10/10/2026
IN THE IOWA DISTRICT COURT FOR POLK COUNTY
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JESSICA L. LAURIE, Individually,:
and as next friend of JANYIA M. :
LAURIE, a minor, :
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0002
1 2 3 4 5 6 7 8 Plaintiffs, :
:
vs. : :
UNITYPOINT HEALTH d/b/a Iowa :
Methodist Medical Center, :
ANN M. FLATLEY, P.A., :
MICHAEL C. MINTZER, M.D., UNITY :
POINT CLINIC OB/GYN AT LAKEVIEW,:
SAM CHENG, M.D., and VIRTUAL :
RADIOLOGIC PROFESSIONALS, LLC, :
a/k/a VIRTUAL RADIOLOGIC :
PROFESSIONS OF MINNESOTA, P.A. :
:
Defendants. :
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Law No. LACL132240
DEPOSITION OF ANN M. FLATLEY, P.A.,
taken by the Plaintiffs before Ann T. Moyna,
Certified Shorthand Reporter of the State of Iowa, at
1900 Hub Tower, 699 Walnut Street, Des Moines, Iowa,
commencing at 2:00 p.m., Wednesday, July 15, 2015.
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ANN T. MOYNA - CERTIFIED SHORTHAND REPORTER
APPEARANCES:
For the Plaintiffs: (via telephone) For Defendants UnityPoint Health and Ann Flatley, ROBIN R. SMITH, ESQ.
Gershon, Willoughby, Getz
& Smith, LLC
25 Hooks Lane, Suite 304
Baltimore, Maryland 21208
ZEV T. GERSHON, ESQ.
Gershon, Willoughby, Getz
& Smith, LLC
25 Hooks Lane, Suite 304
Baltimore, Maryland 20208
JOHN D. HILMES, ESQ.
Finley, Alt, Smith,9 10 11
P.A.: Scharnberg, Craig, Hilmes &
Gaffney, P.C.
699 Walnut Street, Suite 1900
Des Moines, Iowa 50309
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0003
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1 2 For Defendants Michael Mintzer, M.D. and UnityPoint Clinic OB/GYN at Lakeview: For Defendant Sam Cheng, M.D.: Also Present: JOSEPH L. FITZGIBBONS, ESQ.
Fitzgibbons Law Firm, LLC
108 North Seventh Street
P.O. Box 496
Estherville, Iowa 51334-0496
HAYWARD L. DRAPER, ESQ.
Nyemaster, Goode, P.C.
700 Walnut Street, Suite 1600
Des Moines, Iowa 50309-3899
Diane Hartschen-Law
Joe McManus
I N D E X
WITNESS EXAMINATION
Ann M. Flatley, P.A. 4 - Gershon
E X H I B I T S
EXHIBITS MARKED
Plaintiffs' Exhibits:
1 - Handwritten notes 68
P R O C E E D I N G S
ANN FLATLEY, P.A.,3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0005
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0006
1 2 3 4 called as a witness by counsel for the Plaintiffs,
being first duly sworn by the Certified Shorthand
Reporter, was examined and testified as follows:
EXAMINATION
BY MR. GERSHON:
Q. Can you please give us your name and address
for the record.
A. Ann Maria Flatley, 34462 Roseland Drive,
Cummings, Iowa 50061.
Q. Thank you. Ms. Flatley, my name is Sev
Gershon. I'm one of the attorneys for the plaintiffs
in this case. I'm going to be asking you a series of
questions. If at any time you do not understand one
of my questions, please tell me so or ask me to
rephrase it. If you do answer, though, I'll assume
you understood the question and I'll hold you to your
answer. Do you understand?
A. Yes, sir.
Q. Have you given a deposition before?
A. Never.
Q. So you should also know you need to answer
verbally as opposed to a nod of the head or shrug of
the shoulders, so the court reporter can take down
your testimony; okay?
A. Okay.
Q. Now, do you have a CV or resume with you?
A. No, I do not.
Q. Can you briefly take us through your
educational background, where you went to school and
bring us up to the present?
A. So do you want me to start with high school
or college?
Q. When did you start college?
A. I graduated in 1986 from Sparta High School
in Sparta, Wisconsin. So fall of 1986 I started at
the University of Wisconsin Eau Claire. At that time
nursing major, but then found out about the P.A.
profession, and transferred to the University of
Wisconsin Madison.
When I arrived there my sophomore year I
started to--the prerequisites for the P.A. program,
applied, got in to the program in 1989, and graduated
in 1991.
Q. So you're a P.A.?
A. Yes.
Q. What is the title?
A. Physician's assistant.
Q. Perfect.
Okay. And what have you done since 1991?
