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IN THE COURT OF COMMON PLEAS
OF CUYAHOGA COUNTY, OHIO
ELIZABETH BUKOVNIK, EXECUTOR,
et al.,
Plaintiffs,
v.
LAKE HEALTH FOUNDATION,
et al.,
Defendants. )
AT LAW NO.
CV12- 786503
DEPOSITION UPON ORAL EXAMINATION
OF DARYL R. FANNEY, MD
TAKEN ON BEHALF OF THE DEFENDANTS
Norfolk, Virginia
July 10, 2014
TAYLOE ASSOCIATES, INC.
Registered Professional Reporters
Telephone: ( 757) 461 - 1984
Norfolk, Virginia
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Appearances:
On behalf of the Plaintiffs:
WEISMAN, KENNEDY & BERRIS
RICHARD J. BERRIS, ESQUIRE
101 Prospect Avenue West
Cleveland, Ohio 44115
216) 781- 1111
On behalf of Defendants Drs. Hill and Thomas and
Flamur X. Semaj, MD: REMINGER
MARC H. GROEDEL, ESQUIRE
101 Prospect Avenue West
Cleveland, Ohio 44115
216) 687- 1311
On behalf of Defendant Ranjit Tamaskar, MD:
Appearing via video teleconference) REMINGER
CHRISTINE SANTONI, ESQUIRE
101 Prospect Avenue West
Cleveland, Ohio 44115
216) 687- 1311
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INDEX
WITNESS: Examination by Page
Daryl R. Fanney, MD Mr. Groedel 5
Mr. Walters
Mr. Groedel
Mr. Walters
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EXHIBITS
EXHIBITS APPENDED TO THE TRANSCRIPT)
No. Description Page
Exhibit 1 Report 6
Exhibit 2 Curriculum Vitae 7
Exhibit 3 CD of the Chest Radiograph 7
Exhibit 4 Hard Copy ofFilm 10
Exhibit 5 AP chest X ray 41
Exhibits No. 3 - 5 were retained by Mr. Groedel.)
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Appearances: ( Continued)
On behalf of Defendants Lake Emergency Services
Inc.; David A. Jacobs, PAC; and Jennifer J.
Jeromin, MD:
Appearing via video teleconference) REMINGER
STEPHEN E. WALTERS, ESQUIRE
101 Prospect Avenue West
Cleveland, Ohio 44115
216) 687- 1311
On behalf of Defendant Lake Health Foundation:
Appearing via video teleconference) HANNA, CAMPBELL & POWELL, LLP
GREGORY T. ROSSI, ESQUIRE
3737 Embassy ParkwayAkron, Ohio 44333
330- 670 -7600
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Deposition upon oral examination of
DARYL R. FANNEY, MD, taken on behalf of the
Defendants, before Scott D. Gregg, RPR, and Notary
Public for the Commonwealth ofVirginia at Large,
commencing at 12: 46 p.m., July 10, 2014, at the
offices of Tayloe Associates, Incorporated, 253 West
Bute Street, Norfolk, Virginia.
DARYL R. FANNEY, MD, called as a witness,
having been first duly sworn, was examined andtestified as follows:
EXAMINATION
BY MR. GROEDEL:
Q.
A. Dr. Daryl Fanney.
Q. Dr. Fanney, we just met. My name is Marc
Groedel. I represent Dr. Semaj and Drs. Hill and
Thomas, and I'm here to ask you questions about the
opinions you hold in this case.
I know you've testified previously as an
expert witness, so I' ll dispense with the usual
introductory comments.
But I would ask this, that if I ask a
question that you don't understand, will you let me
know?
A. Yes.
Please state your name for the record.
2 ( Pages 2 to 5)
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Q. Ifyou answer a question, I'm going to 1
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Q. Handing you what's been marked Exhibit 3, 2 assume that you understood it and answered it 2 can you identify that for the record? 3 truthfully; fair enough? 3 A. This is a CD of the chest radiograph
4 A. Fair enough. 4 performed at Lake Health July 9, 2010. 5 Q. Okay. And you brought with you your 5 Q. And is that the only film that's6 entire file? 6 contained on that CD?
7 A. Yes. 7 A. I believe so, yes.
8 Q. And it looks as though that file contains 8 Q. And is that the only source that you9 a disk of the X ray; is that correct -- 9 looked at to evaluate Dr. Semaj' s film that he read?
10 A. Yes. 10 A. Yes.
11 Q. -- at issue? 11 Q. In other words, you may know that there
12 And it also contains all of the -- or 12 are hard copies of that film that have been floating13 many of the expert reports both from the plaintiff 13 around at various times in this lawsuit.
14 side and from the defense side, correct? 14 Have you reviewed any of those hard copy15 A. Correct. 15 films?
16 Q. And it also contains the medical records 16 A. Not until today. 17 that you make reference to in your report, correct? 17 Q. Okay. Dr. Semaj marked hard copy films18 A. Correct. 18 during his deposition, and I see that you have his19 Q. Are there any notes that you prepared as 19 deposition in your file.
20 you review either the film or the records in this 2 0 So my question is, did you review any of21 case? 21 the hard copy films that he talked about and marked22 A. No. 22 during his deposition? 23 Exhibit No. 1 was marked.) 23 A. The actual films?
24 BY MR GROEDEL: 24 Q. Yes.
25 Q. I'm going to hand you what's been marked 25 A. No.
7 9
1 as Exhibit 1. 1 Q. Has Mr. Berris asked you to look at
2 That is a copy of the report that you 2 those?
3 wrote in this case? 3 A. The actual films?
4 A. Yes. 4 Q. Yes.
5 Q. Is that the only report that you've 5 A. No.
6 authored? 6 Q. Okay. So as you sit here today, do you7 A. It is. 7 have any plans on looking at those hard copy films8 Q. Does that report contain all of your 8 that Dr. Semaj marked during his deposition? 9 standard of care criticisms of Dr. Semaj? 9 A. I have copies of them. I don't have the
10 A. I believe so, yes. 10 actual films.
11 Exhibit No. 2 was marked.) 11 Q. Well --
12 BY MR. GROEDEL: 12 MR. BERRIS: I did show it to him today. 13 Q. I'm going to hand you what's been marked 13 THE WITNESS: Oh. Well, I did see it
14 as Exhibit 2. 14 today. I thought you meant in the past. 15 Can you identify that for the record? 15 MR. BERRIS: Today is the first time he16 A. That's my CV. 16 saw it.
17 Q. All right. And is that up to date? 17 THE WITNESS: Yeah.
18 A. Except for a couple awards, yes. 18 BY MR. GROEDEL:
19 Q. Okay. Have you written anything or 19 Q. So today you have seen hard copies of the2 0 published anything that you would consider relevant to 20 films that were marked by Dr. Semaj? 21 the issues of this case? 21 A. Yes.
22 A. I don't believe so. 22 Q. Okay. 23 Q. Okay. 23 MR. BERRIS: Just for clarification,
24 Exhibit No. 3 was marked.) 24 films, there was only one. 25 BY MR. GROEDEL: 25 MR. GROEDEL: One film, correct.
3 ( Pages 6 to 9)
4 ( Pages 10 to 13)
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1 So why don't we mark that as an exhibit 1 Q. Since this case, have there been any2 as well then. 2 subsequent cases that you've received from Mr. Berris
3 MR. BERRIS: It's already been marked 3 for review?
4 Plaintiffs Exhibit 3 Semaj, so if you want to put 4 A. No.
5 another sticker on it -- 5 Q. You are an -- you are a member of the
6 MR. GROEDEL: Let's do it just so were 6 American College of Radiology? 7 clear. 7 A. American College -- I'm not specifically8 Exhibit No. 4 was marked.) 8 a member; we do it as a group to get the journals. 9 BY MR. GROEDEL: 9 Q. Okay. Do you --
10 Q. So Plaintiffs Semaj Exhibit 3 and Fanney 10 A. One second. Can I put this back to you?
11 Deposition Exhibit 4 is a hard copy of the film that 11 I don't want to rub the markings off of it by12 is represented on the disk that you reviewed, correct? 12 accident.
13 A. Correct. 13 Q. Do you adhere to the expert witness
14 Q. And is that hard copy a good copy? In 14 guidelines promulgated by the American College of15 other words, can you adequately interpret that film? 15 Radiology? 16 A. Yes. 16 A. I try to, yes. 17 Q. Are there any other hard copies or CDs of 17 Q. I assume you're familiar with them?
18 any film that you've reviewed in this case other than 18 A. Yes.
19 what we've just gone over? 19 Q. You've reviewed them?
20 A. I don't believe so. 20 A. Yes.
21 Q. Okay. I note in looking at your CV that 21 Q. Okay. You're board certified? 22 you're born in Cleveland? 22 A. Yes.
