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HomeMy WebLinkAbout06-4433 SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D, # 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) thvmasrklaw corn LAURA E. HETRICK, : IN THE COURT OF COMMON PLEAS ADMINISTRATRIX OF THE ESTATE : CUMBERLAND COUNTY, PENNSYLVANIA OF SARA J. ZEBRING, Plaintiff Q( Uu-t2 t V. No. a - ?7 l_ L U t , RICHARD N. BLUTSTEIN, M.D., CIVIL ACTION - LAW INDIVIDUALLY and t/d/b/a MEDICAL PROFESSIONAL LIABILITY PENNSBORO PEDIATRICS, ACTION Defendant : JURY TRIAL DEMANDED NO TICETODEFEND YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 2 Liberty Avenue, Carlisle, PA 17013 (717) 249-3166 SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. # 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) thvmanansrklaw com LAURA E. HETRICK, : IN THE COURT OF COMMON PLEAS ADMINISTRATRIX OF THE ESTATE : CUMBERLAND COUNTY, PENNSYLVANIA OF SARA J. ZEHRING, Plaintiff V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY and t/d/b/a PENNSBORO PEDIATRICS, Defendant . No. CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION : JURY TRIAL AVISO USTED HA SIDO DEMANDADO/A EN CORRE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar acci6n dentro de los pr6ximos veinte (20) dias despu6s de la notificaci6n de esta Demanda y Aviso radicando personalmente o por medic, de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar acci6n como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier sums de dinero reclamada en la demanda o cualquier otra reclamaci6n o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad u otros derechos importantes para usted. LISTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI LISTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI LISTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 2 Liberty Avenue, Carlisle, PA 17013 (717) 249-3166 SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. # 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attomeys for Plaintiff(s) thvmanQsrklaw com LAURA E. HETRICK, : IN THE COURT OF COMMON PLEAS ADMINISTRATRIX OF THE ESTATE : CUMBERLAND COUNTY, PENNSYLVANIA OF SARA J. ZEHRING, Plaintiff nn IJ V. . No. ((. - /? y3 3 l .lv?l. 1 RICHARD N. BLUTSTEIN, M.D., CIVIL ACTION - LAW INDIVIDUALLY and t/d/b/a MEDICAL PROFESSIONAL LIABILITY PENNSBORO PEDIATRICS, ACTION Defendant JURY TRIAL. DEMANDED COMPLAINT 1. Laura E. Hetrick is the mother of Sara J. Zehring, deceased and the Administratrix of the Estate of Sara J. Zehring. 2. Defendant Richard N. Blutstein, M.D. is licensed through his practice, Pennsboro Pediatrics in Enola, Cumberland County, Pennsylvania. 3. This is a medical malpractice/ professional liability action. A Certificate of Merit is attached hereto as Exhibit A. 4. Sara J. Zehring has been Defendant Blutstein's pediatric patient almost since birth. Sara began seeing Defendant Blutstein in November 1998 at the age of four months. Sara last saw Defendant Blutstein on January 31, 2005, the same day on which Sara died. 5. On January 31, 2005, Laura Hetrick brought Sara to the Defendant's office with complaints of elevated temperature, vomiting, wheezing, and coughing. 6. Defendant's records show that on the time of the visit Sara had a temperature of 104. 7. At the time of the visit, Sara's heart rate was 173. 8. At the time of the visit, Sara's oxygen saturation was only 93 percent. 9. At the time of the visit, Sara's respiration rate was 46. 10. At the time of the visit, Sara's lungs showed intermittent crackles. 11. Sara's vital signs, oxygenation, and symptoms, heralded a serious medical problem which required hospitalization. Defendant Blutstein, however, chose not to admit Sara where she could be monitored by professional hospital staff, instead, sending her home with her mother and a prescription for an antibiotic. 12. After filling the prescription Sara was taken home by her mother who followed the physician's advice regarding medication and follow-up care.. 13. At approximately 2:15 p.m., only a few hours after she left Defendant Blutstein's office, Laura Hetrick noticed that Sara's lips were blue and that she was having great difficulty breathing. Defendant Blutstein was immediately called who in turn advised Laura to call 911. 14. Laura immediately called the ambulance. However, when the ambulance arrived Sara was already in full respiratory arrest and without a pulse. 15. Her condition remained the same upon arrival at Carlisle Regional Medical Center. Although resuscitation was attempted, the patient never regained spontaneous respirations and was pronounced dead at 3:22 p.m. no more than 5 hours after Sara had been in Defendant's office for treatment. 16. An autopsy was performed which determined Sara's cause of death to be complications of sepsis due to streptococcus pneumonia. 17. Sara Zehring's death was directly and proximately caused by Defendant Blutstein's negligence in: a) Failing to recognize the seriousness of Sara's signs and symptoms during her visit to his office on January 31, 2005; b) Failing to run diagnostic tests to determine the cause of Sara's elevated vital signs; c) Failing to run the tests necessary to determine the cause of Sara's wheezing and lung congestion noted during her visit on January 31, 2005; d) Failing to hospitalize Sara to monitor her vital signs and oxygenation; e) Failing to recognize the significance of a 93 percent oxygenation and take the necessary steps to relieve the underlying condition; 1) Permitting Sara to go home unsupervised except by her mother while her vital signs, oxygen saturation and her clinical symptoms and history indicated a serious, potentially life threatening condition; g) Failing to determine Sara was in, or about to go into, shock and determine the cause of such shock; h) Failing to diagnose that Sara was in, or about was to go into, shock and offer treatment to alleviate or reduce the shock; i) Failing to order blood studies or other diagnostic steps necessary to determine whether Sara had sepsis or other infective process j) Failing to make an accurate diagnosis of Sara's presenting signs and symptoms during her July 31. 2005 visit; k) Failing to make a diagnosis of pneumonia; 1) Failing to make a diagnosis of sepsis; m) Failing to treat Sara's pneumonia, sepsis or symptoms in a manner sufficient to prevent them from progressing to her death within hours of her visit to his office; n) Failing to provide clear simple instructions to Sara Zehring's mother as to the observation she needed to make and when to call for medical help; o) Failing to recognize the presence of petechia during his examination which is a sign of septic shock; and CLAIM I - SURVIVAL ACTION LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING v. RICHARD N. BLUTSEIN. M.D., AND T/D/B/A PENNSBORO PEDIATRICS 18. Paragraphs 1 through 17 of the Complaint are incorporated herein by reference. 19. Plaintiff Laura E. Hetrick, Administratrix of the Estate of Sara J. Zehring, deceased, brings this Survival Action under and by virtue of the Act of 1976, July 9, P.L. 586, No. 142, 2, 42 Pa. Cons. Stat. Ann §8302. 20. Defendant Richard N. Blutstein, M.D. and Pennsboro Pediatrics are liable to the Estate of Sara J. Zehring, deceased, for injuries and damages as set forth herein. 21. Plaintiff Laura E. Hetrick, as Administratrix of the Estate of Sara J. Zehring, deceased, claims on behalf of said Estate, the damages suffered by the said Estate by reason of the death of the decedent, including wage loss and diminution of her earning capacity, funeral and administrative expense, the pain and suffering the decedent underwent prior to death, and for all other damages sustained by the said Estate by reason of the death of the decedent which are recognized under Pennsylvania statute, rules and case law. WHEREFORE, Plaintiff Laura E. Hetrick, Administratrix of the Estate of Sara J. Zehring, deceased, demands judgment against Defendant Richard N. Blutstein in an amount in excess of Twenty-Five Thousand ($25,000) Dollars, exclusive of interest and costs, and in excess of any jurisdictional amount requiring compulsory arbitration. CLAIM II - WRONGFUL DEATH LAURA E. HETRICK. ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING v. RICHARD N. BLUTSEIN, M.D., AND T/D/B/A PENNSBORO PEDIATRICS 22. Paragraphs 1 through 17 of this Complaint is incorporated herein by reference as if set forth at length. 23. Plaintiff Laura E. Hetrick, Administratrix of the Estate of Sara J. Zehring, deceased, brings this action for the wrongful death of Sara J. Zehring on behalf of all persons entitled to recover, therefore, under and by virtue of the Act of 1976, July 9, P.L. 589, No. 142, 2, 42 Pa. Cons. Stat. Ann §8301 and all persons who may be entitled under such statute. 24. Decedent Sara H. Zehring did not bring an action for his injuries during his lifetime. 25. The following are all the names of all the persons entitled by law to recover damages for such wrongful death and their relationship to the decedent: a) Laura E. Hetrick, 504 Windy Hill Road, Shermans Dale, PA 17090, mother of Sara J. Zehring, deceased; and b) Seth Zehring, 20 South Front St. Wormleysburg, PA, father of Sara J. Zehring, deceased. 26. As a result of the death of the decedent, the individuals identified in paragraph 25 above, have suffered a pecuniary loss, and claim all damages for Wrongful Death permitted by Pennsylvania statute, rule or case law, including past and in future loss of the decedent's companionship, contributions, services, support, comfort. WHEREFORE, Plaintiff Laura E. Hetrick, Administratrix of the Estate of Sara J. Zehring, deceased, demands judgment against Defendant Richard N. Blutstein in an amount in excess of Twenty-Five Thousand ($25,000) Dollars, exclusive of interest and costs, and in excess of any jurisdictional amount requiring compulsory arbitration. Respectfully submitted, Date: (' /p2 Ooi SCHMIDT KRAMER PC By: Terry S. Esquire I.D. N . 368 7 209 treet Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiff I, Laura E. Hetrick, verify that the facts set forth in the foregoing COMPLAINT are true and correct to the best of our knowledge, information, and belief. We understand that this Verification is made subject to the provisions of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. 4 41?fL ??, J<Aa Y jtlQ Laura E. Hetrick Date:--l-0-(an SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. # 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 thvmnr, n mrklnw rnm Attomeys for Plaintiff(s) LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, : : : IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. No. RICHARD N. BLUT8TEIN, M.D., INDIVIDUALLY and t/d/b/a PENNSBORO PEDIATRICS CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION Defendant JURY TRIAL DEMANDED CERTIFICATE OF MERIT AS TO RICHARD N. BLUT8TEIN. M.D.. INDIVIDUALLY AND t/d/b/a PENNSBORO PEDIATRICS I, Terry S. Hyman, certify that: 21"'An appropriate licensed professional has supplied a written statement to the undersigned that there is a basis to conclude that the care, skill or knowledge exercised or exhibited by this defendant is the treatment, practice or work that is the subject of the complaint, fell outside acceptable professional standards and that such conduct was a cause in bringing about the harm; R-?The claim that the defendant deviated from an acceptable professional standard is based solely on allegations that other licensed professionals for whom this defendant is responsible deviated from an acceptable professional standard and an appropriate licensed professional has supplied a written statement to the undersigned that there is a basis to conclude that the care, skill or knowledge exercised or exhibited by the other licensed professionals in the treatment, practice or work that is the subject of the complaint, fell outside acceptable professional standards and that such conduct was a cause in bring about the harm. ? Expert testimony of an appropriate licensed professional is unnecessary for prosecution of the claim against this defendant. Respectfully submitted, Date: SCHMIDT KRAMER PC By: Terry S. an, Esquire I.D. N . 36 7 209 to treet Hari burg, PA 17101 (717) 232-6300 Attorney for Plaintiff ? ? t1t ?. fi '?a ,? FOULKROD ELLIS Professional Corporation 2010 Market Street Camp Hill, PA 17011 Attorneys for Defendants: Phone: (717) 909-7006 Richard N. Blutstein, M.D. and Fax: (717) 909-6955 Pennsboro Pediatrics LAURA E. HETRICK, Administratrix of the : IN THE COURT OF COMMON PLEAS Estate of SARA J. ZEHRING, : CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs NO. 06-4433 V. RICHARD N. BLUTSTEIN, M.D., Individually and t/d/b/a PENNSBORO PEDIATRICS, Defendants CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION JURY TRIAL DEMANDED PRAECIPE TO ENTER APPEARANCE TO: PROTHONOTARY Kindly enter our appearance as counsel on behalf of Defendants, Richard N. Blutstein, M.D. and Pennsboro Pediatrics in the above-captioned matter. Respectfully submitted, By: FOULKROD ELLIS PROFESSI NAL CORP RATION Andreix 19. toulkrodkk,Yc , ire Attorney I.D. No. 77394 Michael C. Mongiello, Esquire Attorney I.D. No. 87532 DATE: August L5 1 2006 kJ I HEREBY CERTIFY that a true and correct copy of the foregoing document was served upon all counsel of record this day of August, 2006, by depositing said copy in the United States Mail at Camp Hill, Pennsylvania, postage prepaid, first class delivery, and addressed as follows: Terry S. Hyman, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 Counsel for Plaintiff FOULKROD ELLIS PROFESSIONAL CORPORATION By.. k14 Z 'Cheryl A. Garofalo, Legal S etary ca r_ ?- S -?.,, y_. ??I .I G? ?: ''.. N i! aD `C ^ci y' C_. f.J a! .. -o R (?" 'T? 1'n ?? ?;1T -? -?? -' rn J -i SHERIFF'S RETURN - REGULAR y, CASE NO: 2006-04433 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HETRICK LAURA E VS BLUTSTEIN RICHARD N MD ET AL WILLIAM CLINE Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon MT.TTrrQrr TTxT T?TrPAT?n TAT Mn the DEFENDANT , at 1323:00 HOURS, on the 4th day of August , 2006 at 125 NORTH ENOLA DRIVE ENOLA, PA 17025 by handing to SHARON TOWE, OFFICE MANAGER, ADULT IN CHARGE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: So Answers: Docketing 18.00 Service 13.20 Postage .39 Surcharge 10.00 R. Thomas Kline .00 41.59v-- 08/07/2006 gjayjo(, SCHMIDT RONCA KRAMER Sworn and Subscibed to By: - ?% before me this day Deputy Sheriff of A.D. CASE NO: 2006-04433 P SHERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HETRICK LAURA E VS BLUTSTEIN RICHARD N MD ET AL WILLIAM CLINE , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon BLUTSTEIN RICHARD N MD T/D/B/A PENNSBORO PEDIATRICS the DEFENDANT , at 1323:00 HOURS, on the 4th day of August , 2006 at 125 NORTH ENOLA DRIVE ENOLA, PA 17025 by handing to SHARON TOWE, OFFICE MANAGER, ADULT IN CHARGE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: So Answers: Docketing 6.00 Service .00 Affidavit .00 Surcharge 10.00 R. Thomas Kline .00 16.00,/ 08/07/2006 ?w SCHMIDT RONCA KRAMER Sworn and Subsc ibed to By : '?? 7 ?. before me this day Deputy Sheriff of A. D. FOULKROD ELLIS Professional Corporation 2010 Market Street Camp Hill, PA 17011 Attorneys for Defendant: Phone: (717) 909-7006 Richard N. Blutstein, M.D., Individually Fax: (717) 909-6955 and tld/b/a Pennsboro Pediatrics LAURA E. HETRICK, Administratrix of the IN THE COURT OF COMMON PLEAS Estate of SARA J. ZEHRING, CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff = V. RICHARD N. BLUTSTEIN, M.D., Individually and t/d/b/a PENNSBORO PEDIATRICS, Defendant : NO. 06-4433 : CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION : JURY TRIAL DEMANDED NOTICE TO PLEAD TO: Laura E. Hetrick, Administratrix of the Estate of Sara J. Zehring, Plaintiff c/o Terry S. Hyman, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 YOU ARE HEREBY NOTIFIED to plead to the attached New Matter of Defendant, Richard Blutstein, M.D. Individually and t/d/b/a Pennsboro Pediatrics, within twenty (20) days from service hereof or a default judgment may be entered against you. FOULKROD ELLIS PRO E SIONAL CORPORATION By: An rew ou d, Esquire Attorney I.D. No. 77394 Michael C. Mongiello, Esquire Attorney I.D. No. 87532 FOULKROD ELLIS Professional Corporation 2010 Market Street Camp Hill, PA 17011 Attorneys for Defendant: Phone: (717) 909-7006 Richard N. Blutstein, M.D., Individually Fax: (717) 909-6955 and t/d/b/a Pennsboro Pediatrics LAURA E. HETRICK, Administratrix of the IN THE COURT OF COMMON PLEAS Estate of SARA J. ZEHRING, CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff : NO. 06-4433 V. CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY RICHARD N. BLUTSTEIN, M.D., ACTION Individually and t/d/b/a PENNSBORO PEDIATRICS, Defendant JURY TRIAL DEMANDED DEFENDANT'S ANSWER AND NEW MATTER TO PLAINTIFF'S COMPLAINT AND NOW, comes Defendant, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics (hereinafter referred to as "Dr. Blutstein" or "Answering Defendant") and answers and asserts New Matter to Plaintiff's Complaint as follows: 1. Denied. Dr. Blutstein is advised by counsel and therefore avers that the corresponding averments of Plaintiff's Complaint do not pertain to him and that no further answer is required. 2. Denied as stated. Dr. Blutstein is and was at all relevant times a physician licensed to practice medicine, specifically pediatrics, in the Commonwealth of Pennsylvania. His practice, Pennsboro Pediatrics, is located at 125 North Enola Drive, Enola, PA 17025. 3. Admitted in part and denied in part. It is admitted that Plaintiff is asserting a medical professional liability action against Dr. Blutstein and that a document entitled "Certificate of Merit" is attached to the Complaint. It is specifically denied, however, that Dr. Blutstein was negligent. To the contrary, at all relevant times, Dr. Blutstein met or exceeded the standard of care and at no time caused or contributed to the injuries as alleged. 4-17. Denied. The corresponding averments of Plaintiff's Complaint are denied by operation of Pa.R.C.P. No. 1029(e) and/or as conclusions of law to which no responsive pleading is required. By way of further answer, Dr. Blutstein was not negligent. To the contrary, at all relevant times, Dr. Blutstein met or exceeded the standard of care and at no time caused or contributed to the injuries as alleged. CLAIM I - SURVIVAL ACTION LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING V. RICHARD N. BLUTSTEIN M.D AND T/D/B/A PENNSBORO PEDIATRICS 18. Answering Defendant hereby incorporates by reference the answers contained in paragraphs 1-17 above as though fully set forth herein at length. 19-21. Denied. The corresponding avernents of Plaintiff's Complaint are denied by operation of Pa.R.C.P. 1029(e) and/or conclusions of law to which no responsive pleading is required. By way of further answer, Dr. Blutstein was not negligent. To the contrary, at all relevant times, Dr. Blutstein met or exceeded the standard of care and at no time caused or contributed to the injuries as alleged. WHEREFORE, Defendant, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, demands judgment in his favor and against Plaintiff. CLAIM II -WRONGFUL DEATH LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING V. RICHARD N. BLUTSTEIN M.D. AND T/D/B/A PENNSBORO PEDIATRICS 22. Answering Defendant hereby incorporates by reference the answers contained in paragraphs 1-21 above as though fully set forth herein at length. 23-25. Denied. The corresponding averments of Plaintiff s Complaint are denied by operation of Pa.R.C.P. 1029(e) and/or conclusions of law to which no responsive pleading is required. By way of further answer, Dr. Blutstein was not negligent. To the contrary, at all relevant times, Dr. Blutstein met or exceeded the standard of care and at no time caused or contributed to the injuries as alleged. WHEREFORE, Defendant, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, demands judgment in his favor and against Plaintiff. NEW MATTER 26. The facts set forth in the foregoing Answers to Plaintiffs Complaint are incorporated by reference as though fully set forth herein at length. 27. Plaintiff s Complaint fails to state any claim upon which relief can be granted against Answering Defendant. 28. All care and treatment rendered to Plaintiffs decedent by the employees, agents, apparent agents and/or servants of Answering Defendant was appropriate, reasonable and within the applicable standard of care. 29. At all times relevant hereto, Dr. Blutstein acted within and followed the precepts of a school of thought followed by a considerable number of qualified and well-respected specialists in the field and, accordingly, their professional conduct was fully commensurate with the applicable standard of care. Evidence at trial may establish two or more schools of thought applicable to the issues presented in this case. 30. Plaintiff's allegations of negligence against Answering Defendant are without reasonable basis in fact or medicine and may constitute an abuse of civil process. 31. To the extent that discovery or the evidence at trial may establish that the Plaintiff or her decedent was negligent and that such negligence caused or contributed to cause the injuries and damages of which Plaintiff complains, Answering Defendant expressly reserves the right to assert the affirmative defenses of contributory/comparative negligence and/or assumption of risk. 32. Answering Defendant is entitled to contribution in accordance with the Pennsylvania Comparative Negligence Act, 42 P.S. §7102. 33. In the event that it is determined that Answering Defendant was negligent with regard to any of the allegations contained in, and with respect to Plaintiff's Complaint, said allegations being specifically denied, said negligence was superseded by the intervening negligent acts of other persons, parties and/or organizations other than Answering Defendant and over whom Answering Defendant had no control, right or responsibility. 34. At all times relevant hereto, Dr. Blutstein was a competent and qualified physicians acting in compliance with the applicable standard of care. 35. To the extent that the evidence may show that other persons, partnerships, corporations or other legal entities caused or contributed to the injuries or exacerbation of the pre-existing condition of Plaintiff's decedent, then the conduct of the Answering Defendant was not the legal cause of such conditions or injuries. 36. Acts or omissions of Dr. Blutstein alleged to constitute negligence were not a factual cause of, and did not contribute to, the injuries and damages alleged in Plaintiff's Complaint. 37. Whatever injuries and damages, if any, were sustained by Plaintiff as averred in Plaintiff s Complaint, were caused in whole or in part by persons or entities over whom Answering Defendant had no duty to supervise or control. 38. Plaintiff s decedent's injuries and losses, if any, were not caused by the conduct or negligence of Answering Defendant but rather were caused by pre-existing medical conditions and causes beyond the control of Answering Defendant. 39. The acts or omissions of others, and not Answering Defendant, constituted intervening and/or superseding causes of the injuries and/or damages alleged to have been sustained by Plaintiff and Answering Defendant cannot, therefore, pursuant to Pennsylvania law, be held liable for the alleged injuries to Plaintiff. 40. To the extent currently applicable, or to the extent that it may later become applicable, Answering Defendant plead the Statute of Limitations, 42 Pa.C.S.A. §5524. 41. Answering Defendant asserts and incorporates by reference all limits, defenses and immunities afforded under the Health Care Services Malpractice Act, as amended, 40 P.S. § 1301.101 et seq., and the Medical Care Availability and Reduction of Error Act, 40 P.S. § 1301.101 et seq. 42. Answering Defendant hereby pleads the affirmative defense of release. WHEREFORE, Defendant, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, demands judgment in his favor and against Plaintiff. Respectfully submitted, FOULKROD ELLIS PROFESSIONAL O PORATION By: Andrew . ou od, Esquire Attorney I.D. No. 77394 Michael C. Mongiello, Esquire Attorney I.D. No. 87532 DATE: September ?'? '2006 09/25/2006 13:25 7177328872 PENNSBORO PEDIATRICS PAGE 01/01 VERIFICATION I. RICHARD N. BLUTSTEIN, M.D., Individually and t/d/b/a PENNSBORO PEDIATRICS, hereby certify that I have read the foregoing Defendant's Answer and New Matter to Plaintiffs Complaint which has been. drafted by zany counsel on. my behalf and that the facts set forth therein are true and correct to the best of my knowledge, information and belief. This statement and Verification are made subject to the penalties of 18 Pa.C.S.A. §4904. relating to unswom fabrication to authorities, I verify that all the statements made in the foregoing are true and correct and that false statements may subject me to the penalties of 18 Pa.C.S.A. §4904. Date: ;C61G Richard N. Blutstein M.D. I HEREBY CERTIFY that a true and correct copy of the foregoing document was served upon all counsel of record this 26th day of September, 2006, by depositing said copy in the United States Mail at Camp Hill, Pennsylvania, postage prepaid, first class delivery, and addressed as follows: Terry S. Hyman, Esquire Sclunidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 Counsel. for Plaintiff FOULKROD ELLIS PROFESSIONAL C1 By: -:. ?? . c,.n, ?`-.:-? --t -?- `r"1 t 3 - ? I -. ?=? . ?_ ....,? -r?? ?'- _... . S"° .. . ri -i _ C.,3 - W T3 -< SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) thvmar cr,srklawxom LAURA E. HETRICK, : IN THE COURT OF COMMON PLEAS ADMINISTRATRIX OF THE ESTATE : CUMBERLAND COUNTY, PENNSYLVANIA OF SARA J. ZEHRING, Plaintiff V. : No. 06-4433 CIVIL RICHARD N. BLUTSTEIN, M.D., CIVIL ACTION - LAW INDIVIDUALLY and t/d/b/a MEDICAL PROFESSIONAL LIABILITY PENNSBORO PEDIATRICS, ACTION Defendant JURY TRIAL DEMANDED PLAINTIFF'S ANSWER TO NEW MATTER OF DEFENDANTS RICHARD N. BLUTSTEIN, M.D._ INDIVIDUALLY AND T//D/B/A PENNSBORO PEDIATRICS 46. - 54. The allegations herein are conclusions of law lacking any material facts upon which an affirmative defense may be based. These allegations, therefore, are insufficient as a matter of law to raise any of the defenses asserted herein. Plaintiff is not required to respond to conclusions of law. To the extent any response is required, the allegations are denied pursuant to PA. R.C.P. 1029 (e). Respectfully submitted, KRAMER PC By: v Terry . H man, Esquire I.D. o. 807 209 to Street Harrisburg, PA 17101 (717) 232-6300 Date: /0/91 ?1? Attorney for Plaintiff f ATTORNEY AFFIDAVIT I, Terry S. Hyman, Esquire, being duly sworn according to law, deposes, and states that I am counsel for Plaintiff, that I am authorized to make this Affidavit on behalf of said Plaintiff and that the facts set forth in the foregoing are true and correct to the best of my knowledge, information and belief. Date: yo? 40 Terry S y an, Esquire t _w CERTIFICATE OF SERVICE AND NOW, this ?? day of - I, Janice S. Harmon an employee of SCHMIDT KRAMER PC, do hereby certify that I have served a true and correct copy of the PLAINTIFF'S ANSWER TO NEW MATTER OF DEFENDANTS RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY AND T/D/B/A PENNSBORO PEDIATRICS in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Andrew Foulkrod, Esq. Michael Mongiello, Esq. Foulkrod Ellis P.C. 2010 Market Street Camp Hill, PA 17011 Janice S. Harmon {--J i'l c.;;a c ?.? if ? t ?..'` ?` 1"? i'i .?{ .l_-; ;??'?1 ?, .1.,'. }?? ''t ?c _,:' ?' .. •? `q'i _? _ ?? i SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) thvmana,srklaw com LAURA E. HETRICK, IN THE COURT OF COMMON ADMINISTRATRIX OF THE PLEAS ESTATE OF SARA J. CUMBERLAND COUNTY, ZEHRING, PENNSYLVANIA Plaintiff V. : No. 06-4433 CIVIL RICHARD N. BLUTSTEIN, : CIVIL ACTION - LAW M.D., INDIVIDUALLY and MEDICAL PROFESSIONAL LIABILITY t/d/b/a PENNSBORO ACTION PEDIATRICS, Defendant JURY TRIAL DEMANDED PLAINTIFFS' MOTION FOR A SCHEDULING CONFERENCE And now this 8th day of December, 2006, LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, Plaintiff by her Attorneys Schmidt Kramer PC hereby move this Honorable Court to conduct a Scheduling Conference in the above-captioned case for the following reasons: 1. This medical malpractice claim was filed by Complaint with a Certificate of Merit in July 2006. 2. As a malpractice claim, expert reports will be a necessity, and pre-Trial Motions are the rule, rather than the exception. 3. Setting deadlines for the completion of discovery, exchange of expert reports, motions and a date certain for trial now, will substantially aid in having an orderly, fair, and expeditious pre-trial and trial process. 4. Additionally, Defense Counsel is a very busy trial attorney, whose availability for trial is limited. In November, Mr. Foulkrod already advised Plaintiff's that he has no available trial dates for the entire calendar year of 2007. Presumably attaching defense counsel now will be the only way to assure the case can be tried when it is actually ready. 5. Setting a trial date and discovery schedule will avoid continuances and uncertainties which undermine the Court's, the litigants', counsels and the out of town witnesses' calendars. 6. Defense Counsel is aware of Plaintiffs filing of this Motion, and does not object to a Scheduling Conference being held. WHEREFORE, Plaintiffs prays your Honorable Court will schedule a Scheduling Conference at its earliest convenience. Respectfully submitted, SCHMIDT KRAMER PC By: Ter Hyman, Esquire 1. D Zf3 6 8 07 209 State Street Harrisburg, PA 17101 (717) 232-6300 Date: ,?C )670 Attorney for Plaintiffs CERTIFICATE OF SERVICE AND NOW, this ell-day of 06, I, Janice S. Harmon an employee of SCHMIDT KRAMER, P.C., do hereby certify that I have served a true and correct copy of PLAINTIFFS' MOTION FOR A SCHEDULING CONFERENCE via first class US mail, Harrisburg, Dauphin County, Pennsylvania: Andrew Foulkrod, Esq. Foulkrod Ellis P.C. 2010 Market Street Camp Hill, PA 17011 anice . Har on ? o -T7 _ LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, PLAINTIFF V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY AND t/d/b/a PENNSBORO PEDIATRICS, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 06-4433 CIVIL CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION JURY TRIAL DEMANDED ORDER OF COURT AND NOW, this 19th day of December, 2006, upon consideration of the Plaintiff's Motion for Scheduling Conference, IT IS HEREBY ORDERED AND DIRECTED that each party shall submit to the Court a proposed schedule which will include a date for completion of discovery, the date for filing of dispositive motions, an argument court date for the motions and a proposed date for trial on or before January 9, 2007. IT IS FURTHER ORDERED AND DIRECTED that a status conference in this case will be held in Chambers of Courtroom No. 5 on Wednesday, January 10, 2007 at 8:15 a.m., Cumberland County Courthouse, Carlisle, Pennsylvania. By the Court, erry S. Hyman, Esquire Attorney for Plaintiff drew Foulkrod, Esquire Attorney for Defendant bas M. L. Ebert, Jr., J. 0 SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) thyman(2srklaw com LAURA E. HETRICK, : IN THE COURT OF COMMON PLEAS ADMINISTRATRIX OF THE ESTATE : CUMBERLAND COUNTY, PENNSYLVANIA OF SARA J. ZEHRING, Plaintiff V. : No. 06-4433 CIVIL RICHARD N. BLUTSTEIN, M.D., CIVIL ACTION - LAW INDIVIDUALLY and t/d/b/a MEDICAL PROFESSIONAL LIABILITY PENNSBORO PEDIATRICS, ACTION Defendant JURY TRIAL DEMANDED PLAINTIFF'S OBJECTION TO DEFENDANT'S REQUEST FOR EXPERT REPORTS PURSUANT TO PA. R.C.P 1042.11 The parties have negotiated and submitted a Proposed Joint Scheduling Order agreeable to both sides providing for Plaintiff Expert Reports to be due on August 31, 2007 which is more than 180 days. Defense Counsel then served Plaintiff with a notice requiring Plaintiff to produce an expert report within 180 days. Defense counsel, having agreed to the deadlines set forth in the Proposed Joint Scheduling Order, cannot at the same time, require Plaintiff to produce their expert report earlier. If Defendant wishes to enforce the Notice, Plaintiff will insist on the case being listed for trial within 90 days of the filing of Plaintiff's expert reports. Respectfully submitted, Date: f ©g/? /? SCHMIDT KRAMER PC By: :2? Terry S. n, Esquire I.D. No. 6 7 209 Sta e Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiff s CERTIFICATE OF SERVICE AND NOW, this f4k.-cia007, I, Janice S. Harmon an employee of SCHMIDT KRAME hereby certify that I have served a true and correct copy of the PLAINTIFF'S OBJECTION TO DEFENDANT'S REQUEST FOR EXPERT REPORTS in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Andrew Foulkrod, Esq. Michael Mongiello, Esq. Foulkrod Ellis P.C. 2010 Market Street Camp Hill, PA 17011 Janice S. Harmon r? n o ? 't` - s ? • t ? ? <G- ' ? - Lt`' r.? ? ?? ? - -: r-` ?. -Ate...' ( y ?T1 "?-s , t ?? ? 1 ? ? ?ty Ca "'{ N LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, PLAINTIFF V. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 06-4433 CIVIL CIVIL ACTION - LAW RICHARD N. BLUTSTEIN, MEDICAL PROFESSIONAL LIABILITY M.D., INDIVIDUALLY AND ACTION t/d/b/a PENNSBORO PEDIATRICS, DEFENDANT JURY TRIAL DEMANDED SCHEDULING ORDER OF COURT AND NOW, this 10th day of January, 2007, after status conference with counsel this date, the following schedule is hereby set for discovery motions and trial of this matter: 1. July 6, 2007 - The parties shall complete all factual discovery on or before this date. 2. August 31, 2007 - Plaintiff shall serve any and all expert reports on Defense counsel on or before this date. 3. October 15, 2007 - Defendant shall serve any and all expert reports on Plaintiff's counsel on or before this date. 4. November 15, 2007 - Plaintiff shall file any rebuttal expert report on or before this date. 5. November 15, 2007 - Counsel for Plaintiff shall submit a settlement demand to Defense counsel on or before this date. 6. December 3, 2007 - Any and all dispositive motions and supporting briefs shall be filed on or before this date. Also, Defendant shall respond to Plaintiff's demand, and shall state whether or not his client is willing to mediate. 1 . ..... 7. December 12, 2007 - The Court will hold a Settlement Conference in Courtroom No. 5 at 8:30 a.m. should it determine one will be fruitful. 8. December 17, 2007 - Any party against whom a dispositive motion has been filed shall file a response and brief in opposition thereto on or before this date. 9. Date to be determined by 2008 Court Schedule - Oral argument on any dispositive motion shall be held during the argument court scheduled for January 2008. 10. Three weeks prior to the Monday of trial week - The parties shall file any and all Motions in Limine with supporting briefs. The adverse party briefs are due 10 days later. 11. Trial in this matter shall be heard during the first trial term in 2008 unless the trial term is scheduled for the period February 2 through 9, 2008. Defense counsel has paid a deposit on a vacation during this period. If the trial cannot take place during the first term of Civil Court in 2008, it shall take place at the second term normally scheduled for the March/April time frame. 12. The Court will advise the parties as soon as the 2008 Court schedule is confirmed at which time the Prothonotary will be directed to give this case priority status and a pre-trial conference will be scheduled. 13. Variance of deadlines by mutual agreement of the parties - Counsel may, without Court involvement, mutually agree to vary the discovery and/or expert report deadlines only. By the Court, 1\v-? ?,A?L. Ebert, Jr., J. 2 8I :II I!I l I Nay LOOZ =jai i JO Terry Hyman, Esquire Attorney for Plaintiff Andrew Foulkrod, Esquire Attorney for Defendant bas FOULKROD ELLIS Andrew H. Foulkrod, Esquire Attorney I.D. #77394 Michael C. Mong", Esquire Attorney I.D. #87532 2010 Market Street Camp Hill, PA 17011 Phone: (717) 909-7006 Fax: (717) 90966955 LAURA E. HETRICK, Administratrix of the Estate of Sara J. Zehring, Plaintiff V. RICHARD N. BLUTSTEIN, M.D., individually and t/d/b/a PENNSBORO PEDIATRICS, Defendants Attomeys for Defendant: Richard N. Blutstein, M.D., Individually andVdlbla Pennsboro Pediatrics IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION No. 06-4433 JURY TRIAL DEMANDED MOVM OF DEFE ANTS: Z) FOR lM0Tfk MYt ORO?M AS TO gL,Apf r*F'S RFq"sTKD C ItM INSPEC'I`Ul'+F; 2) TO COWEL FACT 'VV!' T SS DWOVERY; A" 3) R A PRI TYMAL UST-M l G "THE MARCH 31,2W CWR TER OF COURT AND NOW come Defendants, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, by and though their counsel, Foulkrod Ellis, and move this Honorable Court as follows: A. MOTION FOR PROTECTIVE ORDER AS TO PLAINTIFF'S REQUESTED COMPUTER INSPECTION 1. Plaintiff s counsel has expressed a desire to have a computer expert inspect the hard drives of Dr. Blutstein's computer to confirm that notes drafted by him subsequent to Sara Zehring's death were in fact drafted as Dr. Blutstein has described in discovery. 2. To avoid invasion and disruption of Dr. Blutstein's office, defense counsel has had a certified forensic computer examiner make duplicate originals of Dr. Blutstein's hard drives and offered to provide them to Plaintiff for inspection. 3. Plaintiff's counsel has refused, however, demanding that his inspection to include the original hard drives. See Exhibit "1" hereto. 4. Despite repeated requests that Plaintiff identify a reason why the inspection must include the original drives, which would be recommended to Dr. Blutstein if valid, Plaintiff s counsel has not provided any such grounds. See Exhibit "2" hereto. 5. Defense counsel simply cannot recommend allowing Plaintiff into Dr. Blutstein's office to inspect the original drives without reason, thereby resulting in unnecessary and obvious disruption, hassle, annoyance and stress, regardless of whether the inspection is performed during or after business hours. See Supporting Brief. 6. Regardless of this Honorable Court's decision as to whether Plaintiff is entitled to inspect the original hard drives, Dr. Blutstein respectfully requests that appropriate limitations be placed on the scope of Plaintiff's inspection. See Supporting Brief. WHEREFORE, Defendants, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, respectfully request that this Honorable Court enter the attached Order. B. MOTION TO COMPEL FACT WITNESS DISCOVERY 7. Plaintiff has yet to identify fact witnesses who will testify at trial in support of her case despite specific requests for this information prior to passage of the Court-imposed discovery deadline. See Exhibits "3" and "4" hereto and Supporting Brief. WHEREFORE, Defendants, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, respectfully request that this Honorable Court enter the attached Order. C. MOTION FOR A PRIORITY TRIAL LISTING DURING THE MARCH 31, 2007 CIVIL TERM OF COURT 8. Following a status conference held on January 10, 2007, Judge Ebett ordered that "[t]rial in this matter shall be heard during the first term in 2008 unless the trial term is scheduled for the period February 2 through 9, 2008. Defense counsel has paid a deposit on a vacation during this period. If the trial cannot take place during the first term of Civil Court in 2008, it shall take place at the second term normally scheduled for the March/April time frame." See Exhibit "3" hereto. 9. The 2008 Court calendar is now available and the February 2008 civil term does in fact commence during defense counsel's pre-paid family vacation, on February 4, 2008. See also Supporting Brief. WHEREFORE, Defendants, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, respectfully request that this Honorable Court enter the attached Order. ***Pursuant to C.C.R.P. 208.2(d), concurrence in the instant Motion was sought from Plaintiff's counsel on September 18, 2007. Plaintiff's counsel does not concur. Respectfully submitted, FOULKROD ELLIS Prq figsional Corporation By: Atlorne? I.D. #77394 Michael C. Mongiello, Esquire Attorney I.D. #87532 Date: September , 2007 ti SCHMIDT KRAMER PC BY: Terry S. Hyman ESQUIRE I.D. # 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, Plaintiff V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY and t/d/b/a PENNSBORO PEDIATRICS, Defendant Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA : No. 06-4433 CIVIL CIVIL ACTION - LAW JURY TRIAL DEMANDED REQUESTS FOR ENTRY UPON PROPERTY FOR AN INSPECTION OR PRODUCTION OF AN OBJECT DIRECTED TO DEFENDANT TO: Richard N. Blutstein, M.D. c / o Andrew Foulkrod , Esquire Foulkrod Ellis P.C. 2010 Market Street Camp Hill, PA 17011 PLEASE TAKE NOTICE that you are hereby required, pursuant to (Pa. R.C.P. 4009.12 and 4009.32 to make permit entry upon your property for the purposed of inspection of an object thereon, or to produce said object to the undersigned, within thirty (30) days of service of this request as set forth below: REQUEST 1. The computer upon which you allegedly made a note of the events relating to the visit of plaintiff to your office on January 31, 2005. 2. Any copies you or anyone acting on your behalf, made of the hard drive of the computer identified in No. 1 above between January 31, 2005 and the date of the inspection. 3. Any written or computer retrievable protocol, manual, or description which describes any procedure followed to remove, copy, extract, cleanse or analyze the data on the hard drive in any way relating to the note of the events relating to the visit of plaintiff to your office on January 31, 2005. Said inspection shall take place the week of October 15, 2007 by either producing the items listed above at the Office of Plaintiff sCounsel or by permitting Plaintiff and her computer expert to inspect the hard drive at Defendant's office. Plaintiffs inspection will not alter or change the hard drive; will not retrieve or examine any record other than those of Plaintiff, and Defendant may have the computer expert of their choosing present during the inspection. The inspection, if at Defendant's office, will take place outside of his normal business hours. Respectfully submitted, SCHMIDT KRAMER PC By: Terry S . an, quire I.D.