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1 David Edward May, Esq. (Bar No. 083734)
LAW OFFICES OF BRUCE S. OSTERMAN 1/7/2021
2 2300 Contra Costa Blvd., Suite 320
Pleasant Hill, CA 94523-3952
3 Tel: (415) 399-3900
Fax: (415) 399-3920
4 Email: dem@bruceosterman.com
5 Attorneys for Plaintiffs
Ruben Ortega, Fermin Oretga, Crystal Ortega,
6 Ruben Ortega, Jr., Christian Ortega; Saulo Ortega
7 SUPERIOR COURT OF THE STATE OF CALIFORNIA
8 FOR THE COUNTY OF BUTTE
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RUBEN ORTEGA, FERMIN ORETGA, Case No: 20 CV 01510
CRYSTAL ORTEGA, RUBEN ORTEGA,
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JR., CHRISTIAN ORTEGA; SAULO Reply in Support of Motion to Compel
ORTEGA, Answer to Special Interrogatory;
12 Plaintiffs, Declaration of David Edward May in
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vs. Support of Reply
ENLOE MEDICAL CENTER; MIGUEL
14 PUIG-PALOMAR, M.D.; GANSEVOORT Date: Jan. 13, 2021 (Wed.)
H. DUNNINGTON, M.D.; MICHAEL L. Time: 9:00 a.m.
15 HIEB, M.D.; and DOES 1 to 50, Dept: 10 (Judge R. Glusman)
16 Defendants.
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19 1. Introduction.
20 This motion was originally directed to three defendants: Enloe Medical Center, Dr. Puig-
21 Palomar, and Dr. Dunnington.
22 Dr. Puig-Palomar and Dr. Dunnington have since provided further answers to the subject
23 matter interrogatory:
24 "Please describe what caused the cardiopulmonary bypass machine to malfunction
25 during the cardiac surgery performed on Maria Ortega on January 17, 2020."
26 Dr. Dunnington answered (after all the chaff is removed) that he "does not know what caused the
27 alleged malfunction of the cardiopulmonary bypass machine during the surgery on Ms. Ortega on
Reply in Support of Motion to Compel Page 1
1 01/17/20." Dr. Puig-Palomar answered (after all the chaff is removed): "It was my impression that
2 the cardiopulmonary bypass machine malfunctioned. Based on my understanding of subsequent
3 testing on the machine, it appears the oxygenator failed due to the presence of blood clots." Based
4 on these amended responses, moving parties withdraw their motion as to those two defendants.
5 Enloe Medical Center continues to resist answering the interrogatory. Its Opposition recites
6 five reasons for refusing to answer the interrogatory:
7 A. Plaintiff Filed One Motion to Compel Against Three Separate and Distinct Parties;
8 B. Plaintiff’s Special Interrogatory No. 4 Seeks Information Privileged Under Evidence
9 Code section 1157;
10 C. Plaintiff’s Special Interrogatory No. 4 Seeks Information Privileged Under the Patient
11 Safety and Quality Improvement Act of 2005 (Patient Safety Work Product), 42
12 U.S.C. 299b-21 et seq;
13 D. Plaintiff’s Special Interrogatory No. 4 Seeks the Premature Disclosure of Expert
14 Witness Information in Violation of Code of Civil Procedure Sections 2034.260 and
15 2034.270;
16 E. Plaintiff’s Special Interrogatory No. 4 is vague, overbroad, oppressive, and not likely
17 to lead to the discovery of admissible evidence.
18 Each of these will be addressed in order.
19 2. Multiple Defendants.
20 Enloe complains that this motion was directed not only at it, but also two of the other
21 defendants as well. Enloe ignores that the motion concerns the same identical interrogatory and
22 similar objections.
23 Instead Enloe cites C.C.P. §128.7 for the proposition that “each motion should be set forth
24 in a separate document, ...” First of all, the instant motion is not made pursuant to C.C.P. §128.7.
25 That is because “This section shall not apply to disclosures and discovery requests, responses,
26 objections, and motions.” (C.C.P. §128.7 (g); emphasis added.) Furthermore, that section nowhere
27 says that “each motion should be set forth in a separate document.” Instead, it states: “A motion for
Reply in Support of Motion to Compel Page 2
1 sanctions under this section shall be made separately from other motions or requests ...” (C.C.P.
2 §128.7 (c)(1).) The instant motion is made under the discovery statutes, and in particular C.C.P.
3 §2030.300.
4 Next, Enloe states that “California Rule of Court, Rule 3.1112(c) allows a combined motion
5 ‘if the party filing a combined pleading specifies these items separately in the caption of the
6 combined pleading.’ ” (Opposition 7:4-6.) The answer to this false assertion is contained in itself.
7 The Rule pertains to “combined pleadings” not “combined motions.” Rule 3.1112 prescribes what
8 papers are required in a motion. Subsection (c) allows those papers to be filed separately or together
9 in a “combined pleading.” Nothing in the rule talks about combined motions or multiple parties.
10 Finally, Enloe complains that the notice of motion does not “identify every person, party, and
11 attorney against whom the sanction is sought, ...” This also is false. The notice of motion states that
12 it seeks and order specifically against “Defendants Enloe Medical Center, Miguel Puig-Palomar
13 M.D., and Gansevoort H. Dunnington M.D.” (Notice 1:20-21.)
14 3. Evidence Code §1157.
15 Enloe continues to assert Ev. Code §1157 as a total bar of discovery to this event, under the
16 theory than if the incident was reported to a committee referred to in Ev. C. §1157, all information
17 reported to the committee would be protected from discovery. Of course, this is not the law. Enloe
18 ignores the authority provided in the moving Memo of P&A regarding this issue. Information
19 “is not rendered immune from discovery under section 1157 merely because it is later
20 placed in the possession of a medical staff committee or made known to committee
21 members; and this may be so even if the information in question may be relevant in
22 a general way to the investigative and evaluative functions of the committee." (Santa
23 Rosa Memorial Hospital v. Superior Court (1985) 174 Cal.App.3d 711, 724.)
24 In the 5½ pages of Enloe’s §1157 argument, nowhere is it stated how the interrogatory at
25 issue implicates “the proceedings []or the records of organized committees” of Enloe. The
26 interrogatory asks not for proceedings or records. It asks what caused the malfunction of a machine.
27 Indeed, Enloe fails to identify what committee or committees even considered this information, if
Reply in Support of Motion to Compel Page 3
1 any. Instead, we have general and vague assertions (5 ½ pages of them) regarding general practices
2 that may, or may not, have occurred in this case. None of these are attributable to this interrogatory.
3 The only statement about this particular interrogatory in Enloe’s papers is the unsubstantiated hope
4 that Ev.C. §1157 allows them to refuse to answer it.