A. Six months later I got married, headed to
Pensacola-- No. I'm sorry. I can't even think of
the base now. My husband is a Marine. He was a5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0007
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0008
1 2 3 4 5 6 Marine at that time. Pendleton, that's what I was
thinking of. Pendleton. I got my first job in
Escondido, California, in family practice, in
February of '92, and started my career. I was with
Graybill.
Q. Okay. And how long were you there?
A. With the company or in California?
Q. California.
A. We came back to Wisconsin in 2004.
Q. And where did you work?
A. My first job was with Graybill Medical
Group, and I was with them for 14 years. I started
in family practice, started having kids. Switched
over to urgent care because of the flexibility it
gave me. I did urgent care for a total of 17 years.
When I came back to Wisconsin I got another urgent
care job.
Q. And where are you working today?
A. I'm in the emergency room here with
UnityPoint, and I have been with them for four years.
Q. Okay. These four years, is this the first
time you have worked in an emergency room in your
career?
A. Yes.
Q. If you answered I didn't hear you.
A. Yes.
Q. Okay. I think what happens sometimes is I
will wait a second, or so, after you finish your
answer before me asking my next question. And you
too have to wait like a second, or so, after I finish
my question before you answer or it gets cut off. I
think that's what happened; okay?
A. Okay.
Q. Okay. I think you're telling me the four
years you're at UnityPoint was the first time you
worked in an emergency room setting; correct?
A. Yes.
Q. Correct?
A. Yes.
Q. Okay.
MS. SMITH: You'll get the hang of it. Just
give him a second. Okay, Zev.
BY MR. GERSHON:
It's just the electronic thing.
Q. Can I ask where did you get the training to
work in an emergency room setting?
A. Well, you know, with urgent care it's a lot
of acute situations, so for 17 years I took care of
people with acute problems, not chronic. That helped
with me transitioning in to the ED.
Q. Okay. Is it generally true that you
sometimes see sicker or more emergencies, if you7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0009
1 will, in an emergency room setting than you do in an
urgent care setting?
A. Absolutely.
Q. And did you have any particular additional
training or course work that allowed you to
transition to the more emergent patient that you
would see in an emergency department as opposed to an
urgent care center?
MR. HILMES: Object to form and foundation.
The question suggests that some additional training,
other than being a licensed P.A., is required.
Go ahead and answer the question for
Mr. Gershon.
A. No, I did not have further training for the
emergency room setting.
BY MR. GERSHON:
Q. Have you written any articles, chapters in
textbooks, or textbooks, that have to do with being a
physician assistant or medical topics?
A. No.
2 Q. You told us you've never gave a deposition
3 before. Have you ever testified in court before?
4 A. Never.
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1 2 3 4 5 6 7 8 Q. Have you ever had your hospital privileges
suspended, denied or revoked?
A. Never.
Q. Have you ever had your license to practice
as a physician's assistant acted unfavorably upon in
any way?
A. Never.
Q. Have you had an opportunity to review the
medical records of Ms. Laurie?
A. Yes.
Q. Did you remember taking care of this patient
before you saw the medical records?
A. Absolutely.
Q. Do you remember anything about your care or
treatment of the patient once you reviewed the
medical records you realized you forgot to document
something?
A. No.
Q. When you reviewed the medical records do you
believe any of your entries are inaccurate in any
way?
A. No.
Q. Before the lawsuit was filed in this case,
and after Ms. Laurie was taken to surgery, did you
discuss this case with any healthcare providers?
A. So before-- Can you repeat that, please?
Q. Sure.
I will make it easier. After Ms. Laurie was
taken to surgery, and before the lawsuit was filed in9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0011
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0012
1 2 3 4 5 6 7 8 9 10 this case, did you discuss her case with any
healthcare providers?
A. Yes. The following day when I came back on
my shift I wanted to know the outcome. I didn't know
what happened to her. I found out that she survived
and that her condition was due to a ruptured ectopic.
I don't know who I heard that from, it could have
been the shift leader. I really don't remember who
told me that. I inquired about her the following
day.
A few days later I did run in to Dr. Mintzer
and told him what I had heard. He gave me a
little--he gave me some information of what had
happened in the OR and what was found.
Then I ran into him one other time after the
baby was born, and he told me about the baby's club
feet. That's all we talked about.
Q. Okay. Do you have the medical records in
front of you so that should you choose to do so you
could look at them before answering any of my
questions?
MR. HILMES: We have medical records here.
Robin has a set in front of her. I have a set here.
It will be handy to refer to a page number, if we're
going to look at anything in particular, Zev.
They're here if we need to go there.
MR. GERSHON: Super. Do you have the same
pages that I have?
MR. HILMES: Well, I hope so. I think we
have exchanged records. Let me see what I have here,
Zev.
MS. SMITH: At least in part, I hope we do.