# 368 209 State Street Harrisburg, PA 17101 (717) 232-6300 DATE: September 7, 2007 Attorney for Plaintiff(s) CERTIFICATE OF SERVICE AND NOW, this 7th day of September 2007, I, Janice S. Harmon an employee of SCHMIDT KRAMER PC, do hereby certify that I have served a true and correct copy of the REQUESTS FOR ENTRY UPON PROPERTY FOR AN INSPECTION OR PRODUCTION OF AN OBJECT DIRECTED TO DEFENDANT in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Andrew Foulkrod, Esq. Michael Mongiello, Esq. Foulkrod Ellis P. C. 2010 Market Street Camp Hill, PA 17011 r Janice S. Harmon f' 1 e ;i ' a Message -----Original Message----- From: Terry Hyman [maiito:thyman@schmidtkramer.com] Sent: Thursday, September 06, 2007 12:01 PM To: Andrew Foulkrod Subject: RE: computer Page 1 of 6 It is an issue to me how I want to prepare and present my case. 1 have yet to hear any real reasonr why I cannot inspect the original hard drive and make my own copy by my own expert. you can explain your postion to the Judge. -----Original Message----- From: Andrew Foulkrod [mailto:Andrew@foulkrod.com] Sent: Thursday, September 06,'2007 11:53 AM To: Tent' Hyman Subject: RE: computer It is not an issue whether an expert "saw" the original; the copy is the same as the original. I still think you need a reason ...e.g., if your expert says that the copy can't be verified as complete, that's a reason. But my expert says you either copy it or you don't. I don't want to waste the Court's time. If I have a reason to take to my client, I could recommend it. But I can't recommend it without a reason, which my expert says there isn't. ----Original Message----- From: Terry Hyman [maiito:thyman@schmidtkramer.com] Sent: Thursday, September 06, 2007 11:46 AM To: Andrew Foulkrod Subject: RE: computer at a mininimum, I want my expert to say on he stand he saw the original. I will not rely on your experts representation the copy is accurate. -----Original Message----- From: Andrew Foulkrod [mailto:Andrew@foulkrod.com] Sent: Thursday, September 06, 2007 11:39 AM To: Terry Hyman Subject: RE: computer If you give me a reason why the copy is insufficient, I may agree. 4i1 zi,)nm Message Page 2 of 6 -----Original Message----- From: Terry Hyman [mailto:thyman@schmidtkramer.com] Sent: Thursday, September 06, 2007 11:31 AM To: Andrew Foulkrod Subject: RE: computer I am not going to rely on your experts work in my case. I want to have my expert see the original hard drive. You chose, with out any notice to me to have someone do something to the hard drive. You would not let my expert touch the machine without having some one present to assure nothing untoward happend, but cavalierly had your expert do an inspection without me having the same safeguard. (what is your experts names and credentials? My expert was a senior supervisor in computer security for the NSA including high level duties for the NSA in Iraq. I am not going argue by email any further. If you are not going to agree to allow me to inspect the orignal hard drive simply because dr. blustein doesn't want me to be in his office even after business hours, I will leave the matter to the court. Please give me dates or an definive no. From: Andrew Foulkrod [mailto:Andrew@foulkrod.com] Sent: Thursday, September 06, 2007 10:48 AM To: Terry Hyman Subject: RE: computer Terry: All we did was make a copy. Please send me a copy of your "spoliation letter". My expert says you can have the existing duplicate original. (We will just make another copy of that for us - another duplicate original.) We don't feel then that you need access to the original. Dr. Blutstein is not interested in having you in his office when the duplicate original is available. We would like to know the basis for accessing the original in addition to the duplicate original. Will you disclose the qualifications of your expert who contends access to the original is required and who you propose to work on the original? This may help. Andy -----Original Message----- From: Terry Hyman [mailto:thyman@schmidtkramer.com] Sent: Wednesday, September 05, 2007 3:01 PM To: Andrew Foulkrod Subject: RE: computer Andy, I do not consider it a very good idea tfor you to have had your expert do anything to extract information central to the case without my expert being present after I sent you a spoliation letter and after I requested the 9/13/2007 Message Page 3 of 6 right to inspect the hard drive. After speaking to my expert the ONLY method acceptable to me is that my expert have access to both the original hard drive on Dr. Blusteins computer and so called "duplicate original" used by your expert to acquire the data from the hard drive. My expert states unequivocally that his examination of both will not alter either in any fashion we will do this after office hours to avoid any interference with the doctors practice. If this not acceptable to you let me knwo and I will take appropriate steps to get the court involved. Terry S. Hyman Esq. SchmidtKramer PC 209 State St. Harrisburg, Pa. 17101 717-232-6300 fax 717-232-6467 thynan@schmidtkramer.com -----Original Message----- From: Andrew Foulkrod [mailto:Andrew@foulkrod.com] Sent: Wednesday, September 05, 2007 8:50 AM To: Terry Hyman Cc: Mike Mongiello Subject: RE: computer Terry: Our expert made a copy of the original - we can call that a duplicate original- that is "forensically sound". Our expert then made a copy of the duplicate orignial, also forensically sound, on which the testing and programs were run. Apparently, by my understanding, after the testing and programs a copy is no longer is considered forensically sound. The duplicate original is though; it has not been altered in any way, only copied. Our expert proposes to copy the duplicate original for your testing - exactly as was done for us - that way they are working with the same thing, which is forensically sound - and the duplicate orignial is maintained. This finally makes sense to me and doesn't seem to prejudice you at all. Please have your expert respond. Andy -----Original Message----- From: Andrew Foulkrod Sent: Tuesday, September 04, 2007 10:15 AM To: Mike Mongiiello; Terry Hyman' Subject: RE: computer 9/13/2007 Message Page 4 of 6 Tent': Our expert recommends not distributing the original copy of the hard drive, because our expert would not then have that source to go back to after your expert review; it could be altered by mistake, damaged, etc. Our expert recommends producing a "forensically sound copy". This would cost only the cost of 3 hard drives. Is there a reason, other than cost, for which your expert requires the original copy? If so, I will pass it on to our expert. Andy 3 LAURA E. HETRICK, IN THE COURT OF COMMON PLEAS OF ADMINISTRATRIX OF THE CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF SARA J. ZEHRING, NO. 06-4433 CIVIL PLAINTIFF V. : CIVIL ACTION - LAW RICHARD N. BLUTSTEIN, : MEDICAL PROFESSIONAL LIABILITY M.D., INDIVIDUALLY AND : ACTION t/d/b/a PENNSBORO PEDIATRICS, : DEFENDANT JURY TRIAL DEMANDED SCHEDULING ORDER OF COURT AND NOW, this 10'h day of January, 2007, after status conference with counsel this date, the following schedule is hereby set for discovery motions and trial of this matter. 1. July 6, 2007 - The parties shall complete all factual discovery on or before this date. 2. August 31, 2007 - Plaintiff shall serve any and all expert reports on Defense counsel on or before this date. 3. October 15, 2007 - Defendant shall serve any and all expert reports on Plaintiffs counsel on or before this date. 4. November 15, 2007 - Plaintiff shall file any rebuttal expert report on or before this date. 5. November 15, 2007 - Counsel for Plaintiff shall submit a settlement demand to Defense counsel on or before this date. 6. December 3, 2007 - Any and all dispositive motions and supporting briefs shall be filed on or before this date. Also, Defendant shall respond to Plaintiff's demand, and shall state whether or not his client is willing to mediate. 7. December 12, 2007 - The Court will hold a Settlement Conference in Courtroom No. 5 at 8:30 a.m. should it determine one will be fruitful. 8. December 17, 2007 - Any party against whom a dispositive motion has been filed shall file a response and brief in opposition thereto on or before this date. 9. Date to be determined by 2008 Court Schedule - Oral argument on any dispositive motion shall be held during the argument court scheduled for January 2008. 10. Three weeks prior to the Monday of trial week - The parties shall file any and all Motions in Limine with supporting briefs. The adverse party briefs are due 10 days later. 11. Trial in this matter shall be heard during the first trial term in 2008 unless the trial term is scheduled for the period February 2 through 9, 2008. Defense counsel has paid a deposit on a vacation during this period. If the trial cannot take place during the first term of Civil Court in 2008, it shall take place at the second term normally scheduled for the March/April time frame. 12. The Court will advise the parties as soon as the 2008 Court schedule is confirmed at which time the Prothonotary will be directed to give this case priority status and a pre-trial conference will be scheduled. 13. Variance of deadlines by mutual agreement of the parties - Counsel may, without Court involvement, mutually agree to vary the discovery and/or expert report deadlines only. By the Court, M. L. Ebert, Jr., J. 2 Terry Hyman, Esquire Attorney for Plaintiff Andrew Foulkrod, Esquire Attorney for Defendant bas FOULKROD 5LLIS ATTORNEYS AND COUNSELORS AT LAW 2010 Market Street CAMP HILL, PENNSYLVANIA 17011 PHONE (717) 909-7006 FAX (717) 909-6955 MICHAEL C. MONGIELLO June 18, 2007 Via Fax (232-6467) Terry S. Hyman, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 Re: Hetrick v. Blutstein, M.D., et al. FEPC #3558 Dear Terry: PHONE EXTENSION: 2 mike@foulkrod.com I note that pursuant to the Court's January 10, 2007 Scheduling Order, the deadline for completion of discovery is July 6, 2007. If you want to maintain this deadline, please provide dates for depositions of Plaintiff and any fact witnesses whom you intend to call at time of trial within the deadline and we will make ourselves available to accomplish these depositions. Please feel free to give either Andrew or me a call to discuss this matter further. Thank you. Sincerely yours, W ,"4d a V4Wy & 1e,29 Michael C. Mongiello MCM/cag ' Admitted in Pennsylvania and New Jersey e s .. xxxxxxxxxxxxxxx -COMM. JOU, ,- xxxxxxxxxxxxxxxxxxx DATE JUN-_ 2007 xxxxx TIME 11:32 ******** MODE = MEMORY TRANSMISSION START=JUN-18 11:31 END=JUN-18 11:32 FILE N0.=467 STN COMM. ONE-TOUCH/ STATION NAME/EMAIL ADDRESS/TELEPHONE NO. PAGES DURATION NO. ABBR NO. 001 OK a 2326467 001/001 00:00:29 -FOULKROD ELLIS - ***** DP-190 ****xxxxxxxxxxxxxxxxxxx -FOULKROD ELLIS - ***** - 7179096955- ********* FOULKROD ELLIS pup"i"d 45_00"_ ATTORNEYS AND COUNSELORS AT LAW 2010 Market Street CAMP HILL, PENNSYLVANIA 17011 PHONE 17171 909-7006 FAX f717) 909-6955 MICHAEL C. MONGIELLO June 18, 2007 114 Fax /231-6467) Terry S. Hyman, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 Re: Hetrick v. Blutstein. M.D., et al. FEPC #3558 Dear Terry: PHONE EXTENSION: 2 mike@foulkrod.com I note that pursuant to the Court's January 10, 2007 Scheduling Order, the deadline for completion of discovery is July 6, 2007. If you want to maintain this deadline, please provide dates for depositions of Plaintiff and any fact witnesses whom you intend to call at time of trial within the deadline and we will make ourselves available to accomplish these depositions. Please feel free to give either Andrew or me a call to discuss this matter further. Thank you. Sincerely yours, mad a M leaf Michael C. Mongiello MCM/cag Afthud in Pennsylvania and New Jersey I HEREBY CERTIFY that a tue correct copy of the foregoing document was served upon all counsel of record this day of September, 2007, by depositing said copy in the United States Mail at Camp Hill, Pennsylvania, postage prepaid, first class delivery, and addressed as follows: Terry S. Hyman, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 Counsel for Plaintiff FOULKROD ELLIS PROFESSIONAL CORPORATION By: 5 -v1 LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, PLAINTIFF V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY AND t/d/b/a PENNSBORO PEDIATRICS, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : NO. 06-4433 CIVIL CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION JURY TRIAL DEMANDED ORDER OF COURT AND NOW, this 24"' day of September, 2007, upon consideration of the Motion of the Defendant filed September 21, 2007, IT IS HEREBY ORDERED AND DIRECTED that: 1. A Rule is issued upon the Plaintiff to show cause why the relief requested should not be granted; 2. The Plaintiff will file an answer on or before October 15, 2007; 3. If no answer to the Rule to Show cause is filed by the required date, the relief requested by Defendant shall be granted upon the Court's receipt of a Motion requesting Rule be made Absolute. If the Plaintiff files an answer to this Rule to Show Cause, and the answer raises disputed issues of material fact, an evidentiary hearing will then be scheduled. 4. The Prothonotary is directed to forward said Answer to this Court. By the Court, M. L. Ebert, Jr., J. VEN VAl-'S' Nf]ld 8 S :9 WV SZ d3S COOL AbVIGNO!riiU.4'd 3M JO Terry Hyman, Esquire Attorney for Plaintiff Andrew Foulkrod, Esquire Michael Mongiello, Esquire Attorneys for Defendant bas - ) SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 thvman(a,srklaw. com Attorneys for Plaintiff(s) LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, Plaintiff V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY and t/d/b/a PENNSBORO PEDIATRICS, Defendant : IN THE COURT OF COMMON : PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : No. 06-4433 CIVIL CIVIL ACTION -LAW MEDICAL PROFESSIONAL LIABILITY ACTION JURY TRIAL DEMANDED DEFENDANT'S MOTION FOR A PROTECTIVE ORDER TO PRECLUDE PLAINTIFF FROM INSPECTING DEFENDANTS' COMPUTER and OTHER ATTACHED MOTIONS SHOULD NOT BE GRANTED 1. Denied as stated: Plaintiff admits having requested an inspection of Dr. Blutstein's computer. The self-evident purpose of Plaintiff's request to inspect the Defendant's computer is to see if Defendant Blutstein fabricated all or part of a medical record containing facts absolutely central to the case. This medical' malpractice case arises from the death of Sara Zehring, at age sib, about 4 hours after she had been treated by Defendant Blutsteini, her pediatrician, in his office on January 31, 2005. Plaintiff's theory of ?ecovery is that Defendant Blutstein sent Sara home . with her mom, instead of sending her directly to the hospital for monitoring, evaluation, and treatment. In discovery, Defendant produced a self-serving record of the January 31St visit under circumstances giving rise to suspicion it was fabricated, as follows: (a) The entry was created on the Defendant's personal computer. It is the only time Defendant made a note on a patient on his personal computer, rather than in his handwritten charts. (Blutstein Deposition, p. 56, Exhibit 1). (b) The computer entry was supposedly created by Defendant Blutstein on January 31, 2005, the same day of Sara's visit, right after she died. (Blutstein Deposition, p. 47, Exhibit 2), for the purpose of recording everything that happened relating to this unusual event (Blutstein Deposition, p. 56, Exhibit 3), conscious of the fact that a legal claim could arise from the incident. (Blutstein Deposition, p. 199, Exhibit 4). (c) Yet, a few months later, when two different law firms, one of which Defendant knew to be medical malpractice lawyers sent letters personally reviewed by Blutstein asking for all of his January 2005 "records" for Sara, this computer record was not produced. Instead, on two separate occasons, Defendant himself reviewed the request for all records, and produced his handwritten and typed office notes on standard form used, in his office, outside studies and correspondence on 2 1 0 1 his own letterhead to other physicians involved in Sara's care. His computer record supposedly recording the facts of the events for which he thought he might be sued, were not produced. (Blutstein Deposition, p. 184-189, Exhibit 5). (d) The computer note was only produced after suit was started by a Complaint alleging Defendant should have sent Sara to the hospital. (e) The Defendant's computer records contain significant facts from the office visit at issue, many of which are exculpatory. Defendant's computer note claims to have advised Sara's mom that Sara: "could be admitted to a hospital for observation;" and Defendant asked Sara's mom: "Wouldn't you rather have her [Sara] in a hospital?" (Blutstein Deposition, p. 60, Exhibit 6). (f) Sara's mother, Plaintiff Laura Hetrick adamantly denies the conversation recorded in the computer record took place or that she was offered the option to take her child to the hospital (Hetrick Deposition, p. 90, Exhibit 7). (g) Defendant gave unconvincing reasons why he did not produce this computer generated note, supposedly made on the day of death, when her records were requested prior to suit by malpractice law firms. He denied the note was fabricated after suit. He denied anything exculpatory was added after the note was created on January 31, 2005. 2. Admitted that since the computer record addresses all the operative facts in the case, was not produced until after the Complaint 3 was filed, despite two earlier requests for all Defendant's records relating to the office visit, and the note is directly contradictory of Sara's mother's testimony on the central issue in the case, Plaintiff on June 22, 2007, requested Defendants permit Plaintiff inspection of the original document to determine whether it was a fabricated or altered record. Since the document was originally created on a computer, the "original" dates, content and alterations all reside on the Defendants computer hard drive. It is denied that allowing an inspection of Defendant's personal computer in any fashion would disrupt or invade Dr. Blutstein's office or that Defendant has offered any facts whatsoever, establishing a disruption or any other fact establishing a basis for a Protective Order. To the contrary the facts are: (a) At no time has Defendant claimed the computer record is irrelevant or privileged nor that the inspection is not reasonably calculated to lead to admissible evidence. To the contrary, the computer record and its authenticity are directly relevant to the Defendant's creditability on the central issue in the case. (b) When Plaintiff initially asked for the inspection, the only objection raised by Defendant from June 18 through August 21, 2007, was the availabilityll of Defense counsel, Dr. Blutstein and having their own forensic expert present within the time frame requested by Plaintiff's Counsel. (See 10 E?mails exchanged from 06/10/07 through 08/81/07 II 4 . attached as Exhibit A). Plaintiff readily agreed to Defendant having his own expert present to assure the examination of the hard drive was equally transparent to both sides. (c) On August 21, 2007, Defendants raised a second set of objections based on privacy issues and HIPPA. Plaintiff immediately advised that Plaintiff's inspection of the hard drive would only extract records relating to Sara Zehring and no other patient; that his expert would sign a HIPPA agreement, and Plaintiff would stipulate to any Protective Order drafted by Defendant to protect confidential information of any person or patient other than Sara Zehring or Laura Hetrick. (Emails attached as Exhibit B). No claim or mention was made of "office disruption" or any facts showing allowing the inspection would, in fact, in any way impact Defendant's practice in any demonstrable way. (d) Defendants, however, instead of arranging the inspection, hired their own forensic expert, who, without any notice to Plaintiff, went to Doctor Blutstein's office and made what the defense expert calls a "certified forensic copy" of the hard drive. (e) Only at this point, after it had its own expert, ex parte, directly invade and analyze the Defendant's hard drive, did Defendants for the first time, claim Plaintiff's inspection would disrupt Dr. Blutstein's practice. Defense Counsel offers no specific information how it would disrupt the practice beyond a bald conclusory statement to that effect. 5 1 L 1 (f) Defense Counsel acknowledged that their own expert was able, by the simple expedient of conducting the inspection on an Administrative day when no one was in the office, to complete an inspection without disturbing the Defendant's practice. Plaintiff offered to do precisely the same thing by conducting the inspection outside of business hours, but Defense Counsel refused, insisting that Plaintiff rely solely on the certified "copy" produced by the expert hired by the very party Plaintiff believes fudged his records. (Exhibit C). 3. Plaintiff admits that she has consistently asked to have Plaintiff's own expert look at the original record to be sure it is genuine, and that the Defendant is not lying about its creation or contents. Since the actual original record is the data on the hard drive, Plaintiff wants to see the actual hard drive, not a "copy" of the hard drive, made ex parte by an expert hired and controlled by the Defendant whose credibility is at issue. 4. Denied that Plaintiff has not offered a reason to inspect the hard drive. First, it is relevant. Second, it is an original document where the authenticity of the document is at issue. Where a party has a basis to suspect a written record, medical, business or in a criminal proceeding, had been altered or', information inserted after the fact, surely this Court would permit that party have their own document examiner look at the original document, rather than be limited to a "certified copy" prepared by the expert hired b the person they suspect of cheating, where the 6 original is readily available. The fact that the "original" now is the data on a hard drive, rather than a piece of paper, is a distinction without a difference. A party surely does not have to accept a substitute offered by his adversary, where the original evidence is readily available, and Defendant offers no reason to withhold it. 5. Denied as a misstatement of the law. Pa. R.C.P 4003.1 obliges Defense Counsel to produce evidence properly requested under Pa. R.C.P. 4009.31 which is relevant to the case. Plaintiff does not have to offer a "reason" for the request beyond relevance. Rather, it is Defendant's burden to prove why, though relevant, the hard drive should not be produced. To do so, Defendant must offer more than a simple statement showing why production would be "disruptive" but actual facts showing how an after hours inspection similar to the one already done by Defendant's own experts would somehow, in fact, adversely affect Dr. Blutstein's practice No such showing was made on any exhibit attached to Defendant's Motion or in his Brief. 6. Plaintiff has no problem with the Court limiting the inspection to only documents or data related to Sara Zehring or her mother, Laura Hetrick, nor requiring the inspection be done outside of business hours with Defendant's expert present. Plaintiff does 'jask the inspection be Ordered within the 30 days of the Order; that D?fendant refrain from having its own experts do anything further to {the hard drive, and the Defendant produce all copies 7 it has made of the hard drive so they can be compared to the original to assure no alteration was made during the copying process. 7. - 9. Plaintiff finds it a bit inconsistent for Defendant, on one hand, to note that the case will have to be continued until March to (with the agreement of Plaintiff's Counsel) accommodate the prepaid vacation plans, then on the other hand insist on an Order compelling Plaintiff to identify her trial witnesses five months before trial. It should also be noted that Defense Counsel only sought non- concurrence in its Protective Order, with mentioning a Motion to Compel discovery of witness identity would be brought to the Court. Had they done so, Plaintiffs counsel would have agreed to the Court setting a deadline in advance of trial for both parties to identify any non-deposed witnesses they intend to call at trial in time for the adverse party to complete a discovery deposition. Such a deadline has been incorporated into the Proposed Order attached to this Response. Plaintiff is in agreement with giving the case a priority listing and attaching counsel for trial during the March term of Court. Plaintiff sees no reason for factual hearing on any issue presented by the Defendant, as the facts are not in dispute, but on the application of the facts pled by Defendant, as moving party, to the law. 8 Respectfully submitted, SCHMIDT KRAMER PC By: Ter an, Esquire I. . No. 66807 209 State Street Date: Harrisburg, PA 17101 (717) 232-6300 //-0 Attorney for Plaintiff 9 `x l,?b ? ? Z,ehring, Estate of Sara J. Case #: 210687 ( ) 10/2/2007 11:31 AM Date: 06/18/2007 12:03 PM Staff: TSH From: Terry Hyman To: Mike@foulkrod.com; Andrew Foulkrod CC: Janice Harmon Subject: deadlines in hetriick Date Sent: 6/18/2007 11:53:31 AM Case Note - Page 124 of 224 Topic: E-Mail lets exend dicovery until end of july. we will set up lauras deposition. Pursuant to my earlier "spoiliation" emails. I will wnat to have a computer person examine Dr. Blustiens personal computer. Terry S. Hyman Esq. SchmidtKramer PC 209 State St. Harrisburg, Pa. 17101 717-232-6300 fax 717-232-6467 thyman@schmidtkramer.com <mailto:thyman@schmidtkramer.com> Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 1 of 1 Case Status [j Zehlring, Estate of Sara J. Case #: 210687 ( ) 10/2/2007 11:35 AM Date: 07/03/2007 12:17 PM Staff: TSH From: Terry Hyman To: Andrew Foulkrod; Mike@foulkrod.com CC: Melissa Miller; Janice Harmon Subject: Computer inspection Date Sent: 7/3/2007 12:08:05 PM Dear Mike and Andy Case Note - Page 132 of 224 Topic: E-Mail My foresenic computer expert informed me that he will be in harrisburg between july 16-18. 1 very much would like him to conduct his inspection during that time frame. I certainly do not expect dr. Blustein to be present, I would like to think you can accommodate those dates. My preference is to bring the computer from dr. blustien's office to here. Your certainly may have anyone you want present and can take pictures or video whatever you want. This will not be destrucitive in any way. If you have any other conditions to the inspection, I will try to accommodate. Please let me know promptl if the computer will be made available on one date between july 16 and July 18. Terry S. Hyman Esq. SchmidtKramer PC 209 State St. Harrisburg, Pa. 17101 717-232-6300 fax 717-232-6467 thyman@schmidtkramer.com <mailto:thyman@schmidtkramer.com> Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 1 of 1 Case Status E Zehring, Itstate of Sara J. Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Case #:210687 ( ) Class: L5 Assigned: TSH Date Opened: 3/22/2006 10/2/2007 11:36 AM Page 1 of 2 Case Note - Page 133 of 224 Date: 07/05/2007 11:15 AM Staff: TSH From: Terry Hyman To: Andrew Foulkrod CC: Subject: RE: Computer inspection Date Sent: 7/5/2007 11:05:42 AM Topic: E-Mail Please let me know as soon as you do. I do agree we will have to extend discovery deadline to get depos complete. have your secretary call janice to set up an august date. I am likelty to be going of get a amall outpatient laproscopic surgery sometime in aug. so lets set the depos up shortly so it will not conflict with my surgery. ?-----Original Message----- ?From: Andrew Foulkrod [mailto:Andrew@foulkrod.com] []Sent: Thursday, July 05, 2007 10:31 AM ?To: Terry Hyman ?Cc: Mike Mongiello ?Subject: RE: Computer inspection ? []Terry: 11 ?We were out the afternoon of July 3, and just received your email. ? ?I would like to have a similar expert present and have started to identify one (this is a novel issue for me). Dr. Blutstein may also want to be present since its his personal computer - if he is there then Mike or I need to be there and Mike and I are both out of state that week (we'd be happy to show you the respective reservations). 11 ?So if we can get an expert to be present then - and Dr. Blutstein does not want to be present - then ok. Otherwise, we'll need more time to accomodate. 11 ?1 have been told that you are not free 3 of the 4 weeks in July that I was free for your clients dep, so that likely will need to spill over as well. 11 ?I will be in touch soon on this. []Andy ??-----Original Message----- ?[]From: Terry Hyman [mailto:thyman@schmidtkramer.com] ??Sent: Tuesday, July 03, 2007 12:16 PM ?[]To: Andrew Foulkrod; Mike Mongiello ??Cc: Melissa Miller; Janice Harmon ??Subject: Computer inspection ??Importance: High ?? :1? :ill Dear Mike and Andy K] My foresenic computer expert informed me that he will be in harrisburg between july 16-18. 1 very nuch would like him to conduct his inspection during that time frame. I certainly do not expect dr. 3lustein to be present, I would like to think'you can accommodate those dates. My preference is to )ring the computer from dr. blustien's offic?, to here. Your certainly may have anyone you want present ind can take pictures or video whatever you want. This will not be destrucitive in any way. If you have my other conditions to the inspection, I will try to accommodate. 113 Please let me know promptl if the computer will be made available on one date between july 16 ind July 18. Case Status ? Kellring, Estate of Sara J. Case #: 210687 { ) 10/2/2007 11:37 AM Date: 07/17/2007 06:02 PM Staff: TSH From: Terry Hyman To: Andrew Foulkrod; Mike@foulkrod.com CC: Melissa Miller Subject: the computer inspection Date Sent: 7/17/2007 5:52:37 PM Andy, Case Type: MED MAL DOI: 1 /31 /2005 Class: L5 Assigned: TSH Page 1 of 1 Case Note - Pam 140 of 224 Topic: E-Mail I never heard back from you about the inspection. We obviously missed the July dates. You were to determine whether, you, dr. blustein, a defense expert, or none of the above needed to be presetn, and what dates are available. I do want to do this and complete it long before expert reports are due. Please give me some specifics. I dont want to go the court but also dont want to have case delayed, so please get back to me promptly. Terry S. Hyman Esq. SchmidtKramer PC 209 State St. Harrisburg, Pa. 17101 717-232-6300 fax 717-232-6467 thyman@schmidtkramer.com <mailto:thyman@schmidtkramer.com> LIM Date: 1/31/2007 Date Opened: 3/22/2006 Case Status ? 4phring, Estate of Sara J. Case #: 210687 ( ) 10/2/2007 11:38 AM Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 1 of 1 Case Note - Paste 143 of 224 Date: 07/19/2007 01:20 PM Staff: TSH From: Terry Hyman To: Melissa Miller CC: Subject: FW: the computer inspection Date Sent: 7/19/2007 1:10:26 PM -----Original Message----- From: Mike Mongiello [mailto:Mike@foulkrod.com] Sent: Thursday, July 19, 2007 12:44 PM To: Terry Hyman; Andrew Foulkrod Cc: Melissa Miller Subject: RE: the computer inspection Hi Terry, Topic: E-Mail Andy is on family vacation through the rest of this week. I just returned from vacation today. My understanding is that we will definately have someone present for your computer expert's evaluation. i am in the process of getting workable dates and will be in touch very soon. Mike ?-----Original Message----- []From: Terry Hyman [mailto:thyman@schmidtkramer.com] []Sent: Tuesday, July 17, 2007 6:01 PM []To: Andrew Foulkrod; Mike Mongiello []Cc: Melissa Miller []Subject: the computer inspection [] [] []Andy, ?1 never heard back from you about the inspection. We obviously missed the July dates. You were to determine whether, you, dr. blustein, a defense expert, or none of the above needed to be presetn, and what dates are available. I do want to do this and complete it long before expert reports are due. Please give me some specifics. I dont want to go the court but also dont want to have case delayed, so please get back to me promptly. 11 []Terry S. Hyman Esq. []SchmidtKramer PC []209 State St. []Harrisburg, Pa. 17101 []717-232-6300 fax 717-232-6467 []thyman@schmidtkramer.com <mailto:thyman@schmidtkramer.com> Case Status El Ze,hring, Estate of Sara J. Case #: 210687 ( ) 10/2/2007 11:38 AM Date: 07/23/2007 01:15 PM Staff: JSH From: Janice Harmon To: Terry Hyman CC: Melissa Miller Subject: Estate of Sara Zehring Date Sent: 7/23/2007 1:15:58 PM Case Type: MED MAL DOI: 1/31/2005 Class: L5 Assigned: TSH Case Note - Page 149 of 224 Topic: E-Mail LIM Date: 1/31/2007 Date Opened: 3/22/2006 Page 1 of 1 Case Status ? Chery from Mike M. office called. Dr. Blutstein will be on vacation July 25th through August 6th. He anticipates being very busy the week following his vacation. They will try to set something up after August 13th. Zehring, ?stete of Sara J. Case #: 210687 ( ) 10/2/2007 11:39 AM Date: 08/02/2007 02:42 PM Staff: TSH From: Terry Hyman To: Mike@foulkrod.com; Andrew Foulkrod CC: Subject: Blustein computer Date Sent: 8/2/2007 2:42:36 PM Mike, Case Type: MED MAL DOI: 1/31/2005 Class: L5 Assigned: TSH Case Note - Page 162 of 224 Topic: E-Mail I need a conrete date. My expert deadline is Aug 31. 1 therefore need the inspection to take place within the next two weeks. I will have to file a motion to protect myself unless you give me a date or agree to extend the expert deadline. If we do the latter it will be with the understanding that I will not automatically extend your time to respond to my experts, if it will end up effecting the trial date. I requested to do the inspection on July 3. It has been a month and we still dont have a date set up. Give me something concrete please. Terry S. Hyman Esq. SchmidtKramer PC 209 State St. Harrisburg, Pa. 17101 717-232-6300 fax 717-232-6467 thyman@schmidtkramer.com <mailto:thyman@schmidtkramer.com> LIM Date: 1/31/2007 Date Opened: 3/22/2006 Page 1 of 1 Case Status [] Zehring, Estate of Sara J. Case #: 210687 ( ) 10/2/2007 11:40 AM Date: 08103/2007 08:43 AM Staff: TSH From: Mike Mongiello To: Andrew Foulkrod; Terry Hyman CC: Subject: RE: Blustein computer Received: 8/3/2007 8:14:10 AM Hi Terry, Topic: E-Mail I thought you already knew this, but Dr. Blutstein is out for two weeks, returning on 819. When he gets back, we can get this done. What Andy says about the deadline extension goes. Talk to you next week. Mike -----Original Message----- From: Andrew Foulkrod Sent: Friday, August 03, 2007 7:49 AM To: 'Terry Hyman'; Mike Mongiello Subject: RE: Blustein computer I asked my people to get this done. Mike, please have them get this done. Wasn't the holdup that Dr. Blutstein is out of town for two weeks? Terry, I don't have any problem with extensions that don't affect the trial date. Don't waste time on a motion; we would agree anyway. -----Original Message----- From: Terry Hyman [mailto:thyman@schmidtkramer.comj Sent: Thursday, August 02, 2007 2:46 PM To: Mike Mongiello; Andrew Foulkrod Subject: Blustein computer Mike, I need a conrete date. My expert deadline is Aug 31. 1 therefore need the inspection to take place within the next two weeks. I will have to file a motion to protect myself unless you give me a date or agree to extend the expert deadline. If we do the latter it will be with the understanding that I will not automatically extend your time to respond to my experts, if it will end up effecting the trial date. I requested to do the inspection on July 3. It has been a month and we still dont have a date set up. Give me something concrete please. Terry S. Hyman Esq. 3chmidtKramer PC ?09 State St. iarrisburg, Pa. 17101 '17-232-6300 fax 717-232-6467 <mailto:thyman@schmidtkramer.com> thyman@schmidtkramer.com Case Type: IVIED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 1 of 1 Case Note - Pane 164 of 224 Case Status ? Zphfing, Estate of Sara J. Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Case #:210687 () Class: L5 Assigned: TSH Date Opened: 3/22/2006) 1012/2007 11:41 AM Page 1 of 1 Date: 08/21/2007 11:26 AM Staff: TSH Case Note - Pane 183 of 224 Topic: E-Mail Case Status ? From: Terry Hyman To: Mike@foulkrod.com; Andrew Foulkrod CC: Subject: computer exammination in zehring Date Sent: 8/21/2007 11:26:45 AM Mike, I doubt the hold up is you or your office, but the fact reamins I still dont have a date for the inspection of blustein's computer, A Motion to Compel will be filed on August 26, unless I have a specfic date. Also you or andy need to give me dates for Dr. Mack. Will I have to subpoena her or is she still considered part of the practice. Terry S. Hyman Esq. SchmidtKramer PC 209 State St. Harrisburg, Pa. 17101 717-232-6300 fax 717-232-6467 thyman@schmidtkramer.com <mailto:thyman@schmidtkramer.com> 4ehring, Estate of Sara J. Case #: 210687 ( ) 1012/2007 11:43 AM Date: 08/27/2007 09:56 AM Staff: TSH From: Mike Mongiello To: Terry Hyman CC: Andrew Foulkrod; Cheryl Garofalo Subject: RE: computer exammination in zehring Received: 8/24/2007 8:05:08 AM Hi Terry, Topic: E-Mail Case Status D Sorry it has taken me so long to get back to you, but Andy and I are in trial this week. I am leaving to go to the courthouse in a few minutes and no one else is here right now. You say that you will file a motion to compel on 8/26, which is Sunday. ssume this rror and you really mean Monday Can you hold off until close of business on Monday and I will contact ou on Monday morning. Yo r at we will coopera a in a compu er investmation. As far as Dr. Mack, she is no longer employed with the group, but we do represent her as she was Dr. Blutstein's employee at the relevant time. Dr. Blutstein is responsible for her conduct under agency theories. We will provide dates for her deposition inthe immediate future. Have a great weekend. Mike -----Original Message----- From: Terry Hyman [mailto:thyman@schmidtkramer.com] Sent: Tuesday, August 21, 2007 11:31 AM To: Mike Mongiello; Andrew Foulkrod Subject: computer exammination in zehring Mike, I doubt the hold up is you or your office, but the fact reamins I still dont have a date for the inspection of blustein's computer, A Motion to Compel will be filed on August 26, unless I have a specfic date. Also you or andy need to give me dates for Dr. Mack. Will I have to subpoena her or is she still considered part of the practice. Terry S. Hyman Esq. SchmidtKramer PC 209 State St. Harrisburg, Pa. 17101 717-232-6300 fax 717-232-6467 Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 1 of 1 Case Note - Page 188 of 224 <mailto:thyman@schmidtkramer.com> thyman@schmidtkramer.com Fxl.,6?? B 4ehring, Fstate of Sara J. Case #: 210687 ( ) 10/2/2007 11:44 AM Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 2 of 2 Case Note - Page 190 of 224 ?[1?Hi Terry, ??? ? ? ? Dr. Blutstein has some obvious and justifiable concerns with regard to your computer investigation arising out of HIPAA and privacy interests. Under these circumstances, maybe it will be best if you just go ahead and motion the Court in order that we can get some limitations imposed on the whole procedure. With Court oversight, I think everyone involved will feel much better about this. Fair? ??? ? ? ? Thanks. ??? ? ? ? Mike 11 ? ? ?-----Original Message ----- ? ? ? ?From: Terry Hyman [mailto:thyman@schmidtkramer.com] ? ? ? ?Sent: Tuesday, August 21, 2007 11:31 AM ? ? ? ?To: Mike Mongiello; Andrew Foulkrod ? ? ? ?Subject: computer exammination in zehring ???? ???? ????Mike, ???? ????1 doubt the hold up is you or your office, but the fact reamins I still dont have a date for the inspection of blustein's computer, A Motion to Compel will be filed on August 26, unless I have a specfic date. ? [7 ? ?Also you or andy need to give me dates for Dr. Mack. Will I have to subpoena her or is she still considered part of the practice. ???? ? ? ? ?Terry S. Hyman Esq. ? ? ? ?SchmidtKramer PC ? ? ? [1209 State St. ? ? ? o Harrisburg, Pa. 17101 ? ? ? ? 717-232-6300 fax 717-232-6467 ? ? ? ?thyman@schmidtkramer.com <mailto:thyman@schmidtkramer.com> ?Cl?? Z,ehring, Estate of Sara J. Case #: 210687 ( ) 10/2/2007 11:45 AM Date: 08/29/2007 10:05 AM Staff: TSH From: Terry Hyman To: Mike@foulkrod.com; Andrew Foulkrod CC: Subject: computer inspection Date Sent: 8/29/2007 10:05:23 AM Case Type: MED MAL DOI: 1/31/2005 Class: L5 Assigned: TSH Case Note - Page 200 of 224 Topic: E-Mail My computer expert says his methodolgy will only extact info related to my clients from the hard drive. He will sign off on any HIPAA form or reasonabel protective order as will I. Draft whatever you want. If you want court approval I will stipulate to an order. I want to have the inspection within the next 2-3 weeks if you will do it by agreement subject to the protective order. PLease let me know dates if that is ageeable or let me know you have some other impediment to going forward with the inspection. Terry S. Hyman Esq. SchmidtKramer PC 209 State St. Harrisburg, Pa. 17101 717-232-6300 fax 717-232-6467 LIM Date: 1/31/2007 Date Opened: 3/22/2006 Page 1 of 1 Case Status LJ thyman@schmidtkramer.com <mailto:thyman@schmidtkramer.com> ?? ?? b; Zehfing, estate of Sara J. Case Type: IVIED MAL DOI: 1/31/2005 Case #: 210687 O Class: L5 Assigned: TSH 1012/2007 11:48 AM Case Note - Page 206 of 224 Date: 08/31/2007 09:36 AM Staff: TSH Topic: E-Mail From: Terry Hyman To: Mike Mongiello CC: Subject: RE: computer Date Sent: 8/31/2007 9:36:59 AM I want to use the exact same material as your expert. I do not want a copy of a copy. send us thier copy please LIM Date: 1/31/2007 Date Opened: 3/22/2006 Page 1 of 2 Case Status 17] I]-----Original Message----- ?From: Mike Mongiello [mailto:Mike@foulkrod.com] []Sent: Thursday, August 30, 2007 2:03 PM ?To: Terry Hyman ?Cc: Andrew Foulkrod ?Subject: RE: computer ?We o 1 su pose we could just give you our copy, but m expert mentioned making another copy. I will see. We co a eves recen yon an a ministrative day" when the office was closed. Mike ? ?