5 4. Patient Safety Work Product, 42 U.S.C. 299b-21 et seq.
6 This act is even further removed than Ev.C. §1157. Enloe recites no California law on the
7 subject. Instead, Enloe cites cases from Illinois and Pennsylvania that allegedly held that information
8 primarily collected for and provided to a federally certified “PSO”1 is protected by the “PSWP”
9 privilege. The problem is that no Federal or State Court in California has ruled on the application
10 of this privilege to a California state action. Furthermore, there is no evidence that the information
11 requested was primarily collected for or provided to a federally certified “PSO.”
12 Furthermore, the statute itself provides a rule that parallels the holding of Santa Rosa
13 Memorial Hospital v. Superior Court (1985) 174 Cal.App.3d 711, 724 quoted above.
14 “(ii) Information described in subparagraph (A) does not include information that
15 is collected, maintained, or developed separately, or exists separately, from a patient
16 safety evaluation system. Such separate information or a copy thereof reported to a
17 patient safety organization shall not by reason of its reporting be considered patient
18 safety work product.
19 (iii)Nothing in this part shall be construed to limit—
20 (I) the discovery of or admissibility of information described in this
21 subparagraph in a criminal, civil, or administrative proceeding;”
22 (42 U.S. Code §299b-21(7)(B).)
23 5. Expert Witness Information.
24 Enloe argues against the application of the opinion of the State Supreme Court in Schreiber
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26 The protected information must be “assembled or developed by a provider for reporting to
a patient safety organization and are reported to a patient safety organization. (42 U.S. Code §299b-
27 21(7)(A)(i)(I).)
Reply in Support of Motion to Compel Page 4
1 v. Estate of Kiser (1999) 22 Cal.4th 31, 39, which held:
2 “to the extent a physician acquires personal knowledge of the relevant facts
3 independently of the litigation, his identity and opinions based on those facts are not
4 privileged in litigation presenting ‘an issue concerning the condition of the patient.’
5 [Citation.] For such a witness, no expert witness declaration is required, and he may
6 testify as to any opinions formed on the basis of facts independently acquired and
7 informed by his training, skill, and experience.”
8 The basis for this argument is the Enloe is not a “physician.” No reason or authority is given for
9 limiting this holding to physicians, rather than applying it to all “health care providers.” Enloe
10 ignores the fact that the reason it is being sued is that the person (perfusionist) operating the cardio-
11 pulmonary bypass machine during the operation on plaintiffs’ decedent when it malfunctioned,
12 causing plaintiff’s decedent to die, was an employee of Enloe Medical Center. Enloe argues:
13 “Enloe Medical Center should not be compelled to offer opinion evidence about a
14 topic outside the scope of its ‘practice.’ Enloe Medical Center does not engage in the
15 manufacture, sale, or distribution of medical devices and is therefore unable to
16 respond regarding ‘the operation of a machine used during the fatal surgery on
17 plaintiffs decedent.’” (Opposition 17:15-18.)
18 But the“scope of [Enloe’s] ‘practice’” is providing a perfusionist who has the necessary education,
19 skill, and experience to operate the specific cardio-pulmonary bypass machine that failed when it was
20 being used on plaintiffs’ decedent.
21 Furthermore, the interrogatory does not ask for an “opinion.” Enloe’s argument against the
22 relevant quotation in the moving P&A is non-sensical. The law is:
23 “[T]he common law rule [is] that a physician or other treating health care
24 practitioner, who testifies regarding his or her knowledge of the patient’s
25 treatment, diagnosis or prognosis, does not express an expert opinion.” (Brun v.
26 Bailey (1994) 27 Cal.App.4th 641, 654; emphasis added.)
27 Enloe states in direct contravention of the wording of this quote, that it does not apply to Enloe
Reply in Support of Motion to Compel Page 5
1 because “Enloe Medical Center, a hospital, is not a treating physician.” (Opposition, 17:8-9.) But
2 Enloe Medical Center, and its employee perfusionist, are “other teating health care practioners.”
3 Finally, Enloe argues that “defendant Enloe Medical Center did not acquire information, which
4 forms the factual basis for its ‘opinions,’ independently of protected activities.” (Opposition 17:9-
5 10.) What “protected activities” is Enloe talking about? How are they “protected?” What the
6 interrogatory asks for is information obtained by Enloe’s perfusionist when he was operating the
7 cardio-pulmonary bypass machine at the time it stopped functioning during the open heart surgery
8 on plaintiffs’ decedent. That “activity” is the “patient’s treatment” described in the above quote.
9 It is not “protected activity” and, per the quote, “does not express an expert opinion.”
10 6. Vague, Overbroad, Oppressive, Irrelevant.
11 The last of Enloe’s objections is just more boilerplate. The question in not vague; in fact it
12 is very concise, precise, and concrete. There is no dispute that the cardio-pulmonary bypass machine
13 failed in the middle of the open heart surgery. Enloe’s statement that “There is no indication
14 Defendant contends the device malfunctioned” is simply an unethical misrepresentation to this
15 Court. Both defendant surgeons (Dr. Puig-Palomar and Dr. Dunnington) wrote multi-page
16 operative reports, filed in Enloe’s records, that memorialize the malfunction of the machine, and the
17 time spent trying to repair, and then replace, the machine during the surgery. (See attached reports.)
18 Why did it fail? How is that overbroad? How is it oppressive? Enloe’s Opposition certainly
19 doesn’t say. There is no authority cited that would support that conclusion. The interrogatory
20 certainly is relevant. The failure of the machine was the primary cause of death of plaintiffs’
21 decedent. What could be more relevant?
22 7. Conclusion.
23 An order requiring the defendant to answer the special interrogatory should be issued and
24 sanctions awarded.
25 Dated: January 6, 2021 Law Office of Bruce S. Osterman
26
27 By David Edward May
Reply in Support of Motion to Compel Page 6
1 DECLARATION OF DAVID EDWARD MAY IN SUPPORT OF REPLY
2 I am an attorney duly admitted to the bar of this honorable Court, and am in good standing.
3 I represent plaintiffs in the above entitled action. I have personal knowledge of the facts stated
4 herein, and would and could competently testify to those facts if called upon to do so.
5 Attached hereto are the operative reports prepared by defendants Dr. Puig-Palomar and Dr.
6 Dunnington, which are contained in the medical records of defendant Enloe Medical Center, and
7 which describe the fatal surgery performed on plaintiffs’ decedent on January 17, 2020, which is the
8 subject of the above entitled action.
9 I declare under penalty of perjury pursuant to the law of the State of California that the
10 foregoing is true and correct.
