Exhibit A

Expert Testimony

William  Beutel, MD, FACS

and

Frederick Kuitem, MD

My Past Chiefs of Surgery in North Carolina and

Thomas Magnuson, MD, FACS

Chief of General Surgery at Bayview Medical Center, Baltimore, Maryland

and

Associate Professor of Surgery at Johns Hopkins  Medical School, Baltimore, MD

Addressing the five (5) cases at issue.

GENERAL SUllGERY:

WILLIAM D. BEUTEL, M.D., F/.A.C.S

_{DIPLOMATE. AMERICAN BOMD OF SURG Y}

!047 EAST GASTON STREET

P. 0. BOX 811

Telephone; (704) 732-1108

Facsimile: (704) 735-1259

ENDOSCoPY:

_{FllLLOW, BIRKlJJ LE COMMONS / SOCIETY OF AMERICA-N}

····AMERJC>'N'€61.i-!!G --·········•.HUl\!TERSlllLLE,.NQRTli.C!\.I!Q.IJNa)28078 GASTKOINTESTINAL

OF SURGEONS Telephone: (704) 892-0558 ••. {...... llN'OO!lCOl'fC'SIJRCEONS

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_{1 21 September,2004}

Conrad W. Varner, Esq.

VARNER & GOUNDRY

31 West Patrick Street, Suite 100

^{Frederick, Maryland 21701}

Re: Isaac Isaiah, M.D. I Privileges

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I am extensiVely expenenced m surgical care With simdar),cases as these- which are under

consideration. Indeed, I do not perform vascular surgery as I note the opposition witness is primarily a vascular surgeon) but rather I am focused Olfl abdominal, G·l, laparoscopic, and general surgery -to which my CV will attest. In addition to my surgical experience, I

halle served on the board of directors of Lincoln Medicalenter for more than five years in the recent past. During this time I was privy to many p,ocedural and credentialing issues, hospital policy issues, and as chairman of the dep ent of surgery, to many other

medical staff issues, as well. I have been called upon tottend and participate in fair

hearing proceeding.s and am aware of the types of vital c1re issues and ]priorities which must be analyzed.

_{a See my CV,attached. I}

b.- c. I worked concurrently with Dr.lsaac A. Isaiduring the eight years of his

service at Lincoln Medical Center, Lincolnton, NC, 199 r2000. During this time we commonly assisted one another in many surgical cases.was able to cllosely observe his surgical and medical judgment, particularly with referenqe to operative indications, and his surgical operative skills and techniques, all of which I fo?nd to be quite:satisfactory and acceptable. During his tenure at LMC, quality and prom tness of care were maintained

and he has remained in good standing as knowledgeable d competent in his field

d. During this period of time there were some poli ·cal as_pects to the Lincoln Medical community which somewhat adversely affected especially those of us who were in independent private surgical practice. But in spite of ese issues, Dr. Isaiah maintained

e. Dr. Isaiah's surgical training consisted of succe!fsfully completmg a four-year

surgical residency at the Medical Center of Delaware, in/Wilmington. He obtained a strong recommendation from that institution which allowed hinp. to enter a cardia-thoracic fellowship in London, Ontario, in 1982-83. I

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Dr. Isaiah has done surgery in the pediatric age grop without problems,aJ.Id in fact in North Carolina it is not too uncommon to find cholecysfitis in mid- alild occasionally early teenagers. 1

His complication rates were consistently in the no al range in comparison to peers. I have never known of Dr. Isaiah ever having trouble westimating bh)od loss in his

^{······ · ·· · ··-· es, nor of any prior seri ver the matter · · !Spimlstay rates were. .}

unremarkable. Also, his operative times were not a probl m at LMC. ·

g. I have no specific information about denied privi eges at anoth,er institution.

h. I believe it to be improper if not illegal for secret · Iles to exist atld I believe it is contrary to JCHA (Joint Commission for Hospital Accredhation) recommendations and

possibly federal regulations. If such a file exists, it must }je made available to the physician in question. After this sort of issue was raised at LMC, an[Y negative information reported

was confidentially copied an.d delivered to the physicianiquestion. I believe this was worked out at LMC according to JCHA regulations.

i. Operative times have never to my knowledge be n a basis for revocation of privileges. It is commonly known that these vary a lot an. even at my training institution (University of Iowa Hospitals and Clinics) some of the m st respected senior staff surgeons