-----Original Message----- ??From: Terry Hyman (mailto:thyman@schmidtkramer.com] ??Sent: Thursday, August 30, 2007 2:01 PM ? ?To: Mike Mongiello ??Subject: RE: computer ?? ?? ?I though you already had a copy done by your expert? How were they able to examine the hard out disrupting dr. blusteins office? ? ? ?-----Original Message----- ???From: Mike Mongiello (mailto:Mike@foulkrod.com] ? ? []Sent: Thursday, August 30, 2007 12:11 PM ? ? ?To: Terry Hyman ???Cc: Andrew Foulkrod; Janice Harmon ???Subject: RE: computer ??? ??? ???1 assume you will cover the costs associated with coying? ? ? ? ?-----Original Message----- [] ? ? ? From: Terry Hyman (mailto:thyman@schmidtkramer.com] 5???Sent: Thursday, August 30, 2007 11:46 AM J E1 ? ?To: Mike Mongiello ? ? ?Cc: Andrew Foulkrod; Janice Harmon ? ? ?Subject: computer _J ??[] 1011[] ][][][]Mike I??? I ? ? ? 1 talked to my expert. Please send the copy and all paperwork and certification from your hxpert. let you know after my expert looksiat the copy if we need a conference call 7111 []Can you do this as promptly as possible. I want to keep things moving forward. m? []Terry S. Hyman Esq. i ? ? ?SchmidtKramer PC ? ? []209 State St. ]???Harrisburg, Pa. 17101 ,nnn717_?'??_aznn fnv 717_7Q')_AAA7 Zehring, estate of Sara J. Case #: 210687 { ) 10/2/2007 11:49 AM Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 1 of 3 Case Note - Pane 212 of 224 Date: 09/05/2007 03:00 PM Staff: TSH From: Terry Hyman To: Andrew Foulkrod CC: Subject: RE: computer Date Sent: 9/5/2007 3:00:30 PM Andy, Topic: E-Mail I do not consider it a very good idea tfor you to have had your expert do anything to extract information central to the case without my expert being present after I sent you a spoliation letter and after I requested the right to inspect the hard drive. Dr. Blusteins both will not alter either in a and so is that my expert have uneouivocally that his examination of we will do this after office hours to avoid any interference with the doctors practice. If this not acceptable to you let me knwo and I will take appropriate steps to get the court involved. Terry S. Hyman Esq. SchmidtKramer PC 209 State St. Harrisburg, Pa. 17101 717-232-6300 fax 717-232-6467 thyman@schmidtkramer.com <mailto:thyman@schmidtkramer.com> -----Original Message----- From: Andrew Foulkrod [mailto:Andrew@?Foulkrod.com] Sent: Wednesday, September 05, 2007 :50 AM To: Terry Hyman Cc: Mike Mongiello Subject: RE: computer ?Terry: ?Our expert made a copy of the original -- we can call that a duplicate original -- that is "forensically sound". ?Our expert then made a copy of the dup icate orignial, also forensically sound, on which the testing and programs were run. Apparently, by y understanding, after the testing and programs a copy is no 'onger is considered forensically sound. he duplicate original is though; it has not been altered in any ,ray, only copied. Our expert proposes to copy the duplicate original for your testing -- exactly as was Jone for us -- that way they are working w th the same thing, which is forensically sound -- and the iuplicate orignial is maintained. ]This finally makes sense to me and does'n't seem to prejudice you at all. Please have your expert espond. I ]Andy -----Original Message----- 'From: Andrew Foulkrod JSent: Tuesday, September 04, 2007 10:15 AM 11TH- KML gn, NAnnniclln• 'Term Wtimon' Case Status El 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 be -- obviously, you were writing this note the night after the child died. Did you try to be thorough? MR. FOULKROD: I object. You're trying to characterize this as two different days. He didn't write this -- MR. HYMAN: This was the night that the child died. MR. FOULKROD: You said, "the night after." MR. HYMAN: I said, the night of. Q. You're writing this within two hours of the child's death. Were you attempting at this time to be accurate and complete in recording those events? A. I was just trying to write down what I remembered while -- while the things were fresh in my mind. Q. And why did you want to do that? A. Just to have a record. Q. And why did you want to have a record? A. It's an unusual thing when a child dies, you know, shortly after leaving your office. Q. Okay. So this was a unique -- have you ever done -- have you ever -- did you at any other time in Sara's treatment with you in the 60 visits over ten years make a note similar to this? 1 56 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 early morning hours of the 31st and taking us to the time of the child's death. Is that correct? A. Yes . Q. And also some events after the child's death. Is that correct? ,A. Yes. Q. Now, the note -- at the beginning of the note it has, "January 31st, 2005, 1722h." What does the "1722h" refer to? A. Military time. Q. Well, I understand that. What is -- why -- what does that number refer to? A. That's -- that was the date and time that I started this. Q. That you wrote the note? A. Yeah. MR. FOULKROD: Objection. He said, "started this." BY MR. HYMAN: Q. Okay. Well, if you would go to the last page, if you would, and at the end you have "1731, 1750h." Would that be the time that you finished the note? A. Yes Q. So everything was done between 5:20 and 1 47 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 be -- obviously, you night after the chil thorough? MR. FOULKROD: I characterize this as write this -- MR. HYMAN: This died. were writing this note the d died. Did you try to be object. You're trying to two different days. He didn't was the night that the child MR. FOULKROD: You said, "the night after." MR. HYMAN: I said, the night of. Q. You're writing this within two hours of the child's death. Were you attempting at this time to be accurate and complete in recording those events? A. I was just trying to write down what I remembered while -- while the things were fresh in my mind. Q. And why did you want to do that? A. Just to have a record. Q. And why did you want to have a record? A. It's an unusual thing when a child dies, you know, shortly after leaving your office. Q. Okay. So this was a unique -- have you ever done -- have you ever -- did you at any other time in Sara's treatment with you in the 60 visits over ten years make a note similar to this? 56 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 Q. You've never written, up until this -- up until this death, a private note that you kept in your computer separate from the medical records? A. Right. Q. And you say that the only purpose that you wanted to do that was to be sure that you wrote everything down to make sure it was all recorded? A. Right. Q. Nothing to do with concerns about fault or lawsuits. Is that correct? A. Well, I mean, every time you see a patient, there's -- there's that floating in the back of your mind. Q. Okay. Now, going back, after you reviewed the autopsy with her -- I did ask a question if you had offered an explanation to her as to what accounted for the fact that you had seen the patient at -- basically, left her office somewhere around 11 -- 10:15, around a quarter to 11, and was coded at around 14 -- whenever it was -- 1417 when she called you. MR. FOULKROD: That's not a question. MR. HYMAN: I'm asking -- it's not a question yet, I'm just. . . Q. Now, Doctor, have you -- at the time that 1 199 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 had not -- A. No. She said that other people had told her to sue me, but she decided not to. Q. Okay. A. So she did not indicate that she thought there was anything wrong with my care at that time. Q. Okay. Now, did you, subsequent to that meeting and that discussion, get a letter from an attorney asking for your medical records? A. At some point. Q. Okay. Well, if I would show you -- let me show you a letter. A. I think it was like a year later. Q. Right . We'll mark that as an exhibit. (Whereupon, the document was marked as Exhibit No. 4 for identification.) THE WITNESS: Yep. BY MR. HYMAN: Q. Okay. What's the name of that law firm? A. Angino and Rovner. Q. Are you familiar with the law firm of Angino and Rovner? A. Sure. Q. And what do you know about them? 1 184 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 MR. FOULKROD: Objection. THE WITNESS: Well, Neil Rovner is my neighbor. BY MR. HYMAN: Q. Okay. Do you know what kind of law he practices? A. Like medical malpractice. Q. Okay. And this was also -- you had also had at least some indication of the fact that Laura, although being discouraged, had been -- talked about legal action. Is that correct? MR. FOULKROD: Can you repeat that. BY MR. HYMAN: Q. That, in your conversation with Laura a year earlier, she had mentioned at least somebody advising her that she should take legal action against you; are you aware of that? A. Right, her family, friends, whatever. Somebody told her. Q. Okay. A. But she didn't seek legal action at that time. Q. Okay. Correct. Now, would you agree that there was no -- when they requested the information, you said to me, I think earlier in your testimony, that you didn't 1 185 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 get many requests and if something came in from a lawyer it would be -- that it would be shown to you. Is that correct? A. Um-hum. Q. Okay. So when you saw something from a medical malpractice lawyer, under these particular circumstances, did you consider it to be something where they were investigating or at least considering something that might have to do with legal -- A. Sure. Q. -- a medical malpractice? A. Sure. Q. Okay. When you sent the record -- what were the dates that were requested there? A. January 2005. Q. Okay. Until the present date. Is that correct? A. Well, until -- yeah. So, basically, that just was just one day because the only day I saw her in January of 2005 was that day. Q. Okay. Did you include in -- now, at the time of the -- as I remember your prior testimony, at the time of the day of death, within two hours, you wanted to be sure that you captured your memory 1 186 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 accurately and completely and you created a computer document to do that. Is that correct? A. Right. Q. And you did that personally. Is that correct? A. Right. Q. And you obviously -- at that time did it enter your mind at all that there may be at least some question as to why it was that a child had left your office and died on the same day, from a legal standpoint? A. Sure Q. Did you send a copy of that note to -- in response to that letter? A. No. Q. Okay. A. It wasn't on the chart. Q. Did you ever make it part of the chart? A. No . Q. Did that record -- did that say, "Medical record," or did that say -- did that say, "Chart," or did it say, "Any and all medical record"? A. I don't know. I'm not a -- I'm not a lawyer. What does it say? It says, "Any and all records from 1/1/05 1 187 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 to the present." Q. Okay. So you didn't consider that a record? A. Well, it was -- it was basically a private note at that time. Q. A private note? A. It had never -- I had never printed it out. Q. Okay. You had had it in your computer -- you were aware when you looked at that that it existed, though. Is that correct? A. Well, sort of. I mean, I wasn't -- this was a year later. I wasn't thinking about that note at that time. Q. I see . A. I mean, I just said -- you know, I just looked and said, "Oh." And I just said, "Okay. Send them those two pages." Q. Okay. And then when you got a second letter from my law firm, the one we saw earlier, again asking for any and all records relating to the case, again, did you include this note in there? A. No. Again, I was not -- it was not part of the medical record, per se. It was just a private note that was sitting on my hard-drive. Q. Okay. So this was a private note that you 1 188 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 had purposely created to record the data about what happened with at least some understanding at the time of creation that there might be a malpractice claim, but you felt it was not something that was being asked for by the lawyers or something that would be presented to the lawyers when they asked for your records about what happened? A. I didn't think it was something that was part of the chart. Q. Okay. Well, the fact is that this -- it is not -- it's your testimony it was created on the time it was created. Is that correct? A. Yes, it is. Q. It is not something you created after you got sued? A. No, absolutely not. Q. And it's something that you did not produce, though, until after you were sued and got a request for information from the attorney? A. I gave it -- I gave it to him. Q. Okay. Let me ask you a question. Did he specifically ask you -- MR. FOULKROD: Objection. MR. HYMAN: Okay. Q. I think this is -- I don't know if this is 189 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 paraphrasing them. Is that correct? A. That's true. Q. And so you were trying to put down the accurate words? A. I was trying to put down the accurate words. Q. Okay. A. Sitting here today, I don't have a specific recollection of those exact words, but I know that at that time I did. Q. Okay. So those would have been the words that you used. Is that correct? A. Yes. Q. The words that she used? A. Yes. Q. And there was not one but two times during the visit you said to her: We could admit the kid to the hospital for observation. And then you said specifically: Wouldn't you rather have her in the hospital? A. Yes. Q. So that was done on two separate times? A. Yes. I mean, you know, right after -- you know, one right after the other. But there were two, right 1 60 Multi-Page"" LAURA E. HETRICK AUGUST 10, 2007 Page 90 1 alive? 2 A Anything and everything. 3 Q You live your life to keep her alive? 4 A Because if I don't who's going to? 5 MR. MONGIELLO: That's all the questions I have. 6 Thank you very much, and again I'm really sorry about your 7 daughter. 8 EXAMINATION 9 BY MR. HYMAN: 10 Q I have two questions I want to ask you. I showed 11 you Dr. Blutstein's memorandum or note that he put on his 12 computer. I want to read the following statement to you: 13 I considered admitting her to the hospital and discussed 14 that possibility with the mother. I said to Mom, this is a 15 kid we could admit to the hospital for observation. Mom 16 said, I prefer to observe her at home. Later in the 17 conversation I said, wouldn't you rather have her in the 18 hospital. Mom did not answer. She stared at me. After an 19 uncomfortable silence, I said, okay, I guess we're not 20 going to the hospital. Did those conversations occur when 21 you were in Dr. Blutstein's office? 22 A No. He never said that. 23 Q I want to read another thing, same thing, this is 24 Dr. Blutstein's answer to a question when we deposed him. 25 I said this is a kid we can admit to the hospital for Page 91 1 observation. Mom said I prefer to observe her at home. 2 Later in the conversation I said wouldn't you rather have 3 her in the hospital. And the mom didn't answer, she just 4 stared at me. Right. So she never, having brought the 5 child in, she never asked you anything further about why 6 she should do one or the other. Dr. Blutstein answered -- 7 and not only that, when I tried to discuss it with her she 8 didn't want to discuss it. 9 Is that an accurate statement of what occurred? 10 Is that what happened when you were there? 11 A No. 12 MR. HYMAN: That's all the questions I have. 13 (The deposition was concluded at 12:55 p.m..) 14 15 16 17 18 19 20 21 22 23 24 25 I COUNTY OF DAUPHIN 2 : SS Page 92 3 COMMONWEALTH OF PENNSYLVANIA : 4 I, Karen C. Albright, a Notary Public, authorized to 5 administer oaths within and for the Commonwealth of 6 Pennsylvania, do hereby certify that the foregoing is the 7 testimony of LAURA HETRICK. 8 I further certify that before the taking of said 9 deposition, the witness was duly sworn; that the questions 10 and answers were taken down stenographically by the said 11 Reporter-Notary Public, and afterwards reduced to 12 typewriting under the direction of the said Reporter. 13 I further certify the said deposition was taken at 14 the time and place specified in the caption sheet hereof. 15 I further certify I am not a relative or employee or 16 attorney or counsel to any of the parties, or a relative or 17 employee of such attorney or counsel, or financially 18 interested directly or indirectly in this action. 19 I further certify that the said deposition 20 constitutes a true record of the testimony given by the 21 said witness. 22 IN WITNESS WHEREOF, I have hereunto set my hand 23 this 1st day of October, 2007. 24 25 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Page 93 Karen C. Albright, RPR Page 90 -Page 93 1r"T!?L7_,C AY '"014 uT Fni.T7. NATALE 717-540-0220/717-393-5101 CERTIFICATE OF SERVICE AND NOW, this day of007, I, Janice S. Harmon an employee of SCHMIDT KRAMER PC, do hereby certify that I have served a true and correct copy of the PLAINTIFF'S ANSWER TO RULE TO SHOW CAUSE WHY DEFENDANT'S MOTION FOR A PROTECTIVE ORDER TO PRECLUDE PLAINTIFF FROM INSPECTING DEFENDANTS' COMPUTER and OTHER ATTACHED MOTIONS SHOULD NOT BE GRANTED in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Andrew Foulkrod, Esq. Michael Mongiello, Esq. Foulkrod Ellis P.C. 2010 Market Street Camp Hill, PA 17011 Janice S. Harmon 12 _ ?' ?_-? ,. _:? .,,.? ? t-:. ? ? ?:?{ t....? ?J ? y' _ .. t:..3 ?> ;? r Alp FOULKROD ELLIS Professional Corporation Andrew H. Foulkrod, Esquire Attorney I.D. #77394 Michael C. Mongiello, Esquire Attorney I.D. #87532 2010 Market Street Camp Hill, PA 17011 Phone: (717) 909-7006 Fax: (717) 909-6955 LAURA E. HETRICK, Administratrix of the Estate of Sara J. Zehring, Plaintiff V. RICHARD N. BLUTSTEIN, M.D., Individually and t/d/b/a PENNSBORO PEDIATRICS, Defendants No. 06-4433 JURY TRIAL DEMANDED RESPONSE TO PLAINTIFF'S ANSWER TO THE MOTION OF DEFENDANTS FOR PROTECTIVE ORDER AS TO PLAINTIFF'S REQUESTED COMPUTER INSPECTION Plaintiff's proposed Order seeks discovery beyond the original request for inspection, in that it seeks the inspection of "any and all copies made by any person of the hard drive." To the extent that this response addresses that new request, it is premised on counsel's understanding based on expert opinion that evaluation/testing of copies compromises those copies. First, Plaintiff's request to inspect all copies made by Defendant's computer expert is inappropriate, in that such an inspection would permit the recreation of Defendant's computer expert's evaluation/testing, beyond the scope of Rule 4003.5. However, if Plaintiff is permitted to inspect all copies made by Defendant's computer expert, Defendant should similarly be pennitted to inspect all copies made by Plaintiff's computer expert. Second, the purpose of Defendant's computer expert's creation of forensically sound copies of the original hard drive was to maintain at least one forensically sound copy, from Attorneys for Defendant Richard N. Blutstein, M.D., Individually and t/d/b/a Pennsboro Pediatrics IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION which other forensically sound copies could be made and then evaluated/tested, but which itself r low would remain uncompromised. It is respectfully requested that if the Court is inclined to pen-nit inspection of a copy made by Defendant's computer expert, that it be a single forensically sound copy, and that another forensically sound copy be permitted to remain free of evaluation/testing by any party. On another note, it should be pointed out that Plaintiff's proposed Order does not address in any fashion Dr. Blutstein's privacy concerns arising out of Plaitniff s proposed evaluation of information in Dr. Blutstein's computer which has nothing to do with: 1) this case; and, 2) the two documents at issue (on the hard drive there exist privileged attorney-client communications regarding this case that do not pertain to the two documents at issue). Respectfully submitted, FOULKROD Professiogal) By: Andrew H. Foulkrod, Esquire Attorney I.D. #77394 Michael C. Mongiello, Esquire Attorney I.D. #87532 Date: October 10, 2007 AW I HEREBY CERTIFY that a true and correct copy of the foregoing document was served upon all counsel of record this 10th day of October, 2007, by depositing said copy in the United States Mail at Camp Hill, Pennsylvania, postage prepaid, first class delivery, and addressed as follows: Terry S. Hyman, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 Counsel for Plaintiff FOULKROD ELLIS PROFESSIONAL CORPORATION By: r" ? -r1 +:.`r ?? his ? . ?'°} ? rs3 ;?:s ?; N 'J7 C? r ? ?. C ?? ? ` > C: y' C: R"1 . r.... ? ?'? C3"! A LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, PLAINTIFF V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY AND t/d/b/a PENNSBORO PEDIATRICS, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 06-4433 CIVIL : CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION JURY TRIAL DEMANDED ORDER OF COURT AND NOW, this 9th day of November, 2007, upon agreement of counsel in this case, IT IS HEREBY ORDERED AND DIRECTED that trial in this matter shall be scheduled for the June term of civil trials, scheduled for the week of June 23, 2008. The Court noting that Defense counsel has a conflict of his schedule during the February term of civil trials and counsel for the Plaintiff is attached to Dauphin County Court during the March term of civil trials. This case shall be given priority status for the June trial term. By the Court, Terry Hyman, Esquire Attorney for Plaintiff Andrew Foulkrod, Esquire Attorney for Defendant Court Administrator - BAS 111411 vi ,*-A, U'?'v M. L. Ebert, Jr., 0 J. 06? IV-& r""1LLqC(- /t/9/07 bas VINVA'l,kSNN3d )MICO Z :Z1 Nd 6- AOH LOOZ A8VION041.0°'dd 3Nl dp 3OL14M31 ? w ' LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, PLAINTIFF V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY AND t/d/b/a PENNSBORO PEDIATRICS, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 06-4433 CIVIL CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION : JURY TRIAL DEMANDED ORDER OF COURT AND NOW, this 6th day of December, 2007, The Defendant's Motion for a Protective Order is denied, except for the following: 1. Plaintiff may inspect the original hard drive and any and all copies made by any person of the hard drive within 30 days of this Order. 2. The parties shall reach a mutually acceptable time and location for the inspection that is reasonable to both parties and does take into account Defendant's business concerns. If requested, Plaintiff shall do the inspection at a reasonable time outside of Defendant's business hours. 3. Defendant shall have the right to have its own expert or any other person present during the inspection. 4. Defendant shall not in any way inspect, copy or alter the contents of the hard drive from this date until trial without notification to Plaintiff's counsel, and the opportunity of Plaintiff's counsel to oppose any such actions. w In addition, it is further ordered and directed that this case shall be scheduled for the June term of civil trials and Counsel are attached to this Court for that trial. Both parties shall identify any witness they intend to call at trial to the opposite party no later than March 31, 2008. By the Court, N\ ?' M. L. Ebert, Jr., J. ?Terry Hyman, Esquire Attorney for Plaintiff ?Andrew Foulkrod, Esquire Attorney for Defendant bbasVj,,-} ?,, ) cor-cs 07%ut LUL «.?? f o7 2 Sm C :01 V L- 3-10 L I Z A i'd'a.4?6` lfr W f , :2 FOULKROD ELLIS Andrew H. Foulkrod, Esquire Attorney I.D. #77394 Michael C. Mongielio, Esquire Attorney I.D. #87532 2010 Market Street Camp Hill, PA 17011 Phone: (717) 909-7006 Fax: (717) 9096955 Attorneys for Defendant: Richard N. Blutstein, M.D., Individually and t/d/b/a Pennsboro Pediatrics LAURA E. HETRICK, Administratrix of the Estate of Sara J. Zehring, Plaintiff V. RICHARD N. BLUTSTEIN, M.D., Individually and t/d/b/a PENNSBORO PEDIATRICS, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION No. 06-4433 JURY TRIAL DEMANDED DEFENDANT'S MOTION TO PRECLUDE UNTIMELY AND IMPROPER OPINION OF PLAINTIFF'S EXPERT, BARBARA K. BOLLINGER, M.D. AND NOW comes Defendant, Richard N. Blutstein, M.D., Individually and t/d/b/a/ Pennsboro Pediatrics, by and through his counsel, Foulkrod Ellis, and moves this Honroable Court to preclude the untimely and improper opinion of Plaintiff's expert, Barbara K. Bollinger, M.D. as follows: In an effort to assess Plaintiffs medical malpractice claim and prepare a defense thereto, on September 26, 2006, Dr. Blutstein served Plaintiff with Interrogatories, specifically asking for disclosure of expert opinions and the grounds in support thereof. See Exhibit "1" hereto. 2. Plaintiff responded that such information would be provided "upon completion of factual discovery". 3. On January 10, 2007, a status conference was held before Judge Ebert. Judge Ebert accordingly entered a Scheduling Order which established, inter alia, that: factual discovery was to be complete on or before July 6, 2007; Plaintiff's expert reports were to be served on or before August 31, 2007; Defendant's expert report were to be served on or before October 15, 2007; and Plaintiff's rebuttal expert reports were to be served on or before November 15, 2007. See Exhibit "2" hereto. 4. In accordance with Judge Ebert's Scheduling Order, Plaintiff produced an expert report authored by pediatrician, Richard J. Bonforte, M.D. in August of 2007. 5. Defendant timely responded with several expert reports on October 15, 2007. 6. Plaintiff did not serve any rebuttal expert reports within the Court-ordered deadline. 7. Then, on January 2, 2008, Plaintiff served an additional expert report authored by pathologist, Barbara K. Bollinger, M.D. See Exhibit "3" hereto. 8. Dr. Bollinger's report is untimely and completely without disclosed basis and should therefore be precluded. See Supporting Brief. WHEREFORE, Defendant, Richard N. Blutstein, M.D., Individually and t/d/b/a/ Pennsboro Pediatrics, respectfully requests that this Honorable Court enter the attached Order. Respectfully submitted, By: Date: January 21, 2008 FOULKROD ELLIS PRQFES$JONAL CORPORATION 2 FOULKROD ELLIS Professional Corporation 2010 Market Street Camp Hill, PA 17011 Attorneys for Defendant: Phone: (717) 909-7006 Richard N. Blutstein, M.D., Individually Fax: (717) 909-6955 and t/d/b/a Pennsboro Pediatrics LAURA E. HETRICK, Administratrix of IN THE COURT OF COMMON PLEAS the Estate of SARA J. ZEHRING, CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. RICHARD N. BLUTSTEINT, M.D., Individually and t/d/b/a PENNISBORO PEDIATRICS, Defendant : NO. 06-4433 CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION : JURY TRIAL DEMANDED INTERROGATORIES OF DEFENDANT TO BE ANSWERED BY PLAINTIFF - FIRST SET PLEASE TAKE NOTICE that you are hereby required, pursuant to the Pennsylvania Rules of Civil Procedure, Nos. 4005 and 4006, to serve upon the undersigned within thirty (30) days from service hereof your answers in writing and under oath to the Interrogatories. These Interrogatories shall be deemed to be continuing Interrogatories. If, between the time of your Answers to said Interrogatories and the time of the trial of this case, you or anyone acting in your behalf learns the identity and whereabouts of any other witnesses not identified in your said Answers, or if you obtain or become aware of additional requested information not supplied in your Answers, you shall promptly furnish the same to the undersigned by Supplemental Answers. 112. Expert witnesses. -- Identify each expert you intend to call as a witness at the trial of this matter, and for each expert: (a) State the subject matter about which the expert is expected to testify; (b) State the substance of the facts and opinions to which the expert is expected the testify and a summary of the grounds for each opinion; and (c) Identify the expert's education, training and experience. (You may file as your answer to this interrogatory the report and curriculum vitae of the expert or have the interrogatory answered by your expert.) ANSWER: 15 I HEREBY CERTIFY that a correct copy of the foregoing document was served r P?'? upon all counsel of record thi day of September, 2006, by depositing said copy in the United States Mail at Carnp Hill, Pennsylvania, postage prepaid, first class delivery, and addressed as follows: Terry S. Hyman, Esquire Schmidt Krasner, P.C. 209 State Street Harrisburg, PA 17101 Counsel for- Plaintiff' FOULKROD ELLIS PROFESSIONr" CORPORATION By: 2 LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, PLAINTIFF V. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA NO. 06-4433 CIVIL : CIVIL ACTION - LAW RICHARD N. BLUTSTEIN, MEDICAL PROFESSIONAL LIABILITY M.D., INDIVIDUALLY AND ACTION t/d/b/a PENNSBORO PEDIATRICS, DEFENDANT JURY TRIAL DEMANDED SCHEDULING ORDER OF COURT AND NOW, this 10`h day of January, 2007, after status conference with counsel this date, the following schedule is hereby set for discovery motions and trial of this matter: 1. July 6, 2007 - The parties shall complete all factual discovery on or before this date. 2. August 31, 2007 - Plaintiff shall serve any and all expert reports on Defense counsel on or before this date. 3. October 15, 2007 - Defendant shall serve any and all expert reports on Plaintiffs counsel on or before this date. 4. November 15, 2007 - Plaintiff shall file any rebuttal expert report on or before this date. 5. November 15, 2007 - Counsel for Plaintiff shall submit a settlement demand to Defense counsel on or before this date. 6. December 3, 2007 - Any and all dispositive motions and supporting briefs shall be filed on or before this date. Also, Defendant shall respond to Plaintiff's demand, and shall state whether or not his client is willing to mediate. 7. December 12, 2007 - The Court will hold a Settlement Conference in Courtroom No. 5 at 8:30 a.m. should it determine one will be fruitful. 8. December 17, 2007 - Any party against whom a dispositive motion has been filed shall file a response and brief in opposition thereto on or before this date. 9. Date to be determined by 2008 Court Schedule - Oral argument on any dispositive motion shall be held during the argument court scheduled for January 2008. 10. Three weeks prior to the Monday of trial week - The parties shall file any and all Motions in Limine with supporting briefs. The adverse party briefs are due 10 days later. 11. Trial in this matter shall be heard during the first trial term in 2008 unless the trial term is scheduled for the period February 2 through 9, 2008. Defense counsel has paid a deposit on a vacation during this period. If the trial cannot take place during the first term of Civil Court in 2008, it shall take place at the second term normally scheduled for the March/April time frame. 12. The Court will advise the parties as soon as the 2008 Court schedule is confirmed at which time the Prothonotary will be directed to give this case priority status and a pre-trial conference will be scheduled. 13. Variance of deadlines by mutual agreement of the parties - Counsel may, without Court involvement, mutually agree to vary the discovery and/or expert report deadlines only. By the Court, M. L. Ebert, Jr., J. 2 Terry Hyman, Esquire Attorney for Plaintiff Andrew Foulkrod, Esquire Attorney for Defendant bas ¦ 209 State Street Harrisburg, Pennsylvania 17101 SC M I 717.232.6300 h dtKramer FAX 717.232.6467 www.schmidtkramer.com I N J U R Y L A W Y E R S January 2, 2008 Andrew Foulkrod, Esq. Michael Mongiello, Esq. Foulkrod Ellis P.C. 20? 0 Market Street Camp Hill, PA 17011 Re: Estate of Sarah J. Zehring v. Blutstein Dear Gentlemen: Please find enclosed the expert report of Barbara K. Bollinger, M.D. in regard to the above-captioned matter. Very truly yours, TSR/ ish Enclosure D tr??? V SCHMIDT KRAMER PC • AQC `J FOWIIS Saralee PatholOg?' Funke, M.D. ? Snc, amuel Land, M.D. Barbara Bollinger, M.D. November 9, 2007 Terry Hyman, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 RE: Sara Zehring Autopsy No. C-05-73 Dear Mr.Hyman: Having reviewed the records, autopsy findings and clinical history of Sara Zehring, it is my opinion this child would have had an increased likelihood of survival had she been placed in a hospital setting. Sincerely, Barbara K./Bollinger, M.D. BB/krm .. OFFICE 1210 S. CEDAR CREST BLVD., SUITE 3900, ALLENTOWN, PA 16103 (610) 402-8144 FAX(610)402-6637 FIN: 23-2667974 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing was served upon counsel of record and all interested parties this day of 2008, LO-? by depositing said copy in the United States Mail at Camp Hill, Pennsylvania, postage prepaid, first class delivery, and addressed as follows: Terry S. Hyman, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 FOULKROD ELLIS Professional Corporation Cq,o4d ?N z, J Crystal L. Nemetz ?-'' r? C_? r_ ? '? -Yry u':.? ?? . r.. 11.E _ ', ""'J j r? ?;;? -0 ::. r,,_? 4£3 ,J.? ^^? 41 By: --T , k 4' ' i Attorney -q. No. Y739?\ Michael C. Mongiello, Esquire Attorney I.D. No. 87532 FOULKROD ELLIS Andrew H. Foulkrod, Esquire Attorney I.D. #77394 Michael C. Mongiello, Esquire Attorney I.D. #87532 2010 Market Street Camp Hill, PA 17011 Phone: (717) 909-7006 Fax: (717) 909-6955 LAUKA r. rani ll lam, -xuunLixow. .,.? Estate of Sara J. Zehring, Plaintiff V. RICHARD N. BLUTSTEIN, M.D., individually and t/d/b/a PENNSBORO PEDIATRICS, Defendants IN THE COURT OF UMMUN YLLA? Ur CUMBERLAND CO?=, PENNSYLVANIA CIVIL ACTON - LAW MEDICAL PROFES§IONAL LIABILITY ACTION No. 06-4433 JURY TRIAD DEMANDED Attorneys for Defendant: Richard . Blutstein, M.D., Individually an t/d/b/a Pennsboro Pediatrics PRAECIPE TO FILE STIPULATION TO THE PROTHONOTARY: Kindly file of record the attached Stipulation of Counsel Regarding Plaintiff s Inspection of Defendant's Computer Hard Drives. Respectfully submitted, FOULIPD ELLIS PROFESMCIN?L CQRPORAT?,ON DATE: January 23, 2008 3 FOULKROD ELLIS Professional Corporation Andrew H. Foulkrod, Esquire Attorney I.D. #77394 Michael C. Mongiello, Esquire Attorney I.D. #87532 2010 Market Street Camp Hill, PA 17011 Phone: (717) 909-7006 Fax: (717) 909-6955 LAURA. E. HETRICK, Administratrix of the Estate of Sara J. Zehring, Plaintiff V. RICHARD N. BLUTSTEIN, M.D., Individually and t/d/b/a PENNSBORO PEDIATRICS, Defendants Attorneys for Defendant: N. Blutstein, M.D., Individually d t/d/b/a Pennsboro Pediatrics IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION No. 06-4433 JURY TRIAL DEMANDED STIPULATION OF COUNSEL REGARDING PLAINTIFF'S INSPECTION OF DEFENDANT'S COMPUTER HARD DRIVES AND NOW, comes Plaintiff, Laura E. Hetrick, by and through her counsel, Terry S. Hyman, Esquire; and Defendant, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, by and through his counsel, Michael C. Mongiello, Esquiro, and hereby stipulate and agree as follows regarding Plaintiff's requested inspection of Defendant's computer hard drives: 1. Counsel executing this Stipulation hereby represent and warrant that they are authorized to do so by their respective clients. 2. Judge M.L. Ebert, Jr. has ordered that: "Plaintiff's computer expert may inspect the original hard drive [of Defendant's computer] and any and all collies made by any person of the hard drive". 3. Said inspection shall be limited to documents which contain information about Sarah J. Zehring or Laura Hetrick, excluding any document which cclmes from or is addressed to an attorney. No information relating to other patitents shall be inspe4ed I Y s 4. To the extent any other information may be revealed to Plaintiff's computer expert during said inspection, specifically including but not limited to privileged attorney-client communications, whether pertaining to this action or not, such information shall remain strictly confidential and may not be revealed to Plaintiff's counsel or any other person. 5. This Stipulation may be executed in counterparts and shall be considered effective when signed by all counsel, even though signed on separate signature p#ges, and may be filed of record. Facsimile or photocopy reproduction of signatures shall have the effect of original signatures. IN WITNESS WHEREOF, the parties by their counsel have caused this Stipulation to be executed and intend to be legally bound thereby. SCHMIDT KRAMER, P.C. DATE: By: T S. Hym , E uire Attorney for Plaintiff Laura E. Hetrick, Administkatrix of the Estate of Sara J. Zehring DATE: B OlleV 08 ov'' AQ DATE: By: C. Attorney for Defendant,`Ridhard N. Blutstein, M.D., individually and t/d/b/a Pen?sboro Pediatrics CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Foregoing was served upon counsel of record and all interested parties this o73 day of -2008, by depositing said copy in the United States Mail at Camp Hill, Pennsylvania, postage prepaid, first class delivery, and addressed as follows: Terry S. Hyman, Esquire Schmidt Kramer, P.C. 209 State Street Harrisburg, PA 17101 FOULKROD ELLIS Professional Corporati'on Crystal . Nemetz X7 IL . -L LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, PLAINTIFF V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY AND Vd/b/a PENNSBORO PEDIATRICS, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 06-4433 CIVIL CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION JURY TRIAL DEMANDED ORDER OF COURT AND NOW, this 25th day of January, 2008, upon consideration of the Motion to Preclude Untimely and Improper Opinion of Plaintiff's Expert, IT IS HEREBY ORDERED AND DIRECTED that: 1 1. A Rule is issued upon the Plaintiff to show cause why the relief requested should not be granted; 2. The Plaintiff will file an answer on or before February 15, 2008; 3. If no answer to the Rule to Show cause is filed by the required date, the relief requested by Defendant shall be granted upon the Court's receipt of a Motion requesting Rule be made Absolute. If the Plaintiff files an answer to this Rule to Show Cause, and the answer raises disputed issues of material fact, an evidentiary hearing will then be scheduled. 4. The Prothonotary is directed to forward said Answer to this Court. By the Court, N?A"UA % M. L. Ebert, Jr., 0 J. •r is iFi'; Terry Hyman, Esquire Attorney for Plaintiff Andrew Foulkrod, Esquire Michael Mongiello, Esquire Attorneys for Defendant bas SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) thvman(i,srklaw. com LAURA E. HETRICK, : IN THE COURT OF COMMON ADMINISTRATRIX OF THE : PLEAS ESTATE OF SARA J. : CUMBERLAND COUNTY, ZEHRING, PENNSYLVANIA Plaintiff V. : No. 06-4433 CIVIL RICHARD N. BLUTSTEIN, CIVIL ACTION - LAW M.D., INDIVIDUALLY and MEDICAL PROFESSIONAL LIABILITY t/d/b/a PENNSBORO ACTION PEDIATRICS, Defendant JURY TRIAL DEMANDED PLAINTIFFS' MOTION FOR A SCHEDULING CONFERENCE And now this 29th day of January 2008, LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, Plaintiff by her Attorneys Schmidt Kramer PC hereby move this Honorable Court to conduct a Scheduling Conference in the above-captioned case for the following reasons: 1. This medical malpractice claim was filed by Complaint with a Certificate of Merit in July 2006. 2. On January 10, 2007 Judge Ebert issued a scheduling Order which set deadlines for discovery and Motions in anticipation of trial during the January 2008 trial term. 3. Because Defense Counsel had a prepaid vacation the case had to be moved to the next term when counsel was not attached for trial, which was June 23, 2008. 4. Defense Counsel has already filed motions to exclude evidence for timeliness based on the earlier deadlines, despite the fact more than six months still remain before trial. 5. Defendant also delayed producing his computer hard drive or copies of the drive made by the defense expert out of Plaintiff's sight such that the inspection was not performed by Plaintiff's computer expert until January 22, 2008. The existing Order does not set a date for the exchange of the parties' computer experts' reports. 6. Plaintiff's counsel, therefore, respectfully requests the Court hold a brief Scheduling Conference either in person or by phone to set new dates appropriate for the June trial date. WHEREFORE, Plaintiffs prays your Honorable Court will schedule a Scheduling Conference at its earliest convenience. Date: 0// 9/0'?7 Respectfully submitted, SCHMIDT KRAMER PC By: erry S. an, Esquire I.D. No. 6807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs CERTIFICATE OF SERVICE AND NOW, this M64, day of , 2008, I, Janice S. Harmon an employee of SCHMIDT ER, P.C., do hereby certify that I have served a true and correct copy of PLAINTIFFS' MOTION FOR A SCHEDULING CONFERENCE via first class US Mail, Harrisburg, Dauphin County, Pennsylvania: Andrew Foulkrod, Esq. Foulkrod Ellis P.C. 2010 Market Street Camp Hill, PA 17011 Ja 1 S. Harmon .dda y -T) c. ); w CJ N Y M ro 'Ta LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, PLAINTIFF V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY AND t/d/b/a PENNSBORO PEDIATRICS, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 06-4433 CIVIL CIVIL ACTION - LAW MEDICAL PROFESSIONAL LIABILITY ACTION JURY TRIAL DEMANDED ORDER OF COURT AND NOW, this 71h day of February, 2008, upon consideration of the Plaintiff's Motion for a Scheduling Conference, IT IS HEREBY ORDERED AND DIRECTED that a scheduling conference will be held on Tuesday, February 26, 2008, at 11:00 a.m. in Chambers of Courtroom No. 5 of the Cumberland County Courthouse, Carlisle, Pennsylvania. Terry Hyman, Esquire For the Plaintiff M' hael Mongiello, Esquire drew Foulkrod, Esquire For the Defendant By the Court, N-? M. L. Ebert, Jr., J. ,0 h bas cjh ?r'ha £ 0 : ? Wd L- 833 $OOZ lU 80 011 0.