11 Dated: January 6, 2021 ___________________________
David Edward May
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Reply in Support of Motion to Compel Page 7
1 PROOF OF SERVICE
2
3 I am over the age of 18 years, I am not a party to the above-entitled action, and my business
4 address is Law Offices of Bruce S. Osterman, 2300 Contra Costa Boulevard, Suite 320, Pleasant
5 Hill, California 94523-3952. On January 6, 2021, I served a true copy of:
6 Reply in Support of Motion to Compel Answer to Special Interrogatory; Declaration of David
7 Edward May in Support of Reply; and this Proof of Service
8 on the following person(s):
9 Alaina T. Dickens, Esq. Anthony D. Lauria, Esq.
Schuering Zimmerman & Doyle, LLP Lauria Tokunaga Gates & Linn LLP
10 400 University Avenue 1755 Creekside Oaks Drive, Suite 240
Sacramento CA 95825-6502 Sacramento CA 95833-3645
11 Email: ATD@szs.com Email: alauria@ltglaw.net
[Attorneys for Enloe Medical Center] [Attorneys for Michael L. Hieb, M.D.]
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Marc Lyde, Esq. Nicole I. Whately, Esq.
13 Maria Lathrop Winter, Esq. Pollara Law Group
Leonard & Lyde Law Offices 100 Howe Avenue, Suite 165N
14 1600 Humboldt Road, Suite 1 Sacramento CA 95825-8202
Chico CA 95928-8100 Email: NW@pollara-law.com
15 Email: leonardandlyde@gmail.com [Attorneys for Miguel Puig-Palomar, M.D.]
[Attorneys for Gansevort H. Dunnington, M.D.
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17 by electronic service through the Court’s electronic filing and service provider, and by email to the
18 email address listed above.
19 I declare under penalty of perjury pursuant to the law of the State of California that the
20 foregoing is true and correct.
21 Dated: January 6, 2021 ___________________________
David Edward May
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Reply in Support of Motion to Compel Page 8
Enloe Medical Center (Main Ortega, Maria D
campus) MRN: 204502, DOB: 5/1/1972, Sex: F
1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020
CHICO CA 95926
Entire Encounter
Op Note - Encounter Notes (continued)
Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543
Author: Miguel Puig-Palomar, MD Service: Cardiothoracic Surgery Author Type: Physician
Filed: 02/01/20 1543 Date of Service:
01/17/20 1721 Status: Signed
Editor: Miguel Puig-Palomar, MD (Physician) Trans ID: 3064554
Dictation Time: 01/31/20
Trans Time: 01/31/20 Trans Doc Type: Trans Status: Available
1349 1433 Operative Note
SERVICE DATE:01/17/2020
PREOPERATIVE DIAGNOSIS:
Pseudoaneurysm ascending aorta, status post remote emergency aortic valve
replacement with mechanical valve and replacement of the ascending aorta
with a Dacron graft.
POSTOPERATIVE DIAGNOSES:
Pseudoaneurysm ascending aorta, status post remote emergency aortic valve
replacement with mechanical valve and replacement of the ascending aorta
with a Dacron graft. Cardiogenic shock. Coagulopathy.
PROCEDURE PERFORMED:
Replacement of ascending aorta and hemiarch with 30 mm Dacron graft.
Replacement of aortic valve with 21 mm Carpentier-Edwards tissue valve.
Redo replacement, ascending aorta, with 30 mm Dacron graft.
Coronary artery bypass times 1 with saphenous vein graft to right
coronary artery.
Placement of left femoral intraaortic balloon pump. Right axillary
artery cannulation. Right femoral percutaneous venous cannulation.
CO-SURGEONS:
Miguel Puig MD
Gansevoort Dunnington MD
ASSISTANT:
Kelley Alvarez PA
ANESTHESIOLOGIST:
Michael Hieb MD
ANESTHESIA:
General endotracheal.
INDICATIONS:
A 47-year-old female 14 years status post emergency replacement of the
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Op Note - Encounter Notes (continued)
Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543
ascending aorta with Dacron graft and aortic valve, mechanical St. Jude
valve.
The patient was seen in the emergency room status post CT scan of the
chest showing massive pseudoaneurysm from surgical site ascending aorta.
FINDINGS AT TIME OF PROCEDURE:
Intraoperative transesophageal echo showed mechanical aortic valve with a
large jet of insufficiency.
Once the patient was cannulated and cooled down the chest was entered
with immediate massive bleeding. The site of the origin of the
pseudoaneurysm was the distal anastomosis of the Dacron graft to distal
ascending aorta from previous surgery. During the repair of the
pseudoaneurysm, there was concern with poor venous return and arterial
inflow. After troubleshooting, the oxygenator of the heart-lung machine
was presumed nonfunctional for possible clots and required replacement.
Despite expeditious repair of the vascular injury and the parts on the
heart-lung machine, the patient had presumed long period of hypotension
and poor perfusion.
Upon completion of surgery the patient had left and right heart failure.
Despite bypass on the right coronary artery, the patient remained in
profound cardiogenic shock, combined with severe coagulopathy.
Transesophageal echo showed good function of the newly placed
bioprosthesis.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed on the operating
table in the supine position. After induction of general endotracheal
anesthesia, the patient was prepped and draped in usual sterile fashion.
Working in 2 teams, arterial and venous access was gained. Percutaneous
cannulation of the right femoral vein was completed using Seldinger
technique, dilator, and venous cannula. They were secured to the thigh
with adequate suturing.
A right subclavian incision was made. Dissection taken down through the
skin, soft tissue, pectoralis major. The axillary artery was identified
and looped with vessel loop. With the patient fully heparinized, an 8 mm
Dacron graft was sutured end-to-side to the exposed axillary artery with
running 5-0 Prolene. With arterial and venous lines in place, the
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campus) MRN: 204502, DOB: 5/1/1972, Sex: F
1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020
CHICO CA 95926
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Op Note - Encounter Notes (continued)
Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543
patient was entered in cardiopulmonary bypass and cooled down.
A median sternotomy was reentered through the same site of previous
surgery, sternal wires were removed. Once the patient was cooled down,
oscillating saw was used to divide the sternum.
Upon entering the sternal bone, immediate active bleeding from the
surgical field was noted. Expeditiously, the ascending aorta exposure
was completed to identify the site of active bleeding and was repaired
with 4-0 Ethibond pledgeted sutures. That corresponded to the distal
anastomosis of graft to aorta at the 2 o'clock position. At that time, a
low flow situation was reported from the heart-lung machine. Arterial
and venous cannulas were examined. A tear was noted in the right atria
corresponding to the scar tissue and exposure during initial entrance
into the mediastinum. Expeditious repair of the atria was completed with
running suture of 4-0 Prolene. Despite that, the venous return appeared
to be a problem. A double-stage venous cannula was placed to the right
atria into the inferior vena cava and used as a main venous drainage. A
second aortic cannula was placed through the proximal arch.