MR. HILMES: Ours all at the bottom, in the
notebook that I have, and I don't have--I could have
three notebooks, but I don't have all three notebooks
because the emergency room stuff is in one notebook
with about 800 pages. I have UPH-Jessica-0, for
example, 534. That's probably different than what
you have.
MS. SMITH: It is. We gave you this type of
a record that has just a single page written in the
middle.
MR. HILMES: Right. We're not using
Plaintiffs' record numbers, and haven't. Meaning we
numbered our own records and then turned them around
and sent them out.
MS. SMITH: I understand.
MR. HILMES: We have different numbers.
MS. SMITH: We don't have the same records,
Zev.
MR. HILMES: I bet you have the same record
numbers as Robin.11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0013
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0014
1 2 3 4 5 6 7 8 9 10 11 12 MR. GERSHON: You're right.
MR. HILMES: If you have some page number I
bet she can facilitate getting that page to the
witness, and then I'll see if I can find the same
thing in my numbering system. We'll plow through it.
We've done this before. We'll get 'er done.
BY MR. GERSHON:
Q. Okay. Now, Ms. Flatley, I also understand
that you wrote up one page of notes that will help
guide you as to what you did and when you did it; is
that fair?
A. Yes.
Q. Okay. If at the end of the deposition we
can mark that one page of notes as Plaintiffs'
Exhibit No. 1, I would appreciate it.
A. Okay.
Q. Can you tell me in general that day, if you
recall, what were your hours on September 20th, going
into the 21st of 2012?
A. I believe it was the 10:00 p.m. to 7:00 a.m.
shift.
Q. And can you tell again from memory, or your
review of the records, who was the MD who was
attending who supervised you during your shift?
A. Dr. Jeff Wright.
Q. And do you remember any conversations you
had with Dr. Jeff Wright concerning Ms. Laurie during
this shift?
A. Yes, I do.
Q. Please tell me.
A. After I spoke with the patient, examined
her, I went right to Dr. Wright to staff the patient
with him. He agreed with my assessment. I added on
from the abdominal pain protocol an OB ultrasound, a
quantitative HCG, and vaginal cultures.
Q. Where is this protocol written?
A. It's--
MR. HILMES: You mean the abdominal protocol
she mentioned?
MR. GERSHON: Yes.
MR. HILMES: All right. And you understood
that that had already been initiated. Go ahead.
MR. GERSHON: No.
A. Well, when Jessica arrived to the emergency
room she was initially seen by Joyce Rice, Registered
Nurse. Usually when someone comes in with belly pain
the nurses just know to start the abdominal pain
protocol.
BY MR. GERSHON:
Q. Oh, okay. I appreciate that. I'm just
asking is it written down anywhere what this
abdominal pain protocol is?13 14 15 16 17 18 19 20 21 22 23 24 25 0015
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0016
1 2 3 4 5 6 7 8 9 10 11 12 13 14 A. It's just something we all know in the
emergency room. If it's written, I don't know where
it is.
Q. Okay. That's all I was asking.
And you're telling me on top of the
abdominal pain protocol you added some additional
orders; is that correct?
A. Right. With the agreement of Dr. Wright.
Q. An additional order was a quantitative HCG;
correct?
A. Yes.
Q. And, I'm sorry, you said an ultrasound?
A. Yes.
Q. What type of ultrasound?
A. An OB ultrasound.
Q. Okay. Anything else?
A. Vaginal cultures.
Q. Okay. Is an OB ultrasound an abdominal
ultrasound or a transvaginal ultrasound?
A. Transvaginal.
Q. And you know the difference between,
obviously, a transabdominal ultrasound and
transvaginal ultrasound?
A. Yes.
Q. Okay. And when is the first time you saw
your patient, Ms. Laurie?
A. What time did I see the patient, is that
what you asked?
Q. Yes, ma'am.
A. At 11:00 p.m.
Q. Okay. And with what frequency did you want
these additional orders to be done?
A. I'm sorry. Can you repeat that?
Q. Sure. How soon, how rapid did you want the
HCG, the transvaginal ultrasound, and the cultures to
be done on your patient?
A. Stat.
Q. And what does stat mean at your hospital, or
I should say what did stat mean at your hospital in
September of 2012?
A. Immediately. On the electronic medical
records, we have that option to click the button
stat.
Q. Okay. And is it your understanding that
these additional orders you requested to be done stat
were, in fact, done stat?
A. Yes.
Q. Now, can you tell me again from your memory,
or your review of the records, how did the patient
appear when you first saw her?
A. She appeared to be in pain.
Q. Okay. Anything else you recall or can tell15 16 17 18 19 20 21 22 23 24 25 0017
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0018
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 us from your review of the records?
A. No.
Q. Okay. Well, let me try to refresh your
recollection. Can you turn in the medical records to
your first note with the patient?
