the thin mucous membrane

19 layer over the white sclera. In other

20 words, it's outside the cornea.

21 Q. Okay.

22 A. And --

23 Q. What is the sclera, please, sir?

24 A. The sclera is the white of the eye --

25 Q. Okay. 

00035

1 A. -- that we see outside the cornea. And

2 covering that is a thin layer of

3 conjunctiva and a few blood vessels and so

4 on. And it is normally invisible. But if

5 that has dried up and then we cannot use

6 the Type 1, as we call the left one. So we

7 -- I close the lid, I remove the tissue

8 here, I put in the Type 2 keratoprosthesis

9 that has, looks like Type 1 but has an

10 extra stem up front. And then I lead that

11 through the lids, I close the lids and I

12 lead that stem through the upper lid, the

13 edge of the upper lid.

14 And one can see the net result in

15 the lower right corner.

16 Q. Right here?

17 A. There is type, Type 2. Yes, that there.

18 Q. Okay. Yes, sir.

19 A. There is the Type 2 that functions. And I

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20 would come to the --

Witness_ Claes Dohlman, M.D., Ph.D. -: 35:23 - 36:5

23 Q. Okay. On this there is five pictures, sir.

24 And if you would, if you would go through

25 those five pictures with us and basically 

00036

1 tell us what they are in relation to your

2 surgery, we would appreciate that.

3 And as you flip through the

4 pictures, I will show the jury what you're

5 speaking of.

Witness_ Claes Dohlman, M.D., Ph.D. -: 36:8 - 37:2

8 A. The design only shows the dimensions of the

9 device and the way of assembly.

10 Q. Okay.

11 A. And I don't think you should have much

12 interest except that we put it into a

13 standard corneal graft. We make a hole.

14 The second layer up there to the left --

15 Q. Yes, sir.

16 A. -- is the corneal graft. And we punch that

17 out.

18 Q. Here?

19 A. And then we punch a hole in the middle.

20 And then we stick the stem down into that

21 hole. And then we screw or snap that into

22 the backplate with holes for nutrition.

23 And then to lock it, we have a titanium

24 locking ring that we snap on behind the

25 backplate. 

00037

1 Q. Do the --

2 A. And that locks it in.

Witness_ Claes Dohlman, M.D., Ph.D. -: 37:8 - 41:9

8 Q. Yes. Or look at the fourth or fifth also.

9 Tell us, you tell us what's best. That is

10 the second and then there is a third,

11 fourth and fifth. So taking a look at the

12 third, yes, sir, and then the fourth and

13 fifth and tell us what they are, please.

14 A. So here, again, we see the front part of

15 the device. And we have the backplate and

16 then we have the locking ring. And we

17 clamp then the corneal graft in between.

18 And then if we look at it from the

19 back side, this is the way it looks. And

20 so we have, we are looking here now at the

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21 locking ring where centrally we have the

22 stem of the keratoprosthesis.

23 Q. Okay.

24 A. And then we have the locking ring of the

25 titanium behind. And then we see the 

00038

1 backplate with the holes.

2 And then in front of that, of

3 course, is the cornea. And then we put --

4 Q. Is this eye picture a picture of an eye

5 after it has your Boston K-Pro implanted in

6 it?

7 A. This picture is, yes.

8 Q. Yes, sir.

9 A. Correct. And we then trephine out the

10 patient's cornea and then we put in the

11 cornea with the device.

12 Q. And when you say trephine out the patient's

13 cornea, what does that mean, sir?

14 A. Trephine is almost like a cork-boring

15 instrument. It is like a tube with a sharp

16 edge. And we trephine out so that we can

17 then excise the patient's cornea in about

18 eight-millimeters diameter or so.

19 And then we put our cornea that is

20 loaded with the device, we put it into the

21 eye, and then we suture it in place just

22 like a regular cornea transplant.

23 Q. Are these 12 lines we see here on the eye,

24 are those sutures?

25 A. Yes, they are, exactly. 

00039

1 Q. Are those --

2 A. Nylon sutures.

3 Q. Are these 12 nylon sutures through and sewn

4 through a human donor cornea?

5 A. Yes.

6 Q. Okay. If you could look at the next page,

7 please, sir, and tell us what that is.

8 A. This is part of the assembly. And here we

9 have a patch of adhesive. And then we have

10 the front part of the keratoprosthesis,

11 which is the front plate, and there is a

12 stem. And then we put that upside down on

13 the adhesive for standardization, and then

14 we slide over the corneal graft, slide over

15 the stem and push it down. And then we put

16 the backplate on top of that.

17 Q. Is what we're looking at here the human

18 donor corneal tissue?

19 A. Yes.

20 Q. Okay. Is it correct to state that the

21 Boston K-Pro is a mix of both your device,

22 the -- is your device made of plastic?

23 A. Yes.

24 Q. Okay. Is it correct to state that the

25 Boston K-Pro is a mix of your device, which 

00040

1 is plastic, with a human corneal tissue so

2 it's both live tissue as well as plastic?

3 A. Well, I wouldn't define it that way. I

4 think the Boston Keratoprosthesis is the

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5 foreign part. And then we use a standard

6 cornea, donor cornea from an eye bank as a

7 carrier, but not necessarily.

8 Q. And when you say carrier, please tell us,

9 Doctor, what is the vehicle that is

10 delivering sight; is it your plastic or is

11 it the cornea? Please teach us.

12 A. No. The cornea only holds, holds the

13 device in place. But the image and the

14 light goes through the stem of the

15 keratoprosthesis.

16 Q. Look at the last page, please, and maybe

17 that will help you explain.

18 A. So this, again, we see an assembled

19 combination from behind so we see this --

20 here is now the stem. It looks a little

21 milky but it's transparent normally, and

22 then the locking ring of titanium. And we

23 have the backplate with the holes. And

24 then in front of that or under that and

25 sticking out here is the cornea. 

00041

1 Q. Okay. So the red --

2 A. The carrying cornea.

3 Q. Is this red area the carrying cornea in the

4 picture?

5 A. Yes.

6 Q. Okay. So why, teach us about your

7 invention, please.

8 Why mix human tissue with this

9 plastic device?

Witness_ Claes Dohlman, M.D., Ph.D. -: 41:12 - 41:21

12 A. Well, a keratoprosthesis, by definition,

13 will have to be inserted into the eye

14 tissue to be of any use. And to be

15 inserted into the cornea, you can insert it

16 directly into the cornea via incisions and

17 so on, or you can build it in just like

18 this and have that carrier graft implanted

19 with the device, which is much more

20 practical. Not only practical but also

21 gives much less complications, much less.

Witness_ Claes Dohlman, M.D., Ph.D. -: 42:8 - 43:8

8 Those two bottom pictures right

9 there, sir.

10 A. These ones?

11 Q. Yes, sir.

12 A. Okay. The bottom pictures?

13 Q. Yes, sir.

14 A. The bottom picture to the left is where we

15 have been able to get away with a Type 1 in

16 an eye, in a Stevens-Johnson eye which

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17 still has been somewhat wet; in other

18 words, tears still functioning.

19 Q. Okay.

20 A. And it might be even have been Mrs.

21 Bartlett. I don't know.

22 But that is roughly what -- I

23 think Ms. Bartlett was a little more

24 inflamed, but that was the type of

25 operation we did with Mrs. Bartlett. 

00043

1 Because she had still a wet eye, she was

2 very vulnerable and prone to breakdown and

3 so on, but the eye was wet.

4 Q. Right.

5 A. So we did not have to go to a much more

6 stymying and ugly and cosmetically

7 unacceptable Type 2.

8 Q. Right. You raised, you raised a question

Witness_ Claes Dohlman, M.D., Ph.D. -: 44:7 - 45:5

Are

8 all of the 16 people that this study was

9 done about all operated on by one surgeon,

10 namely you?

11 A. Yes.

12 Q. Okay.

13 A. Yes.

14 Q. And is it --

15 A. And we, we took only those cases where we

16 had at least a year or two minimum

17 follow-up and most of them longer.

18 Q. Yes, sir.

19 A. So I don't think she qualified as for

20 follow-up.

21 Q. Yes, sir. And this 2008 published article

22 is entitled, to abbreviate, the Boston

23 K-Pro in SJS. Correct?

24 A. Yes.

25 Q. And it wasn't the first time that you had 

00045

1 been the sole surgeon of a series of

2 patients that was published. Another time

3 was in 2001. The lead author was Doctor

4 Yaghouti and you were a co-author but you

5 were the sole surgeon as well. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 45:8 - 46:13

8 A. Yes. I was a -- yes, I have been the sole

9 surgeon all along until Doctor Chodosh

10 came. Now he is inheriting some of my

11 patients but --

12 Q. And let me ask you. Is Doctor Chodosh, as

13 we sit here today in September of 2009, the

14 only other surgeon at Harvard Medical

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15 School/Mass. Eye & Ear who presently

16 performs the Boston K-Pro other than

17 yourself?

18 A. No. There are several. Dr. Kathryn Colby

19 has a large number, and Dr. Roberto Pineda

20 has some. Ula Uccunas has a few. And I

21 think Doctor Dana has a few, and so on.

22 And Doctor Melky has a number. So really

23 it is all spread all over the system, but

24 they don't tackle these severe cases.

25 Q. Oh, okay. 

00046

1 A. So they, they -- we are handling the worst.

2 Q. I -- there is a newsletter for the Mass.

3 Eye and Ear infirmary. Correct, sir?

4 Is that correct, sir?

5 A. Yes.

6 Q. Okay. And you said that only a few are

7 tackling the worst.

8 Let me ask you, is Doctor Chodosh

9 one who is tackling the worst cases of

10 Stevens-Johnson syndrome?

11 A. Yes.

12 Q. And hopefully curing or attempting to treat

13 those?

Witness_ Claes Dohlman, M.D., Ph.D. -: 46:18 - 47:5

18 A. Yes, he is.

19 Q. Okay.

20 A. Doctor Chodosh. Parenthetically, I will be

21 87 tomorrow, so I have a good reason to

22 look for a successor. And we recruited

23 Doctor Chodosh, who is a very experienced

24 academic. And so he has been here for over

25 a year. 

00047

1 Q. Okay.

2 A. And he has a special interest and special

3 expertise in these severe autoimmune

4 diseases. So I am asking Doctor Chodosh to

5 from now on to take care of that category.

Witness_ Claes Dohlman, M.D., Ph.D. -: 47:8 - 48:11

8 Q. Let me first ask you, is Exhibit No. 130,

9 sir, a copy of a 2008 newsletter for Mass.

10 Eye and Ear Infirmary?

11 (Witness perusing document.)

12 A. Yes.

13 Q. Okay. And if you flip the page there, is

14 that a picture of Doctor Chodosh, oh, about

15 six pages back, one, two, five pages back?

16 (Witness perusing document.)

17 A. Yes.

18 Q. Okay. And it states --

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19 A. You can get a better copy than this. We

20 have better.

21 Q. Yes. I am not trying to do a disjustice to

22 him with my copy. I apologize.

23 But you mentioned very difficult

24 cases. And it says here by Doctor Chodosh,

25 it shows his picture, that he, his clinical 

00048

1 interests include the visual restoration of

2 hopeless cases.

3 A. Yes.

4 Q. Do you see that, sir?

5 A. Yes.

6 Q. Are SJS and TEN what you categorize as

7 hopeless cases?

8 A. Absolutely.

9 Q. Why are SJS and TEN blindness cases

10 categorized by you and your colleagues at

11 Harvard as hopeless cases?

Witness_ Claes Dohlman, M.D., Ph.D. -: 48:14 - 49:8

14 A. Well, I would say -- I wouldn't say that.

15 I wouldn't use the term hopeless, but the

16 most severe.

17 Q. Okay.

18 A. Because experience has shown me, and that

19 was during -- we had a fellow here,

20 Yaghouti, who wrote up some of the early

21 cases. And we found that there were

22 prognostic categories that varied markedly

23 from each other and in the small but

24 important category of autoimmune diseases,

25 among which Stevens-Johnson is one and 

00049

1 perhaps the most severe. But the

2 autoimmune diseases are much more

3 difficult, much much more difficult to

4 carry through than the rest.

5 Q. And Stevens-Johnson syndrome and TEN are

6 classified by you and your colleagues as

7 autoimmune diseases. Correct?

8 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 49:12 - 49:15

12 Is it correct to say that you

13 would never use the word "hopeless" when

14 speaking with a patient?

15 A. Only if they have no light perception.

Witness_ Claes Dohlman, M.D., Ph.D. -: 50:19 - 50:21

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19 Q. Okay. Are you and now Doctor Chodosh the

20 doctors at Harvard who specialize in the

21 most difficult and severe cases?

Witness_ Claes Dohlman, M.D., Ph.D. -: 51:1 - 51:3

1 A. Correct.

2 Q. Okay. Are SJS and TEN the most difficult

3 and severe blindness cases?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 51, Line 5

5 A. In my mind, it is.

Witness_ Claes Dohlman, M.D., Ph.D. -: 51:9 - 51:11

9 Why is it the case that, in your

10 mind, SJS and TEN are the most difficult

11 and severe blindness cases?

Witness_ Claes Dohlman, M.D., Ph.D. -: 51:13 - 52:20

13 A. I learned this early on that

14 Stevens-Johnson, outcome of

15 keratoprosthesis in Stevens-Johnson

16 syndrome was particularly bad. In fact, in

17 the -- excuse me.

18 MR. COSGROVE: Doctor, would you

19 like a glass of water?

20 THE WITNESS: No, it hasn't helped

21 for 87 years. It won't help now.

22 A. In the early '90's, I realized that our

23 results with Stevens-Johnson were so bad so

24 that I had a voluntary moratorium on them.

25 I had seven cases and they all went down 

00052

1 to, to zero vision within five years. And

2 that was in part due to glaucoma and in

3 part due to infection. But then we learned

4 how to use prophylactic antibiotics, and we

5 introduced Vancomycin particularly. So

6 that now we don't have any infections

7 practically as long as we used the

8 antibiotics prophylaxis. The glaucoma

9 situation is also much better because we

10 have added techniques there also.

11 So then I took up Stevens-Johnson

12 again. And the 16 first cases were the

13 ones that we just presented, with a couple

14 linear curve here and there, about 50

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15 percent instead of zero percent had

16 reasonable vision after five years. But 50

17 percent is not 100 percent, and there was

18 still a lot of hassle and there is still,

19 in my firm opinion as we stand now the --

20 it is our worst category.

Witness_ Claes Dohlman, M.D., Ph.D. -: 52:23 - 53:5

23 When SJS and TEN cause blindness,

24 are patients always legally blind in one or

25 both eyes from the time their skin is 

00053

1 sluffing off, or can they get legal

2 blindness caused by SJS and TEN months or

3 years after the person gets out of the

4 hospital and their skin appears to be

5 healing?

Witness_ Claes Dohlman, M.D., Ph.D. -: 53:9 - 54:6

9 A. The latter is correct. That is in fact --

10 Q. Why?

11 A. Why, I don't know. But it is actually the

12 most common sequence of events that they

13 leave the hospital when they seem well and

14 often with tears, and then it takes usually

15 years until so much scarring so that the

16 outflow channels from the lacrimal glands

17 are squeezed off and dried. That dries up

18 the eye, and then the rest is a downhill

19 course.

20 Q. Okay.

21 A. So it is very often that they can see well

22 for 10 years, 20 years or a little bit

23 less, and then eventually they go blind, or

24 they can go blind after a year or two.

25 Q. Let me put some more definite times in my 

00054

1 question.

2 Doctor Dohlman, is it true that

3 SJS and TEN can cause legal blindness a

4 month, a year, and even five years or more

5 after someone's skin appears to be healing

6 from their SJS and TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 54:11 - 55:9

11 A. That is correct.

12 Q. Okay.

13 A. There is no question about it.

14 Q. Okay.

15 A. We see this --

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16 Q. Are you 100 percent certain of that?

17 A. I am 100 percent certain.

18 Q. Okay.

19 A. And we, we've learned about the history, we

20 get the records and we see the

21 developments. And they saw at that time

22 when they left the hospital 20/20 and then

23 they saw 20/70, and then now they see

24 2400's or something like that.

25 Q. Is it correct then in your career, Doctor 

00055

1 Dohlman, you've been involved with many

2 medical symposiums and continuing medical

3 education classes, and you're part of the

4 Boston K-Pro Study Group, and in many of

5 these forums would it be fair to state that

6 you discuss with your medical colleagues

7 matters which include what causes SJS and

8 TEN, what causes blindness, and how, when

9 and why you do surgery?

Witness_ Claes Dohlman, M.D., Ph.D. -: 55:13 - 55:22

13 A. We have the largest experience with

14 Stevens-Johnson in at least in this

15 country. But of course, we always, at

16 meetings, discuss the experience of our

17 colleagues with our colleagues and discuss

18 their experience as well.

19 Q. Have you at any time in your career, Doctor

20 Dohlman, ever read or ever heard any doctor

21 state, suggest or opine that SJS and TEN

22 cannot cause legal blindness?

Witness_ Claes Dohlman, M.D., Ph.D. -: 55:24 - 56:7

24 A. I have never heard that.

25 Q. Okay. In your entire medical career, have 

00056

1 you ever heard of any doctor or have you

2 ever read any assertion or heard any doctor

3 state that, suggest or opine that SJS and

4 TEN cannot cause legal blindness months,

5 years, or even five years after a person's

6 skin appears to be healing from SJS and

7 TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 56:9 - 56:10

9 A. I have never read or seen or heard any such

10 opinion.

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Witness_ Claes Dohlman, M.D., Ph.D. -: 56:18 - 57:20

18 Q. Who is Doctor Papaliodis, sir?

19 A. He is an esteemed colleague here at the

20 hospital and he has expertise in

21 inflammatory eye diseases.

22 Q. Okay. If you would flip to the third

23 letter there.

24 A. Yes.

25 Q. It is dated August 10, 2006. And you are 

00057

1 copied on it, correct?

2 (Witness perusing document.)

3 A. Third letter, okay, to Doctor Lane.

4 Q. And you are copied on the bottom, correct?

5 A. Yes.

6 Q. And in his last sentence of the letter he

7 says, "I suggested evaluation by Dr. Claes

8 Dohlman for consideration of K-Pro in left

9 eye." It says OS, correct?

10 A. Okay.

11 Q. And when you see OS, that is a reference to

12 the left eye, right?

13 A. Correct.

14 Q. And OD is a reference to the right eye,

15 correct?

16 A. Correct.

17 Q. So do you understand this letter to be one

18 that Doctor Papaliodis, another professor

19 here at Harvard, is suggesting that Karen

20 be evaluated by you?

Witness_ Claes Dohlman, M.D., Ph.D. -: 57:23 - 58:11

23 A. Correct.

24 Q. Okay. I just want to show you two letters

25 before that, sir, so we can just do a 

00058

1 timeline.

2 The first letter of Doctor

3 Papaliodis is dated March 1st, '06.

4 Do you see that, sir?

5 A. Yes.

6 Q. And at this time, in paragraph three, he

7 records visual acuity of 20/60 in Karen's

8 right eye and 2100 in her left eye.

9 And neither of those are legally

10 blind, correct?

11 A. Right, correct.

Witness_ Claes Dohlman, M.D., Ph.D. -: 58:15 - 59:18

15 He says in his bottom paragraph,

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16 "She has multiple ophthalmic issues

17 requiring attention. She continues to

18 inadequately lubricate the ocular surface

19 despite punctal plugs."

20 What are the punctal plugs, sir,

21 and how does that relate to inadequate

22 lubrication?

23 A. Punctal plugs are plugging the little

24 outflow channels from the, from the outside

25 of the eye and into the nose. That's where 

00059

1 tears drain normally.

2 And if we have scant tears, there

3 is a technique of plugging those holes and

4 allowing those scant tears to be around a

5 little longer and be more wetting. That is

6 the principle.

7 Q. Okay. And he says, "She may need lateral"

8 -- can you pronounce the words for me -- is

9 it tarsorrhaphy?

10 A. Tarsorrhaphy.

11 Q. What is that, sir?

12 A. That is suturing the lids together.

13 Q. Does that mean you're sewing the eyes shut

14 so the eyes can't open?

15 A. Yes. At least in part.

16 Q. Okay. Why, to your understanding, was it

17 being considered that Karen's eyes be sewn

18 shut?

Witness_ Claes Dohlman, M.D., Ph.D. -: 59:21 - 60:18

21 A. Because they -- it's all a matter of

22 preventing evaporation. Evaporation goes

23 on, drying goes on from the surface of the

24 eye all the time. But if one closes the

25 lids, that is brought to zero, those areas 

00060

1 that are covered. So that often helps in a

2 situation where the tears are drying up.

3 The eye is very drying. And especially if

4 we get ulcers and so on, one can protect

5 the eye quite well with tarsorrhaphy.

6 Q. Okay. Let's go to the next letter, please,

7 sir, and it's just three months later than

8 the first letter. And it is dated June 8,

9 2006.

10 Do you see that, sir? Are you

11 there?

12 A. Yes.

13 Q. And in this letter, Doctor Papaliodis sends

14 a letter to Dr. Leo Lane, who is Karen's

15 primary care physician. And he reports in

16 part that she has ocular surface disease

17 secondary to her Stevens-Johnson syndrome.

18 Do you see that, sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 60, Line 21

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21 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 61:3 - 61:11

3 Q. When he used the word "secondary" here,

4 sir, does that mean the same thing as

5 caused by?

6 A. Yes.

7 Q. Okay. So do you understand this to mean

8 that Doctor Papaliodis, your colleague here

9 at Harvard, has concluded that Karen's

10 ocular surface disease was caused by her

11 Stevens-Johnson syndrome?

Witness_ Claes Dohlman, M.D., Ph.D. -: 61:16 - 61:21

16 A. Yes.

17 Q. Okay. And he at this date records, three

18 months after she is here in March, that she

19 has 20/60 in her right eye, and that she is

20 legally blind with 2200 in her left eye.

21 Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 61:24 - 63:6

24 A. Correct.

25 Q. Okay. And then he says that she has trace 

00062

1 conjunctival injection OU.

2 OU means both eyes, right?

3 A. Both eyes.

4 Q. What does trace conjunctival injection

5 mean? And he also says --

6 A. It's slightly red.

7 Q. Okay. And then he says it has progressive

8 corneal vascularization in the left eye.

9 What does that mean?

10 A. That means that blood vessels are growing

11 into the cornea in the left eye. And that

12 is a bad sign.

13 Q. Why?

14 A. Because it is usually correlated with later

15 development of scarring and irregularity,

16 and perhaps even ulceration of the cornea.

17 Q. Okay. And he -- and then he says that she

18 had some symblephara present temporally.

19 He means in both eyes, right? Is that

20 correct?

21 A. Correct.

22 Q. What does that mean?

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23 A. Symblephara refers to adhesions that form

24 between the lids and the globe, and that

25 shrinks the fornix on both sides. 

00063

1 Q. If you would show us what an adhesion is

2 that he is referring to here, some

3 symblephara.

4 A. We don't have any lids here so it cannot

5 really be shown. But I can show it on one

6 of those images we had up.

Witness_ Claes Dohlman, M.D., Ph.D. -: 63:9 - 64:3

Do you need your

10 2008 publication?

11 A. Yes.

12 Q. Okay. And these pictures right here,

13 these?

14 A. So here, for instance.

15 Q. On the top left, this one?

16 A. Top left.

17 Q. Yes, sir.

18 A. There is an effusion between the lids and

19 the globe.

20 Q. Okay.

21 A. And it is also here. That is almost

22 complete here.

23 Q. Okay. And let me see if -- is it correct

24 to state when you talked about symblephara,

25 that is in very lay terms your eyelid 

00064

1 adhering to your eyeball or sticking to

2 your eyeball?

3 A. Correct.

Witness_ Claes Dohlman, M.D., Ph.D. -: 64:6 - 64:8

6 Q. Is, in very lay terms, your eyelid sticking

7 or fusing to your eyeball caused by SJS and

8 TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 64:11 - 64:16

11 A. Very -- the end stage of Stevens-Johnson,

12 always symblephara. But symblephara can

13 occur also in other diseases.

14 Q. Okay. What percent certain are you that

15 SJS and TEN can and do cause the eyeball to

16 fuse or adhere to the eyeball?

Witness_ Claes Dohlman, M.D., Ph.D. -: 64:19 - 64:23

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19 A. There is no question in my mind that this

20 is what, what occurs in advanced

21 Stevens-Johnson syndrome.

22 Q. 100 percent certain?

23 A. 100 percent certain.

Witness_ Claes Dohlman, M.D., Ph.D. -: 64:25 - 65:4

25 Q. So he, a second time, I am back at Doctor 

00065

1 Papaliodis, in June 2006. He says she may

2 -- he makes a second reference to lateral

3 tarsorrhaphies.

4 A. Tarsorrhaphy, yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 65:20 - 66:3

20 Q. Okay. And when you have a lateral

21 tarsorrhaphy like Doctor Papaliodis is

22 referring to, can you still see?

23 A. Often you have to tilt your head, but you

24 can often see.

25 Q. Is it to protect the eye? 

00066

1 A. Yes.

2 Q. Why does that protect the eye, to sew it

3 partially shut?

Witness_ Claes Dohlman, M.D., Ph.D. -: 66:7 - 66:17

7 A. Because in the normal position of the eye

8 the cornea is mostly covered; and

9 therefore, protected from evaporative

10 damage.

11 Q. Thank you. Let's go to now his third

12 letter. This is again Doctor Papaliodis at

13 Harvard, writing again to Karen's primary

14 physician, Doctor Lane.

15 And he again reports that she has

16 ocular surface disease secondary to her

17 SJS. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 66:20 - 67:3

20 A. Correct.

21 Q. Okay. And Doctor Papaliodis copies you.

22 And by copying you, he reports to you she

23 is now 2400 in her right eye, which is well

24 beyond legally blind. Correct?

25 A. Correct. 

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00067

1 Q. And that she is counting fingers at one

2 feet in her left eye, which is well well

3 beyond legally blind. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 67:8 - 67:15

8 A. Correct.

9 Q. Okay. And he also reports that she has one

10 plus conjunctival injection in both eyes,

11 because it says OU, with progressive

12 corneal neovascularization in both eyes,

13 because it says OU.

14 And can you tell us what that

15 means?

Witness_ Claes Dohlman, M.D., Ph.D. -: 67:18 - 67:25

18 A. The eye is moderately red and the blood

19 vessels are continuing to grow into the

20 cornea.

21 Q. Okay. And then he says that he explained

22 to Ms. Bartlett that her ocular surface

23 disease continues to worsen despite maximal

24 topical therapy.

25 What does that mean, sir? 

Witness_ Claes Dohlman, M.D., Ph.D. -: 68:3 - 68:8

3 A. One can only give so, so much of drops of

4 various kinds to the eye. And then when

5 you reach the end there and then there is

6 still progression, that means that it's

7 beyond medical treatment possibility.

8 Q. Okay. Nonsurgical medical treatment?

Witness_ Claes Dohlman, M.D., Ph.D. -: 68:11 - 68:19

11 A. Correct.

12 Q. Okay. In his next sentence Doctor

13 Papaliodis reports to you and to Doctor

14 Lane, "Given the damage to her limble stem

15 cells, she is unable to adequately

16 re-epithelialize the injured cornea and

17 develops neovascularization/corneal

18 scarring."