23 A. That's correct. 23 Q. Have you been required to retake the
24 Q. Did you grow up in Cleveland? 24 board certification exam since you first passed it, or
25 A. Euclid. 25 are you grandfathered in?
11 13
1 Q. And did you go to high school there? 1 A. Grandfathered in.
2 A. Euclid High School. 2 Q. So you took it once?
3 Q. And for how long did you remain in 3 A. Correct.
4 Cleveland? 4 Q. Okay. Tell us a little bit about your5 A. Until I was 18. 5 current practice.
6 Q. And have you been back? 6 A. Current practice, we have two outpatient
7 A. Oh, yes. 7 facilities, one in Virginia Beach, Virginia, one in
8 Q. Okay. For -- do you have family still in 8 Chesapeake, Virginia. We do MRI, CT, ultrasound,
9 Cleveland? 9 plain radiographs, some procedures such as
10 A. They have moved down to Florida now. 10 arthrograms, myelograms.
11 Q. Okay. Do you know any of the attorneys 11 Q. Explain to me then, is this practice that
12 in the Weisman firm beyond your exposure to them as an 12 you're in in an office building or an outpatient13 expert? 13 setting?
14 A. No. 14 A. That' s correct.
15 Q. How is it that Mr. Berris came to find 15 Q. Okay. And so when you're reviewing16 you to review this case? 16 films, you're reviewing them at your facility either17 A. Well, I had reviewed two other cases. I 17 in Virginia Beach or in Chesapeake?
18 can' t remember how the original case came about. 18 A. Well, that's correct. I can also review
19 Q. Okay. So this would have been the third 19 them from home or other places through teleradiology. 20 case that you've looked at for Mr. Berris? 20 Q. Understood.
21 A. That's correct. 21 Do you currently have any hospital22 Q. Besides Mr. Berris, are there any other 22 privileges?
23 members of the Weisman law firm that you've teviewed 23 A. No. We compete with the hospital.
24 cases for in the past? 24 Q. Okay. And so for how long have you been25 A. No. 25 practicing as a radiologist in this fashion?
4 ( Pages 10 to 13)
1 A. 1998.
2 Q. Okay. You mentioned that you3 interpret -- or your group interprets CTs, MRIs, 4 ultrasounds, plain films.
5 First of all, let me ask you this: How
6 many physicians are in your group? 7 A. Four.
8 Q. And did you start this group? A. No.
Q. Who started it?
A. Charles Hecht - Leavitt.
And was it in existence prior to your
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Q.
joining it? A. Yes.
Do you know when the group actuallyQ.
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started?
A. I believe he acquired an MRI around 1990.
Q. Okay. And you joined in 1997? A. Correct.
Q. What type of radiologic studies do you
interpret?
A. I interpret everything we do. Iinterpret more of the CT studies and ultrasounds than
the others.
Q. From a percentage standpoint, can you
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can you give me a breakdown as to, you know, what
percentage of the plain films are abdominal studies
versus chest studies versus any other type of studies?
You tell me.
A. Well, I would say three - quarters, 70 percent are just chest radiographs.
Q. So can you give me a sense then as to
approximately -- and I know this won't be a ballpark
figure, but approximately how many chest radiographs
you review on a weekly or monthly basis? You tell methe best one.
A. I mean on a week, I probably -- I'd sayaround 50.
Q. And would you say it's been at that
frequency the entirety of the time that you've been
with this group?
A. It's increased.
Q. From what?
A. From zero --
Q. Okay. A. -- because it was added a little bit
later.
Q. Okay. So when did the group first start
reading chest X rays? A. Well, they were performed at other
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give me some sense as to of other radiologic studies
you're involved in, what percentage would be CT scans?
A. I really can't give you a percentage, but
I can give you a relative basis. We do more MRIs than
CTs. And ultrasounds and plain radiographs are about
the same.
Q. Okay. So then can you give me a sense
then as to the percentage of MRIs and CTs you
interpret as part of your complete practice, part of
your -- when I mean " you," I mean you specifically? A.
Q.
A.
I'd be guessing.
I'm not looking for an exact percentage.
Like I say, I probably do, like I say --
let me make sure I add up to a hundred percent.
Q. Right.
A. You know, probably 30 percent, MRI;
30 percent, CT; 20, ultrasound; 20 percent, plain
radiographs.
Q. And within those plain radiographs, does
that also include mammography or not? A. No.
Q. Do you do any interventional work? A. Just arthrograms and steroid injections,
cortisone injections.
Q. And of the plain films that you review,
17
1 facilities. But as far as when we started doing them, 2 again, I can't remember exactly, but I would think3 it's been about ten years ago.
4 Q. So for the past ten years or so, you'd
5 say you've been reviewing roughly 50 chest X rays a6 week?
7 A.
8 Q. 9
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Well, now. Little less back then.
Okay. Understood.
Prior to your coming to this group, how
often were you interpreting chest X rays? A. Oh, high volume.
Q. Okay. And that's because you werehospital -based at that point?
A. That's correct.
Q. And I think according to your CV, you
were working at the Chesapeake Hospital? A. That's correct.
Q. And you were there about seven or
eight years?
A. Correct.
Q. And during your time there, give me a
sense as to how often you were interpreting chestX rays.
A. Well, how often? I mean every day.
Pretty high volume.
5 ( Pages 14 to 17)
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1 Q. Well, if you were reviewing 50 a week2 now, do you have a sense as to about how many you were3 reviewing on a weekly basis back at the hospital? 4 A. Again, somewhat guessing, but I'd say5 more than double that.
6 Q. Okay. And so your job at Chesapeake was7 the first job you had after the completion of your
8 formal training? 9 A. That's correct.
10 Q. So would it be fair to state that 1997
11 would have been the last time you've reviewed a chest
12 X ray that was obtained in an emergency room setting? 13 A. Not an emergency room setting, but from14 an emergency room, hospital -based emergency room. 15 Q. Okay. Tell me then the circumstances in16 which you obtained chest X rays to review in your
17 current practice? How do you get them?
18 A. Well, any study you get from the19 referring physician, they will -- we get a lot of the20 X rays from urgent care centers, so, for instance,
21 someone comes with chest pain and they want to get an
22 X ray, they will send them to us and well perform the23 X ray and interpret it and give them the report. 24 Q. So you get x -ray requests from urgent2 5 care centers, I assume, from private physicians as
20
1 Q. Okay. Sticking for a moment to a PA view2 or an AP view, can you give me a sense as to about how
3 long it usually takes for you to interpret a film? 4 A. On average?
5 Q. On average.
6 A. Chest X rays, usually you can interpret7 within five minutes.
8 Q. Can you interpret them within a lesser
9 period of time?
10 A. I mean, you can get an idea and probably11 be right within a minute, but I would still take five
12 minutes to look at a film.
13 Q. Okay. Is there any medical literature14 that you reviewed for this case?
15 A. Not that I recall, no.
16 Q. Okay. Do you plan on citing to any17 specific medical literature, articles, textbooks,
18 journals, guidelines of any kind that you believe will19 support the opinions you plan on offering at trial?
20 A. Not with regards to aortic dissection.
21 The ACR Practical Guidelines, I could cite that.
22 Q. Well, what is it about the ACR Practical
23 Guidelines that you might cite?
24 A. Well, specifically the things that a2 5 radiologist should communicate; need to detect
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1 well in the community? 2 A. That' s correct.
3 Q. Any other source? 4 A. That' s really it. And then there's some5 doctors who perform the chest X rays in their office
6 and they have us interpret them. 7 Q. Do you also have the technology in your8 office to perform the chest X rays there?
9 A. That' s right. That's what I'm saying, we10 have it both ways; we have ones that they send over11 and we do the chest X ray and interpret it or they do12 the chest X ray and we'll interpret it. 13 Q. And in this day and age, I assume if14 that' s the way they do it, you interpret it digitally? 15 A. Correct.
16 Q. When you're reviewing -- by the way, when17 patients come to your facility for a chest X ray, I18 assume that they get a PA view? 19 A. Well, we can do anything, but generally20 we get a PA view.
21 Q. That' s the preferable view, true?
22 A. Correct.
23 Q. Do you usually get a lateral view as well2 4 when you have a request for a chest X ray? 2 5 A. Yes.
21
1 abnormalities; and then if it's an urgent finding, 2 such as this, to inform the physician in a non routine
3 manner by phone call or in person. 4 Q. Okay. So in other words, those5 guidelines say that if a radiologist is looking at a6 film and those films -- and that film indicates
7 something that might represent an emergency, it's the8 duty of the radiologist to immediately communicate9 those concerns to whoever sent them the film?
10 A. That's correct. If time is important and
11 a delay could adversely affect the patient, then you12 can't rely on a fax or a mailed report; you need to13 call.