I have it, Robin, on our page 81 is a
history.
MR. HILMES: Just let her look at it.
MS. SMITH: Well, I have notes on it and I'm
not going to let her look at it. I'm sorry.
MR. HILMES: This is going to be cumbersome.
BY MR. GERSHON:
Q. Can you turn to your medical records as far
as your initial interactions with the patient and
your history concerning that?
A. It's a typewritten note.
MS. SMITH: I'm showing him our page and
he's trying to find it. The problem is that I have
information written on it. Although, you know what?
I can just--I'll cross out what I have.
MR. HILMES: No. Don't worry.
MS. SMITH: Never mind. I'm not going to
sit here all day.
MR. HILMES: Here you go, ma'am.
MS. SMITH: Okay. Zev, he showed it to her.
MR. GERSHON: You have got to find it in
your records now, Jack; right?
MS. SMITH: He can just look at mine, or
hers, whatever. other.
They're just sitting next to each
A. I don't have the physical exam. have it all. rest.
I just only have the HMP. BY MR. GERSHON:
I don't
I need the
Q. Let me ask this: Page 1, is this your note
on the patient?
A. Yes, it is.
Q. Okay. And it continues for a few pages;
correct?
A. Yes.
Q. And is this your first note on the patient?
A. It's my only note.
Q. Your only note; okay. And if you look--if
we go ahead to pages 90 and 91, is that also the
continuation of your note?
MR. GERSHON: Hey, Jack, could you read into
the record your page number?
MR. HILMES: Zev, I have found the emergency
department note with the corresponding page number
here. Your first one was what, 89, Zev?
MS. SMITH: 81.
MR. GERSHON: 81.17 18 19 20 21 22 23 24 25 0019
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0020
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 MR. HILMES: All right. For us it's 815;
correct?
THE WITNESS: MR. HILMES: Yes.
And then does it continue into
816?
THE WITNESS: Yes.
MR. HILMES: And 817, 818, and was that it?
THE WITNESS: Yes. This is my physical
exam.
MR. HILMES: We have a physical exam a
couple pages into it, I think, Zev.
MR. GERSHON: Okay. Perfect. Let's go
back, if we can, to the beginning of your note on
page 81 when we talk about the history of the present
illness.
MR. HILMES: Got it.
BY MR. GERSHON:
Q. You would agree her primary presenting
complaint was pelvic pain?
A. Yes.
Q. Okay. And she also appeared lethargic to
you; correct?
A. Yes.
Q. She was also in the fetal position; correct?
A. Yes, due to pain.
Q. How often in the emergency room do you see a
patient in the fetal position?
A. I have seen it, but it's not something I see
every day.
Q. Can you somehow quantitate it? Is it a once
a week event, once a month, once a year?
A. Probably once a year.
Q. Okay. In addition, on your physical exam
you found tenderness over the pelvis; correct?
A. Yes, on the left side.
Q. Well, didn't it start on the left side, but
eventually went to the whole pelvis?
A. I would say majority of her pain was on the
left side.
Q. Okay. If you look at your records, the
third page, our page 83, where you say she is in the
fetal position and she had tenderness over the
pelvis. To my eyes those words are bolded, in bold
type. Do you see what I'm talking about?
A. Uh-huh.
MS. SMITH: You need to say yes.
THE WITNESS: Yes. I'm sorry.
BY MR. GERSHON:
Q. I don't know how it works, can you tell us
when--did you dictate these notes into the record or
do you type the notes?
A. I do both, but at this time I don't think we19 20 21 22 23 24 25 0021
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 had Dragon, so I may have typed it.
Q. So I don't want--I don't want you to
speculate. Nobody wants you to guess. But can you
tell us why you put patient is in fetal position and
she grumbles about lying on her back, and patient had
tenderness over the pelvis, all that's in bold type?
A. To be honest, I don't even remember doing
that.
Q. Okay. We only want honesty. We don't want
you guessing today. I appreciate that answer.
The times that you--the last four years that
you were in the emergency department, were you
trained at all how to detect if a patient is having a
surgical abdomen?
A. Yes.
Q. And how were you trained?
A. Well, we look at vitals from our exam. Do
they have absent bowel sounds, are they rigid, is
there rebound, is there guarding. If we suspect it,
we get the images we need to rule that out.
Q. Okay. And in addition, if you suspect the
patient may have a surgical abdomen, do you also
order blood for type and screen?
A. Not necessarily.
Q. And what situations would you order blood
for type and screen?
A. If a woman is pregnant, having a
miscarriage, we want to know if she needs RhoGAM.
Q. Anything else come to mind?
A. Sure. Blood transfusion.
Q. You mean if she's losing blood?
A. Correct.
Q. Is that correct?
A. Yes.
Q. Did Dr. Wright, Jeff Wright, ever write a
note in the chart concerning your patient?