19 What does that mean?

Witness_ Claes Dohlman, M.D., Ph.D. -: 68:22 - 69:19

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22 A. The -- he is referring to, to the stem

23 cells which are the mother cells out of the

24 periphery of the cornea, and they give rise

25 to the surface epithelium. But if they are 

00069

1 damaged and we have an epithelial defect,

2 then that cannot be re-generated if the

3 stem cells are, are damaged.

4 That is a conjecture because one

5 cannot see the stem cells, but we know from

6 histology that under such circumstances

7 they are not there. But it doesn't mean

8 that Doctor Papaliodis has seen the cells

9 or to the extent of the stem cells are

10 damaged. He has seen the epithelial defect

11 and he has observed the fact that it

12 doesn't heal.

13 Q. Okay.

14 A. And then there is more blood vessels and

15 there is more scarring in the cornea.

16 Q. Okay. Does -- do your Harvard colleagues

17 here at Mass. Eye Ear frequently take

18 pictures of new patients, and very

19 frequently take pictures of their eyes?

Witness_ Claes Dohlman, M.D., Ph.D. -: 69:22 - 72:3

22 A. We, we do that at intervals. That is

23 correct.

24 Q. Okay. If you could just look up at the

25 screen, Doctor, I am going to show you some 

00070

1 exhibits, some pictures to take you right

2 before the surgery and then we are going to

3 go to your first surgery.

4 So Exhibit 200 is a picture taken

5 of Karen. The date here is September 1,

6 2006.

7 And that would have been before

8 you first saw her, correct?

9 A. Could I see a better copy?

10 Q. Sure. Yes, sir. Huh?

11 A. If I could just -- yes. That's the way she

12 looked pre-op, yes. This was --

13 Q. If I could give you this one. Here, I will

14 hand you that whole set. Okay.

15 Then here is a picture of her in

16 November 2006, Exhibit 201. And I am going

17 to work up to where you are. Here is a

18 picture of in November 2006 again, Exhibit

19 202.

20 A. Yes.

21 Q. You have them all here in your hand. And

22 here's a fourth --

23 A. When was the first surgery?

24 Q. Your first surgery, sir, was on October 31,

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25 '06. 

00071

1 A. Okay. So this was, this was in September,

2 September 1st, this, these pictures.

3 Q. Yes, sir.

4 A. And they showed her preoperatively, red

5 eyes, some suturing of the lids together

6 but not very extensive, and, and dry

7 looking, broken up reflexes and scarred

8 corneas, and loss of lashes, and rigidity

9 and scarring of the lids and scarring of

10 her whole face, skin as well.

11 And then she had some lung

12 problems also, I understand, and some other

13 problems, urinary problems, and a number of

14 problems --

15 Q. Yes, sir.

16 A. -- from her disease.

17 Q. What I am going to show you now two

18 documents, sir. One is simply a list that

19 I've tried to make accurate of all of the

20 surgeries Karen has had here at Mass. Eye

21 Ear, as well as the eleventh surgery that

22 she had at Beth Israel-Deaconess. And

23 first let me go through the first four,

24 because you see, I have listed you as the

25 surgeon in what I count as four procedures. 

00072

1 First, let me ask you, did you

2 operate on Karen and perform a K-Pro

3 surgery in or about 2006?

Witness_ Claes Dohlman, M.D., Ph.D. -: 72:5 - 72:17

5 Foundation. Also objection to Exhibit 121.

6 A. Correct.

7 Q. Okay. And then did you do a suture removal

8 on or about September, in September 2007?

9 A. Correct.

10 Q. Okay. And then did you do a third surgery

11 on Karen in about March 2008, which was a

12 second K-Pro operation on the same eye, the

13 left eye?

14 A. Correct.

15 Q. And then did you perform a fourth operation

16 in about June 2008, again, re-suturing the

17 same left eye with a corneal graft?

Witness_ Claes Dohlman, M.D., Ph.D. -: 72:19 - 73:24

19 Q. Or re-suturing the corneal graft?

20 A. Correct.

21 Q. Okay. And after your fourth eye operation

22 on Karen, Doctor Dohlman, did you actively

23 follow her in all her visual acuities, or

24 did you turn over her care to Doctor

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25 Chodosh? 

00073

1 A. I --

2 MR. COSGROVE: Objection.

3 Compound.

4 A. Here it says Doctor Kathryn. It should be

5 Kathryn Colby.

6 Q. Oh.

7 A. And then --

8 Q. She changed her last -- she got married or

9 --

10 A. No, no. And then the other is the

11 assistant, and that is Masselam. It is

12 wrongly spelled, married, Hatch. So the

13 second name there is only the assistant.

14 Q. Is Colby spelled C-O-L-B-Y?

15 A. Correct.

16 Q. Okay. And I am going to correct that right

17 now.

18 And you are telling me that Doctor

19 Masselam Hatch is just an assistant on that

20 surgery?

21 A. Yes. She was a fellow.

22 Q. Okay.

23 A. And her name was Masselam.

24 Q. Okay. So she is a Harvard doctor, but she

Witness_ Claes Dohlman, M.D., Ph.D. -: 75:2 - 77:16

2 A. I left the country and I turned over the

3 case to, Mrs. Bartlett, Bartlett's case to

4 Doctor Chodosh. And then when I came back,

5 I asked him to continue.

6 Q. Okay. Thank you. And did you -- besides

7 discussing her case with Doctor Chodosh, as

8 you do with other patients, were you

9 actively looking at her chart after your

10 fourth surgery on her every time she was

11 here or not?

12 A. Not every time, no. But from time to time

13 I discussed her progress with Doctor

14 Chodosh.

15 Q. Thank you, sir. Exhibit No. 122 is the

16 same first pages which I corrected for

17 Doctor Colby, as well as every operative

18 report of your surgeries and others here.

19 Let's flip, therefore, to the first one,

20 please, sir.

21 A. Mm-hmm.

22 Q. Is the very first operative report, your

23 operative report of your first eye surgery

24 on Ms. Bartlett?

25 A. Correct. 

00076

1 Q. Okay. And this surgery that you performed

2 was called lysis of symblephara plus, I

3 will abbreviate, Boston K-Pro, aphakic, in

4 patient's own cornea, plus ECCE, plus soft

5 contact lens in her left eye. Correct?

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6 A. Correct.

7 Q. Can you explain, please explain to the jury

8 and me what that is?

9 A. Okay. So the fusion of the conjunctiva was

10 cut. They gray grossed but we cut them

11 anyway to make place for the soft lens.

12 And then we trephine, meaning make a hole

13 in the cornea.

14 Q. And is that, has this been trephined? Back

15 to this other picture here, I am showing

16 you on the screen, sir.

17 Has that been trephined? Is that

18 the trephine, the cut?

19 A. No, no. This is the assembly of the donor

20 material.

21 Q. Okay.

22 A. But in the patient, in Mrs. Bartlett's eye,

23 in her left eye we trephined a hole eight

24 millimeters. And then I removed the

25 cataract through that opening. And the 

00077

1 cataract is then visible, the pupil is

2 dilated large, and one can cut out the

3 capsule and one can press out the nucleus

4 of the cataract and one can irrigate and

5 aspirate the rest of the cataract. And

6 remaining only the posterior, the back

7 capsule has to be still there for support.

8 And then we put in then the corneal graft

9 with the keratoprosthesis, sutured that in

10 place in the standard way, and then we

11 always cover with a soft contact lens.

12 Q. Okay.

13 A. And the soft contact lens has turned out to

14 be a tremendous boon in that it distributes

15 the evaporative forces so well so that it

16 protects the eye from drying.

Witness_ Claes Dohlman, M.D., Ph.D. -: 78:14 - 78:18

14 Q. What percent of the time now in recent

15 years, the last five years, let's say, just

16 estimate, are you using a donor from an eye

17 bank for the cornea as opposed to the

18 patient's own cornea with your K-Pro?

Witness_ Claes Dohlman, M.D., Ph.D. -: 78:21 - 78:23

21 A. Almost 100 percent.

22 Q. 100 percent which?

23 A. 100 percent with a donor cornea.

Witness_ Claes Dohlman, M.D., Ph.D. -: 81:3 - 81:6

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3 Your preoperative diagnosis for

4 Karen was Stevens-Johnson syndrome,

5 February 2005, plus dryness, plus glaucoma

6 in both eyes. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 81:8 - 82:11

8 A. Correct.

9 Q. Okay. Did -- did -- before you did this

10 operation, did you see Karen Bartlett a

11 number of times to evaluate her?

12 A. If you could --

13 Q. Before you did this operation, did you see

14 Karen Bartlett a number of times and

15 personally evaluate her?

16 A. I personally evaluated her. I don't

17 remember exactly how many times. Probably

18 only once.

19 Q. Okay. And is that common in your surgical

20 history that you might only evaluate a

21 person once before surgery?

22 A. Yes.

23 Q. Okay.

24 A. That is standard, yes. Let me tell you

25 this. We have a big work up. We send them 

00082

1 to ultrasound. We send them to

2 photography. We send them to blood tests,

3 and the informed consents. And all the

4 testing is all from top to bottom so we do

5 that in one sweep.

6 Q. Would it be accurate and fair that

7 generally, before a SJS TEN patient comes

8 to you for evaluation, Doctor Dohlman, that

9 many Harvard Mass. Eye Ear physicians have

10 already evaluated them and believed going

11 to you is the appropriate course?

Witness_ Claes Dohlman, M.D., Ph.D. -: 82:14 - 82:22

14 A. Often. But many times they come from the

15 outside and they have been evaluated or

16 followed for a long time by the physician,

17 referring physician there.

18 Q. Yes. Either way, whether they come from

19 outside Harvard or within Harvard, before

20 they get to you, a number of physicians

21 have evaluated them and believe they need

22 to be considered for Boston K-Pro surgery?

Witness_ Claes Dohlman, M.D., Ph.D. -: 83:1 - 83:24

1 A. Yes.

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2 Q. Okay. When you evaluated Karen, of course,

3 did you review a lot of the materials that

4 were done by your colleague physicians here

5 at Harvard?

6 A. I believe she had been, had been seen also,

7 well, by Doctor Papaliodis, but also by

8 Doctor Foster, I believe.

9 Q. Okay. Yes, sir. And Doctor Foster is who,

10 please?

11 A. Is what?

12 Q. And Doctor Foster is who, please?

13 A. He is a senior clinical professor at

14 Harvard and perhaps the ultimate expert on

15 inflammatory diseases of the eye.

16 Q. Okay. Is SJS and TEN an inflammatory

17 disease of the eye?

18 A. Yes.

19 Q. Okay. When you diagnose -- when your

20 pre-op diagnosis said Stevens-Johnson

21 syndrome, had you at that time made a

22 conclusion as to whether or not

23 Stevens-Johnson syndrome was the cause of

24 Karen Bartlett's legal blindness?

Witness_ Claes Dohlman, M.D., Ph.D. -: 84:2 - 84:8

2 A. There was no reason whatsoever to doubt

3 that from the history.

4 Q. Okay. What percent certain were you when

5 you did this operation that Karen's legal

6 blindness that you were operating on in the

7 left eye was caused by Stevens-Johnson

8 syndrome or TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 84:11 - 84:22

11 A. Well, I was absolutely certain. I had no,

12 no, no other evidence or suggestion that it

13 could be caused by anything else.

14 Q. Okay.

15 A. And I cannot -- it's so typical for

16 Stevens-Johnson, you cannot mistake it.

17 Q. Okay.

18 A. It is absolute typical.

19 Q. Were you 100 percent certain that Karen's

20 legal blindness you were operating on in

21 her left eye was caused by Stevens-Johnson

22 syndrome?

Witness_ Claes Dohlman, M.D., Ph.D. -: 84:25 - 85:4

25 A. Yes. 

00085

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1 Q. Were you also 100 percent certain that her

2 legal blindness in her right eye that you

3 at this time did not operate on was also

4 caused by her Stevens-Johnson syndrome?

Witness_ Claes Dohlman, M.D., Ph.D. -: 85:7 - 85:9

7 A. Yes.

8 Q. Okay. And in this surgery you opted to use

9 Karen's own cornea. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 85:11 - 85:17

11 Q. You see your third paragraph there.

12 (Witness perusing document.)

13 A. Yes. I see that now.

14 Q. Okay. And please read through your

15 operative report to the extent you need to

16 and tell us why you made that decision,

17 sir.

Witness_ Claes Dohlman, M.D., Ph.D. -: 86:2 - 86:23

2 A. I see that now. I had forgotten that.

3 But, but I must have thought at that time

4 that the cornea was sufficiently full and

5 that we had preformed blood vessels so to

6 speak. These blood vessels in the cornea

7 can re, re, easily be re-canalized and the

8 whole healing be speeded up that way.

9 Healing is, in the autoimmune

10 disease, Stevens-Johnson, is a problem,

11 especially since we have to give

12 corticosteroids, prinisolone, to suppress

13 postoperative inflammation, and that cuts

14 down the wound healing rate as well. So

15 starting out with blood vessels speeds up

16 healing. We do that occasionally.

17 Q. Yes, sir. And before we take a break, one

18 word in statistics, and we will come back

19 in your papers, but generally speaking, is

20 it common, Doctor Dohlman, that when a

21 patient gets a K-Pro surgery on an SJS TEN

22 eye that they will likely need more than

23 one surgery down the road?

Witness_ Claes Dohlman, M.D., Ph.D. -: 87:2 - 87:21

2 A. That is just the problem.

3 Q. Okay.

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4 A. The problem is that in all autoimmune

5 diseases the retention of the artificial

6 cornea, the device, is almost 100 percent.

7 There is no ulceration. There is no

8 melting of the tissue and so on.

9 But, but this small important

10 group of autoimmune diseases, and

11 Stevens-Johnson is the worst, can start

12 after a year or two or three years and

13 begin to melt down and perforate here and

14 melt down next to the stem and leak and so

15 on.

16 Q. Okay.

17 A. And then we have a complication that can

18 occur in those cases because of the leak.

19 No infection anymore with our prophylactic

20 antibiotics schedule, but we can get

21 retinal detachment.

Witness_ Claes Dohlman, M.D., Ph.D. -: 88:8 - 88:25

8 Q. Back to your 2008 publication, Doctor

9 Dohlman.

10 A. Mm-hmm.

11 Q. Your first sentence reads, "Stevens-Johnson

12 syndrome often causes severe ocular surface

13 disease and impairment of vision."

14 And the very last sentence in that

15 one year old publication reads, "Patients

16 with SJS who elect to have the procedure,"

17 that's a reference to the Boston K-Pro,

18 correct?

19 A. Yes.

20 Q. Okay. "Patients with SJS who elect to have

21 the procedure must be prepared for a

22 lifelong follow-up with an experienced

23 K-Pro surgeon."

24 Is this that what you published,

25 sir? 

Witness_ Claes Dohlman, M.D., Ph.D. -: 89:5 - 89:8

5 A. That is what we published and this is what

6 I believe.

7 Q. Tell us why it is -- tell us what it is

8 true, please, Doctor.

Witness_ Claes Dohlman, M.D., Ph.D. -: 89:10 - 89:12

10 Q. Tell us why it is true, please, Doctor.

11 A. Why it is true?

12 Q. Yes, sir.

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Witness_ Claes Dohlman, M.D., Ph.D. -: 89:15 - 89:24

15 A. Because of -- it is true because of the

16 risk of tissue melt, handling that with

17 medication, with contact lenses and also

18 with surgery, glue and so on, in these

19 cases which is so frequent in the worst

20 cases.

21 Q. All right. You mentioned, Doctor Dohlman,

22 you will be 87 years young tomorrow.

23 Is Doctor Chodosh such an

24 experienced K-Pro surgeon?

Witness_ Claes Dohlman, M.D., Ph.D. -: 90:2 - 90:12

2 A. He has less experience than me. He is in

3 his early 50's. But he is, has

4 considerable experience already when he was

5 down in Oklahoma, and now even more. And

6 he is taking over this category of patients

7 and working with Doctor Papaliodis on the

8 future treatments.

9 Q. Fair to say that, to your knowledge, you

10 are the most or certainly one of the most

11 experienced K-Pro surgeons in the world?

12 A. I am probably --

Witness_ Claes Dohlman, M.D., Ph.D. -: 90:17 - 90:23

17 A. It is not speculation. I am the most

18 experienced.

19 Q. Okay.

20 A. I am just kidding.

21 Q. You're not kidding about being the most

22 experienced?

23 A. No, no. I am not kidding about that.

Witness_ Claes Dohlman, M.D., Ph.D. -: 90:25 - 91:5

25 Q. Thank you, sir. And in fact, you did, and 

00091

1 let's just go through them here, and what I

2 put before you, sir, after your first

3 surgery in October '06, you did a second

4 surgery on Karen in September '07.

5 Correct, sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: 91:7 - 91:13

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7 Q. Just flip those pages there in your right

8 hand. Yes.

9 A. Correct, yes.

10 Q. And your second surgery was examination

11 under anesthesia plus suture removal, plus

12 sutured canthotomy of her left eye.

13 Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 91:18 - 91:20

18 A. That is correct.

19 Q. Okay. Tell us what that surgery is,

20 please, sir, why you did it.

Witness_ Claes Dohlman, M.D., Ph.D. -: 91:23 - 93:10

23 A. During one of the visits just before that,

24 I noticed that she had a leak and she had a

25 fistula, meaning that there was an opening 

00092

1 in the cornea, a thinning, melting and

2 thinning and digestion of the tissue and a

3 leak and fluid came out.

4 This can be very easily

5 demonstrated by a dye that is diluted by

6 the fluid that leaks out, and the fact that

7 the pressure inside the eye is close to

8 zero. No question about it.

9 So I took her to the operating

10 room and was prepared to repair that. But

11 when she was on the table, I found that the

12 leak had stopped, and it had probably

13 stopped because I had stopped previously

14 just a couple of days beforehand the

15 steroid treatment to the cornea,

16 prinisilone. And that prinisilone keeps

17 the wound healing down, and some

18 Stevens-Johnson patients are very sensitive

19 to that. So I had stopped that and then,

20 voila, on the table no more leak. The

21 fistula was closed. So the only thing I

22 did was do a few minor things to take out a

23 couple of sutures and put the -- yes, I

24 just repaired everything that I had opened

25 just to be able to see it. 

00093

1 Q. Okay. And what is a canthotomy?

2 A. A canthotomy is when the lids are too close

3 or the opening is too small to really be

4 able to work on the eye, and we had to make

5 a cut out into the periphery.

6 Q. Okay.

7 A. And then I suture that back at the end.

8 Q. Thank you. Your third operation on Karen

9 was, oh, I guess, about six months later in

10 March of 2008. Correct, sir?

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Witness_ Claes Dohlman, M.D., Ph.D. -: 93:12 - 94:23

12 A. Correct.

13 Q. Okay. And this third surgery was a Boston

14 K-Pro. This would be the second one,

15 correct, sir?

16 A. Correct.

17 Q. And fresh corneal graft plus anterior

18 vitrectomy, plus soft contact lens OS.

19 Let's start with the anterior

20 vitrectomy. Tell us what that is, please,

21 sir.

22 A. Anterior vitrectomy is when the vitreus is

23 cloudy because of collapse and a leak that

24 has been there for a short time before.

25 And then we remove the jelly-like vitreus, 

00094

1 front part of the vitreus, with a

2 vitrector, which is a cutting suction

3 little pipe, and the light pipe. We shine

4 down in with the light pipe and then we go

5 in with this device that has a little

6 guillotine action inside an opening and at

7 the same time it sucks out what is cut.

8 And so one can cut that jell, the front

9 portion of the jell, which I did.

10 Q. Okay. And you said the preoperative

11 diagnosis was Stevens-Johnson syndrome

12 status post K-Pro, left eye with leak.

13 What does that mean, sir?

14 A. Are you talking about the March --

15 Q. March '08, yes, sir.

16 A. Yes. Well, just as it says, we have had,

17 had a K-Pro before, but that was a massive

18 leak and I felt that we had to do the whole

19 thing over again.

20 Q. And do any of these pictures help you

21 describe what a leak is and why did

22 surgery, this, a second K-Pro was needed

23 for Karen?

Witness_ Claes Dohlman, M.D., Ph.D. -: 95:2 - 95:6

2 A. I would just have to look here exactly

3 where the leak was. Sometimes it's around

4 the stem, sometimes it's further out. But

5 it would take me only a second. That was

6 March. Okay. Around the stem.

Witness_ Claes Dohlman, M.D., Ph.D. -: 95:13 - 95:15

13 Q. And sir, the jury can see what I am

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14 pointing at so you tell me where to point.

15 A. Okay. All right.

Witness_ Claes Dohlman, M.D., Ph.D. -: 95:22 - 96:18

22 A. All this is the cornea. All this here is

23 the cornea.

24 Here is the corneal graft with the

25 keratoprosthesis. And here is the central 

00096

1 stem. It is only three, three and a half

2 millimeters in diameter.

3 And this is where you see through.

4 And --

5 Q. I am going to turn off the light so that

6 you can see better. Okay.

7 Go ahead, Doctor?

8 A. So here is now the three-millimeter stem.

9 And this is crystal clear, nothing can

10 happen to that and you see through that.

11 But here is now the tissue, the corneal

12 tissue outside here holding the device.

13 And here, the tissue had started to melt

14 away on the just outside the stem, not in

15 this case, but this is what happened in, in

16 Mrs. Bartlett's case. So that it started

17 to leak around here and then the whole

18 thing had to be repeated.

Witness_ Claes Dohlman, M.D., Ph.D. -: 97:20 - 97:22

20 Q. And how common, Doctor Dohlman, are these

21 leaks which require a second operation like

22 the second K-Pro you did on Karen?

Witness_ Claes Dohlman, M.D., Ph.D. -: 97:25 - 98:11

25 A. Unfortunately, in very severe 

00098

1 Stevens-Johnson, which this was, it is

2 quite common.

3 Q. Okay.

4 A. And she disappointed us in that sense that

5 she was so prone to meltdown and necrosis

6 and leak, and it was not the last time.

7 Q. We have not addressed that. We talked

8 about that SJS and TEN are one of the worst

9 preoperative diagnoses for K-Pro. We

10 hadn't talked about how severe Karen's was,

11 and you just brought that up.

Witness_ Claes Dohlman, M.D., Ph.D. -: 98:15 - 98:19

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15 severe Karen's case was.

16 MR. COSGROVE: Objection. Form.

17 Foundation.

18 A. She behaved like one of the worst we've

19 had.

Witness_ Claes Dohlman, M.D., Ph.D. -: 98:24 - 99:2

24 Why is it true in your evaluation

25 and operations that Karen was one of the 

00099

1 worst blindness caused by SJS TEN cases

2 you've had?

Witness_ Claes Dohlman, M.D., Ph.D. -: 99:6 - 100:6

6 A. Because of the repeated and frequent

7 episodes of disintegration, disintegration

8 of the tissue, the corneal tissue around

9 the keratoprosthesis resulting in

10 perforations and leaks and risks to the

11 inside of the eye.

12 Q. Okay.

13 A. It is impossible to -- you can ask why do

14 we do this at all with these complications.

15 But we don't know beforehand.

16 After all, in our latest 16 cases,

17 we had 50 percent, 50 percent, 50 percent

18 who did well after five years and 50

19 percent did not. And of course, we

20 explained the risks and the bad prognosis

21 in general. But one can still not predict

22 how an eye will behave after surgery.

23 Q. And on the point you just made, you raised

24 the question why do we do this at all. You

25 have, in fact, published on that. 

00100

1 You published a paper called "Do

2 We Do Keratoplasty? Do We Do K-Pro? Or Do

3 We Do Nothing At All?" And then the title

4 of the paper went on to say an examination

5 of, I will paraphrase, the overlapping

6 indications for surgeries. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 100:9 - 101:2

9 A. Yes. And these indications are the, the

10 borders between these indications will

11 probably forever be fluid as

12 keratoprostheses develops further, which

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13 undoubtedly they will, it is going very

14 well, in general, there will be more and

15 more of them. And it will be less and less

16 a standard corneal transplantation and

17 maybe less also of doing nothing in the

18 severe cases as an example. We have the

19 demand for our Boston Keratoprosthesis is

20 going up like this, and which shows that it

21 does work in the hands of surgeons around

22 the world and they are interested in doing

23 more. So this is a constantly perennial is

24 shifting and in the long run there will be

25 some bright young people coming up with 

00101

1 something much better and that is

2 development in medicine.

Witness_ Claes Dohlman, M.D., Ph.D. -: 101:6 - 101:9

6 Q. Doctor, your fourth surgery on Karen was

7 what, March, April, May, June, about four

8 months after your third operation on

9 Karen's left eye. Correct, sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 101, Line 11

11 A. In June.

Witness_ Claes Dohlman, M.D., Ph.D. -: 101:20 - 102:9

20 Q. Hold on. And this fourth eye surgery you

21 did on Karen's left eye was about four

22 months after your third eye surgery on her

23 left eye. Correct, sir?

24 A. Correct.

25 Q. Okay. What was this fourth eye operation 

00102

1 you performed on Karen Bartlett?

2 A. Again, I was worried about a leak because

3 the pressure of the eye was very low, it

4 was very soft. And but I couldn't find any

5 leak. But the lower wound margin of the

6 graft, the corneal graft had poor healing;

7 so therefore, I put in a string of sutures

8 to hold that together. And it worked well

9 for a while.

Witness_ Claes Dohlman, M.D., Ph.D. -: 102:14 - 102:19

14 Q. Okay. And generally, is it your present

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15 understanding, sir, that Karen Bartlett as

16 we sit here now, just about a year and

17 three or four months after your fourth

18 surgery, has now had four K-Pro surgeries

19 in her left eye?

Witness_ Claes Dohlman, M.D., Ph.D. -: 102:22 - 103:7

22 A. She had one in the right eye.

23 Q. She had a standard corneal transplant in

24 the right eye. I am just sticking with the

25 left eye right now. 

00103

1 A. Oh, okay.

2 Q. The question is is it your understanding

3 now --

4 A. Yes. That is my understanding, yes.

5 Q. Thanks. Okay. And there is always in K-Pro

6 surgeries, there is always lead surgeons

7 and assistant surgeons. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 103:10 - 103:13

10 A. Correct.

11 Q. And for all four of the eye operations we

12 have discussed so far, you were the lead

13 surgeon for Karen Bartlett. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 103, Line 17

17 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 104:5 - 104:9

5 Q. Doctor Dohlman, in terms of Karen and

6 through your four surgeries of her and to

7 the extent you have knowledge beyond your

8 four surgeries, why has she required so

9 many?

Witness_ Claes Dohlman, M.D., Ph.D. -: 104:12 - 105:5

12 A. This is just a fundamental question that we

13 still do not understand. Why do the

14 autoimmune diseases behave so badly, for

15 lack of a better word, compared to

16 non-autoimmune diseases. And there is

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17 something in the tissue that triggers the

18 breakdown and melting away, and disease and

19 chronic inflammation that we do not

20 understand.