Troubleshooting in progress from the perfusion identified possible
oxygenator malfunction that required replacement.
Continuous cooling with available perfusion followed. The remainder of
the ascending aorta and proximal arch were excised under circulatory
arrest and hemiarch repair completed with 30 mm graft expeditiously
sutured, the running suture of 4-0 Prolene. After adequate de-airing of
the arch, the graft was clamped. By then adequate perfusion was
reestablished. Correction of metabolic acidosis and rewarming slowly
followed. During the rewarming time, decision was made to replace the
defective aortic valve and the proximal aorta. They both were excised
sharply. The aortic valve was sized and a 21 mm Carpentier-Edwards
tissue valve was secured in place with horizontal mattress pledgeted
sutures of 2-0 Ethibond, leaving the pledgets on the ventricular side.
Cor-Knot device was used to help secure the valve in place. The coronary
ostia were left undisturbed.
Of note, the patient received a retrograde cardioplegic cannula once the
initial repair of the pseudoaneurysm defect was completed. Through that
retrograde cardioplegia cannula, cardioplegia was given throughout the
crossclamp time. Antegrade cardioplegia was given as initial shot to
protect the heart for an aortic cross clamping.
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campus) MRN: 204502, DOB: 5/1/1972, Sex: F
1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020
CHICO CA 95926
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Op Note - Encounter Notes (continued)
Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543
The coronary ostia, native, were left undisturbed. A 30 mm graft was
anastomosed end-to-end to ascending aorta just distal to the coronary
ostia with running suture of 4-0 Prolene. An antegrade and vent catheter
was placed in the newly placed graft for adequate de-airing.
Once rewarming was completed and the heart was de-aired, crossclamp was
removed following hot shot cardioplegia. Temporary pacing wire placed in
the surface of the right ventricle. At time from weaning from
cardiopulmonary bypass was unsuccessful. Right heart failure was noted.
Intraaortic balloon pump was placed in the left femoral artery and
secured in place in the usual fashion. The patient required high
inotropic support and continued correction of metabolic acidosis.
Several attempts to continue weaning from cardiopulmonary bypass followed
with intermittent periods of rest on pump. Decision was made to bypass
the right coronary artery as a possibility of the right coronary ostium
being compromised with a graft to aorta anastomosis. A segment of
saphenous vein graft was harvested from the left leg from ankle to mid
leg. The vein was prepared in the usual fashion. Incision closed in the
leg with subcutaneous 2-0 Vicryl, subcuticular 4-0 Monocryl for the skin.
Right coronary artery anastomosis completed as per Dr. Dunnington's note.
After multiple efforts to wean from cardiopulmonary bypass, the chest was
drained with chest tube secured to the skin with 0 Ethibond. Cannulas
and catheters removed, extensive hemostasis completed. Chest was closed
with wires for the sternum and #1 Vicryl for fascia, subcutaneous 2-0
Vicryls, subcuticular 4-0 Monocryl for the skin.
The graft on the right axillary incision was oversewn distal to the
anastomosis and buried in pectoralis muscle. Incision closed with #1
Vicryl, muscle subcutaneous 2-0 Vicryl, subcuticular 4-0 Monocryl for the
skin.
The patient was transferred to the ICU with continued cardiogenic shock
and maximum support and intraaortic balloon pump. Family informed.
Prognosis poor.
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1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020
CHICO CA 95926
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Op Note - Encounter Notes (continued)
Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543
__________________________________________
Miguel Puig MD
MP/JJJ
Physician ID: 0185
D: 01/31/2020 1349 / T: 01/31/2020 1433
Job#: 007329 Doc #: 3064554
cc: Miguel Puig MD; Gansevoort Dunnington MD; Kelley Alvarez PA
Electronically Signed by Miguel Puig-Palomar, MD on 02/01/20 1543
Op Note signed by Gansevoort Dunnington, MD Version 1 of 1 at 02/02/20 1820
Author: Gansevoort Dunnington, MD Service: Cardiothoracic Surgery Author Type: Physician
Filed: 02/02/20 1820 Date of Service:
01/17/20 0825 Status: Signed
Editor: Gansevoort Dunnington, MD (Physician) Trans ID: 3064363
Dictation Time: 01/17/20
Trans Time: 01/17/20 Trans Doc Type: Trans Status: Available
1845 2005 Operative Note
SERVICE DATE:01/17/2020
PREOPERATIVE DIAGNOSES:
1. Massive pseudoaneurysm of ascending aorta status post prior mechanical
aortic valve replacement (AVR) and ascending aorta replacement 14 years
ago.
2. Moderate aortic insufficiency.
3. Hypertension.
POSTOPERATIVE DIAGNOSES:
1. Massive pseudoaneurysm of ascending aorta status post prior mechanical
aortic valve replacement (AVR) and ascending aorta replacement 14 years
ago.
2. Moderate aortic insufficiency.
3. Hypertension.
PROCEDURE PERFORMED:
1. Replacement of ascending aorta and hemiarch with a 30 mm Dacron graft.
2. Excision of mechanical aortic valve and aortic valve replacement with a
21 Edwards Magna pericardial valve.
3. Coronary artery bypass graft times 1 with saphenous vein graft from the
aortic graft to the right coronary artery.
4. Placement of intraaortic balloon pump.
5. Right axillary artery exposure and cannulation for cardiopulmonary
bypass, as well as a right femoral percutaneous venous access with
percutaneous suture mediated closure.
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campus) MRN: 204502, DOB: 5/1/1972, Sex: F
1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020
CHICO CA 95926
Entire Encounter
Op Note - Encounter Notes (continued)
Op Note signed by Gansevoort Dunnington, MD (continued) Version 1 of 1 at 02/02/20 1820
CO-SURGEONS:
Gansevoort Dunnington MD
Miguel Puig MD
ASSISTANT:
Kelley Alvarez PA
ANESTHESIOLOGIST:
Michael Hieb MD
ESTIMATED BLOOD LOSS:
Massive.
BLOOD PRODUCTS GIVEN:
Packed red blood cells, FFP, platelets and NovoSeven, multiple rounds.
DISPOSITION:
ICU.
CONDITION:
Grave.
