LymeNet Law Pages
Case History Document



Hanania v Abemayor, et al
Entered By: Ira M Maurer/LymeNetDate Created: 10/4/94
Document Type: Other
Title: Trial Testimony Of Dr. Raymond Dattwyler


SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NASSAU: PART 4
------------------------------------------------------------------------X

ALONY HANANIA, INDEX NO.
8368/96
Plaintiff,

- against -

COMMUNITY HEALTH PROGRAM OF QUEENS AND NASSAU
d/b/a CHP; VIOLET ABEMAYOR, M.D.; and JEANETTE
KOBEL-PEREZ, R.P.A.,

Defendants
-----------------------------------------------------------------------X
Mineola, New York
Tuesday, September 15, 1998

B E F O R E: HON. HOWARD E. LEVITT,
Supreme Court Justice.

A P P E A R A N C E S:

ELKIND, FLYNN & MAURER, PC
11 Martine Avenue
White Plains, New York
by: IRA M. MAURER, ESQ.
Attorney for Plaintiff



BARTLETT, McDONOUGH, BASTONE & MONAGHAN
81 Main Street
White Plains, New York
by: GARRETT LEWIS, ESQ.
Attorney for Defendant







Valerie M. Cole
Official Court Reporter













1 62

10:23:24 2 (The following takes place in the presence of the jury.)

10:25:32 3 THE COURT: I apologize for the late time

10:25:34 4 that we're starting, but, unfortunately even

10:25:38 5 when a case is in progress, emergency situations

10:25:40 6 come up where people are asking for injunctions

10:25:44 7 to stop certain things happening, or to make

10:25:46 8 sure that certain things happen that others do

10:25:48 9 not want to happen, and I must take them when

10:25:52 10 they come in and hear argument and make a

10:25:54 11 decision. So that's what's taken up the time

10:25:56 12 between 9:30 and 10:30. Hopefully we'll do

10:26:00 13 better as time goes by.

10:26:04 14 MR. MAURER: Your Honor, with the Court's

10:26:04 15 permission, I'm going to interrupt the

10:26:06 16 plaintiff's testimony for the purpose of

10:26:08 17 offering the testimony of Dr. Raymond Dattwyler.

10:26:14 18 THE COURT: Very good. The doctor here?

10:26:14 19 MR. MAURER: Yes, he is. Would you please

10:26:16 20 take the stand, Dr. Dattwyler.

21 R A Y M O N D D A T T W Y L E R, M. D., called

22 by Plaintiff, residing at 18 Woodhull Road, East Setauket,

23 New York, was duly sworn and testified as follows:

10:27:08 24 THE COURT: Yes, sir.

25



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1 Dattwyler - Plaintiff - Direct 63

2 DIRECT EXAMINATION

10:27:10 3 BY MR. MAURER:

10:27:10 4 Q Are you duly licensed to practice medicine in

10:27:12 5 the State of New York, Doctor?

10:27:14 6 A Yes, I am.

10:27:14 7 Q Would you be kind enough to summarize for the

10:27:18 8 Court and jury what you are educational background is?

10:27:20 9 You can start from college and move up to graduate school,

10:27:24 10 please?

10:27:24 11 A Sure. I graduated from Hofstra in 1967, then I

10:27:30 12 went on to Buffalo and got a master's degree in

10:27:36 13 microbiology and an M.D., State University of New York at

10:27:40 14 Buffalo, and I graduated from there in 1973. I then did a

10:27:46 15 medical internship at University of Wisconsin, Madison. I

10:27:50 16 then did two years of research fellowship in immunology at

10:27:58 17 Mayo Clinic. I went then to Tufts New England Medical

10:28:04 18 Center where I finished up my internal medicine residency,

10:28:06 19 and went to Harvard Massachusetts General Hospital for

10:28:12 20 another fellowship. I then joined the faculty at Harvard,

10:28:18 21 went into private practice for a year and then came down

10:28:20 22 to Stony Brook. At Stony Brook I'm professor of medicine,

10:28:26 23 chief of the Lyme disease group and chief of the allergy

10:28:32 24 clinical immunology group.

10:28:36 25 Q Are you board certified?



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1 Dattwyler - Plaintiff - Direct 64

10:28:38 2 A Yes. I'm board certified in internal medicine,

10:28:42 3 allergic clinical immunology and diagnostic laboratory

10:28:46 4 immunology.

10:28:48 5 Q What does it mean to be board certified?

10:28:50 6 A It means you have a certain educational

10:28:52 7 background and you're eligible to take a test which

10:28:54 8 certifies that you have a certain level of knowledge.

10:29:00 9 Q Have you participated in any specific

10:29:04 10 organizations that pertain to your field of expertise?

10:29:10 11 A Yes. I'm a consultant to Center for Disease

10:29:14 12 Control vector-borne disease group, the FDA antiinfectives

10:29:20 13 group which is antibiotics, the FDA vaccine group. I've

10:29:28 14 been on a study section which reviews grants and proposals

10:29:36 15 for NIH. I've been involved with World Health

10:29:40 16 Organization and their Lyme disease efforts.

10:29:42 17 Q NIH stands for what?

10:29:46 18 A National Institute of Health.

10:29:46 19 Q CDC stands for --

10:29:48 20 A Center for Disease Control.

10:29:50 21 Q And these are what type of agencies?

10:29:54 22 A They're governmental agencies that deal with

10:29:56 23 public health and infectious diseases.

10:29:58 24 Q Have you attended and presented at any

10:30:02 25 conferences dealing with the subject of Lyme disease?



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1 Dattwyler - Plaintiff - Direct 65

10:30:04 2 A Yes. Many of them starting with the second

10:30:10 3 international conference on Lyme disease. I think I've

10:30:14 4 been at H-1, I've been a presenter at H-1, and I've been

10:30:18 5 involved in organizing a couple of them.

10:30:26 6 Q Have you published any articles dealing with the

10:30:30 7 subject of Lyme disease?

10:30:30 8 A Yes.

10:30:32 9 Q Or on Lyme-related conditions?

10:30:34 10 A My area of research has been Lyme disease, and

10:30:38 11 I've published quite a few. I don't know how many right

10:30:42 12 now. Over 80 and some book chapters, other things.

10:30:46 13 Q Have you performed any studies of any type

10:30:48 14 related to the subject of diagnosis and/or treatment of

10:30:52 15 Lyme disease?

10:30:54 16 A I am a member of the Center for Disease Control

10:31:00 17 serology panel. That's the panel that has looked at the

10:31:06 18 laboratory diagnosis of Lyme disease, how best to do it,

10:31:10 19 and I've been a participant in their recommendations,

10:31:14 20 which are sort of the national recommendations for how one

10:31:18 21 goes about the laboratory diagnosis of Lyme disease. I've

10:31:24 22 also written and done studies on treatment of Lyme disease

10:31:28 23 and the immunodiagnosis of Lyme disease and the genetics

10:31:36 24 of the bacteria that causes Lyme.

10:31:38 25 Q When did you first get involved with the subject



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1 Dattwyler - Plaintiff - Direct 66

10:31:40 2 of Lyme disease?

10:31:44 3 A When I moved from down here from Boston I

10:31:48 4 started. So probably around 1982, 1983 is when I started

10:31:54 5 to get really involved.

10:31:56 6 Q I'd like to ask you some general questions about

10:31:58 7 the subject of Lyme disease. First of all, what is Lyme

10:32:04 8 disease, generally?

10:32:04 9 A Well, Lyme disease is an infection. It's an

10:32:08 10 infectious disease. It's spread by a tick and it's a

10:32:12 11 bacterial disease. It's actually caused by a spirochete

10:32:14 12 and the spirochete is just a corkscrew-shaped bacteria,

10:32:20 13 and it's always spread by ticks. The tick, when it's

10:32:22 14 feeding upon you, actually sucks blood in and then spits

10:32:26 15 back a little blood and saliva. The saliva -- the tick

10:32:30 16 saliva acts as an anticoagulant, so your blood doesn't

10:32:34 17 clot, and it's during that feeding process that the

10:32:38 18 spirochete gets inoculated into the skin and it grows

10:32:40 19 there. Actually I have some slides that point that out,

10:32:44 20 that go through that process.

10:32:46 21 Q Would these slides assist in your presentation

10:32:48 22 in explaining?

10:32:50 23 A Sure.

10:32:50 24 MR. MAURER: With the Court's permission?

10:32:52 25 THE COURT: Any objection?



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1 Dattwyler - Plaintiff - Direct 67

10:32:52 2 MR. LEWIS: I have no objection, Judge.

10:32:54 3 THE COURT: All right. Yes, by all means

10:32:56 4 you can step down and --

10:33:18 5 A If you look at what happens in Lyme, the tick

10:33:22 6 feeds at an area of the skin and the bacteria gets

10:33:26 7 inoculated in there, and the bacteria actually grows there

10:33:30 8 locally. About three quarters of individuals will develop

10:33:32 9 a very characteristic skin lesion which we call erythema

10:33:38 10 migrans. It is a medical term.

10:33:38 11 MR. MAURER: Maybe we can shut the lights

10:33:40 12 down just a little.

10:33:56 13 Q Please proceed, Doctor. I'm sorry.

10:33:58 14 A So if this represents local infection in the

10:34:04 15 skin and it's called erythema migrans -- erythema just

10:34:08 16 means red and migrans means that it's an expanding rash.

10:34:12 17 That's the original description of it. At this point in

10:34:14 18 time there may or may not be some other symptoms, and

10:34:18 19 symptoms, if you have them, are very mild and they're just

10:34:22 20 a little -- few aches and pains, very low grade fever,

10:34:24 21 something like that. And the rash is very characteristic.

10:34:30 22 The classic rash of Lyme disease is there, target rash.

10:34:38 23 The tick bite occurred here and then there's redness, some

10:34:42 24 clearing, and it's more redness and that's the famous

10:34:44 25 target lesion of Lyme disease. I think it's been well



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1 Dattwyler - Plaintiff - Direct 68

10:34:48 2 publicized.

10:34:50 3 Q Do all Lyme rashes act like that type of rash?

10:34:52 4 A No. There's a lot of variety in rashes, and one

10:34:56 5 of the things that we do in -- other people have

10:34:58 6 emphasized that -- the varied nature of this lesion. So

10:35:04 7 you have to really be aware of it as a physician.

10:35:08 8 Classically there's this central clearing area, but here's

10:35:12 9 a variety of the rash in which the central area was more

10:35:16 10 red and then it's less red here as it goes out. The

10:35:20 11 characteristics of the rash is that it expands and it can

10:35:24 12 become quite large. The diagnosis really can't be made on

10:35:30 13 anything that's not a couple -- two, three inches in

10:35:32 14 diameter. Regular insect bites can look small, but as it

10:35:38 15 starts to get -- really expands then you have to have a

10:35:40 16 much higher index of suspicion that it may be Lyme. And

10:35:48 17 here it's in a more evenly red skin lesion on this

10:35:54 18 particular individual. So, as you can see that there's a

10:35:58 19 large variety of things that fall into the category, and

10:36:04 20 if untreated it becomes quite large. This is someone's

10:36:08 21 back, and actually this is the central area. There's some

10:36:12 22 clearing and some more redness, some more clearing and

10:36:14 23 then some more redness, so that you continue to expand.

10:36:18 24 If you don't treat it, it just goes away.

10:36:20 25 Q What goes away?



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1 Dattwyler - Plaintiff - Direct 69

10:36:22 2 A The rash, the skin lesion just goes away. You

10:36:24 3 don't have to treat it, it goes away, and it's just

10:36:28 4 manifestation of the earlier phase of the infection.

10:36:32 5 During the course of infection you start off with this

10:36:34 6 local infectious process, and then it gets into the

10:36:38 7 bloodstream, and it's at this point where the bacteria

10:36:42 8 spreads and it can affect multiple organ systems. At this

10:36:46 9 point in time particular targets are the central nervous

10:36:50 10 system, the brain and spinal cord, also the peripheral

10:36:54 11 nerves. That's the nerves outside of the brain and the

10:36:56 12 spinal cords. One of the hallmarks of this is multiple

10:37:02 13 lesions, and that occurs in about 15 percent of the

10:37:08 14 individuals, but not everybody, even when it's spread like

10:37:10 15 this, has it. Aches and pains are common in this phase of

10:37:16 16 the infection. You can get cardiac involvement, and

10:37:20 17 that's fairly early in the course of the disease this

10:37:26 18 occurs. Maybe weeks to months in the infection is when

10:37:30 19 you are already into this phase.

10:37:32 20 Q Doctor, I see the word meningitis. I didn't

10:37:34 21 hear you say anything about that.

10:37:36 22 A Well, meningitis is infection of the brain and

10:37:40 23 the covering of the brain. It's actually the covering of

10:37:42 24 the brain that gets infected, and it's actually fairly

10:37:46 25 common in this. We did a study a number of years ago in



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1 Dattwyler - Plaintiff - Direct 70

10:37:50 2 which we looked at people with acute disseminated

10:37:54 3 infection, and actually did spinal taps and looked at

10:37:58 4 their spinal fluid, and we have a way of detecting the

10:38:00 5 presence of the bacteria there, and about two thirds of

10:38:04 6 individual had some evidence of infection in their central

10:38:08 7 nervous system. Meningitis is a more overt manifestation

10:38:12 8 of that, which means that they actually have an active

10:38:16 9 process with inflammation that's in the body's immune

10:38:22 10 system to fight that you get increased numbers of white

10:38:24 11 cells in the area, headaches and pain.