14 Q. And is it your opinion that in this case
15 based upon at least what you see on the film, the
16 standard of care would have required that sort of
17 urgent communication?
18 A. Yes.
19 Q. Okay. Obviously urgent communication20 wouldn't have been required ifDr. Semaj felt that the21 film was within normal limits, true?
22 MR. BERMS: Objection.
23 THE WITNESS: Well, if he called it
24 normal, then he wouldn't report an urgent normal,
25 right.
6 ( Pages 18 to 21)
7 ( Pages 22 to 25)
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1 BY MR. GROEDEL: 1 A. That' s correct.
2 Q. And I assume you're not going to testify 2 Q. And when you received that call, I assume
3 that Dr. Semaj, for whatever reason, wouldn't have 3 you would have been told that Mr. Berris was either
4 made an urgent communication even if he had found the 4 prosecuting a malpractice case or potentially
5 abnormalities that you think he should have found? 5 prosecuting a malpractice case, true? 6 MR BERRIS: Objection. 6 A. Well, again, I don't recall the phone
7 THE WITNESS: I'm not sure I followed 7 call. But, in general, I'm receiving a case, you8 that one. Sorry. 8 know, they want me to interpret it and see if the9 MR GROEDEL: I'll withdraw the question. 9 issue is really an issue or not.
10 BY MR. GROEDEL: 10 Q. Well, what issue were you told?
11 Q. You did a fellowship from 1989 to 1990, 11 A. Well, I was just given a chest X ray with12 correct? 12 chest pain is the history. 13 A. Correct. 13 Q. And I assume that because Mr. Berris was
14 Q. And that was in body imaging? 14 handling the case, you probably knew at that point15 A. Correct. 15 that it was an untoward outcome?
16 Q. What is body imaging? 16 A. Well, I think, in general, if there's a
17 A. Body imaging is the radiology of the 17 lawsuit, there's some outcome, but I see cases all the
18 neck, chest, abdomen, pelvis, musculoskeletal system, 18 time where there really is nothing on the radiology19 sort of in contrast to neuroradiology, which is brain 19 part of it.
2 0 and spinal cord. 2 0 Q. But to be fair, when you first looked at
21 Q. Does it involve training in any 21 this film, you would have been aware of the fact that
2 2 particular radiologic modality? 2 2 there was an untoward outcome?
2 3 A. All of them, pretty much. The fellowship 2 3 MR. BERRIS: Objection again. I think
2 4 really concentrated on cross- sectional imaging, which 2 4 he's answered that.
2 5 is CT and MRI, but you also do plain radiographs, you 2 5 THE WITNESS: Yeah, I mean, anytime
23 25
1 do barium type of procedures. 1 there' s a lawsuit, you feel someone is complaining2 Q. Okay. But certainly, I assume, you 2 about something It doesn't -- I don't know if
3 felt -- feel you were adequately trained in reviewing 3 radiology is going to be abnormal though. 4 a plain chest film in your residency program, true? 4 BY MR. GROEDEL:
5 A. Oh, absolutely. I was trained in Miami, 5 Q. Did you learn from Mr. Berris or his law
6 high trauma center, so we did a lot of chest 6 firm that Mr. Bukovnik had sustained an aortic
7 radiographs. 7 dissection prior to looking at the film? 8 Q. When were you contacted to get involved 8 A. No.
9 in this matter? 9 Q. You don't recall when you received the
10 A. It was 2012. The report was 10 film"
11 October 2012, so it had been a little bit before that. 11 A. I don't know the exact date.
12 Q. How were you contacted? 12 Q. Well, do you believe it was close in time
13 A. How? I don't recall. 13 to the date of your report, which is October 28?
14 Q. I didn't see any letter from Mr. Berris 14 A. I mean, I'm believing it is sometime a15 introducing you to the case. 15 little bit earlier in 2012.
16 Is it likely you would have received a 16 Q. Okay. Besides speaking to somebody in17 phone call? 17 Mr. Berris' office, do you know whether or not you
18 A. I'm thinking I may have received a phone 18 spoke with Mr. Berris prior to interpreting the chest19 call. It may have not been from Mr. Berns; it may 19 X ray? 2 0 have been from a secretary and said, will you review 2 0 A. I don't recall.
21 the case? 21 Q. And the disk that you -- the film that
2 2 Q. And I assume from your prior experience 2 2 you received, I assume that's the disk that's been
2 3 you would have known Mr. Ben-is is a lawyer that 2 3 marked a,s Exhibit 3?
2 4 represents plaintiffs in medical malpractice 2 4 A. That's correct.
2 5 litigation? 2 5 Q. And besides that disk, is there any other
7 ( Pages 22 to 25)
8 ( Pages 26 to 29)
26 28
1 information on that -- I'm sorry -- on that disk, is 1 A. Goodman -- I'm sorry -- Allen & Filetti.
2 there any other information other than the film 2 Q. Where are they located? 3 itself? 3 A. That one is in Norfolk.
4 A. I don't believe so. 4 Q. Go ahead.
5 Q. And when you looked at the film, were you 5 A. Stahl & Delaurentis is in New Jersey. 6 provided the report from Dr. Semaj? 6 Q. How do you spell Stahl?
7 A. No. 7 A. S- t- a -h -1. And they have sent me quite a8 Q. Did that come later? 8 few cases. And then there's ones in Richmond. You
9 A. Yes. 9 have to forgive me because I can't remember all those
10 Q. When you reviewed the film, did you make 10 names. But Sands is one of them; S- a- n -d -s.
11 any notes as you were looking at it? 11 Q. That' s a defense firm in Richmond?
12 A. No. 12 A. Right. There's another defense firm, I
13 Q. Would your notes of your review of the 13 believe, in New Jersey and I cannot remember their14 film be encompassed within the first paragraph of your 14 name. I remember the name of the case, but not the
15 report? Feel free to look at it. 15 attorneys. Schwartz was her name.
16 MR. BERRIS: Objection; I'm not sure what 16 Q. What city in New Jersey? 17 you're asking. 17 A. I can't remember. Multiple cities on
18 BY MR. GROEDEL: 18 there.
19 Q. I'm asking whether or not the first 19 Q. Okay. How many deposition testimonies2 0 paragraph of his report is essentially how you would 2 0 would you say you give on a yearly basis? 21 have dictated your findings when you were looking at 21 A. Can be approximately five or six. 2 2 the film? 2 2 Q. And is the split on depositions the same
2 3 A. It wouldn't be precisely how I would 2 3 as your review split as relates to plaintiffs versus
2 4 dictate it if I were in my office. I was just 2 4 defendants?
2 5 providing some findings. 2 5 A. For depositions, it probably is, yes.
27 29
1 Q. Okay. All right. So let's assume that 1 Q. How about trial? How many times have you2 you would have been dictating a report as you were 2 testified in a courtroom?
3 actually -- you know what, strike that question. 3 A. Trial, maybe around ten -- eight to ten.
4 We'll come back to it. 4 But most of those have been plaintiff.
5 Can you just give me a sense of how often 5 Q. Of the trials -- of the eight to ten
6 you get involved in medicolegal reviews? 6 trials, most have been for plaintiff?
7 A. It's been about six to twelve a year. It 7 A. Correct.
8 got a little higher. Closer to 12. 8 Q. How many do you believe have been for the9 Q. And what do you charge for reviewing 9 defense of the eight to ten?
10 records, films, that sort of thing? 10 A. I can remember two.
11 A. It's $ 500 an hour for everything 11 Q. Have you ever testified in trial in Ohio?
12 Q. Deposition time as well? 12 A. No. Maybe another defense firm is in
13 A. Correct. 13 Cleveland; Mannion defense firm.
14 Q. Trial time? 14 Q. Yes. You've reviewed cases for the
15 A. Correct. 15 Mannion law firm?
16 Q. And can you give me a sense as to the 16 A. That's right.
17 breakdown between how often you're looking at a case 17 Q. Besides this case, have you ever reviewed
18 for somebody like Mr. Berris as opposed to a defense 18 another case involving the interpretation of a chest19 attorney? 19 X ray where it turned out the patient sustained an2 0 A. It's about 50/50. 2 0 aortic dissection?
21 Q. Can you give me the names of some of the 21 A. I believe there was another case of
2 2 defense attorneys who retained you over the last year 2 2 aortic dissection, but it involved a CT study and not2 3 or so? 2 3 a chest radiograph.
2 4 A. Goodman, Allen & Filetti. 2 4 Q. So you don't recall testifying in another2 5 Q. Goodman? 2 5 chest X ray case that involved a subsequent aortic
8 ( Pages 26 to 29)
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1 dissection?
2 A. That's correct.
3 Q. Do you advertise your availabilities as
4 an expert witness?
5 A. No.
6 Q. To your knowledge, are you on the roster
7 of any company that advertises its ability to find8 expert witnesses?