A. I don't believe so.
Q. Did you ever discuss this case with him
after the patient went to the OR?
A. No. I didn't see him for a while. I really
didn't run in to him for weeks probably. We don't
see each other--sometimes I don't always see my
supervising physicians for weeks to months because we
have so many of them that we rotate. Sometimes we
just don't cross paths.
Q. If a patient does have a surgical abdomen,
you did know that you have to bring a surgeon in to
the loop to see the patient; correct?
A. Absolutely.
Q. Similarly, if a patient has a surgical
condition of the pelvis, in that situation you would
bring an OB/GYN in to the loop for potential21 22 23 24 25
0023
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 operation; correct?
MR. HILMES: Object to form and foundation.
But you can go ahead and answer.
A. Yes.
BY MR. GERSHON:
Q. Had you worked with Dr. Mintzer before
September 2012?
A. No, sir. That was the first time I ever met
him, was that night or early that morning.
Q. And when you did call him, how did you know
to call him as opposed to another OB/GYN?
A. Because he was on call for the OB/GYN group.
Q. Has it been-- Have you called in other
OB/GYNs in the past when you needed a consult on a
patient who had a pelvic problem?
A. Sure. Or if I just needed to consult with
them about one of their OB patients or a gynecologic
problem.
Q. Has it been your experience that they
generally want to be consulted sooner rather than
later on a patient who has a pelvic problem?
MR. HILMES: Object to form and foundation.
Go ahead.
A. Not necessarily.
BY MR. GERSHON:
Q. Can you tell me a situation when an OB/GYN
would not want to be consulted sooner rather than
later on their patient with an acute pelvic problem?
MR. HILMES: Same objection. Go ahead.
MR. FITZGIBBONS: Join.
A. Can you repeat that?
BY MR. GERSHON:
Q. Sure. Can you tell me a scenario where an
OB/GYN who has a patient with an acute pelvic problem
would not want to be consulted sooner rather than
later?
MR. HILMES: Same objection. Go ahead.
A. Well, a scenario would be a female coming in
with pelvic pain, she's not sure if she's pregnant,
her pregnancy test comes back positive. I would do
an ultrasound to make sure that she doesn't have an
ectopic. If the patient doesn't have an OB/GYN, I
would call the on-call OB/GYN to set up some followup
for a serial beta HCG.
BY MR. GERSHON:
Q. What type of ultrasound would you do to
check for an ectopic?
MR. HILMES: In that scenario?
MR. GERSHON: Okay.
A. If they're pregnant or not pregnant?
BY MR. GERSHON:23 24 25 0025
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0026
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Q. First pregnant then nonpregnant.
A. Well, in our Epic system we have buttons to
push, one would be an OB ultrasound, so I would push
that button. If they are not pregnant I would do the
non-OB ultrasound.
Q. Which is the transvaginal one?
A. Whatever the tech does. I just push the
button and that's what--that's what I'll get. They
know what we need, and if they have questions the
tech would call.
Q. Why is it that if a patient's pregnant you
do the OB ultrasound, and if they're not pregnant you
do the transvaginal ultrasound?
MR. HILMES: I'm not sure that's what she
said, but if it is I'm sure she'll tell you.
A. I'm confused.
BY MR. GERSHON:
Q. I don't want you to be confused. I will ask
the question again.
I thought what you told us is that you order
an ultrasound when the patient is pregnant and not
pregnant and you push the buttons.
A. Yes.
Q. And if the patient is pregnant you will
request with the buttons an OB ultrasound. If they
are not pregnant with the buttons you will press a
transvaginal ultrasound.
A. No, I did not say that.
Q. Is that correct so far, or not?
A. No, it's not correct.
Q. Okay. So tell it to me again. How do you
determine which ultrasound to do if a patient is
pregnant and which ultrasound if they are not
pregnant?
A. If they are pregnant I would order an OB
ultrasound.
Q. Okay. And if they're not pregnant?
A. Then a non-OB ultrasound.
Q. And is a non-OB ultrasound the same as a
transvaginal ultrasound?
A. I believe so.
Q. Okay. Now, let's go to the next step. Why
if they're pregnant do you go and order an OB
ultrasound?
A. If they're pregnant why do I order an OB
ultrasound?
Q. Yes.
A. Because they're pregnant.
Q. Okay. And if they're not pregnant you do
the non-OB ultrasound or the transvaginal ultrasound
because they're just not pregnant; correct?
A. Yes.25 0027
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0028
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0029Q. Okay. And explain this button system to me.
I mean, is that on a computer to send an order
downstairs to the techs?
A. Yes. So I would go to the, it's called
Epic, it's our EMR system, and I would click the
order button. I could--I would type in OB
ultrasound. Then I'll get a drop down with this.