10:38:26 12 Q The meningitis means there is an infection in

10:38:30 13 what part of the body?

10:38:32 14 A In the brain, in the covering of the brain.

10:38:34 15 What Lyme does is it causes infection of the covering of

10:38:40 16 the brain and the covering of the spinal cord, but also of

10:38:42 17 the brain itself, so usually many of these people will

10:38:46 18 have what we call meningeal encephalitis, meningitis and

10:38:52 19 infection of the brain tissue itself, and the cranial

10:38:54 20 nerves are the nerves that come from the base of the brain

10:38:58 21 and innervate the parts of the face or the other parts of

10:39:02 22 the body.

10:39:04 23 Q What do you mean by innervate?

10:39:06 24 A They control that function, come around --

10:39:10 25 they're the nerves that come around, and in this -- in



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1 Dattwyler - Plaintiff - Direct 71

10:39:12 2 Lyme disease the most common cranial nerve that is

10:39:16 3 involved is the seventh cranial nerve, which is called the

10:39:20 4 facial nerve, which controls the face. And large -- and

10:39:28 5 that allows you to smile or blink and things like that,

10:39:30 6 and this represents many times infection of the base of

10:39:34 7 the brain.

10:39:36 8 Q Approximately what percentage of people who get

10:39:40 9 Lyme disease develop a problem with the nerve that

10:39:46 10 controls the facial muscles?

10:39:48 11 A Oh, it's less than 10 percent will develop that

10:39:52 12 type of process.

10:39:54 13 Q Is there a name that is sometimes given to

10:39:56 14 describe that condition?

10:39:58 15 A Well, technically they -- you should call it

10:40:04 16 seventh nerve palsy. Some people call it Bell's palsy,

10:40:06 17 but Bell's palsy should be reserved for cases where we

10:40:10 18 don't know the cause. In a case where you have Lyme

10:40:12 19 disease you know the cause, and it should be seventh nerve

10:40:16 20 palsy secondary to Lyme disease. So it depends on whether

10:40:18 21 you want to split hairs or not, like how you guys have

10:40:22 22 legalisms, we have our own jargon in medicine, too, so we

10:40:26 23 would call it -- standard thing is Bell's palsy, but

10:40:32 24 technically that's not correct.

10:40:34 25 Q I see you also have peripheral neuropathy on



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1 Dattwyler - Plaintiff - Direct 72

10:40:36 2 this slide. What is that?

10:40:38 3 A Well, for whatever reason, this organism likes

10:40:40 4 the nervous system, and you can get infection of the

10:40:44 5 peripheral nerves. Those are the nerves outside of the

10:40:48 6 brain and spinal column. You can also get -- there is

10:40:52 7 something called ganglia, which run along the spine. You

10:40:56 8 can also have infection of those and that can be quite

10:41:00 9 painful. Many of the neurologic aspects of the disease

10:41:04 10 were originally defined in Europe, and if I can digress,

10:41:10 11 actually Lyme disease is named after Lyme, Connecticut,

10:41:14 12 but the reality is this is a European disease and it was

10:41:18 13 originally described in Europe in 1909. We just adopted

10:41:24 14 it. It's a bigger problem than, I think, people realize.

10:41:28 15 That's the disease in sort of a nutshell.

10:41:36 16 Q Okay. We can shut this off now.

10:42:06 17 (The witness resumes the stand.)

10:42:12 18 Q Doctor, has the various aspects of Lyme disease

10:42:18 19 in terms of how it progresses ever been described in terms

10:42:22 20 of it being in stages?

10:42:26 21 A Yes. People have talked about that, and I think

10:42:30 22 that the current acceptable way of looking at it now is to

10:42:34 23 look at it as a local infection that would be at the site

10:42:38 24 of the tick bite. An acute disseminated infection, that's

10:42:42 25 the early phase of the spread of the organism, and then a



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1 Dattwyler - Plaintiff - Direct 73

10:42:44 2 late disease where one has could have manifestations

10:42:50 3 months to years later.

10:42:54 4 Q In June of 1994, based on what you've told us so

10:42:58 5 far, is it fair to say you were familiar with the way that

10:43:02 6 Lyme disease was normally diagnosed and treated in this

10:43:06 7 part of the country?

10:43:06 8 A Sure.

10:43:06 9 Q And what was -- how was Lyme disease routinely

10:43:10 10 diagnosed back then?

10:43:12 11 A Well, it's the same way now, is that the best

10:43:16 12 way to make the diagnosis is to see this rash, this skin

10:43:20 13 lesion. That's diagnostic, and if you see it then you

10:43:24 14 treat it.

10:43:28 15 Q If a patient presents with a rash which is not a

10:43:32 16 classic bull's-eye in appearance, looks like one of the

10:43:36 17 variations that you showed us in one of the slides or

10:43:40 18 several of the slides, what was the standard procedure

10:43:42 19 that was routinely followed in June of 1994 when

10:43:46 20 evaluating a patient for Lyme disease?

10:43:50 21 A Well, the same way that you handle any patient.

10:43:52 22 You take a history, you ask him what's going on, you

10:43:56 23 examine them, quite frankly in -- if you look at

10:44:04 24 throughout the '90's, if you have an expanding red rash on

10:44:08 25 an individual from this region anywhere in the northeast



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1 Dattwyler - Plaintiff - Direct 74

10:44:14 2 in -- during Lyme season, you have to have a very high

10:44:18 3 index of suspicion that this is Lyme disease, and even if

10:44:24 4 you over treat once in awhile, it's much safer to over

10:44:26 5 treat than it is to miss it.

10:44:28 6 Q Should you have -- should a doctor have had a

10:44:32 7 high index of suspicion of Lyme disease back in June of

10:44:34 8 1994, even if the patient presented with an

10:44:38 9 atypical-looking rash?

10:44:40 10 MR. LEWIS: Just to the leading, Judge.

10:44:42 11 THE COURT: Well, I'll allow it.

10:44:46 12 THE WITNESS: So I answer it?

10:44:48 13 THE COURT: Yes, you can answer.

10:44:50 14 A Yes. The -- I mean, there's very few things

10:44:52 15 that do this, and this is an expanding, red skin lesion.

10:44:58 16 The differential diagnosis is fairly small. The

10:45:02 17 differential diagnosis meaning, you know, what's the list

10:45:06 18 of possibilities that we think about. So June is right at

10:45:08 19 the height of Lyme season. If someone presents on Long

10:45:12 20 Island or Westchester County or parts of Connecticut or

10:45:16 21 New England with that type of thing, I mean Lyme disease

10:45:20 22 has to be if not your first diagnosis, one of your -- one

10:45:22 23 of your leading diagnoses. So, I mean, I don't think

10:45:30 24 that's changed at all in the years. I mean, I think it's

10:45:34 25 been well recognized, and even lay people recognize that



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1 Dattwyler - Plaintiff - Direct 75

10:45:38 2 now.

10:45:46 3 Q What is a differential diagnosis, Doctor?

10:45:48 4 A Well, you are -- you list the possibilities that

10:45:52 5 would fit the clinical picture that the patient's

10:45:56 6 presenting with you. So, if someone comes in with, say, a

10:46:00 7 sore throat, you say, well, it could be a virus, it could

10:46:02 8 be strep, it could be mononucleosis, and you list the

10:46:08 9 possibilities, and then you do things to try to confirm or

10:46:10 10 exclude that. In the case of an expanding red skin

10:46:16 11 lesion, in the springtime on Long Island you'd say, well,

10:46:22 12 is this Lyme, is this another infectious disease, and what

10:46:28 13 you could do is you could culture, try to culture the

10:46:32 14 organism, you could biopsy it and look for -- look at the

10:46:38 15 skin under the microscope and have a characteristic

10:46:40 16 picture of infection or an allergic type reaction, if you

10:46:46 17 thought it was that. So, there's both clinical things

10:46:52 18 that you could do in just looking at it, and see if it

10:46:56 19 blanches in your physical exam.

10:46:58 20 Q What do you mean by blanch?

10:47:00 21 A Maybe you just rub it and certain rashes will

10:47:02 22 blanch, and it's the way of examining it.

10:47:04 23 Q What does it mean to blanch?

10:47:06 24 A Go from red or pink, to, you know, normal skin.

10:47:10 25 That means just by doing it, if you have blood in your



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1 Dattwyler - Plaintiff - Direct 76

10:47:12 2 skin, if it's red because you have blood, like certain

10:47:16 3 tick-borne diseases, like Rocky Mountain Spotted Fever,

10:47:20 4 actually causes bleeding in your skin. If you press on it

10:47:22 5 it doesn't -- it doesn't get -- get pink. It stays that

10:47:28 6 red color, and so those are things you can do.

10:47:34 7 Q What does it mean to make a clinical diagnosis?

10:47:36 8 A Well, that means that what you're doing is

10:47:38 9 making the diagnosis without laboratory support. You're

10:47:42 10 just doing it on your clinical judgment, and quite frankly

10:47:46 11 that's how early -- early Lyme disease is mainly

10:47:50 12 diagnosed. You're mainly -- you come in, you look at the

10:47:54 13 skin lesion, you say, "Gee, you know, this looks like

10:47:58 14 erythema migrans, the rash of Lyme disease; I should treat

10:48:02 15 this." There's been some studies which have pointed out

10:48:06 16 on a -- just a mathematical model, if you have a -- even a

10:48:12 17 few percent of suspicion that it's Lyme, it's better to

10:48:16 18 treat than it is to let it go. That was published in the

10:48:18 19 New England Journal.

10:48:22 20 Q How treatable is Lyme disease in the early stage

10:48:26 21 or early part of the illness?

10:48:28 22 A It's very treatable. Cure rates are excellent.

10:48:32 23 In the high 90's.

10:48:34 24 Q And, back in June of 1994, were there specific

10:48:38 25 types of medications that were routinely given to treat



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1 Dattwyler - Plaintiff - Direct 77

10:48:40 2 Lyme disease in its early phase?

10:48:44 3 A Well, the drugs of choice in '94, actually have

10:48:48 4 been in the late '80's were either Amoxicillin or

10:48:52 5 Doxycycline which is a type of cycline-like drug. Either

10:48:56 6 one was considered to be the standard of care. It still

10:49:00 7 is today.

10:49:02 8 Q If someone presented -- well, let me ask you

10:49:08 9 this: What is cellulitis?

10:49:10 10 A Cellulitis means infection of the skin and

10:49:14 11 surrounding tissue.

10:49:16 12 Q And, does cellulitis have a presentation, an

10:49:20 13 appearance, that is similar in any way to the Lyme disease

10:49:24 14 rash in its variations?

10:49:28 15 A It could.

10:49:28 16 Q How?

10:49:30 17 A You could have a red expanding skin lesion.

10:49:34 18 You'd have -- your index of suspicion under those

10:49:36 19 circumstances would probably be strep, the same strep that

10:49:40 20 causes strep throats. That can cut through tissue planes

10:49:44 21 and expand, so, you might do that. That would usually be

10:49:50 22 a bit more inflammatory, you expect people to be sicker

10:49:54 23 under those circumstances, but it could have a somewhat

10:49:56 24 similar presentation.

10:50:02 25 Q What is a central punctate?



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1 Dattwyler - Plaintiff - Direct 78

10:50:06 2 A It just means a little mark, like it could be a

10:50:12 3 bite site, it could be a scratch, just -- or if someone

10:50:16 4 got stabbed with a needle or something like that, so it's

10:50:20 5 just a little central site, a little raised, perhaps.

10:50:24 6 Q Is the presence of a central punctate in the

10:50:28 7 skin of a patient something that is consistent with the

10:50:32 8 patient having been bitten by a deer tick that causes Lyme

10:50:36 9 disease?

10:50:38 10 A Yes. It's quite common that you do that. At

10:50:40 11 the first slide I showed had a punctate lesion centrally

10:50:44 12 at the site of the bite.

10:50:46 13 Q What is a -- an axillary node?

10:50:54 14 A Axillary node means -- your lymph nodes are part

10:50:58 15 of the body's immune system, and they help protect and

10:51:02 16 limit the spread of infection, and an axillary node means

10:51:06 17 on physical exam you could feel a lymph node in the armpit

10:51:12 18 was slightly swollen, so you could feel it.

10:51:14 19 Q Is the presence of a swollen axillary lymph node

10:51:22 20 under the arm consistent with the presence of a Lyme

10:51:28 21 disease infection?

10:51:30 22 A It can be, sure. Anytime you have an infection

10:51:34 23 you are -- you can have a reaction in the local lymph

10:51:40 24 nodes and there could be swelling, so it's not diagnostic

10:51:44 25 of any particular infection, but it's an indication that



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1 Dattwyler - Plaintiff - Direct 79

10:51:46 2 there is, in fact, some inflammatory process or an

10:51:50 3 infectious process in that region, or it could be in a

10:51:56 4 more distal region where that drains. Say you had an

10:52:00 5 infection in a finger, you could have lymph nodes swelling

10:52:04 6 in your elbow area and in your axillary area, so it's in

10:52:08 7 the drainage site of that lymph node chain.

10:52:10 8 Q What does it mean for a rash to be -- withdrawn.