COMPLICATIONS:
1. Malfunction of cardiopulmonary bypass machine with possible clotting of
the circuit requiring replacement of di
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1 David Edward May, Esq. (Bar No. 083734) LAW OFFICES OF BRUCE S. OSTERMAN 1/7/2021 2 2300 Contra Costa Blvd., Suite 320 Pleasant Hill, CA 94523-3952 3 Tel: (415) 399-3900 Fax: (415) 399-3920 4 Email: dem@bruceosterman.com 5 Attorneys for Plaintiffs Ruben Ortega, Fermin Oretga, Crystal Ortega, 6 Ruben Ortega, Jr., Christian Ortega; Saulo Ortega 7 SUPERIOR COURT OF THE STATE OF CALIFORNIA 8 FOR THE COUNTY OF BUTTE 9 10 RUBEN ORTEGA, FERMIN ORETGA, Case No: 20 CV 01510 CRYSTAL ORTEGA, RUBEN ORTEGA, 11 JR., CHRISTIAN ORTEGA; SAULO Reply in Support of Motion to Compel ORTEGA, Answer to Special Interrogatory; 12 Plaintiffs, Declaration of David Edward May in 13 vs. Support of Reply ENLOE MEDICAL CENTER; MIGUEL 14 PUIG-PALOMAR, M.D.; GANSEVOORT Date: Jan. 13, 2021 (Wed.) H. DUNNINGTON, M.D.; MICHAEL L. Time: 9:00 a.m. 15 HIEB, M.D.; and DOES 1 to 50, Dept: 10 (Judge R. Glusman) 16 Defendants. 17 18 19 1. Introduction. 20 This motion was originally directed to three defendants: Enloe Medical Center, Dr. Puig- 21 Palomar, and Dr. Dunnington. 22 Dr. Puig-Palomar and Dr. Dunnington have since provided further answers to the subject 23 matter interrogatory: 24 "Please describe what caused the cardiopulmonary bypass machine to malfunction 25 during the cardiac surgery performed on Maria Ortega on January 17, 2020." 26 Dr. Dunnington answered (after all the chaff is removed) that he "does not know what caused the 27 alleged malfunction of the cardiopulmonary bypass machine during the surgery on Ms. Ortega on Reply in Support of Motion to Compel Page 1 1 01/17/20." Dr. Puig-Palomar answered (after all the chaff is removed): "It was my impression that 2 the cardiopulmonary bypass machine malfunctioned. Based on my understanding of subsequent 3 testing on the machine, it appears the oxygenator failed due to the presence of blood clots." Based 4 on these amended responses, moving parties withdraw their motion as to those two defendants. 5 Enloe Medical Center continues to resist answering the interrogatory. Its Opposition recites 6 five reasons for refusing to answer the interrogatory: 7 A. Plaintiff Filed One Motion to Compel Against Three Separate and Distinct Parties; 8 B. Plaintiff’s Special Interrogatory No. 4 Seeks Information Privileged Under Evidence 9 Code section 1157; 10 C. Plaintiff’s Special Interrogatory No. 4 Seeks Information Privileged Under the Patient 11 Safety and Quality Improvement Act of 2005 (Patient Safety Work Product), 42 12 U.S.C. 299b-21 et seq; 13 D. Plaintiff’s Special Interrogatory No. 4 Seeks the Premature Disclosure of Expert 14 Witness Information in Violation of Code of Civil Procedure Sections 2034.260 and 15 2034.270; 16 E. Plaintiff’s Special Interrogatory No. 4 is vague, overbroad, oppressive, and not likely 17 to lead to the discovery of admissible evidence. 18 Each of these will be addressed in order. 19 2. Multiple Defendants. 20 Enloe complains that this motion was directed not only at it, but also two of the other 21 defendants as well. Enloe ignores that the motion concerns the same identical interrogatory and 22 similar objections. 23 Instead Enloe cites C.C.P. §128.7 for the proposition that “each motion should be set forth 24 in a separate document, ...” First of all, the instant motion is not made pursuant to C.C.P. §128.7. 25 That is because “This section shall not apply to disclosures and discovery requests, responses, 26 objections, and motions.” (C.C.P. §128.7 (g); emphasis added.) Furthermore, that section nowhere 27 says that “each motion should be set forth in a separate document.” Instead, it states: “A motion for Reply in Support of Motion to Compel Page 2 1 sanctions under this section shall be made separately from other motions or requests ...” (C.C.P. 2 §128.7 (c)(1).) The instant motion is made under the discovery statutes, and in particular C.C.P. 3 §2030.300. 4 Next, Enloe states that “California Rule of Court, Rule 3.1112(c) allows a combined motion 5 ‘if the party filing a combined pleading specifies these items separately in the caption of the 6 combined pleading.’ ” (Opposition 7:4-6.) The answer to this false assertion is contained in itself. 7 The Rule pertains to “combined pleadings” not “combined motions.” Rule 3.1112 prescribes what 8 papers are required in a motion. Subsection (c) allows those papers to be filed separately or together 9 in a “combined pleading.” Nothing in the rule talks about combined motions or multiple parties. 10 Finally, Enloe complains that the notice of motion does not “identify every person, party, and 11 attorney against whom the sanction is sought, ...” This also is false. The notice of motion states that 12 it seeks and order specifically against “Defendants Enloe Medical Center, Miguel Puig-Palomar 13 M.D., and Gansevoort H. Dunnington M.D.” (Notice 1:20-21.) 14 3. Evidence Code §1157. 15 Enloe continues to assert Ev. Code §1157 as a total bar of discovery to this event, under the 16 theory than if the incident was reported to a committee referred to in Ev. C. §1157, all information 17 reported to the committee would be protected from discovery. Of course, this is not the law. Enloe 18 ignores the authority provided in the moving Memo of P&A regarding this issue. Information 19 “is not rendered immune from discovery under section 1157 merely because it is later 20 placed in the possession of a medical staff committee or made known to committee 21 members; and this may be so even if the information in question may be relevant in 22 a general way to the investigative and evaluative functions of the committee." (Santa 23 Rosa Memorial Hospital v. Superior Court (1985) 174 Cal.App.3d 711, 724.) 24 In the 5½ pages of Enloe’s §1157 argument, nowhere is it stated how the interrogatory at 25 issue implicates “the proceedings []or the records of organized committees” of Enloe. The 26 interrogatory asks not for proceedings or records. It asks what caused the malfunction of a machine. 27 Indeed, Enloe fails to identify what committee or committees even considered this information, if Reply in Support of Motion to Compel Page 3 1 any. Instead, we have general and vague assertions (5 ½ pages of them) regarding general practices 2 that may, or may not, have occurred in this case. None of these are attributable to this interrogatory. 