9 A. Well, I received cases from these
10 companies, if that's what you mean, yeah.
11 Q. What companies do you receive cases from?
12 A. medQuest, and really just one other13 called The Expert Institute.
14 Q. The cases from medQuest, about how many15 cases have you received from medQuest? And you can
16 give it to me in either a number or percentage of
17 cases you review, any way you'd like. 18 A. They usually send me about three a year. 19 Q. Okay. And The Expert Institute, what20 about them, how often do you receive cases from them?
21 A. Pretty rare I think I've only received22 a total of three cases.
23 Q. Did Mr. Berris find you through medQuest
24 initially? 25 A. I don't recall.
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being impacted by hindsight bias when reviewing a
chest X ray or any radiologic study in a setting likethis?
A. Right. And that's why I only want the
history that the radiologist was provided.
Q. Do you have an understanding as to what
hindsight bias is?
A. Yes.
Q. What's your understanding as to what itis?
A. It's if you already know the outcome ofan event, that you would have been able to predict it.
Q. And is hindsight bias something that can
occur to somebody looking at a study even unwittingly? MR. BERMS: Objection.
THE WITNESS: Well, I'm not sure I
understand the question.
BY MR GROEDEL:
Q. In other words, somebody might honestly
think that they are not being affected by hindsight
bias, but, in fact, they truly are based upon thelevel of knowledge of the outcome?
A. Right. Yeah, hypothetically if you
already know the outcome, the classic is the football
play or you already know they didn't score on fourth
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Q. I apologize for asking this, but have youever been sued for medical malpractice?
A. I was sued once in 1998, I believe, but I
was misidentified as the one who read the image and
nonsuited.
Q. Okay. And that's the only time you'veever had a malpractice case brought against you?
A. Correct.
Q. Have you ever given deposition testimony
in a case involving the interpretation of a chest
X ray?
A. Yes.
Q. And can you tell me about those cases?
A. Well, I can't really remember them all,
but most of them usually deal with lung cancer.
Q.
A.
Q. A.
Q.
Where a mass was missed?
Correct.
Have you ever testified in federal court?
You know, I don't know.
Some experts or physicians keep lists, a
list of all cases that they have given testimony in. Do you have such a list?
A. No.
Q. Would you agree with the general
proposition that you try to avoid as much as possible
33
1 down and you would have predicted, yeah, I could have
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passed instead of ran.
Q. And so your reference to the fact that
this is cold read is premised upon the fact that when
you looked at the film you knew that -- you knew of
the patient's chest pain, that complaint, and had no
other information?
A.
Q.
A.
Q.
A.
That's correct.
Did you know the patient's age?
I may have known the patient's age. Did you know the patient was a male?
Well, you can look at the film and get
some information. I'm not sure exactly what's on
there right now, but generally in the corner it might
have his date ofbirth and name.
Q.
A.
Q.
Okay. Good point.
Yeah.
How would you define the radiologic
standard of care?
A. What a reasonably prudent radiologist
would do in the same or similar circumstances.
Q. Would you agree that one radiologist can
find abnormalities on a chest X ray and another
radiologist read that same study as normal and both be
acting within the standard of care?
9 ( Pages 30 to 33)
34
1 A. That can happen, yes.
2 Q. Why is that? 3 A. Because the finding is subtle or4 obscured.
5 Q. If you were to look at this film, would
6 you agree that there might be a certain percentage of
7 radiologists who would look at it and read it as
8 normal?
9 MR. BERRIS: Objection.
10 THE WITNESS: I mean, if they read it as11 normal, I think they have deviated from the standard12 of care.
13 BY MR. GROEDEL:
14 Q. So any radiologist who looked at this15 film, who read it essentially as Dr. Semaj did, you16 believe would be falling below the standard of care? 17 A. If he read it as normal, yes.
18 Q. So is it your belief then that if a
19 hundred radiologists looked at this film, all one
20 hundred should have found the abnormalities that you
21 found?
22 A. Well, what I'm saying is that if a23 hundred radiologists read this film, I don't know what
24 percentage would call it normal, but that percentage
25 would be below the standard of care.
36
1 A. Right. That goes back to your earlier
2 question. I mean, ifyou don't -- if the finding is3 subtle or obscured, that would fall within the
4 standard of care.
5 Q. In your experience, have you ever missed
6 abnormalities that were later recognized as being due7 to an aortic dissection?
8 A. No.
9 Q. Would you agree that one doesn't use a
10 chest X ray to diagnose an aortic dissection? 11 A. Well, I mean you use a chest X ray in the12 diagnosis of an aortic dissection, but its not a
13 hundred percent definitive of aortic dissection.
14 Q. Well, would it be fair to state that no
15 one would base a diagnosis of aortic dissection upon a
16 plain film alone?
17 A. Solely on a chest X ray, no. 18 Q. Okay. And I take it by your answer that19 there are other radiologic studies that are much more
20 accurate when it comes to diagnosing or ruling out21 aortic dissection, true?
22 A. True.
23 Q. What are they? 24 A. CT angiography would be one, MRI would be25 another, studies that we don't do, but transesophageal
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Q. Okay. So if 30 radiologists read this as
normal, hypothetically, those 30 would be fallingbelow the standard of care?
A.
Q.
That' s correct.
In your practice as a radiologist, have
you ever missed findings on an X ray that were
subsequently discovered on subsequent studies? A. Yes.
Q. Is that something that happens
frequently? Infrequently? Can you give me a sense asto how often that's happened to you?
A. Infrequently.
Q. And on those occasions when it occurred,
did you believe you breached the standard of care
because you missed certain findings that were later
discovered by others? A. I think -- you know, I don't remember a
specific case, but it happens.
Q. Okay. Well, I guess my question is, arethere instances where you can look at a film, not see
anything that is worthy ofnote, somebody else can do
a subsequent study, find abnormalities, and you would
still honestly believe that your interpretation, eventhough in retrospect is not correct, still met the
standard of care?
35
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ultrasound would be one.
Q.
A.
Q.
A.
Q.
setting?
A. Generally it's the same, but MRA is a
type of MRI.
Q. Okay. Let's talk a little bit about your
report, okay.
First of all, you make reference to the
clinical history of chest pain. Would you agree that chest pain is the
most common history you receive for chest x -rayinterpretations?
A. Probably is, yes.
Q. Of those histories that you receive, give
me a sense as to approximately what percentage of them
have a history of chest pain.
A. Again, I can' t really give you a
percentage, but I would say it would be 50 percent orabove.
Q. Okay. In your report, you note that the
patient was mildly rotated to the left?
Aortogram, would that be another?
And, of course, aortogram, right.
Any others? MRI, would that --
I said that one, yeah.
Is the MRI the same as MRA in this
37
10 ( Pages 34 to 37)
38
1 A. That' s correct.
2 Q. Okay. And what do you mean by that? 3 A. Well, the patient is rotated towards his
4 left side.
5 Q. And is that a function of the study being6 taken while he's laying in bed? 7 A. Well, you can have that happen in an
8 upright PA chest film All I know is he wasn't
9 perfectly aligned. He was rotated to the left. 10 Q. Well, sure. But it's more likely that11 you're going to be not perfectly aligned if you're12 having the study taken while you're laying in bed as13 opposed to standing upright, true? 14 A. Well, I mean, if you're laying in bed but15 you're paralyzed, maybe not. If you're jittery while16 you're standing up, you're going to be rotated. 17 I really can't come to the conclusion -- 18 I know what you're trying to ask, but it's really not19 true. It really just comes down to how well the20 technologist gets the person aligned.
21 Q. Well, in this case would a reasonable
22 explanation for the rotation be because the X ray was23 taken while the patient was laying in bed? 24 A. It could be, yeah.
25 Q. Are you going to say there was any other
40
1 frontal radiograph, so that's why I call it mild. If2 it gets to the point that it's almost 45 degrees, then
3 you'd say that's more of a moderate. 4 Q. We're not talking about looking at an5 oblique film here, are we?
6 A. No.
7 Q. We're far from that, right?
8 A. Far from that.
9 Q. Okay. So one of the things you talk10 about is that there is prominence of the ascending11 aortic shadow along the right mediastinal border, and12 you characterize that as an abnormal finding, correct? 13 A. Correct.
14 Q. All right. So why don't we take a look15 at the film.
16 Is this the one that we've marked?
17 Doctor, did we mark this film?
18 A. I didn't mark this.
19 MR. GROEDEL: Let's mark this film then.
20 MR. BERRIS: This is one of the films
21 that you brought today? 22 THE WITNESS: Yeah.
23 BY MR. GROEDEL:
24 Q. Is it?
25 A. Yes.
39
1 reason why the film was slightly rotated? 2 A. No. I mean, it's not really a factor in3 my opinion. It's just a fact. 4 Q. And then you also go on to say, as a5 result, the right heart border is less prominent,
6 which leads me to think that you believe the rotation
7 had some impact upon how the right heart border
8 looked?