10:52:16 9 Is the presence of a sensation of tenderness in a rash

10:52:22 10 something that can be consistent with the presence of Lyme

10:52:26 11 disease infection?

10:52:26 12 A Yes, it can be. Tenderness usually is a sign of

10:52:32 13 inflammation. An inflammation is part of the body's

10:52:34 14 defense mechanisms of how they're fighting off an

10:52:38 15 infection. When you get an infection, the body has a

10:52:40 16 somewhat stereotypic response. The blood vessels open up

10:52:44 17 a bit, it becomes warmer, redder, there's more blood flow

10:52:48 18 in the area, the body brings white cells into the area,

10:52:52 19 the white cells help eat the bacteria or kill the

10:52:56 20 bacteria, and more antibodies come into the area because

10:52:58 21 of increased blood flow, so it's not specific, but it

10:53:04 22 certainly is compatible with Lyme.

10:53:08 23 Q What does it mean for a skin area to be

10:53:10 24 pruritic, P-R-U-R-I-T-I-C?

10:53:14 25 A Itchy.



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1 Dattwyler - Plaintiff - Direct 80

10:53:14 2 Q Is the presence of that type of symptom, an

10:53:18 3 itchiness to the skin in the area of a rash, something

10:53:20 4 that can be consistent with a Lyme disease infection?

10:53:24 5 A It can be. Usually Lyme rashes are not terribly

10:53:26 6 itchy, but it can be mildly pruritic.

10:53:34 7 Q What does it mean for a rash area to be

10:53:36 8 indurated?

10:53:38 9 A Indurated means swollen, a little swelling, sort

10:53:44 10 of a little boggy feeling, and again it's from increased

10:53:50 11 blood flow and some leakiness of the blood vessels where

10:53:52 12 some of the constituents, the liquid constituents of the

10:53:56 13 blood leak out into that area.

10:53:58 14 Q Is the presence of an indurated area of rash in

10:54:00 15 a patient something that can be consistent with the

10:54:04 16 presence of a Lyme disease infection?

10:54:06 17 A You can see it in Lyme disease, yes.

10:54:18 18 MR. MAURER: With the Court's permission,

10:54:18 19 I'd like to show Dr. Dattwyler a portion of

10:54:22 20 plaintiff's exhibit one in evidence, the CHP

10:54:24 21 record.

10:54:26 22 THE COURT: All right. Any objection

10:54:26 23 counsel?

10:54:28 24 MR. LEWIS: None, Judge.

10:54:30 25 Q Dr. Dattwyler, I'm showing you the chart entry



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1 Dattwyler - Plaintiff - Direct 81

10:54:34 2 for 6/3/94, urgent visit, and I would ask you, if you can

10:54:38 3 read it, to read out loud what's written in the chart

10:54:42 4 entry.

10:54:44 5 A Yes. "Patient with complaint of erythematous,

10:54:48 6 tender, slightly pruritic area of skin, left axilla time

10:54:52 7 two days. Denies trauma to skin," and then it's

10:54:56 8 "Objective," which means the examination, "left axilla

10:55:00 9 lateral pectoral muscle with approximately three

10:55:06 10 centimeters erythematous indurated area, minimal

10:55:10 11 tenderness, no drainage, with central punctate." And then

10:55:16 12 it's, "Assessment, question, insect bite with cellulitis.

10:55:20 13 Plan, warm soaks four times a day, Duricef 500 milligrams

10:55:28 14 orally twice a day for seven days. Follow-up, if --"

10:55:38 15 can't really read this --

10:55:42 16 Q Does that say fluctuates? It's hard to tell?

10:55:44 17 A I can't tell. Or symptoms increase. And then

10:55:50 18 it's signed.

10:55:50 19 Q For the record, it's signed by Kobel- Perez,

10:55:56 20 RPA. And I'd like to show you the entry for the next day

10:56:02 21 from this exhibit for 6/4/94, and I'd ask you, if you

10:56:04 22 could, read that out loud, if possible.

10:56:10 23 A "Complaints of growing rash, left chest, seen

10:56:14 24 in --" it looks like, "UV yesterday. RX, Duricef. Denies

10:56:22 25 bite. Took three antibiotic pills. Physical exam, no



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1 Dattwyler - Plaintiff - Direct 82

10:56:28 2 acute distress. Temperature 100.9, positive, slightly

10:56:32 3 swollen." I'm not sure what this says, "Left chest,"

10:56:42 4 something "erythema and positive palp, axillary node," and

10:56:52 5 there's sort of a picture here with just a circle, and it

10:56:56 6 looks like it's expanding, and then, "Insect bite with

10:57:02 7 surrounding erythema. Plan, Duricef," something to see

10:57:10 8 patient if symptoms increase to emergency room, and then

10:57:16 9 it looks like a different handwriting, cellulitis without,

10:57:22 10 and I guess it's pain. Patient --

10:57:26 11 Q I believe that is without pus?

10:57:30 12 A Oh, without pus. Okay. It could be pus.

10:57:34 13 "Patient --" I can't -- this is bad handwriting. I don't

10:57:44 14 know what that says.

10:57:46 15 Q Insisted on this?

10:57:48 16 A Oh. To something abscess.

10:57:52 17 Q To rule out abscess?

10:57:54 18 A Wow. You can read this stuff better than I can.

10:57:58 19 Doctors have bad handwriting. Improvement, will need to

10:58:04 20 change antibiotic or use IV antibiotics, something -- or

10:58:12 21 warm compresses.

10:58:20 22 Q I might as well do this so I don't have to come

10:58:22 23 back. June 30, '94 is the last CHP entry. I'd like you

10:58:26 24 to read for us, please.

10:58:28 25 A Okay. "Temperature, 98.3. Patient with



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1 Dattwyler - Plaintiff - Direct 83

10:58:30 2 headaches times six days, initially at night, on top of

10:58:34 3 head, then left temporal area. He denies facial pressure.

10:58:40 4 He states that he has much pain and when he moves it

10:58:50 5 exacerbates headache." Then it's got, "physical exam,

10:58:54 6 blood pressure 108 over 68. Eyes, pupils equal, round

10:59:02 7 reactive to light and accommodation --"

10:59:04 8 Q Let me just go back. You said he states he

10:59:06 9 has -- I think you said much. I believe that's neck pain?

10:59:10 10 A Oh. Neck pain. Sorry. Neck pain.

10:59:16 11 Q Sorry.

10:59:16 12 A "Extraocular movements intact. Fundi, which

10:59:20 13 means the back of the eyes, disks flat, neck tender. Left

10:59:26 14 occipital area from, F-R-O-M." It's an acronym that I'm

10:59:34 15 not familiar with. "Impression: Neck sprain with

10:59:38 16 resultant headache. General heat, BID, neck support at

10:59:42 17 night. Naprosyn, 375 milligrams twice a day with," and

10:59:50 18 then dispensed 15 tablets and said with food. Norflex at

11:00:00 19 night, and they dispensed seven of them. Patient warned

11:00:06 20 of sort of the complications, and follow-up in two days if

11:00:12 21 no better.

11:00:14 22 Q Doctor, just relying upon the information that

11:00:20 23 you see here on the 6/3/94 and 6/4/94 CHP chart entries,

11:00:30 24 do you agree with the diagnosis that was made and noted in

11:00:32 25 that chart?



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1 Dattwyler - Plaintiff - Direct 84

11:00:34 2 MR. LEWIS: Objection.

11:00:36 3 THE COURT: Yes. To the form. I'll

11:00:38 4 sustain the objection.

11:00:38 5 Q Based on the information contained in that chart

11:00:44 6 and your own knowledge of diagnosis of Lyme disease, do

11:00:48 7 you have an opinion, within a reasonable degree of medical

11:00:52 8 certainty, as to whether or not the diagnosis that's noted

11:00:54 9 in the chart on 6/3 of cellulitis was an appropriate

11:00:58 10 diagnosis?

11:01:00 11 MR. LEWIS: Objection.

11:01:00 12 THE COURT: Can you answer that just based

11:01:02 13 on what you've read from the chart?

11:01:10 14 A It's -- I'm not sure how to answer that.

11:01:12 15 Cellulitis is -- I'd be a little suspicious. I'd expect

11:01:18 16 it to be a bit more painful and a bit more bothersome than

11:01:24 17 is noted here.

11:01:26 18 Q If you saw a patient on June 3, 1994 who

11:01:32 19 presented with the picture noted in the chart on 6/3/94 at

11:01:36 20 CHP, and they presented with the rash as described and the

11:01:40 21 other symptoms as described, what diagnosis would you have

11:01:46 22 considered?

11:01:48 23 A Well, I would have considered that it would be

11:01:50 24 early erythema migrans, that it could be cellulitis, that

11:01:56 25 it could be an insect bite. That's probably my -- that



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1 Dattwyler - Plaintiff - Direct 85

11:01:58 2 would probably be my differential diagnosis at that point

11:02:02 3 in time, but I would put all three in there.

11:02:06 4 Q And what would you have done to -- oh, by the

11:02:10 5 way, when you said early erythema migrans --

11:02:14 6 A Yes, that's the rash of Lyme disease.

11:02:16 7 Q So you are saying you would have considered the

11:02:18 8 possibility that the patient had early Lyme disease?

11:02:20 9 A Correct.

11:02:20 10 Q What would you have done under those

11:02:22 11 circumstances if, as presented on 6/3/94, if the patient

11:02:28 12 had those possible diagnoses and those symptoms?

11:02:30 13 A Well, I would have done one of two things: I

11:02:34 14 would either have taken a pen and I would have outlined

11:02:36 15 the area of redness around the skin lesion.

11:02:40 16 Q Why?

11:02:40 17 A Just to mark it -- the border, and then I would

11:02:44 18 have brought the patient back in the next day to take a

11:02:46 19 look at it if it was expanding. That would have helped me

11:02:50 20 define my diagnosis, because you'd expect the rash of Lyme

11:02:52 21 disease to continue to expand, or, if I decided to treat

11:02:58 22 the patient I would have selected Amoxicillin clavulanic

11:03:10 23 acid which is sold under the name of Augmentin, because it

11:03:14 24 covers not only the organisms that commonly cause

11:03:20 25 cellulitis, but it also covers Lyme disease.



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1 Dattwyler - Plaintiff - Direct 86

11:03:22 2 Q And would that have been an appropriate

11:03:24 3 medication that would have been effective to treat both of

11:03:28 4 those conditions?

11:03:28 5 A Yes. The two most common causes of cellulitis

11:03:32 6 under these circumstances would have been either staph or

11:03:36 7 strep, and they're both covered by Augmentin, and the

11:03:42 8 Duricef covers staph and strep but it doesn't cover Lyme

11:03:46 9 disease, where Augmentin would have covered staph, strep

11:03:50 10 and would have covered for Lyme disease as well.

11:03:52 11 Q Doctor, are -- were there any signs or symptoms

11:03:56 12 of early Lyme disease that you're aware of back in June of

11:04:00 13 1994 that could have been a proper basis for making a

11:04:04 14 diagnosis of early Lyme disease in and of themselves,

11:04:08 15 without any other information?

11:04:10 16 MR. LEWIS: Objection to the form, Judge.

11:04:14 17 THE COURT: You want to read that back?

11:04:38 18 (Whereupon the reporter read back the last question.)

11:04:40 19 THE COURT: I'll allow it.

11:04:40 20 A The thing that is diagnostic, and still is

11:04:44 21 today, is observation of the skin lesion and its behavior.

11:04:48 22 Q The rash?

11:04:48 23 A The rash. So that's how you make the diagnosis.

11:04:52 24 Q When you said that one of the things you might

11:04:54 25 have done, had you seen this presentation back on June 3,



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1 Dattwyler - Plaintiff - Direct 87

11:05:00 2 '94 was to outline the rash, the outer border --

11:05:02 3 A Yes.

11:05:04 4 Q -- and bring the patient back the next day?

11:05:06 5 A Yes. Correct.

11:05:06 6 Q And that was for what reason?

11:05:08 7 A Well, if it's the rash of Lyme disease, it's

11:05:10 8 going to expand, and that can help me make the diagnosis.

11:05:12 9 If I thought it was cellulitis, I'd probably also try to

11:05:16 10 culture it. Culture yields in cellulitis are pretty good.

11:05:24 11 In Lyme disease you can actually culture the organism from

11:05:28 12 the rash as well, if you have the right technology.

11:05:32 13 Q When you say culture the organism, what do you

11:05:34 14 mean, in layman's term?

11:05:36 15 A I mean actually take a piece of skin, either by

11:05:38 16 biopsy, or actually you can insert a needle and actually

11:05:42 17 try to suck out a little tissue juice and inoculate it

11:05:48 18 into a culture plate or into a broth called culture media

11:05:52 19 and grow the bacteria.

11:05:56 20 Q Are you familiar with the Lyme clinic at Long

11:06:00 21 Island Jewish Hospital?

11:06:00 22 A Yes.

11:06:02 23 Q Do you know Dr. Eileen Hilton?

11:06:02 24 A Yes.

11:06:04 25 Q Is she the head of that clinic?



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1 Dattwyler - Plaintiff - Direct 88

11:06:04 2 A Yes.

11:06:06 3 Q And was she back in June of 1994?

11:06:08 4 A Yes.

11:06:08 5 Q As far as you know, did Dr. Hilton's clinic or

11:06:10 6 the lab that worked with her in her clinic have the

11:06:14 7 capacity to do the type of culturing that you just talked

11:06:18 8 about --

11:06:18 9 A Yes, I believe so.

