2.  I enjoyed an extremely close and loving relationship with my late wife.  I was her health care proxy, and throughout the hospitalization right up to the time ██████ was in the operating room, we discussed her care and the recommendations of those providing medical care.

3.  It has been brought to my attention by my attorney that the anesthesiologist shortly before the operation said that ██████ was at very high risk for anesthesia complications including never awakening from anesthesia or dying.  This simply is untrue.  In addition, my attorney has informed me the anesthesiologist testified when he informed my wife of the very high risks associated with anesthesia, she told the anesthesiologist that she would rather die than to be like she was before the surgery.  Once again, this statement attributed to my wife is simply untrue.

4.  As I previously testified, the person I understand to be the anesthesiologist met with my wife and in my presence for about 30 seconds, and while I don't recall what he said, he certainly didn't mention about any risks, let alone being at high risk for death.  I know that if my wife had been told that by going through the surgery she was at high risk for death or not coming out of the anesthetic, she and I would have agreed to forego the surgery and take medication when necessary and restrict her activities if necessary.

5.  Finally, I had an opportunity to review the videotaped testimony of Dr. █████████ in my attorney's office and am able to confirm based on the video that the person in the video is the person who I saw and heard speak to my wife on the day of the surgery.

Nurse ██████ Did Not Deviate from the Standard of Care

83.          For the reasons stated in paragraphs 60-70 above, the allegations listed in those paragraphs are without merit as to Nurse ██████. The remaining allegations will be addressed below.

84.          Plaintiff alleges that Nurse ██████ failed to provide someone properly qualified or trained with respect to anesthesia care or call for help or assistance during and after the operation performed by Dr. ████████ and failed to have a fully trained anesthesiologist present and available at all times. This allegation is without merit since Nurse ██████ does not provide the personnel for the surgery; she is assigned to the case. She, herself, was a properly qualified certified nurse anesthetist assigned to the case. As for calling for help or assistance during or after the surgery, there was no need for Nurse ██████ to do so as the patient's medical course during Nurse ██████'s involvement in the case was acceptable and the hypotensive episodes were properly addressed by whoever addressed them. Furthermore, whether Dr. █████████, Nurse ██████, or Dr. ██████ provided the anesthesia care, they were all fully trained to provide anesthesia care in this case and the anesthesia care provided fell within the standard of care.

85.          Plaintiff alleges that Nurse ██████ failed to document the actions of those involved in the anesthesia care.  Nurse ██████ did not deviate from the standard of care in failing to document the actions of those involved in the anesthesia care. The chart adequately documents the events of anesthesia, including intubation, extubation, the medications and gases given, and the patient's response to same. Moreover, any lack of documentation of those who were involved and their actions had no effect on the patient's medical course and was not a proximate cause of the alleged injuries. That is because the documentation of the blood pressures and the medications given demonstrates that the anesthesia care that was provided fell within the standard of care.

86.          Plaintiff alleges that Nurse ██████ failed to communicate with the surgeon that the plaintiff-decedent was at high risk for anesthesia death; and failed to suggest either before or during the surgery that the plaintiff-decedent was too high a risk to go forward with the surgery. This allegation is without merit since even if she did not communicate with the surgeon that the patient was at high risk of anesthesia death, the patient consented to the surgery after being advised of the surgical risks and the anesthesia risks. The anesthesia consent states the risks of blood clots, stroke, and death.  As for failing to suggest that the patient was too high a risk to go forward with the surgery, the surgeon and the attending anesthesiologist make that decision, not the nurse anesthetist.

87.          Plaintiff alleges that Nurse ██████ failed to document any communication with the surgeon both pre-op, during the surgery, and post op. That allegation is without merit. The standard of care does not require the nurse anesthetist to document any and all communications with the surgeon. Furthermore, any lack of documentation of communications with the surgeon had no effect on the patient's medical course. That is because the anesthesia care provided in connection with the surgery, by whoever provided it, fully complied with the standard of care.

88.          Plaintiff alleges that Nurse ██████ failed to recognize the patient's special needs in light of her pre-existing conditions going into the operation; failed to address low hemoglobin and hematocrits; failed to transfuse the patient; failed to provide stress dose steroids; and failed to make proper recommendations prior to or at the start of the surgery and post-surgery.

89.          Those allegations are without merit. Nurse ██████ took due cognizance, in her role as a nurse anesthetist, of the patient's medical condition, which included two prior cancers and ongoing chemotherapy. It is the attending anesthesiologist and the surgeon who determine how to address low hemoglobin and hematocrit and whether the patient needs a blood transfusion, not the nurse anesthetist. Also, this patient was not in need of a blood transfusion, so the allegation of failure to transfuse is without merit. She was not in need of a blood transfusion since her hemoglobin was acceptable at 9.1 as per guidelines. There is no recommendation that Nurse ██████ failed to make before or at the end of the surgery, so that allegation is without merit.