^{were typically longer in operative times, yet it was never j matter of cri1icism or suspicion.}

j. Dr.Isaiah's low complication and LOS (length or1stay) rates are not a surprise to

k. It borders on tlle ridiculous to suspend a physicillll on performance issues without due process in his peer department. I have never heard off such or even suspected that it could happen. i

1. The question of an anaesthesiologist passing judfuent on a sur.gical decision to

convert a lap chole to an open procedure is not appropria e. The anaestllesiologist by

virtue of his training and tlle limited scope of his responsi ility in tlle case could not qualify

to offer an opinion on the matter. ,

m. A dispute on tlle atnount of blood loss is usual!handled by c:ongenial

compromise between the two parties. Dr. Isaiah offered lfogical reasons why the volume of

blood being weighed and measured was not all blood lol:s Usually tlle1re is a bit more humility about it on tlle part of the nurse or nurse anaestll tist. The truth seems to lie in Dr. Isaiah's favor when one notices the patient's final hemog obin value just prior to

discharge. This value, 123, would indicate about one u , t of blood loss, which is a drop

approximately equivalent to one gram per deciliter of ho,.globin. Normal value for a male would be between 13 and 14. Dr. Isaiah showed her that other fluids were involved besides blood and his contention that it was not all blood was corroborated by the patient's ongoing stable vital signs. Ts issue as groun for revoking a surgeon's hospital privileges would be laughable Ill any court of surgeons. . . .

^{n. As noted in my review of the case, I have never1 been challenged or cnticized for}

prompt cholecystectomy when the diagnosis was clear, ait was in tlle case of the 14-year­

old. I have done possibly six or eight such operations oq patients in thdr early to mid-

_{teenage years over the past ten to twelve ye s. . I . . . . ..}

There is a defined procedure for h dhng proble s, likely supulated 111 the med1cal staff

bylaws, which would consist of action by the me cal or1 surgical deprurtment of the physiciaJ.I in question. Hospital rules and regulations slfuld be properly referenced and

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these safeguards are not in the hospital rules and regs or by)laws, then they should be.'

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_{Case # 88025 J}

In my opinion a 14 year old girl with confirmed gallstones and typical symptoms would beandled.by m self just as Dr.saiproposd to o- rompt cholecystectomy,

laparoscop1cally, If possible. I see nothmg mappropnate e;'(cept m the d€:plorable actions

of the hospital administrator who scuttled this operation anjd inappropriately wrote orders

on this patient for discharge without the attending physicialn's knowledg•. This in my view would certainly go against normal hospital rules and regulations, and would be sure

m - conflict with hospital bylaws. A further violation wmdbe thatthis_e was not!he!L

evaluated by the department of surgery as any such action 1should be.

_{Case # 83359 )}

Acute hemorrhagic cholecystitis with seveninflam toryresponse can be a difficult case to manage operatively; severe and or dense adhesion!can prolong operative time

quite a lot and obscure the anatomy. In these cases the surjgeon's prime 'consideration is to

do the operation safely, not quickly. For instance in my own practice, some operations for laparoscopic cholecystectomy may take Jess than 45 minu es even when cholangiogram is included. But a difficult gallbladder case can take three h urs or more. Generally the more emergent severe cases, admitted in the acute phase, are mqre difficult and take longer. I have not experienced anaesthesiologists in any place where I have work·d giving anyone criticism if such a case is prolonged. As for repair of a mipor serosal separation, the stitch is purely precautionary and inconsequential. It could be notfd in the operative report, but

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_{Case #35328}

This patient had severe acute cholecystitis with extr'nsive inflammatory response --it n:quired open cholecystectomy to complete the operation safely, which Dr. Isaiah did, and the patient recovered nicely without complication.

In all the general surgery continuing medical educatjion courses, it is always stressed

that we convert the operation to open when we are not m ng adequate progress laparoscopically due to inflammation, unusual anatomy, c!r any other reason. Converting laparoscopic to open procedure should not be consideredfailure of tec:hnique, but rather

a matter of applying appropriate open techniques at the p oper time. I carmot stress the importance of this issue enough, since the safety of the patient and the avoidance of a

dreaded common bile duct injury are at stake. Some common bile duct injuries have occurred when laparoscopic techniques were not.approp:i tely abandoiJ:edwhen .. conversion to open would have been a better optton. ThlIS the crux oi this case, and tt ts strongly against surgical protocol, teaching and professionalism to criticize a surgeon on

_{such grounds. . . . !. . • .}

^{A major common bile duct mJury can lead t? exten*ve hep.atic complications,}

peritonitis, and multiple operations, a sho ned lifexpeftancy, tf .n'?t llarly death, and extensive misery to both patient and I?hYSiCian. Avmdusuch. an.i Jury thus.b comes the

overwhelmingrioriy to I;he responsible_s r e n. rg an mcision ts a mtruscule consideration With this wetght of responsib!lity m vtew.