-CI;l#j SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, Plaintiff V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY and t/d/b/a PENNSBORO PEDIATRICS, Defendant : IN THE COURT, : CUMBERLAND( : PENNSYLVANIA : No. 06-4433 CIVIL ACTION - MEDICAL PROF ACTION : JURY TRIAL for Plaintiff(s) COMMON PLEAS W LIABILITY OPINION OF PLAINTIFF'S EXPERT BARBARA K. B LLINGER M.D. 1. Admitted. 2. Admitted in part. Plaintiff could not supply Dr. B Ringer's report until she obtained a copy of it, which did not occ r until January 2, 2008, when the Plaintiff sent a copy to the Def ndant. 3. Admitted in part, denied in part. A Status Confer nce was held before Judge Ebert on January 10, 2007; howeve , the deadlines set by the Scheduling Order were set in order for he partied to prepare for a trial during the January 2008 civil t ial term. However, to accommodate Defense Counsel's sch dule, the trial has been rescheduled to June 23, 2008, allowing Defendants an additional six months to prepare their case. 4. Admitted in part, denied in part. In July 2007, PI intiff asked to have a computer expert examine Defendant's har drive to see if he had changed or fabricated records. Defense Coun el resisted the inspection, resulting in a Court Order compelling 't. Expert discovery concerning the computer inspections ha e not yet been completed, as a direct result of Defendant's decisi n to resist the inspection. 5. Admitted in part and denied in part. Defendants Y ave provided their medical reports, but have not provided the report of their computer expert who examined the computer wi hout Plaintiffs knowledge or presence months before the Court ?rdered inspection by Plaintiff. 6. Denied as stated. Because the original deadline as set for a January trial that has been moved to June, Plai tiff's service of a rebuttal expert report on January 2, 2008 gives he Defendant approximately six months to prepare to respond. This is neither untimely nor prejudicial. 7. Denied as stated. Dr. Bollinger dated her report ithin the Court ordered deadline, however, miscommunication r sulted in the report not being received by Plaintiff's Counsel u til January 2, 2008. Plaintiff's counsel's efforts to solve the co munications with Dr. Bollinger's office are documented in Exhibit attached hereto. When the report was faxed by Dr. Bollinger to Pl intiff's Counsel on January 2, 2008 and a copy was immediately sent to the Defense Counsel. 8. Denied. Dr. Bollinger's report is not "baseless". rll inger was the pathologist who performed Sarah Zehring's a y. The basis of the opinion in her January 2, 2008 report is h r own autopsy and the history therein. The autopsy is 12 pages long and has been in Defendant's possession since the case st rted. The report is not "untimely" in that it will present no surpris at trial and Defense Counsel will have almost six months to repare his examination of Dr. Bollinger. See also Plaintiff's upporting brief. SCHMIDT KRAMER PC Esquire Date: OA// A/ /000 I.D. ?6.. 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plai tiff Zehring, Estate of Sara J. Case #: 210687 ( ) 2/12/2008 11:14 AM Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 1 of 1 Date: 11/19/2007 10:57 AM Staff: JSH From: Janice Harmon To: barbara.bollinger@lvh.com CC: Subject: Estate of Sara Zehring Date Sent: 11/19/2007 10:57:12 AM Dr. Bollinger Case Note - Page 252 of 304 Topic: E-Mail Case Status I have attached a copy of the EMT report in regard to Sara Zehring. Please complete review of this case as discussed with Attorney Hyman. If you should have any further questions please do not hesitate to call. Janice S. Harmon Secretary to Terry S. Hyman, Esq. SCHMIDT KRAMER PC 209 State Street Harrisburg, PA 17101 717/232-6300 Fax 717/232-6467 Attachments: west shore ems.pdf r expert Zehring, Estate of Sara J. Case #: 210687 ( ) 2/12/2008 09:46 AM Date: 12/03/2007 10:50 AM Staff: JSH From: Janice Harmon To: barbara.bollinger@lvh.com CC: Subject: Zehring, Sara Date Sent: 12/3/2007 10:49:43 AM Case Type: IVIED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 1 of 1 Case Note - Page 257 of 304 Topic: E-Mail Dr. Bollinger: Please advise as to the status of your report in regard to Sara Zehring. Janice S. Harmon Secretary to Terry S. Hyman, Esq. SCHMIDT KRAMER PC 209 State Street Harrisburg, PA 17101 717/232-6300 Fax 717/232-6467 Case Status Zehring, Estate of Sara J. Case IV: 210687 ( ) 2/12/2008 09:44 AM Date: 12/20/2007 09:36 AM Staff: JSH From: Janice Harmon To: Terry Hyman CC: Subject: Zehring Date Sent: 12/20/2007 9:36:27 AM Case Type: MED MAL DOI: 1/31/20105 LIM Date: 1/31/2007 Class: L5 Assigned: TSH Date Opened: 3/22/2006 Page 1 of 1 Case Note - Page 273 of 304 Topic: E-Mail Case Status I spoke with Toni in Dr. Bollinger's office. Explained I had emailed several times and had even paged her with no response. She said they have been very busy. Dr. Bollinger is out today but Toni will check with her tomorrow and see what she can find out for us. Zehring, Estate of Sara J. Case Type: MED MAL DOI: 1/31/2005 LIM Date: 1/31/2007 Case #: 210687 ( ) Class: L5 Assigned: TSH Date Opened: 3/22/2006 2/12/2008 09:44 AM Page 1 of 1 Case Note - Page 275 of 304 Date: 01/02/2008 12:07 PM Staff: JSH Topic: Memo To File Case Status spoke w/ Toni in Forensic pathology. She will give message to Dr. Bollinger to call TSH. I < C 1 1ti LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING, PLAINTIFF V. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : NO. 06-4433 CIVIL CIVIL ACTION - LAW RICHARD N. BLUTSTEIN, MEDICAL PROFESSIONAL LIABILITY M.D., INDIVIDUALLY AND ACTION t/d/b/a PENNSBORO : PEDIATRICS, : DEFENDANT JURY TRIAL DEMANDED REVISED SCHEDULING ORDER OF COURT AND NOW, this 26th day of February, 2008, after status conference with counsel this date, IT IS HEREBY ORDERED AND DIRECTED that: 1. Defendant's reply to Plaintiff's Request for Production - Set II, is due by March 12, 2008. 2. Plaintiffs computer expert's report is due no later than March 23, 2008. 3. Defendant's computer expert's report is due no later than April 23, 2008. Defendant shall also have the right to provide reports to rebut Dr. Bollinger on or before April 23, 2008. 4. Plaintiff shall have the right to provide a rebuttal report to Defendant's computer expert no later than May 1, 2008. 5. All Motions in Limine and/or Dispositive Motions with accompanying briefs shall be filed on or before May 28, 2008 with responses to be filed on or before June 3, 2008. By the Court, - lft,?, t 4?.4 M. L. Ebert, Jr., J. U-4 9Z O? i ? - - A 80H ? Terry Hyman, Esquire For the Plaintiff ? Michael Mongiello, Esquire Andrew Foulkrod, Esquire For the Defendant eer'cc rn a t L ?l.__. bas LAURA E. HETRICK, IN THE COURT OF COMMON PLEAS OF ADMINISTRATRIX OF THE CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF SARA J. ZEHRING, NO. 06-4433 CIVIL PLAINTIFF V. : CIVIL ACTION - LAW RICHARD N. BLUTSTEIN, MEDICAL PROFESSIONAL LIABILITY M.D., INDIVIDUALLY AND ACTION t/d/b/a PENNSBORO ; PEDIATRICS, ; DEFENDANT JURY TRIAL DEMANDED ORDER OF COURT AND NOW, this 26th day of February, 2008, upon consideration of the Defendant's Motion to Preclude Opinion of Plaintiff's Expert, Barbara K. Bollinger, M.D., and the Plaintiff's Reply thereto and after conference with Counsel, IT IS HEREBY ORDERED AND DIRECTED that the Defendant's Motion to Preclude the Opinion of Barbara K. Bollinger, M.D. is DENIED. By the Court, ? Terry Hyman, Esquire For the Plaintiff Michael Mongiello, Esquire Andrew Foulkrod, Esquire For the Defendant Nkt - UA M. L. Ebert, Jr., U J. P bas ?tLCd- -64T4't 4006 ?? ?-C. pm 12;38 P-P -?I? SUBPOENA RECORDS COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND Laura E. Hetrick, Administratrix of the Estate of Sara J. Zehring VS. Richard N. Blutstein, M.D., Individually & t/d/b/a Pennsboro Pediatrics Page 3 of 4 Court of Common Pleas Case Number: 06- 4433 CERTIFICATE PREREQUISITE TO THE SERVICE OF A SUBPOENA PURSUANT TO RULE 4009.22 As a prerequisite to service of a subpoena for documents and things pursuant to Rule 4009.22, Litigation Solutions, LLC ('LSLLC') on behalf of Andrew Foulkrod, Esquire of Foulkrod Ellis PC certifies that: (1) A notice of intent to serve the subpoena with a copy of the subpoena attached thereto was mailed or delivered to each party at least twenty days prior to the date on which the subpoena is sought to be served; (2) A copy of the notice of intent, including the proposed subpoena, is attached to this certificate; (3) No objection to the subpoena has been received, and; (4) The subpoena which will be served is identical to the subpoena which is attached to the notice of intent to serve the subpoena. Date: 3/26/2008 CC: Andrew Foulkrod, Esquire Foulkrod Ellis PC 2010 Market Street Camp Hill PA 17011 Litigation Solutions, LLC on behalf of Andrew Foulkrod, Esquire of Foulkrod Ellis PC Attorney for the Defense http://rats.litsol. comlratseventslsubpoena_records.asp? WRid=WR29767&PLid=PL25O456... 3/26/2008 SUBPOENA NOTICE OF INTENT Page 1 of 3 ,. PENNSYLVANIA COURT OF COMMON PLEAS COUNTY OF CUMBERLAND Laura E. Hetrick, Administratrix of the Estate of Sara 3. Zehring Court of Common Pleas VS. Richard N. Blutstein, M.D., Individually & t/d/b/a Pennsboro 06-4433 Pediatrics NOTICE OF INTENT TO SERVE A SUBPOENA TO PRODUCE DOCUMENTS AND THINGS FOR DISCOVERY PURSUANT TO RULE 4009.21 Provider: Record Type: Forensic Pathology Associates, Inc. TO: Terry Hyman, Esquire note: please see enclosed list of all other interested counsel Miscellaneous Litigation Solutions, LLC ('LSLLC') on behalf of Andrew Foulkrod, Esquire intends to serve a subpoena identical to the one that is attached to this notice. You have twenty (20) days from the date listed below in which to file of record and serve upon the undersigned an objection to the subpoena. If the twenty day notice period is waived or if no objection is made, then the subpoena may be served. Date of Issue: 3/10/2008 CC: Andrew Foulkrod, Esquire - Court of Common Pleas If you have any questions regarding this matter, please contact: Litigation Solutions, LLC (412.263.5656) Brentwood Towne Centre 101 Towne Square Way, Suite 251 Pittsburgh, PA 15227 Litigation Solutions, LLC on behalf of: Andrew Foulkrod, Esquire Defense http://rats.litsol.com/ratsevents/notice_of intent.asp?save_report_to_db=X&PLid=PL2504... 3/10/2008 SUBPOENA NOTICE OF INTENT Page 2 of 3 COUNSEL LISTING FOR LAURA E. HETRICK, ADMINISTRATRIX OF THE ESTATE OF SARA J. ZEHRING VS. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY & T/D/B/A PENNSBORO PEDIATRICS County of Cumberland Court of Common Pleas Counsel Firm Counsel Type Hyman, Esquire, Terry 209 State Street Harrisburg PA 17101 opposing Counsel cll- http://rats.titsol.com/ratsevents/notice-of intent.asp?save_report_to_db=X&PLid=PL2504... 3/10/2008 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND Laura E. Hetrick, Administratrix of the Estate of Sara J. Zehring vs. Richard N. Blutstein, M.D., Individually & t/d/b/a Pennsboro Pediatrics 06-4433 File No. SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 TO: Forensic Pathology Associates, Inc. (Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents or things: PLEASE SEE ATTACHED RIDER at 101 Towne Square Way, Suite 251 Pittsburgh, PA 15227 (Address) You may deliver or mail legible copies of the documents or produce things requested by this subpoena, together with the certificate of compliance, to the party making this request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after.its service, the party serving this subpoena may seek a court order compelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: Andrew Foulkrod, Esquire A.DDRESS2010 Market Street Camp Hill PA, 17011 TELEPHONE:71 7-909-7006 SUPREME COURT ID# 7 7 3 9 4 ATTORNEY FOR: D e f e n s e bate: 3 07 O Seal o the Court BY THE URT: P, othonotary, iv' on Deputy SUBPOENA RIDER Rider to Subpoena Explanation of Required Documents and Things TO: CUSTODIAN OF RECORDS FOR: Forensic Pathology Associates, Inc. 1210 S. Cedar Crest Boulevard Suite 3900 Allentown PA 18103 Attention: Records Department Subject: Zehring (deceased), Sara SS#: Date of Birth: 7/29/1998 Page 1 of 1 Requested Items: *PLEASE RUSH * Recuts of pathology slides from 1/31/2005 to 2/1/2005 prepared at autopsy (Autopsy No. C-05-073). http://rats.litsol.com/ratseventslsubpoena_rider.asp?PLid=PL250456&WRid=WR29767 3/10/2008 ?? ??j ?'l c? ...{ ?,, 'T'! 1'l 4? 'p1F, ?? ' ., ... 3 -rTl ) .. ...'? ,a ^ Y "'d t .. 1 FOULKROD 11LIS Andrew H. Foulkrod, Esquire Attorney I.D. #77394 Michael C. Mongiello, Esquire Attorney I.D. #87532 2010 Market Street Camp Hill, PA 17011 Phone: (717) 909-7006 Fax: (717) 909-6955 LAURA E. HETKICK, Administratrix of the Estate of Sara J. Zehring, Plaintiff V. Attorneys for Defendant: Richard N. Blutstein, M.D., Individually and Vd/b!a Pennsboro Pediatrics IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW RICHARD N. BLUTSTEIN, M.D., Individually MEDICAL PROFESSIONAL LIABILITY and t/d/b/a PENNSBORO PEDIATRICS, ACTION Defendants No. 06-4433 JURY TRIAL DEMANDED DEFENDANT'S MOTION INLIMINE TO LIMIT USE OF AUTOPSY PHOTOGRAPHS AT TRIAL AND NOW comes Defendant, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, by and through his counsel, Foulkrod Ellis, and moves this Honorable Court to limit the use of autopsy photographs at trial as follows: I. During Sara Zehring's February 1, 2005 autopsy, ten (10) photographs were taken and depict Sara's bloody, naked, dead body on an examining table with medical lines and devices in and around it and apparent bruising to the mouth from intubation that was performed in an effort to save her life. Color copies of these photographs are collectively attached hereto as Exhibit "I". 2. Plaintiff's counsel has advised that he intends to publish these gruesome and prejudicial photographs to the jury at trial in order to show "blotches" found on post-mortem pathologic examination. If V I 3. This is so despite the following facts: 1) there can be no evidence offered at trial to establish that these findings were present at the time of Dr. Blutstein's physical examination of Sara; 2) there is no dispute by the defense that "blotches" were present on autopsy (see Defendant's expert report authored by pathologist, Arthur H. McTighe, M.D., attached hereto as Exhibit "2", p. 4, first full bullet); 3) the pathologist who performed the autopsy, Barbara K. Bollinger, M.D., documents in her autopsy report that the "anterior surface of the torso, arms and legs are mottled pink-purple and have a fine papular rash" (said autopsy report is attached hereto as Exhibit "3"; see p. 4, second full paragraph under the heading "EXTERNAL EXAMINATION"); and 4) Dr. Bollinger is Plaintiff's pathology expert in this case and can personally testify at trial regarding the presence and appearance of the pathologic findings including "blotches". 4. Nonetheless, Defendant does not object to use of the seemingly irrelevant autopsy photographs at trial, if limited to portions that depict the "blotches" and exclude the irrelevant and prejudicial remainder (i.e. the entire dead body, genitals, blood, medical devices and lines, autopsy table and identifying wrist band). See Supporting Brief and examples of easily created excised photographs in this regard, attached hereto as Exhibit "411 . WHEREFORE, Defendant, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, respectfully requests that this Honorable Court enter the attached Order. Respectfully submitted, By: Date: May _o32008 SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) thymanAa srklaw com LAURA E. HETRICK, : IN THE COURT OF COMMON PLEAS ADMINISTRATRIX OF THE : CUMBERLAND COUNTY, ESTATE OF SARA J. ZEHRING, : PENNSYLVANIA Plaintiff V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY and t/d/b/a PENNSBORO PEDIATRICS, Defendant : No. 06-4433 CIVIL CIVIL ACTION -LAW MEDICAL PROFESSIONAL LIABILITY ACTION JURY TRIAL DEMANDED JOINT MOTION TO REINSTATE AND NOW on behalf of counsel for both parties in the above-captioned matter Counsel hereby jointly move Your Honorable Court to reinstate the above-captioned matter to the trial list for the June 23, 2008 Civil Term for the following reasons: 1. The above-captioned case was subject to two Scheduling Conferences before Judge Ebert. 2. Judge Ebert specifically listed the case for the June 23, 2008 trial term in order to accommodate complexity of the case and the schedules of witnesses and parties. The case was set for the June 23, 2008 list by Judge Ebert's Order of November 9, 2007. 3. Both parties have scheduled experts and witnesses on the assumption that the case will be tried during the June 23, 2008 trial term. 4. Unfortunately, neither Counsel for Plaintiff nor Counsel for Defendant calendared the call of the list which took place today, May 27, 2008. Therefore, neither party was present to call the case, although both parties desire the case go forward as scheduled by Judge Ebert. 5. Counsel for the parties have acted promptly to request the reinstatement. Both parties aver that reinstatement is in their best interests as well as the Courts. 6. Although filed by Plaintiffs Counsel, Defense counsel does jointly request the relief sought herein. WHEREFORE, the parties hereby pray Your Honorable Court will grant its Joint Motion to Reinstate the above-captioned case to the June 23, 2008 Civil Trial List. Date: 0,6171D & Respectfully submitted, SCHMIDT KRAMER PC By. Terry an, Esquire I.D. 0. 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiff CERTIFICATE OF SERVICE AND NOW, this sue. day of 2008) I, Janice S. Harmon an employee of SCHMIDT KRAMER PC, do hereby certify that I have served a true and correct copy of the JOINT MOTION TO REINSTATE in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Andrew Foulkrod, Esquire Foulkrod Ellis P.C. 2010 Market Street Camp Hill, PA 17011 Janice S. Harmon SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) thyrnan(a-)srldaw com LAURA E. HETRICK, : IN THE COURT OF COMMON PLEAS ADMINISTRATRIX OF THE ESTATE : CUMBERLAND COUNTY, PENNSYLVANIA OF SARA J. ZEHRING, Plaintiff V. : No. 06-4433 CIVIL RICHARD N. BLUTSTEIN, M.D., CIVIL ACTION -LAW INDIVIDUALLY and t/d/b/a MEDICAL PROFESSIONAL LIABILITY PENNSBORO PEDIATRICS, ACTION Defendant JURY TRIAL DEMANDED PLAINTIFF'S MOTIONS IN LIMINE MOTION IN LIMINE NO. I DEFENDANT SHOULD BE PRECLUDED FORM OFFERING THE TESTIMONY OF FOUR DIFFERENT MEDICAL EXPERTS THAT SARA J. ZEHRING DID NOT NEED TO BE HOSPITALIZED BY THE DEFENDANT NOR WOULD HOSPITALIZATION HAVE PREVENTED HER DEATH WHERE THE EXPERTS' TESTIMONY IS REDUNDANT, UNNECESSARY, AND CUMULATIVE. 1. This medical malpractice claim arises from a single office visit. At about 10:15 AM on January 31, 2005, Sara J. Zehring came to Defendant Blutstein's office with a very high fever, a high heart rate, a very high respiration rate, and a significantly lower than normal level of oxygen in her blood stream. Sara was sent home by Defendant Blutstein at about 10:30 AM. Around 2:30 PM, Sara turned blue, stopped breathing, and died in her mother's arms. 2. Sara's cause of death, according to the Coroner's Report and the pathologist hired by the Coroner, was sepsis from a bacterial infection in her blood stream. 3. The case presents only a single medical issue on the standard of care. Plaintiff's expert, Richard Bonforte, M.D., a pediatrician from Mount Sinai Hospital in New York, criticized Dr. Blutstein for failing to send Sara to the hospital emergency room given her abnormal vital signs, overall presentation, and low oxygenation. 4. To address this single issue, Defendant has chosen to use a sledgehammer, intending to present five separate medical witnesses on the standard of care: the defendant himself, three separate pediatricians, and a pathologist. See Defendant's expert reports of Timothy Doran, Jonathon Finder, Judith Martin, and Arthur McTighe attached hereto as Exhibits A, B, C, and D. 5. When read fairly each of the defense experts actually reached the same opinions that: 1) Sara had a viral infection; 2) Sara's high fever accounted for her high respiration and heart rate, which is a common presentation of children of Sara's age; 3) the oxygen level, while low, did not require hospitalization or follow-up; 4) Sara did not have signs of septic shock while in Defendant Blutstein's office; and 5) no one could predict from Sara's presenting signs that she would deteriorate rapidly and die. 6. Each expert, as well as the Defendant, also opines that Sara would have died even with hospitalization. ¦ A 7. In addition to these issues, the Defendant also has hired an expert to dispute the cause of death listed on the Death Certificate. Experts will testify on both sides of that issue. 8. In addition to the medical experts, the Defendant disputes Plaintiff's loss of earning capacity claim. Economic experts will be presented by both sides on that issue. 9. In addition to the medical experts and the economic experts, a dispute exists whether the Defendant altered a computer record Defendant Blutstein made of Sara's medical treatment on January 31, 2005. Both parties have retained and proffered reports by forensic computer experts on the integrity of the computer record. 10. Allowing the Defendant to take four bites at the same apple, by having four different experts express the same opinions on the same subjects is an unnecessary waste of time. 11. In a case in which the parties are already presenting multiple experts on multiple issues and producing redundant testimony from four different experts all reaching exactly the same conclusions will extend the length of the trial. 12. In a case in which the parties are already presenting multiple experts on multiple issues and producing redundant testimony from four different experts all reaching exactly the same conclusions is an unnecessary and confusing waste of time, which has the potential to mislead the jury into deciding the case by the number' of witnesses offered by the party not the strength of their testimony. k 13. Pa. R.C.P 233(1) and P.R.E. 403 gives this Court authority over its Courtroom, specifically granting the right to limit cumulative witnesses and cumulative testimony. 14. It does not take five doctors to explain what happened in the single office visit lasting less than thirty minutes. Neither fairness, judicial efficiency nor clarity are served by allowing Defendant to present five opinions on the standard of care of one doctor on one visit. WHEREFORE, Plaintiff prays Your Honorable Court will preclude Defendant from offering more than one expert on the standard of care or causation' other than the doctor himself. MOTION IN LIMINE NO. II SECTION 512 OF THE MCARE ACT PRECLUDES A PATHOLOGIST FROM OFFERING TESTIMONY ABOUT THE STANDARD OF CARE OF A PEDIATRICIAN. 1. The standard of care in this case is that of a Board Certified Pediatrician treating a child in his office. 2. Defense expert, Arthur McTighe, is by training, a pathologist. His CV attached hereto as Exhibit E, shows no training, experience, or practice in treating children as a pediatrician or in an office setting. 3. At no time while treating Sara Zehring, did Dr. Blutstein request a pathological examination or request any infectious disease information from any source such as a pathologist or infectious disease expert during the care at issue in this case. 1 Causation issues other than the "cause of death" dispute between pathologists. ? Z 4. A pathologist by the nature of his specialty does not prescribe or recommend treatment for children in the same fashion as a pediatrician. 5. The Pennsylvania MCare Act Section 512 permits expert testimony on the standard of care only if the expert is in the same subspecialty as Defendant or a subspecialty that has a substantially similar standard of care for the specific care at issue (§512(c)) or has proven experience and training in the applicable standard for a pediatrician within the last five years (§512(e)). 6. Nothing in Dr. McTighe's CV exists which demonstrates he has the specific training in the diagnosis and treatment of children presenting to a pediatrician's office with abnormal vital signs and low oxygenation to meet the more stringent standards for expert testimony under the MCare Act. Wherefore, Plaintiff prays Defendant be precluded from offering any standard of care testimony from Dr. Arthur McTighe. Respectfully submitted, Date: U.? 8/ofl SCHMIDT KRAMER PC By: Te S. Hy squ I.D. No 807 209 to eet Harris urg, PA 17101 (717) 232-6300 Attorney for Plaintiff E)kh i b i+ R UY 12: bZ FOULKROD ELL15 Y1Y9U9b9bb F.W Timothy F. Doran, M.D. . 8,32 William St. Baltimore, MD 21230 Mr. Michael MongielloFoulkrod Ellis 2010 Market St. Camp hill, PA 17011 October 14, 2007 RE: Hetrick v. Blutstein, M.D. This is a letter in response to a request from Mr. Michael Mongiello of the law firm Foulkrod Ellis regarding the pediatric cane rendered to Sara Zefiring by Dr. Richard . following documents relevant to the case in arriving amyopinion Ingthis case: I have reviewed the 1. Records of Richard Blutstein, M.D. 2. Records of Carlisle Regional Medical Center from 1/31/2005 3. Records of West Shore EMS 4. Dr. Blutsteln's notes from his computer dated 1/31/2005 5. Autopsy report 6. Coroner's report 7. Deposition of Dr.. Blutstein 8. Deposition of Laura Hetrick 9. Letter from Richard J. Bonforte, M.D. 10. Letter from Judith M. Martin, M.D. 11. Letter from Jonathan Jonathan D. Finder, M.D. Sara Zehring was a patient of Dr. Blutsteen since her blrth July 291i, 1998. Sara was treated by Dr. Blutstein for a number of medical issues over her tragically brief life, including reactive airway disease, asthma, croup, recurrent otitis media, a seizure disorder, dacryostenosis and an atrial septal defect, n the early morning of January 31, 2005 (3:30 AM), Dr. Blutstein received a telephone call from the nother of Sara Zehring infiorming him that Sara was having difficulty breathing. Dr. Blutstein's office ote and deposition indicate that Sara had a "croupy" cough over the phone and recommended a trial f cold air. In Ms. Hetrick's deposition, she described the cough as a "harsh, hard cough." He informed he mother to see him later that morning if Sara's breathing cleared up. Mom relates in her deposition hat the cough did improve after going into the cold air. mother brought Sara in to see Dr. Blutstein later that morning at which time the mother related the ory of "high temperature, vomiting, wheezing, cough." On Dr. Blutstein's note, he recounted the at 3:30 in the morning and his advice of cold air for what he thought was croup and that it had led. Ms. Hetrick corroborated this in herdeposition. Mom then called the next noting and rl(T`..U_21JU*( 12:bZ FOULKHUI) ELL15 W(HUS16Hbb V X4 scheduled a sick visit for later in the morning. At the time of the visit, Sara apparently walked into the office without assistance and her appearance was described as "good" by Dr. Blutstein's assistant. The temperature was noted to be 104 Fahrenheit, with a respiratory rate of 46, heart rate of 173 and a puJsoximetry reading of 93%. The physical exam revealed some "audible tubular breath sounds" in the neck and "Intermittent crackles" with good air entry and epigastric retractions in the lungs. Ii was specifically noted that Sara was speaking v0K," He felt that Sara was suffering from a combination of croup and reactive airway disease (RAD) and mentioned the physical findings of fever and crackles. In response to his exam, he treated her with oral steroids, inhaled steroids, and azithromycin for possible pneumonia. According to his supplemental note, he discussed the possibility of admitting Sara to the hospital, but decided that she could be started on the medications and observed at home with instructions to the motherto call him if she was worse in any way. The mother has no recollection of this conversation in her deposition. Ms. Hetrick relates that she went to the Giant Pharmacy to pick up the medications after leaving Dr. Blutstein's office, and she remembers pushing Sara in the shopping cart. She was not described in any way In the pharmacy as obtunded or moribund. The mother then took her home, administered the steroid and decided to wait a while until giving her the antibiotic. Sara was lying on the couch, then on a recliner with her mother, and finally in her bed. Mom relates that she was "walking in and out of the bedroom a couple of times." At around 213M, Ms. Hetrick remembers Sara saying "mama" and "she just like fell into my arms. i just grabbed her. She seemed to shake a bit." She remembers her turning blue and her breathing slowing down. Mom called 911. The next call Dr. i3lutstein received was from the mother informing him that Sara had seized, stopped breathing and was blue. Unfortunately, heroic attempts at resuscitation by the paramedics and the hospital were unable to resuscitate her. Discussion The cause of death was listed by the Dr. Bollinger, the forensic pathologist, as complications of pneumococcal sepsis due to Streptococcus Pneumonia. Although I have no other explanation, the course of her illness varies significantly from the course of pneumococcal sepsis and raises the issue of a sudden death from another etiology. Even the most fulminant of bacterial infections In children, meningococcal sepsis, does not progress from a conversant, oriented child to a sudden death in the manner described by her mother over the course of minutes. It is clear that she had an infection, and It s likely that she had viral croup as an underlying pathology. She certainly could have sustained a secondary bacterial infection in this situation, but the usual course of a bacterial tracheltis would be 3rogressively worsening croup and strider that is not described In this case. These children are gasping or air with marked respiratory stridor. There are autopsy findings consistent with a necrotizing ra cheo bronchitis, but her clinical course did not reflect these findings. Sepsis is always a possibility and the most likely etiology we have, but her sudden collapse is distinctly unusual. espite the fatal outcome in this case, there is nothing in the medical records that indicates a breach in ie standard of care in this case, There was nothing in this child's symptoms or signs that would predict catastrophic event. Sara presented to Dr. Blutstein with classic features of croup. She suffered from a arsh cough that was heard by an experienced pediatrician as a croupy cough. She responded nicely to e usual therapeutic trial of cold air in the middle of the night. UUT-18-LUU7 12:b:3 FOULKRUD ELL I S '(1'fyU!3b,9bb 1'.Ub There was discussion in Dr. Blutstein's deposition as to whether or not the child should have been admitted to the hospital. Criteria for admission for respiratory disorders include a child with moderate dehydration and a need for intravenous fluids, moderate or severe respiratory distress with aeration and oxygenation, failed outpatient antibiotic there i pgor pneumonia), ora situation where it is unsafe to send the chid home (relmote access, etc.). SaaraJhad none of these, The discussion about the possibility of admission occurs regularly with pediatricians and parents. Dr. Bonforte claims that a pulsoxfinetry reading of 93% argues for hospital admission. While i agree with him that a pulsoximetry reading of 93% is not normal, it is also not low enough to warrant hospital admission in the absence ofthe above criteria. Dr. Bonforte also points to the fact that the temperature was elevated, as was the respiratory rate and the pulse rate. All children with high fever have elevated heart rates and respiratory rates and it would be more worrisome if Sara had had a normal heart rate with such an elevated temperature I Sara did have an increased temperature, fever, respiratory rate and mildly depressed oxygen saturation. The respiratory rate and depressed oxygen saturation were explainable at the time of her visit by either her reactive airway disease (asthma) or community acquired pneumonia. Croup is usually caused by viruses and is associated with fever and stridor. Dr. Blutstein arrived at a list of diagnostic possibilities that were consistent with her symptoms and signs and treated her with the proper medications. I can find no fault here. In fact, in studies on bacteremia, it is close follow-up that is the most important factor in preventing the complications of invasive bacterial disease. Dr. Blutstefn was meticulous in triaging and treating Sara in the middle of the night with close follow-up arranged in the morning and instructions to follow-up if she worsened after his careful history and physical exam. There are no guidelines that I have ever seen that would have mandated a hospital admission in these circumstances. There was also absolutely no reason to believe that Sara was septic at the time of the evaluation by Dr. Blutstein. She was ambulatory, speaking and had adequate oxygenon. and Is easily detected by experienced clinicians. Finally, there is no reason to believe that aot referral to the hospital after the office visit would have saved her life. In summary, 1 find no deviation from the standard of care in the treatment of Sara Zehring. Yours, Timothy F. Doran, M. D. TOTAL P.05 IE-Xhl brt F-> Oct 12 2007 2:20PM HP LASERJET FAX ,JONATHAN D. FINDER, MD PEDIATRIC PULMONOLOGIST S541 BEvERLY PLACE PITTSBURGH, PA 15206 October 9, 2007 RE: Hetrick v Blutstein, M.D. FEPC #3558 I have been asked to review plaintiffs' complaint and expert report and the medical records of Sara Zehring, date of birth 7/29/1998, who died on January 31, 2005 at 15:22. A brief summary of the facts of the case follows: • Sara Zehring was a 6-and-a-half year old girl whose past medical history was notable for asthma, a seizure disorder, and a small heart defect known as a secundurn atrial septal defect. Despite these three disorders, she was by all accounts a relatively healthy girl, whose seizure disorder had apparently resolved, whose heart defect was nearly closed at the time of her death, and who was not taking asthma medication in the weeks prior to her death. - Sara had been given relatively few courses of antibiotics in her life prior to the events surrounding her death. She had received: Amoxicillin 31118/01 at age 2.5 years Azithromycin 1/24102 at age 3.5 years Azithromycin 6/24102 at age nearly 4 years Amoxicillin 3/25/03 at age 4.5 years Amax/clavulanate (high dose) 6/20103 age nearly 5 Azithromycin 4/4/04 age 5 years 9 months Azithromycin on the day of her demise. In short she had 6 prior courses of antibiotics in a total of 6 years, or approximately 1-2 course per year on average. This is within normal limits for age and does not suggest any of the common immunodeficiencies. Sara had a history of asthma, which was treated fairly intermittently. Review of the pharmacy records indicated that her parents filled prescriptions for Pulmicort 3 times (30 day supplies at each refill) between 2002 and 2005. They filled prescriptions for Singulair 6 rimes (30 days supply at each time) between 11/26/02 and 5/13/04. I found only 4 prescriptions for albuterol, but 2 were within 2 days on 211 and 214/00 in 2 formulations. Taken together, this suggests that she had asthma that ranged from nvld intermittent to mild persistent in severity. According to her records, her main asthma trigger was viral respiratory infections. Although one of the records indicated that Sara's mother smoked during her pregnancy (Dr. Todd Barron noted in his letter dated March 23, 200Qttig "the mother did use some tobacco during the pregnancy") she herself P.2 Oct 12 2CC7 2:20PM HP LASER;iET FAX F.3 denied smoking during pregnancy in her deposition. Mrs. Hetrick stated in her deposition that she did not smoke in the house, • On the ni;ht before her demise, Sara's mother contacted her pediatrician with a concern that Sara had a croupy cough which had started 2 days prior, and seemed to worsen. She spoke to her pediatrician approximately 3:30 AM on 1/31/05, who advised her to take Sara outside for cold air exposure. This improved Sara immediately and she was able to fall asleep. Both Dr. Blustein's notes and the mother's deposition supports this relatively rapid improvement in Sara's cough with cold air exposure. By morning, Sara's mother noted that her daughter had persistent cough but no evident fever. • Sara was seen later the same day by Dr. Blutstein in the office. Dr. Blutstein did a careful evaluation, which included a set of vital signs, a history, and a physical examination. He offered to observe the child in the hospital based on a combination of a borderline low hemoglobin saturation of 93% and a fever of 104 degrees, but according to his note, her mother declined (she denies this in her deposition). He prescribed azithromycin for possible bacterial infection, prednisolone based on her history of asthma and her low saturation (which was indicative of asthma). There was no evidence of acute upper airway obstruction (e.g., no drooling, no stridor) and only mild respiratory distress. • Sara's mother stated that she did not administer the prescribed antibiotic to Sara before her cardiopulmonary arrest. • 2 or 3 hours after Sara and her mother returned from the pharmacy (to which they had proceeded from Dr. Blutstein's office), Sara became gravely ill and went into cardiopulmonary arrest. 911 was called and there was a rapid response with initiation of cardiopulmonary resuscitation. Her death was attributed to sepsis (bacterial infection in the bloodstream). Her chest radiograph prior to her death did not show any infiltrates that would suggest a pneumonia. At autopsy she was not noted on gross examination of the lungs to have any obvious pneumonia, although on microscopic evaluation there was evidence of both asthma and pneumonia. ASSESSMENT: The death of Sara Zehring is as puzzling as it is tragic. It is highly likely that Sara's initial presentation was a viral respiratory infection, leading to croup (viral laryngotracheobronchitis). Viral croup is a common childhood infection and generally is a benign and self-limited disease, resolving spontaneously. In Sara's case there was a bacterial superinfection (a secondary tracheitis) with invasion through the injured epithelium into the bloodstream, leading to sepsis and death. Streptococcus pneumoniae (also known as Pneumococcus) remains a common cause of bacterial disease in children, and is a common cause of otitis media and sinusitis. Invasive bacterial infection (sepsis and meningitis) with Streptococcus pneumoniae, in contrast, has greatly decreased in incidence with the introduction of Prevnar, the 7-valent conjugate vaccine against this organism (Whitney, et at. NEJM 2003-,348: 1737-1746). Oct 12 2007 2:20PM HP LRSER3ET r=RX Bacterial infection with Streptococcus pneumoniae resulting in bloodstream infection can be "occult" - e.g., without other signs or symptoms other than fever. Occult bacteremia with streptococcus pneumoniae is most common in children under age 2, and also can occur in patients who have had splenectomy or with immune deficiency states. Sara Zehring had no evidence of an immunodeficiency and had no identifiable risk factors for invasive pneumocoeeal disease (other than possible environmental tobacco smoke exposure). The plaintiffs allege that Dr. Blutstein failed to diagnose Sara's "pneumonia" when the chest radiograph at the time of her death showed no infiltrates, and even gross inspection of the lungs at the time of autopsy showed no evidence of pneumonia. Only under microscopic evaluation was there evidence of pneumonitis in Sara's lungs. In addition the pathologist found microscopic evidence of asthma, which was the cause of her borderline low oxygen saturation in the office. The borderline low oxygen saturation was not caused by pneumonia, as the plaintiff is implying, but by viral-induced bronchospasm. It should be noted that a pulse of 173 and a mildly elevated respiratory rate of 46 are entirely consistent with the fever that Sara had and do not suggest sepsis or other invasive bacterial disease in and of themselves, I can state with confidence that Dr. Blutstein did not act improperly in his treatment of Sara Zehring. Nothing in her past history suggested that she had a predisposition to invasive bacterial disease, and nothing in her examination suggested sepsis. An ambulatory child, as Sara was on the morning of her examination, cannot be in septic shock. Fever is one of the most common reasons for children to seek medical attention. Based on Sara's history of a croupy cough, which responded to cold air treatment, Dr. Blutstein's clinical impression was of an acute viral croup, with secondary viral bronchospasm. Although viral cultures were not obtained at autopsy, had one been performed the likely source would have been parainfluenza virus. Sara experienced a bacterial secondary infection through the virally injured respiratory epithelium. There was no lobar pneumonia or other large source of bacteria. In this regard Sara's case is highly unusual and could not have been expected. Dr. Blutstein treated Sara's borderline low oxygen saturations with albuterol, and her mother did immediately administer this therapy. He initiated antibiotic treatment, but Sara's mother did not give the first dose of the azithromycin. It is impossible to say whether had she given the first dose promptly Sara would have survived. The use of steroid in the setting of an acute asthma exacerbation is well established and Dr. Blutstein was using usual standard of care for an asthma exacerbation. The choice of azithromycin for treating pneumonia is an excellent one, as it covers both "atypical" and usual bacterial agents. The vast majority of pneumonias are treated with Oct 12 2007 2:20FM H° LASERJET FAX p.5 oral antibiotics in the outpatient setting. Thus Dr. Blutstein's decision-making was well within the standards of care. Dr. Blutstein did offer to hospitalize Sara, which her mother declined. Although Sara's mother denies this in her deposition, it is natural for a mother of several children to not want to have to be in the hospital. As it was, Sara's mother was not able to be with Sara in the emergency room and waited for her other children. I found Dr. Blutstein's notes, which were taken within hours of the visit, very credible, while Sara's mother's deposition in which she denies this conversation (taken on August 10, 2007, more than 2 years later), are more likely to reflect an imperfect memory. In summary I find that Dr. Blutstein did at no time vary from established standards of care, and could not have predicted the tragic outcome of Sara Zehring. All aspects of his care were appropriate. It is impossible to predict the effect of Mrs. Hetrick's not having administered Sara's antibiotics, but I would conjecture that one dose of antibiotics whether oral or intravenously administered would likely not have altered the course of this illness. lo)IZ/U?