3 The only statement about this particular interrogatory in Enloe’s papers is the unsubstantiated hope 4 that Ev.C. §1157 allows them to refuse to answer it. 5 4. Patient Safety Work Product, 42 U.S.C. 299b-21 et seq. 6 This act is even further removed than Ev.C. §1157. Enloe recites no California law on the 7 subject. Instead, Enloe cites cases from Illinois and Pennsylvania that allegedly held that information 8 primarily collected for and provided to a federally certified “PSO”1 is protected by the “PSWP” 9 privilege. The problem is that no Federal or State Court in California has ruled on the application 10 of this privilege to a California state action. Furthermore, there is no evidence that the information 11 requested was primarily collected for or provided to a federally certified “PSO.” 12 Furthermore, the statute itself provides a rule that parallels the holding of Santa Rosa 13 Memorial Hospital v. Superior Court (1985) 174 Cal.App.3d 711, 724 quoted above. 14 “(ii) Information described in subparagraph (A) does not include information that 15 is collected, maintained, or developed separately, or exists separately, from a patient 16 safety evaluation system. Such separate information or a copy thereof reported to a 17 patient safety organization shall not by reason of its reporting be considered patient 18 safety work product. 19 (iii)Nothing in this part shall be construed to limit— 20 (I) the discovery of or admissibility of information described in this 21 subparagraph in a criminal, civil, or administrative proceeding;” 22 (42 U.S. Code §299b-21(7)(B).) 23 5. Expert Witness Information. 24 Enloe argues against the application of the opinion of the State Supreme Court in Schreiber 25 1 26 The protected information must be “assembled or developed by a provider for reporting to a patient safety organization and are reported to a patient safety organization. (42 U.S. Code §299b- 27 21(7)(A)(i)(I).) Reply in Support of Motion to Compel Page 4 1 v. Estate of Kiser (1999) 22 Cal.4th 31, 39, which held: 2 “to the extent a physician acquires personal knowledge of the relevant facts 3 independently of the litigation, his identity and opinions based on those facts are not 4 privileged in litigation presenting ‘an issue concerning the condition of the patient.’ 5 [Citation.] For such a witness, no expert witness declaration is required, and he may 6 testify as to any opinions formed on the basis of facts independently acquired and 7 informed by his training, skill, and experience.” 8 The basis for this argument is the Enloe is not a “physician.” No reason or authority is given for 9 limiting this holding to physicians, rather than applying it to all “health care providers.” Enloe 10 ignores the fact that the reason it is being sued is that the person (perfusionist) operating the cardio- 11 pulmonary bypass machine during the operation on plaintiffs’ decedent when it malfunctioned, 12 causing plaintiff’s decedent to die, was an employee of Enloe Medical Center. Enloe argues: 13 “Enloe Medical Center should not be compelled to offer opinion evidence about a 14 topic outside the scope of its ‘practice.’ Enloe Medical Center does not engage in the 15 manufacture, sale, or distribution of medical devices and is therefore unable to 16 respond regarding ‘the operation of a machine used during the fatal surgery on 17 plaintiffs decedent.’” (Opposition 17:15-18.) 18 But the“scope of [Enloe’s] ‘practice’” is providing a perfusionist who has the necessary education, 19 skill, and experience to operate the specific cardio-pulmonary bypass machine that failed when it was 20 being used on plaintiffs’ decedent. 21 Furthermore, the interrogatory does not ask for an “opinion.” Enloe’s argument against the 22 relevant quotation in the moving P&A is non-sensical. The law is: 23 “[T]he common law rule [is] that a physician or other treating health care 24 practitioner, who testifies regarding his or her knowledge of the patient’s 25 treatment, diagnosis or prognosis, does not express an expert opinion.” (Brun v. 26 Bailey (1994) 27 Cal.App.4th 641, 654; emphasis added.) 27 Enloe states in direct contravention of the wording of this quote, that it does not apply to Enloe Reply in Support of Motion to Compel Page 5 1 because “Enloe Medical Center, a hospital, is not a treating physician.” (Opposition, 17:8-9.) But 2 Enloe Medical Center, and its employee perfusionist, are “other teating health care practioners.” 3 Finally, Enloe argues that “defendant Enloe Medical Center did not acquire information, which 4 forms the factual basis for its ‘opinions,’ independently of protected activities.” (Opposition 17:9- 5 10.) What “protected activities” is Enloe talking about? How are they “protected?” What the 6 interrogatory asks for is information obtained by Enloe’s perfusionist when he was operating the 7 cardio-pulmonary bypass machine at the time it stopped functioning during the open heart surgery 8 on plaintiffs’ decedent. That “activity” is the “patient’s treatment” described in the above quote. 9 It is not “protected activity” and, per the quote, “does not express an expert opinion.” 10 6. Vague, Overbroad, Oppressive, Irrelevant. 11 The last of Enloe’s objections is just more boilerplate. The question in not vague; in fact it 12 is very concise, precise, and concrete. There is no dispute that the cardio-pulmonary bypass machine 13 failed in the middle of the open heart surgery. Enloe’s statement that “There is no indication 14 Defendant contends the device malfunctioned” is simply an unethical misrepresentation to this 15 Court. Both defendant surgeons (Dr. Puig-Palomar and Dr. Dunnington) wrote multi-page 16 operative reports, filed in Enloe’s records, that memorialize the malfunction of the machine, and the 17 time spent trying to repair, and then replace, the machine during the surgery. (See attached reports.) 18 Why did it fail? How is that overbroad? How is it oppressive? Enloe’s Opposition certainly 19 doesn’t say. There is no authority cited that would support that conclusion. The interrogatory 20 certainly is relevant. The failure of the machine was the primary cause of death of plaintiffs’ 21 decedent. What could be more relevant? 22 7. Conclusion. 23 An order requiring the defendant to answer the special interrogatory should be issued and 24 sanctions awarded. 25 Dated: January 6, 2021 Law Office of Bruce S. Osterman 26 27 By David Edward May Reply in Support of Motion to Compel Page 6 1 DECLARATION OF DAVID EDWARD MAY IN SUPPORT OF REPLY 2 I am an attorney duly admitted to the bar of this honorable Court, and am in good standing. 3 I represent plaintiffs in the above entitled action. I have personal knowledge of the facts stated 4 herein, and would and could competently testify to those facts if called upon to do so. 5 Attached hereto are the operative reports prepared by defendants Dr. Puig-Palomar and Dr. 6 Dunnington, which are contained in the medical records of defendant Enloe Medical Center, and 7 which describe the fatal surgery performed on plaintiffs’ decedent on January 17, 2020, which is the 8 subject of the above entitled action. 9 I declare under penalty of perjury pursuant to the law of the State of California that the 10 foregoing is true and correct. 