9 A. That's correct. When you're rotated to
10 the left, okay, anterior structures which are on the11 right side, like the right heart border and the
12 ascending aorta, are going to be shifted more over the13 spine, you're not going to see them as well when14 you're rotated to the left.
15 Q. So in other words, the right atrium would
16 be shifted more medially as a result of that rotation? 17 A. Correct.
18 Q. The level of rotation, the amount of
19 rotation, you characterize as mild?
20 A. Mild.
21 Q. Okay. Is there any way you can quantify22 that with a number? Is that just an eyeball estimate?
23 You tell me.
24 A. I mean, if you say mild, moderate, or25 severe, it's just -- it still looks pretty much like a
41
1 MR. BERRIS: This is not the one I
2 brought?
3 I've got mine.
4 ( Exhibit No. 5 was marked.)
5 BY MR. GROEDEL:
6 Q. So we're looking now at Exhibit 5. And7 this is Mr. Bukovnik's AP chest X ray, correct? 8 A. Correct.
9 Q. All right. And this is good for
10 interpretation; and you have no trouble interpreting11 it, right?
12 A. Correct.
13 Q. So why don't you mark for us where you14 believe the prominent ascending aortic shadow is. 15 MR. BERRIS: Again, do you want to use --
16 this is not a permanent marker.
17 MR. GROEDEL: Do you want to use a pen?
18 Would a pen be better?
19 MR. BERRIS: Something that you have to20 be able to mark on plastic with -- if you want to mark
21 with that pen, but I presume you would want to use a
22 permanent marker.
23 ( There was a pause in the proceedings.)
24 MR. GROEDEL: We're going to go back on25 the record.
11 ( Pages 38 to 41)
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BY MR. GROEDEL:
Q. So, Doctor, what I'd like you to do is to
draw a line where you believe the prominent ascending
aortic shadow is along the right mediastinal border. A. ( Witness complying.)
Q. All right. Would you agree that that
prominence could be caused by magnification effect
because we're looking at an AP film here as opposed toa PA?
A. No.
Q. Not at all?
A. No.
Q. Don't you agree that AP views will
slightly magnify the heart and the mediastinalstructures?
A. Well, an AP film can magnify structures;
it won't change the relationship of structures and
also wouldn't account for the fact that the ascendingaorta should be less prominent with leftward rotation.
Q. But that rotation would also cause the
right atrium to be more medial and less prominent as
well, correct?
A. Both of them, correct. So the whole
right side of this cardiac silhouette, which I usually
say is the heart and the mediastinum, would be moved
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Q. Okay. So now what Pd like you to do forme is draw the outline of the right atrium.
A. ( Witness complying.)
Q. We have two lines here and I'm glad you
separated the two so there's no dispute what we're
looking at.
The upper line represent the ascendingaorta; the lower line represents the right atrium,
correct?
A. Correct.
Q. And it would appear to me, just from a
lay perspective, that both shadows appear to be atabout the same level, so to speak; wouldn't that be
true?
MR. BERRIS: Objection.
THE WITNESS: No, that' s not true. What
you would look at is -- when you say " level," there's
a vertical line coming like this; you can see that the
ascending aortic shadow is lateral to the right atrialshadow, and that should be the reverse.
BY MR. GROEDEL:
Q. Okay. So how would you characterize the
degree ofprominence of the ascending aortic shadowvis -a -vis the right atrium?
A. I'm not sure I understand your question.
43
1 medially over the spine shadow. We would see less of2 it.
3 In this case, the aorta is too prominent
4 for leftward rotation.
5 Q. Okay. So is it your belief then that -- 6 and your testimony that when you have an AP film and7 it's going to magnify structures, it's going to8 magnify the entire structure, the heart and the aorta? 9 A. That' s correct; it's just a matter of
10 where the beam is striking at a structure and the11 distance to the --
12 Q. Well, isn't it true though that with an
13 AP film you can have a situation where the aorta is
14 magnified and the right atrium or the heart isn't?
15 A. No.
16 Q. So it's got to be both?
17 A. Correct.
18 Q. And do you believe that rotation in this
19 film has any impact upon where the aorta, the20 ascending aorta sits?
21 A. It has an effect on how the ascending22 aortic shadow appears. Normally, normal chest X ray23 with leftward rotation, the ascending aorta shadow24 would move medially over the spine, and so you
25 wouldn't see it at this prominent or lateral position.
45
1 I would characterize it as, you know, a significant
2 abnormal finding. 3 Q. I mean, when I'm looking at this, it4 doesn't seem as though there's a significant
5 difference between the locations of the shadows.
6 You don't agree?
7 MR. BERRIS: Objection.
8 THE WITNESS: Based on my education and
9 training as a radiologist, I don't agree with that. 10 BY MR. GROEDEL:
11 Q. Okay. So if this film wasn't rotated, 12 would the border of the ascending aorta be more medial13 if the film wasn't rotated?
14 A. So you're saying if it wasn't rotated to15 the left -- is that what you're asking? 16 Q. Yeah. If it wasn't rotated the way it17 was, would the ascending aorta shadow be a little bit18 more medial?
19 A. No. The leftward rotation causes the
20 shadow to be more medial. So if it wasn't rotated, it
21 would be a little bit more lateral.
22 Q. Okay. And the right atrium would also be23 a little more lateral?
24 A. Right, because they are both relatively25 anterior structures. So if you think of a
12 ( Pages 42 to 45)
13 ( Pages 46 to 49)
46 48
1 cross - section through here, a circle, okay, and you 1 relationship and you call it normal because the fact2 rotate the patient to the left, which is over here on 2 that it's medial to the right atrium. If it's lateral
3 this side, anterior structures are going to move to 3 to the right atrium, then it's abnormal.
4 the left, posterior structures are going to move to 4 Q. Would you agree that assessing the5 the right. 5 ascending aortic shadow and the right heart -- the
6 Q. Do you believe that a normal chest X ray 6 right atrium shadow is easier on a PA view as opposed
7 always has to have the margin of the ascending aorta 7 to an AP view?
8 medial to the margin of the right atrium? 8 A. No.
9 A. To call it normal, yes. If you have the 9 Q. Why not? 10 reverse, then it's abnormal. 10 A. The same thing, AP view and a PA view11 Q. So you can never have a normal chest 11 doesn't change the relationship of the ascending12 X ray with the margin of the ascending aorta lateral 12 aortic shadow to the right atrial shadow.
13 to the margin of the right atrium? 13 Q. Can the manner in which the heart is
14 A. Right. I mean, your question sort of 14 laying in the chest cavity have an impact upon the15 begs the answer. But if it's reverse, then it's not a 15 relationship between these two structures that we've16 normal chest radiograph. 16 been talking about? 17 MR. ROSSI: AP or PA? 17 A. I'm not sure I understand that question.
18 BY MR. GROEDEL: 18 Q. I mean, are there different variations in
19 Q. And that would even be on an AP view? 19 the way the heart may be resting within the thorax20 A. AP and PA does not change relationships 20 that gives -- that allows for a range of findings when
21 of the structure, per se, here of the mediastinum. 21 assessing whether or not the ascending aorta is22 There's some magnification factors, but it's not going 22 lateral to the right atrium border?
23 to change the relationship. 23 A. I'm not aware of anything that states the24 Q. And so you're saying then anytime the 24 heart being -- laying in different positions. 25 ascending aorta is even slightly lateral to the border 25 Q. Okay. If the heart is in systole, would
47. 49
1 of the right atrium, that's an abnormal -- that's an 1 the right atrium appear differently than it does if2 abnormal finding that warrants follow -up? 2 it's in diastole?
3 A. Yeah. And, again, clinical setting, but 3 A. Well, the right atrium in isolation could
4 that's an abnormal fmding where the ascending aortic 4 have more blood in it at one point than another, but
5 shadow is lateral to the right atrium and particularly 5 it won't change, again, the relationship with the6 if you have someone with sudden onset of chest pain. 6 aorta.
7 Q. We don't know that it was a sudden onset 7 Q. Well, if the right heart has more blood
8 of chest pain, do you? 8 in it, that would cause the right heart to appear
9 A. Chest pain. 9 differently how? 10 Q. Do you know how long the chest pain was 10 A. Well, if you have more blood in the
11 occurring? You don't know if it was chronic -- 11 atrium, it could be dilated.