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This patient had chronic cholec:ystitis, recove ng f om gall tone pancreauus,

operative time was 2 hours and 15 mmutes. The_ patle lJor electi':e l_ap '?ho e. underwent an uneventful operation except that prior C-Secuons WLT lower mtdlme mclSlonal

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The criticisn'*that the laparoscopic incision was toq large (but note that the collapsed emptied gallbladder was 9.0x3.2x2.8 em). This 'eems an inappropriate criticism since the size of the laparoscopic incision is a minute, not qonsequential detail compared with the priority of entering and leaving the peritoneal cavtty safely, which can be difficult when encountering adhesions from prior surgery. I suspeclt that this issu'e would never

have arisen in a proper surgical peer review process. i

_{·· ·-· · ·· · Case #..70.164 =-}

This patient with a "fist sized" right colon inflamm,torymass suggesme·cil..

perforated appendicitis, appears to have been handled in acfepted fashion for a

omplicati_on sueas this. Si ce the !ippen?ix as actually 1found no.t to be.the cause of the mflammatwn, a hkely cause IS contamed diVerticular rupture, complicated mflammatory bowel disease, p.erforating colon cancer, or other cause. ith this in view, anything less than right hemicolectomy would in my view be inappropri"rte. Two consiiderations which

non-surgical folks would miss, are that right hemicolectomr gives the be!;t blood supply to the anastomosis, and is the indicated operation in emergen<;Y situations when emergency removal of any portion of the right colon is required. Alsoj this operation does not require a colon prep in emergency situations and it will typically havle a low complication rate even without the prep. Therefore, in my opinion, the suggestion! of backing out and prepping the colon is inappropriate. The suggestion that right hemicole4tomy is too much surgery is wrong. And the operative time is reasonable in this marke ly inflamed case. So, in the court

Thank you for this opportunity to be of service.

WilliarnD.IBeutel, MD,MPH, FACS Enclosure:

CURRICULUM VITAE William Dean Beutel, M.D.

_{1. hxsonill2m}

^{a) Citizenship Status: ljJ.S.A.}

1971 B.S.

1974 M.A.

1979 M.D.

1981 M.P.H.

Wheaton College, Wheaton, Illinois Occidental College, Los Angeles, CA Abraham Lincoln School of Medicine, University of Illinois at the Medical Center, Chicago, Illinois

School of Public Health, University of

lllinois at the Medical Center, Chicago, Illinois

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1979·84 Resident, Surge?'

1984-85 Fdlow, Clinical,i

General Surgery I

and Transplant Rbsearch

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The University ofiowa College of

Medicine, Iowa City, Iowa

The University of Iowa College of

Medicine, Iowa City, Iowa

_{1V. h&ad.emic.. Appointments [}

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1986 Associate in Surge

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V. Offices I

The University ofiowa College of

Medicine, Iowa City, Iowa

1047 East Gaston Street, lfincolnton, NC 28092

_{16627 Birkdale Commons! Parkway Suite 100 Huntersville, N.C. 28078}

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V1. .e.tti..tkatilmJmdll nsJ.ut.c.

a) Certification '

American Board of S gery, #30387, March 1985

Recertified October 17, 2003 b) Licensure :

Iowa,# 22839, FebrurujY 1982 (Expires December 1, 2003)

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VII. b::ofessiorlill.Affiliations r including offices held)

VITI.

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1979-2004 Christian Medical Society (National Delegate 1990)

_{1986-2004 North Carolfua Medical Society}

_{1986-2004 Cleveland C}^'_{ounty Medical Society}

1989-2004 Fellow AmJrican College of Surgeons

1990-2004 North Carolilna Chapter, American College of Surgeons

1990-2004 SAGES I

1992-2004 Southern M dical Association

1995-2004 Society of L paroendoscopic Surgeons

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Surgical and physiologic aspects of biliary and pancreatic diseases and pancreatic transplantation;

Endocri.ne surgery; 1

Gastrointestinal motiliproblems and epithelial physiology; Epithelial migration anultra structure.