11 Dated: January 6, 2021 ___________________________ David Edward May 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Reply in Support of Motion to Compel Page 7 1 PROOF OF SERVICE 2 3 I am over the age of 18 years, I am not a party to the above-entitled action, and my business 4 address is Law Offices of Bruce S. Osterman, 2300 Contra Costa Boulevard, Suite 320, Pleasant 5 Hill, California 94523-3952. On January 6, 2021, I served a true copy of: 6 Reply in Support of Motion to Compel Answer to Special Interrogatory; Declaration of David 7 Edward May in Support of Reply; and this Proof of Service 8 on the following person(s): 9 Alaina T. Dickens, Esq. Anthony D. Lauria, Esq. Schuering Zimmerman & Doyle, LLP Lauria Tokunaga Gates & Linn LLP 10 400 University Avenue 1755 Creekside Oaks Drive, Suite 240 Sacramento CA 95825-6502 Sacramento CA 95833-3645 11 Email: ATD@szs.com Email: alauria@ltglaw.net [Attorneys for Enloe Medical Center] [Attorneys for Michael L. Hieb, M.D.] 12 Marc Lyde, Esq. Nicole I. Whately, Esq. 13 Maria Lathrop Winter, Esq. Pollara Law Group Leonard & Lyde Law Offices 100 Howe Avenue, Suite 165N 14 1600 Humboldt Road, Suite 1 Sacramento CA 95825-8202 Chico CA 95928-8100 Email: NW@pollara-law.com 15 Email: leonardandlyde@gmail.com [Attorneys for Miguel Puig-Palomar, M.D.] [Attorneys for Gansevort H. Dunnington, M.D. 16 17 by electronic service through the Court’s electronic filing and service provider, and by email to the 18 email address listed above. 19 I declare under penalty of perjury pursuant to the law of the State of California that the 20 foregoing is true and correct. 21 Dated: January 6, 2021 ___________________________ David Edward May 22 23 24 25 26 27 Reply in Support of Motion to Compel Page 8 Enloe Medical Center (Main Ortega, Maria D campus) MRN: 204502, DOB: 5/1/1972, Sex: F 1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020 CHICO CA 95926 Entire Encounter Op Note - Encounter Notes (continued) Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543 Author: Miguel Puig-Palomar, MD Service: Cardiothoracic Surgery Author Type: Physician Filed: 02/01/20 1543 Date of Service: 01/17/20 1721 Status: Signed Editor: Miguel Puig-Palomar, MD (Physician) Trans ID: 3064554 Dictation Time: 01/31/20 Trans Time: 01/31/20 Trans Doc Type: Trans Status: Available 1349 1433 Operative Note SERVICE DATE:01/17/2020 PREOPERATIVE DIAGNOSIS: Pseudoaneurysm ascending aorta, status post remote emergency aortic valve replacement with mechanical valve and replacement of the ascending aorta with a Dacron graft. POSTOPERATIVE DIAGNOSES: Pseudoaneurysm ascending aorta, status post remote emergency aortic valve replacement with mechanical valve and replacement of the ascending aorta with a Dacron graft. Cardiogenic shock. Coagulopathy. PROCEDURE PERFORMED: Replacement of ascending aorta and hemiarch with 30 mm Dacron graft. Replacement of aortic valve with 21 mm Carpentier-Edwards tissue valve. Redo replacement, ascending aorta, with 30 mm Dacron graft. Coronary artery bypass times 1 with saphenous vein graft to right coronary artery. Placement of left femoral intraaortic balloon pump. Right axillary artery cannulation. Right femoral percutaneous venous cannulation. CO-SURGEONS: Miguel Puig MD Gansevoort Dunnington MD ASSISTANT: Kelley Alvarez PA ANESTHESIOLOGIST: Michael Hieb MD ANESTHESIA: General endotracheal. INDICATIONS: A 47-year-old female 14 years status post emergency replacement of the Generated on 2/11/20 8:18 AM Page 662 Enloe Medical Center (Main Ortega, Maria D campus) MRN: 204502, DOB: 5/1/1972, Sex: F 1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020 CHICO CA 95926 Entire Encounter Op Note - Encounter Notes (continued) Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543 ascending aorta with Dacron graft and aortic valve, mechanical St. Jude valve. The patient was seen in the emergency room status post CT scan of the chest showing massive pseudoaneurysm from surgical site ascending aorta. FINDINGS AT TIME OF PROCEDURE: Intraoperative transesophageal echo showed mechanical aortic valve with a large jet of insufficiency. Once the patient was cannulated and cooled down the chest was entered with immediate massive bleeding. The site of the origin of the pseudoaneurysm was the distal anastomosis of the Dacron graft to distal ascending aorta from previous surgery. During the repair of the pseudoaneurysm, there was concern with poor venous return and arterial inflow. After troubleshooting, the oxygenator of the heart-lung machine was presumed nonfunctional for possible clots and required replacement. Despite expeditious repair of the vascular injury and the parts on the heart-lung machine, the patient had presumed long period of hypotension and poor perfusion. Upon completion of surgery the patient had left and right heart failure. Despite bypass on the right coronary artery, the patient remained in profound cardiogenic shock, combined with severe coagulopathy. Transesophageal echo showed good function of the newly placed bioprosthesis. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed on the operating table in the supine position. After induction of general endotracheal anesthesia, the patient was prepped and draped in usual sterile fashion. Working in 2 teams, arterial and venous access was gained. Percutaneous cannulation of the right femoral vein was completed using Seldinger technique, dilator, and venous cannula. They were secured to the thigh with adequate suturing. A right subclavian incision was made. Dissection taken down through the skin, soft tissue, pectoralis major. The axillary artery was identified and looped with vessel loop. With the patient fully heparinized, an 8 mm Dacron graft was sutured end-to-side to the exposed axillary artery with running 5-0 Prolene. With arterial and venous lines in place, the Generated on 2/11/20 8:18 AM Page 663 Enloe Medical Center (Main Ortega, Maria D campus) MRN: 204502, DOB: 5/1/1972, Sex: F 1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020 CHICO CA 95926 Entire Encounter Op Note - Encounter Notes (continued) Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543 patient was entered in cardiopulmonary bypass and cooled down. A median sternotomy was reentered through the same site of previous surgery, sternal wires were removed. Once the patient was cooled down, oscillating saw was used to divide the sternum. Upon entering the sternal bone, immediate active bleeding from the surgical field was noted. Expeditiously, the ascending aorta exposure was completed to identify the site of active bleeding and was repaired with 4-0 Ethibond pledgeted sutures. That corresponded to the distal anastomosis of graft to aorta at the 2 o'clock position. At that time, a low flow situation was reported from the heart-lung machine. Arterial and venous cannulas were