11:06:20 10 Q -- back in June of 1994?

11:06:20 11 A Yes, I believe so. They have -- they're quite

11:06:24 12 capable.

11:06:24 13 Q And you had the same ability at Stony Brook at

11:06:26 14 that time?

11:06:28 15 A Yes.

11:06:30 16 Q Now, turning to the note for June 4, 1994, you

11:06:48 17 indicated that the entry started with the growing rash --

18 A Yes.

11:06:54 19 Q -- on the left chest. Had you seen the patient

11:06:56 20 on June 4, 1994, aware of his presentation on June 3,

11:07:02 21 1994, and you saw there was a growing rash, what would you

11:07:08 22 have likely done, if anything, in diagnosis and treatment?

11:07:12 23 MR. LEWIS: Judge, may we approach?

11:07:12 24 THE COURT: Yes, all right. Sure.

11:07:14 25 (Whereupon there was a side bar conference.)



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1 Dattwyler - Plaintiff - Direct 89

11:07:50 2 MR. MAURER: I'll rephrase my question.

11:07:52 3 Q Doctor, if a patient presented with what you've

11:07:56 4 already told us Mr. Hanania presented with on June 3, 1994

11:08:02 5 and then came back and presented with the expanding rash,

11:08:06 6 what would have been the standard of care for diagnosis

11:08:10 7 and treatment of that condition in June of 1994 in this

11:08:14 8 part of the country?

11:08:16 9 MR. LEWIS: Objection.

11:08:16 10 THE COURT: I'll allow it.

11:08:20 11 THE WITNESS: Should I answer it?

11:08:20 12 THE COURT: Yes, you can answer it.

11:08:22 13 A In this area, an expanding red skin lesion in

11:08:26 14 the spring of the year, the index of suspicion of Lyme has

11:08:30 15 to be very high, and Lyme, you should treat for Lyme.

11:08:36 16 Q Do you have an opinion as to whether or not the

11:08:40 17 doctor's failure and the physician's assistant's failure

11:08:48 18 to diagnose and treat Lyme disease on either June 3 or

11:08:50 19 June 4 of 1994 constituted a deviation from accepted

11:08:54 20 standards of medical care?

11:08:58 21 MR. LEWIS: Just to the form, Judge.

11:09:00 22 THE COURT: I'll allow it.

11:09:00 23 MR. LEWIS: He is asking a compound

11:09:02 24 question with regard to two separate events.

11:09:04 25 MR. MAURER: I'll break it down.



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1 Dattwyler - Plaintiff - Direct 90

11:09:06 2 MR. LEWIS: You see what I mean?

11:09:08 3 THE COURT: Very good.

11:09:08 4 Q First of all, with reference to the physician's

11:09:12 5 assistant who saw Mr. Hanania on June 3, 1994, based upon

11:09:16 6 the information noted in the chart and your own knowledge

11:09:20 7 and experience, do you have an opinion as to whether or

11:09:22 8 not Jeanette Kobel-Perez, the physician's assistant, who

11:09:28 9 diagnosed Mr. Hanania with cellulitis and treated with

11:09:32 10 Duricef, whether or not that diagnosis and treatment was a

11:09:36 11 deviation from accepted standards of medical care at the

11:09:40 12 time?

11:09:44 13 A I would have been very suspicious of Lyme.

11:09:48 14 Anytime you present with that type of rash, I think Lyme

11:09:50 15 has to be included. It wasn't, therefore, that's a

11:09:56 16 mistake, so that I think that's a deviation from what I

11:10:02 17 would expect to have occurred.

11:10:06 18 Q And, with reference to Dr. Violet Abemayor who

11:10:10 19 made part of the entry and saw Mr. Hanania on June 4,

11:10:14 20 1994, given the information noted in the chart for June 4,

11:10:18 21 with the expanding rash and no pus being present --

11:10:24 22 A Yes.

11:10:26 23 Q -- and the other things that were noted in the

11:10:30 24 chart, given the doctor's continuation of Mr. Hanania's

11:10:36 25 treatment for cellulitis with Duricef, do you have an



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1 Dattwyler - Plaintiff - Direct 91

11:10:40 2 opinion as to whether or not that diagnosis and treatment

11:10:42 3 was a deviation from accepted standards of medical care

11:10:48 4 back at that time?

11:10:50 5 MR. LEWIS: Just to the form, Judge.

11:10:52 6 THE COURT: I'll allow it.

11:10:52 7 MR. LEWIS: The characterization of the

11:10:54 8 record and the prior testimony.

11:10:56 9 THE COURT: Well, all right. I'll allow

11:10:58 10 it, though. Go ahead. You can answer it.

11:11:00 11 A Yes. That's more of a deviation, because now

11:11:02 12 you've already instituted good treatment for cellulitis,

11:11:06 13 you're continuing to have worsening of the process and

11:11:12 14 it's -- now you've got more evidence that it's behaving

11:11:16 15 like erythema migrans, so that should raise additional

11:11:20 16 questions about your initial diagnosis, so that at that

11:11:24 17 point in time I would have said you should have been --

11:11:28 18 rethought the whole process, and with that additional

11:11:32 19 information, so, yes.

11:11:32 20 Q Doctor, I'd like you to assume that Jeanette

11:11:40 21 Kobel-Perez, the physician's assistant, did not refer Mr.

11:11:42 22 Hanania to any Lyme clinic when she saw him for a second

11:11:46 23 opinion on June 3, 1994. Do you have an opinion as to

11:11:52 24 whether or not the failure to make a referral to an area

11:11:56 25 specializing in Lyme such as Long Island Jewish's Lyme



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1 Dattwyler - Plaintiff - Direct 92

11:12:00 2 clinic or your clinic at Stony Brook was a deviation from

11:12:04 3 accepted standards of medical care, based upon all the

11:12:08 4 information you've told us about today?

11:12:08 5 A Well, I would have expected they would have made

11:12:10 6 the diagnosis initially themselves. Certainly I know I

11:12:14 7 give a lot of lectures to the local physicians and I know

11:12:18 8 the people at LIJ do as well, so the familiarity with that

11:12:22 9 skin lesion, I think, is high, and it's been high on Long

11:12:26 10 Island for a long time, so I would expect them to make the

11:12:28 11 initial diagnosis. If they were unsure, then I think

11:12:32 12 there's plenty of resources around they could have

11:12:36 13 referred to a Lyme clinic or asked for a dermatological

11:12:40 14 opinion from -- they don't have to send it to us. They

11:12:42 15 could have asked a dermatologist to take a look at it as

11:12:46 16 well.

11:12:46 17 Q Dr. Dattwyler, did you actually have the

11:12:52 18 opportunity to evaluate Mr. Hanania at anytime?

11:12:56 19 A Yes.

11:12:56 20 Q And was that, in fact, as a patient?

11:13:00 21 A Yes. He's my patient.

11:13:02 22 Q When did you first evaluate him, if you recall?

11:13:08 23 A I don't have my notes in front of me. Probably,

11:13:10 24 you know, some months after he developed facial palsy and

11:13:18 25 meningitis.



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1 Dattwyler - Plaintiff - Direct 93

11:13:20 2 Q And, what did you do for him as a physician at

11:13:26 3 that time?

11:13:28 4 A We tried to evaluate his status and define as

11:13:32 5 best we could what was going on. He had been treated with

11:13:40 6 two intravenous drugs and had allergic reactions to them,

11:13:44 7 although he probably had a sufficient amount to eradicate

11:13:46 8 the infection. We gave him some additional antibiotic

11:13:50 9 just to be sure.

11:13:54 10 Q And, for how long a period of time did you

11:13:58 11 continue to see Mr. Hanania?

11:14:02 12 A He's still a patient of mine now.

11:14:04 13 Q When is the last time that you recall seeing him

11:14:06 14 as a patient?

11:14:08 15 A A few months ago.

11:14:12 16 Q And, from the time you first saw him up until

11:14:16 17 the last time you saw him, can you characterize for the

11:14:20 18 Court the condition that you observed as you were treating

11:14:24 19 him?

11:14:26 20 A Well, he has a number of complaints. He has

11:14:32 21 complaints of cognitive disability, of pain syndrome with

11:14:38 22 the various neurologic-like pains, and just an inability

11:14:46 23 to function at a high level.

11:14:48 24 Q And, are those types of complaints that he has

11:14:54 25 made to you consistent with the type of condition that he



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1 Dattwyler - Plaintiff - Direct 94

11:14:58 2 developed in June of 1994 and July of 1994?

11:15:02 3 A Yes. There are some individuals who after Lyme

11:15:06 4 disease just develop a pain syndrome just to -- don't do

11:15:12 5 well, and it's been our observation and it's been the

11:15:14 6 subject of two articles, one published from the

11:15:18 7 Westchester County Medical Center and another one

11:15:22 8 published out of Boston that have observed the same thing,

11:15:24 9 that some individuals, if not treated properly for Lyme

11:15:30 10 disease, can develop these pain syndromes.

11:15:32 11 Q You mentioned cognitive problems. What are you

11:15:34 12 referring to?

11:15:36 13 A It's inability to think clearly. It's called

11:15:42 14 encephalopathy, and you can -- I try to objectively

11:15:48 15 measure that by things like psychometric tests.

11:15:54 16 Q Who does that type of testing? Is there a

11:15:56 17 specific area of specialty who does that?

11:16:00 18 A Neuropsychologists do it, and then you try do

11:16:04 19 define it as best you can.

11:16:10 20 Q Doctor, is the history of Mr. Hanania

11:16:14 21 complaining to you of cognitive-like problems consistent

11:16:20 22 with the diagnosis of Lyme meningitis?

11:16:24 23 A It's consistent, yes. There's two aspects. One

11:16:28 24 we understand some of the mechanisms and the other one we

11:16:32 25 don't. Certainly meningitis can cause actual brain



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1 Dattwyler - Plaintiff - Direct 95

11:16:38 2 damage. You can have some of the neurons in the brain die

11:16:42 3 with meningitis. You get inflammation, and infection can

11:16:46 4 do that. The most severe meningitides are the bacterial

11:16:50 5 meningitides. That can be quite profound. In Lyme it's

11:16:56 6 much more subtle, and fortunately Lyme doesn't kill you,

11:17:02 7 so we don't have autopsy studies to prove it.

11:17:08 8 Q Doctor, are you familiar with the nature of the

11:17:10 9 treatment that Mr. Hanania has been getting during the

11:17:12 10 time he's been your patient?

11:17:14 11 A Yes.

11:17:14 12 Q And what is the kind of treatment that you're

11:17:16 13 aware of?

11:17:18 14 A Well, we've tried to control his pain

11:17:24 15 manifestations as much as we can. We've tried a number of

11:17:28 16 different things. We've tried Elavil, Paxil, which are

11:17:32 17 antidepressant type medication which also have a favorable

11:17:36 18 influence on neuropathic pain. He states that he feels

11:17:42 19 better on Minocycline or Doxycycline. I don't think

11:17:48 20 there's continued infection, but the tetracyclines have an

11:17:52 21 anti-inflammatory effect, and I've given him that on

11:17:56 22 occasion because it affords some degree of relief. That's

11:18:02 23 primarily what we've done.

11:18:04 24 Q The anti-inflammatory thing that you just

11:18:08 25 referred to, what specific aspect of Mr. Hanania's



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1 Dattwyler - Plaintiff - Direct 96

11:18:16 2 condition did you prescribe that for?

11:18:18 3 A Really two. He says that he thinks more clearly

11:18:22 4 when he's on the anti-inflammatory, and also that it

11:18:26 5 relieves his pain. His musculoskeletal pains, his aches

11:18:32 6 and pains are decreased.

11:18:34 7 Q Doctor, in 1994 and up to the present, have you

11:18:42 8 become aware of any specific standard, length of treatment

11:18:46 9 with antibiotics that is routinely used to treat a

11:18:50 10 condition like what Mr. Hanania has developed with Lyme

11:18:54 11 disease?

11:18:54 12 MR. LEWIS: To the form, Judge.

11:18:56 13 THE COURT: No, I'll allow it.

11:18:58 14 A Well, the standard of care for Lyme disease is

11:19:00 15 anywhere from two to four weeks of therapy, and there's

11:19:06 16 never been a study that's looked at in the infection

11:19:10 17 process or prospective, you know, well-controlled study

11:19:12 18 that's looked at the infection aspects of it. As far as

11:19:22 19 using a tetracycline drug in this fashion, I don't do it

11:19:28 20 routinely. The -- and I know of no study that has looked

11:19:34 21 at it in Lyme disease that I accept. There's been some

11:19:40 22 talk of it in the literature. There are studies on other

11:19:44 23 forms of arthritis --

11:19:44 24 MR. LEWIS: Judge, I'll object to

25 literature.



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1 Dattwyler - Plaintiff - Direct 97

11:19:48 2 THE COURT: Yes. I think you're going

11:19:50 3 beyond the question itself.

11:19:52 4 THE WITNESS: Okay.

11:19:54 5 Q Is -- you mentioned standard treatment length of

11:19:56 6 two to four weeks, I believe. Is that with a specific

11:20:00 7 kind of antibiotic?