12 A. I'm sorry. When I interpreted the case, 12 Q. And so more lateral?
13 it was just chest pain. 13 A. Right. Again, it wouldn't change the
14 Q. Right. How much medial does the 14 relationship
15 ascending aorta have to be to the right atrium border 15 Q. But if the right heart was in diastole,
16 for it to be normal? 16 then the right atrium border would be more medial,
17 MR. BERRIS: Objection. 17 true?
18 THE WITNESS: The ascending aorta margin 18 A. Well, no. If the right atrium was in
19 must be medial to the right atrial border. 19 diastole, then it potentially could be more lateral. 20 BY MR. GROEDEL: 20 Q. So if it's systole, it would be more
21 Q. By how much? 21 medial?
22 A. Any amount. 22 A. In your theory. 23 Q. Okay. Like half a millimeter and then 23 Q. Couldn't that have an impact upon how far
24 that's sufficient to be normal? 24 out the right atrium shadow is?
25 A. Well, then that would fall into a normal 25 A. Well, it could affect the exact position
13 ( Pages 46 to 49)
50
1 of the right atrial. Just like rotation, it won't
2 change the relationship to the ascending aorta. 3 Q. Just so I have this clear in my head, 4 what is it in systole or diastole where the heart
5 would be -- the right atrium would be dilated?
6 A. Well, in diastole, you have filling, 7 okay.
8 Q. So that's when the right atrium would be
9 more dilated?
10 A. Could be, in theory, more dilated. 11 Q. So if it's more dilated, the shadow would
12 be a little bit more lateral?
13 A. In theory. 14 Q. If the heart was in diastole, that
15 wouldn't have an impact upon the shadow of the
16 ascending aorta, would it? 17 A. Well, I mean, whatever -- again, these
18 are all these hypotheticals. Whenever you apply to19 the right atrium, you have to apply also to the aorta. 20 So if this is dilated -- if this moves laterally, this21 moves laterally. 22 Q. So you're saying if the heart is in23 diastole and the right atrium is dilated, that should
24 also cause the ascending aorta to be dilated laterally25 a bit, too?
52
1 answered.
2 THE WITNESS: Significant.
3 MR. ROSSI: Marc -- this is Gregg Rossi4 again -- the doctor just said that this is the
5 critical abnormality, and he was pointing to6 something. Can you guys just clarify in the record7 what he meant by that -- 8 MR. GROEDEL: Yeah.
9 MR. ROSSI: -- what that is?
10 BY MR GROEDEL:
11 Q. What we've been talking about, but why12 don't you say it again. 13 A. The critical abnormality is the14 prominence of the ascending aortic shadow.
15 MR. BERRIS: Aortic -- oh, the -- the
16 aortic shadow. I'm sorry. I misunderstood. 17 BY MR. GROEDEL:
18 Q. And is the aortic -- the ascending aortic
19 shadow, that' s within what's known as the mediastinum?
20 A. Correct.
21 MR. ROSSI: Thank you, Marc.
22 Thanks, Doctor.
23 BY MR GROEDEL:
24 Q. Will you be offering an opinion at trial25 as to what this finding represents? And I'm talking
51
1 A. What I'm saying -- and this is
2 critical -- this relationship always stays like this3 when the ascending aorta is lateral to the right4 atrium. There' s all sorts of factors you can
5 hypothesize like systole, diastole, aortic motion
6 possibly, but the relationship needs to be reversed to7 be called normal.
8 Q. So then you don't agree with the
9 proposition that the ascending aorta can be slightly10 lateral to the right atrium border on a normal chest
11 X ray? 12 A. Right. You would not call it a normal
13 chest X ray. 14 Q. And is it then your belief that this is a
15 fmding that should have been referenced in some16 fashion in Dr. Semaj' s report? 17 A. Correct. He should have identified --
18 this is the critical abnormality that prominence of19 the ascending aorta should have been put in as a2 0 fmding. Aortic pathology, dissection being the key21 one, and then calling referring physician to order a22 CT study. 23 Q. How would you characterize the degree of
24 abnormality?
25 MR. BERRIS: Objection; asked and
53
1 about the top line that we have here. 2 A. Yes.
3 Q. What is going to be your opinion? 4 A. My -- although it's not specific, it's
5 worrisome for aortic pathology such as a dissection. 6 Q. Well, is it going to be your opinion then7 that that finding based upon everything you know about8 that case represents an aortic dissection?
9 A. Yes.
10 Q. Generally speaking, are AP portable x -ray11 units less powerful than regular units that you use
12 for a PA study? 13 A. What do you mean by "powerful "? 14 Q. There's less power utilized for them.
15 A. I mean, I'm not sure I can answer that
16 question.
17 Q. Are AP photographs taken at a shorter
18 distance from the film compared to a PA radiograph?
19 A. Generally. 2 0 Q. And the further away the x -ray source is21 from the film, the sharper and the less magnified the
22 image?
23 A. Well, generally with an AP film, you have24 a little more magnification, a little less sharp. 25 Q. Okay. So an AP film is not as sharp and
14 ( Pages 50 to 53)
15 ( Pages 54 to 57)
54 56
1 slightly magnified when compared to a PA film? 1 THE WITNESS: So a little over nine.
2 A. That's correct. 2 BY MR GROEDEL:
3 Q. Is a widened mediastinum a potential 3 Q. So would be within normal limits, true?
4 radiographic sign of an aortic dissection? 4 MR. BERRIS: Objection.
5 A. Yes. 5 THE WITNESS: Okay. So borderline, 6 Q. And I assume you know how to assess 6 borderline.
7 whether or not there's a widened mediastinum? 7 BY MR. GROEDEL:
8 A. Well, you're looking for the mediastinal 8 Q. Okay. Well, would you agree that a9 width; and there' s different ways to do it. 9 widened mediastinum is the most common radiographic
10 I think in this specific case though, the 10 abnormality seen on a chest X ray that's associated11 critical finding, again, is the prominent ascending 11 with an aortic dissection?
12 aortic shadow. In it by itself, that's all you need. 12 A. I'm not sure. It's one of the findings.
13 So even if I found a normal mediastinal width, it 13 Q. But isn't it -- when they list the14 would not. 14 abnormalities that can be seen in association with an
15 Q. And that's because in this case you would 15 aortic dissection, isn't widened mediastinum the most
16 agree that the mediastinal width in this case is 16 commonly seen abnormality on a chest film? 17 within normal limits? 17 A. Again, I'm not sure it's the most common;
18 A. I'd need a ruler right now. I think, to 18 it' s definitely one of them listed. 19 me, just eyeballing it, it looks close to being 19 Q. Well, what are the other ones?
20 abnormal. Eight centimeters is generally what is 20 A. Other ones would be rightward tracheal
21 used. 21 deviation, indistinctness of the aortic knob, loss of
22 Q. Well, wouldn't you agree that for an AP 22 the aorta pulmonary clear space. You can also have a23 film, the range of normal is even a bit higher than 23 more advanced case called an apical cap, c -a -p,
24 eight centimeters? 24 pleural effusion.
25 A. And there's different ways to measure 25 Q. And, by the way, when you measured the
55 57
1 that. You can measure it straight across, you can 1 mediastinal width here, what structures did you
2 measure it mid trachea over. There's several methods 2 measure? From where to where?
3 to do it. 3 A. Well, I was measuring through the4 Q. Okay. But as you look at this film now, 4 prominence of the aortic shadow across.
5 you would agree that this is likely within the normal 5 Q. Well, did you, like -- where did you
6 range of mediastinal width? 6 start from in relation to the atrium?
7 MR. BERRIS: Objection. 7 A. Well, I'm above the atrium because we're
8 THE WITNESS: I mean, honestly eyeballing 8 doing the mediastinal width, so I did a transverse9 it, I'd say it's borderline abnormal. Not grossly 9 diameter of the mediastinum.
10 abnormal, but borderline. 10 Q. Would you agree the mediastinal widening, 11 BY MR. GROEDEL: 11 true mediastinal widening is the most commonly seen12 Q. Would you agree that normal mediastinal 12 radiographic sign and is seen in up to 61 percent of13 width for an AP chest X ray is up to about nine and a 13 those patients who have an aortic dissection?
14 half centimeters? 14 A. Again, I'm not aware of the exact
15 A. I don't think that's unreasonable. 15 figures. I know it's one of the findings that you can
16 Q. Do you want to measure it and see what it 16 have.
17 comes up to, or would you agree that this is less than 17 Q. You wouldn't take issue with that number
18 nine and a half centimeters? 18 though, would you?
19 A. Again, it's not the critical finding, but 19 A. I think what's important is you
20 I'll look at it if you'd like. 20 wouldn't -- you say the absence of mediastinal21 MR. BERRIS: Do you want him to measure 21 widening in the presence of other findings would22 it? He said it's not relevant. It's up to you. 22 exclude you further pursuing the diagnosis of an23 MR. GROEDEL: Maybe not to him. 23 aortic dissection.
24 MR. BERRIS: He can measure whatever you 24 Q. Would you agree that approximately25 want him to measure. 25 20 percent of patients who end up having a dissection
15 ( Pages 54 to 57)
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have a normal chest X ray that's properly interpreted? A.