examined. A tear was noted in the right atria corresponding to the scar tissue and exposure during initial entrance into the mediastinum. Expeditious repair of the atria was completed with running suture of 4-0 Prolene. Despite that, the venous return appeared to be a problem. A double-stage venous cannula was placed to the right atria into the inferior vena cava and used as a main venous drainage. A second aortic cannula was placed through the proximal arch. Troubleshooting in progress from the perfusion identified possible oxygenator malfunction that required replacement. Continuous cooling with available perfusion followed. The remainder of the ascending aorta and proximal arch were excised under circulatory arrest and hemiarch repair completed with 30 mm graft expeditiously sutured, the running suture of 4-0 Prolene. After adequate de-airing of the arch, the graft was clamped. By then adequate perfusion was reestablished. Correction of metabolic acidosis and rewarming slowly followed. During the rewarming time, decision was made to replace the defective aortic valve and the proximal aorta. They both were excised sharply. The aortic valve was sized and a 21 mm Carpentier-Edwards tissue valve was secured in place with horizontal mattress pledgeted sutures of 2-0 Ethibond, leaving the pledgets on the ventricular side. Cor-Knot device was used to help secure the valve in place. The coronary ostia were left undisturbed. Of note, the patient received a retrograde cardioplegic cannula once the initial repair of the pseudoaneurysm defect was completed. Through that retrograde cardioplegia cannula, cardioplegia was given throughout the crossclamp time. Antegrade cardioplegia was given as initial shot to protect the heart for an aortic cross clamping. Generated on 2/11/20 8:18 AM Page 664 Enloe Medical Center (Main Ortega, Maria D campus) MRN: 204502, DOB: 5/1/1972, Sex: F 1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020 CHICO CA 95926 Entire Encounter Op Note - Encounter Notes (continued) Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543 The coronary ostia, native, were left undisturbed. A 30 mm graft was anastomosed end-to-end to ascending aorta just distal to the coronary ostia with running suture of 4-0 Prolene. An antegrade and vent catheter was placed in the newly placed graft for adequate de-airing. Once rewarming was completed and the heart was de-aired, crossclamp was removed following hot shot cardioplegia. Temporary pacing wire placed in the surface of the right ventricle. At time from weaning from cardiopulmonary bypass was unsuccessful. Right heart failure was noted. Intraaortic balloon pump was placed in the left femoral artery and secured in place in the usual fashion. The patient required high inotropic support and continued correction of metabolic acidosis. Several attempts to continue weaning from cardiopulmonary bypass followed with intermittent periods of rest on pump. Decision was made to bypass the right coronary artery as a possibility of the right coronary ostium being compromised with a graft to aorta anastomosis. A segment of saphenous vein graft was harvested from the left leg from ankle to mid leg. The vein was prepared in the usual fashion. Incision closed in the leg with subcutaneous 2-0 Vicryl, subcuticular 4-0 Monocryl for the skin. Right coronary artery anastomosis completed as per Dr. Dunnington's note. After multiple efforts to wean from cardiopulmonary bypass, the chest was drained with chest tube secured to the skin with 0 Ethibond. Cannulas and catheters removed, extensive hemostasis completed. Chest was closed with wires for the sternum and #1 Vicryl for fascia, subcutaneous 2-0 Vicryls, subcuticular 4-0 Monocryl for the skin. The graft on the right axillary incision was oversewn distal to the anastomosis and buried in pectoralis muscle. Incision closed with #1 Vicryl, muscle subcutaneous 2-0 Vicryl, subcuticular 4-0 Monocryl for the skin. The patient was transferred to the ICU with continued cardiogenic shock and maximum support and intraaortic balloon pump. Family informed. Prognosis poor. Generated on 2/11/20 8:18 AM Page 665 Enloe Medical Center (Main Ortega, Maria D campus) MRN: 204502, DOB: 5/1/1972, Sex: F 1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020 CHICO CA 95926 Entire Encounter Op Note - Encounter Notes (continued) Op Note signed by Miguel Puig-Palomar, MD (continued) Version 1 of 1 at 02/01/20 1543 __________________________________________ Miguel Puig MD MP/JJJ Physician ID: 0185 D: 01/31/2020 1349 / T: 01/31/2020 1433 Job#: 007329 Doc #: 3064554 cc: Miguel Puig MD; Gansevoort Dunnington MD; Kelley Alvarez PA Electronically Signed by Miguel Puig-Palomar, MD on 02/01/20 1543 Op Note signed by Gansevoort Dunnington, MD Version 1 of 1 at 02/02/20 1820 Author: Gansevoort Dunnington, MD Service: Cardiothoracic Surgery Author Type: Physician Filed: 02/02/20 1820 Date of Service: 01/17/20 0825 Status: Signed Editor: Gansevoort Dunnington, MD (Physician) Trans ID: 3064363 Dictation Time: 01/17/20 Trans Time: 01/17/20 Trans Doc Type: Trans Status: Available 1845 2005 Operative Note SERVICE DATE:01/17/2020 PREOPERATIVE DIAGNOSES: 1. Massive pseudoaneurysm of ascending aorta status post prior mechanical aortic valve replacement (AVR) and ascending aorta replacement 14 years ago. 2. Moderate aortic insufficiency. 3. Hypertension. POSTOPERATIVE DIAGNOSES: 1. Massive pseudoaneurysm of ascending aorta status post prior mechanical aortic valve replacement (AVR) and ascending aorta replacement 14 years ago. 2. Moderate aortic insufficiency. 3. Hypertension. PROCEDURE PERFORMED: 1. Replacement of ascending aorta and hemiarch with a 30 mm Dacron graft. 2. Excision of mechanical aortic valve and aortic valve replacement with a 21 Edwards Magna pericardial valve. 3. Coronary artery bypass graft times 1 with saphenous vein graft from the aortic graft to the right coronary artery. 4. Placement of intraaortic balloon pump. 5. Right axillary artery exposure and cannulation for cardiopulmonary bypass, as well as a right femoral percutaneous venous access with percutaneous suture mediated closure. Generated on 2/11/20 8:18 AM Page 666 Enloe Medical Center (Main Ortega, Maria D campus) MRN: 204502, DOB: 5/1/1972, Sex: F 1531 ESPLANADE Adm: 1/13/2020, D/C: 1/17/2020 CHICO CA 95926 Entire Encounter Op Note - Encounter Notes (continued) Op Note signed by Gansevoort Dunnington, MD (continued) Version 1 of 1 at 02/02/20 1820 CO-SURGEONS: Gansevoort Dunnington MD Miguel Puig MD ASSISTANT: Kelley Alvarez PA ANESTHESIOLOGIST: Michael Hieb MD ESTIMATED BLOOD LOSS: Massive. BLOOD PRODUCTS GIVEN: Packed red blood cells, FFP, platelets and NovoSeven, multiple rounds. DISPOSITION: ICU. CONDITION: Grave. COMPLICATIONS: 1. Malfunction of cardiopulmonary bypass machine with possible clotting of the circuit requiring replacement of di