11:20:02 8 A The treatments of early Lyme disease, the

11:20:06 9 recommended treatment is either Doxycycline or Amoxicillin

11:20:10 10 or Ceftin. For disease where the organism has spread into

11:20:18 11 the nervous system, one uses either Ceftriaxone or

11:20:24 12 Claforan, and generally it's two to four weeks of therapy

11:20:28 13 for that as well.

11:20:30 14 Q And the first three medications you mentioned,

11:20:32 15 are those oral medications?

11:20:34 16 A Yes, generally.

11:20:34 17 Q And the last two medications, the Ceftriaxone,

11:20:40 18 that's Rocephin; is that correct?

11:20:42 19 A That's correct.

11:20:42 20 Q And the cefotaxime, is it?

11:20:44 21 A Yes.

11:20:46 22 Q That's Claforan?

11:20:46 23 A Claforan.

11:20:48 24 Q And those are administered how?

11:20:48 25 A Usually intravenously, or they can be given



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1 Dattwyler - Plaintiff - Direct 98

11:20:52 2 intramuscularly, but that hurts usually intravenously.

11:20:56 3 They're not oral drugs.

11:20:56 4 Q Doctor, based upon the length of time that Mr.

11:21:00 5 Hanania has continued to relate the complaints to you that

11:21:04 6 you have mentioned, do you have an opinion, within a

11:21:10 7 reasonable degree of medical certainty, as to whether or

11:21:14 8 not any of the conditions that are causing him to give you

11:21:16 9 these complaints are permanent in nature?

11:21:20 10 A Yes. I mean, I think something certainly is

11:21:24 11 going on for a long period of time. It seems to have some

11:21:28 12 inflammatory component to it because it responds to an

11:21:32 13 anti-inflammatory medication, but I think some of it's

11:21:38 14 permanent, yes.

11:21:38 15 Q What part of it do you believe is permanent?

11:21:42 16 A Well, he doesn't -- I think cognitively he

11:21:46 17 doesn't seem to be as sharp as I would expect someone with

11:21:50 18 his educational level and degree of functioning. I didn't

11:21:56 19 know him before this episode so I can't, you know, tell

11:21:58 20 you definitively, but he doesn't seem as sharp as I would

11:22:06 21 expect someone with his educational level to be.

11:22:08 22 Q And that observation is based on what? How did

11:22:12 23 you arrive at that?

11:22:14 24 A Just my subjective judgment. But that's why,

11:22:16 25 you know, you have to do things like psychometric tests to



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1 Dattwyler - Plaintiff - Direct 99

11:22:20 2 objectify things something like my subjective judgments.

11:22:24 3 Q And are those psychometric tests something that

11:22:26 4 a neurologist normally does, as far as you know?

11:22:30 5 A Yes.

11:22:30 6 Q Neurologists do psychometric testing?

11:22:32 7 Earlier --

11:22:34 8 A Not neurologists.

11:22:34 9 Q Earlier you said neuropsychologists?

11:22:38 10 A Neuropsychologists, I'm sorry.

11:22:38 11 Neuropsychologists. Usually it's under the direction of

11:22:42 12 the neurologist that does it. In our group what we

11:22:44 13 usually do is refer these individuals to the neurology

11:22:48 14 group, and then they subsequently have neuropsychologists

11:22:52 15 that work with them.

11:23:00 16 Q I don't think I asked this. Is Duricef

11:23:02 17 effective in treating Lyme disease?

11:23:04 18 A No, it's not.

11:23:06 19 Q Would it have been an appropriate antibiotic to

11:23:08 20 treat Lyme disease in June of 1994?

11:23:12 21 A No, it would not have been.

11:23:22 22 Q Mr. Hanania testified yesterday that he

11:23:24 23 experienced this problem with his face, which eventually

11:23:28 24 went over to both sides of his face. What significance,

11:23:30 25 if any, does that have in terms of diagnosis?



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1 Dattwyler - Plaintiff - Direct 100

11:23:34 2 A Well, the facial nerve involvement is the most

11:23:38 3 common cranial neuropathy in Lyme disease, so that's a

11:23:44 4 common thing, and bilateral facial involvement is very

11:23:46 5 rare and it's only seen in a very limited number of

11:23:50 6 conditions, Lyme disease being one of them. So if you see

11:23:54 7 someone with bilateral Bell's palsy or facial nerve palsy

11:24:00 8 in the summer on Long Island, that's Lyme disease until

11:24:02 9 proven otherwise. The only other disease that can do that

11:24:06 10 with any regularity would be a sarcoidosis, and that's

11:24:12 11 very rare. There are other entities that might do it, but

11:24:14 12 you'd be deathly ill, and that's not the way you'd

11:24:18 13 present.

11:24:22 14 Q I'd like to just show you a follow-up note which

11:24:28 15 I guess I should mark, since it was -- since I'm showing

11:24:32 16 it to you.

11:24:42 17 MR. MAURER: I'll mark it as three for

11:24:42 18 identification.

19 (Whereupon, the reporter marked Plaintiff's

20 Exhibit 3 for identification.)

11:25:16 21 THE COURT: Before we have any questions

11:25:18 22 with that, we'll take a brief recess, so don't

11:25:22 23 forget, do not discuss the case among yourselves

11:25:24 24 or with anyone else.

11:25:26 25 (Whereupon there was a recess.)



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1 Dattwyler - Plaintiff - Direct 101

11:35:44 2 (The following takes place in the presence of the jury.)

11:35:56 3 THE CLERK: The witness is reminded he's

11:35:58 4 still under oath.

11:36:04 5 Q Doctor, would you please look at that follow-up

11:36:08 6 note that we'd marked just before the recess? What's the

11:36:12 7 date of that note?

11:36:14 8 A January 29, 1998.

11:36:18 9 Q And, this is exhibit three. What exactly is

11:36:24 10 exhibit three?

11:36:26 11 A It's a clinic note from the Lyme Disease Center,

11:36:32 12 Lyme Disease Center at Stony Brook.

11:36:34 13 Q Where you are?

11:36:34 14 A Yes.

11:36:34 15 Q And does this particular note reflect the

11:36:38 16 information that Mr. Hanania conveyed about what was

11:36:42 17 currently bothering him at the time?

11:36:46 18 A Correct.

11:36:46 19 Q And what's indicated?

11:36:46 20 A You want me to read it?

11:36:48 21 Q With the Court's permission, yes.

11:36:50 22 THE COURT: All right.

11:36:50 23 A Sure. It says, "Follow up: Mr. Hanania

11:36:54 24 returned to our Lyme disease center for follow-up. He has

11:36:56 25 continued on the Minocycline 100 milligrams twice a day



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1 Dattwyler - Plaintiff - Direct 102

11:37:00 2 for the past three and a half months, and feels generally

11:37:02 3 improved. He still experiences, quote, 'good days and bad

11:37:08 4 days,' unquote. He also continues to experience headaches

11:37:10 5 which he describes as quote, 'band like,' unquote, in the

11:37:14 6 frontal region. He also has arthralgias involving mostly

11:37:18 7 his knees and hips. He has not had any joint effusion.

11:37:22 8 The quote, 'nerve pain,' unquote, that he continues to

11:37:26 9 experience occurs mostly at night. The patient did have a

11:37:30 10 CBC," that's complete blood count, "liver function and

11:37:34 11 urinalysis approximately two weeks ago which were within

11:37:38 12 normal limits. Physical exam, head, eyes, ears, neck, and

11:37:44 13 throat. Nasal mucosa inflamed, lungs clear, joints

11:37:48 14 without effusion, neurological exam grossly intact.

11:37:52 15 Tinel's and Phalen's negative."

11:37:56 16 Q What does that refer to?

11:37:56 17 A That's the median nerve runs through the wrist

11:38:02 18 and that's the carpal bones, and you can get carpal tunnel

11:38:06 19 syndrome can cause pain up the extremities, and Tinel's

11:38:10 20 and Phalen's are ways of examining for carpal tunnel

11:38:14 21 syndrome, so they're physical signs. "Impression and

11:38:16 22 plan: The patient has been cautioned about prolonged

11:38:18 23 antibiotic use and also warned about increasing adverse

11:38:24 24 events of prolonged therapy. He is aware that some of the

11:38:28 25 effects he may be feeling actually result from the



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1 Dattwyler - Plaintiff - Direct 103

11:38:30 2 anti-inflammatory properties and not antibiotic properties

11:38:36 3 of the medication. He will contact us in the future for

11:38:38 4 follow-up on an as-needed basis." Then it's signed by my

11:38:42 5 physician's assistant, Susan Conaty, and myself.

11:38:48 6 Q What did you mean about what he was aware of

11:38:50 7 involving the anti-inflammatory versus antibiotic

11:38:54 8 properties?

11:38:54 9 A There are some individuals in the Lyme community

11:38:56 10 who believe in prolonged antibiotics for Lyme disease, and

11:39:04 11 we had discussed that, and I was just telling him that

11:39:10 12 these drugs have significant anti-inflammatory effects and

11:39:14 13 that this type of medication has significant

11:39:18 14 anti-inflammatory effects, and not to equate improvement

11:39:22 15 with the antibiotic effects, necessarily.

11:39:30 16 Q Sir, you were telling him that the improvement

11:39:30 17 he was noting from the medication was from the

11:39:32 18 anti-inflammatory aspects of this medicine you were

11:39:36 19 prescribing?

11:39:38 20 A Correct.

11:39:40 21 Q Doctor, was Lyme disease your diagnosis -- let

11:39:44 22 me withdraw that. I'll rephrase it. Based upon the

11:39:48 23 information you received from Mr. Hanania and -- did you

11:39:52 24 review medical records pertaining to Mr. Hanania during

11:39:56 25 the course of your treatment of him?



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1 Dattwyler - Plaintiff - Direct 104

11:39:58 2 A Yes. When he first came to us he brought some,

11:40:00 3 and then subsequently as well.

11:40:00 4 Q Did that include any records from Long Island

11:40:02 5 Jewish Hospital where he was admitted?

11:40:04 6 A Yes, it did.

11:40:06 7 Q Based upon your review of medical records at

11:40:08 8 various times pertaining to Mr. Hanania and your own

11:40:12 9 experience, what diagnoses do you believe were the

11:40:16 10 appropriate diagnoses for Mr. Hanania's condition in June

11:40:18 11 of 1994?

11:40:20 12 MR. LEWIS: Asked and answered, Judge.

11:40:22 13 Several times.

11:40:24 14 THE COURT: I think it has, but, all right,

11:40:26 15 I'll allow it.

11:40:28 16 A Yes. I think he had Lyme disease, and that's

11:40:34 17 what the LIJ records indicated, that they felt that -- and

11:40:38 18 I concurred with that and came to that conclusion based

11:40:42 19 upon the history and physical of myself.

11:40:44 20 Q Now, the Long Island Jewish Hospital record,

11:40:46 21 which is exhibit two in evidence, also makes reference to

11:40:50 22 a diagnosis of Lyme meningitis. Do you agree with that

11:40:56 23 diagnosis as well?

11:40:58 24 A Yes. They had good evidence both clinically and

11:41:04 25 laboratory evidence of -- to support that diagnosis.



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1 Dattwyler - Plaintiff - Direct 105

11:41:10 2 Q Doctor, have you ever testified in a court of

11:41:12 3 law before?

11:41:12 4 A Yes, I have.

11:41:14 5 Q Have you ever testified in any matters where I

11:41:16 6 was representing one of the litigants?

11:41:18 7 A Yes, I have.

11:41:18 8 Q And did you ever testify on behalf of one of my

11:41:22 9 clients?

11:41:22 10 A Yes. It was a case of work risk, where a

11:41:30 11 patient acquired Lyme disease in the workplace.

11:41:32 12 Q And that had to do with some Long Island

11:41:34 13 Railroad employees?

11:41:36 14 A Correct. And there was another case, too, of

11:41:38 15 another railroad employee up in Westchester.

11:41:40 16 Q And you testified in the federal court and once

11:41:44 17 on videotape and once in person?

11:41:46 18 A Correct.

11:41:46 19 Q Had you testified in any other matters on behalf

11:41:50 20 of my office for any clients of mine?

11:41:52 21 A No, not that I'm aware of.

11:41:54 22 Q Have you ever been a consultant at the request

11:41:56 23 of any defendants to any litigation?

11:42:00 24 MR. LEWIS: Objection, your Honor.

11:42:00 25 THE COURT: No. I'll allow it.



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1 Dattwyler - Plaintiff - Direct 106

11:42:02 2 A Yes. That's -- I have been on a number of

11:42:08 3 occasions on the defendant's side.

11:42:12 4 Q So you have been a consultant and an expert on

11:42:16 5 both sides of the fence at different times?

11:42:18 6 A Correct.

11:42:22 7 MR. MAURER: I believe I'm done. Just one

11:42:24 8 moment, please.

11:42:40 9 Q Let me just go back to that note from January

11:42:42 10 '98. With reference -- you made reference to something of

11:42:44 11 a neurologic nature. Could you just find that, please?

11:42:50 12 A Well, there's a couple of references to that,

11:42:54 13 both quotes from Mr. Hanania, the nerve pain that he

11:43:00 14 experiences.

11:43:00 15 Q What were you referring to?

11:43:04 16 A His complaints of pain and the way he was

11:43:06 17 describing it, and then also there's references to our

11:43:10 18 physical exam which we could find nothing grossly abnormal

11:43:18 19 in his neurologic exam when we did the physical exam.