- ?xh?b?? C March 31, 2008 Foulkrod Ellis 2010 Market Street Camp Hill, PA 17011 Re: Hetrick v. Blutstein, MD Dear Mr. Mongielio, I have reviewed the records that were provided to me regarding Sara Zehring. These include the following items: Deposition of Dr. Blutstein Plaintiffs Complaint Plaintiffs Deposition Expert Report for the Plaintiff Autopsy Report of Sara Zehring and Coroner's View Medical Records from Pennsboro Pediatrics Medical Records from Polyclinic Hospital Medical Record from Carisle Hospital Death Certificate West Shore EMS Records Giant Pharmacy Records Hershey Medical Center Records Transcription of Dr. Blutstein's Notes Notes from Dr. Blutstein's Computer Chest radiograph from 1/31/05 I base my opinion regarding this matter upon these records. Sara Zehring was born on 7/29/98. Dr. Blutstein and Pennsboro Pediatrics provided her primary medical care with the assistance of a variety of consultants. There were many documented visits to Pennsboro Pediatrics for routine well child care, and sick visits. Sara appeared to have good growth and received all of the standard immunizations and some influenza vaccine doses. Sara was noted to have several medical problems including an atrial septal defect, dacryostenosis, a seizure disorder, reactive airway disease/asthma and recurrent episodes of acute otitis media and otitis media with effusion. She had a prior emergency department visit for a closed head injury on 11112000, as well as two hospital admissions. The first was on 1/2/2000 for seizures and the second was on 1/4/2001 for vomiting, diarrhea and dehydration. Page I of 4 i I Sara's illness began a few days prioI to 1 /31 /05 when she developed a cough and fever, She was with her father tlver the weekend and returned to her mother on Sunday 1/30/05. The following tit`neline describes the events that occurred on 1/31/05 as per the documentation reviewed, listed above, Monday 1131105 03:30 Dr. Blutstein received a phone call from Sara's mother. He assessed that Sara likely had croup from the information that her mother provided and the way her cough sounded. He advised Sara's mother to take her outside because the cold air would help her breathing. H6 also stated that if it did not help, that she should take Sara to the Emergency bepartment. He asked her to call the office to inform them if she went to the Hospital and offered to see her in the office. 10:15 (Time approximate) Dr. Blutstein saw Sara in the office. His assessment was that she had fever, croup, reactive airways disease and possibly pneumonia. As per his personal notes, he discussed the option of admitting Sara to the hospital with her mother and she declined and stated that she preferred to observe her at home. Dr. Blutstein then prescribed Orapred, Flovent and azithromycin and told her to call him! if Sara worsened and asked her to return to the office the following day. Time unknown - Sara's mother filled her prescriptions at Giant Pharmacy and took her home. i 14:17 Dr. Blutstein received a call from Sara's mother that Sara was blue and not breathing. He advised her to call 911 immediately and to'go to Harrisburg Hospital. 14:22 Dr. Blutstein called Sara's mother back and found that there was assistance at the house and she informed him that they were going to Carlisle Hospital. 14:22 (Time as per EMS notes) Medic 85 was dispatched to meet the ambulance enroute to Carlisle Hospital to provide care for Sara. 14:27 Dr. Blutstein called Carlisle Hospital to provide medical history regarding Sara Zehring. 14:32 Dr. Blutstein contacts Dr. Mack to meet the patient at the Emergency Department to render assistance. 14:37 Dr. Blutstein received a call from Sara's mother; she asked Dr. Blutstein if he had heard anything about Sara, he had not heard anything at that time. 14:40 Time per the EMS records the patient was successfully intubsted. 14:52 EMS and the patient arrived at Carlisle Hospital. 14:58 First recorded time on the Cardiopulmonary Resuscitation flow sheet at Carlisle Hospital. 15:05 Dr. Blutstein called the Carlisle Emergency Department and was informed about Sara's condition. During the same phone call the phone was given to Dr. Mack. She informed Dr. Blutstein that the team had stopped resuscitation efforts. Page 2 of 4 15:22 Time code terminated as per the Cardiopulmonary Resuscitation flow sheet. 17:22-17:50 Dr. Blutstein types his recollections of the day in a note on his computer. Assessment: Sara Zehring first presented to medical attention with the illness in question with a phone call early on Monday 1 /31 /05. She was appropriately managed by telephone and was offered an appointment the following day and was told that she could go to the Emergency Room if her mother felt that was necessary. Her illness likely began as a viral process such as influenza, parainfluenza or an upper respiratory infection, These are very common in children at this time of year. Her illness and symptoms persisted; this prompted an appointment being scheduled that same morning 1/31/05. A physical examination is well documented on Monday 1/31/05. The documentation and the physician's deposition support that there was no evidence of septic shock. Children of Sara's age with high fever would also be expected to have an elevated heart rate and respiratory rate. In addition Dr. Blutstein felt that she was having an exacerbation of her reactive airway disease/asthma, croup and possibly pneumonia, which explained her oxygen saturations and epigastric retractions. Children with septic shock would have poor peripheral perfusion, and would have decreased mental status. Sawa was cooperative with the examination and is not described as toxic appearing, drooling or lethargic. Her oxygen saturations were measured at 93%. This in and of itself, is not an absolute indication for hospitalization. Children with bacterial pneumonia or tracheitis and bronchitis often begin with a viral illness that looks like a common cold or the "flu". Dr. Blutstein recognized that Sara was ill and offered hospital admission to her mother who declined that option and preferred to watch her at home. This is reasonable in a child who is Sara's age who is able to verbalize how she feels and can be observed by a family member. It was also early in the day; this would easily allow that Sara could be reassessed. Dr. Blutstein informed Sara's mother to call him if anything changed. Dr. Blutstein prescribed antibiotics (azithromycin) for a possible bacterial process. He prescribed Orapred and Flovent for management of her asthma exacerbation. This is standard practice for these conditions in a child this age. At times blood work such as a complete blood count or a blood culture is obtained if the child is toxic appearing. This is done in order to assess whether the child is bacteremic. Since the physician believed that a diagnosis of croup and reactive airway disease explained the illness in this child, and since she was not toxic in appearance, he did not require additional diagnostic testing. He presumed that there might be a bacterial infection and prescribed an appropriate antibiotic, therefore, a chest radiograph was not indicated at that time. Even if a chest radiograph was obtained earlier on Monday morning I do not think that it Page 3 of 4 would have changed Sara's management. It is not clear that the radiograph would be abnormal given that the radiograph that was obtained in the Emergency Department was not very impressive. I believe that Sara had worsening respiratory distress and became bacteremic with the Streptococcus pneumoniae at some point after leaving the office on Monday morning. There is no report of a significant change in her clinical appearance until 14:17 when Dr. Blutstein received a call from Sara's mother that she was blue and not breathing. The autopsy report indicates Sara had pneumonia, tracheitis and bronchitis with a blood culture that was positive for Streptococcus pneumoniae. She likely also had septic shock syndrome given her rapid decline. Streptococcus pneumoniae can be a very aggressive pathogen. Even with the best medical care in an intensive care unit at a pediatric hospital, children die of theses types of infections. Appropriate antibiotic treatment cannot stop the inflammatory response and cytokine release that occur with these infections. In addition, different children have different genetic make-ups. This affects thier ability to handle serious infections. This cannot be predicted. Two children can have the same infection and respond very differently dependent on the host immune response or lack of host response. At this time, we cannot alter the child's immunogenetics. Sara Zehrig was seen and evaluated in the office on Monday 1/31/05. 1 believe that her medical care was appropriate. From the office notes and depositions it appears that Sara was not toxic during her evaluation by Dr. Blutstein. k is my opinion, within a reasonable degree of medical certainty that Sara received appropriate medical care prior to her death. Sincerely, q",e2?? - / O J dith M. Martin, MD 3/31108 Addendum: I have also reviewed the additional information provided in the report of Dr. Bollinger and the deposition of Dr. Mack. I believe that her medical care was appropriate. I have found no information that leads me to believe that admitting Sara to the hospital for observation would have altered her outcome. Judith M. Martin, MD Page 4 of 4 October 12, 2007 Foulkrod Ellis 2010 Market Street Camp Hill, PA 17011 Re: Hetrick v. Blutstein, MD Dear Mr. Mongiello; I have reviewed the records that were provided to me regarding Sara Zehring. These include the following items: Deposition of Dr. Blutstein Plaintiffs Complaint Plaintiffs Deposition Expert Report for the Plaintiff Autopsy Report of Sara Zehring and Coroner's View Medical Records from Pennsboro Pediatrics Medical Records from Polyclinic Hospital Medical Record from Carisle Hospital Death Certificate West Shore EMS Records Giant Pharmacy Records Hershey Medical Center Records Transcription of Dr. Blutstein's Notes Notes from Dr. Blutstein's Computer Chest radiograph from 1/31/05 I base my opinion regarding this matter upon these records, Sara Zehring was bom on 709/98. - Dr. Blutstein and Pennsboro Pediatrics provided her primary medical care with the assistance of a variety of consultants. There were many documented visits to Pennsboro Pediatrics for routine well child care, and sick visits. Sara appeared to have good growth and received all of the standard immunizations and some influenza vaccine doses. Sara was noted to have several medical problems including an atrial septa) defect, dacryostenosis, a seizure disorder, reactive airway disease/asthma and recurrent episodes of acute otitis media and otitis media with effusion. She had a prior emergency department visit for a closed head injury on 1/1/2000, as well as two Page 1 of 4 hospital admissions. The first was on 1/212000 for seizures and the second was on 1/4/2001 for vomiting, diarrhea and dehydration. Sara's illness began a few days prior to 1/31/05 when she developed a cough and fever. She was with her father over the weekend and returned to her mother on Sunday 1/30/05. The following timeline describes the events that occurred on 1 /31 /05 as per the documentation reviewed, listed above. Monday 1131/05 03:30 Dr. Blutstein received a phone call from Sara's mother. He assessed that Sara likely had croup from the information that her mother provided and the way her cough sounded. He advised Sara's mother to take her outside because the cold air would help her breathing. He also stated that if it did not help, that she should take Sara to the Emergency Department. He asked her to call the office to inform them if she went to the Hospital and offered to see her in the office. 10:15 (Time approximate) Dr. Blutstein saw Sara in the office. His assessment was that she had fever, croup, reactive airways disease and possibly pneumonia. As per his personal notes, he discussed the option of admitting Sara to the hospital with her mother and she declined and stated that she preferred to observe her at home. Dr. Blutstein then prescribed Orapred, Flovent and azithromyc:in and told her to call him if Sara worsened and asked her to return to the office the following day. Time unknown - Sara's mother filled her prescriptions at Giant Pharmacy and took her home. 14:17 Dr. Blutstein received a call from Sara's mother that Sara was blue and not breathing. He advised her to call 911 immediately and to go to Harrisburg Hospital. 14:22 Dr. Blutstein called Sara's mother back and found that there was assistance at the house and she informed him that they were going to Carlisle Hospital. 14:22 (Time as per EMS notes) Medic 85 was dispatched to meet the ambulance enroute to Carlisle Hospital to provide care for Sara. 14:27 Dr. Blutstein called Carlisle Hospital to provide medical history regarding Sara tehring. 14:32 Dr. Blutstein contacts Dr. Mack to meet the patient at the Emergency Department to render assistance. 14:37 Dr. Blutstein received a call from Sara's mother; she asked Dr. Blutstein if he had heard anything about Sara, he had not heard anything at that time. 14:40 Time per the EMS records the patient was successfully intubeted. 14:52 EMS and the patient arrived at Carlisle Hospital. 14:58 First recorded time on the Cardiopulmonary Resuscitation flow sheet at Carlisle Hospital. 15:05 Dr. Blutstein called the Carlisle Emergency Department and was informed about Sara's condition. During the same phone call the phone was given to Dr. Page 2 of 4 Mack. She informed Dr. Blutstein that the team had stopped resuscitation efforts. 15:22 Time code terminated as per the Cardiopulmonary Resuscitation flow sheet. 17:22-17.50 Dr. Blutstein types his recollections of the day in a note on his computer. sAMW: Sara Zehring first presented to medical attention with the illness in question with a phone call early on Monday 1/31/05. She was appropriately managed by telephone and was offered an appointment the following day and was told that she could go to the Emergency Room if her mother felt that was necessary. Her illness likely began as a viral process such as influenza, parainfluenza or an upper respiratory infection. These are very common in children at this time of year. Her illness and symptoms persisted; this prompted an appointment being scheduled that same morning 1/31 /05. A physical examination is well documented on Monday 1/31/05. The documentation and the physician's deposition support that there was no evidence of septic shock. Children of Sara's age with high fever would also be expected to have an elevated heart rate and respiratory rate. In addition Dr. Blutstein felt that she was having an exacerbation of her reactive airway disease/asthma, croup and possibly pneumonia, which explained her oxygen saturations and epigastric retractions. Children with septic shock would have poor peripheral perfusion, and would have decreased mental status, Sara was cooperative with the examination and is not described as toxic appearing, drooling or lethargic. Her oxygen saturations were measured at 93°x6. This in and of itself, is not an absolute indication for hospitalization. Children with bacterial pneumonia or tracheitis and bronchitis often begin with a viral illness that looks like a common cold or the 'flu". Dr. Blutstein recognized that Sara was ill and offered hospital admission to her mother who declined that option and preferred to watch her at home. This is reasonable in a child who is Sara's age who is able to verbalize how she feels and can be observed by a family member. It was also early in the day, this would easily allow that Sara could be reassessed. Dr. Blutstein informed Sara's mother to call him if anything changed. Dr. Blutstein prescribed antibiotics (azithromycin) for a possible bacterial process. He prescribed Orapred and Flovent for management of her asthma exacerbation. This is standard practice for these conditions in a child this age. At times blood work such as a complete blood count or a blood culture is obtained if the child is toxic appearing. This is done in order to assess whether the child is bacteremic. Since the physician believed that a diagnosis of croup and reactive airway disease explained the illness in this child, and since she was not toxic in appearance, he did not require additional diagnostic testing. He presumed that there might be a bacterial infection and prescribed an appropriate Page 3 of 4 antibiotic, therefore, a chest radiograph was not indicated at that time, Even if a chest radiograph was obtained earlier on Monday morning I do not think that it would have changed Sara's management. It is not clear that the radiograph would be abnormal given that the radiograph that was obtained in the Emergency Department was not very impressive. I believe that Sara had worsening respiratory distress and became bacteremic with the Streptococcus pneumoniae at some point after leaving the office on Monday morning. There is no report of a significant change in her clinical appearance until 14:17 when Dr. Blutstein received a call from Sara's mother that she was blue and not breathing. The autopsy report indicates Sara had pneumonia. tracheitis and bronchitis with a blood culture that was positive for Streptococcus pneumoniae. She likely also had septic shock syndrome given her rapid decline. Streptococcus pneumoniae can be a very aggressive pathogen. Even with the best medical care in an intensive care unit at a pediatric hospital, children die of theses types of infections. Appropriate antibiotic treatment cannot stop the inflammatory response and cytokine release that oc curwith these infections. In addition, different children have different genetic make-ups. This affects thier ability to handle serious infections. This cannot be predicted. Two children can have the same infection and respond very differently dependent on the host immune response or lack of host response. At this time, we cannot alter the child's immunogenstics. Sara Zehrig was seen and evaluated in the office on Monday 1/31/05. 1 believe that her medical care was appropriate. From the office notes and depositions it appears that Sara was not toxic during her evaluation by Dr. Blutstein. It is my opinion, within a reasonable degree of medical certainty that Sara received appropriate medical care prior to her death. Sincerely, 4?? /??. lnz.,? Ju lth M. Martin, MD Page 4 of. 4 Exh I b 1+ "D Arthur H. McTighe, M.D. 107 Witherspoon Road Baltimore, Maryland 21212 April 21, 2008 Andrew Foulkrod, Esq. Foulkrod Ellis 2010 Market Street Camp Hill, Pennsylvania 17011 RE: Hetrick v. Blutstein, et al. Dear Mr, Foulkrod: Thank you for asking me to review this case on behalf of Dr. Blutstein, I am the Medical Director of the Department of Laboratory Medicine and the Chief Pathologist of a relatively large community teaching hospital in Baltimore, Maryland, with very active pulmonary medicine, infectious diseases, pediatrics and medicine services. Formerly, I was the medical director and chief pathologist of two hospital pathology departments in Pennsylvania. At one of these Pennsylvania hospitals I also served as the Vice President for Medical Affairs, and as such I was responsible for monitoring and improving the quality of medical care. I have been engaged in the practice of autopsy and surgical pathology for 33 years and am board certified in the disciplines of anatomic pathology and clinical pathology by the American Board of Pathology. In addition, I am certified in the subspecialties of Medical Microbiology, Dermatopathology and Cytopathology by the American Board of Pathology. Medical Microbiology is that subspecialty of pathology that deals with infectious diseases and their associated pathologic changes, such as pneumonia and sepsis, the pathogenic bacteria producing pneumonia and sepsis, and the pathologic changes of pneumonia and sepsis seen in various organs of the human body. I was a member of the pathology faculty at the Johns Hopkins School of Medicine for 15 years until relocating to Pennsylvania in 1991, and I have been an Associate Clinical Professor of Pathology at the Pennsylvania State University, School of Medicine in Hershey, Pennsylvania since 2000. At your request I reviewed 15 glass slides prepared from autopsy pathology tissue specimens, which were processed by Forensic Pathology Associates, Inc., of Allentown, Pennsylvania. These 15 slides were identified as C 05-73 1 through 5 and C 05-73 01 through B10. The slides were sent to me on April 10, 2008. As is my usual practice I examined these slides "blindly," i.e., without reviewing the autopsy report or any other record until after my examination of the slides was complete. In addition, I received the following medical records and other materials, which I have also reviewed: Andrew Foulkrod, Esq., Foulkrod Ellis, RE: Hetrick v. Blutstein, et al. 2 A) Medical Records: Records of Pennsboro Pediatrics (Dr. Blutstein), Records of the Carlisle Regional Medical Center (January 31, 2005 ER), Transcriptions of Dr, Blutstein's handwritten note, Records of West Shore EMS, Records of the Giant Pharmacy, Death Certificate, Records of the Hershey Medical Center, Records of the Polyclinic Hospital, Final autopsy report of Sara Zehring (C 05-73). B) Other Materials: Coroner's View, Deposition transcript of Laura Hetrick, Deposition transcript of Dr. Richard Blutstein, Deposition transcript of Dr. Vicki Mack, Expert report of Dr. Jonathan Finder, Expert report of Dr. Timothy Doran, Expert report of Dr. Judith Martin, Expert report of Dr. Richard Bonforte, and Expert report Dr. Barbra Bollinger. . You asked that I review the medical records, autopsy pathology slides, autopsy pathology reports, and the other materials in detail. My findings and opinions are as follows: Sara Zehring was a 6 % year-old girl who had been a patient of Dr. Blutstein since her birth. Her past medical history was remarkable for asthma, a seizure disorder that had been essentially inactive for the three years before her tragic death, and an atrial septal defect that had nearly closed at the time of autopsy, Her asthma was well managed by Dr. Blutstein, and the seizure disorder and atrial septal defect produced no limitation of activity or other symptoms for the few years before her death. She was a well and active child, She had received the standard immunizations and had also received influenza vaccine. Over the course of her life, she had received a few courses of antibiotics, including amoxicillin and azithromycin for upper respiratory infections and otitis media. She recovered from these infections uneventfully, and there is nothing in her record to suggest an immunodeficiency disorder. Sara returned to her mother's home the day before her death. She apparently had developed a croupy cough two days before and this appeared to worsen. Sara's mother contacted Dr. Blutstein because of this cough at approximately 3:30 a.m. on January 31, 2005. Dr. Blutstein could hear the croupy cough over the telephone and advised Sara's mother to take Sara outside into the cold air for both diagnostic and therapeutic reasons, as croup usually improves after cold-air exposure. Dr. Blutstein did advise Sara's mother that should her cough not improve she should be taken immediately to the local hospital emergency room, and in any case K her cough improved with cold-air exposure, she should be brought to see him the following morning, Sara's cough almost immediately improved on cold-air exposure, and she easily fell asleep in her mother's arms. Andrew Foulkrod, Esq.. Foulkrod Ellis, RE: Hetrick v. Blutstein, et al. 3 Later that morning Sara's mother noted that her cough had returned and she took Sara to Dr. Blutstein's office at approximately 10:15 a.m. Sara's mother reported that her daughter was wheezing and coughing and had developed fever. Dr. Blutstein conducted a thorough examination and evaluation of Sara and offered to evaluate and observe Sara in the hospital based on her mildly reduced oxygen saturation of 93°x6, her respiratory symptoms, and fever. However, her mother preferred to watch Sara at home rather than having her admitted to the hospital. Dr. Blutstein told Sara's mother to call him in the event that Sara's condition or symptoms worsened. Dr. Blutstein prescribed azithromycin for a possible bacterial infection and medications for her asthma, based on her relatively mild respiratory distress. • Sara's mother did have these prescriptions tilled at a local Giant pharmacy and she describes pushing Sara in a shopping cart through the store in order to pick up the prescriptions at the pharmacy counter. Sara was not described as being obtunded or severely ill. Sara's mother took her home, gave her some of the medications, but decided not to give her the antibiotic, azithromycin, at that time. Sara was reclining on the couch and later went to bed. Sara, according to her mother, walked in and out of the bedroom a couple of times. At about 2 p.m., however, Sara called out for her mom, seem to shake a bit, and fell into her arms. Sara's mother describes Sara as turning blue and having decreased breathing. At 2:17 p.m., Dr. Blutstein received a telephone call from Sara's mother advising him that Sara had turned blue, had a possible seizure, and was no longer breathing. Dr. Blutstein advised Sara's mother to call 911 at once. West Shore Emergency Medical Services responded immediately, began CPR, and took Sara to the Carlisle Regional Medical Center. Sara arrived at the Carlisle Regional Medical Center at 2:58 p.m..and was evaluated by Dr. Guarracino. Dr. Guarracino described Sara as a "e-year-old white female who presents via EMS in cardiopulmonary arrest." He noted that Sara had been sick with a croup-like cough. She had been evaluated in the pediatrician's office and was found to have a mildly reduced oxygen saturation of 93°x6 but was "able to talk without difficulty." A portable chest x-ray was performed in the Emergency Room and Dr. Guarracino states that the "portable chest x-ray interpreted by myself showed no evidence of pneumonia." In his examination he also noted that he visually inspected the oropharynx and found the endotracheal tube to be in place. He also noted, "There was no obvious evidence of epiglottitis or swollen paralaryngeal tissues." Skin rash or skin hemorrhages or petechiae were not present. CPR was continued, but this was to no avail and Sara was pronounced dead at 3:22 p.m. on January 31, 2005. • At the request of the Cumberland County Coroner, Sara Zehring underwent an autopsy performed by Dr. Barbra Bollinger at 10 a.m. on February 1, 2005. The autopsy was performed approximately 18'/: hours after Sara had been pronounced dead. • Dr. Bollinger in her autopsy report (C-05-073) reported that Sara's epiglottis was slightly red, discolored, and swollen. She also noted, 'There are no obstructive lesions of the oropharynx, nasopharynx or larynx. The laryngeal mucosa is pink, f , Andrew Foulkrod, Esq., Foulkrod Ellis, RE. Hetrick v. Blutstein, et al. 4 smooth, and non-edematous. The trachea is straight, patent, and is lined by intact, pink-red mucosa." Dr. Bollinger found a small septal defect in the right atrium that measured 0.1 cm. Sara's heart was otherwise unremarkable. Sara's lungs weighed 210 and 220 grams, and Dr. Bollinger reported, "The cut sections of the lungs show no obstructions, tracheobronchial tree contains a slighmasses or focal lesions. t amount of thick yellowhmucus and is otherwise unremarkable." Dr. Bollinger also noted "each bilateral adrenal gland is in its normal anatomic position and is grossly unremarkable." In her microscopic examination, Dr. Bollinger reported that the adrenal glands were "without pathologic abnormalities.' She described the tracheal mucosa as "denuded and with underlying acute and chronic inflammation." She described inflammation of the bronchial mucous glands and a focal acute inflammatory infiltrate within the alveolar spaces of the lung. Dr. Bollinger lists sepsis, asthma, seizure disorder, atrial septa) defect, and contusions of the left lower extremity as her final pathologic diagnoses. Under sepsis she lists history of cough and fever, fine papular rash of the torso, acute tracheitis and bronchitis, acute bronchopneumonia, and blood cultures with growth of Streptococcus pneumoniae. In the section of Dr. Bollinger's report ,entitled "Opinion" she states that Sara's epiglottis was slightly red and swollen, her trachea was also pink-red, and microscopic examination of the lungs and trachea demonstrated acute inflammation and necrosis of the tracheobronchial mucosa. She also stated "Focally, the alveolar septae had neutrophilic inflammation which extended into the alveolar spaces. " A post-mortem blood culture that was performed at Health Network Laboratories grew two organisms. The first organism reported is Streptococcus pneumoniae, and the second reported organism is alpha hemolytic streptococcus. No antimicrobial susceptibilities are reported for these organisms. I disagree with several parts of Dr. Bollinger's autopsy report. The findings that she has listed under the heading of "sepsis" in her final anatomical diagnoses are overreaching and are clearly written from the perspective of hindsight. History of fever and cough and fine papular rash of the torso have numerous causes, including their rare association with sepsis. Similarly, patients with acute tracheitis and bronchitis and acute bronchopneumonia only occasionally develop sepsis. Furthermore, blood cultures from patients with sepsis usually only grow a single microorganism. The blood culture that is reported from Health Network Laboratories, in contrast, apparently grew two organisms streptococcus pneumoniae and alpha hemolytic streptococcus. Alpha hemolytic streptococcus is common contaminant in blood cultures that are collected after an inadequate disinfection of the arm or other site of blood collection. Streptococcus pneumoniae is generally a pathogenic organism. However, it may be misidentified if the studies performed to identify the organism are not properly quality controlled or are evaluated by not adequately trained personnel. In addition, the antimicrobial susceptibility testing of Streptococcus pneumoniae was not performed. The antimicrobial susceptibility of this organism, if it had been determined, might have helped to confirm it as Streptococcus pneumoniae. Andrew Foulkrod, Esq., Foufkrod Ellis, RE: Hetrick v. Blutstein, et al. 5 • In addition, post mortem blood cultures are often contaminated by the over growth of bacteria in the body after death, particularly if the autopsy occurs several hours after death. This further compromises the reliability of the reported culture results. • While Streptococcus pneumoniae may certainly produce sepsis, the incidence of sepsis and other forms of invasive disease caused by this organism has declined significantly since the introduction and widespread use of the pneumococcal conjugate vaccine. By 2003 a significant reduction in invasive Streptococcus pneumoniae infections had been seen in children both through the direct effects of vaccination and through "herd immunity," i.e., the decrease in prevalence of streptococcus pneumoniae infection in the general population because antibodies to Streptococcus pneumonia, produced by vaccination, exist in most members of the population. • The antimicrobial susceptibility of the possible Streptococcus pneumoniae organism isolated from Sara's blood was not determined; however, most isolates of Streptococcus pneumoniae are susceptible to azithromycin, the antibiotic that Dr. Blutstein prescribed for Sara during his office visit with her on the morning of her death. Dr. Bollinger did not find any evidence of pneumonia by gross examination of the lung tissue, and the chest x-ray performed at the Carlisle Regional Medical Center was also negative for bronchopneumonia, suggesting that significant bronchopneumonia was probably not present. I have also reviewed the lung tissue present in the recut autopsy sections that were supplied to me. There is little acute inflammation involving the alveolar parenchyma of the lung, and in my opinion, the degree of inflammation present is too little to support the diagnosis of bronchopneumonia. • Dr. Bollinger described the epiglottis as being only slightly red, discolored, and swollen and described the trachea as being lined by pink-red mucosa. No areas of grossly obvious exudate or necrosis were described at either of these sites. I have reviewed recut sections of the tracheal mucosa and agree with Dr. Bollinger that there is some inflammation of the tracheal mucosa, but most of the inflammation is chronic, and the intense acute inflammation that would be expected with a bacterial infection is not observed. These areas of tracheitis probably correspond to the croup-like illness with cough. I agree with Dr. Bollinger that there is hypertrophy of the bronchiolar smooth muscle, consistent with the history of chronic bronchial asthma. There is also focal chronic inflammation involving the bronchiolar tissue, again consistent with chronic bronchial asthma. I have reviewed the sections of the brain and agree with Dr. Bollinger that there is no evidence of meningitis or of any other significant intracranial pathology. In summary, therefore, Sara Zehring's most unfortunate and tragic death is not explained by the autopsy findings. The diagnosis of sepsis advanced by Dr. Bollinger hinges on the blood culture that is reportedly positive for Streptococcus y ? Andrew Foulkrod, Esq., Foulkrod Ellis, RE: Hetrick v. Blutstein, et al. 6 pneumoniae. This is an organism that may be confused with other non- pathogenic bacteria. For all the reasons mentioned earlier, Streptococcus pneumonise rarely produces sepsis in children with Sara Zehring's findings and history. The inflammation described within the tracheal mucosa appears to be more consistent with the results of a viral infection, as would be expected in a child with croup. • I also disagree with Dr. Bollinger's contention that Sara Zehring would have had an increased likelihood of survival had she been placed in the hospital setting. This opinion is not supported by the autopsy results conducted by Dr. Bollinger, In any case, her opinion is clearly the result of speculation and viewing her reported findings through the "retrospectoscope." I find the medical care of Dr. Blutstein to be entirely appropriate and to be well within the standard of care. He knew Sara Zehring well. He had been her pediatrician since birth and was very familiar with her past medical history. He suggested a reasonable therapeutic and diagnostic maneuver when contacted by Sara's mother at 3:30 a.m. on January 31, 2005. The prompt response of Sara's cough to exposure to cold air was as would be expected with croup. He suggested to Sara's mom that in any case he should see Sara in the office the next morning and that if Sara's symptoms did not respond she should be taken immediately to a local hospital emergency room. He evaluated her in the office the following morning, offered admission and observation to the local hospital, but Sara's mother opted for observation at home. Dr. Blutstein advised her that if there were any significant change in Sara's signs and symptoms, he should be informed immediately. He prescribed medications for asthma as well as azithromycin, an antibiotic that would likely be effective against Streptococcus pneumoniae. Subsequently, however, Sara tragically developed a respiratory arrest and died for reasons that are unclear, I hold all of these opinions to a reasonable degree of medical certainty. If additional information becomes available, 1 may wish to issue a supplemental report. I am available to testify at trial regarding these matters. If I can be of further assistance, please contact me. Very truly yours, Arthur H. McTighe, M. D., F.C.A.P, F S.C.P. xhl6lt ? _ no4 CURRICULUM VITAE ARTHUR H. McTIGHE, MD ADDRESS: 107 WITHERSPOON ROAD DATE OF BIRTH: OCTOBER 7,1944 BALTIMORE, MD 21212 PHONE: 410 433-0346 MEDICAL SCHOOL: UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE, M.D., 1969. TRAINING: INTERNSHIP IN PATHOLOGY, PRESBYTERIAN-UNIVERSITY HOSPITAL, PITTSBURGH, PA 1969-70. RESEARCH AND EXPERIMENTAL PATHOLOGY, U.S. PUBLIC HEALTH SERVICE ROCKVILLE, MD 1970-72. FELLOW IN LABORATORY MEDICINE, YALE NEW HAVEN HOSPITAL, NEW HAVEN, CT 1972-74. BOARD CERTIFICATION: AMERICAN BOARD OF PATHOLOGY, ANATOMIC AND CLINICAL PATHOLOGY, 1975. AMERICAN BOARD OF PATHOLOGY, MEDICAL MICROBIOLOGY, 1978. AMERICAN BOARD OF DERMATOLOGY AND AMERICAN BOARD OF PATHOLOGY, DERMATOPATHOLOGY, 1985. AMERICAN BOARD OF PATHOLOGY, CYTOPATHOLOGY, 1997. LICENSED: MARYLAND, PENNSYLVANIA, AND DELAWARE POSITIONS: UNION MEMORIAL HOSPITAL, BALTIMORE, MD MEDICAL DIRECTOR, DEPARTMENT OF LABORATORY MEDICINE and CHIEF OF PATHOLOGY, AUGUST 2004 TO PRESENT EVANGELICAL COMMUNITY HOSPITAL, LEWISBURG, PA DIRECTOR OF LABORATORIES, 1991-2004 VICE PRESIDENT FOR MEDICAL AFFAIRS/MEDICAL DIRECTOR, JUNE 2000-2004 PATIENT SAFETY OFFICER, 2002-2004 SUNBURY COMMUNITY HOSPITAL, SUNBURY, PA DIRECTOR OF LABORATORIES, MARCH 1997-2004 CURRICULUM VITAE - ARTHUR H. McTIGHE, M.D. PAGE TWO MARYLAND GENERAL HOSPITAL, BALTIMORE, MD VICE CHIEF OF PATHOLOGY, 1979-91 ASSISTANT TO THE MEDICAL DIRECTOR, 1987-1991 FRANKLIN SQUARE HOSPITAL, BALTIMORE, MD, 1977-79. U. S. PUBLIC HEALTH SERVICE HOSPITAL, BALTIMORE, MD, 1974-77. FACULTY: PENN STATE COLLEGE OF MEDICINE MILTON S. HERSHEY MEDICAL CENTER CLINICAL ASSOCIATE PROFESSOR OF PATHOLOGY, 2001-PRESENT. JOHNS HOPKINS UNIVERSITY, SCHOOL OF MEDICINE INSTRUCTOR IN PATHOLOGY, 1978-1993. FELLOW: AMERICAN COLLEGE OF PHYSICIAN EXECUTIVES COLLEGE OF AMERICAN PATHOLOGISTS AMERICAN MEDICAL ASSOCIATION AMERICAN SOCIETY FOR CLINICAL PATHOLOGY MARYLAND SOCIETY OF PATHOLOGISTS (PAST PRESIDENT, 1986-1988) PENNSYLVANIA SOCIETY OF PATHOLOGISTS (CAP DELEGATE 1998-2004) MARYLAND SOCIETY OF PATHOLOGISTS (CAP DELEGATE 2004-PRESENT) HOSPITAL MEDICAL STAFF AND MEDICAL SOCIETY OFFICES: UNION MEMORIAL HOSPITAL, BALTIMORE, MD: MEMBER, MEDICAL EXECUTIVE COMMITTEE CHAIRMAN, LAB MED. PERFORMANCE IMPROVEMENT COMMITTEE MEMBER, INFECTION CONTROL COMMITTEE MEMBER, TUMOR BOARD MEMBER, CANCER COMMITTEE MEMBER, RISK MANAGEMENT COMMITTEE MEMBER, LAB-NURSING PERFORMANCE IMPROVEMENT COMMITTEE EVANGELICAL COMMUNITY HOSPITAL, LEWISBURG, PA: PRESIDENT OF THE MEDICAL STAFF, 1999-2000 VICE PRESIDENT OF THE MEDICAL STAFF, 1997-1999 SECRETARY OF THE MEDICAL STAFF, 1995-1997 MEMBER, MEDICAL EXECUTIVE COMMITTEE, 1995-2004 CHAIRMAN, INFECTION CONTROL COMMITTEE, 1993-2004 VICE CHAIRMAN, BIOETHICS COMMITTEE, 1997-2004 MEMBER, QUALITY ASSURANCE COMMITTEE, 1995-2004 CHAIRMAN, PATIENT SAFETY COMMITTEE, 2002-2004 PATIENT SAFETY OFFICER, 2002-2004 UNION COUNTY (PENNSYLVANIA) MEDICAL SOCIETY, PRESIDENT, 1994-1996 PROGRAM CHAIRMAN, 1996-2004 SUNBURY COMMUNITY HOSPITAL, SUNBURY, PA: MEMBER, MEDICAL EXECUTIVE COMMITTEE, 1997-2004 CHAIRMAN, INFECTION CONTROL COMMITTEE, 1997-2000 CHAIRMAN, TISSUE AND TRANSFUSION COMMITTEE, 1997-2000 MEMBER, PATIENT SAFETY COMMITTEE, 2002-2004 CURRICULUM VITAE - ARTHUR H. McTIGHE, M.D. PAGE THREE CURRENT MEDICAL STAFF PRIVILEGES: UNION MEMORIAL HOSPITAL, BALTIMORE, MD (ACTIVE) EVANGELICAL COMMUNITY HOSPITAL, LEWISBURG, PA. (NOW HONORARY) SUNBURY COMMUNITY HOSPITAL, SUNBURY, PA. (NOW HONORARY) MARYLAND GENERAL HOSPITAL, BALTIMORE, MD. (NOW AFFILIATE) HONORS AND AWARDS: GOLDEN APPLE AWARD, FOR OUTSTANDING TEACHING, 1984-1985, PRESENTED BY THE DEPARTMENT OF MEDICINE HOUSESTAFF, OF THE MARYLAND GENERAL HOSPITAL. CERTIFICATE OF APPRECIATION, PRESENTED BY THE BALTIMORE POLICE DEPARTMENT, 1987, FOR SERVICE IN DEVELOPING A PROGRAM FOR EXPEDITED HIV TESTING. CERTIFICATE OF APPRECIATION, PRESENTED BY THE MEDICAL STAFF OF THE MARYLAND GENERAL HOSPITAL, 1991, FOR DEDICATED SERVICE TO THE INSTITUTION AND THE MEDICAL STAFF. CERTIFICATES OF APPRECIATION, PRESENTED BY THE COLLEGE OF AMERICAN PATHOLOGISTS, IN 1999, 2000, 2001 AND 2003, FOR OUTSTANDING AND DEDICATED SERVICE IN ADVOCATING FEDERAL AND STATE ISSUES OF IMPORTANCE TO PATIENTS, CLINICIANS AND PATHOLOGISTS. OTHER EXPERIENCE: ASSISTANT TO THE MEDICAL DIRECTOR, MARYLAND GENERAL HOSPITAL, 1987-1991 WITH RESPONSIBILITY FOR HEALTH INFORMATION SERVICES, QUALITY ASSURANCE, UTILIZATION REVIEW, AND INFECTION CONTROL. CO-OWNER AND PATHOLOGIST OF THREE PRIVATE LABORATORIES IN BALTIMORE, MARYLAND 1981-1991 (BALTIMORE BIOMEDICAL LAB, PHYSICIANS' SERVICE LAB, AND BALTIMORE DIAGNOSTICS LAB). MEDICAL DIRECTOR, SMITHKLINE BEECHAM CLINICAL LABORATORIES, BALTIMORE REGIONAL LAB, 1986-1991. COLLEGE OF AMERICAN PATHOLOGISTS (CAP), INSPECTOR LAB ACCREDITATION PROGRAM, 1985 TO PRESENT MEMBER, PATHOLOGY ADVOCACY NETWORK, 1992 TO PRESENT, FOR ADVOCACY AT THE FEDERAL AND STATE LEVELS ON PATHOLOGY, PHYSICIAN, HOSPITAL, AND PATIENT ISSUES. DELEGATE FROM MARYLAND TO CAP HOUSE OF DELEGATES MEMBER CAP HOUSE OF DELEGATES STEERING COMMITTEE CHAIR, CAP HOUSE OF DELEGATES STEERING COMMITTEE TASK FORCE -ON PATIENT SAFETY IN PATHOLOGY PRACTICE MEMBER, BOARD OF DIRECTORS, PATHOLOGY POLITICAL ACTION COMMITTEE (PathPAC), 1999 TO 2007. MEMBER, CAP SPOKESPERSONS NETWORK, 1995 TO PRESENT. MARYLAND STATE COMMISSIONER, CAP, LAB ACCREDITATION PROGRAM. PENNSYLVANIA STATE HOUSE OF REPRESENTATIVES MEMBER, WORK GROUP ON AIDS AND HIV POLICY, 1999. TESTIMONY BEFORE THE INDEPENDENT REGULATORY REVIEW COMMISSION (IRRC) OF PENNSYLVANIA, RE: HIV REPORTING REGULATIONS, 2002. CURRICULUM VITAE - ARTHUR H. McTIGHE, M.D. PAGE FOUR PUBLICATIONS: McTIGHE, A.H., ANTIMICROBIAL RESISTANCE OF NEISSERIA GONORRHOEAE, LABORATORY MEDICINE, 9:45-48,1978. McTIGHE, A.H. and CHIN, B., USE OF AN AGGLUTINATION METHOD IN THE LABORATORY DIAGNOSIS OF NEISSERIA GONORRHOEAE, ABSTRACTS OF THE ANNUAL MEETING OF THE AMERICAN SOCIETY FOR MICROBIOLOGY 1979, (PRESENTED AT THE POSTER SESSION, MAY 5, 1979, HONOLULU, HI). McTIGHE, A.H., CHIN, B., PATEL, C., and SMITH, L., USE OF AN AGGLUTINATION METHOD IN THE LABORATORY DIAGNOSIS OF NEISSERIA GONORRHOEAE, ABSTRACTS OF THE ANNUAL MEETING OF THE AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS 1980, (PRESENTED AT THE POSTER SESSION, MARCH 26, 1980, ATLANTA, GA). McTIGHE, A.H., PATEL, C., SMITH, L. ET AL, CONTINUING EDUCATION UPDATE: MICROBIOLOGY I. LABORATORY MEDICINE, 11:524-632,1980. McTIGHE, A.H., GONORRHEA DIAGNOSIS WITH CERTAINTY. DIAGNOSTIC MEDICINE, 3:36-57,1980. WEINBERG, L.G. and McTIGHE, A.H., A SIMPLE, RAPID SCREENING SYSTEM FOR IDENTIFICATION OF THE BACTEROIDES FRAGILIS GROUP, ABSTRACTS OF THE ANNUAL MEETING OF THE AMERICAN SOCIETY FOR MICROBIOLOGY 1981, (PRESENTED AT THE POSTER SESSION, MACH, 1981, HOUSTON, TX). McTIGHE, A.H., FISHER, B. and PATNAIK, P., PENICILLIN-RESISTANT GONORRHEA: CATCHING THE PENICILLIN RESISTERS. DIAGNOSTIC MEDICINE, 4:47-50,1981. McTIGHE, A.H., THE SEASON FOR VIBRIOS. DIAGNOSTIC MEDICINE, 4.