Q. A.
I agree.
Why is that? It can be a mild dissection at that point
so that -- the dissection is the blood is dissected
between the layers in the wall of the aorta, so if
that dissection is thin at that point, it may not showup on a chest radiograph.
You made reference to the aortic knob.
What is the aortic knob?
A. The aortic knob is a finding on achest -- a frontal chest radiograph that represents
the aortic arch seen sort of -- and a cross- section.
Q. Is the aortic knob better visualized on a
PA film as opposed to an AP film?
A. You see it on both.
Q.
Q.
Can you see it better on a PA as opposed
to an AP?
A. Better? It probably depends on a
case -by -case.
Q. In your report you state that the
superior margin of the aortic margin is indistinct?
Take a look.
A. The superior margin of the aortic knob?
Q. Correct. So what are we talking about
60
1 Q. Okay. So in this case, can you have an2 indistinct superior margin of an aortic knob and be
3 able to see the left border of the knob and consider
4 that to be within the normal range?
5 A. Yeah, if that were just an isolated
6 fmding, yes. 7 Q. So the aortic knob fmding in and of8 itself doesn't cause you to be concerned about a
9 potential dissection?
10 A. No. Again, the critical finding is the11 ascending aortic prominence. And then after that, you12 start to look for supporting evidence, and I would13 call that in the supporting evidence. 14 Q. Okay. But if Dr. Semaj didn't say15 anything about the aortic knob, you wouldn't say he16 breached the standard of care in that regard, true?
17 MR. BERRIS: Objection.
18 THE WITNESS: Well, I think I have a
19 problem with him not detecting the aortic knob in20 conjunction with not detecting an ascending aortic21 shadow.
22 BY MR. GROEDEL:
23 Q. Well, I take it from what you've already24 told me, you believe he breached the standard of care
25 in failing to recognize the prominent ascending aortic
59
1 here? Why don't you mark where the aortic knob is on
2 this film.
3 A. Okay. This is the left lateral margin of4 the aortic knob here; and you can see that fairly5 well. And then the superior margin, I'm going to6 estimate, to be along this dotted line; you just don't7 really see it that well. 8 Q. Okay. And would you agree that according9 to the literature, there's usually an obliteration of
10 the aortic knob with an aortic dissection?
11 MR. BERRIS: Objection.
12 THE WITNESS: Is there usually an13 obliteration? I mean, you can have an obliteration,
14 but, like you said, in 20 percent of cases, it can be
15 normal, and maybe even a higher percentage with aortic
16 knob can be okay. 17 BY MR. GROEDEL:
18 Q. Okay. In this case though there's no19 doubt you can certainly see the aortic knob along its20 left border, correct?
21 A. Yes.
22 Q. All right. And you say you don't see it23 well along its superior border where you've got the24 dots?
25 A. Correct.
61
1 shadow, correct?
2 A. Correct.
3 Q. Leaving that aside for a moment, do you4 believe he breached the standard of care in not
5 believing or recognizing that this supposed indistinct6 border of the aortic knob represented an issue that
7 needed follow -up? 8 A. I guess I can't -- you can't answer that
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question in isolation.
Q. There are other folks who have looked at
this film who say they can, in fact, see the superiormargin.
A.
Q. A.
Q.
You would disagree?
I disagree, yes.
You don't think you can see it at all?
I think it's indistinct.
Indistinct meaning it's difficult todelineate?
A. Correct.
Q. All right. Are there other structures in
this area of the aortic knob?
A. I don't understand.
Q. For instance, are there any structureson -- what portion of the aorta does the aortic knob
represent?
16 ( Pages 58 to 61)
62
1 A. The aortic knob is sort of the posterior
2 arch.
3 Q. Of the aortic arch?
4 A. Correct.
5 Q. So are there any vessels or other6 structures in front of the aortic knob?
7 A. Well, not really. You have vessels that8 come off the aorta. You can have veins that come
9 across that could come right in front.
10 Q. Anything else? Any other structures11 around the area of the aortic knob, vessels or
12 structures?
13 A. Well, I mean, you have lung. I'm not14 sure exactly what you're asking.
15 Q. Yeah, that's what I'm asking. 16 A. Yeah. As long as the reason why you17 generally see it, and, therefore, the fact that you18 don't see it very well is a worrisome finding in19 constellation with this prominent ascending aortic20 shadow.
21 Q. Are you aware of any literature that says22 that just seeing an indistinct portion of the margin23 is potentially worrisome for a dissection? 24 A. Talking about the aortic knob again? 25 Q. Yes.
64
1 imagine seeing it, but it' s not distinct again and2 clear as you usually see it because the space contains3 fat and fat makes it dark on an X ray, and you just4 don't see the space as well as you usually do. 5 Q. Would you mark the area where you believe
6 the aortopulmonary window is? 7 A. ( Witness complying.) 8 Q. And is it true that sometimes it's
9 difficult to visualize this finding or this space10 because of adjacent structures of fat that may get in11 the way of it? 12 A. Well, you may -- sometimes it's just hard
13 to see on a chest X ray. If you maybe lost some of14 the fat or for other various reasons. So in
15 isolation, you might not see it.
16 Q. Okay. So I take it from what you're17 saying, you don't fault Dr. Semaj for not commenting18 upon the inability to see the aortopulmonary window, 19 true?
20 A. Well, again, I fault him for not
21 commenting on all of these ancillary findings in the22 presence of this critical finding. Once you have the23 critical finding, you need to comment on other24 findings.
25 Q. If he had just commented on the prominent
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A. I'm not aware of specific literature, no.
Q. Is this an abnormality that you have
63
recognized and commented upon in your own practice in
reading chest X rays?
A. Yes.
How many times would you say you'veQ.
recognized an indistinct aortic knob or an obliterated
aortic knob?
A. I have no idea.
Q. You also make reference to the
aortopulmonary window in your report, correct?
A. Correct.
Q• And can you define for us what the
aortopulmonary window is? A. The aortopulmonary window is an anatomic
space between the aorta and pulmonary artery. Q. And would you agree that on an AP film,
the aortopulmonary window may be difficult tovisualize?
A. It may be.
Q. Do you see the aortopulmonary window inthis case?
A.
Q.
A.
Not well.
Do you see it to some degree?
Well, it's hard to tell. I try to
65
1 ascending aortic shadow and recommended further2 follow -up, would that have been sufficient without3 mentioning these other abnormalities that you believe4 are present?
5 A. I believe so. If he would have
6 identified the abnormality of the ascending aortic7 shadow, offered the differential diagnosis of an
8 aortic dissection, recommended a CT of the chest, and
9 then called the physician, that would have met the
10 standard.
11 Q. Okay. But by itself, you don't believe12 the absence of any reference to the aortopulmonary13 window constitutes a breach of the standard of care by14 itself?
15 A. Right. It's hard to talk about it by16 itself. But, yeah, if he just called it normal in
17 that hypothetical, that's okay. 18 Q. Are there any other significant19 abnormalities on this film that you believe are
20 present that we have yet to talk about?
21 A. Well, just the tracheal deviation. And,
22 again, the tracheal shadow is this dark tube coming23 down the center.
24 If you rotate it to the left and the
25 trachea is located in the anterior half, it should go
17 ( Pages 62 to 65)
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to the left. So you would like to see the tracheal
shadow with a normal rotation to the left, follow the
medial clavicle of the left clavicle that way.
Instead, it's slightly to the right. So that would be
also considered a worrisome finding of an aorticdissection.
Q. You didn't make reference to it in your
report though, did you?
I believe I did.
So would it be fair to state that in your
A.
Q. report you made no reference to tracheal deviation?
A. Yeah, I did not mention it in my report. And, again, you know, I think I find that just to be
more of a -- a more subtle supportive finding, not the
critical finding.
Q. Okay. You would agree that there's -- would you agree that the tracheal location is within
normal limits given the degree of rotation?
A. You mean by itself? Q. Yeah.
A. Again, I would be worried about it in the
presence of this aortic shadow. If everything else
was normal, then I would probably not be as worriedabout it.
Q. So if you looked at the trachea first,
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the aortic knob and the clear space, make me worried
that this is also involving the descending distal tothe left subclavian artery.
Q. Would you agree that there' s no bulgingof the trachea?
A. What does " bulging" mean?
Q. To have a bulge in it.
A. I mean, that' s not generally a finding.
If you have a bulge in something, it would usuallymean a weakening of a wall.
Q. Is the right heart -- right heart border
normal?
A. Right heart border is normal, yes.
Q. There' s no apical capping? A. No apical capping.
Q. What is that in association with aortic
dissection?
A. Generally it means you have a leaking ofblood, and so the blood tracts over the superior
margin of the lung.