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1984-86 Taught students and residents in classroom, wards, and operating room

20 wklyr 8hr/wk /

X. Th<!&ltiog Activities dther than classroom or clinical, including teaching of undergraduate (pre-b*calaureate), graduate, and post-doctoral students

and continuing education.

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Confersm9_ G.mnd B^' ounds Journal Clubs. etc

_{1981-84 Grand Roun s. on six occasions 2 wks/yr}

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_{Continuing_Edu}

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Resident Research D y, Department of Surgery, The University of Iowa, Iowa City, l<)Wa, Healing of the isolated rabbit ureter ( W.D. Beutel and K.C. Pringle), May 21, 1982, presenied by W.D. Beutel.

_{Resident Research D y}^'

_{, Department of Surgery, The University oflowa. Iowa}

0thers, including devqlopment of curriculum or new teaching materials, methods

_{of evah.1ation, prograrrl supervision, etc.}

a) Inpatient:

Care of Team IIGberal Surgery patients includi11g pre and postoperative evaluation of patieht, inpatient care, operative and postoperative management.

_{b) Outpatient:}

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Care of Team II plttients in General Surgery Clinic.

c) Otber:

Endoscopy: Uppr GI and colonoscopy as part of General Surgery

Clinical responsibility.

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Medical Assistance Pl^' rogram, Readers Digest International Fellowship (RDIF)

_{2 months, Externship! at Duncan Hospital Raxaul, Bihar, India, 1979}

XIII. .sli;al Facilities

_Offices:

I 047 East Gaston Strdet

Lincolnton, N.C. 280 2

16627 Birkdale Commons Parkway Ste 1 00

_{Huntersville, N.C. 28078}

XIV. Offices li<Ud

Surgical Department qhairman, Lincoln Medical Center, Lincolnton, N.C. 1997

Preside:11t, Christian International and Domestic Services (50 I c3 Charitable Org) (1992-present) '

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1986-present - ^{WiJliam D. Bflutel, M.D.}

_{General and dparoscopic Surgery}

^{Lincolnton anll Huntersville, N.C. area}

B.efereuc :s.

1) Fredrick Kuitems, M.D.

8013 Agape Lane

Waxhaw, NC 28173

2) Issac Isaiah, M.D.

Memorial Medical Office $ldg. Suite 202 ¹

Cumberland, MD 21502 i

• 3) Claude Falls, M.D.

SOl N. Aspen Street

Lincolnton, N.C. 28092 ,

4) Neveen Habashi, M.D.

501 N. Aspen Street

Lincolnton, NC 28092

5) Robert Reid, Jr., M.D.

614 Center Drive

Lincolnton. NC 28092

September 22, 2004

Mr. Conrad W. Varner

_{Vamer & Goundry}

._,,-,,-,, '-' I ,.._,....,,_ I I I -..>1 "'-''-'

_{31 West Patrick Street, Suite 100 - , , -- . . ······ ·}

^{Fredenci<;M'ru:yiiiiiCT2T7oT ·· ·· ··· ··}

Re: Isaac Isaiah, M.D.!Privileges Matter

Dear Mr. Varner,

This is to affirm that I have known Dr. Isaiah from 1999 when he applied to Lincoln County Hospital. I was Chief of Staff and reviewed his credentials. I have known him since then and worked with him as a colleague and consultant and have assisted him in surgery. Duri11g that time, I found him to be a competent and knowledgeable General Surgeon who sought and accepted the advice of other surgeons when needed. He got along well with the staff and other physicians. He behaved in a gentlemanly manner.

Regarding courtesy privileges at Gaston Hospital, the basic denial was based on his not having sufficient cases in the Gaston County area and was not based on his competence.

As to a "secret file" kept on Dr. Isaiah I can assure you. that this violates standards of the A.M.A. and the "Sunshine Law" in which anyone can review his own file so that a man can answer his accusers. Having such a file violates basic justice and staff governance.

As to the five specific areas reviewed by Dr. Snider, my expert opinion is as follows: Case 35328, involves a 5'5" man weighing 245 lbs. This fact of obesity was omitted by

Dr. Snider. This certainly is a reason for long operating room time. Another factor

omitted by Dr. Snider was that the gallbladder was intrahepatic with a possible aberrant duct.