21 We are here mounting a rather

22 massive research project just on this

23 issue. And Doctor Chodosh, Doctor

24 Papaliodis, Doctor Foster, myself and other

25 people, we are particularly interested in 

00105

1 Stevens-Johnson and Pemphigoid and what we

2 can do by --

3 COURT REPORTER: And what?

4 THE WITNESS: Pemphigoid,

5 P-E-M-P-H-I-G-O-I-D, I guess.

Witness_ Claes Dohlman, M.D., Ph.D. -: 105:10 - 105:14

10 Q. And you've published on Stevens-Johnson

11 syndrome and that other one, Pemphigoid,

12 you just referred to, in relation to K-Pro.

13 Correct?

14 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 105:18 - 105:21

18 A. Yes.

19 Q. And we will get to it later. But you are

20 also a member of the Boston K-Pro Study

21 Group, correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 105, Line 23

23 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 106, Line 16

Q. Yes, sir.

Witness_ Claes Dohlman, M.D., Ph.D. -: 107:1 - 107:7

1 This picture is taken about four

2 and a half months after your first surgery

3 in October '06. And it is taken March 14,

4 '07. Now, with those -- now please tell us

5 what is going on with Karen's eyes here in

6 these pictures.

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7 A. March --

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 107, Line 10

10 A. No. Everything was fine then.

Witness_ Claes Dohlman, M.D., Ph.D. -: 107:13 - 109:12

13 A. There was no, there was no problem at that

14 stage.

15 Q. Thank you, sir. Now, please go to Exhibit

16 206, the next page.

17 MR. JENSEN: Thanks.

18 Q. And that is taken on April 16, 2007, so

19 about seven months after your first

20 surgery.

21 Tell us what we see here. First

22 of all, is this Karen's left eye on Exhibit

23 206?

24 A. We saw March, March '07. We looked at

25 that. 

00108

1 Q. Yes, sir.

2 A. That was fine. The next is May. Are you

3 interested in that or --

4 Q. Yes, sir. Yes. Tell us what is going on

5 there, please.

6 A. The soft lens seemed to be removed. And we

7 have an epithelial defect which is stained

8 by a green dye.

9 Q. Okay.

10 A. That means that the epithelium is, is off

11 because of the inflammation, and it is set

12 up for further melt of the underlying

13 tissue.

14 Q. These pictures are numbered two through

15 ten. Tell us which picture I should focus

16 in on so you can show us, if you can, where

17 the epithelial defect is.

18 A. We can say number six.

19 Q. Okay. I will zoom in on number six.

20 And tell us what we can see there

21 from Karen's picture of her left eye in

22 number six?

23 A. In other words, this area here which is

24 stained by a green dye, this here, and also

25 a little bit here. And that dye stains the 

00109

1 underlying tissue if there is no epithelium

2 covering, so that means that there is an

3 epithelial defect. And that means that the

4 underlying tissue is in jeopardy and can

5 melt down, actually, at any time.

6 Q. What is a corneal melt?

7 A. Well, it's when the tissue just simply

8 fades away, it disappears.

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9 Q. Did Karen Bartlett have a corneal melt?

10 A. Yes, she has had several.

11 Q. Did Stevens-Johnson syndrome cause Karen

12 Bartlett's several corneal melts?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 109, Line 15

15 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 109:18 - 109:20

18 Q. What percent certain are you that Karen

19 Bartlett's several corneal melts were

20 caused by Stevens-Johnson syndrome?

Witness_ Claes Dohlman, M.D., Ph.D. -: 109:22 - 110:6

22 A. The reason is that this is how

23 Stevens-Johnson patients behave in contrast

24 to all others.

25 Q. Okay. 

00110

1 A. With 95 percent or 99 percent of the world

2 population.

3 Q. Are you 100 percent certain that Karen

4 Bartlett's several corneal melts were as a

5 result and caused by her Stevens-Johnson

6 SJS TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 110:8 - 110:24

8 A. Yes, I am. 100 percent.

9 Q. Now, so when you say a corneal melt is the

10 tissue, tell me if I have it right, the

11 tissue is disappearing?

12 A. Yes.

13 Q. Okay.

14 A. It melts away.

15 Q. And what tissue is melting away or

16 disappearing?

17 A. On the surface, from the surface because

18 the enzymes are regulated, up regulated for

19 some reason and they digest away the

20 tissue. The corneal tissue becomes thinner

21 and thinner and then we can have a

22 perforation.

23 Q. Okay. Is there a relationship between

24 epithelial defect and corneal melt or not?

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Witness_ Claes Dohlman, M.D., Ph.D. -: 111:3 - 111:15

3 A. Definitely. There can be no corneal melt

4 without epithelial defect.

5 Q. Okay. Let me ask you, were you treating

6 Karen's epithelial defect and Karen's

7 corneal melt, melts?

8 A. I don't remember offhand the treatment.

9 But normally, we use a small amount of

10 steroids in addition to the antibiotics to

11 protect from infection, plus a soft contact

12 lens.

13 Q. Okay.

14 A. And try to protect these epithelial

15 defects. They take a long time to heal.

Witness_ Claes Dohlman, M.D., Ph.D. -: 111:23 - 112:9

23 Q. Is the very reason for the Boston K-Pro

24 surgeries you did an attempt to save

25 Karen's vision? 

00112

1 A. Well, of course. Yes.

2 Q. Okay. Yes, sir. And now let me ask you,

3 based upon your care and treatment of her,

4 let's hypothetically assume that you did

5 not do these four surgeries for a moment,

6 Doctor Dohlman. If you hypothetically had

7 not done them, and let's say she never got

8 any surgeries on her left eye at all, what

9 would be her vision today --

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 112, Line 11

11 Q. -- in her lifetime?

Witness_ Claes Dohlman, M.D., Ph.D. -: 112:15 - 113:4

15 A. I can, I can say with certainty that we

16 would be at the most light perception only,

17 possibly no light perception.

18 Q. Okay.

19 A. One cannot leave an open eye for any length

20 of time without the severe risk of retinal

21 detachment and destruction of the eye,

22 collapse of the eye.

23 Q. Let me see if I have it right.

24 You are certain that had she never

25 had operations on her left eye, her vision 

00113

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1 would have been worse than counting

2 fingers, worse than hand motion, and light

3 perception at best?

4 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 113:8 - 113:15

8 Q. Your answer?

9 A. Yes.

10 Q. Okay. Now, let's go to the next picture,

11 sir. It is Exhibit 207. And it is taken

12 on nine, on September 12th of 2007.

13 And that is about nine days before

14 your second surgery. Tell us what we see

15 here, sir, please.

Witness_ Claes Dohlman, M.D., Ph.D. -: 113:18 - 116:6

18 A. I see a blanching of the corneal tissue

19 around the keratoprosthesis.

20 Q. Which image should I hone in on, please.

21 Give me a number.

22 A. Yes.

23 Q. Which number?

24 A. For instance, any of them, for instance,

25 six. 

00114

1 Q. Okay. And what do you see here about nine

2 days before your second operation, please,

3 sir?

4 A. And there is, there is a blanching of the

5 tissue around here. And that blanching

6 means that there are no, no blood vessels.

7 There are blood vessels here, there are

8 blood vessels out here, but there are no

9 blood vessels here. And this means that

10 the whole tissue is necrotizing,

11 necrotizing meaning that it's sort of

12 nonviable. There are no cells. It

13 doesn't, it doesn't live. It just sits

14 there waiting to be, fall apart,

15 essentially.

16 Q. Does necrosis mean --

17 A. It was alarming.

18 Q. Does necrosis mean death?

19 A. Yes.

20 Q. Does that --

21 A. Cell death and breakdown of the tissue.

22 Q. When you said this necrotizing process was

23 alarming, what do you mean?

24 A. That necrosis, meaning that it's nonviable,

25 not vascularized, there are no blood 

00115

1 vessels and no life in the tissue. And it

2 is being digested away, melted away by

3 enzymes. And it is a predictably downhill

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4 course after that.

5 And that must have been the reason

6 why I decided to do the whole thing over

7 again, including the donor cornea.

8 Q. Okay. And show us again, please, visually

9 where this blanching is or this evidence of

10 the dying process or the necrotizing

11 process you told us about, please.

12 A. So everything that is white here means that

13 there are no blood vessels in it. And, and

14 that is a sitting duck for just total

15 disintegrations sooner or later.

16 Q. Now, I think I see a ring right there.

17 Isn't that the -- do I see the ring?

18 A. No. That, that is the edge of the front

19 plate.

20 Q. Okay.

21 A. It is -- I don't -- I don't think that you

22 see the ring.

23 Q. I see. So that circle that we see there is

24 the edge of the front plate of her K-Pro?

25 A. Yes. 

00116

1 Q. Thank you, sir. Now, let's go to Exhibit

2 208. And this, Exhibit 208, was done on

3 September 19, 2007, which is two days

4 before your second eye operation.

5 Tell us what we see here, please,

6 sir.

Witness_ Claes Dohlman, M.D., Ph.D. -: 116:18 - 119:20

18 Q. Yes.

19 A. September '07, the 19th. She had a

20 pressure --

21 Q. Okay.

22 A. -- in the eye.

23 Q. Tell us what date you are talking about

24 now, please, sir.

25 A. Well, for instance, three. Number three 

00117

1 here.

2 Q. Okay. And tell us on September 19th --

3 A. Here, September 19th.

4 Q. Okay. What --

5 A. It is not so much a question of what we see

6 here, which hasn't changed much.

7 Q. Okay.

8 A. But the fact that she has had episodes of

9 low pressure, which she noticed herself.

10 And I measured the pressure that was close

11 to zero and that was since that morning.

12 And that was the fifth episode of collapse

13 of the eye, meaning leak; and therefore,

14 the pressure goes down.

15 Q. Okay.

16 A. So and the Sidell, which is a test for

17 leak, was positive. And this actually

18 happened to be not around the stem this

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19 time, but out in the periphery, the

20 periphery of the graft.

21 Q. Okay.

22 A. And therefore, I decided that I had to do

23 the whole thing again. It was just too

24 dangerous. She had had five episodes of

25 very soft eye, meaning leak. 

00118

1 Q. Okay. Explain to us what you meant by five

2 episodes of either low pressure in the eye

3 or leak in the eye.

4 What does that mean?

5 A. Well, she noticed herself, she could feel

6 the pressure. And when the vision dims,

7 then she realizes that something is not

8 right; so then she palpates the globe and

9 finds that it is zero, totally without

10 pressure. And that has only one meaning

11 and that is there has been a leak. And but

12 it has fluctuated evidently, but she had

13 five such episodes. And during those

14 episodes, and now it's we're talking about

15 a melt out in a more periphery of the

16 graft, and epithelium can wander in and

17 cause an epithelialized fistula and then

18 you are in for endless trouble.

19 Q. Okay. Is that what occurred? Did she have

20 an epithelialized, epithelialized fistula?

21 A. Most, most likely.

22 Q. Okay. Why -- strike that.

23 Is the fact that you do a Boston

24 K-Pro commonly result in pressure going

25 down in the eye? 

00119

1 MR. COSGROVE: Objection. Form.

2 Foundation. Calls for expert testimony.

3 Beyond the scope of --

4 MR. JENSEN: Better question.

5 Q. Is pressure going down in the eye a common

6 complication after a Boston K-Pro surgery?

7 MR. COSGROVE: Same objection.

8 A. No, not at all. As a rule, the other

9 categories, it rarely happens, very rarely.

10 But in the autoimmune diseases,

11 Stevens-Johnson, entirely different.

12 Q. Okay. And is Stevens-Johnson syndrome -- I

13 will ask you the question again.

14 In SJS eyes, is pressure going

15 down a common complication after a Boston

16 K-Pro surgery?

17 MR. COSGROVE: Same objection.

18 A. Yes.

19 Q. Why?

20 A. I wish I knew.

Witness_ Claes Dohlman, M.D., Ph.D. -: 116:19 - 118:21

19 A. September '07, the 19th. She had a

20 pressure --

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21 Q. Okay.

22 A. -- in the eye.

23 Q. Tell us what date you are talking about

24 now, please, sir.

25 A. Well, for instance, three. Number three 

00117

1 here.

2 Q. Okay. And tell us on September 19th --

3 A. Here, September 19th.

4 Q. Okay. What --

5 A. It is not so much a question of what we see

6 here, which hasn't changed much.

7 Q. Okay.

8 A. But the fact that she has had episodes of

9 low pressure, which she noticed herself.

10 And I measured the pressure that was close

11 to zero and that was since that morning.

12 And that was the fifth episode of collapse

13 of the eye, meaning leak; and therefore,

14 the pressure goes down.

15 Q. Okay.

16 A. So and the Sidell, which is a test for

17 leak, was positive. And this actually

18 happened to be not around the stem this

19 time, but out in the periphery, the

20 periphery of the graft.

21 Q. Okay.

22 A. And therefore, I decided that I had to do

23 the whole thing again. It was just too

24 dangerous. She had had five episodes of

25 very soft eye, meaning leak. 

00118

1 Q. Okay. Explain to us what you meant by five

2 episodes of either low pressure in the eye

3 or leak in the eye.

4 What does that mean?

5 A. Well, she noticed herself, she could feel

6 the pressure. And when the vision dims,

7 then she realizes that something is not

8 right; so then she palpates the globe and

9 finds that it is zero, totally without

10 pressure. And that has only one meaning

11 and that is there has been a leak. And but

12 it has fluctuated evidently, but she had

13 five such episodes. And during those

14 episodes, and now it's we're talking about

15 a melt out in a more periphery of the

16 graft, and epithelium can wander in and

17 cause an epithelialized fistula and then

18 you are in for endless trouble.

19 Q. Okay. Is that what occurred? Did she have

20 an epithelialized, epithelialized fistula?

21 A. Most, most likely.

Witness_ Claes Dohlman, M.D., Ph.D. -: 119:14 - 119:16

14 In SJS eyes, is pressure going

15 down a common complication after a Boston

16 K-Pro surgery?

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Witness_ Claes Dohlman, M.D., Ph.D. -: 121:1 - 121:4

1 Q. When approximately, in relation to your

2 four surgeries that is, were these five

3 episodes of Karen, of that pressure going

4 down in Karen's eyes?

Witness_ Claes Dohlman, M.D., Ph.D. -: 121:7 - 121:8

7 A. Just before the surgery on September 21,

8 '07.

Witness_ Claes Dohlman, M.D., Ph.D. -: 121:11 - 121:15

11 What were the most biggest

12 problems with Karen's eyes that led to this

13 second surgery? Was it low pressure? Was

14 it this death or necrotizing process, or

15 what was it?

Witness_ Claes Dohlman, M.D., Ph.D. -: 121:18 - 122:17

18 A. The low pressure means that the eye is

19 open. There is a leak to the outside. And

20 if that is left alone, sooner or later in

21 these cases we would end up with an

22 irreparable retinal detachment and loss of

23 the eye, loss of vision, possibly light

24 perception remaining but not more.

25 Q. Okay. Then you did the surgery two days 

00122

1 after this 208. Let's go to 209. And this

2 is in January of 2008, so about four months

3 after your second surgery.

4 And tell us what we see there,

5 please, Doctor.

6 A. It looks pretty good to me. There is a

7 little blanching.

8 Q. Which image should I focus on, please, sir?

9 A. You can say six.

10 Q. Okay. And tell us what we see there. I

11 will turn the light off. Hold on.

12 A. It is a little blanched here where you see

13 the white. There are no vessels and no --

14 the normal redness that you can see up

15 here, and that is possibly a little

16 disconcerting. But I think she did well at

17 that time.

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Witness_ Claes Dohlman, M.D., Ph.D. -: 123:4 - 123:10

4 Q. And this would have been taken two days

5 before your second K-Pro on March 26th,

6 sir. So this is two days before your third

7 operation.

8 A. Correct.

9 Q. Tell me what you see there that is

10 relevant, sir, please.

Witness_ Claes Dohlman, M.D., Ph.D. -: 123:13 - 125:23

13 A. It is not so much what one can see because

14 one really cannot see it well on the

15 photos. But she did have a clear melt

16 around the stem this time and --

17 Q. Understanding you can't see it well in the

18 photos, just kind of give us an idea of

19 what this is in the eye and which picture

20 we should look at, please, sir.

21 A. We can look at seven, for instance.

22 Q. Okay.

23 A. And I have a feeling that there is around

24 here, around here that tissue has

25 disappeared; and therefore, there is a 

00124

1 leak.

2 Q. Is that a corneal melt, sir?

3 A. I think so.

4 Q. Okay.

5 A. Next to the stem.

6 Q. Yes, sir.

7 A. And that left us with no other option than

8 to repeat it.

9 Q. Okay.

10 A. Repeat the procedure.

11 Q. Your first post-op picture after your third

12 eye surgery is Exhibit 211, and it is dated

13 in April of '08, which is about a month

14 post-op.

15 Please tell us what we see there,

16 sir.

17 A. Here we look at a different appearance

18 because at that time we had solid evidence

19 that titanium backplate was better than a

20 plastic backplate.

21 Q. Is that what we see on the picture, a

22 titanium backplate, sir?

23 A. Yes.

24 Q. Okay. This is still her left eye?

25 A. Still the left eye. 

00125

1 Q. Okay.

2 A. And it looks very solid.

3 Q. What picture should we hone in on, please?

4 A. For instance, seven.

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5 Q. Okay.

6 A. I don't see, I don't see anything wrong

7 with that at all. There is some healthy

8 vascularization out here and we see in

9 front of the titanium backplate the cornea

10 is fine, as we would expect at that time so

11 soon after surgery.

12 But the titanium backplates are

13 better. That is the only material that I

14 am using nowadays as a backplate.

15 Q. Okay. Let me show you a picture of Karen

16 that was taken, of her eye taken after her

17 tenth eye surgery at Harvard, before her

18 eleventh eye surgery which was at Beth

19 Israel, a non-professional picture.

20 And those were her eyes there.

21 Can we see on her left eye there the

22 corneal graft? Can you see it, Doctor

23 Dohlman?

Witness_ Claes Dohlman, M.D., Ph.D. -: 126:2 - 126:13

2 A. I -- I cannot see the details here.

3 Q. Okay.

4 A. It looks a little red, but otherwise I

5 cannot see.

6 Q. What is -- do you know, can you tell what

7 the white material here is I am pointing

8 out? What is that?

9 A. It is sort of roped and hardened mucous.

10 Q. Okay.

11 A. And mucous forming in an inflamed eye and

12 then lack of tears and then it is sort of

13 hardness.

Witness_ Claes Dohlman, M.D., Ph.D. -: 127:2 - 128:2

And then let's go to the next

3 picture which is 214. And 214 is taken

4 June 13, 2008, which is the day before your

5 fourth eye surgery.

6 Please tell us what we see here

7 the day before your fourth eye surgery

8 which was your re-suturing of her corneal

9 graft.

10 A. Here has been a --

11 Q. Number seven.

12 A. For instance, seven, yes. On the lower

13 portion here, it has necrotized here so the

14 tissue is mushy and --

15 Q. So again, that is a death process we

16 discussed? The necrotizing meaning it is a

17 death process?

18 A. Yes.

19 Q. Okay.

20 A. Yes. And it has not healed in well. It

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21 has not vascularized well and it is just

22 breaking down. And I believe that this is

23 when we decided we had to try to re-suture.

24 That is 6/14.

25 Q. And you performed your surgery -- you 

00128

1 performed your surgery the day after those

2 pictures were taken?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 128, Line 4

4 Q. Is that correct, sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: 128:6 - 128:19

6 Q. I will show you your operative report here,

7 sir. It is on the screen.

8 A. Yes.

9 Q. Okay.

10 A. And there was actually a leak also down

11 below where that disintegrating tissue

12 existed.

13 Q. Back to this picture you showed us the day

14 before your fourth eye surgery, Doctor

15 Dohlman.

16 What percent certain are you that

17 this necrotizing death process, corneal

18 melt was as a result of Karen's

19 Stevens-Johnson syndrome TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 128:23 - 129:8

23 A. I would say, of course.

24 Q. Okay.

25 A. There is no question, 100 percent certain. 

00129

1 Q. Thank you, sir. Okay. What are cataracts,

2 Doctor Dohlman?

3 A. I beg your pardon?

4 Q. What are cataracts, please, sir?

5 A. Cataracts are clouding of the natural

6 crystalline lens.

7 Q. Are cataracts a common complication of SJS

8 TEN eyes that undergo K-Pro's?

Witness_ Claes Dohlman, M.D., Ph.D. -: 129:11 - 129:21

11 A. Yes.

12 Q. Okay.

13 A. If the situation is so severe and so

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14 advanced so that the K-Pro is indicated,

15 they usually have a cataract also. And

16 this was, in her case, the lens was taken

17 out early, at the earliest surgery.

18 Q. Okay. Based upon your treatment and

19 evaluation of Karen, were Karen's cataracts

20 caused by her SJS and TEN and/or her K-Pro

21 surgeries that she got for her SJS or TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 129:24 - 130:4

24 A. Well, this is a nonspecific complication

25 but easily explained by the events that 

00130

1 preceded her surgery at that time. The

2 cataract was taken out in October '06.

3 Q. Exhibit 136, sir, is a publication by

4 Doctor Zerbe, Z-E-R-B-E.

Witness_ Claes Dohlman, M.D., Ph.D. -: 130:11 - 130:16

11 Q. And while you are --

12 A. Et al.

13 Q. And while you are not a listed author on

14 this 2006 publication, it was by the Boston

15 K-Pro Study Group, in which you are a part.

16 Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 130:18 - 131:6

18 A. Yes. I am part of it in the sense that we

19 send in our cases for evaluation. We do

20 that on a constant basis. But at that time

21 it was in my interest to distance myself

22 from this particular publication. I wanted

23 it, our device to be evaluated

24 independently from the outside, and this

25 was one of several such publications of 

00131

1 that kind.

2 Q. Yes, sir. And on the second to last page

3 they list the study, the Boston K-Pro Study

4 Group, and they don't list them

5 alphabetically, and they list you first.

6 Do you see that, sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: 131:8 - 131:12

8 A. Well, that was nice of them. But we had

9 the largest, largest material so that it

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10 probably was because of that.

11 Q. Yes, sir. And I would like to refer your

12 attention to 17, 1782, Table 7.

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 131, Line 16

16 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 131:25 - 132:2

Generally, this study is 

00132

1 about Boston K-Pro and how patients are

2 doing with it. Fair?

Witness_ Claes Dohlman, M.D., Ph.D. -: 132:4 - 132:8

4 A. Yes.

5 Q. Okay.

6 A. Yes.

7 Q. Table 7 lists occurrences of nonsurgical

8 post-op complications. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 132:10 - 132:15

10 A. Correct.

11 Q. What I would like you to do, please, sir,

12 is just go through that list. And if Karen

13 had such a nonsurgical post-op

14 complications, could you, please, identify

15 it for us.

Witness_ Claes Dohlman, M.D., Ph.D. -: 132:18 - 132:20

18 Q. Please take a look at Table 7. And if

19 Karen had one of these nonsurgical post-op

20 complications, please identify it for us.

Witness_ Claes Dohlman, M.D., Ph.D. -: 132:25 - 133:20

25 A. It would be listed under Other. 

00133

1 Q. Okay. And then --

2 A. And particularly --

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3 Q. You identify it, and I will highlight it,

4 please.

5 A. Wound leak.

6 Q. Yes, sir.

7 A. Peripheral corneal thinning.

8 Q. Yes, sir.

9 A. Corneal melting.

10 Q. Yes, sir.

11 A. Wound dehiscence.

12 COURT REPORTER: Wound what?

13 THE WITNESS: Dehiscence,

14 D-E-H-I-S-C-E-N-C-E. That's it.

15 Q. Okay. What percent certain are you that

16 Karen Bartlett's wound leak, peripheral

17 corneal thinning, corneal melting and wound

18 dehiscence are as a result of and caused by

19 her SJS and TEN or the surgeries she had to

20 attempt to restore her vision?

Witness_ Claes Dohlman, M.D., Ph.D. -: 133:22 - 134:2

22 Foundation. Compound. Calls for expert

23 testimony. Assumes facts. Misleading.

24 A. There is no question about the correlation

25 in my mind. 

00134

1 Q. Are you 100 percent certain?

2 A. 100 percent certain.

Witness_ Claes Dohlman, M.D., Ph.D. -: 134:4 - 134:7

4 Q. Now, what I would like to refer your

5 attention to, sir, is a paper that you were

6 a co-author of in 2001, whose lead author

7 was Doctor Yaghouti.

Witness_ Claes Dohlman, M.D., Ph.D. -: 134:19 - 135:3

19 Q. Is that a 2001 publication that you

20 co-authored, sir?

21 A. That is correct.

22 Q. Okay. And this told us or reported how

23 long, on the fourth page it has a chart of

24 percentage of eyes retaining a vision of

25 between 20/20 and 2200 for a given period 

00135

1 of years based on what their preoperative

2 condition was.

3 Is that correct, sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: 135:6 - 135:15

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6 A. Table 2?

7 Q. Yes, sir.

8 A. Yes.

9 Q. Okay. And for example, it lists Graft

10 Failure and the Pemphigoid that you

11 discussed, and it also lists Chemical Burns

12 and it also lists as a fourth category

13 Stevens-Johnson syndrome.

14 Correct, sir?

15 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 135:17 - 135:22

17 Q. And do you agree this reported, this study

18 that you co-authored, that Stevens-Johnson

19 syndrome had the worst presentation; and

20 that is at four, that at four and a half

21 years, zero percent had vision that was

22 better than legal blindness. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 136:1 - 136:4

1 A. That is correct.

2 Q. Okay. All -- even chemical burns had a

3 better course after operations than

4 Stevens-Johnson syndrome. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 136:6 - 136:20

6 A. Correct.

7 Q. Are you familiar, sir, with the Bersudsky

8 2001 publication entitled --

9 A. Yes.

10 Q. -- "The Profile of Repeated Corneal

11 Transplantation"?

12 A. Yes.

13 Q. Okay. That is Exhibit No. 132. And it

14 reported on page three what the expectancy

15 was for patients who were followed of how

16 long their grafts would last after a first

17 re-graft, which would mean a second

18 operation, or a subsequent re-graft which

19 would mean a third operation.

20 Correct, sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: 136:23 - 137:7

23 A. Right.

24 Q. And your answer, sir?

25 A. Correct. 

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00137

1 Q. And these grafts that they are referring

2 to, those are K-Pro's, correct?

3 A. No.

4 Q. Okay. What grafts --

5 A. No, no.

6 Q. What grafts are they?

7 A. Standard corneal transplant.

Witness_ Claes Dohlman, M.D., Ph.D. -: 137:10 - 137:13

10 This graph reports from the study

11 that for standard corneal transplants, non

12 K-Pro surgeries, what the expected course

13 of those such surgeries are. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: 137:16 - 138:1

16 A. Correct. That is an outcome study for

17 standard corneal transplantation in Israel.

18 And it is not the first graft, but it is

19 the second graft, which is a thin line, and

20 the thick line is subsequent grafts.

21 Q. So for standard corneal transplants, non

22 K-Pro, this reports that when you get your

23 third operation, meaning your second

24 re-graft, at five years there is a zero

25 expectancy that you would still be able to 

00138

1 retain such a graft. Correct?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 138, Line 4

4 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 138:7 - 138:8

7 Q. Well, first of all, is that correct, my

8 question?