11:43:22 20 Q Do you have an opinion as to what was the cause

11:43:24 21 of the nerve pain that he referred to?

11:43:30 22 A I don't think we understand the exact mechanism

11:43:32 23 that occurs of why patients like this experience pain

11:43:36 24 after Lyme disease. That's still an area I think that is

11:43:40 25 under some active investigation, both at our center and



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1 Dattwyler - Plaintiff - Direct 107

11:43:46 2 also other centers like Tufts and Yale and Mayo Clinic,

11:43:52 3 Westchester County Medical Center.

11:43:54 4 Q When you evaluate a patient, do you have to

11:43:56 5 evaluate the patient's truthfulness as part of your exam?

11:44:00 6 MR. LEWIS: Objection.

11:44:02 7 THE COURT: To evaluate the truthfulness?

11:44:06 8 MR. MAURER: Yes.

11:44:06 9 Q Do you make observations of the patient to make

11:44:10 10 any determination as to whether or not you believe they're

11:44:12 11 being truthful in the information they report to you?

11:44:14 12 MR. LEWIS: Objection, Judge.

11:44:16 13 THE COURT: I'll sustain the objection.

11:44:18 14 Q Have you ever observed Mr. Hanania to say or do

11:44:22 15 anything during the time you've been treating him which

11:44:24 16 led you to conclude that he wasn't telling you the truth

11:44:26 17 about his problem?

11:44:28 18 THE COURT: I sustain an objection to it.

11:44:38 19 I'm not allowing the questions.

11:44:34 20 MR. LEWIS: Objection.

11:44:34 21 MR. MAURER: I have nothing further. Thank

11:44:36 22 you.

11:44:36 23 MR. LEWIS: May I, Judge?

11:44:36 24 THE COURT: Please.

25



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1 Dattwyler - Plaintiff - Cross 108

2 CROSS-EXAMINATION

11:44:46 3 BY MR. LEWIS:

11:44:46 4 Q We're late into the morning, Dr. Dattwyler. My

11:44:48 5 name is Garrett Lewis. We were introduced just a few

11:44:52 6 moments ago. Doctor, just for purposes of the record, you

11:44:58 7 did not bring to court today your original records or a

11:45:04 8 copy of the set of records of Mr. Hanania; would that be

11:45:10 9 fair to say?

11:45:12 10 A That's correct.

11:45:12 11 Q Did I give you an opportunity before you took

11:45:16 12 the stand to peruse a fairly legible copy of the records

11:45:22 13 that I have from your office?

11:45:24 14 A That's correct.

11:45:24 15 Q Did they appear to be complete and --

11:45:28 16 A Yes, they did.

11:45:30 17 Q -- accurate up until that point?

11:45:30 18 A Yes.

11:45:32 19 Q Okay. Doctor, I'm not being facetious, but you

11:45:36 20 weren't here yesterday listening to Mr. Hanani's

11:45:42 21 testimony; fair to say?

11:45:46 22 A No, I wasn't.

11:45:46 23 Q Cellulitis is a painful condition?

11:45:48 24 A Usually.

11:45:50 25 Q Would it be fair to say that generally Lyme



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1 Dattwyler - Plaintiff - Cross 109

11:45:54 2 disease is not a painful condition in terms of the Lyme

11:45:58 3 disease rash?

11:45:58 4 A Usually, that's correct.

11:46:00 5 Q Did Mr. Maurer tell you yesterday that Mr.

11:46:04 6 Hanania said that the rash that he had in early June of

11:46:10 7 1994 was painful?

11:46:14 8 A No, he didn't tell me that.

11:46:16 9 Q Would a painful rash be more consistent with

11:46:18 10 cellulitis than the rash of Lyme disease?

11:46:24 11 A Yes, it would have been.

11:46:28 12 Q If I may, Doctor, I just want to review for a

11:46:32 13 few moments some of -- some aspects of your testimony. We

11:46:40 14 know in early July that Mr. Hanania received two different

11:46:48 15 types of intravenous antibiotics?

11:46:52 16 A That's correct.

11:46:52 17 Q Rocephin?

11:46:54 18 A Yes.

11:46:54 19 Q And the other trade name of the other

11:46:56 20 antibiotic?

11:46:56 21 A Claforan.

11:46:58 22 Q And it was your opinion, was it not, that you

11:47:02 23 expressed a few moments ago, that he did receive

11:47:04 24 sufficient amounts of those intravenous medications to

11:47:08 25 eradicate his Lyme disease infection?



VC





1 Dattwyler - Plaintiff - Cross 110

11:47:10 2 A Probably, yes.

11:47:12 3 Q As a matter of caution, you gave your patient

11:47:18 4 some additional antibiotic therapy; fair to say?

11:47:22 5 A Yes.

11:47:24 6 Q The therapy that he received back in LIJ was the

11:47:26 7 standardized therapy, though, for someone who had acute

11:47:30 8 disseminated Lyme disease infection; correct?

11:47:34 9 A Correct. It was foreshortened a little bit

11:47:36 10 because of adverse reactions, but, yes.

11:47:38 11 Q Cumulatively, though, did he have sufficient

11:47:44 12 standardized intravenous antibiotic treatment for the

11:47:48 13 eradication of acute disseminated Lyme disease?

11:47:52 14 A Yes.

11:47:52 15 Q Was there the presentation as of July, early

11:47:56 16 July, 1994, of early Lyme disease?

11:47:58 17 A It's early disseminated Lyme disease, yes.

11:48:02 18 Q Okay. There's clinicians like you who

11:48:04 19 specialize in Lyme disease, sometimes distinguished

11:48:08 20 between early disseminated and late Lyme disease; correct?

11:48:12 21 A That's correct.

11:48:12 22 Q Early Lyme disease, if treated with antibiotics,

11:48:18 23 most often oral results in excellent cure rates?

11:48:24 24 A Absolutely, yes.

11:48:26 25 Q Would you also agree that with sufficient



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1 Dattwyler - Plaintiff - Cross 111

11:48:30 2 intravenous antibiotic therapy, the cure rate for early

11:48:38 3 disseminated Lyme disease is similarly excellent?

11:48:44 4 A Yes, it's very good.

11:48:44 5 Q We're talking about cure rates in 90 percent of

11:48:48 6 the categories; correct?

11:48:48 7 A Correct.

11:48:50 8 Q The converse of that would be, Doctor, that

11:48:52 9 there are some patients, approximately 10 percent of them,

11:48:58 10 that even with effective appropriate treatments and

11:49:02 11 therapy, they don't get a hundred percent well; fair to

11:49:08 12 say?

11:49:08 13 A That's fair to say. In early local infection I

11:49:10 14 think we're really talking about, you know, even higher

11:49:14 15 percentages than in acute disseminated, and people divide

11:49:18 16 acute disseminated with active neurologic involvement and

11:49:22 17 without active neurologic involvement.

11:49:26 18 Q Overall the probability of effective cure is

11:49:28 19 still high in all those stages, although with early Lyme

11:49:32 20 disease that's where you get the best result; correct?

11:49:34 21 A That's correct.

11:49:36 22 Q Now, when people get effective antibiotic

11:49:40 23 therapy, there's still that subset of patients who have

11:49:46 24 subjective complaints despite the fact that they've

11:49:48 25 received appropriate antibiotic treatment; correct?



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1 Dattwyler - Plaintiff - Cross 112

11:49:52 2 A Correct.

11:49:52 3 Q Is that what you attribute Mr. Hanania's

11:49:56 4 continuing subjective complaints to, this unknown category

11:49:58 5 of patients?

11:50:00 6 A Yes, I think he falls into that.

11:50:04 7 Q Doctor, it's also correct on your direct

11:50:14 8 examination it's your perception or opinion, with medical

11:50:16 9 certainty -- probability, that Mr. Hanania doesn't have

11:50:20 10 present infection today?

11:50:22 11 A Correct.

11:50:22 12 Q Fair to say that was eradicated several years

11:50:26 13 ago as a result of this intravenous therapy?

11:50:28 14 A That's my opinion, yes.

11:50:30 15 Q Doctor, you first saw Mr. Hanania on or about

11:50:38 16 October 20, 1994? I know you don't have your notes, and

11:50:42 17 I'd be happy to --

11:50:44 18 A No, that is -- that's correct.

11:50:44 19 Q Would it be fair to say that Mr. Hanania was

11:50:48 20 seen at that time by a physician's assistant who worked

11:50:52 21 with you at the Lyme disease clinic?

11:50:54 22 A Yes. Virtually all our patients are seen by my

11:50:56 23 physician's assistant.

11:50:58 24 Q And there are times when you would get involved

11:51:00 25 and consult or -- you'd get involved with the patients



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1 Dattwyler - Plaintiff - Cross 113

11:51:06 2 also; correct?

11:51:06 3 A Virtually always I'm involved.

11:51:08 4 Q Okay. Would it be fair to say that as of

11:51:12 5 October 20, 1994, it was your joint opinion that Mr.

11:51:18 6 Hanania fell around 95 percent in terms of improvement of

11:51:22 7 his overall condition, in terms of what his condition was

11:51:26 8 before he contracted Lyme disease?

11:51:28 9 A Correct.

11:51:30 10 Q Now --

11:51:32 11 A That's what he stated, and that's, you know, I

11:51:34 12 took it on its face value.

11:51:36 13 Q Doctor, back in the early '90's, continuing up

11:51:42 14 to today, Stony Brook was a regional or perhaps a national

11:51:48 15 center for the study and treatment of Lyme disease?

11:51:50 16 A I think so, yes.

11:51:52 17 Q I'm giving you some free advertising.

11:51:54 18 A Yes.

11:51:54 19 Q Let me throw out some more free advertising.

11:51:56 20 Would Westchester County Medical Center also be a regional

11:52:00 21 or national study for the treatment and management of Lyme

11:52:04 22 disease?

11:52:04 23 A Yes, it would.

11:52:04 24 Q The director there is a physician by the name of

11:52:06 25 Gary Wormzer?



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1 Dattwyler - Plaintiff - Cross 114

11:52:08 2 A Yes.

11:52:08 3 Q Do you know Dr. Wormzer?

11:52:10 4 A Very well. We worked together on a number of

11:52:12 5 projects.

11:52:12 6 Q Is Dr. Wormzer an expert in the field of Lyme

11:52:16 7 disease, it's treatment and management?

11:52:18 8 A Yes.

11:52:20 9 Q Do you know whether Mr. Hanania saw Gary

11:52:22 10 Wormzer, the director of the Lyme disease clinic at

11:52:26 11 Westchester County Medical Center?

11:52:28 12 A No, I don't.

11:52:30 13 Q There's another distinguished physician, who I

11:52:32 14 think you know, John Halperin?

11:52:34 15 A Sure. John and I have worked together. He was

11:52:38 16 originally at Stony Brook and now he's chief of neurology

11:52:40 17 at North Shore.

11:52:42 18 Q He would work with you, write with you and

11:52:44 19 address the neurological components of patients who had

11:52:48 20 Lyme disease?

11:52:50 21 A Yes.

11:52:52 22 Q Do you know that the plaintiff saw John Halperin

11:52:56 23 prior to your -- seeing you?

11:52:58 24 A I'm not sure I remember that.

11:53:02 25 Q Okay. You certainly accept John Halperin as an



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1 Dattwyler - Plaintiff - Cross 115

11:53:04 2 authority in Lyme disease?

11:53:06 3 A Absolutely.

11:53:08 4 Q Lyme disease -- and we're going to go into just

11:53:10 5 a few moments of history, in the United States, was first

11:53:14 6 described as a result of a incidence of infections that

11:53:22 7 arose in the old Lyme area of Connecticut?

11:53:24 8 A That's correct.

11:53:26 9 Q And that was first reported by physicians up at

11:53:30 10 Yale University?

11:53:32 11 A Yes. Dr. Allan Steer and his colleagues first

11:53:34 12 described it.

11:53:36 13 Q And, would Yale University and its Lyme disease

11:53:40 14 center be a regional national center for Lyme disease?

11:53:46 15 A Oh, sure.

11:53:46 16 Q Who's his current director?

11:53:50 17 A On the clinical side, it's Rob Schoen.

11:53:52 18 Q Is Dr. Schoen, in your opinion, an authority on

11:53:54 19 Lyme disease that you would respect?

11:53:56 20 A Yes.

11:53:58 21 Q Doctor, you indicated at a certain point that at

11:54:06 22 the conclusion of your direct testimony that there is some

11:54:10 23 individuals who believed in prolonged antibiotic therapy

11:54:14 24 for the treatment of subjective Lyme disease complaints?

11:54:16 25 A Yes.



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1 Dattwyler - Plaintiff - Cross 116

11:54:18 2 Q I took it from that that you're not one of those

11:54:20 3 individuals who believe in prolonged antibiotic therapy

11:54:24 4 for subjective complaints of Lyme?

11:54:26 5 A You took that correctly. I'm not one of those

11:54:28 6 individuals.

11:54:30 7 Q Do you know that Mr. Hanania went to see a

11:54:36 8 physician by the name of Dr. Joseph Bourascano out in East

11:54:40 9 Hampton?

11:54:40 10 A I know he said he was going to. I didn't know

11:54:44 11 he did it, though.

11:54:44 12 Q Did you receive that? Did you ever see that

11:54:48 13 physician's records of Mr. --

11:54:50 14 A No, I haven't.