Then I would have an option of doing less than 14
weeks OB ultrasound versus just a regular OB
ultrasound. There is like two different buttons if
you're an OB patient.
Q. Have you ever ordered on any patient when
you were in the ER, ordered both an OB ultrasound and
a non-OB ultrasound, or transvaginal ultrasound, on
the same patient?
A. No. Never.
Q. Now, when did you first learn that
Ms. Laurie was pregnant?
A. When I entered the room and talked to her at
11:00 p.m.
Q. Okay. And around that time you ordered
blood work as well; correct?
A. The only blood work I ordered was the
quantitative HCG after I spoke with her and Dr.
Wright.
Q. The regular blood work was already ordered
before you saw the patient?
A. Yes. Protocol was initiated by the RN
before I came into the room.
Q. Okay. And when did you learn the results of
the hemoglobin and hematocrit?
A. The first one or the second one?
Q. The first one.
A. At 11:27.
Q. And is there somewhere in the medical
records that tells you--that tells you that you
learned of those results at 11:27?
A. No-- Well, yeah, it tells the time it
resulted in Epic.
Q. Perfect. I have that. I just wanted to
know where you're getting that from. I see the
results and times. That's great.
So is it fair to say after you got those
results at 11:27 you knew your patient was bleeding
somewhere?
A. No. bleeding.
I never suspected that she was
Q. When you got the hemoglobin and hematocrit
results at 23:27, and you knew your patient had
tenderness over the pelvis, that she was in the fetal
position, to what did you attribute her low
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1 2 hemoglobin and hematocrit?
MR. HILMES: Object to form. Foundation, I
guess too, Zev.
Go ahead, Ann.
A. I didn't. Considering she was in her second
trimester I wouldn't consider that to be abnormal.
BY MR. GERSHON:
Q. Did you look at the reference range that
Unity Point Health has for hemoglobin and hematocrit
to determine whether or not those are normal or
abnormal values for a pregnant woman?
A. It's right in Epic. You can pull down the
normal and abnormal ranges. It's all connected with
the labs.
Q. And you're saying when you do that a
hemoglobin of 10.3 and hematocrit of 29 is normal;
correct?
MR. HILMES: Go ahead.
A. For a pregnant woman I would consider that
to be normal.
BY MR. GERSHON:
Q. I understand what you consider. But I'm
saying when you looked at the medical records and the
chart and pulled down what you do, you're saying
those numbers are in the normal range at Unity Point
Health, correct, for a nonpregnant woman?
MR. HILMES: Wait a minute.
BY MR. GERSHON:
Q. Okay. Do they give you the reference range
for a pregnant woman at Unity Point Health?
A. No.
Q. Can you refer me to any textbook that would
back up your statement for a pregnant woman a
hemoglobin of 10.3 and hematocrit of 29 is normal?
A. Not at this moment.
Q. Did you have access the day you saw your
patient in the emergency room to information as to
what her prior hemoglobin or hematocrit had been?
A. No.
Q. Were you aware that if a patient is bleeding
somewhere inside their body they can have a low
hemoglobin or hematocrit?
A. Yes.
Q. Did you know in 2012 that one way to detect
if a patient is commonly bleeding inside is to repeat
the hemoglobin or hematocrit to check to see if it's
further decreasing over time?
A. Yes.
Q. When you first saw your patient what was her
blood pressure?
A. 100 over 52.
Q. Did you see her blood pressure decrease over3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0032
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1 2 3 4 time?
A. The only time I noticed that it dropped was
after she received Fentanyl.
Q. What time did she receive Fentanyl?
A. 11:46.
Q. Okay. How long does it take Fentanyl to
work?
A. Immediately if it's IV. She got IV
Fentanyl.
Q. Okay. Have you had other patients in the
emergency room who had blood pressure decreases after
they had been given Fentanyl?
A. Yes, I have seen that.
Q. How quickly had those other patients blood
pressure dropped after they received Fentanyl?
A. Within-- I don't really remember. I assume
pretty much right away, within minutes, since it's
IV.
Q. Okay. Does that mean for your patient,
Ms. Laurie, when her blood pressure decreased after
she was given Fentanyl, you attributed her low blood
pressure to Fentanyl?
A. Yes.
Q. Did you know in 2012 another cause of low
blood pressure in a patient is continuing to
hemorrhage internally?
A. I was not expecting that.
Q. I know you were not expecting it, but
nonetheless, I'm asking in your knowledge base in
2012, did you realize that a patient, any patient who
continues to bleed internally, can have a lowered
blood pressure as a result?
A. Sure. Sure.
Q. When did you first consider that your
patient, Ms. Laurie, if you ever considered it, was
bleeding internally?