Witness_ Claes Dohlman, M.D., Ph.D. -: 138:10 - 138:20

10 A. That is correct. But this has -- this is

11 correct, but it has very little if anything

12 to do with Stevens-Johnson because what

13 they did, they had a -- they had all the

14 cases that they found, and the number with

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15 severe Stevens-Johnson or autoimmune

16 diseases were just a couple of cases out of

17 70 something, so and they were not

18 separated out. And you would think that

19 they would probably be the first to go, but

20 that doesn't -- it is not shown here.

Witness_ Claes Dohlman, M.D., Ph.D. -: 139:21 - 139:24

21 You are listed here as amongst the

22 22 surgeons that contributed to this poster

23 presentation.

24 Correct, sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: 140:1 - 140:20

1 A. Oh, I see down there. Okay. Oh,

2 absolutely.

3 Q. Okay. And then --

4 A. Yes, yes.

5 Q. Thank you, sir. Do you know whether or not

6 the results from this poster presentation

7 have been published yet, sir?

8 A. One early publication has been published

9 in, I believe, in Ophthalmology. And then

10 there have been follow-ups.

11 And it is interesting that the

12 Stevens-Johnson, the autoimmune category is

13 dropping way down. The others are having a

14 very nice retention.

15 Q. Okay. And --

16 A. Let me see here.

17 Q. And the purpose of this poster

18 presentation, it says right here under

19 Purpose --

20 A. Yes. You can see that already here.

Witness_ Claes Dohlman, M.D., Ph.D. -: 140:21 - 141:2

21 Q. Hold on, Doctor. Let me get the questions

22 out and then you can give answers.

23 A. All right.

24 Q. Was the purpose of this presentation to

25 report the causes of failure to retain the 

00141

1 Boston K-Pro?

2 A. Correct.

Witness_ Claes Dohlman, M.D., Ph.D. -: 141:5 - 141:8

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5 Q. Okay. And did this report that patients

6 with autoimmune disease had the poorest

7 K-Pro retention mostly due to corneal

8 melting around the implant --

Witness_ Claes Dohlman, M.D., Ph.D. -: 141:11 - 141:12

11 Q. Was that the conclusion, Doctor.

12 A. That is correct.

Witness_ Claes Dohlman, M.D., Ph.D. -: 141:15 - 142:3

15 A. That is correct.

16 Q. Okay. Is that what happened to Karen

17 Bartlett?

18 A. Yes.

19 Q. And Karen Bartlett had --

20 A. She was in that category.

21 Q. Yes, thank you.

22 A. That lower group that separates itself from

23 the other groups.

24 COURT REPORTER: The lower group

25 that what? 

00142

1 THE WITNESS: That separates,

2 separates itself from the other groups so

3 markedly.

Witness_ Claes Dohlman, M.D., Ph.D. -: 142:16 - 143:1

16 Q. Okay. And then this poster presentation

17 references these two figures. And it says

18 Figures 1 and 2 demonstrate repeat corneal

19 transplant survival.

20 And that is the Boston K-Pro

21 survival, correct, sir?

22 A. Correct. And that is, the first is a

23 quotation from the Israeli study.

24 Q. The one we just --

25 A. The one we just talked about. 

00143

1 Q. Yes, sir. And that is Bersudsky. Okay.

Witness_ Claes Dohlman, M.D., Ph.D. -: 143:15 - 145:5

15 Q. And then Figure 2, sir, is what, please?

16 A. I beg your pardon?

17 Q. What is Figure 2?

18 A. Yes.

19 Q. What is it, please?

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20 A. Survival of the Boston K-Pro Stratified by

21 Preoperative Diagnosis.

22 Q. Okay. And what -- tell us what that means,

23 please, sir.

24 A. This is the so-called Kaplan-Meyer Survivor

25 Curve, meaning that the so-called other, 

00144

1 plus the chemical burns, they are retained

2 very well. Those are the two lines up

3 there.

4 Q. Okay.

5 A. And the third group is the small but

6 important autoimmune category, and this is

7 the lower group that falls down here, way

8 down.

9 Q. Okay.

10 A. And subsequent data are reinforcing this

11 very markedly --

12 Q. Okay.

13 A. -- so that the autoimmune diseases are

14 going way down.

15 Q. First let me ask, so this, this blow up

16 here of Figure 2 is the same Figure 2 that

17 is on the first page in smaller form.

18 Correct?

19 A. Yes.

20 Q. Okay. And let's take a look at this bigger

21 one. Okay.

22 So survival probability is on this

23 axis, and this would be 100 percent, and

24 this would be 20 percent. Correct?

25 A. Correct. 

00145

1 Q. Okay. And then what is on this axis is

2 months, right, so --

3 A. Correct.

4 Q. -- 48 months is five years or 48 months is

5 four years, right?

Witness_ Claes Dohlman, M.D., Ph.D. -: 145:7 - 145:12

7 A. Yes.

8 Q. Okay. So is what this study reported from

9 the 23 surgeons, one of which was you, that

10 if you have an autoimmune disease like SJS,

11 that at more than four years the retention

12 was about 25 percent?

Witness_ Claes Dohlman, M.D., Ph.D. -: 145:18 - 145:22

18 A. Correct.

19 Q. Okay. And is what that means is you have a

20 75 percent chance after four years of not

21 being able to keep in the original K-Pro

22 from your first surgery?

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Witness_ Claes Dohlman, M.D., Ph.D. -: Page 145, Line 25

25 A. Correct. 

Witness_ Claes Dohlman, M.D., Ph.D. -: 146:10 - 146:18

10 Q. Okay. Is there any study that would tell

11 us or that reports, just case series, case

12 report, that tells us what percent of SJS

13 TEN patients with ocular surface diseases

14 from SJS and TEN keep K-Pro's how long --

15 strike that.

16 Is there any study or report or

17 case series that tells us how many K-Pro

18 surgeries SJS and TEN patients get?

Witness_ Claes Dohlman, M.D., Ph.D. -: 146:20 - 147:5

20 Foundation. Calls for expert testimony.

21 A. Well, the Kaplan-Meyer --

22 COURT REPORTER: Kaplan-Meyer?

23 A. Kaplan, K-A-P-L-A-N, hyphen, M-E-Y-E-R,

24 presentation technique shows just that

25 because it shows at which time was there a 

00147

1 loss.

2 So here, for instance, here was

3 one, here was one, here was one, here was

4 one, here was one, and here was one and

5 here was one. They are not --

Witness_ Claes Dohlman, M.D., Ph.D. -: 147:9 - 148:6

9 Q. Well, your answer? Go ahead, Doctor.

10 A. These are not, were not that many cases at

11 this time. There are many many more up

12 here.

13 But the problem, we can go to the

14 Sayegh and Ang study. There we can see

15 with a little better with 16 cases --

16 Q. Okay.

17 A. -- of Stevens-Johnson.

18 Q. I am going to go there next. But before we

19 do, look at the screen, please, Doctor.

20 Okay.

21 Tell us every time it drops here,

22 what does that mean, sir?

23 A. That means that one case is dropping out,

24 meaning, meaning it has to be replaced.

25 Q. I see. So does that mean that if we count, 

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00148

1 there is one, two, three, four, five, six,

2 seven dropouts?

3 A. And seven, yes.

4 Q. And does a dropout mean someone who needed

5 a K-Pro replacement?

6 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 149:12 - 149:17

12 Q. Yes. What do you think best resulted in or

13 why was there better results in this 2008

14 series of 15 patients than, for example,

15 the 2001 series from Yaghouti which had --

16 A. Seven.

17 Q. --many -- seven SJS patients?

Witness_ Claes Dohlman, M.D., Ph.D. -: 149:19 - 150:18

19 A. The reason was, number one, that we have

20 eliminated infections. And that has been a

21 dramatic improvement for the whole, for the

22 whole field. Previously, virtually all

23 severe cases succumbed to endophthalmitis,

24 meaning infection of the inside of the eye

25 or loss of the eye. But now with our 

00150

1 prophylactic antibiotics schedules,

2 particularly the introduction of

3 Vancomycin, has been enormously effective.

4 And so we haven't, for ten years we haven't

5 had a single acute bacterial

6 endophthalmitis while treated with

7 Vancomycin. They have been dramatic. So

8 that has been one, one, one reason.

9 The other reason is we are more

10 aware of the danger of glaucoma in these

11 cases. Karen Bartlett did not have

12 glaucoma but, but, but other people had.

13 And so that together brought five-year

14 results in our hands from zero to 50

15 percent.

16 Q. And here is your results on page 441,

17 correct, sir, and there is the graph that

18 shows them?

Witness_ Claes Dohlman, M.D., Ph.D. -: 150:20 - 151:1

20 A. Yes.

21 Q. Okay.

22 A. That is correct.

23 Q. And you actually compared these results to

24 the Yaghouti 2001 publication, which is

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25 here that we have been discussing, correct? 

00151

1 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 151:3 - 151:5

3 Q. And here in the blue and red lines were the

4 results from this study, correct?

5 A. Correct.

Witness_ Claes Dohlman, M.D., Ph.D. -: 151:7 - 151:15

7 Q. And in comparing this group of 15 patients

8 to the Yaghouti group of seven patients and

9 the surgeries involved, you were comparing

10 your own surgeries to your own prior

11 surgeries because you had --

12 A. Correct.

13 Q. -- all the surgeries in the Yaghouti series

14 and you did all the surgeries in this

15 series?

Witness_ Claes Dohlman, M.D., Ph.D. -: 151:17 - 151:21

17 A. That is correct.

18 Q. Let me ask you, sir, do you think that from

19 the 2001 series of patients to this 2008

20 series of patients that your surgical

21 techniques improved?

Witness_ Claes Dohlman, M.D., Ph.D. -: 151:25 - 152:4

25 A. Not really the surgical technique. But 

00152

1 postoperative treatment, I would say.

2 Q. Okay. Has endophthalmitis resulting in

3 loss of the eye due to infection been

4 virtually eradicated by Vancomycin?

Witness_ Claes Dohlman, M.D., Ph.D. -: 152:7 - 153:10

7 A. That is correct. And that has at long last

8 been published just this month in a large

9 number of cases.

10 COURT REPORTER: What?

11 A. The effect of Vancomycin in preventing

12 infection after keratoprosthesis has been

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13 published this month. Durand, our

14 infectious disease specialist, is the first

15 author and me, all my cases. And the net

16 effect that we had not a single, for ten

17 years, while on Vancomycin, not a single

18 acute bacterial endophthalmitis or loss of

19 the eye. We cultured what is technically

20 called slow growing microbacterium from one

21 disintegrating eye but it can be also

22 virtually neglected. But so it has

23 enormous, enormous effect, preventive

24 effect.

25 Q. I spoke with you earlier, Doctor Dohlman, 

00153

1 about timeline up to first surgeries. Now

2 I would like to speak with you, sir, if I

3 might, about timelines after surgeries.

4 My question, sir, is does the

5 ocular surface disease caused by SJS when

6 it is significant enough to result in legal

7 blindness or worse, how ever you want to

8 teach us that that disease is defined, does

9 it ever get cured or go away, the physical

10 results of SJS or TEN?

Witness_ Claes Dohlman, M.D., Ph.D. -: 153:14 - 154:2

14 A. No, it doesn't really go, go completely

15 away. But I have observed that many times

16 people who had had Stevens-Johnson episode,

17 ten, 20, 30 years earlier, they have a more

18 benign course than somebody like Karen

19 Bartlett, who had the episode the year

20 before.

21 Q. Okay.

22 A. They are more acutely inflamed.

23 Q. Can the ocular surface disease caused by

24 SJS and TEN when it is significant to

25 result in legal blindness last 10 or 20 

00154

1 years despite the best treatments known to

2 modern medicine?

Witness_ Claes Dohlman, M.D., Ph.D. -: 154:6 - 154:10

6 A. Absolutely.

7 Q. Can the ocular surface disease and

8 blindness when it's caused by SJS when it's

9 significant enough to cause legal

10 blindness, or worse, be permanent?

Witness_ Claes Dohlman, M.D., Ph.D. -: 154:12 - 154:15

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12 A. Again, absolutely.

13 Q. Okay. You've been working on K-Pro's since

14 your first series of patients was published

15 in 1974. Correct, sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: 154:18 - 154:21

18 A. Correct.

19 Q. Okay. You've been publishing on K-Pro's

20 and their potential use for SJS since what

21 year, sir, approximately?

Witness_ Claes Dohlman, M.D., Ph.D. -: 154:24 - 155:17

24 A. I think really Yaghouti was the first

25 meaningful publication and -- 

00155

1 Q. It's the one we have been discussing?

2 A. We just discussed that, yes.

3 Q. Yes, sir.

4 A. And Ang, sir, was the second.

5 COURT REPORTER: And who?

6 THE WITNESS: Ang, A-N-G, Ang is

7 from Singapore.

8 Q. And when was that published, sir?

9 A. A year ago.

10 Q. Okay. And the title of it?

11 A. You had it there. It was Sayegh, Ang

12 actually.

13 Q. Yes. Sayegh, Ang, got it, which I have

14 been referring to as your 2008 publication?

15 A. Yes.

16 Q. You are the senior listed author, correct?

17 A. Yes. All my cases.

Witness_ Claes Dohlman, M.D., Ph.D. -: 155:19 - 155:24

19 Q. So is it correct to state, sir, that the

20 two biggest analyses of K-Pro treatment and

21 SJS were 2001, that you were a co-author

22 of; and in 2008, that you were a co-author

23 of; and both times you did 100 percent of

24 the operations?

Witness_ Claes Dohlman, M.D., Ph.D. -: 156:2 - 156:10

2 A. That is correct. But there is one larger

3 study and that is, that comes from

4 Barcelona, and it is Temprano is the senior

5 surgeon there. I don't have the -- this

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6 came out about a year ago.

7 And it shows rather similar

8 results in Stevens-Johnson, but in more

9 cases than what we had, to what we had with

10 Sayegh and Ang.

Witness_ Claes Dohlman, M.D., Ph.D. -: 156:22 - 157:1

22 Q. In cases where the person does not have SJS

23 or an autoimmune disease, which is SJS as

24 you have taught us, have the results of

25 your Boston K-Pro provided vision to many 

00157

1 people who would otherwise be blind?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 157, Line 5

5 A. That is correct. In the --

Witness_ Claes Dohlman, M.D., Ph.D. -: 157:7 - 157:10

7 How effective and good is the

8 Boston K-Pro in cases unlike Karen's, where

9 people don't have SJS or an autoimmune

10 disease, please?

Witness_ Claes Dohlman, M.D., Ph.D. -: 157:12 - 158:9

12 A. Our, our internal results unpublished is

13 that the non-autoimmune disease, in

14 non-severe chemical burn cases, sort of the

15 standard bulk of corneal failures for

16 scarring and so on, which on a worldwide

17 basis, I am sure, would be at least 98

18 percent of all corneal blindness. There

19 they can, can do wonderfully well. There

20 the problem is more than in advanced

21 disease that could happen, glaucoma

22 occurring and/or even retina problems and

23 so on. But not the cornea, the cornea we

24 can replace now.

25 Q. Okay. 

00158

1 A. It is an entirely different shift in, a

2 paradigm shift in the treatment.

3 Q. To your knowledge, Doctor Dohlman, based

4 upon your care and treatment of Karen

5 Bartlett, did she have any preexisting eye

6 conditions or other eye conditions which

7 predisposed her to having these corneal

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8 melts and adhesions and leaks which

9 resulted in all these operations?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 158, Line 11

11 Q. And her blindness?

Witness_ Claes Dohlman, M.D., Ph.D. -: 158:14 - 158:17

14 A. Not to my knowledge. She had LASIX, but

15 that doesn't lead to any Stevens-Johnson

16 symptoms and it would have been totally

17 irrelevant in this situation.

Witness_ Claes Dohlman, M.D., Ph.D. -: 160:1 - 160:7

1 Did you and your colleagues at

2 Harvard start using Remicade to attempt to

3 save Karen's vision?

4 A. Yes.

5 Q. What's Remicade? What is Remicade?

6 A. It is technically an antagonist blocker of

7 tumor necrosis alpha.

Witness_ Claes Dohlman, M.D., Ph.D. -: 160:13 - 160:20

13 THE WITNESS: Factor. Tumor

14 necrosis factor alpha. And which is an

15 ugly component causing inflammation. And I

16 have a couple of spectacular results in

17 Stevens-Johnson, other patients than Karen.

18 Q. Approximately how much does Remicade cost

19 per year?

20 A. About 25,000.

Witness_ Claes Dohlman, M.D., Ph.D. -: 161:1 - 161:15

1 Q. Did Karen continue Remicade through now, or

2 did you and your colleagues take her off

3 it?

4 A. We took her off.

5 Q. Why?

6 A. Because I thought that we, we did -- she

7 had some lung symptoms of, asthma-like lung

8 symptoms from before, undoubtedly, in my

9 interpretation, related to Stevens-Johnson

10 because lung problems can occur in

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11 Stevens-Johnson. I had a young lady die

12 from it, from lung complications with

13 Stevens-Johnson, one of my patients. But

14 and then I did not want to push the

15 Remicade under those circumstances.

Witness_ Claes Dohlman, M.D., Ph.D. -: 161:18 - 161:22

18 Q. Understanding that you don't publish in the

19 area of all the things that SJS can cause,

20 is it true that you also told the video

21 technician here today, he's commented that

22 SJS and TEN can cause basically everything?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 161, Line 25

25 A. Yes, almost everything. 

Witness_ Claes Dohlman, M.D., Ph.D. -: 164:7 - 164:19

7 Q. Are all of your opinions, observations, and

8 prognoses, in other words, everything that

9 you saw and did with respect to Ms.

10 Bartlett is contained within this binder.

11 Correct?

12 A. Yes. And, and reasons are not doing this

13 or that are not well spelled out. We don't

14 have the time in the heat of the clinic to

15 go into details. We cannot refer to

16 literature and we cannot -- we just say

17 that this is what we are going to do and

18 it's not a question of explaining exactly

19 why.

Witness_ Claes Dohlman, M.D., Ph.D. -: 165:15 - 166:2

15 Q. Okay. Fair to say that you did not

16 specifically rely upon any of those studies

17 during the course and treatment, your

18 course and treatment of Ms. Bartlett?

19 A. Well, those studies are forming part of my

20 knowledge base and overall Gestalt

21 information of the SJS. And that -- this

22 is how we work and physicians work in

23 general by long-term experience and, and

24 sort of intuition of where to go. But we

25 don't have the time in the clinic to 

00166

1 justify a legal opinion why we do every

2 step this way or that way.

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Witness_ Claes Dohlman, M.D., Ph.D. -: 172:23 - 175:3

23 And my question to you is is Ms.

24 Bartlett's case a hopeless case?

25 A. No. It is a question of nomenclature. I 

00173

1 think when Doctor Chodosh talks about

2 hopeless cases, hopeless cases, hopeless by

3 standard treatment, standard eye treatment.

4 And that is common jargon.

5 But here we can take many cases a

6 bit further; and those who have been

7 previously deemed hopeless, particularly

8 with regard to standard corneal

9 transplantation, we can now tackle with

10 success.

11 Q. Would you agree that Ms. Bartlett was, in

12 fact, very fortunate to have the service of

13 you and your clinic?

14 A. Well, we, we'll see about that ten years

15 from now how much, how much help we have

16 been to her.

17 Q. Mm-hmm. And what is your, based on what

18 you know of her, the course and scope of

19 her treatment up to your fourth eye surgery

20 on her and your intermittent check ins with

21 Doctor Chodosh, what would you say is her

22 prognosis now with respect to her vision?

23 A. I would say that it's highly uncertain.

24 She has reacted with more inflammation,

25 more necrosis, more melts than was 

00174

1 expected, and more than most other

2 Stevens-Johnson cases we have had. So she

3 has been really permanent in terms of her

4 inflammation.

5 Q. Would you say that, with respect to

6 Stevens-Johnson patients, her course has

7 been unique or an outlier?

8 A. Well, not entirely but, but certainly on

9 the, on the very complicated side, yes.

10 Q. All right. Can you identify on a going

11 forward basis if there will be some tipping

12 point or threshold at which it will be able

13 to be determined if her vision will improve

14 or get worse?

15 A. If everything stabilizes and there will be

16 no more melts or very little inflammation

17 in the corneal carrier, then there is hope.

18 But with these repeated melts and leaks,

19 the risk of retinal detachment is very

20 high.

21 Q. Mm-hmm.

22 A. And I have only recently been digging into

23 that topic and I will give a presentation

24 in Slovinia in two weeks on that topic.

25 And we have in Stevens-Johnson a very high 

00175

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1 rate of retinal detachment. And half of

2 them can be repaired, but they, they don't

3 see well.

Witness_ Claes Dohlman, M.D., Ph.D. -: 175:19 - 175:21

19 Q. What is the risk of retinal detachment in

20 SJS cases, Doctor?

21 A. The risk of retinal detachment --

Witness_ Claes Dohlman, M.D., Ph.D. -: 175:25 - 176:11

25 A. A retinal detachment after keratoprosthesis 

00176

1 is very high.

2 Q. How high?

3 A. In Stevens-Johnson, we have, I think, of

4 all the Stevens-Johnson that we have done,

5 I don't remember how many there were, but I

6 think that 40 percent ended up with a real

7 retinal detachment, which is extremely

8 high.

9 Q. For the approximately 60 percent who don't

10 have retinal detachment, can those 60

11 percent be repaired to restored vision?

Witness_ Claes Dohlman, M.D., Ph.D. -: 176:15 - 176:21

15 A. The 60 percent have no retinal detachment.

16 Q. Okay.

17 A. So far.

18 Q. Okay.

19 A. But 40 percent have.

20 Q. And what does that lead to in that you have

21 retinal detachment?

Witness_ Claes Dohlman, M.D., Ph.D. -: 176:24 - 177:14

24 A. When you have the retinal detachment, an

25 attempt is to repair. And one cannot 

00177

1 anatomically repair and put back the retina

2 and reattach it in nearly half the cases of

3 detachment. But and very few see well,

4 very very few.

5 Q. Defining opinions arising or relating to

6 your care and treatment of Karen Bartlett

7 as including any literature that relates to

8 preoperative diagnoses, postoperative

9 retention rates of K-Pro's meaning how long

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10 people can keep them, and complications

11 including corneal melts, did you have all

12 the literature we discussed today in mind

13 in the course of your care and treatment of

14 Karen Bartlett?

Witness_ Claes Dohlman, M.D., Ph.D. -: 177:20 - 178:4

20 A. Yes. If I have the literature in my mind,

21 is that what your question?

22 Q. Yes.

23 A. I think so.

24 Q. Yes. Is it correct to state that you have

25 many opinions about prognosis for patients, 

00178

1 including Karen Bartlett, through the last

2 time you were actively treating her, that

3 you do not write down in your medical

4 record?

Witness_ Claes Dohlman, M.D., Ph.D. -: 178:9 - 178:15

9 A. Of course.

10 Q. Let me ask, why is it true, Doctor, that

11 you don't write down every single opinion

12 you have, specific opinion regarding Karen

13 Bartlett in Karen Bartlett's medical chart?

14 A. In the heat of the battle in the clinic

15 there is simply no time.

Witness_ Claes Dohlman, M.D., Ph.D. -: 179:2 - 179:25

The first document I am going to

3 show you, sir, is I will represent to you

4 is written by Dr. John T. Schulz. If you'd

5 look at the screen, it's probably easier,

6 sir.

7 And Dr. John T. Schulz, I will

8 represent to you, was an attending burn

9 surgeon for Karen at Mass. General. And on

10 August, excuse me, October 6, 2005, here is

11 what he said. I will blow it up.

12 He said, "Karen's bracelet needs

13 to add NSAID Sulindac." And then he said,

14 "The risk of TEN to other meds,

15 parenthetically, probably more than one per

16 million discussed," he says, "Emphasized

17 that she must avoid all NSAID's and that

18 this should be on her Med Alert bracelet."

19 And he said, "Other meds probably okay

20 unless they have chemical structure

21 resembling Sulindac. Any class of meds she

22 tolerated during her admission should be

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23 okay."

24 Did I read that correctly, first

25 of all, Doctor? 

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 180, Line 2

2 A. I think so, yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 180:7 - 180:19

7 A. Yes.

8 Q. Thank you. Okay. The second document is

9 Exhibit 38. And it is seven pages from

10 here at Mass. Eye Ear clinic. And the

11 first one is by Doctor Papaliodis where he

12 lists NSAID's Sulindac. The second one,

13 the Mass. Eye Ear, and it is on 10/31/06,

14 and it says NSAID, it looks like it has got

15 an arrow, it says Sulindac caused

16 Stevens-Johnson syndrome, and it says

17 Sulfa.

18 Do you see that, Doctor?

19 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: 180:24 - 181:6

24 Q. Okay. The third page at Mass. Eye Ear

25 again lists NSAID Sulindac, Stevens-Johnson 

00181

1 syndrome. And that is signed by Doctor

2 Gupta, who you have --

3 A. One of our fellows, yes.

4 Q. And he has done surgeries with you on Karen

5 Bartlett. Correct?

6 A. Yes.

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 181, Line 10

10 A. Correct.

Witness_ Claes Dohlman, M.D., Ph.D. -: 181:16 - 181:24

16 Q. Okay. This document at Mass. Eye Ear says

17 Sulfa, NSAID Sulindac.

18 The next page says NSAID Sulindac,

19 Stevens-Johnson syndrome.

20 The next page says NSAID Sulindac,

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21 and that has got an arrow, and it says

22 caused Stevens-Johnson syndrome. And it

23 has got your name on it, it is dated

24 10/31/06.

Witness_ Claes Dohlman, M.D., Ph.D. -: 182:6 - 182:8

The next page says NSAID

7 Sulindac, Stevens-Johnson syndrome,

8 10/31/06, also signed by Doctor Gupta.

Witness_ Claes Dohlman, M.D., Ph.D. -: 182:11 - 182:14

11 Q. The next page says NSAID Sulindac Sulfa, it

12 says allergies/reactions, NSAID's Sulindac.

13 Do you recognize that signature,

14 sir?

Witness_ Claes Dohlman, M.D., Ph.D. -: 182:17 - 183:3

17 A. Dauger.

18 Q. Okay.

19 A. Mona Dauger, a cornea fellow.

20 Q. Thank you, sir. And the last page on

21 9/28/07, also at Mass. Eye Ear, says

22 allergies, Sulindac, NSAID.

23 My question, sir, is to your

24 knowledge did anyone at Mass. Eye Ear,

25 including yourself, ever reach a conclusion 

00183

1 contrary, let's be clear, to this

2 statement, NSAID's Sulindac caused

3 Stevens-Johnson syndrome?

Witness_ Claes Dohlman, M.D., Ph.D. -: Page 183, Line 6

6 A. No,

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Page 1

Witness_ Nam Heui Kim - Vol. 1.txt: 1:1 - 1:24

UNITED STATES DISTRICT COURT

2 FOR THE DISTRICT OF NEW HAMPSHIRE

3 

4 --------------------------------x

5 KAREN L. BARTLETT and

6 GREGORY S. BARTLETT,

7 Plaintiffs

8 Civil Action

9 vs. No. 08-CV-358-JL

10 

11 MUTUAL PHARMACEUTICAL COMPANY,

12 INC., and UNITED RESEARCH

13 LABORATORIES, INC.,

14 Defendants

15 --------------------------------x

16 

17 

18 VIDEOTAPED DEPOSITION OF NAM HEUI KIM, a witness

19 called by and on behalf of the Plaintiffs, taken

20 pursuant to Federal Rules of Civil Procedure, before

21 Nicole E. Guilbert, a Notary Public in and for the

22 Commonwealth of Massachusetts, at UMass Medical

23 Center, 55 Lake Avenue North, on Wednesday, September

24 30, 2009, commencing at 9:14 a.m.