-33-36,1981. McTIGHE, A.H., ANTENATAL AND NEONATAL BACTERIAL INFECTIONS: PATHOGENESIS, SIGNIFICANCE, AND DIAGNOSIS. CLINICS IN LABORATORY MEDICINE, 1: 345-360,1981. McTIGHE, A.H. (EDITOR), SYMPOSIUM: BACTERIOLOGIC SYNDROMES OF THE 1970s AND 1980s. LABORATORY MEDICINE, 13:611-643,1982. ANTHONY, W.C. and MCTIGHE, A.H., MECHANISMS OF DRUG RESISTANCE: STAPHYLOCOCCUS AUREUS and NEISSERIA GONORRHOEAE. LABORATORY MEDICINE, 13:618-620,1982. MCTIGHE, A.H. GARDNERELLA VAGINALIS: ROLE IN NONSPECIFIC VAGINITIS AND OTHER SYNDROMES. LABORATORY MEDICINE, 13:624-626,1982. 06 CURRICULUM VITAE - ARTHUR H. MCTIGHE, M.D. PAGE FIVE PUBLICATIONS (CONTINUED): ORBEGOSO, C. M., ULANOWICZ, N.I. and McTIGHE, A.H., NEW ANAEROBIC BACTERIOLOGIC SYNDROMES. LABORATORY MEDICINE, 13:628-632,1982. MCTIGHE, A.H., ASSOCIATION OF KAPOSI'S SARCOMA AND OPPORTUNISTIC INFECTIONS IN HOMOSEXUALS. LABORATORY MEDICINE, 13:633-636,1982. MCTIGHE, A. H., CHLAMYDIA TRACHOMAT/S: REVIEW OF HUMAN CHLAMYDIAL INFECTIONS AND LABORATORY DIAGNOSIS. LABORATORY MEDICINE, 13:638-643,1982. MCTIGHE, A.H., COMPARISON OF IMMULOK CULTURESET WITH REFERENCE TISSUE CULTURE METHODS IN THE DIAGNOSIS OF GENITAL HERPETIC INFECTION, ABSTRACTS OF THE ANNUAL MEETING OF THE AMERICAN SOCIETY FOR MICROBIOLOGY 1983, (PRESENTED AT THE POSTER SESSION, MARCH 1983, NEW ORLEANS, LA). COURSES AND WORKSHOPS PRESENTED: UPDATE IN MEDICAL MICROBIOLOGY, AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS WORKSHOP, PHILADELPHIA, PA, APRIL 24, 1982. NEW MICROBIOLOGICAL SYNDROMES OF THE 1970s AND 1980s, AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS WORKSHOP, PHILADELPHIA, PA, SEPTEMBER 10, 1983. NEW MICROBIOLOGICAL SYNDROMES OF THE 1970s AND 1980s, AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS WORKSHOP, MONTGOMERY, AL, APRIL 27, 1984. SEXUALLY TRANSMITTED DISEASES LAB THEORY AND PRACTICE, PRESENTED AS A PART OF THE STD CLINICIAN TRAINING COURSE, CITY OF BALTIMORE, HEALTH DEPARTMENT, 1983 AND 1984. INTERPRETING LAB RESULTS, WORKSHOP SPONSORED BY RESOURCE APPLICATIONS, PRESENTED IN WASHINGTON, DC, NEW YORK CITY, BOSTON, TORONTO, MONTREAL, CALGARY, EDMONTON, VANCOUVER, LOS ANGELES AND SAN FRANCISCO, 1983, 1984 AND 1985. LABORATORY TESTS: INTERPRETATION AND IMPLICATIONS, PRESENTED AT TRITON COLLEGE, RIVER GROVE, ILLINOIS, JULY 11, 1987. I CERTIFICATE OF SERVICE AND NOW, this Q day of 2008, I, Janice S. Harmon an employee of SCHMIDT KRAMER PC, do hereby certify that I have served a true and correct copy of the PLAINTIFF'S MOTIONS IN LIMINE in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Andrew Foulkrod, Esq. Michael Mongiello, Esq. Foulkrod Ellis P.C. 2010 Market Street Camp Hill, PA 17011 Janice S. Harmon MAY 2 8 2008 N' BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) thyman(&srklaw. com LAURA E. HETRICK, : IN THE COURT OF COMMON ADMINISTRATRIX OF THE : PLEAS ESTATE OF SARA J. : CUMBERLAND COUNTY, ZEHRING, PENNSYLVANIA Plaintiff V. RICHARD N. BLUTSTEIN, M.D., INDIVIDUALLY and t/d/b/a PENNSBORO PEDIATRICS, Defendant : No. 06-4433 CIVIL CIVIL ACTION -LAW MEDICAL PROFESSIONAL LIABILITY ACTION JURY TRIAL DEMANDED ORDER AND NOW this L ' day of 2008 it is hereby ORDERED and DECREED that the case of Laura E. Hetrick, Administratrix of the Estate of Sara J. Zehring v. Richard N. Blutstein, Civil Action Docket Number 06-4433 is hereby reinstated to the June 23, 2008 Civil Trial List and shall proceed under all existing Scheduling Orders and applicable Rules of Court. ?T >- cry ., .1W f_ cv € IJ Lt- C"i 1 LAURA E. HETRICK, Administratrix of the Estate of Sara J. Zehring,: v RICHARD N. BLUSTEIN, M.D.,: Individually and t/d/b/a Pennsboro Pediatrics IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 06-4433 CIVIL TERM IN RE: CASE STRICKEN FROM LIST ORDER OF COURT AND NOW, this 27th day of May, 2008, upon consideration of the call of the civil trial list with respect to the above-captioned case, and no counsel having called the case for trial, this case is stricken from the trial list. ? Terry S. Hyman, Esquire 209 State Street Harrisburg, PA 17101-1130 For Plaintiff Andrew W. Foulkrod, Esquire 2010 Market Street Camp Hill, PA 17011-4703 For Defendant Court Administrator :mae ?O tES rYt:p t CL S/29/D? By the Court, r s ?E? I-Ij t SCHMIDT KRAMER PC BY: TERRY S. HYMAN, ESQUIRE I.D. #36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Pl tiff(s) thyman(d)sr1daw com LAURA E. HETRICK, : IN THE COURT OF COMMON PLEAS ADMIIfISTRATRIX OF THE : CUMBERLAND COUNTY, ESTATE OF SARA J. ZEHRING, : PENNSYLVANIA Plaintiff V. : No. 06-4433 CIVIL RICHARD N. BLUTSTEIN, M.D., CIVIL ACTION - LAW INDIVIDUALLY and t/d/b/a MEDICAL PROFESSIONAL LIABILITY PENNSBORO PEDIATRICS, ACTION Defendant JURY TRIAL DEMANDED PLAINTIFF'S RESPONSE TO DEFENDANT'S MOTION IN LIMINE CONCERNING AUTOPSY PICTURES Admission or exclusion of evidence under Pa. R.C.P. 403 is wholly within the discretion of the Court. As the Superior Court stated, in affirming a Lower Court's decision to deny a Defendant's Motion in Limine to exclude photographs of Plaintiff's open wound and condition right after surgical procedures. In Fahrinzer v. Rinehimen 283 Pa. Super. 93, 423 A.2d 731 (1980), we said: The admission of photographs into evidence is within the discretion of the lower court. Nyice v. Mu ley, 384 Pa. 107, 119 A.2d 530 (1956); Piso v. Weirton Steel Co., 235 Pa. Super. 517, 345 A.2d 728 1975. Merely because a photograph is gruesome is not a reason to exclude it. Commonwealth v Dickerson 406 Pa. 102, 176 A.2d 421 1962. [***10] The court must consider whether the evidentiary value of the photograph outweighs the danger that it will upset the jury. Even when a witness has described an injury, a photograph may still have evidentiary value in that it may make the description more intelligible. West v. Morzan, 345 Pa. 61, 27 A.2d 46 (1942). l We affirm the trial court's admission of the photographs in question and we agree with its finding that while the pictures were not particularly pleasant neither were they particularly gruesome. Cervone v. Reading, 371 Pa. Super 279, 287, 538 A.2d 16, 20 1988). (Emphasis added.) Here, as in Cervone, the photos of Sara Zehring "while not particularly pleasant" neither are they "particularly gruesome." Gruesome photos show a body or parts of the body dismembered, or blood filled or deformed or contorted or rotting and or disfigured in some viscerally repulsive manner. Sara's body in these photographs has none of those characteristics. Here, as in Cerone, showing the photographs makes the evidence "more intelligible to the jury." on an issue, which Defendant has chosen to make a controversy at trial. The cause of death on Sara Zehring's Death Certificate is "overwhelming sepsis." To reach that determination, the Cumberland County Coroner hired Dr. Barbara Bollinger, a forensic pathologist to perform Sara's autopsy. This was done pursuant to the Coroner's official duties not, for the purpose of litigation. As part of that official process, Dr. Bollinger took pictures of Sara to document the presence of a papular rash which was prominent and wide spread across her body prior to doing the autopsy. The papular rash was a specific finding and factual predicate to Dr. Bollinger's determination that Plaintiffs cause of death was overwhelming sepsis. Defendant, however, has hired his own pathologist to place Dr. Bollinger's findings of sepsis at issue. Additionally, all of the Defense experts assert that sending Sara to the hospital would not have change the outcome of the case. A jury is unlikely to understand what a "papular rash" is. The photos certainly aid in making Dr. Bollinger's testimony about that condition not only "more intelligible," generally, but also show them the precise condition of the person whose cause of death is at issue. Additionally, the presence of a widespread rash as seen on the photographs would have bearing on the interventions and diagnosis Sara would have received, had she been sent to the hospital. Without the photos, a jury, just hearing the words "papular" rash from an expert, will not have any sense of what it looks like or how severe it was in Sara's case. It is both fair and relevant for the jury to see for themselves what this rash looked like in this particular patient on the day that she died. That is simply "factual" evidence upon which a jury can, and should rely, in deciding whether Sara died of sepsis and whether being in the hospital would have made a difference. Where the cause of death was at issue, the Supreme Court found photos of a victim's corpse, which had been beaten, admissible. Commonwealth v. Dickerson, 406 Pa. 102, 176 A.2d 421 (1962). Here the cause of death is also at issue, and civil litigants have none of many evidentiary protections afforded criminal Defendants in a murder trial. Defendant's Brief seems to implicitly acknowledge the relevancy of these photographs as it argues as much to limit what is shown to the jury as vigorously as complete preclusion. Indeed, Defendant's Motion includes "cropped" photographs it suggests be used at trial. Plaintiff does not intend to show all of the pre-autopsy photographs to the jury. Plaintiff will not use the photographs showing tubes or treatment equipment. Plaintiff further agrees that the portions of photographs showing Sara's genitals are unnecessary and should be blocked or cropped. On the other hand, the cropped photographs Defendant offers with its Motion are less intelligible and more confusing than no photographs at all. The Defendant's photos are so close and so limited in view as to be indecipherable. They look as much like a close up of a sweater as they do human being. They provide no perspective as to how widespread or severe the rash was in Sara's case. The purpose of evidence is to make the jury's job easier, not harder. In light of Defendant's objection, Plaintiff proposes, instead, to show one or two photographs showing an overview of Sara from the front and the back, with her genitals blacked out or obscured. Further, Plaintiff's Counsel will show the photographs to the Court and Defense Counsel in advance of the start of trial, to assure nothing beyond the pale is shown to the jury. In sum, Plaintiff submits the photos are relevant and can be handled in a way which does not cross the line. Plaintiff asks that the Court reserve judgment until photographs along the lines described above has been completed and submitted to the Court and Counsel for view. Date: ?j Y Respectfully submitted, SCHMIDT KRAMER PC By: Terry S. Hym squire I.D. No. 36807 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiff CERTIFICATE OF SERVICE AND NOW, this day of 2008, I, Janice S. Harmon *Vmf -1 61 an employee of SCHMIDT KRAMER PC, do hereby certify that I have served a true and correct copy of the PLAINTIFF'S RESPONSE TO DEFENDANT'S MOTION IN LIMINE CONCERNING AUTOPSY PHOTOGRAPHS in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Andrew Foulkrod, Esq. Michael Mongiello, Esq. Foulkrod Ellis P.C. 2010 Market Street Camp Hill, PA 17011 anic(e S. Harmon 0 r? ?F ti r„ a FOULKROD ELLIS P-k4 wal a-A-,&- Andrew H. Foulkrod, Esquire Attorney I.D. 177394 Michael C. Mongiello, Esquire Attorney I.D. 087532 2010 Market Street Attorneys for Defendant: Camp Hill, PA A 1701 17011 Richard N. Blutstein, M.D., Individually 9.7006 Phone. Fax: (717) 909.6955 and Udlb/a Pennsboro Pediatrics LAURA E. HETRICK, Administratrix of the IN THE COURT OF COMMON PLEAS OF Estate of Sara J. Zehring, CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION - LAW V. MEDICAL PROFESSIONAL LIABILITY RICHARD N. BLUTSTEIN, M.D., Individually ACTION and t/d/b/a PENNSBORO PEDIATRICS, Defendants No. 06-4433 JURY TRIAL DEMANDED RESPONSE TO PLAINTIFF'S MOTIONS INLIMINE AND NOW comes Defendant, Richard N. Blutstein, M.D., individually and t/d/b/a Pennsboro Pediatrics, by and through his counsel, Foulkrod Ellis, and responds to Plaintiff s Motions In Limine as follows: PLAINTIFF'S MOTION INLIMINE TO PRECLUDE ALLEGED CUMULATIVE TESTIMONY BY DEFENDANT'S EXPERTS 1. This case involves pulmonary issues (asthma, croup and pneumonia) and infectious disease issues (bacterial infection, use of antibiotics and sepsis) arising out of the care and treatment provided by primary care pediatrician, Dr. Blutstein. 2. Dr. Blutstein therefore intends to present the testimony of four (4) expert witnesses at trial. 3. Specifically, standard of care testimony will be offered by three (3) physicians, all of whom practice in separate and distinct sub-specialties of medicine, each specifically relevant to the factual scenario of this case: pediatric pulmonologist, Jonathan D. Finder, M.D. (see curriculum vitae attached hereto as Exhibit "I"); pediatric infectious disease specialist, Judith M. Martin, M.D. (see curriculum vitae attached hereto as Exhibit "2"); and primary care pediatrician, Timothy F. Doran, M.D. (see curriculum vitae attached hereto as Exhibit "3") 4. Expert causation testimony (and some standard of care testimony to the extent qualified; see §II infra) will be offered by pathologist, Arthur H. McTighe, M.D. 5. While the pre-trial reports of Drs. Finder, Martin and Doran admittedly contain related opinions (see Exhibits "4", "5" and "6" attached hereto respectively), these physicians will each offer importantly different testimony and non-cumulative at trial. See Supporting Brief. WHEREFORE, Defendant, Richard N. Blutstein, M.D., Individually and t/d/b/a Pennsboro Pediatrics, respectfully requests that this Honorable Court deny Plaintiffs Motion In Limine. II. PLAINTIFF'S MOTION IN LIMINE TO PRECLUDE PATHOLOGIST, ARTHUR H. MCTIGHE, M.D. FROM TESTIFYING AS TO STANDARD OF CARE 6. At trial, Dr. Blutstein will present expert testimony of pathologist and microbiologist Arthur H. McTighe, M.D. See Exhibit "7" hereto. 7. In accordance with his pre-trial report, Dr. McTighe will primarily testify on issues of causation in response to testimony from Plaintiff's pathology expert that Sara Zehring would have had an increased chance of survival had she been admitted to the hospital. See Exhibit "7", pp. 2-6. 2 8. Dr. McTighe, however, may also testify regarding standard of care issues (see Exhibit "T at p. 6, last bullet), such as the appropriateness of sending a child home on Zithromax to cover potential bacterial infections, based on his education, training and experience. See Exhibit "8" hereto and Supporting Brief. Respectfully submitted, By: Date: ay , 2008 )0rc 1 Revised October 8. 2007 Name: Jonathan D. Finder BIOGRAPHICAL Home Address: 5541 Beverly Place Pittsburgh, PA 15206 Home Phone: 412-361-3330 Business Address: Division of Pulmonology Children's Hospital of Pittsburgh 3705 Fifth Avenue Pittsburgh, PA 15213 Business Phone: 412-692-5630 Birth Date: December 10, 1960 Birth Place: Kabul, Afghanistan Citizenship: USA Email address: finder@pitt.edu Business fax: 412-692-6645 UNDERGRADUATE: 1978-1982 GRADUATE: 1982-1986 POST-GRADUATE: CURRICULUM VITAE EDUCATION AND TRAINING Yale University BA 1982 Albany Medical College MD 1986 INTERNSHIP AND RESIDENCY: 1986-1989 Pediatrics Massachusetts General Hospital, Boston, MA Program director: Dr. Donald Medearis (deceased) major biology FELLOWSHIP: 1990-1993 Pediatric Pulmonology Massachusetts General Hospital, Boston, MA Program director: Dr. Daniel Shannon 2 APPOINTMENTS AND POSITIONS: July 1989-June 1990 Cambridge Hospital, Cambridge MA Pediatrician September1993- University of Pittsburgh Assistant Professor July 2003- University of Pittsburgh Associate Professor July 2005- February 2007 CHP Pulmonary Function Lab Medical Director February 2007- CHP Pulmonology Division Clinical Director July 2007 - The Children's Home Medical Director CERTIFICATION AND LICENSURE SPECIALTY CERTIFICATION American Board of Pediatrics 1989 (recertified 2006, #042371) American Board of Pediatric Pulmonology 1994 (recertified 2002, #000401) MEDICAL LICENSURE Massachusetts no. 70379 1989-1993 Pennsylvania no. MD 050538-L 1993- Drug Enforcement Agency #BF1785130 1989- MEMBERSHIPS in PROFESSIONAL and SCIENTIFIC SOCIETIES American Association for the Advancement of Science 1991-2004 American Thoracic Society 1991- HONORS Alpha Omega Alpha 1986 R.J. Wharton Prize, Albany Medical College 1986 Kenneth B. Olson Prize, Albany Medical College 1986 Daggett Trust Prize, Albany Medical College 1986 Nominated, Golden Apple Teaching Award, University of Pittsburgh School of Medicine 1996 UPSOM Excellence in Education Award 2000 Outstanding Achievement in Patient Care Award 2003 (Top 25 Overall Quality of Doctor Care CHP) Named to "Best Doctors in America" 2003- Outstanding Achievement in Patient Care Award (Highest Overall Quality of Doctor Care CHP) 2004 & 2007 Named to Academy of Master Educators, University of Pittsburgh 2006 "Top Performer Patient Perception Award" for top 25% 2006 nationally for overall quality of doctor care, pediatrics "Change it" Champion 2007 Parent Project Duchenne MD 2007 3 PUBLICATIONS Refereed articles 1. Kinane TB. Shang C. Finder JD. Ercolani L. CAMP regulates G-protein alpha i-2 subunit gene transcription in polarized LLC-PK1 cells by induction of a CCAAT box nuclear binding factor. J Biol Chem. 268(33):24669-76, 1993 Nov 25. 2. Kinane TB. Finder JD. Kawashima A. Brown D. Abbate M. Shang C. Fredericks WJ. Rauscher FJ 3rd. Sukhatme VP. Ercolani L. Growth of LLC-PK1 renal cells is mediated by EGR-1 up-regulation of G protein alpha i-2 protooncogene transcription. J Biol Chem. 269(44):27503-9, 1994 Nov 4. 3. Finder J. Stark WW Jr. Nakayama DK. Geller D. Wasserloos K. Pitt BR. Davies P. TGF- beta regulates production of NO in pulmonary artery smooth muscle cells by inhibiting expression of NOS. Am J Physiol. 268(5 Pt 1):L862-7, 1995 May. 4. Kinane TB. Finder JD. Kawashima A. Brown D. Abbate M. Shang C. Fredericks WJ. Rauscher FJ 3rd. Sukhatme VP. Ercolani L. Growth of LLC-PK1 renal cells is mediated by EGR-1 up-regulation of G protein alpha i-2 protooncogene transcription. J Biol Chem. 269(44):27503-9, 1994 Nov 4. 5. Wong HR. Finder JD. Wasserloos K. Pitt BR. Expression of NOS in cultured rat pulmonary artery smooth muscle cells is inhibited by the heat shock response. Am J Physiol. 269(6 Pt 1):L843-8, 1995 Dec. 6. Wong HR. Finder JD. Wasserloos K. Lowenstein CJ. Geller DA. Billiar TR. Pitt BR. Davies P. Transcriptional regulation of NOS by IL-1 beta in cultured rat pulmonary artery smooth muscle cells. Am J Physiol. 271(1 Pt 1):L166-71, 1996 Jul. 7. Finder JD. Primary bronchomalacia in infants and children. J Pediatr. 130(1):59-66, 1997. 8. Finder JD. Litz JL. Blaskovich MA. McGuire TF. Qian Y. Hamilton AD. Davies P. Sebti SM. Inhibition of protein geranylgeranylation causes a superinduction of nitric-oxide synthase-2 by interleukin-10 in vascular smooth muscle cells. J Biol Chem. 272(21):13484- 8, 1997 May 23. 9. Gondor M. Michaels MG. Finder JD. Non-aspergillus allergic bronchopulmonary mycosis in a pediatric patient with cystic fibrosis. Pediatrics. 102(6):1480-2, 1998 Dec. 10. Finder JD. Yellon R. Charron M. Successful management of chronic saliva aspiration with tracheal constant positive airway pressure (CPAP). Pediatrics, 2001; 107:1343-1345. 11. Finder JD. Petrus JL. Hamilton A. Villavicencio RT. Pitt BR. Sebti SM. Signal transduction pathways of IL-10-mediated induction of NOS in cultured rat pulmonary vascular smooth muscle cells. Am J Physiol: Lung Cell and Molecular Biology, 2001: 281;1,816-1,823. 12. Reynolds SD, Reynolds PR, Pryhuber GS, Finder JD, Stripp BR. Secretoglobins SCGB3A1 and SCGB3A2 define secretory cell subsets in mouse and human airways. Am J Physiol: Lung Cell and Molecular Biology, 166: 1498-1509, 2002. 4 13. Fridell, JA; Bond, GJ; Mazariegos, GV; Orenstein, DM; Jain, A; Sindhi, R; Finder, JD; Molmenti, E; Reyes, J. Liver transplantation in children with cystic fibrosis: a long-term longitudinal review of a single center's experience. J Pediatr Surg, 38: 1152-1156, 2003. 14. Kaditis, A.G., Finder, J.D., Alexopoulos, E.I., Starantzis, K., Tanou, K., Gampeta, S., Agorogiannis, E., Christodoulou, S., Pantazidou, A., Gourgoulianis, K., Molyvdas, P.A. Sleep-Disordered Breathing in 3680 Greek Children. Pediatr Pulmonol, 37: 499-509, 2004. 15. Finder JD, Birnkrant D, Carl J, Farber HJ, Gozal D, Iannaccone ST, Kovesi T, Kravitz RM, Panitch H, Schramm C, Schroth M, Sharma G, Sievers L, Silvestri JM, Sterni L, American Thoracic Society. Respiratory care of the patient with Duchenne muscular dystrophy: An official ATS consensus statement. Am J Respir Crit Care Med, 170: 456-465, 2004. 16. Mc Allister F, Henry A, Kreindler JL, Dubin PJ , Ulrich L, Steele C, Finder JD, Pilewski JM, Carreno BM, Goldman SJ, Pirhonen J, Kolls J. Role of IL-17A, IL-17F and the IL-17 receptor in regulating Gro-a and G-CSF in Bronchial Epithelium: implications for airway inflammation in cystic fibrosis. J. Immunol., Jul 2005; 175: 404-412. 17. Birnkrant BJ, Panitch, HB, Benditt JO, Boitano LJ, Carter ER, Cwik VA, Finder JD, Iannaccone ST, Jacobson LE, Kohn GL, Motoyama EK, Moxley RT, Schroth, MK, Sharma GD, Sussman MD. American College of Chest Physicians Consensus Statement on the Respiratory and Related Management of Patients with Duchenne Muscular Dystrophy Undergoing Anesthesia or Sedation. Chest, 2007, in press. 18. Flume PA, O'Sullivan BP, Robinson KA, Goss CH, Mogayzel PJ, Willey-Courand DB, Bujan J, Finder J, Lester M, Quittell L, Rosenblatt R, Vender RL, Hazle L, Sabadosa K, and Marshall B. Cystic Fibrosis Pulmonary Guidelines: Chronic Medications for Maintenance of Lung Health. Am J Respir Crit Care Med, in press. Reviews, invited published papers, monographs, editorials, book chapters: 1. Finder J. Noyes BE. Orenstein DM. Pediatric Pulmonary Disorders. In: Atlas of Pediatric Physical Diagnosis, 3rd ed. Mosby: 1997. 2. Orenstein D. Finder J. The Child Who Coughs. Semin Pediatr Infect Dis, 9 (2): 126- 137, 1998. 3. Finder JD. Understanding airway disease in infants. Curr Probl Pediatr. 29(3):65-81, 1999 Mar. 4. Finder J. Pediatric Pulmonary Disorders. In: Atlas of Pediatric Physical Diagnosis, 4th ed. Mosby: 2002. 5. Finder J. Non-infectious disorders of the lower respiratory tract. In: Pediatric Otolaryngology, Bluestone, et al, ed. 4th ed. Saunders, 2003. 6. Finder J. Atelectasis. In: UptoDate, Rose, BD (Ed), UptoDate, Wellesley, MA, 2007 7. Green, T and Finder, J. Congenital disorders of the lung. In: Nelson Textbook of Pediatrics, 17th ed. WB Saunders, Philadelphia, 2003 5 8. Finder, JD. "Respiratory management of Duchenne muscular dystrophy" in "Giving a Face to Duchenne MD" a DVD produced and distributed by Parent Project MD, Cincinnati, OH, 2003 9. Finder, JD. "Respiratory Management of the Patient with Neuromuscular Disease: the (not so) New Paradigm." RT The Journal for Respiratory Care Practitioners. July, 2004, p. 37-38. 10. Finder, JD. "'Treating' the Common Cold in Pediatric Patients: The Doctor's Dilemma." Clinical Views, Fall 2004. 11. Finder, JD. "Airway Clearance in Cystic Fibrosis." RT The Journal for Respiratory Care Practitioners. January, 2005. 12. Finder, JD. "In Support of PFT's."[editorial] RT The Journal for Respiratory Care Practitioners. February, 2005. 13. Finder, JD. "Airway Clearance in the Intensive Care Unit." RT The Journal for Respiratory Care Practitioners. March, 2005. 14. Finder, JD. "Passive Smoking" Clinical Views, Spring 2005 15. Finder, JD and Michelson P. Congenital disorders of the lung. In: Nelson Textbook of Pediatrics, 18th ed. WB Saunders, Philadelphia, 2007 (in press) 16. Finder, JD. Tracheomalacia and Bronchomalacia. In: Nelson Textbook of Pediatrics, 18th ed. WB Saunders, Philadelphia, 2007 (in press). 17. Finder, JD. "Airway clearance in pediatric patients." RT The Journal for Respiratory Care Practitioners. January, 2006 18. Finder, JD. Pulmonary Disorders. In: Atlas of Pediatric Physical Diagnosis, 5th ed. Basil Zitelli and Holly Davis, editors, Mosby, Philadelphia, 2007, in press. 19. Finder, JD. "Review of Airway Clearance Technologies." RT The Journal for Respiratory Care Practitioners. July, 2006 20. Finder, JD. "Airway Clearance in Cystic Fibrosis: Overcoming Barriers to Adherence." Advance for Managers of Respiratory Care, 2006, December, page 75 21. Finder, JD. "Silent Reflux: the Missing Piece of the Puzzle in Pediatric Asthma?" RT The Journal for Respiratory Care Practitioners. January, 2007 22. Finder, JD. "Airway Clearance." RT The Journal for Respiratory Care Practitioners. November, 2007 Published Abstracts: 1. Finder J. Self resolving insulin-dependent diabetes in an adult with cystic fibrosis and severe wasting. Cystic Fibrosis Foundation, 1992. 6 2. Kinane TB. Finder J. Ercolani L. cAMP increases G-protein cd-1 subunit gene transcription in epithelial cells.. American Thoracic Society, 1992. 3. Kinane TB. Finder J. Ercolani L. Hormonal regulation of porcine Gai 2 and ai-3 genes in renal cells. Massachusetts General Hospital Research Symposium. 1992. 4. Kinane TB. Finder J. Shang C. Ercolani L. Cell growth is mediated by Egr-1 activation of the GIi-2 protooncogene in epithelial cells. American Thoracic Society, 1993. 5. Finder J. Nakayama D. Davies P. TGF-R1 completely suppresses expression of inducible nitric oxide synthase protein in rat pulmonary artery smooth muscle cells. American Thoracic Society, 1994. 6. Reyes J. Jabbourt N. Ohya T. Finder J. Kocoshis S. Fung J. Starzl T. Liver transplantation In children with cirrhosis And hepatopulmonary syndrome. Annual Meeting of the North American Society For Pediatric Gastroenterology and Nutrition, 1995. 7. Finder J. Wasserloos K. Davies P. NF-ElB can be demonstrated in nuclear extracts of rat pulmonary smooth muscle cells following stimulation with IL1-0 American Thoracic Society, 1995. 8. Gaston B. Brown R. Haver K. Finder J. Cooper D. Robinson W. Pediatric flexible bronchoscopy: intubation and morbidity. American Thoracic Society, 1995. 9. Finder J. Sebti S. Hamilton A. Litz J. Davies P. Inhibition of ras farnesylation reduces I1-1 R- stimulated iNOS in pulmonary artery smooth muscle cells(PASMC) American Thoracic Society, 1996. 10. Finder J. Litz J. Pitt BR. Sebti S. Inhibition of protein geranylgeranylation causes a superinduction of nitric oxide synthase by IL-10 in vascular smooth muscle cells. American Thoracic Society, 1997. 11. Molmenti EP. Finder J. Orenstein DM. Mazariegos GV. Fung JJ. Reyes J. University of Pittsburgh experience in orthotopic liver transplantation (OLT) for end-stage liver disease secondary to cystic fibrosis. Third International Congress on Pediatric Transplantation, 1998. 12. Finder J. Walczak SA. Respiratory impedance plethysmography (RIP) as a means of diagnosing dynamic collapse of the intrathoracic upper airway. American Thoracic Society, 1998. 13. Finder JD. Petrus JD. Villavicencio RT. Watkins S. Pitt BR. Dual signaling pathways for IL- 1 induced nitric oxide synthase. American Thoracic Society, 1999. 14. Bond GJ. Molmenti E. Finder J. Mazariagos GM. Sindhi R. Orenstein DM. Reyes J. Liver transplantation in cystic fibrosis. American Society of Transplant Physicians, 1999. 15. Finder JD. Petrus JL. Villavicencio RT. Pitt BR. The role of small G-proteins in the signal transduction of IL-1 [i-mediated inducible nitric oxide synthase (iNOS). American Thoracic Society, 2000 16. Finder JD, Engman, CL, Reynolds, SD, Stripp, B.R. Clara Cell Secretory Protein in Cystic Fibrosis Bronchoalveolar Lavage Fluid. North American Cystic Fibrosis Conference, 2003 (appears in: Pediatric Pulmonology, Supplement 25, 2003, p 238). 17. Finder, JD, Engman, CL, Tyurina, Y, Kagan K. Bronchoalveolar Lavage Fluid from Patients with Cystic Fibrosis Have Diminished Levels of Reduced Glutathione. North American Cystic Fibrosis Conference, 2003 (appears in: Pediatric Pulmonology, Supplement 25, 2003, p 238). OTHER PUBLICATIONS 1. Finder, JD and Steinfeld, J. Congenital Pulmonary Lymphangiectasis. New England Journal of Medicine, 350: 948, 2004 (Letter to the Editor) 2. Finder, JD. "Clear the Air at Our Zoo." Pittsburgh Post Gazette, April 20, 2005 [editorial] 7 PROFESSIONAL ACTIVITIES TEACHING UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE: Course Director Pulmonary elective, 4th year medical student elective `97-`present Community Ambulatory Care Clerkship: Pediatric pulmonology 3td year selective Integrated Life Sciences course creator/director "Molecular Medicine" Nov. `98, 99, '00, `01, '02, '03, '04, '05, `06 Problem-based learning /small group teaching Instructor Integrated Case Studies (April 10, 11, 12, 17, 18, 19, 24, 25, 26, May 1, 2, 3, 2000) Instructor (and co-designer) Ambulatory Care Clerkship Respiratory Illness course. 1999,2000 (lecture + PBL groups) taught 9/13/99, 12/6/99, 3/6/00, 5/30/00. PBL group leader 3/03. Instructor, University of Pittsburgh Pediatric Physical Diagnosis course, 1996, 1998, 2000, 2003, 2006 Instructor, University of Pittsburgh School of Medicine, "Structure, Function, and Development of Specialized Tissue" course (Tissue Fibrosis PBL), January 22/28 1998, January 21/27 1999, and January 20/26, 2000, January 2001. Instructor, University of Pittsburgh School of Medicine, Lung Block, (problem-based learning small group), 1998-2006 (7 2-hour sessions) Instructor, University of Pittsburgh Host Defenses course, Dept. Pharmacology, March 1997, 1998, 1999, 2000 Instructor, University of Pittsburgh "Introduction to becoming a physician course" 1994, 1995, 1996, 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2005, 2006, 2007 Medical School didactic lectures "Understanding respiratory disease in children" Medical school lecture. Given to every third year student group rotating through CHP July 1995-June 2006 (appr 10/year, or-110 lectures 7/96-6/2006). "Medicine: Where have we been and where are we going" Introduction to being a physician course, 1998, 1999, 2000, 2001, 2002, 2003, 2005, 2006, 2007 "Cystic Fibrosis from Benchside to Bedside" Introduction to being a physician course, August 24, 2005. Pulmonary Physiology Lectures (2): Lung Block 2"d yr course Oct. `98, Oct. '99, Oct. '00, Oct. '01, Oct. '02. Oct '03, Oct '04, Oct 105 Ambulatory medicine lecture "Wheezing in infants and children" 3/1/04, 5/22/06 "Molecular aspects of Cystic Fibrosis" for 4th year students in Molecular Medicine ILS, November 2002, 2003, 2004, 2005 "Lessons learned from being a patient" given to University of Pittsburgh School of Medicine Humanism Honor Society, May 12, 2006. "Cystic Fibrosis Molecular Biology Update" November 7, 2006 - given to Molecular Medicine ILS, 4th year students "Forensic use of DNA/Case studies" November 16, 2006 - given to Molecular Medicine ILS, 4th year students "Dealing with Difficult Patients" May 9, 2007. Given to 41h years medical students in the "Becoming a Resident' 'course Graduate School didactic lectures 8 "Cystic Fibrosis" Given to Human Genetics graduate students 2000, 2001, 2002, 2003, 2004, 2005, 2006 "Cystic Fibrosis" Given to Genetic Counseling graduate students, March 2005, February 2006 "Newborn screening in CF" Given to Genetic Counseling graduate students, January 12. 2006 "Abnormal exercise test in a girl referred for exercise induced asthma" Given to Genetic Counseling graduate students, September, 2006 Children's Hospital of Pittsburgh Teaching Activities: Housestaff/Fellow conferences "Lung volumes" Pulmonary fellows conference July 21, 1995. "Diffusion"." Pulmonary fellows conference August 18, 1995. "Matching of ventilation and perfusion." Pulmonary fellows conference, August 25, 1995, November 1996 "Sleep studies." Pulmonary fellows conference, October 13, 1995. "Ventilation and Mechanics Part 1." Pulmonary fellows conference July 28, 1995, Sept. 96 "Ventilation and Mechanics Part 2." Pulmonary fellows conference Aug. 4, 1995, Sept 96 "Pulmonary mechanics." Pulmonary fellows conference 95,96,97 "Oxygen exchange in the periphery." Pulmonary fellows conference, 95,96,97 "Pulmonary function testing," Mercy Hospital outpatient conference, June 13, 1996 "Pulmonary function testing," Adolescent medicine conference, CHP July 1996 "Apnea and Sleep Studies." Department of Otolaryngology, CHP Sept. 1996 "Apnea and Sleep Studies" CHP house staff lecture, Dec. 1996 "Pediatric lung disease" Anesthesia fellows conference, CHP, 3/5/97, 4/22/98, 3/8/99 "Understanding PFT's" House staff lecture, CHP, 10/22/97 "Apnea, sleep Studies, and home monitors" House staff/medical student talk CHP, 1/23/97 "Apnea, SIDS, and monitors, 1999" 7/7/99 "Respiratory care of Duchenne muscular dystrophy patients" 7/9/99 "Pulmonary function testing" CHP 7/12/99 "Chest Physical exam part 2/ chest rounds" 7/16/99 "Understanding the chest physical exam" 7/14/99 "Asthma" CHP 7/19/99 (part 1), 7/21/99 (part 2) "Common Respiratory Problems" 1/31/00. Pediatric anesthesia fellowship lecture. "Airway disease in pediatrics" 9/25/02 Pediatric anesthesia lecture. "Understanding airway disease in infants" January 29, 2003 "The Hateful Patient" January 27, 2003 "Exercise testing" January 22, 2003 "SIDS and the `Apnea Hypothesis "'January 20, 2003 "Sleep studies" November 11, 2003; March 16, 2004 "Apnea and home monitors" January 26, 2005 (Pediatric house staff) "Pulmonary function testing" August 31, 2005 (Pediatric house staff) "Pulmonary function testing" April 27, 2006 (Allergy-Immunology fellows and faculty) "Induction Oscillometry testing" May 11, 2006 (Allergy-Immunology fellows and faculty) "Non-asthmatic causes of wheezing" August 29, 2006 (Allergy-Immunology-Pulmonology) 9 Children's Hospital of Pittsburgh Invited Symposia "Not everything that wheezes is asthma. "Allergy-Pulmonology conference, Nov. 1996 "Primary bronchomalacia," Allergy-Pulmonary Conference, May 4, 1996 "Asthma and the school athlete: competitive and non-competitive" Children's Hospital of Pittsburgh outreach education program "Managing Allergy and Asthma in School Children" June 20, 1996. "Pneumograms and home monitors" Three Rivers Clinical Pediatric Update, June 5, 1997 "Noisy Breathing" Three Rivers Clinical Pediatric Update, May 20, 2006 Other Teaching Activities: Grand Rounds "Respiratory management of patients with neuromuscular weakness." Mater Children's Hospital, Bribane, Australia, October 26, 2006 "Respiratory management of patients with neuromuscular weakness." University of Queensland, Brisbane, Australia, October 27, 2006 "An inpatient experience with pain: a cautionary tale." UPMC Department of Anesthesiology, March 9, 2006. "Respiratory management of the child with special needs" The Children's Institute, Pittsburgh, PA February 8, 2006 "SIDS, The Apnea Hypothesis, and Home Monitoring: A Cautionary Tale" UPMC Sleep Medicine, January 12, 2006 "Respiratory management of the neuromuscularly weak patient" Hershey Medical Center. November 2, 2004 "Respiratory management of the neuromuscularly weak patient' 'West Virginia University Dept. of Anesthesiology. June 23, 2004 "Management of challenging pediatric asthma" Indiana Regional Medical Center. May 19, 2004. "Barium Swallow, Salivagram, or Milk Scan? Evaluation and Management of the Child with Possible Aspiration" Children's Hospital of Pittsburgh, March 9, 2000 "Understanding Airway Disease in Infants" Depts Anesthesia and Pediatrics, West Virginia University Robert C. Byrd Health Sciences Center, February 8, 1999. "SIDS, Apnea, and home monitoring: what have we learned?" Children's Hospital of Pittsburgh Grand Rounds, August 24, 1998. "Advances in diagnosis and treatment of pediatric airway disease" Massachusetts General Hospital April 7 1998. "Bronchomalacia: a common disorder" December 18, 1997, Armstrong Memorial County Hospital "Bronchomalacia: a common disorder" University of Hong Kong/Queen Mary Hospital Department of Pediatrics Grand Rounds, April 10, 1997 "Bronchomalacia: a common disorder" Children's Hospital of Pittsburgh Grand Rounds, March 6, 1997 "Primary bronchomalacia," Mercy Hospital Pediatric Grand Rounds, June 11, 1996 "Not everything that wheezes is asthma" Ellis Hospital, Schenectady, NY, June 1993 Community Lectures 10 "Not everything that wheezes is asthma" Pennsylvania Society for Respiratory Care, September 2000. "Asthma: a pulmonologist's perspective" given to the Alma Illery Health Center February 15, 2001 "Asthma: Pitfalls and Pratfalls in diagnosis and management" given to Breck, Wolfson pediatric practice, Pittsburgh PA, June 4, 2001 "Difficult asthma cases" given to Pediatric Alliance, October 29, 2003. "Respiratory care of the special needs child" given to Achieva (formerly: Allegheny Association of Retarded Citizens) November 12, 2003, June 2005 "Respiratory care of the patients with neurologic and neuromuscular disease" given to Gateway Health Plan medical directors and case managers January 10, 2006. "Respiratory management of children with special needs." Given to parents at The Children's Institute, Pittsburgh, PA April 27, 2006. "Respiratory management of children with neurologic and neuromuscular disease." Given to staff at The Western Pennsylvania School for the Blind, Pittsburgh, PA May 10, 2006 "Respiratory management of children with neurologic and neuromuscular disease." Given to staff at Maguire Home, New Brighton, PA November 7, 2006 GRANTS RECEIVED 2002-2003 G-proteins and particulate-induced airway inflammation. CHP Research advisory committee grant. $30,000. 1996-2001 NIH K08 grant HL03578, $412,000. Ras-CAAX peptidomimetics and pulmonary inflammation. 1993-1996 Child Health Research Center grant: Molecular mechanisms of disease in childhood. $90,000. Farnesylation of p21 Ras and other small G-proteins and IL- 1 signal transduction.. 1994-1995 University of Pittsburgh New Faculty Start-up grant. $60,000. NF-iiB and iNOS expression in pulmonary artery. 1992-1993 NIH NRSA fellowship number 1 F32 DK08838-01. $30,000. Role of EGR1 and WTI in G protein ? i 2 transcription. CLINICAL RESEARCH Site principal investigator, "A multicenter, randomized, placebo controlled, double-blinded trial of azithromycin in patients with CF chronically infected with pseudomonas aeruginosa (Lisa Saiman, MD and Bruce Marshall, MD, Co-PI's). 2000-2001. Site principal investigator, "BIIL 284 in cystic fibrosis." A Cystic Fibrosis Foundation Therapeutic Development Network study funded by Boeringer-Ingleheim. (Principal investigator, Michael Konstan). 