A. I never considered it.
Q. I'd like to turn, if we could, to some
orders that you--when you ordered the ultrasound. I
could give you our page No. 278. It'll just take you
a minute, I'm sure, to get it. It's imaging clinical
orders.
MR. HILMES: Is this for an OB ultrasound?
MS. SMITH: It looks like this (indicating).
MR. HILMES: I think we're in the same
vicinity. I've got on my page pick chest, frontal
view, OB transvaginal--
MS. SMITH: That's it.
MR. HILMES: --et cetera, et cetera. It
says page 107 in the right-hand corner.
MR. GERSHON: Would that help if I give you
the page number that's in the right-hand corner?5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0034
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1 2 3 4 5 6 MR. HILMES: Yes. I think we might have the
same pages.
MS. SMITH: I just gave him 107.
MR. GERSHON: Perfect.
MR. HILMES: Page 107. not the same page.
Look, Robin, it's
MS. SMITH: Yeah. I don't know. got them from you guys. 278.
MR. HILMES: Okay.
I mean, we
MS. SMITH: MR. HILMES: I think you had it right.
I think we're here, and our
page 920 is, Zev, order No. 2503538.
MS. SMITH: MR. GERSHON: 254. No.
I don't see that. Our bottom
of 278, I see an ultrasound OB transvaginal.
MR. HILMES: Okay.
BY MR. GERSHON:
Q. And apparently you ordered it, Ms. Flatley,
at 23:17. Do you see that?
MR. HILMES: Here we go.
A. Yes.
BY MR. GERSHON:
Q. It's our page. And you also ordered that
stat. Do you see that?
A. Yes.
Q. And then just above it, apparently at 01:18,
18 minutes after midnight, you ordered a
transabdominal ultrasound also stat. Do you see
that?
A. Uh-huh.
MR. HILMES: That's a yes?
MS. SMITH: You need to say yes or no.
A. Yes, I see that.
BY MR. GERSHON:
Q. Okay. So my first question is--
MR. DRAPER: What was that time?
MS. SMITH: 01:18. Go ahead.
BY MR. GERSHON:
Q. So my first question is, if you can
remember, because we don't want you to guess, why did
you order the transvaginal ultrasound on your patient
at 23:17?
A. done.
Because that was the test I chose to have
Q. The question is: Do you remember why you
ordered it, ma'am?
A. Sure. I was trying to rule out a ruptured
ovarian cyst or a torsion?
Q. And you wanted it stat to be done for what
reason?
A. To rule out an ovarian cyst ruptured or an
ovarian torsion.7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0036
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1 2 3 4 5 6 7 8 MS. SMITH: Why did you order it stat?
BY MR. GERSHON:
Q. No. I asked why did you order it stat?
A. Because everything in the ER is ordered
stat.
Q. Okay. And then why did you order a
transabdominal ultrasound at 18 minutes after
midnight?
A. Because my first order was incorrect per
ultrasound, and they wanted me to reorder the other
one.
Q. Why did ultrasound want you not to have a
transvaginal one and instead have a transabdominal
one?
A. Because she was less than 14 weeks pregnant
with an intrauterine pregnancy.
Q. And what does that mean?
A. I think it has to do with billing purposes
or they felt that was the best test to do because she
reported being 13 weeks pregnant.
Q. Who was the one who had this conversation
with you?
A. It was-- You know, I don't remember. All I
can probably think of is they called up to the
department and may have told the nurse, and then that
was relayed to me. I discontinued the other order
and put this one in, but that didn't--
Q. Do you know who called up?
A. Staff in ultrasound. Maybe the tech. I
don't know.
Q. Do you know the level of their medical
knowledge?
A. They could have consulted with the
radiologist and asked the radiologist. I don't know.
Q. We're just speculating now. You don't know
the level of knowledge of the person who called up
and asked you to change the order?
A. No. This happens frequently.
Q. Would you agree with me that a transvaginal
ultrasound is different than an abdominal OB
ultrasound?
A. Yes.
Q. Would you agree with me that a transvaginal
ultrasound can see different things, some better,
some worse, than a transabdominal ultrasound?
A. Yes.
Q. When you ordered the transvaginal
ultrasound, is it fair to say that you chose that
ultrasound over a transabdominal ultrasound?
A. Initially.
Q. Until that billing clerk called you;
correct?9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0038
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1 2 3 4 5 6 7 8 9 10 MR. HILMES: Object to form.
BY MR. GERSHON:
Q. Is that correct?
MR. HILMES: We're not saying it was a
billing clerk. That's the problem with your
question.
BY MR. GERSHON:
Q. Whichever clerk called you; correct?
A. I assume it was the ultrasound tech.
Q. Well, which nurse did you speak to who
relayed whoever called from radiology?
A. I don't remember. It could have been the
clerk in the ED who takes the calls.