Witness_ Nam Heui Kim - Vol. 1.txt: 4:24 - 7:8

24 Q. Please state your name for the record.

25 A. Nam Heui Kim. 

00005

1 Q. And what do you do for a living?

2 A. I am a trauma and general surgeon and

3 intensivist at UMass Medical Center.

4 Q. And are we at UMass Medical Center today?

5 A. Yes, we are.

6 Q. And do you hold any board certifications,

7 Doctor?

8 A. I hold board certification in general surgery

9 and surgical critical care.

10 Q. And are you licensed to practice in any states?

11 A. I'm licensed to practice in Massachusetts.

12 Q. And did you previously do either a residency or

13 an internship or a fellowship, Doctor?

14 A. Yes. I've done an internship, a residency, and

15 a number of fellowships.

16 Q. Okay. If you take us through chronologically,

17 please, first, where'd you go to medical school,

18 please, Doctor?

19 A. I went to medical school at Einstein in New York

20 City.

21 Q. And what year did you graduate from Albert

22 Einstein Medical School?

23 A. Let's see, that was 1993.

24 Q. And what did you do after you -- and did you

25 become a doctor in 1993 licensed to practice in New 

00006

1 York?

2 A. No. I became a doctor without a license and

3 started a residency in Boston.

4 Q. Okay. And what year did you start that

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5 residency in Boston, please?

6 A. 1993.

7 Q. And what was the residency -- where was it at?

8 A. St. Elizabeth.

9 Q. What was the residency, tell us about the

10 residency, please.

11 A. It was in general surgery.

12 Q. And how many years did you do your residency in

13 general surgery at St. Elizabeth?

14 A. Five years.

15 Q. Are all surgery residencies that long, Doctor?

16 A. Some are longer. Five years is if there is no

17 research or time taken off.

18 Q. So you went to medical school for four years?

19 A. I went to medical school for four years.

20 Q. And then you did a residency in general surgery

21 for another five years, so you --

22 A. Right.

23 Q. -- had nine years of medical training?

24 A. Right.

25 Q. What did you do next, please? 

00007

1 A. I did a fellowship in tissue engineering at the

2 Center for Engineering and Medicine at Shriners Burn

3 Center and Mass General Hospital.

4 Q. And how many years was that fellowship?

5 A. About two and a half years.

6 Q. Okay. And I got to 1998 through your five years

7 of general surgery.

8 A. Right.

Witness_ Nam Heui Kim - Vol. 1.txt: 7:19 - 9:1

And so tell us when your fellowship

20 in tissue engineering at Shriners and Mass General

21 ended, please?

22 A. It ended in September of 2000.

23 Q. Thank you. And what did you do -- and then

24 September 2000, you went to Brigham Hospital?

25 A. No. In July of 2002 I went to the Brigham 

00008

1 Hospital.

2 Q. And that was your surgical critical care

3 fellowship?

4 A. Surgical critical care fellowship.

5 Q. And what did you do next?

6 A. Then I became assistant in surgery or also known

7 as a fellow on the burn service at Mass General

8 Hospital.

9 Q. And when you were the assistant in surgery at

10 Mass General Hospital and also doing a fellowship

11 there, was that -- were you also seeing and treating

12 patients at Shriners at the time?

13 A. Yes.

14 Q. Tell us about the relationship, please, between

15 Shriners and Mass General and Harvard Medical School.

16 A. Well, they're both teaching hospitals of Harvard

17 Medical School. They -- the relationship is kind of

18 difficult. They're almost -- they both have burn

19 services. The Shriners only treats pediatric burns or

20 almost only. There is -- there has been exceptions but

21 they're fairly rare. And the Mass General treats the

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22 adults. The -- Shriners doesn't really have an ED. So

23 even the pediatrics will go through the Mass General ED

24 before they get to Shriners.

25 Q. You're referring to the emergency department? 

00009

1 A. Right. Emergency department, ED.

Witness_ Nam Heui Kim - Vol. 1.txt: 9:2 - 10:18

2 Q. Got it. Tell us, please, about what types of

3 surgeries you did while you were assistant in surgery

4 at Mass General.

5 A. I did mostly excisions and debridements.

6 Q. And were most of these excisions and

7 debridements virtually all on burn patients?

8 A. Yes.

9 Q. How long -- I've seen records, Dr. Kim, which

10 both list you as an attending physician and some list

11 you as not the attending physician while you were at

12 Mass General in relation to Karen Bartlett.

13 A. Right.

14 Q. Can you please explain that to us.

15 A. The Mass General has a different system than a

16 lot of hospitals, and fellows there are sometimes also

17 assistants in surgery, okay, and they are --

18 essentially have attending privileges, all right. So

19 they have the right to admit, to treat, to operate on

20 their own.

21 Q. And for the ladies and gentlemen of the jury who

22 might have never heard of the difference between an

23 attending and a fellow with or without admission or

24 treatment or operation privileges, please explain what

25 those things are. 

00010

1 A. Fellows tend to be in training. Many places the

2 fellows will not have admitting privileges, will not

3 have the right to operate on their own, and to treat on

4 their own except under the supervision of an attending.

5 So an attending is someone who has ultimate

6 responsibility of the patient.

7 Q. Were you one of the treating physicians for

8 Karen Bartlett at Mass General Hospital in 2005?

9 A. Yes, I was.

10 Q. When you were one of Karen Bartlett's treating

11 physicians, did you have full admission and treatment

12 and operation privileges just like Dr. Ryan and Dr.

13 Schultz and Dr. Sheridan?

14 A. Yes, I did.

15 Q. And were the four main doctors, if you will, at

16 Mass General when Karen Bartlett was treated yourself,

17 Dr. Kim, Dr. Schultz, Dr. Sheridan, and Dr. Ryan?

18 A. Right

Witness_ Nam Heui Kim - Vol. 1.txt: Page 10, Line 22

22 A. Yes

Witness_ Nam Heui Kim - Vol. 1.txt: 11:4 - 11:15

tell us, then, how it worked on a

5 day-to-day basis or week-to-week basis in terms of who

6 was in charge of the patient like Karen Bartlett on a

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7 given day between the four of you, please.

8 A. Well, if -- if any of the -- if Rob Sheridan or

9 Colleen Ryan or Dr. John Schultz, if any of them were

10 there, I would say that they had the say in whatever

11 was going on. If they were absent, just by default it

12 would be myself.

13 Q. And their absence created a lot of times where

14 you were Karen's primary physician, correct?

15 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 11:19 - 11:21

19 Q. You did a number of or participated in a number

20 of line placements for Karen Bartlett while you were

21 there, correct?

Witness_ Nam Heui Kim - Vol. 1.txt: 12:2 - 12:17

I know I was involved with at least one.

3 I don't recall how many exactly I was involved with.

4 Q. Fair enough. What is a line placement, please,

5 Doctor?

6 A. Well, patients who are, you know, fairly sick,

7 and she was fairly sick, they would need access, IV

8 access for -- a venous access for fluids and for

9 medications and sometimes for blood draws. And often

10 peripheral for the access available on their arms would

11 be insufficient or we would run out of access, meaning

12 that the veins would eventually just sort of blow out

13 and not be appropriate for use for intravenous lines,

14 or IVs. So then we would have to put in a central line

15 which would go into one of the larger veins of the

16 body, typically it would go into the internal jugular,

17 the subclavian, or the femoral veins.

Witness_ Nam Heui Kim - Vol. 1.txt: 12:25 - 13:24

Did you do one 

00013

1 or more bronchoscopies on Karen Bartlett while you were

2 a treating physician of hers?

3 A. Yes, I did.

4 Q. What is a bronchoscopy?

5 A. A bronchoscopy is performed by taking a flexible

6 scope, okay, so a fiberoptic scope and typically taking

7 down the endotracheal tube, that's the breathing tube,

8 or a tracheostomy tube, depending on what they have,

9 and sometimes it can also be done without a tube at all

10 in an awake patient. And essentially you thread it

11 down to look at their airway, usually the trachea and

12 the more distal airways like the main stem airways

13 which branches to the right and left lung and sometimes

14 you can get to some of the secondary airways and

15 essentially to -- it's done for either just cleaning it

16 out or what we sometimes call toileting, essentially

17 cleaning it out, or to look for diagnostic purposes.

18 Q. What was the main condition for which Karen

19 Bartlett needed treatment at Mass General burn hospital

20 when you were one of her physicians?

21 A. Well, she was diagnosed with TENS.

22 Q. And what is that, please, Doctor?

23 A. Oh, toxic epidermal necrolysis, essentially

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24 where the body just sloughs off part of their skin.

Witness_ Nam Heui Kim - Vol. 1.txt: 14:23 - 15:17

Doctor, have I just placed

24 on the screen a copy of the resume you were kind enough

25 to provide me? 

00015

1 A. Yes.

2 Q. Okay. Thank you. And this shows your medical

3 degree --

4 A. Right.

5 Q. -- and your two prior degrees in mechanical

6 engineering and bioengineering, correct?

7 A. Right.

8 Q. And it shows now that you're or in -- excuse me,

9 it shows that in '05 and '06, you were a trauma fellow

10 at Hartford Hospital in Connecticut?

11 A. Right.

12 Q. Is that after Mass General?

13 A. That is after Mass General.

14 Q. So when you were treating Ms. Bartlett, that's

15 when you were a burn fellow and clinical fellow in

16 surgery at Mass General Hospital, correct?

17 A. Right

Witness_ Nam Heui Kim - Vol. 1.txt: 17:15 - 17:18

both when you

16 were at Mass General and now in saving lives that but

17 for treatment would not be saved?

18 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 17:25 - 18:3

Have I thanked you on 

00018

1 Karen Bartlett's behalf for your excellent --

2 A. Yes.

3 Q. -- and life-saving care and treatment?

Witness_ Nam Heui Kim - Vol. 1.txt: 18:8 - 19:8

Dr. Kim,

9 I'm going to show you a record and represent to you

10 it's a record that happened three days before Karen

11 Bartlett saw Dr. John Schultz in 2006, and it's a

12 record of Karen Bartlett's primary care physician,

13 Dr. Leo Lane. And Dr. Lane states, in part, "When

14 she," referring to Karen, "speaks with a specialist in

15 Boston, I have requested," that'd be the doctor, "that

16 she ask him if she is at increased risk in the future

17 for Stevens-Johnson syndrome if we need to be concerned

18 about any of the drug classes as I just spoke with Ms.

19 Bartlett that our concern will be that some day we will

20 need to give her medication and just the concern where

21 she has already had this once."

22 And then show you that three days after this --

23 Karen's doctor made this request, Dr. Schultz saw Karen

24 and he documented that Karen's med alert bracelet needs

25 to add NSAIDs/sulindac, and he also said, "Other meds 

00019

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1 probably okay unless they have a chemical structure

2 resembling sulindac."

3 Do you interpret Dr. Schultz's words that she

4 should -- "other meds probably okay unless they have a

5 chemical structure resembling sulindac" to mean that

6 Dr. Schultz has concluded that sulindac was the cause

7 of Karen Bartlett's TEN that you treated her for along

8 with Dr. Schultz and others?

Witness_ Nam Heui Kim - Vol. 1.txt: 19:15 - 19:20

15 A. Most likely the sulindac is suspected of being

16 the most likely cause of her TENS, and therefore all

17 medications in the same family of sulindac and -- or

18 with a similar structure of sulindac should be avoided.

19 That's actually very, very typical of medication

20 allergies.

Witness_ Nam Heui Kim - Vol. 1.txt: 20:18 - 21:9

These pages that I'm

19 showing you now, Dr. Kim, are all medication

20 administration records from Mass General while you were

21 one of her treating physicians. And I did write on

22 them. I wrote a number on the top of every page and

23 the reason I did that is just so we would know how many

24 pages all say: Adverse reaction to drugs, either

25 sulindac or, at the very end, we'll get to sulindac and 

00021

1 NSAIDs.

2 And was it your -- did you have knowledge while

3 you were treating Ms. Bartlett that sulindac was a drug

4 that had been either at the top of the differential or

5 identified to be the most likely causative agent of her

6 TEN as according to these Mass General medication

7 administration records sulindac is listed as the drug

8 that she had an adverse reaction to?

9 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 21:13 - 21:17

knowledge that

14 sulindac was the drug that was concluded to be the one

15 most likely to be the precipitating or causative agent

16 in Karen Bartlett's TEN from both her history and from

17 these medication administration records?

Witness_ Nam Heui Kim - Vol. 1.txt: 21:21 - 22:5

Well, I wouldn't just

22 take it from the medical records but from

23 her history, it is the -- the most recent

24 medication that she had that has been known

25 to potentially cause TENS. 

00022

1 Q. (By Mr. Jensen) To your knowledge based upon

2 your care and treatment of Karen Bartlett, was any

3 medication or drug other than sulindac ever identified

4 as a possible causal agent in her TEN as opposed to

5 sulindac?

Witness_ Nam Heui Kim - Vol. 1.txt: 22:8 - 22:13

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8 THE WITNESS: Not to my knowledge.

9 Q. (By Mr. Jensen) Restated, based upon your care

10 and treatment of Karen Bartlett, sulindac was the sole

11 identified drug to be the one that explained why she

12 had TEN and why she was in the burn unit; is that

13 correct?

Witness_ Nam Heui Kim - Vol. 1.txt: 22:16 - 22:20

16 THE WITNESS: At the time, yes.

17 Q. (By Mr. Jensen) And did your understanding that

18 sulindac was the drug that most likely caused Karen's

19 TEN ever change or did it remain the same?

20 A. Remained the same.

Witness_ Nam Heui Kim - Vol. 1.txt: 22:25 - 23:4

25 A. Remained the same. 

00023

1 Q. Thank you. And did you know in 2005 that

2 sulindac was in the class of drugs called nonsteroidal

3 anti-inflammatory drugs or, for short, NSAIDs?

4 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 23:15 - 23:18

15 Q. (By Mr. Jensen) He's got a good point. As of

16 2005, why would it have been the case as you pointed

17 out when sulindac was concluded to have caused her TEN

18 to avoid other drugs in that class, please?

Witness_ Nam Heui Kim - Vol. 1.txt: 23:21 - 24:9

21 THE WITNESS: Because they often have

22 similar mechanisms of action and similar

23 chemical forms, and therefore we do not

24 want to risk exposure of a medication in

25 the same family to someone who had an 

00024

1 adverse reaction.

2 Q. (By Mr. Jensen) Is the following correct

3 statement, Dr. Kim: To your knowledge in 2005 that

4 while sulindac was concluded by you and Dr. Ryan, I'll

5 represent to you, to be the medication that had caused

6 Karen Bartlett's TEN, you didn't know whether or not

7 other NSAIDs would have an adverse reaction with Karen

8 but you avoided them to be safe?

9 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 24:12 - 24:16

12 THE WITNESS: Yes.

13 Q. (By Mr. Jensen) Thank you. Is that your

14 understanding of why Dr. Schultz said: Avoid sulindac

15 and any drugs with a chemical structure similar to

16 sulindac?

Witness_ Nam Heui Kim - Vol. 1.txt: 24:18 - 25:7

18 THE WITNESS: Yes. It's very

19 standard.

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20 Q. (By Mr. Jensen) Tell us about what happens to

21 someone's skin when they have TEN, please, Dr. Kim.

22 A. Well, the skin tends to slough off, it first

23 blisters and then sloughs off. The adhesions of the

24 skin to the underlying base layer is disrupted. I

25 don't think it's actually clearly understood exactly 

00025

1 why, but it's disrupted. So it's essentially like a

2 burn.

3 Q. Were you involved in treating Karen with

4 Acticoat, silver nitrate, aqua gel, and other

5 techniques and materials to attempt to treat her skin

6 wounds?

7 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 25:23 - 27:4

23 Q. Without checking your records, do you recall

24 whether or not xenografts were also used with

25 Ms. Bartlett? 

00026

1 A. I believe they were.

2 Q. And what is a xenograft, please, Doctor?

3 A. A xenograft is skin from another animal other

4 than a human. Typically at Mass General, we used pig

5 skin.

6 Q. Tell us, please, about the teams when -- when

7 you were Karen's primary physician on any given day,

8 you used the word "by default." I'll use the words

9 "Karen was lucky enough to have you that day." Tell us

10 about the team that you worked with in treating Karen,

11 please.

12 A. Well, there was always the physician team which

13 included myself or another physician, attending

14 physician as well as a resident team, okay. There was

15 a number of nursing members of the team. There was

16 also psychiatry involved. Also, Mass General utilized

17 physical therapy and occupational therapy team as well.

18 And I'm sure there were nursing support systems such

19 as, you know, a personal care provider of some kind.

20 I'm not sure, can't remember exactly what they may have

21 called them at Mass General but these are people who

22 are not certified as nurses but can help them.

23 So there's, you know, the team at Mass General

24 is actually quite extensive. Oh, and nutritionists,

25 there's always a nutritionist on the Mass General team. 

00027

1 Q. How would you describe Dr. Schultz and

2 Dr. Sheridan's and Dr. Ryan's standing, if you will, or

3 reputation on a national or international basis in the

4 burn community for being excellent at what they do?

Witness_ Nam Heui Kim - Vol. 1.txt: 27:7 - 27:9

7 Q. (By Mr. Jensen) Based upon your knowledge in

8 2005?

9 A. They --

Witness_ Nam Heui Kim - Vol. 1.txt: 27:11 - 27:17

11 THE WITNESS: They're experts in

12 their field. They're very well known.

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13 Q. (By Mr. Jensen) To your knowledge in 2005, are

14 all three of them, Dr. Schultz, Dr. Ryan, and

15 Dr. Sheridan, to your knowledge, regarded as some of

16 the premier burn surgeons in the world?

17 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 27:19 - 27:20

19 Q. (By Mr. Jensen) No doubt of that in your mind?

20 A. No doubt.

Witness_ Nam Heui Kim - Vol. 1.txt: 28:2 - 28:8

Let me show you a record of

3 Dr. Ojikutu and it's dated March 8, 2005, so after

4 Karen's been there approximately a month and four days.

5 She got there on February 4. And Dr. Ojikutu

6 documents, in part, "45-year-old female with TEN

7 questioning NSAIDs in burn unit." See that, Doctor?

8 A. Mm-hmm.

Witness_ Nam Heui Kim - Vol. 1.txt: 28:10 - 28:16

10 THE WITNESS: Yes.

11 Q. (By Mr. Jensen) And just with that line, would

12 you understand from reading that that this infectious

13 disease doctor had NSAIDs at the top of their

14 differential and was not including anything else in

15 their differential as the potential cause of Karen

16 Bartlett's TEN?

Witness_ Nam Heui Kim - Vol. 1.txt: Page 28, Line 19

19 THE WITNESS: Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 29:2 - 29:11

Now I'm going to show you

3 another note, this one typed up by Dr. Ojikutu or

4 somebody typed up for her. It's Exhibit 26 and it's

5 about two weeks later on March 24, a little more than

6 that. And she lists allergies: NSAIDs, if you can see

7 that. There you go. There's the date. And she goes

8 on. On her fourth page, there's Dr. Ojikutu's

9 signature, and her impression is, "This is a

10 45-year-old woman with TEN likely secondary to NSAIDs."

11 Did I read that correctly, Doctor?

Witness_ Nam Heui Kim - Vol. 1.txt: 29:13 - 29:18

13 THE WITNESS: You did read that

14 correctly.

15 Q. (By Mr. Jensen) Would it have been your

16 interpretation of those words that this doctor was now

17 concluding that Karen Bartlett's TEN was likely

18 secondary to NSAIDs?

Witness_ Nam Heui Kim - Vol. 1.txt: 29:21 - 29:24

21 THE WITNESS: That was they are

22 likely secondary to NSAIDs. I don't think

23 there's any conclusion there but that's

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24 their leading suspect.

Witness_ Nam Heui Kim - Vol. 1.txt: 30:7 - 30:11

7 Q. (By Mr. Jensen) And NSAIDs -- of all of the

8 NSAIDs, the only one you knew of as Karen Bartlett's

9 treater that she had taken was sulindac, correct?

10 A. Yes.

11 Q. So do you --

Witness_ Nam Heui Kim - Vol. 1.txt: 30:14 - 30:17

14 Q. (By Mr. Jensen) -- interpret likely as this

15 doctor saying that the most likely cause is NSAIDs and

16 the only one you know of is sulindac?

17 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 30:21 - 31:10

21 A. Yes.

22 Q. Thank you. Karen Bartlett was actually

23 readmitted to Mass General after being at Northeast

24 Rehab Hospital for a number of days, and Dr. Schultz

25 wrote or signed Karen Bartlett's second discharge 

00031

1 summary, which I'm going to show to you. I'll find it.

2 Sorry, Doctor. There we go.

3 This is Exhibit 117 for the record. Now,

4 Dr. Schultz authored Karen Bartlett's second discharge

5 summary and it's Exhibit 117 and it shows a second

6 discharge date of 4/27/05 and a second admission date

7 of 4/18/05. And there's Dr. Schultz's electronic

8 signature on the last page dictated by Nurse

9 Practitioner Sally Morton. Did you know Sally Morton?

10 A. Yeah.

Witness_ Nam Heui Kim - Vol. 1.txt: 31:11 - 31:19

And

12 Dr. Schultz lists allergies as sulindac and NSAIDs.

13 A. Mm-hmm.

14 Q. Based upon seeing his other note, was it --

15 would it be your interpretation of this second

16 discharge summary that Dr. Schultz was still concluding

17 that sulindac was the most likely cause and also

18 instructing by listing an allergy for NSAIDs that she

19 should avoid that entire class of drugs?

Witness_ Nam Heui Kim - Vol. 1.txt: 31:22 - 32:18

22 THE WITNESS: Yes.

23 Q. (By Mr. Jensen) Sally Morton also, like she

24 apparently dictated this discharge summary for

25 Dr. Schultz, she dictated the first discharge summary 

00032

1 for you, correct, Doctor?

2 A. Yes.

3 Q. Okay. And tell us who Sally Morton is, please.

4 A. She's a nurse practitioner on the burn unit.

5 She does a lot of the things that makes -- made the

6 life much easier on the physicians including --

7 including dictating discharge summaries and other

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8 clinical duties as well.

9 Q. I'm going to show you three documents in

10 succession now, Doctor, and talk about the language in

11 each of them and ask you some questions about it. The

12 first one I'm going to show you is Dr. Austen's

13 February 18, '05 consult, and Dr. Austen states, in

14 part, "She was," for Karen of course, "She was

15 transferred to" -- Northeast -- excuse me, "New England

16 Medical Center February 4 where biopsy revealed TEN

17 attributed to NSAIDs versus Chinese food."

18 Do you see that?

Witness_ Nam Heui Kim - Vol. 1.txt: 32:20 - 32:25

20 THE WITNESS: Yes.

21 Q. (By Mr. Jensen) In the second document I'm

22 going to show you is a couple weeks later and it's an

23 ID consult. It doesn't have the similar language,

24 Doctor. It has the exact same language. Please tell

25 me if that's true. 

Witness_ Nam Heui Kim - Vol. 1.txt: 33:13 - 33:20

13 Q. (By Mr. Jensen) The second document I'm going

14 to show you, Dr. Kim, is on March 4, 2005. It also

15 reads, "She was transferred to NEMC 2/4 where biopsy

16 revealed TENS attributed to NSAIDs versus Chinese

17 food."

18 Does that appear to be the identical language

19 that Dr. Austen wrote down a couple weeks earlier?

20 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 33:22 - 34:2

22 Q. (By Mr. Jensen) And then in the discharge

23 summary that Sally Morton dictated for you, it says:

24 She was transferred, I'll abbreviate, to NEMC, on 2/4

25 where a biopsy revealed, I'll abbreviate, TEN syndrome 

00034

1 attributed to NSAIDs versus Chinese food.

2 Is that what it says?

Witness_ Nam Heui Kim - Vol. 1.txt: 34:4 - 34:8

4 THE WITNESS: Yes.

5 Q. (By Mr. Jensen) Please explain how you believe

6 that sentence got in your discharge summary and whether

7 or not it relates to these prior statements which are

8 nearly identical?

Witness_ Nam Heui Kim - Vol. 1.txt: 34:11 - 35:23

11 THE WITNESS: Well, typically, what

12 happens is when a patient is transferred

13 from one hospital to the other hospital,

14 not only are they -- come with some sort of

15 a summary of their hospitalization from the

16 previous hospital, but they also come with

17 a verbal sign-out from another physician at

18 the previous hospital, whether it's an

19 attending versus a resident. But they come

20 out with some sort of verbal -- verbal

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21 information that's not on paper.

22 And what's happens is typically you

23 include their incoming history of the

24 current illness along with their transfer.

25 So if New England Medical Center was 

00035

1 unclear as to what the potential cause was

2 and they said: Well, you know, she had

3 Chinese food and had a -- had some belly,

4 you know, abdominal complaints and she also

5 took a nonsteroidal anti-inflammatory for

6 that, that would most likely get into the

7 history and physical on her admission at

8 the accepting hospital and often will also

9 get into the discharge summary of her

10 discharge from that particular hospital

11 that she has been transferred to.

12 Q. (By Mr. Jensen) Okay. If you had

13 hypothetically been asked on this date, April 14, '05:

14 Dr. Kim, do biopsies attribute cause to TEN, what would

15 your answer have been?

16 A. Biopsies do not determine cause.

17 Q. Okay. Because it was your belief and

18 understanding, of course, correctly in 2005 that

19 biopsies do not attribute cause, do you agree that to

20 the extent this is repeated in the records by

21 Dr. Austen and this infectious disease fellow and in

22 the discharge summary, that's not a correct statement?

23 A. No, it's not correct.

Witness_ Nam Heui Kim - Vol. 1.txt: 36:8 - 36:16

8 Q. (By Mr. Jensen) And first, let me ask you,

9 Dr. Kim, did you ever conclude in your care and

10 treatment of Karen Bartlett that her TEN was attributed

11 to Chinese food?

12 A. No.

13 Q. Okay. Did you ever believe there was any

14 realistic possibility that her TEN was attributed to

15 Chinese food or Chinese food poisoning or the stomach

16 flu or gastroenteritis?

Witness_ Nam Heui Kim - Vol. 1.txt: 36:19 - 36:24

19 THE WITNESS: No.

20 Q. (By Mr. Jensen) Why was it never your

21 conclusion that there was any realistic possibility

22 that any of those things could have caused it, Chinese

23 food caused it, Chinese food, Chinese food poisoning,

24 gastroenteritis, and stomach flu?

Witness_ Nam Heui Kim - Vol. 1.txt: 37:2 - 37:4

2 THE WITNESS: Well, those -- those

3 mechanisms are not known in the literature

4 to cause TENS.

Witness_ Nam Heui Kim - Vol. 1.txt: 37:6 - 38:6

Do you

7 frequently get discharge summaries dictated for you

8 that you review to some extent and then electronically

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9 sign?