11:54:52 15 Q Is Dr. Bourascano -- is he one of the devotees

11:54:54 16 for prescribing antibiotics for subjective complaints of

11:54:56 17 Lyme --

11:54:58 18 A Yes.

11:54:58 19 Q -- on a prolonged long-term basis?

11:55:00 20 A Yes.

11:55:00 21 Q Do you know a physician who practices up in

11:55:02 22 Westchester by the name of Kenneth, is it Legner?

11:55:06 23 A Legner. Yes, I know him.

11:55:08 24 Q Do you know that Mr. Hanania saw that physician?

11:55:12 25 A No.



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1 Dattwyler - Plaintiff - Cross 117

11:55:12 2 Q Does that physician, to your knowledge, is he in

11:55:16 3 a school of physicians who believe in prolonged antibiotic

11:55:22 4 therapy for subjective complaints of Lyme disease?

11:55:24 5 A Yes.

11:55:26 6 Q Prolonged antibiotic therapy, Doctor, can cause

11:55:30 7 adverse side effects?

11:55:30 8 A Absolutely.

11:55:34 9 Q Can prolonged antibiotic therapy cause

11:55:40 10 subjective complaints of joint pain? Well, let me

11:55:48 11 withdraw that question. Can prolonged antibiotic therapy

11:55:52 12 cause constitutional symptoms such as fatigue, depression?

11:55:54 13 A Yes.

11:55:54 14 Q Subjective complaints?

11:55:56 15 A Yes, it could.

11:55:56 16 Q And is that one of the reasons why there's a

11:56:00 17 school of thought that you adhere to that does not

11:56:04 18 advocate prolonged use of antibiotics?

11:56:08 19 A Well, when you approach medicine, what you have

11:56:10 20 to do is you have to weigh the risks and the benefits and

11:56:14 21 try to minimize risks and maximize benefits, so, yes, I

11:56:18 22 belong to the school of thought that does that.

11:56:24 23 Q Doctor, I agree that Duricef is not a --

11:56:28 24 MR. MAURER: Objection to form.

11:56:30 25 THE COURT: Yes, okay. To form.



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1 Dattwyler - Plaintiff - Cross 118

11:56:32 2 MR. LEWIS: Okay.

11:56:32 3 THE COURT: You are in agreement.

11:56:36 4 MR. LEWIS: I agree that it's bad form,

11:56:38 5 Judge, so I'm going to withdraw the question and

11:56:40 6 ask it in another way.

11:56:42 7 THE COURT: Very good.

11:56:44 8 Q Doctor, Duricef is not an antibiotic of any

11:56:46 9 choice for the treatment of Lyme disease; is that correct?

11:56:50 10 A Correct.

11:56:50 11 Q It is an antibiotic of first choice for the

11:56:52 12 treatment of cellulitis; is that fair to say?

11:56:54 13 A It's one of the effective ones, sure.

11:56:56 14 Q Would it be fair to say that Augmentin is not an

11:56:58 15 antibiotic of first choice for the treatment of

11:57:02 16 cellulitis?

11:57:04 17 A I wouldn't say that, because a lot of cellulitis

11:57:06 18 is strep, and there's never been a resistant strep --

11:57:10 19 beta-hemolytic streptococci that is resistant to

11:57:14 20 penicillin, so I think it would be one of the choices.

11:57:18 21 For staph cellulitis you would -- it would not be the

11:57:24 22 first choice.

11:57:24 23 Q Does Augmentin have a high incidence of side

11:57:28 24 effects such as GI disturbance, GI diarrhea?

11:57:32 25 A It causes a lot of diarrhea, yes.



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1 Dattwyler - Plaintiff - Cross 119

11:57:34 2 Q Do you know whether Mr. Hanania had prior

11:57:36 3 history of GI problems?

11:57:38 4 A Yes.

11:57:42 5 Q Doctor, up until today, have you ever read the

11:57:46 6 plaintiff's examination before trial?

11:57:50 7 A No, I have not.

11:57:50 8 Q Up until today have you ever read the

11:57:54 9 examination before trial of the physician's assistant,

11:57:58 10 Jeanette Kobel?

11:58:00 11 A No, I have not.

11:58:00 12 Q Up until today have you ever read the

11:58:02 13 examination before trial of Violet Abemayor?

11:58:06 14 A No, I have not.

11:58:08 15 Q Doctor, one of the features of a differential

11:58:14 16 diagnosis is obtaining a history?

11:58:16 17 A Correct.

11:58:18 18 Q One of the things that a history is based on is

11:58:22 19 communication between one party and another?

11:58:26 20 A Yes.

11:58:26 21 Q One of the things that you're doing here today

11:58:28 22 was discussing the whole concept of differential

11:58:32 23 diagnosis; correct?

11:58:32 24 A Correct.

11:58:36 25 Q Fair to say you didn't learn of Violet



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1 Dattwyler - Plaintiff - Cross 120

11:58:42 2 Abemayor's history of communication with Mr. Hanania since

11:58:46 3 you didn't read her deposition?

11:58:48 4 A That's correct.

11:58:52 5 Q I could ask the same question with regard to the

11:58:54 6 history of Mr. Hanania's communication or contact with

11:59:02 7 Jeanette Kobel; fair to say?

11:59:04 8 A Right. The only information I have is the

11:59:06 9 medical reports, medical records.

11:59:10 10 Q Up until today what medical records did you see,

11:59:12 11 Doctor? Obviously your own at a certain point?

11:59:16 12 A Our own and some records that he had brought to

11:59:20 13 the Lyme disease center at Stony Brook.

11:59:24 14 Q Do you recall what records they were?

11:59:28 15 A No. Offhand I don't.

11:59:30 16 Q Now, at a certain point you wrote a letter to

11:59:38 17 Mr. Maurer on -- it's difficult to read, December of 1995?

11:59:44 18 A Yes.

11:59:46 19 Q Are you familiar with this letter? I can give

11:59:46 20 you a copy of it.

11:59:48 21 A Yes, I'm basically familiar with it.

11:59:50 22 Q Doctor, prior to creating this letter of

11:59:54 23 December of 1995, do you know what medical records you

12:00:00 24 consulted in preparing that?

12:00:04 25 A There were some medical records from LIJ that he



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1 Dattwyler - Plaintiff - Cross 121

12:00:06 2 had brought along.

12:00:08 3 Q Do you know whether you had consulted any

12:00:10 4 medical records from CHP?

12:00:14 5 A I think there was. I am not sure.

12:00:16 6 Q Doctor, that letter, and again, I'll show it to

12:00:20 7 you, refers to that, "Mr. Hanania developed an expanding

12:00:26 8 erythematous skin lesion that reached about 12 centimeters

12:00:30 9 in diameter. He consulted his physician on June 1, 1994"?

12:00:38 10 That's your letter?

12:00:38 11 A That was based mainly on what Mr. Hanania was

12:00:42 12 telling us at that point.

12:00:44 13 Q So, when Mr. Hanania saw you on the occasions up

12:00:46 14 to the creation of this letter, it was your assumption

12:00:50 15 that when the doctors saw him in early June his erythema

12:00:56 16 migrans rash measured 12 centimeters in diameter?

12:01:00 17 A That was what it expanded to -- that's what we

12:01:04 18 were advised by him, that it expanded to that diameter.

12:01:08 19 Q On June 1, was he seen by any physician?

12:01:12 20 A No.

12:01:12 21 Q The history given to you by Mr. Hanania was

12:01:16 22 inaccurate?

12:01:16 23 A It was off by a couple of days, yes.

12:01:20 24 Q Well, not only was it off by a couple of days,

12:01:22 25 but it would be fair to say that when he was first seen on



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1 Dattwyler - Plaintiff - Cross 122

12:01:24 2 June 3, the rash measured under three centimeters in

12:01:30 3 diameter?

12:01:32 4 A In the thing it says about three, yes.

12:01:34 5 Q Okay. Would it be fair to say that a rash

12:01:36 6 anywhere from one to three centimeters cannot be used to

12:01:40 7 diagnose Lyme disease?

12:01:44 8 A The -- yes. The standard of definition of

12:01:48 9 erythema migrans is it must be at least five centimeters

12:01:52 10 in diameter.

12:01:54 11 Q Okay. I quoted some learned words just a few

12:01:58 12 moments ago, and I think you recognize those words? Those

12:02:00 13 are your words?

12:02:02 14 A Sure.

12:02:02 15 Q Okay.

12:02:04 16 A They're also in the CDC surveillance case

12:02:08 17 definition which I helped to write, so.

12:02:10 18 Q So that it doesn't -- and you are a consultant

12:02:14 19 to the CDC, so it doesn't meet the criteria for erythema

12:02:18 20 migrans rash if it's under five centimeters?

12:02:22 21 A Yes.

12:02:22 22 Q Or it has to be equal to five centimeters?

12:02:24 23 A Equal or greater than.

12:02:26 24 Q Okay. I got it reversed. So, on June 3, 1994,

12:02:32 25 that rash wasn't a rash that was consistent with erythema



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1 Dattwyler - Plaintiff - Cross 123

12:02:40 2 migrans; correct?

12:02:40 3 A Well, it could be consistent with very early

12:02:42 4 erythema migrans and not diagnostic of, and that's a

12:02:46 5 subtle point, but I think it's important, and that's why

12:02:50 6 we always teach people draw the circle around it and bring

12:02:52 7 the patient back.

12:02:54 8 Q Okay. Fair to say, then, and it's a subtle

12:02:58 9 distinction, that there wasn't a failure to diagnose a

12:03:02 10 rash of erythema migrans on June 3 by Jeanette Kobel?

12:03:08 11 A Technically, no; you're right.

12:03:10 12 Q The important thing would be to have the patient

12:03:14 13 seen the next day or two days after in order to make that

12:03:18 14 evaluation if the rash had changed in any way; correct?

12:03:22 15 A Correct.

12:03:24 16 Q That's what happened here; correct?

12:03:26 17 A Correct.

12:03:26 18 Q The patient came back on June 4?

12:03:28 19 A Correct.

12:03:30 20 Q Would it be fair to say, then, that there's no

12:03:32 21 substantial factor because the patient was seen within 24

12:03:38 22 hours later, between Jeanette Kobel's failure to diagnose

12:03:44 23 this rash as erythema migrans and the ultimate diagnosis,

12:03:50 24 because she was -- Mr. Hanania was seen by a physician the

12:03:54 25 next day?



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1 Dattwyler - Plaintiff - Cross 124

12:03:56 2 A Yes, I guess so, yes. I get your point.

12:04:10 3 Q And this rash was pruritic?

12:04:14 4 A It means itchy, yes.

12:04:16 5 Q Are rashes of cellulitis itchy or pruritic?

12:04:22 6 A Occasionally you can have an itchy sensation,

12:04:24 7 yes.

12:04:24 8 Q More often than not, a rash of cellulitis itchy?

12:04:28 9 A No, it's usually not. It's usually painful, but

12:04:32 10 not itchy.

12:04:36 11 Q Rashes of erythema migrans are typically not

12:04:42 12 elevated or raised?

12:04:44 13 A That's right. They're usually flat and they're

12:04:46 14 usually nonpruritic and nontender.

12:04:50 15 Q Is there a reference in the June 3 note that

12:04:54 16 this rash was tender?

12:04:56 17 A Yes. Let me just --

12:05:00 18 Q Do you have it there?

12:05:02 19 A Yes. Let me just look for a second.

12:05:04 20 Q Maybe on the other side.

12:05:06 21 A Yes, I've got it. Minimal tenderness, yes.

12:05:14 22 Q Doctor, you've testified, and there's no

12:05:22 23 disagreement, that there can be a lot of rashes that are

12:05:26 24 erythema migrans and are consistent with Lyme disease;

12:05:28 25 correct?



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1 Dattwyler - Plaintiff - Cross 125

12:05:28 2 A You mean there's a lot of variety, yes.

12:05:34 3 Q However, the characteristic rash or the

12:05:36 4 classical rash is that bull's-eye rash; correct?

12:05:38 5 A Correct.

12:05:40 6 Q Have you seen medical records of Mr. Hanania in

12:05:44 7 which he describes the rash as not being a bull's-eye

12:05:48 8 rash?

12:05:50 9 A Yes. I don't think it's described as a

12:05:50 10 bull's-eye rash.

12:05:52 11 Q Okay. You mentioned that slide show before,

12:05:54 12 Doctor. Did your clinic in 19 -- before 1994 have

12:06:02 13 brochures and pamphlets that were given to patients that

12:06:06 14 contain pictures just like the pictures that you displayed

12:06:10 15 to this jury?

12:06:10 16 A Yes.

12:06:12 17 Q Do you know that Mr. Hanania's brother, Steven,

12:06:16 18 was a patient of yours or saw you in consultation?

12:06:22 19 A I think I remember, but it's vague.

12:06:24 20 Q Do you remember him getting any pamphlets or

12:06:26 21 literature?

12:06:26 22 A Oh, I'm sure he did. We give them out quite

12:06:28 23 freely.

12:06:44 24 MR. LEWIS: Judge, I just want to, if I

12:06:46 25 can, just go through some of the doctor's



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1 Dattwyler - Plaintiff - Cross 126

12:06:48 2 records. If I may just stand next to him since

12:06:52 3 this is the only set.

12:06:52 4 THE COURT: Please.

12:06:54 5 Q Do you mind that, Doctor?