Q. How do you know that it's a different
billing number for a transvaginal ultrasound versus
an OB ultrasound?
A. I don't know if it's a billing issue. They
just--if they feel we didn't order the right one
they'll call us and ask us to switch to a different
test.
Q. So as we sit here today, you do or you do
not know that they have different billing codes for
those two ultrasounds?
A. I don't know.
Q. So where does it say in the record that you
cancelled the transvaginal ultrasound?
A. It's on that page that you have.
MR. HILMES: I think Dr. Wright discontinued
these orders later, Zev, according to this.
BY MR. GERSHON:
Q. Is that at 05:13?
A. Yeah, that's what we're looking.
MR. HILMES: Yeah, that's what we're looking
at.
BY MR. GERSHON:
Q. Ma'am, is that your answer, that at 05:13
Dr. Wright cancelled the transvaginal ultrasound?
A. No. He cosigned it by then.
Q. I'm sorry. Could you repeat that?
A. It was cosigned by Dr. Wright at that time.
Q. To discontinue it?
A. Yes.
Q. When did you originally discontinue it?
A. I don't have that. I don't have the records
to look it up.
Q. Did you discover what the transabdominal
ultrasound showed?
A. Yes. When it resulted at 1:42.
Q. Can you explain to me, if it was ordered on
a stat basis at 01:18--
A. The patient already left for ultrasound
before this was reordered.11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0040
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1 2 3 4 5 6 7 8 9 10 11 12 Q. The patient went to ultrasound, I believe,
at 12:05. Is that what you have?
A. Yes.
Q. Okay. You ordered the stat abdominal
ultrasound at 18 minutes after midnight after the
patient already left for what was supposed to be a
transvaginal ultrasound; correct?
A. Yes.
Q. Is that correct?
A. Yes.
Q. Okay. So my point is the patient was
already in radiology when this switch was made; fair?
A. Yes.
MR. HILMES: She said yes. We'll have to
work on our timing, Zev. She said yes.
BY MR. GERSHON:
Q. Okay. Do you know why, Ms. Flatley, that
the patient is in radiology certainly by 01:18, why
it took over an hour for the ultrasound to be done?
MR. HILMES: I don't know if that correctly
states the record. Ultrasound was probably done
before that because she's back on the floor before
that.
BY MR. GERSHON:
Q. Well, I have ultrasound done at 01:24.
In any event, do you have an explanation,
Mrs. Flatley, as to why it took so long if it was
stat?
MR. HILMES: 01:24, I think she's back on
the floor at 00:58. Did you have--did you mean
12:00?
MR. GERSHON: Do you want to show me that
page, Jack? That's fine.
MR. HILMES: I'm thinking I've seen it. I
will get it for you.
MR. DRAPER: If it makes it easier you may
have misspoken and you want 01:42.
MR. GERSHON: 01:42 is the timing on the
report.
MR. DRAPER: Correct. I thought maybe, did
you mean that?
MR. HILMES: I'll show Robin the page from
our numbers and then she can maybe figure it out.
It's a nurse note, Zev, by Rachel Jones, RN, at 00:58
stating, "Patient returned from ultrasound." Then it
goes on to say, "States pain when she takes a deep
breath." And it says Ann notified.
MR. GERSHON: Okay. I just need the page
number because the actual ultrasound report, our page
227, it has the ultrasound being performed at 01:24.
Robin, what page were you referring to?
MS. SMITH: I'm trying to find it, dear.13 14 15 16 17 18 19 20 21 22 23 24 25 0042
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0043
1 2 3 4 5 6 7 8 9 10 11 12 13 14 MR. HILMES: MR. GERSHON: it a flow sheet?
I'm working with you.
What's the top of the page, is
MS. SMITH: The sequence is all different,
Zev.
MR. GERSHON: What's the top of the page
say?
MR. HILMES: It says ED notes, Zev. It's a
nurse note.
MR. GERSHON: Doesn't say flow sheet at the
top?
MR. HILMES: No, it says ED notes continued.
MR. GERSHON: I don't--
MS. SMITH: We have it. I've seen it
before. I'm just trying to find it.
Off the record.
(Off the record discussion.)
MR. GERSHON: Let's go back on the record.
This says at the bottom right corner page
160, if that helps you at all.
MR. HILMES: Probably not.
MS. SMITH: It's this (indicating).
MR. GERSHON: It's an ultrasound report that
says it's performed at 01:24.
MS. SMITH: I'm showing it to him.
MR. HILMES: I see it, and I have seen the
ultrasound report, but it makes little sense if it
was done if she's back in her room.
MR. GERSHON: I don't have an answer for
which of these times is incorrect. I'm just pointing
it out.
MR. HILMES: Just to corroborate the back in
the room thing. We're catching vital signs at the
same time, Zev, back up in the