10 A. Yes.

11 Q. Okay. Tell us how carefully you review

12 discharge summaries while you were at Mass General in

13 2005 to make sure every sentence and every word is

14 accurate.

15 A. I just make sure that they're not huge bloopers.

16 Q. Why is that the case, Doctor?

17 A. Well, there are so many of these summaries that

18 you just want to give whoever's accepting the patient a

19 general idea of what has happened, what their diagnoses

20 are, and how they were treated, what complications they

21 may have had. And if that suffices without major

22 errors, we're -- you know, I generally sign them

23 without looking through the details of the grammar.

24 For instance, this sentence would be correct if

25 there was a period and a few additional words. For 

00038

1 instance, if she said: She was transferred to New

2 England Medical Center on February 4 where a biopsy

3 revealed toxic general -- epidermal necrolysis

4 syndrome, period. The TENS was attributed to possible

5 NSAIDs versus Chinese food at New England Medical

6 Center, period.

Witness_ Nam Heui Kim - Vol. 1.txt: 38:7 - 38:17

If I were to represent

8 to you that I've had the opportunity to ask questions

9 of then a third-year resident at Tufts New England

10 Medical Center and he testified, Dr. Deon Wolpowitz, to

11 the following: A, he never attributed Karen Bartlett's

12 TEN to Chinese food; and B, to his knowledge -- and

13 Karen Bartlett was only there a day. It's a very small

14 medical record. And B, to his knowledge, no one at

15 Tuft's New England Medical Center ever attributed Karen

16 Bartlett's TEN to Chinese food, would that surprise you

17 in 2005?

Witness_ Nam Heui Kim - Vol. 1.txt: 38:20 - 38:24

20 THE WITNESS: It -- it wouldn't

21 surprise me.

22 Q. (By Mr. Jensen) Why would it not surprise you

23 that no one at Tufts ever thought Karen Bartlett got

24 TEN from Chinese food?

Witness_ Nam Heui Kim - Vol. 1.txt: 39:1 - 40:7

1 THE WITNESS: Well, it is like that

2 telephone game where someone makes a call

3 to someone else, relays some information,

4 and then someone -- that person makes a

5 call to another person, a third person, and

6 then that third person makes a call to a

7 fourth person and then it gets back around

8 after a few people to the first person who

9 originated that they called and gave the

10 information and you find that the

11 information has been a little garbled and

12 not completely recognizable anymore.

13 So if someone at New England Medical

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14 Center said: Well, you know, this all

15 started when she had Chinese food and had a

16 stomach upset and she took some, you know,

17 some medications for that and then this

18 happened, it could easily be misinterpreted

19 by the receiving person to have said:

20 Well, they thought it was attributed to

21 either that Chinese food or the medications

22 she took for her stomach upset.

23 So it is unfortunately why a written

24 record is preferable in many ways to a

25 verbal record. However, I think often the 

00040

1 verbal record has more depth of information

2 than the written one.

3 Q. (By Mr. Jensen) I needed to ask you, has all

4 the testimony you've been providing today and do you

5 agree that all the testimony you will provide today

6 will be based upon a reasonable degree of medical or

7 scientific certainty?

Witness_ Nam Heui Kim - Vol. 1.txt: 40:21 - 40:22

21 THE WITNESS: Reasonable amount of

22 scientific certainty, yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 40:24 - 41:3

was it your

25 conclusion when you were treating Karen Bartlett in 

00041

1 2005 to a reasonable degree of medical and scientific

2 certainty that the cause of her TEN was her prior

3 ingestion of sulindac?

Witness_ Nam Heui Kim - Vol. 1.txt: 41:8 - 41:18

8 THE WITNESS: Yes.

9 Q. (By Mr. Jensen) To your knowledge, was there

10 anyone at Mass General who disagreed with you, and I'll

11 represent to you Dr. Ryan, who yesterday testified that

12 it was her belief at the time that sulindac was the

13 most likely cause of Karen Bartlett's TEN, and asking

14 you to accept that as true for purposes of my question,

15 to your knowledge, Dr. Kim, was there anyone at Mass

16 General Hospital that disagreed with your belief and

17 Dr. Ryan's belief that sulindac was the most likely

18 cause of Karen Bartlett's TEN?

Witness_ Nam Heui Kim - Vol. 1.txt: 41:20 - 41:22

20 THE WITNESS: No.

21 Q. (By Mr. Jensen) To your knowledge, there was

22 not?

Witness_ Nam Heui Kim - Vol. 1.txt: 41:24 - 41:25

24 THE WITNESS: Not that was made known

25 to me. 

Witness_ Nam Heui Kim - Vol. 1.txt: 44:3 - 45:13

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3 Q. Do you believe that February 12, based upon your

4 recollection, was the first time you saw Karen Bartlett

5 or was the first time you were directly involved in her

6 care?

7 A. It may -- I really wouldn't be able to know

8 because if notes had been written by another physician,

9 another -- if it had been written by either Dr. Ryan,

10 Dr. Schultz, or Dr. Sheridan, I may still have been

11 involved but they would have done all the

12 documentation.

13 Q. And this day you spoke of an SVT yesterday.

14 What is that, please?

15 A. Supraventricular tachycardia.

16 Q. And you say, "Self-Limited episode of SVT

17 yesterday without hemodynamic instability." What does

18 that mean?

19 A. That means she had a fast heart rate but her

20 blood pressure was okay.

21 Q. Did you ever reach any conclusions or make any

22 assessments in your mind as to what was causing or

23 precipitating Karen's SVTs?

24 A. I do not document it but I suspect that from

25 this entire case, that most likely one of our leading 

00045

1 causes would be either dehydration or pain or a

2 combination of both.

3 Q. Okay. And why would either dehydration or pain

4 or a combination cause an SVT, please, Doctor?

5 A. Well, when someone is dehydrated, their

6 circulating blood volume decreases and in order to make

7 what blood you have go around sufficiently, people will

8 often develop a tachycardia if there is -- if they are

9 able to mount that response. And pain causes a lot of

10 people to become tachycardic.

11 Q. And tachycardic means what, please?

12 A. Fast heart rate. It's a heart rate a hundred or

13 above.

Witness_ Nam Heui Kim - Vol. 1.txt: 45:18 - 45:21

As of 2005 why did

19 pain cause a lot of people as you just testified to

20 have a high heart rate, in particular Karen Bartlett

21 maybe?

Witness_ Nam Heui Kim - Vol. 1.txt: 45:24 - 46:15

24 THE WITNESS: It's part of the

25 sympathetic response. 

00046

1 Q. (By Mr. Jensen) Fair to say I provided you some

2 Mass General medical records before we began here today

3 so you could refresh your recollection about your care

4 and treatment of Karen Bartlett?

5 A. Yes.

6 Q. Fair to say we had one substantive conversation

7 regarding your care and treatment of Karen Bartlett?

8 A. Yes.

9 Q. Do you recall telling me in that conversation

10 about Karen's chart that something about a fight or

11 flight mechanism?

12 A. Yes. Well, that's --

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13 Q. Tell us what that -- tell us what a fight or

14 flight mechanism is in relation to what we're

15 discussing now of pain and SVTs.

Witness_ Nam Heui Kim - Vol. 1.txt: 46:18 - 47:17

18 THE WITNESS: Well, the flight or

19 fight, we also, more scientifically, we

20 call it the sympathetic response. So

21 essentially when your -- one is either

22 scared or are threatened in some manner,

23 the heart rate may go up. Most people, I

24 would say, the heart rate goes up. There

25 are some people who may actually go 

00047

1 bradycardic, meaning the heart rate may go

2 down.

3 But it's not an uncommon response for

4 the heart rate to go up when someone is in

5 pain or is in fear or feels jeopardized in

6 some way.

7 Q. (By Mr. Jensen) Explain the relationship in

8 Karen Bartlett's specific situation and others like her

9 in 2005 of the fact that she was sedated in whole or in

10 part but still feeling pain?

11 A. Well, we do our best to decrease their pain and

12 we also do our best to decrease their awareness of

13 what's going on because when people are intubated and

14 in a critical care unit, it can be a very, very scary

15 thing, okay. So they are sedated for the anxiety and

16 the fear, and then pain medications for whatever pain

17 they might be in.

Witness_ Nam Heui Kim - Vol. 1.txt: 48:14 - 49:15

14 Q. (By Mr. Jensen) You go on in your note to say,

15 "Bolus area is sloughing." And then you say, "Will

16 plan for extubation when wounds have healed better and

17 mucosal involvement improving." Is that what you say?

18 A. I'm trying to find it -- yeah, "Bolus" -- "Bolus

19 areas are sloughing," okay, and "Plan for extubation

20 when wounds have healed better and mucosal involvement

21 improving," yes.

22 Q. Was she intubated at the time? Is that why

23 you're planning for an extubation?

24 A. Yes, she is intubated at this time.

25 Q. What does it mean to be intubated, Doctor? 

00049

1 A. That is having a breathing tube in from --

2 typically into the -- through the mouth into the

3 trachea to allow ventilation with a mechanical

4 ventilator.

5 Q. Does that commonly in patients like Karen

6 Bartlett in 2005 create problems; in other words,

7 they're in pain, they're sedated, and they have a

8 breathing tube?

9 A. Yes. Well, the breathing tube itself can cause

10 pain and anxiety, and being on a mechanical ventilator

11 intubated can put the patient at risk for what we call

12 ventilator-associated pneumonia.

13 Q. And Karen is -- would Karen, in your estimation,

14 have been surviving at the time without mechanical

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15 ventilation?

Witness_ Nam Heui Kim - Vol. 1.txt: 49:18 - 49:21

18 THE WITNESS: Unlikely.

19 Q. (By Mr. Jensen) Why is that true that it's

20 unlikely she could have lived on her own without

21 mechanical ventilation at the time?

Witness_ Nam Heui Kim - Vol. 1.txt: 49:24 - 50:8

24 THE WITNESS: Her mucosa was involved

25 including the mucosa of her airway, so 

00050

1 essentially means that the TENS impacted

2 her airway as well. So essentially it's

3 like having burns in the airway.

4 Q. (By Mr. Jensen) Was that an ongoing medical

5 concern in Karen Bartlett's care and treatment by you

6 and the others at Mass General, the fact that she had

7 burning not only on her outside on her skin but she had

8 burning in her esophageal tract?

Witness_ Nam Heui Kim - Vol. 1.txt: 50:10 - 52:1

10 THE WITNESS: She had mucosal

11 involvement in her -- both probably her GI

12 and her -- and her respiratory tract.

13 Q. (By Mr. Jensen) And tell us how -- tell us why

14 that was an issue and how it was dealt with, please.

15 A. Well, it's an issue because the area can swell

16 and cause a mechanical obstruction for breathing,

17 that's one; two, it can cause debris that can impact

18 the airways and make, essentially, the airways cause

19 another obstruction of there. So you have two ways:

20 One, it is -- it can cause a mechanical swelling; and

21 two, the debris itself from the sloughing can cause

22 essentially junk in the airways that she would not be

23 able to breathe.

24 Q. And is that why you did what you referred to as

25 the toilet bronchoscopies? 

00051

1 A. Yes. That's often done. It can also be done if

2 someone has a pneumonia or secretions that are so bad

3 that they need to be cleaned out because they're unable

4 to clean it out themselves.

5 Q. I flip to the first bronchoscopy report that has

6 your name on it and actually, as we mentioned earlier,

7 lists you as the attending physician, correct?

8 A. Yes.

9 Q. Okay. And perhaps in relation to this diagram,

10 you can please ex -- perhaps you can point your page

11 towards the jury, Doctor, forget about mine, and tell

12 the jury in relation to that diagram how a bronchoscopy

13 is done, please.

14 A. Okay. I'm actually holding it upside down

15 because it's easier to understand upside down for most

16 people. This is essentially the main airway, we call

17 the trachea, and this is the -- would be the left main

18 stem and this is the right main stem. And essentially

19 what happens is your endotracheal tube or your

20 breathing tube would be -- come down right about here,

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21 and you would take the flexible fiberoptic bronchoscope

22 and thread it through the endotracheal tube and thread

23 it down these airways and suck up whatever mucus,

24 debris, blood, whatever may be there for whatever

25 patient is undergoing this procedure. Then you would 

00052

1 come back up and then do the same for the other side

Witness_ Nam Heui Kim - Vol. 1.txt: 52:12 - 52:14

12 Q. And why was -- why didn't one bronchoscopy solve

13 this problem for Karen Bartlett? Why did she need

14 multiple based upon your care and treatment?

Witness_ Nam Heui Kim - Vol. 1.txt: 52:17 - 54:5

17 THE WITNESS: Well, first of all, the

18 -- all the mucosa will not slough at once.

19 It will -- it will be doing that on a, you

20 know, it just doesn't happen all at once.

21 Just some will happen today, tomorrow, the

22 next day. And gradually when the process

23 finishes, then it's done. Also, you know,

24 when someone is intubated, they often have

25 a more difficult time clearing their 

00053

1 secretions, any debris in there that they

2 might have, and so it may have to be done a

3 number of times until they improve.

4 Q. (By Mr. Jensen) On your 2/20 -- what is the

5 date of the second page, Doctor, please?

6 A. Second page?

7 Q. Yes, please.

8 A. 2/20.

9 Q. Thank you. So on February 20, you, under Neuro,

10 say, "Ativan IV," and tell us why you gave her Ativan

11 by intravenous method, please.

12 A. Well, Ativan is an anxiolytic. It's one of the

13 benzodiazepines. And we would be giving it IV either

14 for fast effect or we would be giving it IV because we

15 didn't have access to the GI tract.

16 Q. And then you say, "Methadone in place to prep

17 for wean." What does that mean, please?

18 A. Methadone is used for pain. And so essentially

19 we started her on Methadone, and if we want to wean --

20 we want to wean the morphine and Versed grips is

21 what's, I think, it's implying.

22 Q. Can you read your entry under GI, please.

23 A. "Still has extensive perioral lesions. Ongo

24 tube feeds."

25 Q. And perioral lesion is what, please? 

00054

1 A. Lesions around the mouth.

2 Q. Were you involved in many decisions in your care

3 and treatment of Karen Bartlett as to how much and what

4 types of blood products or transfusions she needed?

5 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 54:6 - 54:19

Why

7 did Karen need blood transfusions?

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8 A. Well, her -- I wouldn't be able to tell you

9 without the record exactly as to what she needed when,

10 but typically a person needs blood transfusions when

11 the hematocrit goes down for packed red blood cells.

12 For fresh frozen plasma, it might be as a volume

13 expander or because they're developing a coagulopathy

14 of some kind, meaning their inability to coagulate or a

15 compromise in their coagulation. So without

16 specific -- specifically what days and what days she

17 had the transfusions and what her blood work was at the

18 time, I can't tell you specifically exactly when and

19 why she needed something.

Witness_ Nam Heui Kim - Vol. 1.txt: 56:1 - 56:19

1 Q. Let's pick one out. The first day you

2 apparently saw Karen was February 12, and if you look

3 at the blood transfusions on the next day, she got 500

4 of albumin and it's page 685. We can flip to page 685.

5 Does that help you tell us why -- on Exhibit 141, if

6 you flip to page 685 --

7 A. 685?

8 Q. Yeah. The far right column is the page numbers.

9 A. Okay.

10 Q. Yes. And then when you flip to page 685, does

11 that help you tell us, Doctor, why she needed the

12 albumin that day or does that just report that she got

13 it?

14 A. Yeah, that's just to report that she got it. I

15 mean, essentially, I would say albumin is typically

16 used as a volume expander. So if her urine output was

17 low or if her blood pressure was low or if her heart

18 rate was high would be the typical situations where

19 albumin might be used.

Witness_ Nam Heui Kim - Vol. 1.txt: 56:22 - 57:1

22 Q. (By Mr. Jensen) And let's go now to your second

23 day was February 20 and stay on February 20. On that

24 day she got all three. She got packed blood cells,

25 fresh frozen plasma, and albumin. So was the very day 

00057

1 you saw her, can you tell us why, please.

Witness_ Nam Heui Kim - Vol. 1.txt: 57:3 - 57:14

3 THE WITNESS: Unfortunately this note

4 is not timed. 20.1 percent would be

5 considered adequate. It would be helpful

6 to know what her hematocrit was on the

7 19th. Her blood pressure was a little bit

8 soft, 105 over 68, which -- or 115 over 60.

9 Urine output was adequate, 40 to 80 CCs an

10 hour.

11 Q. (By Mr. Jensen) Here's Dr. Ryan's note from the

12 19th. It's page 143 of Exhibit 137. Does that help

13 you?

14 A. Okay.

Witness_ Nam Heui Kim - Vol. 1.txt: 57:16 - 58:8

16 THE WITNESS: Okay. Her hematocrit

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Page 20

17 was somewhat lower, 25.4 from the previous

18 day, from the day that I saw her, which was

19 28. So it's likely she got a blood

20 transfusion between when Dr. Ryan saw her

21 and when I saw her. And her blood pressure

22 was soft at 105, meaning that, you know,

23 typically 120 over 80 is a typical number.

24 And her urine output, at some point in

25 time, had gone to 30 CCs an hour which is a 

00058

1 little bit low.

2 Q. (By Mr. Jensen) Okay. So in lay terms, why the

3 day you saw her did she get all three of these blood

4 products?

5 A. It is not absolutely clear to me but I suspect

6 she got them because her blood pressure was a little

7 bit soft, her urine output had dropped a little bit,

8 and -- and her hematocrit was a little bit low.

Witness_ Nam Heui Kim - Vol. 1.txt: 58:22 - 59:7

22 Q. So does that note tell us that the -- at least

23 part of the reason she needed it -- that blood

24 transfusion for was because her mouth was bleeding from

25 TEN? 

00059

1 A. Well, my note documents that she got FFP at the

2 time for the bleeding.

3 Q. In her mouth?

4 A. Perioral, around her mouth, yes.

5 Q. Let's go to your next note, please, Doctor, of

6 March 2 and there under the exam, do you say, "Sedated

7 but agitates easily"?

Witness_ Nam Heui Kim - Vol. 1.txt: Page 59, Line 10

10 A. Yes

Witness_ Nam Heui Kim - Vol. 1.txt: 59:13 - 59:25

And then you also

14 say, "Wounds" -- "Wounds back very oozy on Acticoat."

15 What --

16 A. Yes.

17 Q. What does that mean?

18 A. It probably means there was -- there was some

19 bleeding from the back, not discrete bleeding like a

20 vessel bleeding but just oozy, just, you know, just

21 sort of a low grade sort of a blood loss from the back.

22 Q. And then under Neuro, do you say, "Sedated on

23 Dilaudid and Versed," and those are both to -- Dilaudid

24 is a pain medication and Versed is a sedative, correct?

25 A. Right. 

Witness_ Nam Heui Kim - Vol. 1.txt: 60:2 - 60:5

2 Q. (By Mr. Jensen) And then you say, "Will

3 increase pain medication for possibility of pain

4 causing tachycardia"?

5 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 60:8 - 60:10

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Were

9 you concerned that Karen was having fight or flight

10 reactions to the totality of her treatment?

Witness_ Nam Heui Kim - Vol. 1.txt: 60:13 - 60:15

13 THE WITNESS: I was concerned that

14 she may be in some pain and that might be

15 causing tachycardia.

Witness_ Nam Heui Kim - Vol. 1.txt: 61:3 - 61:12

3 Q. So far in these first three days, February 12

4 and 20th and March 2, in lay terms give us a general

5 picture of what your medical concerns are regarding

6 Karen.

7 A. Well, it looks like she is in respiratory

8 failure on a ventilator. She has wounds that are

9 oozing to the point where some clinician at some time

10 felt she needed both FFP to support her ability to

11 coagulate and some blood from bleeding. Generally,

12 she's -- she's very sick.

Witness_ Nam Heui Kim - Vol. 1.txt: 61:19 - 62:23

19 Q. (By Mr. Jensen) Please tell us from a lay

20 perspective how she's doing two days later when you see

21 her on March 4.

22 A. On March 4 -- okay. Well, she has a fever and

23 she's requiring blood pressure support with Levophed.

24 She remains tachypneic. She remains on the ventilator.

25 Urine output is acceptable. So essentially she -- it 

00062

1 sounds like over the few days that I've seen her, that

2 she is somewhat sicker but actually may be coming out

3 of her decline, because it is saying that the events

4 were that she required Levophed, which is a blood

5 pressure -- for blood pressure support but down in my

6 drips, it also says that the Levophed is off, so

7 therefore she must have just come off the Levophed,

8 which is -- would be interpreted at least as an

9 improvement.

10 Q. Can you please read your first line under your

11 neuro statement.

12 A. "Sedated. Not consistently opening eyes. May

13 be secondary to edema."

14 Q. And what does that mean?

15 A. Well, it's saying she is sedated but we like

16 people to be responsive enough that they can, you know,

17 respond to stimulus. Otherwise they may be

18 oversedated, okay. She's not opening her eyes

19 persistently, and I'm questioning whether or not it's

20 because she cannot mechanically open her eyes because

21 her eyelids are too swollen.

22 Q. Were you aware that Karen was receiving multiple

23 eye or ophthalmologic consults at the time?

Witness_ Nam Heui Kim - Vol. 1.txt: 63:1 - 64:1

1 THE WITNESS: I'm likely to have

2 known about it. It is not documented in

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Page 22

3 this note.

4 Q. (By Mr. Jensen) About six days later on March

5 10, please read us your neurological statement there.

6 A. "Oversedated. Will decrease Dilaudid and

7 decrease Versed. Methadone 20 BID."

8 Q. And what does that mean, oversedated?

9 A. Means that her sedation is too high.

10 Q. How could you tell?

11 A. Well, if they're not responding to stimuli you

12 would expect them to respond to, like, you know,

13 preferably they respond to your voice. Their anxiety

14 is sufficiently taken care of that they can still

15 respond to you. She may not be, you know -- typically

16 I would consider someone oversedated if they're not

17 responding to physical stimuli, verbal stimuli and --

18 and/or even pain.

19 Q. And what did you do by way of physical stimuli

20 to determine whether they were sedated properly or not

21 back in '05?

22 A. I don't know. All I know is that she does react

23 to pain. So I did at some point give her some noxious

24 stimuli, potentially in a sternal rub or a pinch to see

25 if she woke up and would open her eyes or something to 

00064

1 indicate that she felt it

Witness_ Nam Heui Kim - Vol. 1.txt: 65:6 - 66:4

6 Q. We talked about your bronchoscopy. And then the

7 very next day, you see her on March 11. And so that

8 would have been after she was at Mass General for about

9 a month and five days. Please tell us based upon your

10 perception how she's doing that day.

11 A. How she's doing?

12 Q. Yes, ma'am, please.

13 A. Well, she has some bright red blood per rectum.

14 So she's bleeding from below.

15 Q. Where's that note so I can find it?

16 A. This is number 282 and it's at the top. It

17 says, "Events," and it says: Some BRBRP -- "Some

18 BRBPR," that's bright red blood per rectum. She also

19 has some red blood cells in her urine. Her sputum is

20 bloody as well. She remains, you know, mildly febrile

21 at 101.4. Her blood pressure remains soft. She's

22 still on the mechanical ventilator. Her respiration

23 rate is still tachypneic but improved.

24 She is on vasopressin, which is providing some

25 blood pressure support. She's on tube feeds and, of 

00066

1 course, she's still on the mechanical ventilator.

2 Q. Tell us what this stands for again under Events,

3 the five letters.

4 A. B --

Witness_ Nam Heui Kim - Vol. 1.txt: 66:6 - 66:7

6 THE WITNESS: BRBPR, bright red blood

7 per rectum.

Witness_ Nam Heui Kim - Vol. 1.txt: 66:14 - 66:23

14 Q. (By Mr. Jensen) I'm going to show you the

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15 initial diagram done the day Karen was admitted to Mass

16 General and it's entitled "Burn Diagram" and it's dated

17 the day she arrived, February 4, and it provides this

18 diagram of where Karen had TEN versus rash. Do you

19 understand this diagram to tell us, or its reader, that

20 Dr. Sabatini believed that Karen's rash was on her

21 lower arms and lower legs and posterior and -- first of

22 all, is that yes?

23 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 66:25 - 67:3

25 Q. (By Mr. Jensen) Did you understand Dr. Sabatini 

00067

1 was also communicating that on Karen's arrival, her

2 TENS was on her chest, her upper arms, her back, her

3 neck, her face as well as her rectal area?

Witness_ Nam Heui Kim - Vol. 1.txt: 67:6 - 67:18

6 THE WITNESS: Well, unfortunately,

7 Dr. Sabatini did not use the correct

8 diagram. So essentially he's documenting

9 for a male. He does seem to imply that it

10 is affecting the perineum.

11 Q. (By Mr. Jensen) The perineum is what, Doctor?

12 A. The area where the -- between the -- that has

13 like the vagina, the labia, and the anus.

14 Q. And would you have interpreted this, because of

15 the cross-marked nature for TEN and the cross-marked

16 nature by the vaginal area, that Dr. Sabatini was

17 concluding that upon arrival, Karen had TENS involving

18 her vaginal area?

Witness_ Nam Heui Kim - Vol. 1.txt: 67:20 - 68:5

20 THE WITNESS: Well, once again,

21 Dr. Sabatini used the wrong diagram. He

22 used the diagram for a male. But, you

23 know, assuming that he -- that he's still

24 using the same areas, that would be that it

25 did affect the area involving at least the 

00068

1 posterior vaginal or labial area and the

2 anus as well, but I cannot see -- that

3 little dot right there in the lower diagram

4 would be the anus.

5 Q. (By Mr. Jensen) Thank you.

Witness_ Nam Heui Kim - Vol. 1.txt: 68:8 - 68:10

8 Q. (By Mr. Jensen) Did you become aware that

9 Dr. Ryan had documented a vaginal adhesion in her care

10 and assessment of Ms. Bartlett?

Witness_ Nam Heui Kim - Vol. 1.txt: 68:13 - 68:16

13 THE WITNESS: I don't know who

14 documented but I know that the GYN service

15 was involved for -- for the adhesions in

16 the vaginal area.

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Witness_ Nam Heui Kim - Vol. 1.txt: 68:20 - 69:5

What are the mucosal areas that you

21 understood in 2005 that TEN attacks or affects?

22 A. Well, it can affect any of the mucosal areas,

23 the mouth --

24 Q. Tell us what those are, please.

25 A. The mouth, the respiratory tract, the vagina, 

00069

1 potentially, I guess, your anus too, though that's very

2 uncommon. So...

3 Q. Is it your understanding in 2005 that TEN

4 primarily attacks those mucosal areas you just

5 identified as well as the skin?

Witness_ Nam Heui Kim - Vol. 1.txt: 69:8 - 70:18

8 THE WITNESS: The mucosal involvement

9 is not as well known as the skin.

10 Q. (By Mr. Jensen) But you knew then it attacks

11 and affects both?

12 A. It can, yes.

13 Q. And it was your belief that it did affect the

14 mucosal areas and attack them of Karen Bartlett?

15 A. Well, it definitely attacked the mucosa of her

16 perioral area and her respiratory tract, and it is my

17 understanding from the other practitioners that it

18 affected her vagina as well.

19 Q. I'd now like to turn your attention to your --

20 is it March 14 entry, Doctor?