The case was properly converted to an open cholecystectomy. This in my opinion shows good surgical judgment. The dissections were from fundus down, which is a slower procedure. There was severe fibrosis of the porta hepatis. Tissue report confirmed acute necrotic complication.

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Case 88025 was a 14 year old girl with bilary colic. Again Dr. Snider is in error. The time of admission was 11:55 a.m. and the request for an Operation permit was 2:28 p.m. as documented on the chart. Lap. cholecystecomy was indicated. The patient was discharged

^{· -··7nlf704,ffieoay·orallmi.sSiOnanasmelyffiiirwasn:orintne mTifdfeortiienig11.f: · ·······}

I understand that the Vice President of the hospital intervened and told the patient to leave. This is a violation of patient-physician relationship and is against hospital governance in that physician-patient relations are not to be violated by administrators.

Chart 53799 is that of a 21 year old woman whose lap cholecystectomy was uneventful except for the instrument that broke and was not mentioned in the Op. report. This is a trivial matter and justifies no comment. Incidentally, the time of surgery is average and the patient was discharged the following day.

The comment that there was a bowel perforation is an untruth. There was a serosal nick repaired without any evidence of spillage of bowel content. This certainly is not even worth mentioning except that with the patient bucking from inadequate anesthesia caused the nick, as the bowel was grasped with a clamp to retract it into the abdomen. The

patient did very well post-op. and was discharged without problems.

Case 70164 was a 37 year old man with a cecal mass requiring a right hemi.colectomy. The CAT scan could not determine whether appendiceal abscesses were present.

Properly a right hemicolectomy was done. The Op. time was 3 hours and 20 minutes which is reasonable.

The patient recovered on the third day and was discharged without complication.

his Hb was 12.3 gms. He was discharged without complications.

The following questions are about:

h. I commented above that it is improper for a hospital to maintain a secret file on a

_{It is illegal to do this without}

involves adverse reporting.

notifying the physician.

i.I know of no standard of surgical privileges anywhere that specifies the nonn of operative time. All other cases of Dr. Isaiah are ofavera perative times which is excellent. An occasional case of prolonged operative time is not unusual and depends upon the patient's status, obesity, prior surgery, anatomical difficuhics, instrument problems, bleeding, etc. A few cases oflong operative times do not indicate a problem with competence.

j. Dr. Isaiah's complication rate is exceptionally low and was so during my time with him in Lincolnton, North Carolina.

k. A summary suspension should be an emergency procedure and immediately reviewed by his general surgical peers. If this was not done, it violates all rules whereby a man is judged by his peers.

m. I previously commented on blood loss in Case 35328.

n. The length of stay of Dr. Isaiah's patients is average and within accepted norm.

r trust that the above information and opinion will help in alleviating the injustice done to

Dr. Isaiah. I will be happy to be there as an expert witness.

Yours truly,

Fredrick H. Kuitems, M.D., D.A.B.S.

• FREDRICK H. KUITEMS, M.D.

8013 Agape Lane

Waxhaw, NC 28173

(704) 843-0120

EDUCATION

1950 Graduated Union College

1954 Graduated George Washington University School of Medicine

1955-1956 Internship, Hackensack Hospital

1957-1961 East Orange Veterans Administration Hospital (NJ) General Surgical Residency

EMPLOYMENT HISTORY

1955-1957 U.S.P.H.S. Indian Service (Az) General Practice Physician

General Medicine, Surgery, Hospital Administrator

1965-1967 U.S.P.H.S. Staten Island.. NY Assistant Chief of Surgery

J 967-1985 Private Practice of General Surgery. Ridgewood, NJ Med Staff Member at Valley Hospital

Diplomat, American Board of Surgery (68)

Med Staff Rep to Bergen Co. Medical Society (76-78) IPA/HMO Task Force, Bergen Co. Med Society (80)

1977-1979 Bergen Pines Hospital (NJ) Chief of Surgery

!985-1998 Lincoln Medical Center, Lincolnton, NC Chief of Surgery (88)

Med Staff Secretary (90-91) Chief of Staff (92)

President of Lincoln Co. Med Society (95-96)

1998-Prcsent Retired from Private Practice

PROFESSIONAL LICENSURE

North Carolina NC29132