90.          As for the allegations as to failure to administer stress dose steroids, Nurse ██████ testified that she definitely gave them at surgery – 100 mgs of Hydrocortisone before surgery. That dosage and that drug are appropriate. She did not document that she gave those drugs, but the patient's ultimate course indicates that she did not suffer from an adrenal crisis. Stress dose steroids are given before surgery to surgical patients who are on long-term steroids so as to avoid an adrenal crisis. An adrenal crisis is evidenced by the patient going into shock. Shock involves uncontrollable low blood pressures. While the patient had episodes of hypotension at surgery, she did not have dangerously low blood pressures and she did not go into shock. Also, the patient's hypotension was improved by the timely use of the appropriate drugs – Phenylephrine and Ephedrine. Therefore, even if stress dose steroids were not given, it would not have changed the patient's medical course or outcome.

91.          Plaintiff alleges that Nurse ██████ failed to provide proper supervision for the CRNA. This allegation is without merit and cannot possibly apply to Nurse ██████, who is the CRNA.

92.          Plaintiff alleges that Nurse ██████ made false statements regarding the status of the plaintiff-decedent's immediately post-op, including during the extubation of patient as well as to what the patient's status was in the recovery room. This allegation is without merit. Nurse ██████'s documented emergence at 1:13 p.m., including suctioning, own airway, and sustained head lift. That documentation falls within the standard of care for documenting emergence.

93.          Plaintiff alleges that Nurse ██████ prematurely and inappropriately extubated the patient and failed to timely call for help from a qualified physician both during and after the operation in question. That allegation is without merit. Nurse ██████ properly extubated the patient, and documented appropriately in the chart that she suctioned the patient, the patient was using her own airway and had a sustained head lift.  A patient who has a sustained head lift upon extubation has properly emerged from anesthesia.

94.          Plaintiff alleges that Nurse ██████ failed to document any communication either she or Dr. █████████ had prior to the operation in question or during the operation in question with Dr. ██████ as to the plaintiff's pre-operative status and that Dr. ██████ would be relieving ██████████████; failed to document that she was being relieved by Dr. ██████; and failed to document when she left the operating room and when she returned.

95.          Those allegations are without merit. It was not a deviation from the standard of care not to document any such communication that either she or Dr. █████████ had with Dr. ██████ before the surgery or during the surgery, or regarding Dr. ██████ relieving Nurse ██████, or regarding when Nurse ██████ left and returned to the operating room. It is customary that anesthesia providers are given breaks by other anesthesia providers during surgery. It is not a deviation from the standard of care not to document who provides the breaks or when anesthesia providers leave or return to the room. Furthermore, the anesthesia care provided by the anesthesia provider, whether it was Dr. █████████, Nurse ██████, or Dr. ██████, complied with the standard of care. Therefore, any lack of documentation of communication with Dr. ██████ or of when Nurse ██████ left and returned to the operating room had no effect on the patient's medical course and was not a proximate cause of her alleged injuries or death.

No Act or Omission Proximately Caused The Alleged Injuries or Death

96.          No act or omission on the part of Dr. █████████ or Nurse ██████ caused or contributed to the decedent's alleged injuries or death.

97.          The CT stroke study that was done on the patient on March 20, 2015, did not diagnose a stroke.  A CT scan, however, does not always diagnose a stroke. A brain MRI was then ordered to rule out a stroke or metastatic lesion.

98.          Upon my review of the brain MRI done on March 22, 2015, it shows findings compatible with an extensive cerebral infarction. As radiologist Dr. ████████, who read the brain MRI stated, it shows extremely extensive diffusion in all vascular territories of the cerebral hemispheres, midbrain, brainstem, and posterior fossa. Such findings are consistent with an extensive cerebral infarction. A cerebral infarction causes a stroke, and occurs when a blood vessel becomes blocked or leaks outside of the vessel walls.

99.          Significantly, the brain MRI does not show a watershed territory infarction, as Dr. ████████ indicated on her radiology report. A watershed territory infarction is a finding associated with global hypoperfusion of the brain. Hypoperfusion means inadequate supply of blood to an organ (such as the brain) or extremity. A watershed stroke is a brain ischemia occurring at the border zones between the tissues supplied by the anterior, posterior, and middle cerebral arteries. The watershed areas of the brain are the regions of the brain that simultaneously receive blood supply from two separate groups of arteries.  Watershed infarcts typically occur following reduced perfusion pressure, often secondary to cardiac events or severe bleeding.