21 A. Is that 298?

22 Q. Yes, ma'am. Is that the date on it? I'm just

23 trying to --

24 A. Day number 39, yes.

25 Q. Okay. And so here we know from your note that 

00070

1 she's still in the actual ICU, one of the five ICU beds

2 at Mass General on her 39th day?

3 A. Yes.

4 Q. And tell us from a lay perspective how she's

5 doing on day number 39 in one of the five ICU beds.

6 A. Okay. She remains intubated. Her temperature

7 still remains with a moderate fever, though it's

8 improving. Her blood pressure is adequate. Her heart

9 rate is acceptable and improving. Her oxygenation is

10 not requiring an extensive amount of support since

11 she's only on 35 percent FIO2. She is, as far as I can

12 tell, she is not on any blood pressure support.

13 She's not following commands, so neurologically

14 she is still either delirious or oversedated or -- or

15 something because she is not following commands. She's

16 not alert enough or oriented enough to protect her

17 airway so a trach is being planned for, it looks like,

18 March 16 possibly.

Witness_ Nam Heui Kim - Vol. 1.txt: 70:20 - 71:9

20 A. She is tolerating tube feeds. She's moving her

21 bowels. There's a question of hemorrhoids because of

22 the bleeding over the weekend from her rectum. She

23 remains on multiple antibiotics and she's had some

24 positive blood cultures. I mean, generally, it looks

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25 like she's still very sick but actually has shown some 

00071

1 improvement.

2 Q. Thank you, Doctor. I'm going to ask you a

3 couple questions about your neuro notes, and you start

4 by saying, "Well sedated, attempts to further reduce

5 Versed," which is a sedative, "cause tachypnea"?

6 A. Tachypnea. So that means that when I or when

7 attempts to decrease the amount of sedative that she's

8 getting, which is Versed, that she's -- her breathing

9 rate goes high.

Witness_ Nam Heui Kim - Vol. 1.txt: 72:12 - 73:3

12 Q. (By Mr. Jensen) Now, you told us that as of

13 this day, she's still intubated with the breathing

14 tube, correct?

15 A. Yes.

16 Q. And you told us that there's a plan for a

17 possible tracheostomy, correct?

18 A. Yes.

19 Q. Tell us the difference between the two, please.

20 A. Well, an endotracheal tube goes through,

21 typically, the either the mouth and sometimes the nose

22 into the trachea and that is essentially the way the

23 ventilator can essentially breathe for the patient. A

24 tracheostomy would go through the anterior neck

25 directly into the trachea. 

00073

1 Q. What are the pros and cons medically for Karen

2 Bartlett in 2005 to potentially getting this

3 tracheostomy versus not getting it, please?

Witness_ Nam Heui Kim - Vol. 1.txt: 73:6 - 74:25

6 THE WITNESS: Well, the benefits of a

7 tracheostomy is that it is often more

8 comfortable for the patient because they

9 can -- there's nothing in their mouth.

10 They can have better dental and oral

11 hygiene. Potentially if they're awake and

12 alert enough, they may attempt speech or at

13 least mouthing words. The potential

14 benefit of a trachea -- of a tracheostomy

15 is that most people will wean off the

16 ventilator quicker. It's easier to do

17 pulmonary toileting, for instance, with

18 just sucking out secretions blindly, which

19 the nurses can do.

20 The risks, of course, include that,

21 you know, the tracheostomy is a surgical

22 procedure. It can cause bleeding. There

23 can be loss of airway during the process.

24 As all surgical procedures, they could

25 potentially get infected. They could have 

00074

1 long-term problems with tracheal malacia.

2 Q. (By Mr. Jensen) What's that, Doctor?

3 A. It's when the cuff of the trach or the

4 endotracheal tube -- both of them can cause tracheal

5 malacia -- it causes pressure on the wall of the

6 trachea, decreasing blood flow to the area and

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7 essentially that area, it just is not -- is not

8 healthy. The cartilage does not support the trachea as

9 well, and it could potentially, like, collapse when you

10 breathe. So when you breathe, you cause negative

11 airway pressure in your lungs and then you suck air in.

12 Well, that's a problem if your trachea doesn't -- the

13 cartilage is not working very well. And when you

14 breathe, instead of sucking the air through, it causes

15 collapse of the trachea.

16 Q. What, if any, are the further risks as you were

17 describing for us, or the cons, of getting a

18 tracheostomy, please?

19 A. Bleeding. I would say bleeding is one of the

20 major ones.

21 Q. Did this decision between keeping the breathing

22 tube in versus getting a potential tracheostomy have

23 anything to do with when or whether Karen Bartlett

24 could be discharged from the burn unit and go to a

25 rehab facility? 

Witness_ Nam Heui Kim - Vol. 1.txt: 75:2 - 76:3

2 THE WITNESS: It is not clear from

3 the notes. However, most -- unless you

4 want to send someone to a ventilator rehab

5 facility, they have to be off the

6 ventilator.

7 Q. (By Mr. Jensen) Okay.

8 A. It is typically easier to wean someone off the

9 ventilator when they have a tracheostomy.

10 Q. Why is that true?

11 A. Well, it's -- one, it's a shorter airway. So

12 instead of having to have the air go all the way

13 through an endotracheal tube, I mean, think about how

14 long that is. Think about trying to suck through a

15 straw, breathe through a straw for days and days at a

16 time. It makes more energy and more effort to breathe

17 through a straw that's long than to breathe through a

18 straw that's short. It's also easier for pulmonary

19 toileting and it's also more secure.

20 I mean, if this tube comes out in a vent

21 facility of some kind, there has to be people expert in

22 the ability to intubate, to put the tube back in the --

23 meanwhile, she may potentially, you know, either die or

24 have anoxic or lack of oxygen. So in a vent facility,

25 you would have to have a tracheostomy for instance. 

00076

1 Q. If, heaven forbid, you needed a trach, can you

2 tell -- show us where, the jury, where on your neck

3 that would -- the surgical hole would be, please?

Witness_ Nam Heui Kim - Vol. 1.txt: 76:5 - 76:19

5 THE WITNESS: The -- typically it is

6 placed above the sternal notch. This is

7 right where your -- your manubrium or this

8 little bone right at the top of your chest

9 is and then you can feel your thyroid

10 cartilage or -- in men it would be the

11 Adam's Apple and right below that there's

12 another very hard ring that's called a

13 cricoid. So between the cricoid and the

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14 sternal notch.

15 Q. (By Mr. Jensen) Thank you. Now, would Karen

16 Bartlett at the time, Doctor, would she have had input

17 or say in whether she got a trach or not or would it be

18 the case that she would not have had input because she

19 couldn't really communicate; she had a breathing tube?

Witness_ Nam Heui Kim - Vol. 1.txt: 76:21 - 77:9

21 THE WITNESS: It would -- the

22 decision would have been made by either her

23 proxy or next of kin.

24 Q. (By Mr. Jensen) And have you just told us that

25 Karen Bartlett, because a proxy had to speak for her, 

00077

1 would not have had a say in whether that procedure was

2 done or not?

3 A. Right.

4 Q. Would it be correct to state that Karen was so

5 ill through this time, March 14, that based upon your

6 care and treatment, she didn't have any say in whether

7 or not she got any medical procedures. It was

8 authorized by her husband or her proxy?

9 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 77:11 - 78:6

11 Your next note, Doctor, or part of that note says, "Not

12 alert or oriented enough to protect airway." What does

13 that mean?

14 A. Well, there's several criteria we often used for

15 whether or not a patient can be extubated, okay. That

16 means whether or not we can take the breathing tube

17 out. One is they have to be able to show that

18 mechanically, they can breathe on their own, okay. The

19 other one is that they can -- are neurologically awake

20 enough so that they don't aspirate because your -- your

21 mechanisms to protect your lungs from, for instance,

22 aspiration is very dependent on your neurological

23 processes. So if -- if those mechanisms are awry

24 because neurologically you're not there, then we worry

25 that someone cannot protect their airway, that they 

00078

1 will potentially aspirate their own saliva or

2 regurgitate instead of being able to, you know, throw

3 it down the side, they breathe it in.

4 Q. Protecting the airways, is that, in part, that

5 they're neurologically active enough to be able to

6 vomit to protect their airway?

Witness_ Nam Heui Kim - Vol. 1.txt: 78:9 - 79:9

9 THE WITNESS: It's hard to -- it's

10 hard to explain but you have a lot of

11 neurological processes that you're not

12 consciously aware of but that you use to

13 protect your airway. So you swallow, and

14 when you swallow, you have it go down the

15 esophagus and not the trachea. People who

16 are not neurologically in tact may have

17 lost that mechanism. So they may swallow

18 or aspirate. They -- they may vomit and

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19 instead of having the vomit go out, they

20 may actually breathe it in.

21 There's -- it's unfortunately not

22 simple and it's difficult to explain, but

23 we do consider it a risk when someone is

24 not neurologically in tact that they are

25 unable to protect their airway from either 

00079

1 aspiration, from vomit, and that they

2 just -- they are unable to have the

3 appropriate mechanisms.

4 Q. (By Mr. Jensen) You touched on this but please

5 teach us the relationship between the mechanical

6 ventilator, also known as the breathing machine, and

7 either the line she's breathing through or the

8 potential tracheostomy; is it easier to get off the

9 breathing machine if you get trached?

Witness_ Nam Heui Kim - Vol. 1.txt: 79:11 - 80:3

11 THE WITNESS: Yes.

12 Q. (By Mr. Jensen) Why is that true?

13 A. Typically it's easier to get -- once again,

14 because it's the tracheostomy is a more secure access

15 for, one, pulmonary toileting, for suctioning; two,

16 it's a shorter airway so it's a shorter straw to

17 breathe through versus a long straw to breathe through

18 like the endotracheal tube. It's easy to attach and

19 unattach, meaning that it's always there. If you

20 extubate someone and take them off the breathing

21 machine and take the tube out, then if they are

22 failing, you would have to reintubate them, which is a

23 process that can have complications. In order to see

24 if someone can breathe on their own, it's very simple

25 with a tracheostomy. You can just take them off the 

00080

1 mechanical ventilator, and when they look like they're

2 not doing well, you can simply reattach it.

3 Q. Would you have usually in the course of your

Witness_ Nam Heui Kim - Vol. 1.txt: 81:5 - 81:13

let me show you part

6 of Exhibit 135, Dr. Sheridan asked for this RICU

7 consult and it's seven pages long and it's signed at

8 the bottom of the seventh page by Dr. Ken Shepherd.

9 And he first says on page one of his consult, he

10 crosses out NKDA.

11 A. That is no known drug allergies. And then he

12 crosses it out because he understands that she does

13 have an allergy listed which is sulindac.

Witness_ Nam Heui Kim - Vol. 1.txt: 82:20 - 83:2

20 Q. So based upon this note, her RICU consult, would

21 it be your understanding that Dr. Shepherd is likely a

22 lung doctor, also known as a pulmonologist?

23 A. Well, yes. Most often the respiratory intensive

24 care unit is taken care of by pulmonologists.

25 Q. And this lung doctor, or pulmonary specialist, 

00083

1 writes, "No history of preexisting lung disease,"

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2 correct?

Witness_ Nam Heui Kim - Vol. 1.txt: 83:4 - 83:10

4 THE WITNESS: Yes.

5 Q. (By Mr. Jensen) Would you have interpreted that

6 in your care and treatment of Karen Bartlett to mean

7 that this lung specialist is communicating to other

8 healthcare providers like you who read this note that

9 he believes that Karen Bartlett's lung issues are not a

10 result of anything she had before she got TEN?

Witness_ Nam Heui Kim - Vol. 1.txt: 83:14 - 83:17

14 THE WITNESS: Yes. Essentially he's

15 saying that before this illness, she didn't

16 have any lung diseases like COPD, asthma,

17 or other typical diseases.

Witness_ Nam Heui Kim - Vol. 1.txt: 83:19 - 84:10

What's ARDS, acute respiratory

20 distress syndrome, please, Doctor?

21 A. ARDS is a -- it's a syndrome where the lung is

22 damaged. It's often -- well, essentially, the damage

23 is in the alveoli or the alveoli wall is typically very

24 thin like a cell layer thick and allows easy diffusion

25 of oxygen and carbon dioxide from the air space to the 

00084

1 bloodstream, okay. What happens is in ARDS is this

2 typically becomes very thickened, fibrous, and it

3 becomes more difficult for oxygen, typically oxygen --

4 CO2 usually diffuses easier anyways -- but it makes it

5 more difficult for gases to exchange across the cell

6 barrier.

7 Q. And do you recollect that Karen Bartlett was

8 diagnosed with ARDS, and I guess here as of March 1,

9 '05, in relation to this bronchoscopy done by a

10 resident and supervised by Dr. Ryan?

Witness_ Nam Heui Kim - Vol. 1.txt: 84:12 - 85:1

12 THE WITNESS: Well, the -- she -- it

13 says the diagnosis but ARDS is, you know,

14 typically requires a certain criteria

15 which, you know, you would have to list

16 whether or not, you know, they had a

17 certain -- a gradient, whether or not they

18 had certain pressures, etc., whether they

19 had findings on chest x-ray. So typically

20 you would not diagnose this by

21 bronchoscopy.

22 Q. (By Mr. Jensen) Thank you for that explanation.

23 That in mind, was it your understanding based upon your

24 care and treatment of Ms. Bartlett that she didn't have

25 ARDS, didn't have COPD, and didn't have any need for a 

00085

1 mechanical ventilatory support before she got TEN?

Witness_ Nam Heui Kim - Vol. 1.txt: 85:2 - 85:10

2 MR. GEOPPINGER: Objection; form.

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3 THE WITNESS: Before she got sick,

4 she had none of these. I mean...

5 Q. (By Mr. Jensen) Was it -- was it at this point

6 in your care and treatment of Karen Bartlett, Dr. Kim,

7 a true statement that based upon everything you knew

8 about Karen Bartlett and her condition, that everything

9 you were treating was a direct or indirect consequence

10 of her toxic epidermal necrolysis, or TEN?

Witness_ Nam Heui Kim - Vol. 1.txt: 85:13 - 85:18

13 THE WITNESS: Yes.

14 Q. (By Mr. Jensen) Restated, was it your belief

15 and clear understanding that if Karen Bartlett would

16 have never had TEN secondary to, most likely, sulindac

17 as concluded by you and Dr. Ryan, that she would have

18 never needed to be in a burn unit?

Witness_ Nam Heui Kim - Vol. 1.txt: 85:22 - 86:25

22 THE WITNESS: If she never had TENS,

23 she would not have required a burn unit.

24 Q. (By Mr. Jensen) You --

25 A. If she didn't have TENS, she would not have 

00086

1 needed a burn unit.

2 Q. And you say, "Suspicious for possible

3 coagulation disorder," correct, Doctor?

4 A. Which page is that?

5 Q. On page 298, the bottom of your March 14 note,

6 please.

7 A. Okay. So --

8 Q. Just for -- is that what it says, Doctor?

9 A. It says, "Suspicious for possible coagulation

10 disorder."

11 Q. Can coagulation disorders cause something called

12 a deep vein thrombosis?

13 A. Yes.

14 Q. Did Karen Bartlett get a deep vein thrombosis?

15 A. I do not remember.

16 Q. Okay. Does immobility or, as doctors call it,

17 stasis often result in deep vein thrombosis?

18 A. It is a risk factor.

19 Q. Representing to you there's documentation that

20 Karen Bartlett had a DVT and was, therefore, treated

21 with blood thinners or what doctors call anticoagulants

22 in the Mass medical chart, do you believe based upon

23 your care and treatment of Ms. Bartlett that that DVT

24 also would have been an indirect consequence of her

25 TEN? 

Witness_ Nam Heui Kim - Vol. 1.txt: Page 87, Line 3

3 THE WITNESS: Most likely.

Witness_ Nam Heui Kim - Vol. 1.txt: 89:21 - 89:23

21 Q. Disseminated intravascular coagulopathy is a

22 condition that, if it progresses, can quickly lead to

23 death, correct?

Witness_ Nam Heui Kim - Vol. 1.txt: 90:1 - 90:20

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1 THE WITNESS: Yes. But according to

2 this note --

3 Q. (By Mr. Jensen) Let me ask a new question. Was

4 DIC ever a concern of yours in the treatment of Karen

5 Bartlett?

6 A. She's hospitalization number 41 on that note on

7 the -- on the 16th, and on the 14th I'm concerned that

8 she has some sort of coagulation disorder, though I do

9 not mention DIC. So someone on the 15th must have

10 started a DIC workup. So someone apparently was

11 suspicious for DIC because on the 16th I have the

12 results and say that it's not consistent with DIC.

13 Q. Is DIC strongly associated with multiorgan

14 failure and --

15 A. It can be, yes.

16 Q. Is DIC and multiorgan failure strongly

17 associated with end-stage of death process?

18 A. Yes, it can be.

19 Q. Hence, someone did a DIC workup to hopefully

20 avoid that from happening?

Witness_ Nam Heui Kim - Vol. 1.txt: 90:23 - 91:19

23 THE WITNESS: Well, sometimes when

24 someone is bleeding or has a DVT or doing

25 both at the same time, there's concern that 

00091

1 she is not coagulating appropriately. The

2 whole thing about DIC is that you may be

3 coagulating in the wrong places and not

4 coagulating in the wrong places.

5 Q. (By Mr. Jensen) Let's just quickly catalog, if

6 we might, Doctor, I have you seeing Karen Bartlett four

7 times over the 10th; the 11th is the fifth; 14th is the

8 sixth; 16th is the seventh -- 17th -- 18th would be the

9 ninth; the 21st would be the tenth; 23rd would be the

10 12th; 24th, thirteenth; 25, fourteenth; 28th is the

11 fifteenth; 30th is the sixteenth; 31st, seventeenth;

12 April 1st, the eighteenth; April 3 the nineteenth;

13 April 4 the twentieth; April 10 the twenty-first; April

14 11 the twenty-second; April 12 the twenty-third; and

15 April 24 the twenty-fourth time.

16 With that approximate catalog in mind, does it

17 appear to you that you actually saw Karen Bartlett

18 approximately 24 times in a critical care setting at

19 Mass General?

Witness_ Nam Heui Kim - Vol. 1.txt: 91:22 - 91:25

22 THE WITNESS: Yes.

23 Q. (By Mr. Jensen) And would you approximate that

24 on each of these occasions, you spent over 35 minutes

25 or so with Karen? 

Witness_ Nam Heui Kim - Vol. 1.txt: 92:3 - 92:5

3 THE WITNESS: Yes. I mean, it's

4 roughly 30-some minutes is very, very

5 typical from most of these notes.

Witness_ Nam Heui Kim - Vol. 1.txt: 93:20 - 93:21

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Is that your signature on the bottom

21 of 412, Doctor? The date is March 28, '05.

Witness_ Nam Heui Kim - Vol. 1.txt: Page 94, Line 6

6 A. Yes. The bottom of the page is mine.

Witness_ Nam Heui Kim - Vol. 1.txt: 94:16 - 94:21

And had you read it before you

17 started writing on the same page, you would have seen

18 that Dr. Ojikutu here said, Impression Recommendations,

19 "45-year-old female with TEN secondary to NSAIDs,

20 clinically improving," correct?

21 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 96:5 - 96:14

5 Q. (By Mr. Jensen) I'd like now to direct your

6 attention, please, Doctor, to your March 18 entry.

7 Tell me when you're there, please.

8 A. Okay. All right.

9 Q. And there you say, "The trach," that we've been

10 discussing, "is cancelled due to patient's family

11 reluctance to proceed with feelings of doom and

12 forboding associated with the prospect of the procedure

13 delayed to Monday, the 21st," correct?

14 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 96:18 - 97:1

18 Q. Let me show you Dr. Sheridan's note of a similar

19 date or -- strike that. Let me first show you the

20 pulmonologist's note of -- let's get a date here --

21 same day, 3 -- March 18. And he says, "I feel she is

22 not ready for extubation now and likely for some time

23 to come." Would you have understood that to be talking

24 about the same topic whether or not she should get

25 trached? 

00097

1 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 97:24 - 98:8

24 Q. (By Mr. Jensen) Dr. Kim, the same day you made

25 this note on March 18, '05, about the trach being 

00098

1 cancelled, Dr. Sheridan made this typed up note and he

2 said, "She has been considered for tracheostomy over

3 the past few weeks. This has been delayed because of

4 extensive bleeding she has had from visceral locations,

5 including her airway, in fear of operating in that

6 environment."

7 What are the visceral locations he'd be

8 referring to, please?

Witness_ Nam Heui Kim - Vol. 1.txt: 98:10 - 98:18

10 THE WITNESS: Well, he's not precise

11 about it, but from her history I would

12 suspect that the perioral area, the airway,

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Page 33

13 you know, and -- well, actually, including

14 her airway, he says, and from her GI tract.

15 Q. (By Mr. Jensen) Dr. Sheridan also on March 18,

16 '05 says here at the bottom that "Certainly prognosis

17 for her survival remains guarded and the family is

18 aware." Do you see that?

Witness_ Nam Heui Kim - Vol. 1.txt: 98:21 - 99:2

21 A. Yes.

22 Q. Okay. Based upon you treating and evaluating

23 and caring for Karen the same day, would you concur

24 with what Dr. Sheridan reported that day that her

25 survival remained or -- her prognosis for survival 

00099

1 remained guarded at that time?

2 A. Yeah. She's still critically ill.

Witness_ Nam Heui Kim - Vol. 1.txt: 99:19 - 99:24

19 Q. Did Karen have a feeding tube? Is that how she

20 was being fed --

21 A. Yes. It says, "tube feeds." She's on tube

22 feeds.

23 Q. When you see a TF, that's tube feeds?

24 A. Typically it's tube feeds.

Witness_ Nam Heui Kim - Vol. 1.txt: 100:13 - 100:20

13 Q. And when's the last time you've seen her on a

14 tube feed according to your review of the records,

15 please?

16 A. From my review of the records you gave me of

17 notes I wrote, the last time is on April 12.

18 Q. So that would have been approximately two months

19 and eight days after she got to the hospital on

20 February 4, correct?

Witness_ Nam Heui Kim - Vol. 1.txt: 100:22 - 101:4

22 THE WITNESS: I'd have to do the

23 math.

24 Q. (By Mr. Jensen) That's why I said,

25 "approximately." 

00101

1 A. Yeah, approximately.

2 Q. Okay. On March 21 you make a note that says,

3 "Status post tracheostomy today." Does that mean she

4 got it that day?

Witness_ Nam Heui Kim - Vol. 1.txt: 101:7 - 101:8

7 A. Yes, that would mean that she had it done that

8 day.

Witness_ Nam Heui Kim - Vol. 1.txt: 102:11 - 102:15

11 Q. (By Mr. Jensen) And in lay terms to Karen

12 Bartlett on this date, what did it mean that she was

13 still in respiratory failure?

14 A. That means she still required a mechanical

15 ventilator.

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Witness_ Nam Heui Kim - Vol. 1.txt: 103:16 - 104:3

16 Q. And here you enter "Prophylactic Nexium,

17 Fragmin." Does prophylactic mean precautionary?

18 A. It's to prevent -- to prevent something.

19 Q. And because they're blood thinners or Fragmin

20 is --

21 A. Fragmin is a blood thinner.

22 Q. -- would that have meant you're trying to

23 prevent a coagulation problem like a --

24 A. Like a DVT, yes.

25 Q. Okay. And you document in the next day after 

00104

1 her trach, March 22, that she remains in the ICU,

2 correct?

3 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 104:25 - 105:13

25 Q. Were you actually interpreting Karen's chest 

00105

1 x-rays?

2 A. Yes.

3 Q. And the next day on March 23, you said, "The

4 chest x-ray showed pleural effusions worsening."

5 First, tell us what a pleural effusion is when a doctor

6 like you saw it on her x-ray?

7 A. On which day, sorry?

8 Q. March 23.

9 A. March 23.

10 Q. So, first, please tell us what a pleural

11 effusion is.

12 A. A pleural effusion is fluid between the lung and

13 the chest wall.

Witness_ Nam Heui Kim - Vol. 1.txt: 106:14 - 106:18

On March 24, the

15 next day, you spend another 39 minutes, it looks like,

16 in critical care and treatment of Karen, and there you

17 state, in part, that she's sedated and not adequately

18 waking up yet?

Witness_ Nam Heui Kim - Vol. 1.txt: 106:21 - 107:15

21 A. Yes.

22 Q. And you say, "Weaning the sedative Versed is

23 tolerated. Methadone, Ativan, and Haldol to be

24 continued." We haven't spoke about Haldol yet. What

25 is that, please? 

00107

1 A. Haldol is a -- trying to remember the name of

2 the class -- but it's an antipsychotic.

3 Q. Ativan is a what, please?

4 A. Benzodiazepine.

5 Q. Is it used for antiseizure?

6 A. Ativan can be used in seizures but --

7 Q. Oh -- Sorry.

8 A. Go ahead.

9 Q. Is it also used for pain control?

10 A. No. It's used for -- it's an anxiolytic, like

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11 Versed. It's in the same family.

12 Q. Why was she being given an antipsychotic drug

13 Haldol?

14 A. Because often it will decrease their need for

15 anxiolytics.

Witness_ Nam Heui Kim - Vol. 1.txt: 109:7 - 109:24

7 Q. (By Mr. Jensen) On March 25, the next day, you

8 document hospital day 50, it looks like, and you say,

9 "Chest tube placed yesterday with excellent result.

10 New central line today." And that was entered why?

11 A. Well, I usually go over the events and that's

12 why I place events of pertinence there. The chest tube

13 was placed because of the pleural effusions. If it's

14 gets large enough, then we worry that it can impact the

15 mechanical -- the mechanical -- the ability for the

16 lung to ventilate.

17 Q. Okay.

18 A. It just takes up space.

19 Q. Based on your entries here that she was awake

20 and under Neuro, you say, "A little more agitated but

21 more awake," would it have been, from your review of

22 your notes, would Karen have, at that point, been able

23 to communicate with her doctors and participate in her

24 care decisions or not?

Witness_ Nam Heui Kim - Vol. 1.txt: 110:1 - 110:14

1 THE WITNESS: To a low level because

2 I also state in her exam that she is awake

3 and she's nodding to questions. So she's

4 at least able to answer simple questions,

5 like: Are you in pain, are you not in

6 pain, are you hungry, not hungry, things

7 like that.

8 Q. (By Mr. Jensen) Hence, would it, therefore,

9 based upon what you just told us still have been your

10 impression based upon your review of your notes that at

11 that point Karen was not able to participate actively

12 in her care yet, but she would still need her husband

13 or her sister or whoever her proxy was to make

14 decisions for her?

Witness_ Nam Heui Kim - Vol. 1.txt: 110:17 - 111:1

17 THE WITNESS: At this point it's most

18 likely that all major medical decisions

19 were made by her proxy.

20 Q. (By Mr. Jensen) On the same day, second page,

21 you say, under Wounds, can you read us your note there,

22 please.

23 A. Okay. Yes.

24 Q. Can you read it, please.

25 A. Oh, "Granulating back wound, some 

00111

1 epithelialization but still very raw and oozy."

Witness_ Nam Heui Kim - Vol. 1.txt: 111:8 - 111:11

Let's go, then, to March 28. And you

9 write, "Waking up nicely as we decrease medications,"

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10 correct?