2003-2004 Principal investigator: "Biomarkers of lung disease in bronchoalveolar lavage fluid" Funded by CHP internal funds, 70020-047137-8612, 2005- Co-investigator: "PITT 0503: Clinical Trial of Coenzyme Q 10 and Prednisone in Duchenne Muscular Dystrophy" (PI: Dr. Paula Clemens) SERVICE 11 1. University of Pittsburgh School of Medicine University of Pittsburgh Institutional Review Board (IRB) 2004 - Search committee, University of Pittsburgh School of Medicine for Department of Pediatrics Chair, 1999-2000. Dean's Admissions interviewing committee, University of Pittsburgh School of Medicine, 1996- 2005 Faculty adviser, University of Pittsburgh School of Medicine, 1995-present Curriculum committee, Children's Hospital of Pittsburgh Pediatric Physical Diagnosis course 2004 Grant reviewer, Children's Hospital of Pittsburgh Child Health Research Center 2. Hospital activities Children's Hospital of Pittsburgh GCRC Advisory Committee, 2002-2004 Children's Hospital of Pittsburgh Pharmacy and Therapeutics committee member, 2000- Children's Hospital of Pittsburgh Foundation: Co-director medical staff giving campaign, 2001- 3. Community Activities Board member and medical director, Wings for Children, 2001-2006 Advisor to Board, Parent Project Muscular Dystrophy, 2000- 4. Peer Review: American Journal of Respiratory Cell and Molecular Biology American Journal of Respiratory and Critical Care Medicine American Journal of Physiology (Lung) Anesthesia and Analgesia Chest European Respiratory Journal Journal of Clinical Investigation Journal of Pharmacology and Experimental Therapeutics The Journal of Respiratory Diseases Pediatric Research Annals of Otology, Rhinology, & Laryngology American Journal of Rhinology American Journal of Hematology Pediatric Pulmonology Editorial Advisory Board member, RT magazine, 2004- 5. National Organizations: Leadership and Participation 12 Chair, Consensus committee on the Respiratory Care of the Muscular Dystrophy Patient. American Thoracic Society, 2001-2004 Pulmonary Subcommittee, Muscular Dystrophy Association, 2005- American Thoracic Society, Pediatric section, Nominating committee, 2004-6 American Thoracic Society, Pediatric planning committee, 2007- Centers for Disease Control, Duchenne Muscular Dystrophy Care Considerations Steering Committee, 2005-2007 Cystic Fibrosis Foundation, Clinical Practice Guidelines Pulmonary Subcommittee, 2006- SMA Standards of Care Committee, Stanford University, 2006 Centers for Disease Control/Muscular Dystrophy Association, Duchenne Dystrophy Respiratory considerations expert panel PARTICIPANT BY INVITATION IN NATIONAL MEETINGS: Invited research presentations: National Institutes of Health Child Health Research Centers Annual Meeting: Galena, IL. October 1994. National Institutes of Health Child Health Research Centers Annual Meeting: Traverse City, MI. October 1995. Pulmonary research conference, Presbyterian University Hospital. "Inducible nitric oxide synthase expression and farnesyl transferase inhibition." November 2, 1995. "Signal transduction of IL-I P mediated nitric oxide synthase" CHP research conference, July 12, 2001 LECTURES AT NATIONAL/INTERNATIONAL MEETINGS Invited case discussant, "Pediatric Chest Rounds," American Thoracic Society, 1997 Parent Project Muscular Dystrophy: "Respiratory management of Duchenne MD" lecture given in July of 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007. Muscular Dystrophy Association, clinical trials development meeting, Tucson, AZ, June 2004 Centers for Disease Control, Becker/Duchenne Muscular Dystrophy Planning Workgroup, February 1, 2005. "Challenges in the respiratory management of the neuromuscularly weak patient" American Thoracic Society, May 20, 2005. (I was co-chairman of this symposium). Parent Project Muscular Dystrophy of Italy: "A respiratory consensus statement for Duchenne MD" June 11, 2005, Rome, Italy. 13 Muscular Dystrophy Association: "Challenges in Drug Development for Muscle Disease: A Stakeholders' Meeting: Pulmonary Endpoints" August 4-5, 2005, Bethesda, MD. American Academy for Cerebral Palsy and Developmental Medicine, September 14, 2005: "Respiratory care of the patient with neuromuscular weakness." Muscular Dystrophy Association: Pulmonary Subcommittee Meeting, Chicago, September 20, 2005. American College of Chest Physicians: "Respiratory care of the patient with neuromuscular weakness." Montreal, Canada. November 1, 2005. Gillette Children's Hospital, Paul and Sheila Wellstone Muscular Dystrophy Center Conference on Cardiopulmonary Management of Neuromuscular Disease: "Respiratory management of the patient with Duchenne MD" November 11, 2005. "Lessons Learned from the Duchenne Respiratory Care consensus." Stanford University, SMA Standards of Care Conference, May 5, 2006. "Respiratory management of patients with neuromuscular weakness." Given to Annual meeting of Parent Project Australia, Brisbane, Australia, October 28, 2006. "Respiratory Issues in Spinal Muscular Atrophy." Given to Annual meeting of Parent Project Australia, Brisbane, Australia, October 28, 2006. "Assisting cough." Given to Annual meeting of Parent Project Australia, Brisbane, Australia, October 27, 2006. "Respiratory management of patients with neuromuscular weakness." Given to Annual meeting of Muscular Dystrophy Association, Australia, Perth, Australia, April 14, 2007. "Respiratory Issues in Spinal Muscular Atrophy." Given to Annual meeting of Muscular Dystrophy Association, Australia, Perth, Australia, April 14, 2007. ass ? JUDITH M. MARTIN, MD Home Address Business Address 19 Arbor Court Children's Hospital of Pittsburgh Irwin, PA 15642 Division of Infectious Disease 3705 Fifth Avenue; 415205 Judy.Martin@chp.edu Pittsburgh, PA 15213 (412) 692-7438 FACULTY POSITION July 2006 to present Associate Professor of Pediatrics, Division of Infectious Diseases, Children's Hospital of Pittsburgh July 1999 to June 2006 Assistant Professor of Pediatrics, Division of Allergy, Immunology and Infectious Diseases, Children's Hospital of Pittsburgh July 1998 to June 1999 Instructor, Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Pittsburgh University of Pittsburgh School of Medicine RESIDENCY AND FELLOWSHIP TRAINING July 1995 to July 1998 Pediatric Infectious Disease Fellowship, Director: Ellen R. Wald, MD, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania. July 1994 to June 1995 Pediatric Chief Resident, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania. July 1991 to June 1994 Pediatric Resident, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania. EDUCATION August 2001 to July 2002 Clinical Research Training Program, University of Pittsburgh School of Medicine and the Graduate School of Public Health Degree received: Certificate in Clinical Research August 1987 to May 1991 Mount Sinai School of Medicine, New York, New York. Degree received: Doctor of Medicine. August 1983 to May 1987 University of Pennsylvania, Philadelphia, Pennsylvania. Degree received: Bachelor of Arts, Dual Majors: Philosophy of Science and Biological Basis of Behavior, Minor: Chemistry. HONORS AND AWARDS Michael Miller Young Investigators Award 2002- Children's Hospital of Pittsburgh Research Advisory Committee Chief Pediatric Resident - Children's Hospital of Pittsburgh Judith M. Martin, MD Revised: October 2006 Page 2 Alpha Omega Alpha Medical Honor Society University of Pennsylvania - Dean's List 1984 to 1987, graduated Cum Laude SOCIETIES AND MEMBERSHIPS The Society for Pediatric Research - 2004 to present The Lancefield Society - 1998 to present Infectious Disease Society of America - 1995 to present Pediatric Infectious Disease Society - 1995 to present American Academy of Pediatrics - 1991 to present Alpha Omega Alpha Medical Honor Society - 1994 to present CERTIFICATIONS AND LICENSURE American Board of Pediatrics - Board Certified in Pediatric Infectious Diseases-2001 American Board of Pediatrics - Board Certified in Pediatrics -1995, renewed 2002 Drug Enforcement Administration (DEA) license Pennsylvania MD license National Board of Medical Examiners - Parts 1, 11 and III Pediatric Advanced Life Support (PALS) Advanced Trauma Life Support (ATLS) Basic Life Support (BLS) HOSPITAL COMMITTEES Research Advisory Committee of the Children's Hospital of Pittsburgh - March 2006 to present General Clinical Research Center Advisory Committee - September 2005 to present Infection Control Committee - July 1995 to present Library Committee - July 1994 to June 1995 Executive Committee - July 1994 to June 1995 Pediatric Residency Selection Committee - July 1994 to June 1995 TEACHING General Pediatric Inpatient Ward Rotator Attending - 2004 to present Pediatric Resident Scholarly Projects -1997 to present Pediatric Resident Teaching Conferences -1994 to present Infectious Disease Fellow Teaching Conference - 2002 to present Infectious Disease Attending Inpatient Service -1998 to present Infectious Disease Case Conferences - 1995 to present Infectious Disease Journal Club - 1995 to present Infectious Disease Grand Rounds - 1995 to present First year medical students - Host Defenses Course 2001 to present Second year medical students Integrated Cases and Physical Diagnosis course-1995 to present Pediatric Advanced Life Support - 1994 to present Pediatric resident teaching conferences - 1994 to present Third year medical student teaching conferences - 1994 to present Children's Hospital of Pittsburgh Pediatric Grand Rounds - June 1994, June 2000 1995 Update on Emergency Pediatrics - April 1995 Judith M. Martin, MD Revised. October 2006 Page 3 PERSONAL Birthdate - May 20, 1965 Place of birth - Camp Hill, Pennsylvania Social Security Number 161-62-4734 Spouse - Joseph L. Lipinski PUBLICATIONS Refereed Publications 1. Martin JIM, Prystowsky MB, Angeletti RH. Preproenkephalin mRNA in T-cells, macrophages and mast cells. Journal of Neuroscience Research 1987;18:82-87. 2. Martin JM, Sacks HS. Do HIV-infected children in foster care have access to clinical trials of new treatments? AIDS and Public Policy Journal 1990;5:3-8. 3. Trager JDK, Martin JM, Barbadora K, Green M, Wald ER. Probable community acquisition of Group B streptococcus in an infant with late-onset disease: Demonstration using pulsed-field gel electrophoresis. Arch Pediatr Adolesc Med 1996;150:766-768. 4. Martin JM, Neches WH, Wald ER. Infective endocarditis: Thirty-five years' experience at a children's hospital. Clin Infect Dis 1997;24:669-675. 5. Martin JM, Wald ER, Green M. Field inversion gel electrophoresis as a typing system for group A streptococcus. J Infect Dis 1998;177:504-507. 6. Martin JIM. Evaluating Sore Throats in Children: The diagnosis and management of streptococcal pharyngitis. J Clin Outcomes Manag 1998;5:70-81. 7. Martin JM, Pitetti R, Maffei F, Tritt J, Smail K, Wald ER. Treatment of shigellosis with cefixime: two days vs. five days. Pediatr Infect Dis J 2000; 19:522-26. 8. Martin JM, Green M, Barbadora KA, Wald ER. Erythromycin resistant Group A streptococci in schoolchildren in Pittsburgh. N Engl J Med 2002;346:1200-1206. 9. Martin JM, Barbadora KA, Wald ER, Green M. Classification of M Nontypeable Group A Streptococcus with the Use of Field Inversion Gel Electrophoresis. Pediatr Pathol Mol Med 2003; 22:303-309. 10. Banks DJ, Porcella SF, Barbian K, Martin JM, Musser JM. Structure and distribution of an unusual chimeric genetic element encoding macrolide resistance in phylogenetically diverse clones of Group A Streptococcus. J Infect Dis 2003;188:1899-1909. 11. Green M, Martin JM, Barbadora KA, Beall B, Wald ER. Reemergence of macrolide resistance in pharyngeal isolates of Group A Streptococci in Southwestern Pennsylvania. Antimicrob Agents Chemother 2004;48:473-476. 12. Banks DJ, Porcella SF, Barbian KD, Beres SB, Philips LE, Voyich JM, DeLeo FR, Martin JM, Somerville GA, Musser JM. Progress towards characterization of the Group A Streptococcus metagenome: Complete genome sequence of a macrolide-resistant serotype M6 strain. J Infect Dis 2004; 190:727-738. 13. Martin JIM, Green M, Barbadora KA, Wald ER. Group A streptococci among school-age children: Clinical characteristics and the carrier state. Pediatrics 2004;114: 1212-1219. 14. Orscheln RC, Johnson DR, Olson SM, Presti RM, Martin JIM, Kaplan EL, Storch GA. Intrinsic reduced susceptibility of serotype 6 Streptococcus pyogenes to fluoroquinolone antibiotics. J Infect Dis 2005;191:1272-1279. Judith M. Martin, MD Revised. October 2006 Page 4 15. Green M, Allen C, Bradley J, Dashefsky B, Gilsdorf JR, Marcon MJ, Schutze GE, Smith C, Walter E, Martin JM, Edwards KA, Barbadora KA, Rumbaugh RM, Wald ER. In vitro activity of telithromycin in macrolide-susceptible and macrolide-resistant pharyngeal isolates of Group A Streptococci in the United States. Antimicrob Agents Chemother 2005; 49;2487-2489. 16. Green MD, Beall B, Marcon MJ, Allen CH, Bradley JS, Dashefsky B, Gilsdorf JR, Schutze GE, Smith C, Walter EB, Martin JM, Edwards KM, Barbadora KA, Wald ER. Multicentre surveillance of the prevalence and molecular epidemiology of macrolide resistance among pharyngeal isolates of group A streptococci in the USA. J Antimicrob Chemother. 2006 Jun;57(6):1240-3. 17. Martin JM, Barbadora KA. Continued high caseload of rheumatic fever in western Pennsylvania: Possible rheumatogenic emm types of Streptococcus pyogenes J Pediatr. 2006 Jul; 149(l):58-63. Abstracts 1. Martin JIM, Wald ER. Infective endocarditis: Thirty-five years' experience at a major children's hospital. Pediatric Research 1995;37:183A.Abstract 1081. 2. Hoberman A, Hickey R, Wald E, Reynolds E, Charron M, Scherzer DJ, Martin JM. Pyuria as a marker of infection vs. colonization of the urinary tract in febrile children 1-24 months. Pediatric Research 1995;37:139A.Abstract 816. 3. Martin JIM, Barbadora KA, Wald ER, Facklam RR, Green MD. Ongoing experience with field inversion gel electrophoresis (FIGE) as a typing system for group A streptococcus. Pediatric Research 1996;39:179A.Abstract 1058. 4. Martin JM, Wald ER, Webber SA, Michaels MG. Recurrent Streptococcus pneumoniae bacteremia in pediatric thoracic organ transplant recipients. Abstract submitted for the 1997 meeting, The American Society of Transplant Physicians. 5. Martin JIM, Pitetti R, Maffei F, Tritt J, Smail K, Wald ER. Treatment of shigellosis with cefixime: Two days vs five days. Pediatric Research 1997;41:126A. Abstract 740. 6. Makoroff KL, Martin JM, Wald ER. Cerebrospinal fluid cell (CSF) counts in infants < 60 days of age. Pediatric Research 1997;41:223A.Abstract 1325. 7. Martin JIM, Barbadora KA, Wald ER, Facklam RR, Green M. The use of field inversion gel electrophoresis to classify M nontypeable group A streptococcus. Abstract accepted to the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, Canada, September 1997. 8. Green M, Barbadora K, Martin J, Wald ER. Analysis of penicillin-resistant Streptococcus pneumoniae from a single center with field inversion gel electrophoresis. Abstract accepted to the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, Canada, September 1997. 9. Martin JIM, Burckart GJ, Howrie D, Wald ER. The pharmacokinetics of oral ganciclovir in pediatric patients with cytomegalovirus infections. Clin Infect Dis 1997;25:487, Abstract 714. 10. Michaels, MG, Estabrook M, Barrocas J, Green M, Martin JM, Wald E. Evaluation of triple drug combination therapy in children infected with human immunodeficiency virus. Abstract accepted to the 36th Annual Meeting of the Infectious Disease Society of America, November 1998.. Clin Infect Dis 1998;27:1003, Abstract 433. 11. Green M, Martin JM, Farley A, Barbadora K, Wald ER. Simultaneous spread of different clones of vancomycin-resistant Enterococcus faecium (VREF) in a Children's hospital. Judith M. Martin, MD Revised: October 2006 Page 5 Abstract accepted to the 36th Annual Meeting of the Infectious Disease Society of America, November 1998. Clin Infect Dis 1998;27:1035, Abstract 603. 12. Martin JM, Green M, Barbadora KA, Lucca KL, Evangelista TR, Wald ER. High frequency of subclinical Group A Streptococcal infections in children. Abstract accepted to the 37 h Annual Meeting of the Infectious Disease Society of America, November 1999. Clin Infect Dis 1999;29:984, Abstract 126. 13. Martin JM, Green M, Barbadora KA, Lucca KL, Evangelista TR, Wald ER. High frequency of Group A Streptococcal infections in children in a school setting - an update. Abstract accepted to the 38`h Annual Meeting of the Infectious Disease Society of America, September 2000, New Orleans, LA, Clin Infect Dis 2000:31;233, Abstract 116. 14. Martin JIM, Wald ER, Barbadora KA and Green M. High frequency of erythromycin resistance in pharyngeal Group A Streptococcal isolates in children in a school setting. Abstract accepted to the Interscience Conference on Antimicrobial Agents and Chemotherapy December 2001, Chicago, IL. 15. Green M, Wald ER, Barbadora K, Martin J. Surveillance for macrolide resistance in pharyngeal isolates of Group A Streptococci: One year follow-up to outbreak in southwestern Pennsylvania. Abstract submitted to Infectious Disease Society of America Annual Meeting, October 2002, Chicago, IL. 16. Orscheln RC, Johnson DR, Olson SM, Presti RM, Martin JM, Kaplan EL, Storch GA. Streptococcus pyogenes of Miemm type 6 possesses natural resistance to fluoroquinolones. Abstract submitted to National Foundation for Infectious Diseases, June 2004 Annual Conference on Antimicrobial Resistance. 17. Green M, Allen C, Beall B, Bradley J, Dashefsky B, Gilsdorf JR, Marcon MJ, Schutze GE, Smith C, Walter E, Martin JIM, Barbadora K, Wald ER. Molecular Epidemiology of Macrolide Resistant (MR) Group A Streptococci (GAS) in the US: Results of Multicenter Surveillance (2002-2003). The 42nd Annual Meeting of IDSA, Boston, MA. September 30 - October 3, 2004. Abst# 343. 18. Green M, Allen C, Beall B, Bradley J, Dashefsky B, Gilsdorf JR, Marcon MJ, Schutze GE, Smith C, Walter E, Martin JM, Barbadora K, Rumbaugh R, Wald ER. Macrolide Resistance Among Pharyngeal Isolates of Group A Streptococci (GAS) in the USA: Multicenter Surveillance Study Year 2 (2003-2004). The 42nd Annual Meeting of IDSA, Boston, MA. September 30 - October 3, 2004. Abst# 344. 19. Keough WL, Turkson N, Martin JM, Green MD, Buchanan J, Nizet V, Mietzner TA. MefA Mediated Macrolide Resistance (MR) in Clonal Group A Streptococcus (GAS) Isolates. The 42nd Annual Meeting of IDSA, Boston, MA. September 30 - October 3, 2004. Abst# 347. 20. Green M, Allen C, Beall B, Bradley J, Dashefsky B, Gilsdorf JR, Marcon MJ, Schutze GE, Smith C, Walter E, Martin JM, Barbadora K, Rumbaugh R, Wald ER Macrolide Resistance (MR) Among Pharyngeal Isolates of Group A Streptococci (GAS) in the USA:Multicenter Surveillance Study Year 3 (2004-2005). The 42"d Annual Meeting of IDSA, San Francisco, CA. October 6-9, 2005. Abst# 493. 21. Euler C, Ryan P, Martin JM, Fischetti. A DNA methyltransferase contained on a mefA- encoding lysogenic phage may play a role in host strain surival and pathogenesis. Presented at the Lancefield Society Meeting, September 2005. Judith M. Martin, MD Revised: October 2006 Page 6 CHAPTERS 1. Martin JM, Stevens D. Therapy of Group A streptococcal infections. In: www.antimicrobe.orq (Yu VL, ed.) ESun Technologies, 2006. 2. Martin JM, Stevens D. Therapy of Group A streptococcal infections. In: Antimicrobial Therapy and Vaccines, Vol I. Microbes (Yu VL, ed.), 3rd ed. ESun Technologies, 2006 3. Martin JM, Green M. Group A Streptococcus. Semin Pediatr Infect Dis. Elsevier. 2006 Jul; 17(3):140-148. RESEARCH SUPPORT Current 09/05-08/07 American Heart Association PI - 20% effort Beginning Grant-in-Aid; Group A streptococcal carriage in children Longitudinal study of GAS carriage in children ($90,908) 03/05 - 03/06 Children's Hospital of Pittsburgh PI - 5% effort General Clinical Research Center Acute Rheumatic Fever in Allegheny County: incidence and GABHS M types ($ Laboratory supplies as needed) 7/06-6/07 Children's Hospital of Pittsburgh PI - 20% effort Research Advisory Committee-Bridge Funds Recurrent Group A Streptococcal Pharyngitis in Children ($50,000) Pending 12/06-11/08 National Institute of Health - R21 PI 20% effort Cytokines in Saliva Specimens of Children with Streptococcal Infections ($200,000) 10/06-11/09 Thrasher Research Fund PI 20% effort Recurrent Streptococcal Pharyngitis in School-aged Children ($526,907) Completed 10/00 - 9/05 National Institute of Health - K23 PI 5K23 A101713 - 75% effort Mentored-Patient Oriented Research Career Development Award - Group A Streptococcal Infections in Children. Five-year longitudinal study of GAS infections in elementary school children. ($577,250) 9/00-8/05 Children's Hospital of Pittsburgh General Clinical Research Center A Longitudinal Cohort Study of the Natural History of Group A Streptococcal (GAS) Infections in elementary school children ($ Laboratory supplies as needed) 1/01-6/03 Children's Hospital of Pittsburgh Research Advisory Committee-Start Up Funds . Judith M. Martin, MD Revised: October 2006 Page 7 Group A Streptococcal Infections in Children ($80,000) 7/99-6/01 9906202U Beginning Grant-in-Aid American Heart Association A Longitudinal Cohort Study of the Natural History of Group A Streptococcal Infections in Children ($63,636) 7/99-6/01 CMRF 3999-1000 Competitive Medical Research Fund University of Pittsburgh Medical Center Group A Streptococcal Infections in School-age Children ($25,000) 8/98-7/99 Roche Laboratories, Inc Pharmacokinetics of Oral Ganciclovir in Pediatric Patients ($13,500) f CURRICULUM VITAE TIMOTHY F. DORAN, M.D. ADDRESS 6565 N. Charles Street, Suite 309 Baltimore, Maryland 21204 443-849-2780 832 William Street Baltimore, Maryland 21230 410-576-0685 PERSONAL BACKGROUND Born: November 13, 1951 Married: Robin Weiss, M.D., October 12, 1980 Children: Gabriel Weiss Doran, April 12, 1983 Sarah Weiss Doran, December 11, 1986 CURRENT POSITION Chairman, Department of Pediatrics Greater Baltimore Medical Center 6701 N. Charles Street Baltimore, MD 21204 Pediatric Practice Greater Baltimore Medical Center Assistant Professor of Pediatrics The Johns Hopkins University School of Medicine 2 EDUCATION AND TRAINING 1983 -1985 Fellowship General Pediatrics Academic Development Program Robert Wood Johnson Foundation The Johns Hopkins University School of Medicine Baltimore, Maryland 1983 - 1985 Graduate courses in epidemiology and biostatistics The Johns Hopkins University School of Hygiene and Public Health Baltimore, Maryland 1980-1981 Chief Resident (PGY-4) Department of Pediatrics Albert Einstein School of Medicine Montefiore Hospital and Medical Center The Bronx, New York 1977 -1980 Pediatric Residency (PGY 1-3) Montefiore Hospital and Medical Center The Bronx, New York 1973 -1977 M.D. Tufts University School of Medicine Boston, Massachusetts 1969 - 1973 B.A. Harvard College Cambridge, Massachusetts LICENSURE AND CERTIFICATION 1984 Diplomate, American Board of Pediatrics 1983 Board of Medical Examiners, State of Maryland #D29613 1978 The University of the State of New York #138175 1978 National Board of Medical Examiners HONORS 1998 Pediatrician of the Year Maryland Chapter, American Academy of Pediatrics 1973 cum laude in Biology, Harvard College 1969-1973 Dean's List, Harvard College PROFESSIONAL ACTIVITIES 1985 - Present Fellow, American Academy of Pediatrics 1990 - 2001 Member, Medical and Chirurgical Faculty of Maryland EMPLOYMENT 1999 - Present Chairman, Department of Pediatrics Greater Baltimore Medical Center Baltimore, Maryland 1999 - Present Private practice of pediatrics Greater Baltimore Medical Center Baltimore, Maryland 1991-1999 Private practice of pediatrics Sigler, Roskes, Holden & Schuberth, PA Baltimore, Maryland 1991-1999 Medical Director Child Advocacy Center/Howard County Ellicott City, Maryland 1988-1991 Associate Pediatrician-in-Chief Sinai Hospital Baltimore, Maryland 1985 - 1988 Assistant Medical Director Chesapeake Health Plan 4940 Eastern Avenue Baltimore, Maryland 21224 1985 - 1988 Medical Director Sexual Abuse Treatment Program Bayview Medical Center Baltimore, Maryland 1981 -1983 Co-Director, Pediatric Ward Kingstown General Hospital St. Vincent and the Grenadines West Indies Kingstown General Hospital is the major medical facility for St. Vincent and the Grenadines, a sovereign state with a population of 110,000. The pediatric ward had forty beds for infants and children, and a five bed unit for premature and sick full-term newborns. Responsibilities included direct patient care, administration of the ward, supervising and teaching visiting medical students and residents, establishing a nutrition ward for the rehabilitation of infants with severe malnutrition, research on infant diarrheal disease, formal nursing education, and community education. 4 COMMITTEES AND BOARDS 2001-2004 Member Maryland DHMH State Advisory Council on Medical Privacy and Confidentiality 1996-present Manuscript Reviewer for Pediatrics. 2001 -2002 Chairman National Nominating Committee American Academy of Pediatrics 1999 - 2001 Chairman Committee on Children with Special Health Care Needs State of Maryland Department of Health & Mental Hygiene 1999 - 2001 Member National Nominating Committee American Academy of Pediatrics 1998 Chair Case Management Task Force State of Maryland Department of Health & Mental Hygiene 1996 -1998 President Maryland Chapter American Academy of Pediatrics 1991 -1997 Member, Board of Directors Advocates for Children and Youth 300 Cathedral Street Baltimore, Maryland 21201 1990 - 1993 Chairman, Committee on Hospital Care Maryland Chapter, American Academy of Pediatrics 1990 -1993 Member, Immunization and Infectious Disease Subcommittee Committee on Public Health Medical and Chirurgical Faculty of Maryland 1989 -1997 Member, Board of Directors Child Advocacy Network State's Attorney's Office Baltimore, Maryland 1988 -1993 Member, Board of Directors Court Appointed Special Advocates University of Maryland School of Law Baltimore, Maryland 1988 -1990 Member, Subcommittee on Medical Care Planned Parenthood of Maryland Baltimore, Maryland 1988 -1990 Member, Institutional Review Board Sinai Hospital Baltimore, Maryland 1987 Member, AIDS Policy Committee Baltimore City Department of Social Services 1986 - 1990 Member of the Advisory Board Sexual Assault Recovery Center Baltimore, Maryland 1986 -1987 Consultant, Childhood Sexual Abuse Baltimore City Health Department Baltimore City Police Department 1981 Medical Consultant Committee on the Handicapped Chappaqua Board of Education Chappaqua, New York 1980 -1981 Member, Housestaff Affairs Committee Montefiore Hospital and Medical Center 1979 -1980 Delegate, Committee of Interns and Residents Montefiore Hospital and Medical Center 6 GRAND ROUNDS/PRESENTATIONS 1985 "Fever: Friend or Foe?" Grand Rounds University of Maryland Department of Pediatrics Baltimore, Maryland 1989 "Sexual Abuse in Children" Grand Rounds Sinai Hospital Baltimore, Maryland 1990 "Kawasaki Disease" Grand Rounds Sinai Hospital Baltimore, Maryland 1990 "Controversies in the Examination of Sexually Abused Children" Grand Rounds St. Agnes Hospital Baltimore, Maryland 1991 "Occult Bacteremia: Update 1991" Grand Rounds Sinai Hospital Baltimore, Maryland 1991 "Medical Evaluation of Sexually Abused Children" Pediatric Trends The Johns Hopkins Hospital Department of Pediatrics Baltimore, Maryland 1993 "Group A Beta Hemolytic Strep: The Old and the New" Grand Rounds Sinai Hospital Baltimore, Maryland 1994 "Flesh Eating Bacteria in the Flesh: Invasive Group A Bacteremia" Grand Rounds St. Agnes Hospital Baltimore, Maryland 1999 "Invasive Group A Strep: What, Me Worry?" Grand Rounds GBMC Department of Pediatrics 6 • 2002 Lyme Disease 2002: An Update from Ground Zero Grand Rounds GBMC Department of Pediatrics Baltimore, MD 2002 Lyme Disease in Children Pri-Med Conference and Exhibition Washington, D.C. 2003 The Pink Eye in Pediatrics Pediatric Ophthalmology for the Pediatrician GBMC Baltimore, MD y M • PUBLICATIONS Doran TF Pediatricians and Their Practices. Arch PediatrAdolesc Med - 01-Jan-1999; 153(1):8 Wood RA, Doran TF. Atopic Disease, Rhinitis and Conjunctivitis, Upper Respiratory Infections, and Insect Stings and Snake Bites. Curr Opin Peds 1994; 6:607-619. Wood RA, Doran TF, Schuberth KC. Atopic Disease, Rhinitis and Conjunctivitis, Upper Respiratory Infections, and Insect Stings and Snake Bites. Curr Opin Peds 1993; 5(5):623-635. Berlin LE, Rorabaugh ML, Heldrich F, Roberts K, Doran TF, Modlin J. Aseptic Meningitis in Infants Younger than 2 years of Age: Diagnosis and Etiology. J Infect Dis 1993; 168(4):888- 892. Rorabaugh ML, Berlin LE, Heldrich F, Roberts K, Doran TF, Modlin J. Aseptic Meningitis in Infants Younger than 2 Years of Age: Acute Illness and Neurologic Complications. Pediatrics 1993; 92(2):206-211. Chang YT, Germain-Lee EL, Doran TF, Migeon CJ. Hypocalcemia in Nonwhite Breast Fed Infants, Vitamin K Deficiency Revisited. Clin Pediatrics (Philadelphia) 1992; 31(11):695-698. Doran TF, DeAngelis C, Baumgardner RA, Mellits ED. Acetaminophen: More Harm than Good for Chicken Pox.? Journal of Pediatrics 1989; 114:1045-1048. Doran TF, Weiss RW. Group B Streptococcus in St. Vincent. CAREC Surveillance Report; 9(1), January 1983. Doran TF. Breast Abscesses in Adolescents Abstract, APA-SPR-APS, Spring 1981 Uot le euu,/ e:zUPM HP LHSERJET FAX JONATHAN D. FINDER, MD PEDIATRIC PULMONOLOGIST 5541 BEVERLY PLACE PITTSBURGH, PA 15206 October 9, 2007 RE: Hetrick v Blutstein, M.D. FEPC #3558 I have been asked to review plaintiffs' complaint and expert report and the medical records of Sara Zehring, date of birth 7/2911998, who died on January 31, 2005 at 15:22. A brief summary of the facts of the case follows- * Sara Zehring was a 6-and-a-half year old girl whose past medical history was notable for asthma, a seizure disorder, and a small heart defect known as a secundurn atrial septal defect. Despite these three disorders, she was by all accounts a relatively healthy girl, whose seizure disorder had apparently resolved, whose heart defect was nearly closed at the time of her death, and who was not taking asthma medication in the weeks prior to her death. • Sara had been given relatively few courses of antibiotics in her life prior to the events surrounding her death. She had received: Amoxicillin 3/18/01 at age 2.5 years Azithromycin 1/24/02 at age 3.5 years Azithromycin 6/24/02 at age nearly 4 years Amoxicillin 3/25/03 at age 4.5 years Amox/clavulanate (high dose) 6120x03 age nearly 5 Azithromycin 4/4104 age 5 years 9 months Azithromycin on the day of her demise. In short she had 6 prior courses of antibiotics in a total of 6 years, or approximately 1-2 course per year on average. This is within normal limits for age and does not suggest any of the common immunodeficiencies. • Sara had a history of asthma, which was treated fairly intermittently. Review of the pharmacy records indicated that her parents filled prescriptions for Pulmicort 3 times (30 day supplies at each refill) between 2002 and 2005. They filled prescriptions for Singulair 6 times (30 days supply at each time) between 11/26/02 and 5/13104. I found only 4 prescriptions for albuterol, but 2 were within 2 days on 211 and 214100 in 2 formulations. Taken together, this suggests that she had asthma that ranged from mild intermittent to mild persistent in severity. According to her records, her main asthma trigger was viral respiratory infections. Although one of the records indicated that Sara's mother smoked during her pregnancy (Dr. Todd Barron noted in his letter dated March 23, 2000th4"the mother did use some tobacco during the pregnancy") she herself I p.2 Ict 12 2007 2:20PM HP LASERJET FAX 0, . denied smoking during pregnancy in her deposition. Mrs. Hetrick stated in her deposition that she did not smoke in the house. • On the night before her demise, Sara's mother contacted her pediatrician with a concern that Sara had a croupy cough which had started 2 days prior, and seemed to worsen. She spoke to her pediatrician approximately 3:30 AM on 1131/05, who advised her to take Sara outside for cold air exposure. This improved Sara immediately and she was able to fall asleep. Both Dr. Blustein's notes and the mother's deposition supports this relatively rapid improvement in Sara's cough with cold air exposure. By morning, Sara's mother noted that her daughter had persistent cough but no evident fever. • Sara was seen later the same day by Dr. Blutstein in the office. Dr. Blutstein did a careful evaluation, which included a set of vital signs, a history, and a physical examination. He offered to observe the child in the hospital based on a combination of a borderline low hemoglobin saturation of 93% and a fever of 104 degrees, but according to his note, her mother declined (she denies this in her deposition). He prescribed azithromycin for possible bacterial infection, prednisolone based on her history of asthma and her low saturation (which was indicative of asthma). There was no evidence of acute upper airway obstruction (e.g., no drooling, no stridor) and only mild respiratory distress. • Sara's mother stated that she did not administer the prescribed antibiotic to Sara before her cardiopulmonary arrest. • 2 or 3 hours after Sara and her mother returned from the pharmacy (to which they had proceeded from Dr. Blutstein's office), Sara became gravely ill and went into cardiopulmonary arrest. 911 was called and there was a rapid response with initiation of cardiopulmonary resuscitation. Her death was attributed to sepsis (bacterial infection in the bloodstream). Her chest radiograph prior to her death did not show any infiltrates that would suggest a pneumonia. At autopsy she was not noted on gross examination of the lungs to have any obvious pneumonia, although on microscopic evaluation there was evidence of both asthma and pneumonia. ASSESSMENT: The death of Sara Zehring is as puzzling as it is tragic. It is highly likely that Sara's initial presentation was a viral respiratory infection, leading to croup (viral laryngotracheobronchitis). Viral croup is a common childhood infection and generally is a benign and self-limited disease, resolving spontaneously. In Sara's case there was a bacterial superinfection (a secondary tracheitis) with invasion through the injured epithelium into the bloodstream, leading to sepsis and death. Streptococcus pneumoniae (also known as Pneumococcus) remains a common cause of bacterial disease in children, and is a common cause of otitis media and sinusitis. Invasive bacterial infection (sepsis and mehingitis) with Streptococcus pneumoniae, in contrast, has greatly decreased in incidence with the introduction of Prevnar, the 7-valent conjugate vaccine against this organism (Whitney, et al. NEJM 2003: 348: 1737-1746). Oct 12 2007 2:20PM HP LASERJET FAX P.4 Bacterial infection with Streptococcus pneumoniae resulting in bloodstream infection can be "occult" - e.g., without other signs or symptoms other than fever. Occult bacteremia with streptococcus pneumoniae is most common in children under age 2, and also can occur in patients who have had splenectomy or with immune deficiency states. Sara Zehring had no evidence of an immunodeficiency and had no identifiable risk factors for invasive pneumococcal disease (other than possible environmental tobacco smoke exposure). The plaintiffs allege that Dr. Blutstein failed to diagnose Sara's "pneumonia" when the chest radiograph at the time of her death showed no infiltrates, and even gross inspection of the lungs at the time of autopsy showed no evidence of pneumonia. Only under microscopic evaluation was there evidence of pneumonitis in Sara's lungs. In addition the pathologist found microscopic evidence of asthma, which was the cause of her borderline low oxygen saturation in the office. The borderline low oxygen saturation was not caused by pneumonia, as the plaintiff is implying, but by viral-induced bronchospasm. It should be noted that a pulse of 173 and a mildly elevated respiratory rate of 46 are entirely consistent with the fever that Sara had and do not suggest sepsis or other invasive bacterial disease in and of themselves. I can state with confidence that Dr. Blutstein did not act improperly in his treatment of Sara Zehring. Nothing in her past history suggested that she had a predisposition to invasive bacterial disease, and nothing in her examination suggested sepsis. An ambulatory child, as Sara was on the morning of her examination, cannot be in septic shock. Fever is one of the most common reasons for children to seek medical attention. Based on Sara's history of a croupy cough, which responded to cold air treatment, Dr. Blutstein's clinical impression was of an acute viral croup, with secondary viral bronchospasm. Although viral cultures were not obtained at autopsy, had one been performed the likely source would have been parainfluenza virus. Sara experienced a bacterial secondary infection through the virally injured respiratory epithelium. There was no lobar pneumonia or other large source of bacteria. In this regard Sara's case is highly unusual and could not have been expected. Dr. Blutstein treated Sara's borderline low oxygen saturations with albuterol, and her mother did immediately administer this therapy. He initiated antibiotic treatment, but Sara's mother did not give the first dose of the azithromycin. It is impossible to say whether had she given the first dose promptly Sara would have survived. The use of steroid in the setting of an acute asthma exacerbation is well established and Dr. Blutstein was using usual standard of care for an asthma exacerbation. The choice of azithromycin for treating pneumonia is an excellent one, as it covers both "atypical" and usual bacterial agents. The vast majority of pneumonias are treated with Oct 12 2007 2:20PM HP LRSERJET FAX P.5 F• oral antibiotics in the outpatient setting. Thus Dr. Blutstein's decision-making was well within the standards of care. Dr. Blutstein did offer to hospitalize Sara, which her mother declined. Although Sara's mother denies this in her deposition, it is natural for a mother of several children to not want to have to be in the hospital. As it was, Sara's mother was not able to be with Sara in the emergency room and waited for her other children. I found Dr. Blutstein's notes, which were taken within hours of the visit, very credible, while Sara's mother's deposition in which she denies this conversation (taken on August 10, 2007, more than 2 years later), are more likely to reflect an imperfect memory. In summary I find that Dr. Blutstein did at no time vary from established standards of care, and could not have predicted the tragic outcome of Sara Zehring. All aspects of his care were appropriate. It is impossible to predict the effect of Mrs. Hetrick's not having administered Sara's antibiotics, but I would conjecture that one dose of antibiotics whether oral or intravenously administered would likely not have altered the course of this illness. loJlz?p?- ". . JONATHAN D. FINDER, MD PEDIATRIC PULMONOLOGIST 5541 BEVERLY PLACE PITTSBURGH, PA 15206 March 13, 2008 Attorney Michael C. Mongiello Foulkrod Ellis 2010 Market Street Camp Hill, PA 17011 RE: Hetrick v Blutstein, M.D. FEPC #3558 Supplemental report from Dr. Bollinger and deposition of Dr. Mack Dear Mr. Mongiello: I have reviewed the above documents. With regard to Dr. Bollinger's single sentence report, I do not find it in any way credible. Dr. Bollinger is a pathologist, whose training is to identify cause of death or disease. She is neither a practicing intensivist emergency doctor, nor pediatrician. She does not take care of living patients. She is a clinical assistant professor of pathology. As such I would not expect that her judgments about clinical management of pneumonia is not based on experience or training. I do not feel that she has standing to discuss whether or not survival of this patient would have been affected by admission to hospital. The deposition of Dr. Mack does not change my views on this case, either. Please do not hesitate to contact me if you have any questions regarding this note. _-T Jonathan D. Finder, MD March 31, 2008 Poulkrod Ellis 2010 Market Street Camp Hill, PA 17011 Re: Hetrick v. Bluestein, MD Dear Mr. Mongleilo; I have reviewed the records that were provided to me regarding Sara Zahring. These include the following items: Deposition of Dr. Bluestein Plaintiffs Complaint Plaintiffs Deposition Expert Report for the Plaintiff Autopsy Report of Sara Zehring and Coroner's View Medical Records from Pennsboro Pediatrics Medical Records from Polyclinic Hospital Medical Record from Carisle Hospital Death Certificate West Shore EMS Records Giant Pharmacy Records Hershey Medical Center Records Transcription of Dr. Blutstein's Notes Notes from Dr. Blutstein's Computer Chest radiograph from 1131105 I base my opinion regarding this matter upon these records. Sara Zehring was born on 7/29!98. Dr. Bluestein and Pennsboro Pediatrics provided her primary medical care with the assistance of a variety of consultants. 'there were many documented visits to Pennsboro Pediatrics for routine well child care, and sick visits. Sara appeared to have good growth and received all of the standard immunizations and some influenza vaccine doses. Sara was noted to have several medical problems including an atrial septall defect, decryostenosis, a seizure disorder, reactive airway diseaWasthma and recurrent episodes of acute otitis media and otitis media with effusion. She had a prior emergency department visit for a dosed head injury on 111/2000, as well as two hospital admissions. The first was on 11'2/2000 for seizures and the second was on 114/2001 for vomiting, diarrhea and dehydration. Pace 1 of 4 Sara's illness began a few days prior` to 1/31105 when she developed a cough and fever. She was with her father duet the weekend and returned to her mother on Sunday 1130/05. The following ti? eiine describes the events that occurred on 1/31/06 as per the documentation reWewed, listed above, Monday 1131105 03:30 Dr. Blutstein received a phone call from Sara's mother. He assessed that Sara likely had croup from the information that her mother provided and the way her cough sounded. He advised Saw's mother to take her outside because the cold air would help her breathing.. H6 also stated that if it did not help, that she should take Sara to the Emergency bepartment. He asked her to call the office to inform them if she went to the Hospital and offered to see her in the office. 10:15 (Time approximate) Dr. Blutstein saw Sara in the office. His assessment was that she had fever, croup, reactive airways disease and possibly pneumonia. As per his personal notes, he disws6ed the option of admitting Sara to the hospital with her mother and she declined and stated that she preferred to observe her at home. Dr. Blutstein then prescribed Orapred, Fiovent and azithromycin and told her to call him! if Sara worsened and asked her to return to the office the following day. Time unknown - Sara's mother filled her prescriptions at Giant Pharmacy and took her home. 14:17 Dr. Blutstein received a cell from Sara's mother that Sara was, blue and not breathing. He advised her to call 9111 immediately and to'go to Harrisburg Hospital. 14:22 Dr. Blutstein called Sera's mother back and found that there was assistance at the house and she informed him that they were going to Carlisle Hospital. 14:22 (Time as per EMS notes) Medic 85 was dispatched to meet the ambulance enroute to Carlisle Hospital to provide care for Sara. 14:27 Dr. Blutstein called Carlisle Hbspital to provide medical history regarding Sara Zehring. 14:32 Dr. Blutstein contacts Dr. Mack to meet the patient at the Emergency Department to render assistance. 