100.        If the patient had sustained an anoxic brain injury because of hypotensive episodes during surgery, one would expect to see evidence on the brain MRI of a watershed territory infarction. The lack of that finding makes it much more likely than not that the patient did not experience an anoxic brain injury. Furthermore, the hypotensive episodes at surgery did not involve dangerously low blood pressure and were of a limited duration, and would not have caused an anoxic brain injury. Also, the patient's oxygen saturations during surgery were in the high 90s, which is consistent with the patient not having experienced brain anoxia during the surgery.

101.        Moreover, the brain MRI supports that the patient experienced a stroke caused by emboli. An embolus is a blood clot.  Because of the extensive diffusion seen on the brain MRI, one would consider a widespread embolic shower as the cause of her stroke. A widespread embolic shower is not caused by hypotensive blood pressures at surgery.

102.        That the cause of the patient's alleged injuries and death is due to an embolic stroke, and not due to an anoxic brain injury, is also strongly supported by other facts in the record.

103.        The patient had risks for blood clotting. First, her cancer itself causes a hypercoagulable state, and makes her more vulnerable to blood clots. Second, the surgeon elected to prescribe the patient tranexamic acid at surgery, which reduces bleeding but promotes blood clotting. Third, the type of surgery she had – hip surgery – carries with it an increased risk of emboli because of the proximity of the surgery to major blood vessels supplying the legs.

104.        Also, the fact that the patient's echocardiogram on March 22, 2015, showed severe pulmonary hypertension and right ventricular dilatation is significant. Pulmonary hypertension and right ventricular dilatation may be a marker of emboli going to the lungs and may indicate a hypercoagulable state generating emboli throughout the body.

105.        Therefore, it is my opinion within a reasonable degree of medical certainty, that the cause of the patient's alleged injuries and death was a brain infarction caused by an embolic shower. It is my opinion, to reasonable degree of medical certainty, that the patient's alleged injuries and death were not proximately caused by the transient hypotensive episodes that she experienced during surgery.

8.  In sum it is my opinion that there is sufficient evidence in the material I have reviewed to support my opinion that the defendants deviated from the standards of good and accepted medical practice in treating the decedent during her admission to ████, and there is also sufficient evidence to support a finding that the decedent's death was causally related to the actions or omissions of the defendants.

9.  This patient was frail with multiple comorbidities, not the least of which was she had been receiving steroids for her lung cancer.  I agree with Dr. █████████ that this patient should have been provided with stress dose steroids at the outset of this case.  As I reviewed the medical records, I would have expected to see, in accordance with the standard of care that there would have been a recording in both the anesthesia record as well as in the medical administrative record that stress dose steroids were ordered and given.  Unfortunately, there was no record in either place.  I am certainly not in a position to state whether the stress dose steroids were given or not.  However, what I can say if Nurse ██████ did not provide the stress dose steroids as ordered by Dr. █████████, this would have been a clear deviation from accepted practice.  I agree with both Dr. █████████ and also Nurse ██████ that giving the stress dose steroids was very important, in part because they would have been beneficial in the face of prolonged and refractory hypotension as was present during this case.  Once again, in my opinion, if the stress dose steroids were not given, it would have been a contributing factor to the profound and refractory hypotension which more than likely was the cause of inadequate circulation to the brain leading to anoxia and brain damage.

10.  In my opinion there was a significant deviation of the standard of care during the critical period of time between 11:40 and 12:04 when the patient was experiencing dangerously low blood pressures otherwise referred to as significant periods of hypotension that were not being properly managed.  During this time, and as a consequence of anesthetic administration including the drugs, Fentanyl, Propofol, Midazolam and Sevoflurane, ████████████'s blood pressure descended from her baseline of 108/63 at 11:35 to extremely low levels thereafter.  Following the administration of these drugs, her blood pressure fell to 56/41 at 11:40 and remained dangerously low with a repeat value of 57/38 taken ten minutes later at 11:50 and 57/38 at 11:51.  Severe hypotension continued and at 12:02 the blood pressure was also very low at 65/39.  Only by 12:04 did the blood pressure normalize leaving the interval between 11:35 and 12:04 (or a period as long as 29 minutes), during which ████████████'s cerebral circulation was jeopardized and compromised by severe hypotension.  During this long interval of hypotension there were only 2 minutes of respite at 11:53 and 11:54 when the blood pressure was restored by the use of two drugs known as vasopressors, namely phenylephrine and ephedrine.  The effect of these drugs was fleeting, however, as once their effect wore off, the blood pressure fell precipitously again.