11 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 112:7 - 113:15

Were you involved in making

8 decisions as to what would be used on different

9 portions of Karen's body for her skin care? Dr. Ryan,

10 I'll represent to you testified that to the effect that

11 different things can be used on different locations of

12 her body. Pig skin might be used on her chest, for

13 example, and Acticoat might be used on other portions.

14 Were you involved in those decisions?

15 A. Yes.

16 Q. Tell us what the most severe areas would get.

17 A. It depends really on the location, I mean, and

18 what -- what state they were in. So -- and for

19 instance, the back and Acticoat, for instance, on the

20 back would be very easy. We have huge, very large

21 Acticoat sheets that could just be placed on the bed

22 and she could lie on the Acticoat. I mean, none of

23 these -- none of these wounds required excision and

24 grafting, so our primary goal of care was, one, to take

25 care of -- to prevent infection, to provide support, to 

00113

1 hopefully prevent a lot of losses of fluid from open

2 raw areas. So...

3 Q. On March 30 you document, in part, that the

4 wounds back slowly closing, correct?

5 A. Mm-hmm.

6 Q. What -- was the back a primary area of bleeding

7 for Karen and skin care?

8 A. Well, multiple -- many of these notes say that

9 her back was oozy. So her back was fairly -- sounds

10 like it was fairly raw and was a source of some, you

11 know, oozy bleeding.

12 Q. For a layperson who might not understand, why

13 can a person be at Mass General for 55 days and still

14 have their back be bleeding? Tell us how it's possible

15 that that can still be true.

Witness_ Nam Heui Kim - Vol. 1.txt: 113:17 - 114:16

17 THE WITNESS: Well, it has to

18 epithelialize. That means that your own

19 body has to create the epidermis to go over

20 the back. And one, you lie on your back

21 all the time and she had wounds all over.

22 So it's like you can't -- it's very

23 difficult to have someone on their stomachs

24 when they're intubated. So she's on her

25 back a lot. 

00114

1 Q. (By Mr. Jensen) Is a lay definition of

2 reepithelialize the body's creation of new skin where

3 skin has fallen off?

4 A. It is -- you know how you have a layer of skin

5 over your -- well, the skin is actually very complex,

6 and the dermis is the living layer of skin and the

7 epidermis is the top layer of it. Essentially in TENS

8 you don't lose the entire dermis. So you're not

9 technically completely making new skin but you have to

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10 have a protective layer on top of the skin. So that's

11 what she needed.

12 Q. With the teaching you just provided us, and

13 thank you for it, Doctor, is a correct lay definition

14 of reepithelialize your body's creation of the top

15 layer of your dermis that has fallen off?

16 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 114:18 - 116:8

18 Q. (By Mr. Jensen) On hospital day 56, March 31,

19 you say, "Versed off." Does that mean she's completely

20 off that --

21 A. She is completely off the Versed. However, she

22 is now on Ativan. She's getting it three milligrams

23 four times a day, if that -- is that the little 4 --

24 that little 4 on top, okay.

25 Q. Still getting Methadone and now getting Haldol 

00115

1 six times a day?

2 A. Six times a day.

3 Q. And you document the next day, her wounds back

4 slowly healing, still has TEN, correct?

5 A. Mm-hmm.

6 Q. And on April 1 you say, "Exam: Sedated but

7 awakens." Have you further decreased her sedatives or

8 painkillers at this time?

9 A. No. It sounds like I probably did not make any

10 changes from the previous day on her Ativan, Methadone,

11 and Haldol.

12 Q. And you note in the second page that she still

13 has some open spots scattered throughout but her wounds

14 are better, correct?

15 A. Yes. And it does seem like we were treating her

16 with Acticoat and Mepitel. So we --it was Acticoat.

17 Q. And what's -- thank you for that. And what's

18 Mepitel?

19 A. It's just a -- it's like a flexible plastic

20 sheet that goes between the Acticoat just to prevent

21 sticking. So it itself doesn't have any therapeutic

22 properties. It just helps the Acticoat from sticking

23 against her.

24 Q. And what's Acticoat?

25 A. Acticoat is the silver dressing. It has silver 

00116

1 as the active agent.

2 Q. What's aqua gel?

3 A. Aquacel.

4 Q. Aquacel.

5 A. It's a cellulose type of agent. It can be

6 absorbent but that was not used on her back.

7 Q. Was Aquacel used on Karen Bartlett for her --

8 A. I don't recall if Aquacel was used on her.

Witness_ Nam Heui Kim - Vol. 1.txt: 116:14 - 116:20

14 Q. (By Mr. Jensen) Here's Dr. Ryan's note of

15 February 28 and she says, "Wounds: Xenograft to back

16 and silver nitrate. Sloughs reepithelializing. Mouth

17 still very bloody. She has vaginal adhesion." Does

18 that refresh your recollection that Karen had pig skin

19 as one of the treatments that you and your colleagues

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20 were using?

Witness_ Nam Heui Kim - Vol. 1.txt: 116:22 - 118:3

22 THE WITNESS: Well, yeah, clearly.

23 She documents that xenograft was used.

24 Q. (By Mr. Jensen) And tell us -- we've heard it's

25 pig skin but beyond it being called a xenograft and we 

00117

1 know it's pig skin, tell us what it is and how it's

2 applied to help the wound heal.

3 A. Well, it prevents -- it's used essentially as a

4 barrier, okay. It's a biological dressing and it helps

5 prevent fluid loss but -- and often if someone does

6 need grafting -- in her, I don't think she ever needed

7 grafting -- but if they do need grafting, if the

8 xenograft takes, it's a good indication that your skin

9 graft, when you harvest from the patient herself or

10 himself, will -- is likely to take as well. So you

11 don't waste an excision and grafting episode in -- on

12 an area that is not ready for a graft.

13 Q. I'm going to skip to April 4, Doctor, and on

14 that day on the second page, do you state that Karen

15 still has too many pulmonary secretions to try PM value

16 [sic] on trach?

17 A. Yes.

18 Q. What does that mean?

19 A. Essentially it still has too many pulmonary

20 secretions to try a Passy-Muir valve on the trach.

21 Q. What is that?

22 A. The Passy-Muir valve actually plugs up the trach

23 enough so that she can have air going past her vocal

24 cords so she can talk.

25 Q. Does that mean she was able to talk at that 

00118

1 time?

2 A. Well, no because we couldn't use a Passy-Muir

3 valve because I felt her secretions were too much.

Witness_ Nam Heui Kim - Vol. 1.txt: 118:11 - 118:18

11 Q. On April 10, which I guess is about two months

12 and a week into her hospitalization, you document,

13 "Patient pulled out IntroFlex. It was replaced

14 yesterday." What is that that was pulled out?

15 A. IntroFlex is a feeding tube.

16 Q. And is it -- is it not uncommon as of 2005, in

17 your experience, Doctor, that patients both, A, want to

18 pull out their feeding tube; and B, pull them out?

Witness_ Nam Heui Kim - Vol. 1.txt: 118:21 - 118:25

21 THE WITNESS: Unfortunately, it's not

22 uncommon.

23 Q. (By Mr. Jensen) Why is it not uncommon based

24 upon your care and treatment of Karen Bartlett that

25 this occurs? 

Witness_ Nam Heui Kim - Vol. 1.txt: 119:3 - 119:24

3 THE WITNESS: Because people don't

4 like foreign bodies in their nose going

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5 down into their stomachs, and when they're

6 uncomfortable and they're not thinking,

7 they pull it out.

8 Q. (By Mr. Jensen) On the next day, April 11, I

9 guess is the day before her discharge, you write,

10 "Stable. Fiberoptic endoscopic evaluation swallow FEES

11 tomorrow." Tell us what that's about, please.

12 A. Essentially, we want to know that if she can

13 safely swallow. So if she can safely swallow, then she

14 can be fed.

15 Q. And you -- did you do that test to determine

16 whether she could safely swallow?

17 A. No. It's done by another service.

18 Q. And what does FEES stand for?

19 A. Fiberoptic endoscopic evaluation of swallow.

20 Q. And then the next day on 4/12, which I think is

21 the date of Karen's first of two discharges from Mass

22 General, you say, "If okay, will decannulate the

23 tracheostomy." What does that mean, Doctor?

24 A. It means take the tracheostomy out.

Witness_ Nam Heui Kim - Vol. 1.txt: 120:6 - 120:13

6 Q. And I'll show you and refresh your recollection

7 in a moment that at least for some of those twelve

8 days, she was at Northeast Rehab Hospital. I'll show

9 you the discharge summary from her second

10 hospitalization where she got back to Mass General on

11 4/18 and left for a second time on 4/27. And

12 Dr. Schultz documents that she was --

13 A. So she failed her FEES.

Witness_ Nam Heui Kim - Vol. 1.txt: 120:14 - 120:19

I'll show you what

15 happened for some of the time period that you just

16 referred to when she was out at a different hospital,

17 then came back to Mass General. And you see Karen

18 while she came back for her second hospitalization on

19 April 24?

Witness_ Nam Heui Kim - Vol. 1.txt: Page 120, Line 24

24 A. I wrote a note so I must have seen her.

Witness_ Nam Heui Kim - Vol. 1.txt: 121:15 - 122:5

please, to tell us

16 what your understanding would have been when you were

17 treating her in her second hospitalization as to why

18 she needed that treatment, please.

19 A. So she was readmitted for respiratory issues.

20 Apparently she was very secretional. It appeared she

21 grew out multiple organisms during her stay, including

22 respiratory and urinary organisms. So she both had,

23 looks like, some sort of either pneumonia or

24 tracheobronchitis with copious secretions as well as a

25 urinary tract infection. She was also deemed to be 

00122

1 dehydrated with a free water deficit of four liters.

2 Q. So in summary, very briefly, the first

3 hospitalization, you were involved from day 8 all the

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4 way to day -- the last day of her service, which was

5 April 12, 2005, correct, Doctor?

Witness_ Nam Heui Kim - Vol. 1.txt: Page 122, Line 8

8 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 124:7 - 124:12

7 Q. Based upon this review we've done and your

8 review of other portions of the record, was it your

9 belief and impression for all of Karen's treatment at

10 Mass General in 2005 that it was all needed as a direct

11 or indirect result of her TEN which was concluded to be

12 a likely consequence of her ingestion of sulindac?

Witness_ Nam Heui Kim - Vol. 1.txt: 124:15 - 124:25

15 THE WITNESS: It -- her

16 hospitalization and whatever she needed was

17 a consequence of her TENS, and her TENS was

18 thought to be due to sulindac.

19 Q. (By Mr. Jensen) Have you seen patients this

20 week, Doctor?

21 A. Yes.

22 Q. Are you to see patients tomorrow?

23 A. Yes.

24 Q. Did you see patients last night?

25 A. Yes. 

Witness_ Nam Heui Kim - Vol. 1.txt: 125:19 - 125:22

have you ever

20 heard as of 2005 that anyone ever got TENS from

21 anything they ate in Chinatown or, for that matter,

22 anywhere in Boston?

Witness_ Nam Heui Kim - Vol. 1.txt: 125:24 - 126:1

24 THE WITNESS: No.

25 Q. (By Mr. Jensen) No, you have not heard that? 

00126

1 A. I have not heard that.

Witness_ Nam Heui Kim - Vol. 1.txt: 126:16 - 126:25

16 Q. (By Mr. Jensen) I asked Dr. Ryan, I'll

17 represent to you yesterday, whether she likes Chinese

18 food. She told me yes. And I asked her then whether

19 she's cut down her Chinese food consumption having

20 anything to do as a result of Karen Bartlett's care and

21 treatment, and she told me no. Asking you to assume

22 those facts are true, have you in any way cut down on

23 where you eat or what Chinese food you might eat as a

24 result of your care and treatment of Karen Bartlett?

25 A. No. 

Witness_ Nam Heui Kim - Vol. 1.txt: 127:2 - 127:6

2 THE WITNESS: No.

3 Q. (By Mr. Jensen) And have you occasioned the

4 Chinatown area to eat not too far from Mass General in

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5 Boston?

6 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 127:9 - 127:19

9 Q. I'm going to show you an exhibit, Dr. Kim, that

10 Dr. Ryan physically wrote on, and those are her

11 initials CMR on Exhibit 157. And it's a blow-up of a

12 table from a publication of Dr. Ryan's, and she agreed

13 that when I added, systemic features and complications,

14 I added, "of TEN," that that was an accurate statement

15 of what those things are on the chart.

16 In your review of that one page, do you agree

17 that, to your knowledge in 2005, those are some of the

18 systemic features and complications that occur with

19 TEN?

Witness_ Nam Heui Kim - Vol. 1.txt: 127:22 - 128:8

22 THE WITNESS: Yes, these are some of

23 the systemic features and potential

24 complications of TENS.

25 Q. (By Mr. Jensen) Like you, of course, Dr. Kim, 

00128

1 Dr. Ryan didn't see Karen every day because either you

2 were or Dr. Schultz or Sheridan. What she did is she

3 initialed for me things that she knew of that Karen

4 Bartlett had in relation to her TEN. I'd like you to

5 please review it and tell us whether or not you can add

6 any additional complications or features that

7 Ms. Bartlett had as a result of her TEN that you know

8 of, please.

Witness_ Nam Heui Kim - Vol. 1.txt: 128:11 - 128:20

11 THE WITNESS: So what she initialed

12 is essentially correct.

13 Q. (By Mr. Jensen) Okay. And do you know of any

14 additional complications, direct or indirect, of

15 Karen's TEN that you know of that Dr. Ryan did not

16 initial?

17 A. The vulvovaginal synechiae, which I did not

18 observe myself. It's -- Dr. Ryan diagnosed that.

19 Q. And would you put your initials by that, please,

20 on 157.

Witness_ Nam Heui Kim - Vol. 1.txt: 128:24 - 128:25

24 Q. And you put NK by that for the record?

25 A. Yeah. 

Witness_ Nam Heui Kim - Vol. 1.txt: 129:1 - 129:11

And then I'll show it to you on the

2 screen. It's easy to see. I went through this list

3 with Dr. Ryan also, it's a publication of Dr. Ryan's,

4 and it says, "General Treatment Strategy for" -- I'll

5 hand you Exhibit 158 that Dr. Ryan also put her

6 initials on and she agreed that that was a list of the

7 general treatment strategies for burn patients

8 including patients with TEN, and ask you if you agree

9 that Karen got each one of these.

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10 Did Karen get an early referral to a specialist

11 in a burn unit?

Witness_ Nam Heui Kim - Vol. 1.txt: 129:13 - 129:15

13 THE WITNESS: Yes.

14 Q. (By Mr. Jensen) Did Karen have prompt

15 withdrawal of the causative agent?

Witness_ Nam Heui Kim - Vol. 1.txt: 129:19 - 129:23

19 THE WITNESS: Well, it wasn't

20 withdrawn. It just wasn't given.

21 Q. (By Mr. Jensen) The causative agent sulindac

22 had been ceased before she got to Mass General?

23 A. Right.

Witness_ Nam Heui Kim - Vol. 1.txt: Page 130, Line 16

16 A. Yes

Witness_ Nam Heui Kim - Vol. 1.txt: 131:7 - 131:14

7 Q. Good afternoon, Dr. Bartlett [sic]. My name is

8 Jeffrey Geoppinger. I represent the defendant in this

9 case and I just have a few quick follow-up questions

10 and then we'll hopefully have you on your way, all

11 right.

12 Doctor, you and I have never met before,

13 correct?

14 A. Right.

Witness_ Nam Heui Kim - Vol. 1.txt: 131:20 - 132:22

20 Q. Is this the discharge summary that you completed

21 at the time of Karen Bartlett's discharge from

22 Massachusetts General on 4/14/2005?

23 A. I signed it.

24 Q. Did you dictate the information that's included

25 in here? 

00132

1 A. No.

2 Q. Who did?

3 A. That would be our nurse practitioner, Sally

4 Morton.

5 Q. All right. How did that work, did you -- how

6 did you convey the information to the nurse

7 practitioner such that she could get it into this

8 record?

9 A. What she does is she reviews the record, does a

10 dictation. And then I review her dictation and sign

11 it.

12 Q. So Ms. --

13 A. I don't tell her what to dictate. She just goes

14 through the record.

15 Q. So the information contained in, for instance,

16 this first section, history of present illness, was

17 obtained from Karen Bartlett's medical records by Nurse

18 Practitioner Sally Morton, correct?

19 A. Yes.

20 Q. That was not information that you yourself

21 placed into the history of present illness, correct?

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22 A. No.

Witness_ Nam Heui Kim - Vol. 1.txt: 135:1 - 137:24

1 Q. We've gone through those in quite some detail

2 today, and correct me if I'm wrong, but is it a fair

3 statement to say that nowhere in this exhibit did you

4 make any notation regarding NSAIDs being a triggering

5 or a hypothetical cause of Ms. Bartlett's TENS?

6 A. I don't think I have put it there, you know,

7 without reviewing everything, but it wouldn't -- it

8 wouldn't be something that I would note because it's

9 not an event and it's not a new allergy. It's not

10 anything new that's happened since her admission. So

11 it's very likely I may not have mentioned anything.

12 Q. Okay. As we sit here today, you can't point me

13 to anything that I missed --

14 A. No.

15 Q. -- because I believe I've read it.

16 A. I can't --

17 Q. Obviously it's your handwriting and --

18 A. I can't pinpoint anything at this, you know,

19 maybe if I took a microscope, maybe I could find

20 something. But from my review, I would say that no.

21 Q. Thank you. Doctor, is it a fair statement to

22 say that your primary concern with respect to

23 Ms. Bartlett is providing treatment for her TENS,

24 correct?

25 A. Yes. 

00136

1 Q. Your primary concern during her hospitalization

2 and during the course and scope of your treatment is

3 not to determine the etiology of her TENS, correct?

4 A. It is not to determine the etiology. It is --

5 except for the fact that we have to stop exposure to

6 it. But no. If we believe we've stopped exposure to

7 it, it's not something that I would spend a lot of time

8 investigating.

9 Q. Is it a fair statement to say that in the

10 interest of stopping exposure to potential reasons for

11 TENS, you're overly cautious in that respect?

12 A. You mean like prescribing the other drugs in the

13 same classification or with similar chemical

14 structures?

15 Q. What I mean is that in the interest of making

16 sure that you don't expose the patient to any potential

17 or hypothetical or possible reason why they had

18 initially contracted the TENS, that you're going to be

19 -- would it be fair to say that you're overly cautious

20 in that regard?

21 A. Well, we don't like to be overly but we like to

22 be reasonably cautious --

23 Q. All right. Fair.

24 A. -- okay, because you can rule out all sorts of

25 drug classes if you say that everything potentially 

00137

1 could be causing it. So we would like to be reasonably

2 cautious and make sure that the most likely culprits

3 are at least she's not exposed to again.

4 Q. Right. And when you say, "the most likely

5 culprits," is it a fair statement that your

6 determination, if you made one, that the most likely

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7 culprit in this case would be the use of an NSAID was

8 based upon her history and physical, correct?

9 A. It would be based on her history. Her physical

10 would give you no clue.

11 Q. Okay. And her history was what?

12 A. Her history was that she came in from New

13 England Medical Center with biopsy-proven TENS after

14 exposure to sulindac and eating Chinese food.

15 Q. And when -- another way of saying exposure to

16 sulindac is that she had taken sulindac in temporal

17 proximity to the diagnosis of TEN, correct?

18 A. Yes.

19 Q. Other than that temporal proximity, did you do

20 any type of experiment or any other type of process by

21 which to attempt to determine that --

22 A. No.

23 Q. -- sulindac had something to do with the TEN?

24 A. No.

Witness_ Nam Heui Kim - Vol. 1.txt: 145:5 - 145:9

Is there an identifiable class of people who

6 develop TENS?

7 A. Yes. Someone who may have had it before.

8 Q. Okay. Beyond that?

9 A. Beyond that, no.

Witness_ Nam Heui Kim - Vol. 1.txt: 148:2 - 148:13

2 Q. Were you compensated for your time spent

3 reviewing the medical records prior to coming to your

4 deposition today?

5 A. No.

6 Q. Do you intend to be?

7 A. I hope so.

8 Q. Are you going to bill for it?

9 A. Yes. I'm going to bill for it. It's a lot of

10 hours here.

11 Q. Sure. I understand. And you're going to bill

12 Mr. Jensen for it?

13 A. Yes.

Witness_ Nam Heui Kim - Vol. 1.txt: 148:18 - 149:7

18 BY MR. JENSEN:

19 Q. My first question, Doctor, is how much per hour

20 are you going to bill me for, please, ma'am?

21 A. Well, that's been a matter of debate. So I just

22 asked my boss what he charges and he said 500 an hour.

23 Q. Okay. So that will likely be the charge per

24 hour for your time spent away from your patients

25 reviewing your whole chart for Karen Bartlett? 

00149

1 A. Yes.

2 Q. The defense attorney for Mutual just pointed out

3 that you didn't get the entire medical chart from me.

4 Representing to you that it was over 1500 pages, at

5 $500 an hour would that have been something that you

6 would have reviewed the entire thing of? Would you

7 have even had time?

Witness_ Nam Heui Kim - Vol. 1.txt: 149:9 - 149:18

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9 THE WITNESS: I would not have

10 reviewed the entire record.

11 Q. (By Mr. Jensen) Would it -- of course the

12 defense attorney had the opportunity to provide you the

13 entire record today and so far they haven't, correct?

14 A. Correct.

15 Q. Okay. As of 2005, Dr. Kim, did you write down

16 every thought that entered your mind in your medical

17 records regarding the cause or etiology of a person's

18 TEN or other burn condition at Mass General?

Witness_ Nam Heui Kim - Vol. 1.txt: 149:22 - 150:2

22 THE WITNESS: No.

23 Q. (By Mr. Jensen) Is your answer no?

24 A. No.

25 Q. Why did you not write down every thought that 

00150

1 entered your head as to cause or etiology of a person's

2 TEN or other burn condition at Mass General?

Witness_ Nam Heui Kim - Vol. 1.txt: 150:4 - 150:11

4 THE WITNESS: While I was at Mass

5 General -- it's really not important to my

6 care of the patient.

7 Q. (By Mr. Jensen) Would you also as a matter of

8 practice not write down things that were already

9 documented in the medical records such as the repeated

10 statement that NSAIDs or sulindac was the cause of

11 Karen Bartlett's TEN?

Witness_ Nam Heui Kim - Vol. 1.txt: 150:14 - 150:17

14 THE WITNESS: I wouldn't be writing

15 down that information. I also don't write

16 down -- always write down treatment unless

17 it changes.

Witness_ Nam Heui Kim - Vol. 1.txt: 151:2 - 151:11

2 Q. (By Mr. Jensen) Do you recall the questions you

3 were asked about a mechanism of action just a couple

4 minutes ago?

5 A. Yes.

6 Q. As of 2005, Dr. Kim, did you know of any

7 examples where doctors like yourself did not know what

8 the mechanism of action was between an agent and a

9 condition or between Condition A and Condition B but

10 still believed there was a causal relationship between

11 the two?

Witness_ Nam Heui Kim - Vol. 1.txt: 151:15 - 151:20

15 THE WITNESS: Yeah.

16 Q. (By Mr. Jensen) In other words, in 2005 is it

17 correct to state that Dr. Kim knew that doctors didn't

18 need to know the cause of action to make sound medical

19 conclusions about causal relationships in certain

20 instances; is that fair?

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Witness_ Nam Heui Kim - Vol. 1.txt: 151:23 - 152:4

23 THE WITNESS: In certain instances,

24 yes.

25 Q. (By Mr. Jensen) Can you give us some examples 

00152

1 that you would have known of in 2005 of when doctors

2 like yourself did not know the mechanism of action but

3 still believed there was a causal relationship between

4 the two?

Witness_ Nam Heui Kim - Vol. 1.txt: 152:8 - 153:1

8 THE WITNESS: Well, ARDS. It's like

9 we don't always know the cause of ARDS.

10 Often it's infection or fluid overload, but

11 we still treat it the same way. Pneumonia

12 we just treat with antibiotics and hope we

13 get the right ones, broad spectrum, and

14 then tailor down if we get the information.

15 Q. (By Mr. Jensen) So you're telling us about you

16 don't know the mechanism of action between treatment

17 and cure, but you still believe there's a relationship,

18 a positive one between the two?

19 A. For --

20 Q. For ARDS and for pneumonia?

21 A. Well, sometimes the exact mechanism is unknown

22 but you treat it the same way, okay. And often it's

23 like if you delay treatment, for instance, in

24 infection, like a pneumonia, for waiting for the exact

25 mechanism, you have delayed for several days and the 

00153

1 patient is doing worse for it.

Witness_ Nam Heui Kim - Vol. 1.txt: 153:11 - 153:12

Is -- does idiopathic or idiosyncratic mean you

12 do not know the cause?

Witness_ Nam Heui Kim - Vol. 1.txt: 153:14 - 154:5

14 THE WITNESS: They actually mean two

15 different things, okay. Idiosyncratic

16 means that someone has a reaction that is

17 different than anyone else's reaction, and

18 idiopathic means it's an unknown cause.

19 Q. (By Mr. Jensen) So when you speak of an

20 idiopathic disease, that's not a cause for the disease.

21 That means doctors don't know the cause for the

22 disease, correct?

23 A. Yes.

24 Q. And is it correct to state that based upon your

25 care and treatment of Karen Bartlett, you knew of 

00154

1 nothing that but for the events that led to her TEN,

2 taking sulindac specifically, would have made her

3 predisposed or more likely to get TEN than anyone else

4 in this room or in the world?

5 A. Yes. We just don't know.

Witness_ Nam Heui Kim - Vol. 1.txt: 154:14 - 155:11

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Is it correct to state that you knew

15 of nothing about Karen Bartlett's past medical history

16 or her medical and physical conditions which

17 predisposed her to getting TEN based upon your care and

18 treatment?

19 A. Yes.

20 Q. Yes, you did not know of any such things,

21 correct?

22 A. I did not -- I do not know of any such things.

23 Q. Okay. Do you recall the question you were asked

24 about whether you did an experiment to determine if

25 sulindac caused her TEN? 

00155

1 A. Would I do an experiment?

2 Q. No. Do you recall being asked by Mutual's

3 attorney whether you did an experiment or not to

4 determine if sulindac caused Ms. Bartlett's TEN?

5 A. Yeah, something like that.

6 Q. In 2005, Dr. Kim, was there any experiment that

7 you knew of or that, to your knowledge, was known to

8 medicine other than a positive rechallenge that could

9 have been done to confirm your conclusion and Dr.

10 Ryan's conclusion that sulindac had caused Karen

11 Bartlett's TEN?

Witness_ Nam Heui Kim - Vol. 1.txt: 155:14 - 156:2

14 THE WITNESS: I don't know of any way

15 to do that test except rechallenging

16 someone with the -- what is believed to be

17 the causative agent.

18 Q. (By Mr. Jensen) And a rechallenge, do you

19 agree, would mean reintroducing or giving her sulindac

20 again, which would be highly unethical to do?

21 A. Yes. It could potentially have very harmful

22 effects if it is the causative agent.

23 Q. So in short, as you knew it in 2005, there was

24 no test known to modern medicine other than that highly

25 unethical option to do what the defense attorney asked 

00156

1 you about, to do an experiment to confirm causation,

2 correct?

Witness_ Nam Heui Kim - Vol. 1.txt: Page 156, Line 6

6 A. Yes.

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