12:06:54 6 A No. Not at all. Is it easier if I stand?

12:07:02 7 Q Oh, no. I'll stand and -- I apologize for the

12:07:20 8 legibility, Doctor, and if there's points where you can't

12:07:22 9 read something, just bring that to my attention. Would

12:07:26 10 this have been a reference to a neurology examination of

12:07:34 11 October 20, 1994?

12:07:40 12 A It's probably -- the date's here.

12:07:42 13 Q Sure.

12:07:44 14 A Yes.

12:07:46 15 Q As best you can decipher it, were there any

12:07:50 16 focal neurological findings, positive neurological

12:07:52 17 findings on October 20, 1994?

12:07:54 18 A No, there were not.

12:07:56 19 Q Okay. You gave Mr. Hanania various instructions

12:08:00 20 in terms of follow-up care?

12:08:02 21 A Yes.

12:08:04 22 Q Parenthetically, did you also learn his history

12:08:06 23 of lumbar puncture -- spinal taps and their results?

12:08:10 24 A Yes.

12:08:10 25 Q Would it be fair to say that the results that



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1 Dattwyler - Plaintiff - Cross 127

12:08:14 2 you were made aware of showed a decline in abnormal

12:08:18 3 values?

12:08:18 4 A Yes.

12:08:18 5 Q And that's a positive finding, doctor, in terms

12:08:22 6 of the body's immune system fighting off this cerebral

12:08:26 7 meningitis?

12:08:28 8 A Sure.

12:08:42 9 Q You next saw Mr. Hanania -- would it be a month

12:08:46 10 later?

12:08:48 11 A Yes.

12:08:48 12 Q And, at that time were there any positive

12:08:52 13 physical findings that you found on your examination?

12:08:58 14 A No.

12:09:02 15 Q Okay.

12:09:02 16 A I'm sorry. I didn't mean --

12:09:04 17 Q That's all right. If you are going to

12:09:06 18 anticipate my questions, you know, please go ahead.

12:09:08 19 September 5, 1995 was the next visit?

12:09:10 20 A Yes.

12:09:12 21 Q Were there any physical findings, positive, of

12:09:16 22 some abnormalities on the physical examination that was

12:09:18 23 performed on that day?

12:09:24 24 A No, there weren't. No.

12:09:28 25 Q Okay. And, by physical examination, you would



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1 Dattwyler - Plaintiff - Cross 128

12:09:32 2 look at different organ systems, including his joints?

12:09:38 3 A Yes.

12:09:38 4 Q You would do a neurological examination?

12:09:40 5 A Yes. A cursory one, but, yes.

12:09:42 6 Q Okay. Did you ever refer Mr. Hanania to a

12:09:46 7 neurologist for a neurological examination?

12:09:50 8 A Yes, I did.

12:09:50 9 Q Do you know if that was performed?

12:09:52 10 A It was not.

12:09:54 11 Q Do you know who you referred Mr. Hanania to?

12:09:56 12 A Dr. Patricia Coyle.

12:09:58 13 Q And she's a neurologist at Stony Brook?

12:10:02 14 A Yes.

12:10:02 15 Q She's written extensively on Lyme disease?

12:10:04 16 A Yes.

12:10:06 17 Q She's an expert on Lyme disease?

12:10:08 18 A Yes.

12:10:08 19 Q Had you ever referred the plaintiff for

12:10:12 20 neuropsychological testing?

12:10:14 21 A No. She would have done that.

12:10:16 22 Q Okay. But Stony Brook has the capability of

12:10:20 23 doing neuropsychological testing?

12:10:22 24 A Yes. We do it routinely.

12:10:26 25 Q Okay. You next saw Mr. Hanania in April of



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1 Dattwyler - Plaintiff - Cross 129

12:10:32 2 1996?

12:10:32 3 A Yes.

12:10:34 4 Q Based upon your physical examination, were there

12:10:36 5 any positive findings?

12:10:38 6 A No.

12:10:40 7 Q By positive findings, anything that you were

12:10:42 8 able to elicit on physical examination?

12:10:44 9 A Physical signs, no. There were no physical

12:10:46 10 signs.

12:10:46 11 Q You next saw him in July?

12:10:48 12 A Yes.

12:10:50 13 Q On physical examination were there any objective

12:10:52 14 findings?

12:10:56 15 A No, there were not.

12:11:00 16 Q Would it be fair to say, then, and go through

12:11:02 17 the records, that the next examination that you performed

12:11:06 18 was on January of 1998?

12:11:10 19 A Correct.

12:11:12 20 Q And, at that time there were no positive

12:11:14 21 physical findings?

12:11:16 22 A It look like he had a head cold, so his mucous

12:11:18 23 membranes in his nose were slightly inflamed.

12:11:20 24 Q Okay.

12:11:22 25 A But that's probably, you know, viral, cold.



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1 Dattwyler - Plaintiff - Cross 130

12:11:30 2 Q Doctor, in terms of skin cultures, things like

12:11:36 3 that, withdrawn. Laboratory testing for Lyme disease in

12:11:42 4 June of 1994, there was a lag time of four to six weeks

12:11:48 5 after the onset of symptoms before laboratory tests would

12:11:52 6 show reliable data as to the presence of disease?

12:11:56 7 A You could get it earlier, but the technology has

12:12:00 8 improved since then, so that now it's down to about two

12:12:02 9 weeks you can get good antibiotic testing. Then it was

12:12:06 10 standard about a month.

12:12:10 11 Q Okay. Doctor, did you ever do any follow-up

12:12:14 12 serological examination on Mr. Hanania to see if there's

12:12:20 13 active infection going on?

12:12:24 14 A You can't do it that way. What the test

12:12:26 15 measures is antibodies against the bacteria that causes

12:12:30 16 Lyme disease, and there's -- their exposure tests are not

12:12:34 17 active disease tests, so the test doesn't tell you disease

12:12:38 18 active, it only tells you that you were exposed and were

12:12:40 19 infected with that organism at one point in your life.

12:12:46 20 Q And it's your opinion that he doesn't have any

12:12:48 21 active Lyme disease at present?

12:12:50 22 A Well, active infection, yes.

12:12:52 23 MR. LEWIS: I have no further questions.

12:12:56 24 THE COURT: Redirect examination.

12:12:56 25 MR. MAURER: Yes, your Honor.



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1 Dattwyler - Plaintiff - Redirect 131

2 REDIRECT EXAMINATION

12:13:00 3 BY MR. MAURER:

12:13:00 4 MR. MAURER: I'd like to mark the records

12:13:00 5 you showed to Dr. Dattwyler --

12:13:04 6 MR. LEWIS: Sure.

12:13:04 7 MR. MAURER: -- collectively, if you have

12:13:04 8 it.

12:13:06 9 MR. LEWIS: I do, Judge.

12:13:06 10 THE COURT: All right. You want that in

12:13:08 11 evidence?

12:13:08 12 MR. MAURER: Yes, please.

12:13:10 13 THE COURT: All right.

12:13:10 14 MR. MAURER: Just mark the whole group of

12:13:12 15 the records as exhibit four.

16 (Whereupon, the reporter marked Plaintiff's

17 Exhibit 4 in evidence.)

12:13:52 18 Q Doctor, when we're talking about a cure of Lyme

12:13:56 19 disease, what does that mean, by definition to you?

12:14:00 20 A Well, if you're talking about a cure of

12:14:02 21 infection, it's eradication of the spirochete. If you're

12:14:06 22 talking about a cure, you'd like to have someone return to

12:14:10 23 baseline values and be normal again.

12:14:12 24 Q Okay. In your opinion, has Mr. Hanania had a

12:14:18 25 cure in terms of his return to baseline values?



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1 Dattwyler - Plaintiff - Redirect 132

12:14:22 2 A No. He continues to have ongoing problems.

12:14:26 3 Q So, when counsel was asking you questions on

12:14:30 4 cross-examination about a cure, what were you referring

12:14:34 5 to?

12:14:36 6 A Bacteriological.

12:14:38 7 MR. LEWIS: To the form, Judge.

12:14:40 8 THE COURT: Go ahead.

12:14:40 9 A A bacteriologic cure, meaning eradication of the

12:14:44 10 infecting organism.

12:14:46 11 Q So it's your opinion that Mr. Hanania no longer

12:14:48 12 has the Lyme disease-causing bacteria in his body?

12:14:50 13 A Correct.

12:14:52 14 Q And to that extent his antibiotic treatment has

12:14:54 15 been effective?

12:14:56 16 A Correct.

12:15:12 17 Q You were asked if you were aware of Mr. Hanania

12:15:16 18 having any gastroenterological problems by counsel?

12:15:20 19 A Yes.

12:15:20 20 Q What was your understanding about what Mr.

12:15:22 21 Hanania had in that area prior to June of 1994?

12:15:26 22 A He's had some episodes of diarrhea and spastic

12:15:28 23 colon like things.

12:15:30 24 Q Okay. And based upon that history, your

12:15:34 25 knowledge of it, would that change any of the opinions



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1 Dattwyler - Plaintiff - Redirect 133

12:15:36 2 that you've expressed here today with regard to the

12:15:42 3 failure of Dr. Violet Abemayor to diagnose and treat Lyme

12:15:48 4 disease in Mr. Hanania's case?

12:15:52 5 MR. LEWIS: Objection.

12:15:52 6 THE COURT: Would it change his opinion?

12:15:54 7 MR. MAURER: Yes.

12:15:56 8 Q In other words would his knowledge of that

12:15:56 9 history change any of the opinions you gave about Dr.

12:16:00 10 Abemayor's failure to treat with an appropriate antibiotic

12:16:04 11 for Lyme disease?

12:16:06 12 THE COURT: I'll allow that.

12:16:08 13 A No.

12:16:16 14 Q Based on Mr. Hanania's gastroenterological

12:16:20 15 history that existed before June of 1994, do you have an

12:16:26 16 opinion, within a reasonable degree of medical certainty,

12:16:28 17 as to whether or not it would have been inappropriate to

12:16:32 18 treat Mr. Hanania with Augmentin on June 4, 1994?

12:16:38 19 A Would it have been inappropriate under the

12:16:38 20 circumstances; no, it wouldn't have been inappropriate at

12:16:40 21 all. It's a known complication of that. Anything that

12:16:42 22 works there's complications, and you have to weigh the

12:16:46 23 individual's situation with risks and the benefits.

12:17:00 24 Q With regard to Mr. Hanania's prolonged

12:17:04 25 antibiotic treatment that he has received since June of



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1 Dattwyler - Plaintiff - Redirect 134

12:17:06 2 1994, on and off, do you have an opinion, within a

12:17:10 3 reasonable degree of medical certainty, as to whether or

12:17:14 4 not any of Mr. Hanania's cognitive problems that you've

12:17:18 5 discussed here today were caused by his prolonged

12:17:20 6 antibiotic treatment?

12:17:22 7 MR. LEWIS: Objection.

12:17:24 8 THE COURT: No, I'll allow it.

12:17:26 9 A No. I think Minocycline and Doxycycline are

12:17:34 10 used for treatment of acne, and in adolescents with acne

12:17:38 11 are treated for months, for a very prolonged period of

12:17:42 12 time with those agents without much in the way of side

12:17:44 13 effects.

12:17:44 14 Q So your answer is?

12:17:46 15 A I don't think -- no, I don't think it relates to

12:17:48 16 his cognitive difficulties.

12:17:50 17 Q Do you have an opinion, within a reasonable

12:17:52 18 degree of medical certainty, as to whether or not any of

12:17:56 19 the other complaints Mr. Hanania related to you in January

12:17:58 20 of 1998 are related to his prolonged receipt and treatment

12:18:04 21 with antibiotics?

12:18:06 22 A The ones I gave him, no.

12:18:08 23 Q No, what?

12:18:10 24 A I don't think his complaints are secondary to

12:18:14 25 that.



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1 Dattwyler - Plaintiff - Redirect 135

12:18:22 2 Q And with regard to Mr. Hanania's diagnosis and

12:18:26 3 treatment, do you have an opinion, within a reasonable

12:18:30 4 degree of medical certainty, as to whether or not Mr.

12:18:32 5 Hanania would have gone onto develop Lyme meningitis and

12:18:38 6 the facial paralysis, had he been treated with an

12:18:42 7 appropriate antibiotic for Lyme disease on June 4, 1994?

12:18:46 8 MR. LEWIS: Objection, Judge. Beyond the

12:18:48 9 scope of redirect examination.

12:18:50 10 THE COURT: I'll sustain the objection.

12:19:38 11 MR. MAURER: I'd just like to mark for

12:19:40 12 identification the report that was made

12:19:42 13 reference to of Dr. Dattwyler from December 19,

12:19:46 14 1995.

12:19:48 15 MR. LEWIS: It's already in part of the

12:19:50 16 records that I showed the doctor, so it's in

12:19:52 17 evidence already.

12:19:54 18 MR. MAURER: Okay. Thank you.

12:20:00 19 THE COURT: Counselor?

12:20:00 20 MR. MAURER: That's it. Thank you.

12:20:02 21 THE COURT: Okay, thank you. Members of

12:20:04 22 the jury, what perfect timing we've had. 12:30

12:20:06 23 is our lunch break, so have a good lunch.

12:20:10 24 Remember, do not discuss the case among

12:20:10 25 yourselves or with anyone else. See you at two



VC

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