14:37 Dr. Blutstein received a call ft6m Sara's mother; she asked Dr. Blutstein if he had heard anything about Sara, he had not heard anything at that time. 14:40 Time per the EMS records the patient was successUy intubsted. 14:52 EMS and the patient arrived at Carlisle Hospital. 14:58 First recorded time on the Cardiopulmonary Resuscitation flow sheet at Carlisle Hospital. 15:05 Dr. Blutstein called the Carlisle Emergency Department and was informed about Sara's condition. During the same phone call the phone was given to Dr. Mack. She informed Dr. Blutstein that the team had stopped resuscitation efforts. Page 2 of 4 15:22 Time code terminated as per the Cardiopulmonary Resuscitation flow sheet. 17:22-17:50 Dr. 8lutstein types his recollections of the day in a note on his computer. Asssssrnint. Sara 2ehring first presented to medical attention with the illness in question with a phone call ewly on Monday 1/31/05. She was approprotely managed by telephone and was offered an appointment the following day and was told that she could go to the Emergency Room if her mother felt that was necessary. Her illness likely began as a viral process such as influenza, parainfluenza or an upper respiratory infection. These are very common in children at this time of year. Her illness and symptoms persisted; this prompted an appointment being scheduled that same morning 1/31105. A physical examination is well documented on Monday 1 /31 /05. The documentation and the physician's deposition support that them was no evidence of septic shock. Children of Sara's age with high fever would also be expected to have an elevated heart rate and respiratory rate. In addition Dr. Blutstein 1Wt that she was having an exacerbation of her restive airway disease/asthma, croup and possibly pneumonia, which explained her oxygen saturations and epigastric retractions. Chiles with septic shock would have poor peripheral perfusion, and would have decreased mental status. Sera was cooperative with the examination and is not described as toxic appearing, drooling or lethargic. Her oxygen saturations were measured at 93%. This in and of itself, is not an absolute indication for hospitalization. Children with bacterial pneumonia or tracheitis and bronchitis often begin with a viral illness that looks like a common cold or the "flu". Dr. Blutstein recognized that Sara was ill and offered hospital admission to her mother who declined that option and preenred to watch her at home- This is reasonable in a child who is Sara's age who is able to verbalize how she feels and can be observed by a family member. It was also early in the day; this would easily allow that $are could be reassessed. Dr. Blutstein informed Sara's mother to call him if anything changed. Dr. Blutstein prescribed antibiotics (azithromycin) for a possible bacterial process. He prescribed Orapred and Flovent for management of her asthma exacerbation. This is standard practice for these conditions in a child this age. At times blood work such as a complete blood count or a blood culture is obtained if the child is toxic appearing. This is done in order to assess whether the child is bacteremic. Since the physician believed that a diagnosis of croup and reactive airway disease explained the illness in this child, and since she was not toxic in appearance, he did not require additional diagnostic testing. He presumed that there might be a bacterial infection and prescribed an appropriate antibiotic, therefore, a chest radiograph was not indicated at that time. Even if e chest radiograph was obtained earlier on Monday morning I do not think that it Page 3 of 4 would have changed Sara's management. It is not clear that the radiograph would be abnormal given that the radiograph that was obtained in the Emergency Department was not very impressive. I believe that Sara had worsening respiratory distress and became bacteremic with the Streptococcus pneumonme at some point after leaving the office on Monday morning. There is no report of a significant change in her clinical appearance until 14:17 when Dr. Blutstein received a call from Sara's mother that she was blue and not breathing. The autopsy report indicates Sara had pneumonia, tracheitis and bronchitis with a blood culture that was positive for Streptococcus paeumonise. She likely also had septic shock syndrome given her rapid decline. Strepkx=cus pneumoniae can be a very aggressive pathogen. Even with the best medical care in an intensive care unit at a pediatric hospital, cNidren die of theses types of infections. Appropriate antibiotic treatment cannot stop the inflammatory response and cytokine release that occur with these infections. In addition, diflbrent children have different genetic make-ups. This affects thier ability to handle serious infections. This cannot be predicted. Two children can have the same infection and respond very differently dependent on the host immune response or lack of host response. At this time, we cannot alter the child's immunogenetics. Sara Zehrig was seen and evaluated in the office on Monday 1131/05. 1 believe that her medical care was appropriate. From the office notes and depositions it appears that Sara was not toxic during her evaluation by Dr. Blutstein. It is my opinion, within a reasonable degree of medical certainty that Sara received appropriate medical care prior to her death. Sincerely, J dith M. Martin, MD 3/31 /08 Addendum: I have also reviewed the additional information provided in the report of Dr. Bollinger and the deposition of Dr. Mack. I believe that her medical care was appropriate. I have found no information that leads me to believe that admitting Sara to the hospital for observation would have altered her outcome. Judith M. Martin, MD Page 4 of 4 6 „mUVF1Y vuRan Timothy F. Doran, M.D. 832 William St. Baltimore, MD 21230 Mr. Michael MongielloFoulkrod Ellis 2010 Market St. Camp Hill, PA 17011 October 14, 2007 RE: Hetrick V4 Blutstein, M.D. p.[ This is a letter in response to a request from Mr. Michael Mongiello of the law firm Foulkrod Ellis regarding the pediatric care rendered to Sara Zehring by Dr. Richard Blutstein. I have reviewed the following documents relevant to the case in arriving at my opinion in this case: 1. Records of Richard Blutstein, M.D. 2. Records of Carlisle Regional Medical Center from 1131/2005 3. Records of West Shore EMS 4. Dr. Blutstein's notes from his computer dated 1/31/2005 S. Autopsy report 6. Coroner's report 7. Deposition of Dr. Blutstein 8. Deposition of Laura Hetrick 9. Letter from Richard J. Bonforte, M.D. 10. Letter from Judith M. Martin, M.D. 11. Letter from Jonathan Jonathan D. Finder, M.D. Sara Zehring was a patient of Dr. Blutstien since her birth July 2e, 1998. Sara was treated by Dr. Blutstein for a number of medical issues over her tragically brief life, including reactive airway disease, asthma, croup, recurrent otitis media, a seizure disorder, dacryostenosis and an atrial septa) defect. ?i jam- in the early morning of January 31, 2005 (3:30 AM), Dr. Blutstein received a telephone call from the mother of Sara Zehring informing him that Sara was having difficulty breathing. Dr. Blutstein's office note and deposition indicate that Sara had a "croupy" cough over the phone and recommended a trial of cold air. In Ms, Hetrick's deposition, she described the cough as a "harsh, hard cough." He informed the mother to see him later that morning if Sara's breathing cleared up. Mom relates in her deposition that the cough did improve after going into the cold air. The mother brought Sara in to see Dr. Blutstein later that morning at which time the mother related the history of "high temperature, vomiting, wheezing, cough." On Dr. Blutstein's note, he recounted the call at 3:30 in the morning and his advice of cold air for what he thought was croup and that it had helped. Ms. Hetrick corroborated this in herdeposition. Mom then called the next morning and -, do p•3 scheduled a sick visit for later in the morning. At the time of the visit, Sara apparently walked into the office without assistance and her appearance was described as "good" by Dr. Blutstein's assistant. The temperature was noted to be 104 Fahrenheit, with a respiratory rate of 46, heart rate of 173 and a pulsoximetry reading of 93%. The physical exam revealed some "audible tubular breath sounds" in the neck and "intermittent crackles" with good air entry and epigastric retractions in the lungs. It was specifically noted that Sara was speaking "OK." He felt that Sara was suffering from a combination of croup and reactive airway disease (RAD) and mentioned the physical findings of fever and crackles. in response to his exam, he treated her with oral steroids, inhaled steroids, and azithromycin for possible pneumonia. According to his supplemental note, he discussed the possibility of admitting Sara to the hospital, but decided that she could be started on the medications and observed at home with instructions to the mother to call him if she was worse in any way. The mother has no recollection of this conversation in her deposition. Ms. Hetrick relates that she went to the Giant Pharmacy to pick up the medications after leaving Dr. Blutstein's office, and she remembers pushing Sara in the shopping cart. She was not described in any way in the pharmacy as obtunded or moribund. The mother then took her home, administered the steroid and decided to wait a while until giving her the antibiotic. Sara was lying on the couch, then on a recliner with her mother, and finally in her bed. Mom relates that she was "walking in and out of the bedroom a couple of times." At around 2PM, Ms. Hetrick remembers Sara saying "mama" and "she just like fell into my arms. I just grabbed her. She seemed to shake a bit." She remembers her turning blue and her breathing slowing down. Mom called 911. The next call Dr. Blutstein received was from the mother informing him that Sara had seized, stopped breathing and was blue. Unfortunately, heroic attempts at resuscitation by the paramedics and the hospital were unable to resuscitate her. Discussion The cause of death was listed by the Dr. Bollinger, the forensic pathologist, as complications of pneumococcal sepsis due to Streptococcus pneumonia. Although 1 have no other explanation, the course of her illness varies significantly from the course of pneumococcal sepsis and raises the issue of a sudden death from another etiology. Even the most fulminant of bacterial infections in children, meningococcal sepsis, does not progress from a conversant, oriented child to a sudden death in the manner described by her mother over the course of minutes. It is clear that she had an infection, and it is likely that she had viral croup as an underlying pathology. She certainly could have sustained a secondary bacterial infection in this situation, but the usual course of a bacterial tracheitis would be progressively worsening croup and stridor that is not described in this case. These children are gasping for air with marked respiratory stridor. There are autopsy findings consistent with a necrotizing tracheobronchitis, but her clinical course did not reflect these findings. Sepsis is always a possibility and is the most likely etiology we have, but her sudden collapse is distinctly unusual. Despite the fatal outcome in this case, there is nothing in the medical records that indicates a breach in the standard of care in this case. There was nothing in this child's symptoms or signs that would predict a catastrophic event. Sara presented to Dr. Blutstein with classic features of croup. She suffered from a harsh cough that was heard by an experienced pediatrician as a croupy cough. She responded nicely to the usual therapeutic trial of cold air in the middle of the night. , -all pA There was discussion in Dr. Blutstein's deposition as to whether or not the child should have been admitted to the hospital. Criteria for admission for respiratory disorders include a child with moderate dehydration and a need for intravenous fluids, moderate or severe respiratory distress with poor aeration and oxygenation, failed outpatient antibiotic therapy (in a child with community acquired pneumonia), or a situation where it is unsafe to send the child home (remote access, etc.). Sara had none of these, The discussion about the possibility of admission occurs regularly with pediatricians and parents. Dr. Bonforte claims that a pulsoximetry reading of 93% argues for hospital admission. While i agree with him that a pulsoximetry reading of 93% is not normal, it is also not low enough to warrant hospital admission in the absence of the above criteria. Dr. Bonforte also points to the fact that the temperature was elevated, as was the respiratory rate and the pulse rate. All children with high fever have elevated heart rates and respiratory rates and it would be more worrisome if Sara had had a normal heart rate with such an elevated temperature! Sara did have an increased temperature, fever, respiratory rate and mildly depressed oxygen saturation. The respiratory rate and depressed oxygen saturation were explainable at the time of her visit by either her reactive airway disease (asthma) or community acquired pneumonia. Croup is usually caused by viruses and is associated with fever and stridor. Dr. Blutstein arrived at a list of diagnostic possibilities that were consistent with her symptoms and signs and treated her with the proper medications. 1 can find no fault here. In fact, in studies on bacteremia, it is close follow-up that is the most important factor in preventing the complications of invasive bacterial disease. Dr. Blutstein was meticulous in triaging and treating Sara in the middle of the night with close follow-up arranged in the morning and instructions to follow-up if she worsened after his careful history and physical exam. There are no guidelines that I have ever seen that would have mandated a hospital admission in these circumstances. There was also absolutely no reason to believe that Sara was septic at the time of the evaluation by Dr. Blutstein. She was ambulatory, speaking and had adequate oxygenation. Overwhelming sepsis is not subtle, and is easily detected by experienced clinicians. Finally, there is no reason to believe that a referral to the hospital after the office visit would have saved her life. In summary, I find no deviation from the standard of care in the treatment of Sara Zehring. Yours, I"- -rax- Timothy F. Doran, M.D. 161 1 Arthur H. McTighe, M.D. 107 Witherspoon Road Baltimore, Maryland 21212 April 21, 2008 Andrew Foulkrod, Esq. Foulkrod Ellis 2010 Market Street Camp Hip, Pennsylvania 17011 RE: Hetrick v. Slutstein, et ai. Dear Mr. Foulkrod: Thank you for asking me to review this case on behalf of Dr. Blutstein. I am the Medical Director of the Department of Laboratory Medicine and the Chief Pathologist of a relatively large community teaching hospital in Baltimore, Maryland, with very active pulmonary medicine, infectious diseases, pediatrics and medicine services. Formerly, l was the medical director and chief pathologist of two hospital pathology departments in Pennsylvania. At one of these Pennsylvania hospitals i also served as the Vice President for Medical Affairs, and as such I was responsible for monitoring and improving the quality of medical care. I have been engaged in the practice of autopsy and surgical pathology for 33 years and am board certified in the disciplines of anatomic pathology and clinical pathology by the American Board of Pathology. In addition, I am certified in the subspecialties of Medical Microbiology, Dermatopathology and Cytopathoiogy by the American Board of Pathology. Medical Microbiology Is that subspecialty of pathology that deals with infectious diseases and their associated pathologic changes, such as pneumonia and sepsis, the pathogenic bacteria producing pneumonia and sepsis, and the pathologic changes of pneumonia and sepsis seen in various organs of the human body. I was a member of the pathology faculty at the Johns Hopkins School of Medicine for 15 years until relocating to Pennsylvania in 1991, and I have been an Associate Clinical Professor of Pathology at the Pennsylvania State University, School of Medicine in Hershey, Pennsylvania since 2000. At your request I reviewed 15 glass slides prepared from autopsy pathology tissue specimens, which were processed by Forensic Pathology Associates, 'Inc., of Allentown, Pennsylvania. These 15 slides were identified as C 05731 through 5 and C 05-73 81 through B10. The slides were sent to me on April 10, 2008. As is my usual practice, I examined these slides "blindly," i.e., without reviewing the autopsy report or any other record until after my examination of the slides was complete. In addition, I received the following medical records and other materials, which I have also reviewed: .. ` Andrew Foulkrod, Esq., Foulkrod Ellis, RE. Hetrick v. Biutstein, et al. 2 A) Medical Records: Records of Pennsboro Pediatrics (Dr. Biutstein), Records of the Carlisle Regional Medical Center (January 31, 2006 ER), Transcriptions of Dr, Blutstein's handwritten note, Records of West Shore EMS, Records of the Giant Pharmacy, Death Certificate, Records of the Hershey Medical Center, Records of the Polyclinic Hospital, Final autopsy report of Sara Zehring (C 05-73). B) Other Materials: Coroner's View, Deposition transcript of Laura Hetrick, Deposition transcript of Dr. Richard Biutstein, Deposition transcript of Dr. Vicki Mack, Expert report of Dr. Jonathan Finder, Expert report of Dr. Timothy Doran, Expert report of Dr. Judith Martin, Expert report of Dr. Richard Bonforte, and Expert report Dr. Barbra Bollinger. You asked that I review the medical records, autopsy pathology slides, autopsy pathology reports, and the other materials in detail. My findings and opinions are as follows: Sara Zehring was a 6 % year-old girl who had been a patient of Dr. Biutstein since her birth. Her past medical history was remarkable for asthma, a seizure disorder that had been essentially inactive for the three years before her tragic death, and an atrial septa( defect that had nearly closed at the time of autopsy. Her asthma was well managed by Dr. Biutstein, and the seizure disorder and atrial septai defect produced no limitation of activity or other symptoms for the few years before her death. She was a well and active child. She had received the standard immunizations and had also received influenza vaccine. Over the course of her life, she had received a few courses of antibiotics, !including amoxicillin and azithromycin for upper respiratory infections and otitis media. She recovered from these infections uneventfully, and there is nothing in her record to suggest an immunodeficiency disorder. Sara returned to her mother's home the day before her death. She apparently had developed a croupy cough two days before and this appeared to worsen. Sara's mother contacted Dr. Biutstein because of this cough at approximately 3:30 a.m. on January 31, 2005. Dr. Biutstein could hear the croupy cough over the telephone and advised Sara's mother to take Sara outside into the cold air for both diagnostic and therapeutic reasons, as croup usually improves after cold-air exposure. Dr. Biutstein did advise Sara's mother that should her cough not improve she should be taken immediately to the local hospital emergency room, and in any case if her cough improved with cold-air exposure, she should be brought to see him the following morning. Sara's cough almost immediately improved on cold-air exposure, and she easily fell asleep in her mother's arms. Andrew Foulkrod, Esq., Foulkrod Ellis, RE: Hetrick v, Blutstein, at al. Later that morning Sara's mother noted that her cough had returned and she took Sara to Dr. Blutstein's office at approximately 10:15 a.m. Sara's mother reported that her daughter was wheezing and coughing and had developed fever. Dr. Blutstein conducted a thorough examination and evaluation of Sara and offered to evaluate and observe Sara in the hospital based on her mildly reduced oxygen saturation of 93%, her respiratory symptoms, and fever. However, her mother preferred to watch Sara at home rather than having her admitted to the hospital. Dr. Blutstein told Sara's mother to call hinh in the event that Sara's condition or symptoms worsened. Dr. Blutstein prescribed azithromycin for a possible bacterial infection and medications for her asthma, based on her relatively mild respiratory distress. • Sara's mother did have these prescriptions tilled at a local Giant pharmacy and she describes pushing Sara in a shopping cart through the store in order to pick up the prescriptions at the pharmacy counter. Sara was not described as being obtunded or severely ill. Sara's mother took her home, gave her some of the medications, but decided not to give her the antibiotic, azithromycih, at that time. Sara was reclining on the couch and later went to bed. Sara, according to her mother, walked in and out of the bedroom a couple of times. At alpout 2 p.m., however, Sara called out for her mom, seem to shake a bit, and fell into her arms. Sara's mother describes Sara as turning blue and having decreased breathing. At 2:17 p,m., Dr. Blutstein received a telephone call from Sara's mother advising him that Sara had turned blue, had a possible seizure, and was no longer breathing. Dr. Blutstein advised Sara's mother to call 911 at once. West Shore Emergency Medical Services responded immediately, began CPR, and took Sara to the Carlisle Regional Medical Center, Sara arrived at the Carlisle Regional Medical Center at 2:58 p.m. and was evaluated by Dr. Guarracino. Dr. Guarracino described Sara as a 06-year-old white female who presents via EMS in cardiopulmonary arrest." He noted that Sara had been sick with a croup-like cough. She had been evaluated in the pediatrician's office and was found to have a mildly reduced oxygen saturation of 93% but was "able to talk without difficulty." A portable chest x-ray was performed in the Emergency Room and Dr. Guarracino states that the "portable chest x-ray interpreted by myself showed no evidence of pneumonia." In his examination he also noted that he visually inspected the oropharynx and found the endotracheal tube to be in place. He also noted, "There was no obvious evidence of epiglottitis or swollen paralaryngeal tissues." Skin rash or skin hemorrhages or petechiae were not present. CPR was continued, but this was to no avail and Sara was pronounced dead at 3:22 p.m. on January 31, 2005. • At the request of the Cumberland County Coroner, Sara Zehring underwent an autopsy performed by Dr. Barbra Bollinger at 10 a.m. on February 1, 2005. The autopsy was performed approximately 18'x4 hours after Sara had been pronounced dead. • Dr. Bollinger in her autopsy report (C-05-073) reported that Sara's epiglottis was slightly red. discolored, and swollen, She also noted, "There are no obstructive lesions of the oropharynx, nasopharynx or larynx. The laryngeal mucosa is pink, K . Andrew Foulkrod, Esq., Foulkrod Ellis, RE, Hetrick v, Blutstein, et al. 4 smooth, and non-edematous. The trachea is straight, patent, and is lined by intact, pink-red mucoua.' Dr. Bollinger found a small septa) defect in the right atrium that measured 0.1 cm. Sara's heart was otherwise unremarkable. Sara's lungs weighed 210 and 220 grams, and Dr. Bollinger reported, "The cut sections of the lungs show no obstructions, masses or focal lesions. The tracheobronchial tree contains a slight amount of thick, yellow mucys and is otherwise unremarkable." Dr. Bollinger also noted "each bilateral adrenal gland is in its normal anatomic position and is grossly unremarkable." In her microscopic examination, Dr. Bollinger reported that the adrenal glands were "without pathologic abnormalities.' She described the tracheal mucosa as "denuded and with underlying acute and chronic inflammation." She described inflammation of the bronchial mucous glands and a focal acute inflammatory infiltrate within the alveolar spaces of the lung. Dr. Bollinger lists sepsis, asthma, seizure disorder, atrial septal defect, and contusions of the left lower extremity as her final pathologic diagnoses. Under sepsis she lists history of cough and fever, fine papular rash of the torso, acute tracheitis and bronchitis, acute bronchopneumonia, and blood cultures with growth of Streptococcus pneumoniae. In the section of Dr. Bollinger's report entitled "Opinion" she states that Sara's epiglottis was slightly red and swollen, l her trachea was also pink-red, and microscopic examination of the, lungs and OAc & trachea demonstrated acute inflammation and necrosis of the tracleobronchlal f mucoua. She also stated "Focally, the alveolar septae had neutrophilic inflammation which extended into the alveolar spaces. " A post-modem blood culture that was performed at Health Network Laboratories grew two organisms. The first organism reported is Streptococcus pneumoniae, and the second reported organism is alpha hemolytic streptococcus. No antimicrobial susceptibilities are reported for these organisms. • I disagree with several parts of Dr. Bollinger's autopsy report. The findings that she has listed under the heading of "sepsis" in her final anatomical diagnoses are overreaching and are clearly written from the perspective of hindsight. History of fever and cough and fine papular rash of the torso have numerous; causes, including their rare association with sepsis. Similarly, patients with acute tracheitis and bronchitis and acute bronchopneumonia only occasionally develop sepals. Furthermore, blood cultures from patients with sepsis usually only grow a single microorganism. The blood culture that is reported from Health Network Laboratories, in contrast, apparently grew two organisms Streptococcus pneumoniae and alpha hemolytic streptococcus. Alpha hemolytic streptococcus is common contaminant in blood cultures that are collected after an inadequate disinfection of the arm or other site of blood collection. Streptocodcus pneumoniae is generally a pathogenic organism. However, it may be misidentified if the studies performed to identify the organism are not properly quality controlled or are evaluated by not adequately trained personnel. In addition, the antimicrobial susceptibility testing of Streptococcus pneumoniae was not performed. The antimicrobial susceptibility of this organism, if it had been determined, might have helped to confirm it as Streptococcus pneumoniae. Andrew Foulkrod, Esq., Foulkrod Ellis, RE: Hetrick v. Blutstein, st al. 5 • in addition, post mortem blood cultures are often contaminated by the over growth of bacteria in the body after death, particularly if the autopsy occurs several hours after death. This further compromises the reliability of the reported culture results. • While Streptococcus pneumoniae may certainly produce sepsis, the incidence of sepsis and other forms of invasive disease caused by this organism has declined significantly since the introduction and widespread use of the pneumococcal conjugate vaccine. By 2003 a significant reduction in invasive Streptococcus pneumonise infections had been seen in children both through the dlreot effects of vaccination and through "herd immunity," i.e., the decrease in prevalence of Streptococcus pneumonise infection in the general population because antibodies to Streptococcus pneumonia, produced by vaccination, exist in most members of the population. • The antimicrobial susceptibility of the possible Streptococcus pneumonise organism isolated from Sara's blood was not determined; however, most isolates of Streptococcus pneumonise are susceptible to azithromycin, the antibiotic that Dr. Blutstein prescribed for Sara during his office visit with her on the moaning of her death. Dr. Bollinger did not find any evidence of pneumonia by gross examination of the lung tissue, and the chest x-ray performed at the Carlisle Regional Medical Center was also negative for bronchopneumonia, suggesting that significant bronchopneumonia was probably not present. I have also reviewed the lung tissue present in the recut autopsy sections that were supplied to me. There is little acute inflammation involving the alveolar parenchyma of the lung, and in my opinion, the degree of inflammation present is too little to support the diagnosis of bronchopneumonia. Dr. Bollinger described the epiglottis as being only slightly red, discolored, and swollen and described the trachea as being lined by pink-red mucosa. No areas of grossly obvious exudate or necrosis were described at either of these sites. I have reviewed recut sections of the tracheal mucosa and agree with Dr. Bollinger that there is some inflammation of the tracheal mucosa, but most of the inflammation is chronic, and the intense acute inflammation that would be expected with a bacterial infection is not observed. These areas of tracheitis probably correspond to the croup-like illness with cough. • 1 agree with Dr. Bollinger that there is hypertrophy of the bronchiolar smooth muscle, consistent with the history of chronic bronchial asthma. There is also focal chronic inflammation involving the bronchiolar tissue, again consistent with chronic bronchial asthma. • i have reviewed the sections of the brain and agree with Dr. Bollinger that there is no evidence of meningitis or of any other significant intracranial pathology. • In summary, therefore, Sara Zehring's most unfortunate and tragic death is not explained by the autopsy findings. The diagnosis of sepsis advanced by Dr. Bollinger hinges on the blood culture that Is reportedly positive for Straptococcus Andrew Foulkrod, Esq., Foulkrod Ellis, RE: Hetrick v. Biutstein, et al. 6 pneumonia& This is an organism that may be confused with other non- pathogenic bacteria. For all the reasons mentioned earlier, Streptococcus pneumonia* rarely produces sepsis in children with Sara Zehring's findings and history. The inflammation described within the tracheal rnucosa appears to be more consistent with the results of a viral infection, as would be expected in a child with croup. • I also disagree with Dr. Bollinger's contention that Sara Zehring would have had an increased likelihood of survival had she been placed in the hospital setting. This opinion is not supported by the autopsy results conducted by Dr. Bollinger. In any case, her opinion is clearly the result of speculation and viewing her reported findings through the "retrospectoscope." • 1 find the medical care of Dr. Blutstein to be entirely appropriate and to be well within the standard of care. He knew Sara Zehring well. He had been her pediatrician since birth and was very familiar with her past medical history. He suggested a reasonable therapeutic and diagnostic maneuver when contacted by Sara's mother at 3:30 a.m. on January 31, 2005. The prompt response of Sara's cough to exposure to cold air was as would be expected with croup. He suggested to Sara's mom that in any one he should see Sara in the office the next morning and that if Sara's symptoms did not respond she should be taken immediately to a local hospital emergency room. He evaluated her in the office the following morning, offered admission and observation to the local hospital, but Sara's mother opted for observation at home. Dr. Blutstein advised her that if there were any significant change in Sara's signs and symptoms, he should be informed immediately. He prescribed medications for asthma as well as azithromycin, an antibiotic that would likely be effective against Streptococcus pneumoniae. Subsequently, however, Sara tragically developed a respiratory arrest and died for reasons that are unclear. I hold all of these opinions to a reasonable degree of medical certainty. If additional information becomes available, I may wish to issue a supplemental report. I am available to testify at trial regarding these matters. If I can be of further assistance, please contact me. Very truly yours, Arthur H. McTighe, M.D., F.C.A.P S.C.P. ,' CURRICULUM VITAE ARTHUR H. McTIGHE, MD ADDRESS: 107 WITHERSPOON ROAD BALTIMORE, MD 21212 PHONE: 410 433-0346 DATE OF BIRTH: OCTOBER 7,1944 MEDICAL SCHOOL: UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE, M.D., 1969. TRAINING: INTERNSHIP IN PATHOLOGY, PRESBYTERIAN-UNIVERSITY HOSPITAL, PITTSBURGH, PA 1969-70. RESEARCH AND EXPERIMENTAL PATHOLOGY, U.S. PUBLIC HEALTH SERVICE ROCKVILLE, MD 1970-72. FELLOW IN LABORATORY MEDICINE, YALE NEW HAVEN HOSPITAL, NEW HAVEN, CT 1972-74. BOARD CERTIFICATION: AMERICAN BOARD OF PATHOLOGY, ANATOMIC AND CLINICAL PATHOLOGY, 1975. AMERICAN BOARD OF PATHOLOGY, MEDICAL MICROBIOLOGY, 1978. AMERICAN BOARD OF DERMATOLOGY AND AMERICAN BOARD OF PATHOLOGY, DERMATOPATHOLOGY, 1985. AMERICAN BOARD OF PATHOLOGY, CYTOPATHOLOGY, 1997. LICENSED: MARYLAND, PENNSYLVANIA, AND DELAWARE POSITIONS: UNION MEMORIAL HOSPITAL, BALTIMORE, MD MEDICAL DIRECTOR, DEPARTMENT OF LABORATORY MEDICINE and CHIEF OF PATHOLOGY, AUGUST 2004 TO PRESENT EVANGELICAL COMMUNITY "HOSPITAL, LEWISBURG, PA DIRECTOR OF LABORATORIES, 1991-2004 VICE PRESIDENT FOR MEDICAL AFFAIRS/MEDICAL DIRECTOR, JUNE 2000-2004 PATIENT SAFETY OFFICER, 2002-2004 SUNBURY COMMUNITY HOSPITAL, SUNBURY, PA DIRECTOR OF LABORATORIES, MARCH 1997-2004 CURRICULUM VITAE - ARTHUR H. McTIGHE, M.D. PAGE TWO MARYLAND GENERAL HOSPITAL, BALTIMORE, MD VICE CHIEF OF PATHOLOGY, 1979-91 ASSISTANT TO THE MEDICAL DIRECTOR, 1987-1991 FRANKLIN SQUARE HOSPITAL, BALTIMORE, MD, 1977-79. U. S. PUBLIC HEALTH SERVICE HOSPITAL, BALTIMORE, MD, 1974-77. FACULTY: PENN STATE COLLEGE OF MEDICINE MILTON S. HERSHEY MEDICAL CENTER CLINICAL ASSOCIATE PROFESSOR OF PATHOLOGY, 2001-PRESENT. JOHNS HOPKINS UNIVERSITY, SCHOOL OF MEDICINE INSTRUCTOR IN PATHOLOGY, 1978-1993. FELLOW: AMERICAN COLLEGE OF PHYSICIAN EXECUTIVES COLLEGE OF AMERICAN PATHOLOGISTS AMERICAN MEDICAL ASSOCIATION AMERICAN SOCIETY FOR CLINICAL PATHOLOGY MARYLAND SOCIETY OF PATHOLOGISTS (PAST PRESIDENT, 1986-1988) PENNSYLVANIA SOCIETY OF PATHOLOGISTS (CAP DELEGATE 1998-2004) MARYLAND SOCIETY OF PATHOLOGISTS (CAP DELEGATE 2004-PRESENT) HOSPITAL MEDICAL STAFF AND MEDICAL SOCIETY OFFICES: UNION MEMORIAL HOSPITAL, BALTIMORE, MD: MEMBER, MEDICAL EXECUTIVE COMMITTEE CHAIRMAN, LAB MED. PERFORMANCE IMPROVEMENT COMMITTEE MEMBER, INFECTION CONTROL COMMITTEE MEMBER, TUMOR BOARD MEMBER, CANCER COMMITTEE MEMBER, RISK MANAGEMENT COMMITTEE MEMBER, LAB-NURSING PERFORMANCE IMPROVEMENT COMMITTEE EVANGELICAL COMMUNITY HOSPITAL, LEWISBURG, PA: PRESIDENT OF THE MEDICAL STAFF, 1999-2000 VICE PRESIDENT OF THE MEDICAL STAFF, 1997-1999 SECRETARY OF THE MEDICAL STAFF, 1995-1997 MEMBER, MEDICAL EXECUTIVE COMMITTEE, 1995-2004 CHAIRMAN, INFECTION CONTROL COMMITTEE, 1993-2004 VICE CHAIRMAN, BIOETHICS COMMITTEE, 1997-2004 MEMBER, QUALITY ASSURANCE COMMITTEE, 1995-2004 CHAIRMAN, PATIENT SAFETY COMMITTEE, 2002-2004 PATIENT SAFETY OFFICER, 2002-2004 UNION COUNTY (PENNSYLVANIA) MEDICAL SOCIETY, PRESIDENT, 1994-1996 PROGRAM CHAIRMAN, 1996-2004 SUNBURY COMMUNITY HOSPITAL, SUNBURY, PA: MEMBER, MEDICAL EXECUTIVE COMMITTEE, 1997-2004 CHAIRMAN, INFECTION CONTROL COMMITTEE, 1997-2000 CHAIRMAN, TISSUE AND TRANSFUSION COMMITTEE, 1997-2000 MEMBER, PATIENT SAFETY COMMITTEE, 2002-2004 CURRICULUM VITAE - ARTHUR H. McTIGHE, M.D. PAGE THREE CURRENT MEDICAL STAFF PRIVILEGES: UNION MEMORIAL HOSPITAL, BALTIMORE, MD (ACTIVE) EVANGELICAL COMMUNITY HOSPITAL, LEWISBURG, PA. (NOW HONORARY) SUNBURY COMMUNITY HOSPITAL, SUNBURY, PA. (NOW HONORARY) MARYLAND GENERAL HOSPITAL, BALTIMORE, MD. (NOW AFFILIATE) HONORS AND AWARDS: GOLDEN APPLE AWARD, FOR OUTSTANDING TEACHING, 1984-1985, PRESENTED BY THE DEPARTMENT OF MEDICINE HOUSESTAFF, OF THE MARYLAND GENERAL HOSPITAL. CERTIFICATE OF APPRECIATION, PRESENTED BY THE BALTIMORE POLICE DEPARTMENT, 1987, FOR SERVICE IN DEVELOPING A PROGRAM FOR EXPEDITED HIV TESTING. CERTIFICATE OF APPRECIATION, PRESENTED BY THE MEDICAL STAFF OF THE MARYLAND GENERAL HOSPITAL, 1991, FOR DEDICATED SERVICE TO THE INSTITUTION AND THE MEDICAL STAFF. CERTIFICATES OF APPRECIATION, PRESENTED BY THE COLLEGE OF AMERICAN PATHOLOGISTS, IN 1999, 2000, 2001 AND 2003, FOR OUTSTANDING AND DEDICATED SERVICE IN ADVOCATING FEDERAL AND STATE ISSUES OF IMPORTANCE TO PATIENTS, CLINICIANS AND PATHOLOGISTS. OTHER EXPERIENCE: ASSISTANT TO THE MEDICAL DIRECTOR, MARYLAND GENERAL HOSPITAL, 1987-1991 WITH RESPONSIBILITY FOR HEALTH INFORMATION SERVICES, QUALITY ASSURANCE, UTILIZATION REVIEW, AND INFECTION CONTROL. CO-OWNER AND PATHOLOGIST OF THREE PRIVATE LABORATORIES IN BALTIMORE, MARYLAND 1981-1991 (BALTIMORE BIOMEDICAL LAB, PHYSICIANS' SERVICE LAB, AND BALTIMORE DIAGNOSTICS LAB). MEDICAL DIRECTOR, SMITHKLINE BEECHAM CLINICAL LABORATORIES, BALTIMORE REGIONAL LAB, 1986-1991. COLLEGE OF AMERICAN PATHOLOGISTS (CAP), INSPECTOR LAB ACCREDITATION PROGRAM, 1985 TO PRESENT MEMBER, PATHOLOGY ADVOCACY NETWORK, 1992 TO PRESENT, FOR ADVOCACY AT THE FEDERAL AND STATE LEVELS ON PATHOLOGY, PHYSICIAN, HOSPITAL, AND PATIENT ISSUES. DELEGATE FROM MARYLAND TO CAP HOUSE OF DELEGATES MEMBER CAP HOUSE OF DELEGATES STEERING COMMITTEE CHAIR, CAP HOUSE OF DELEGATES STEERING COMMITTEE TASK FORCE ON PATIENT SAFETY IN PATHOLOGY PRACTICE MEMBER, BOARD OF DIRECTORS, PATHOLOGY POLITICAL ACTION COMMITTEE (PathPAC), 1999 TO 2007. MEMBER, CAP SPOKESPERSONS NETWORK, 1995 TO PRESENT. MARYLAND STATE COMMISSIONER, CAP, LAB ACCREDITATION PROGRAM. PENNSYLVANIA STATE HOUSE OF REPRESENTATIVES MEMBER, WORK GROUP ON AIDS AND HIV POLICY, 1999. TESTIMONY BEFORE THE INDEPENDENT REGULATORY REVIEW COMMISSION (IRRC) OF PENNSYLVANIA, RE: HIV REPORTING REGULATIONS, 2002. CURRICULUM VITAE - ARTHUR H. McTIGHE, M.D. PAGE FOUR PUBLICATIONS: McTIGHE, A.H., ANTIMICROBIAL RESISTANCE OF NEISSERIA GONORRHOEAE, LABORATORY MEDICINE, 9:45-48,1978. McTIGHE, A.H. and CHIN, B., USE OF AN AGGLUTINATION METHOD IN THE LABORATORY DIAGNOSIS OF NEISSERIA GONORRHOEAE, ABSTRACTS OF THE ANNUAL MEETING OF THE AMERICAN SOCIETY FOR MICROBIOLOGY 1979, (PRESENTED AT THE POSTER SESSION, MAY 5, 1979, HONOLULU, HI). MCTIGHE, A.H., CHIN, B., PATEL, C., and SMITH, L., USE OF AN AGGLUTINATION METHOD IN THE LABORATORY DIAGNOSIS OF NEISSERIA GONORRHOEAE, ABSTRACTS OF THE ANNUAL MEETING OF THE AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS 1980, (PRESENTED AT THE POSTER SESSION, MARCH 26, 1980, ATLANTA, GA). McTIGHE, A.H., PATEL, C., SMITH, L. ET AL, CONTINUING EDUCATION UPDATE: MICROBIOLOGY I. LABORATORY MEDICINE, 11:524-532,1980. McTIGHE, A.H., GONORRHEA DIAGNOSIS WITH CERTAINTY. DIAGNOSTIC MEDICINE, 3:36-57,1980. WEINBERG, L.G. and McTIGHE, A.H., A SIMPLE, RAPID SCREENING SYSTEM FOR IDENTIFICATION OF THE BACTEROIDES FRAGILIS GROUP, ABSTRACTS OF THE ANNUAL MEETING OF THE AMERICAN SOCIETY FOR MICROBIOLOGY 1981, (PRESENTED AT THE POSTER SESSION, MACH, 1981, HOUSTON, TX). McTIGHE, A.H., FISHER, B. and PATNAIK, P., PENICILLIN-RESISTANT GONORRHEA: CATCHING THE PENICILLIN RESISTERS. DIAGNOSTIC MEDICINE, 4:47-50,1981. McTIGHE, A.H., THE SEASON FOR VIBRIOS. DIAGNOSTIC MEDICINE, 4:33-36,1981. MCTIGHE, A.H., ANTENATAL AND NEONATAL BACTERIAL INFECTIONS: PATHOGENESIS, SIGNIFICANCE, AND DIAGNOSIS. CLINICS IN LABORATORY MEDICINE, 1: 345-360,1981. McTIGHE, A.H. (EDITOR), SYMPOSIUM: BACTERIOLOGIC SYNDROMES OF THE 1970s AND 1980s, LABORATORY MEDICINE, 13:611-643,1982. ANTHONY, W.C. and MCTIGHE, A.H., MECHANISMS OF DRUG RESISTANCE: STAPHYLOCOCCUS AUREUS and NEISSERIA GONORRHOEAE. LABORATORY MEDICINE, 13:618-620,1982. McTIGHE, A.H. GARDNERELLA VAGINALIS: ROLE IN NONSPECIFIC VAGINITIS AND OTHER SYNDROMES. LABORATORY MEDICINE, 13:624-626,1982. CURRICULUM VITAE - ARTHUR H. McTIGHE, M.D. PAGE FIVE PUBLICATIONS (CONTINUED): ORBEGOSO, C. M., ULANOWICZ, N.I. and McTIGHE, A.H., NEW ANAEROBIC BACTERIOLOGIC SYNDROMES. LABORATORY MEDICINE, 13:628-632,1982, McTIGHE, A.H., ASSOCIATION OF KAPOSI'S SARCOMA AND OPPORTUNISTIC INFECTIONS IN HOMOSEXUALS. LABORATORY MEDICINE, 13:633-636,1982. McTIGHE, A.H., CHLAMYDIA TRACHOMATIS: REVIEW OF HUMAN CHLAMYDIAL INFECTIONS AND LABORATORY DIAGNOSIS. LABORATORY MEDICINE, 13:638-643,1982. MCTIGHE, A.H., COMPARISON OF IMMULOK CULTURESET WITH REFERENCE TISSUE CULTURE METHODS IN THE DIAGNOSIS OF GENITAL HERPETIC INFECTION, ABSTRACTS OF THE ANNUAL MEETING OF THE AMERICAN SOCIETY FOR MICROBIOLOGY 1983, (PRESENTED AT THE POSTER SESSION, MARCH 1983, NEW ORLEANS, LA). COURSES AND WORKSHOPS PRESENTED: UPDATE IN MEDICAL MICROBIOLOGY, AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS WORKSHOP, PHILADELPHIA, PA, APRIL 24, 1982. NEW MICROBIOLOGICAL SYNDROMES OF THE 1970s AND 1980s, AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS WORKSHOP, PHILADELPHIA, PA, SEPTEMBER 10, 1983. NEW MICROBIOLOGICAL SYNDROMES OF THE 1970s AND 1980s, AMERICAN SOCIETY OF CLINICAL PATHOLOGISTS WORKSHOP, MONTGOMERY, AL, APRIL 27, 1984. SEXUALLY TRANSMITTED DISEASES LAB THEORY AND PRACTICE, PRESENTED AS A PART OF THE STD CLINICIAN TRAINING COURSE, CITY OF BALTIMORE, HEALTH DEPARTMENT, 1983 AND 1984. INTERPRETING LAB RESULTS, WORKSHOP SPONSORED BY RESOURCE APPLICATIONS, PRESENTED IN WASHINGTON, DC, NEW YORK CITY, BOSTON, TORONTO, MONTREAL, CALGARY, EDMONTON, VANCOUVER, LOS ANGELES AND SAN FRANCISCO, 1983, 1984 AND 1985. LABORATORY TESTS: INTERPRETATION AND IMPLICATIONS, PRESENTED AT TRITON COLLEGE, RIVER GROVE, ILLINOIS, JULY 11, 1987. OTHER PRESENTATIONS: NUMEROUS MORBIDITY AND MORTALITY, TUMOR BOARD, SURGICAL PATHOLOGY, AUTOPSY PATHOLOGY, GYNECOLOGIC PATHOLOGY, MEDICAL GASTROINTESTINAL PATHOLOGY, AND GRAND ROUNDS PRESENTATIONS WITH ADDITIONAL DIDACTIC PATHOLOGY LECTURES TO HOUSESTAFF (ON AVERAGE ONCE A WEEK FOR MANY YEARS). _ERTIFIC ATE aF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing ion counsel of record and all interested was served parties this day of 'depositing said copy in the United States Mail at Camp Hill, Pennsylvania, postage :paid, first class delivery, and addressed as follows: Terry S. Hyman, Esquire Schmidt Kramer, p.C. 209 State Street Harrisburg, pA 17101 FOULKRQD ELLIS Professional Corporation Crystal L. Nemet" h1 i i "1 t i ? ,.j ? ;.. i `?.- m_ t ? .: :, ?' ,