11.  It is my opinion that the anesthesia team mismanaged the decedent's blood pressures between 11:40 and 12:04.  The management of the blood pressure was unacceptable and outside the standard of care.  The medical record, including both the anesthesia records as well as the recorded Vital Signs Records ( See pp. 680-681 of Exhibit S), establish and show this patient was experiencing profound hypotension.  The medications that were provided to address these dangerously low blood pressures were grossly inadequate for the clinical presentation.   This was not a healthy patient and because of her anemia, frailty and comorbidities, the standard of care required and necessitated phenylephrine and/or ephedrine to be provided at 3-5 minute intervals continuously until appropriate restoration of appropriate blood values were achieved.  Both phenylephrine and ephedrine have an extremely short duration of action lasting at best for only a few minutes at a time.  In this case given the nearly half hour interval during which refractory hypotension was evident, the administration of these vasopressors needed to be more frequent and in larger doses.  It is clear that whoever was providing the anesthesia care during this critical period of time grossly underdosed the vasopressors and did not appropriately correct the hypotension.    Furthermore, during this prolonged period of hypotension during which the cerebral circulation was vulnerable to the inadequacy of oxygenation, the patient was also being hyperventilated as evidenced by the end tidal carbon dioxide monitoring.  This was recorded on the anesthetic record and indicative of significant hyperventilation with values generally in the range of 25 to 29 during this period.   Carbon dioxide serves as a fundamental regulation of cerebral blood flow with the lower values seen here as causative to cerebral vasoconstriction resulting in lower blood flow to the brain.  This physiologic disruption coupled together with the profound hypotension would be expected to result in an additive compromise to brain oxygenation.

12.  In my opinion the "anesthesia team" which consisted of Dr. █████████, Nurse ██████ and Dr. ██████, deviated from accepted medical practice in the management of this patient.  It should be emphasized that the medical records do not support that Dr. ██████ was actively involved in the management of this patient's anesthesia care during the hypotensive time period but indicates it was Nurse ██████.  However, the deposition testimony of Nurse ██████ placed Dr. ██████ in the operating room providing the anesthesia care during the time period while she was at lunch.  I am not in a position to resolve this issue.   Therefore my opinion is that whoever was in the operating room during the critical time period of severe hypotension deviated from accepted practice in their management of this patient's care.

13.  The fact that the patient's blood pressure was adequately restored by 12:04 in this case does not indicate that substantial brain injury did not evolve during the interval prior to this.  In my opinion the damage to the patient's brain due to impaired circulation and oxygen deprivation had occurred during the significant periods of hypotension between 11:40 and 12:04.

14.  In my opinion ████████████'s profoundly low blood pressure needed to be treated more aggressively especially in light of the notable respiratory alkalosis, and that the failure to do so was a clear deviation from the standard of care.  The standard of care required that whoever was in the operating room needed to provide more frequent and higher doses of vasopressor medications, and had they been provided, the decedent more likely than not would not have suffered brain damage and death as a result of being deprived of the oxygen to her brain.   The fact that the patient's blood pressure was restored around 12:04 does not rule out the evolving damage that had been done prior to this time.

15.  The medical records, including the MAR records, would provide more than sufficient evidence to conclude that it was Nurse ██████ alone who was managing the patient's anesthesia care after induction and until extubation.    In reviewing the Medication Administration Records during the time from in question it shows that ██████ both ordered and provided medications (pp. 150-151- Exhibit S).  In looking at that portion of the ████ chart entitled "Vital Signs" from 11:35 through 12:06 the records say the Vital Signs including blood pressures were recorded by Nurse ██████ (See pp. 680-682).  In my opinion, if it is true that Nurse ██████ alone was in charge of this patient's care during the critical period of time, the standard of care would have been for her to call either her supervising attending or another anesthesiologist when the patient experienced these significant episodes of hypotension.  Although Ms. ██████ is an experienced CRNA, she is not an anesthesiologist and, as such, is required to be supervised by an anesthesiologist.  In this case from my review of the records, it was readily apparent that the profound and sustained hypotension warranted, under the standard of care, that she call for help.  Ironically in reviewing Nurse ██████'s deposition testimony, she agreed that, "if she had these blood pressures for that length of time, she would call the anesthesiologist."  However, once again, because Nurse ██████ has testified she was not in the room during this critical period of time since she had been relieved by Dr. ██████, I am not in a position to determine any issues of credibility.

16.  I have had an opportunity to view the affirmation of a neuroradiologist who I understand has been retained by plaintiff's counsel and has provided an opinion that the patient's death has resulted from a global deprivation of oxygen which is fully consistent with significant and profound episodes of hypotension as reflected in the anesthesia records and consistent with my opinion.