Q. A.
Q.
There's no pleural effusion?
Correct.
And how is pleural effusion relevant to
aortic dissection?
A. Again, it would be a more advanced or
67
1 then you would say that it looks to be relatively2 within normal limits, the tracheal shadow?
3 A. Well, no. I'd like it to be more to the
4 left. So in the presence of this abnormality5 ascending aorta, the fact that it's more to the right6 bothers me. If I didn't have any other findings and7 the only thing was that, then it wouldn't worry me as8 well.
9 Q. If an aortic dissection was present,
10 wouldn't you expect the tracheal deviation to be going11 the other direction?
12 A. No.
13 Q. And why is that? 14 A. Because the dissection started in the
15 ascending aorta and then it's moving down to the16 descending aorta and that's -- you see where the knob
17 is going to the left of the trachea; its going to18 push it to the right.
19 Q. Well, you don't know if there was a
20 dissection in the descending aorta when this film was21 taken, do you?
22 A. I definitely am worried about the23 ascending aorta, which is the critical finding. 24 That's the surgical fmding. 25 Now, the other fmdings I've mentioned,
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worrisome stage where you actually have leaking of
blood outside the aorta into the pleural cavity. Q. Would you agree that the lateral wall of
the aortic arch is distinct?
A. Of the aortic knob, yes.
Q. And the -- okay.
And would you agree that the entire
length of the descending portion of the aorta isdistinct?
A.
Q. A.
Q.
A.
Yes.
Lungs are clear?
Yes.
The cardiac silhouette, is that normal?
The heart is borderline enlarged, but
other than that...
Q. It's -- when you say " borderlineenlarged," it's within the range of normal limits of
somebody who might have -- well, within the normal
range of heart size?
A. Right. To a referring physician, that
would mean that it' s right on the margin ofbeingabnormal on a chest radiograph.
Q. But that finding, in and of itself,
wouldn't cause a radiologist to pick up a phone andcall an ER doc, right?
18 ( Pages 66 to 69)
19 ( Pages 70 to 73)
70 72
1 A. No. Cardiomegaly, you would not. 1 down.
2 Q. No calcium sign present, correct? 2 Would you agree generally with the3 A. Correct. 3 proposition that the standard of care is not a
4 Q. No depression of the left main stem 4 standard of perfection but, rather, a standard of
5 bronchus? 5 reasonable care?
6 A. That's correct. 6 A. It's not a standard ofperfection, I
7 Q. How is that finding relevant in the 7 agree.
8 setting of aortic dissection? 8 Q. And you would agree you certainly cannot9 A. Well, if you had a mediastinal hematoma 9 rule out a dissection on a chest X ray?
10 on the left side of the descending aorta, it could 10 A. That's correct.
11 push down the left main stem bronchus. 11 Q. Are aortic dissections rare in
12 Q. There' s no loss of the partracheal 12 individuals in their mid 40s?
13 stripe? 13 A. Well, I mean, it's more common in 40 to
14 A. Correct. 14 60 age range than being 20. 15 Q. How is that relevant in the setting of 15 Q. Or 40?
16 aortic dissection? 16 A. Huh?
17 A. Again, more advanced phase, leaking of 17 Q. Or in their 40s?
18 blood, sort of similar to the apical cap. 18 A. Well, it depends.
19 MR. BERRIS: Sony, Marc. 19 Q. Depends on what?
2 0 What was that finding? 2 0 A. Well, I mean, what's the person's
21 THE WITNESS: Similar to the leaking of 21 clinical history. 2 2 blood. 2 2 Q. I'm sorry. What? 2 3 MR. BERRIS: But what's it called? 2 3 A. What's the person's clinical history. 2 4 MR. GROEDEL: Paratracheal stripe. 2 4 Q. Are there in your radiology parlance2 5 THE WITNESS: It's the right paratracheal 2 5 variations or ranges in the way various structures
71 73
1 stripe, yes, which is on the right side of the 1 within the thorax can appear on a chest X ray? 2 trachea. 2 A. Can you be more specific?
3 BY MR. GROEDEL: 3 Q. No, I can't.
4 Q. Would you agree there are occasions where 4 A. Okay. Well, then, repeat it. 5 a dissected aorta may not be dilated? 5 Q. Are there variations or ranges in the way6 A. Well, that's correct. 6 various structures within the chest can appear on a
7 Q. And so in that scenario, its image may 7 chest X ray? 8 not be displaced or widened on a chest X ray? 8 A. There' s variations of structures on chest
9 A. That would result in a normal chest 9 X rays, yes.
10 X ray. 10 Q. Can you explain what you mean by that? 11 Q. Dr. Semaj noted subtle left basilar 11 And talk about it in relation to the portions of the
12 densities, which might represent atelectasis. 12 heart, for instance.
13 Do you agree with that? 13 A. Well, I mean, the heart can be smaller,
14 A. I don't have any real criticism of that. 14 the heart could be larger, you can have variations in
15 Q. Was there any evidence of consolidation 15 the amount of costal cartilage that you have on the
16 on this film? 16 ribs; one diaphragm could be a little more lobular
17 A. No. 17 than the other one.
18 Q. No masses? 18 Q. Can there be variations in the way the19 A. No lung masses, no. 19 heart chamber will appear on a chest X ray? 2 0 Q. Right. Were the osseous structures 2 0 A. Now you're talking normal variations? 21 unremarkable? 21 Q. Yes, within normal range.
2 2 A. Yes. 2 2 A. Yes, there could be a range of normals.
2 3 Q. No evidence of pneumothorax? 2 3 Q. And can you further explain what you mean
2 4 A. Correct. 2 4 by that? 2 5 Q. I'm getting tired, so I'm going to sit 2 5 A. Not really.
19 ( Pages 70 to 73)
20 ( Pages 74 to 77)
74 76
1 Q. So can there also be variations within 1 have an aortic dissection?
2 the normal range ofhow the aorta can appear, the 2 A. While ifs possible that they don't have3 descending and the ascending aorta? 3 an aortic dissection, it's definitely an abnormal4 A. Well, there's variations ofhow they can 4 chest radiograph that needed further evaluation.
5 appear as far as whether -- again, I wouldn't call 5 Q. And why is it possible that this could be6 them normal variations, but you can have a little more 6 the X ray of a person with chest pain who does not7 ectasia or tortuosity. 7 have a dissection?
8 Q. Do you see any -- 8 A. I think that overwhelmingly would be my9 A. I'm sorry. But the relationship again of 9 first choice in a differential diagnosis. But other
10 the ascending aorta to the right atrium, that's not 10 possibilities would be an aortic aneurysm. Another
11 going to vary. 11 would be a mediastinal mass or cancer.
12 Q. Do you see any evidence of aortic 12 Q. So you're saying under no circumstances13 tortuosity in this case? 13 then would you say that this is a normal chest X ray? 14 A. I wouldn't call really any degree of 14 A. That' s correct.
15 tortuosity here. 15 Q. Okay. So what rd like you to do now is16 Q. You reviewed Dr. Semaj' s deposition? 16 look at the film and pretend as though you are
17 A. Yes. 17 interpreting the film as you would as a radiologist18 Q. You know, I didn't look through it. Did 18 and read it for us and dictate your report as you
19 you make any notes on it while you were reading it? 19 would as a radiologist.
20 A. No. 20 A. Okay. 21 Q. Is there any comment you would like to 21 Q. Go ahead.
22 make about what Dr. Semaj testified to in his 22 A. I'll go this way so you can hear me23 deposition that go beyond what you've already 23 better.
24 testified to today? 24 Okay. AP frontal chest radiograph. The25 A. I don't believe so, no. 2 5 lungs are clear. The heart is borderline enlarged.
75 77
1 Q. His deposition was videotaped. 1 The patient is mildly rotated to the left. There is2 Did you see the videotape? 2 abnormal prominence of the ascending aortic shadow,
3 A. No. 3 which is located lateral to the rightheart border.
4 Q. I know we've touched upon this -- and I'm 4 This finding is worrisome for aortic5 not really sure I understood your answer and I 5 pathology, such as aortic dissection in the clinical6 apologize for being somewhat repetitive, but when you 6 history of chest pain. There' s also indistinctness of7 come to court to testify, are you going to have an 7 the superior margin of the aortic knob, comma, loss of
8 opinion to within a reasonable degree of medical 8 the aortopulmonary clear space, comma, and slight
9 probability as to, first of all, if there was a 9 rightward tracheal deviation, comma, all findings
10 dissection at the hospital; and if so, how far that 10 which may be seen with aortic dissection, period. No11 dissection extended? 11 apical cap or pleural effusion, period. No12 A. Yes. I think my opinion will be that 12 pneumothorax, period.
13 there was a dissection on this chest X ray; and I 13 Then I'd probably go, the impression, 14 definitely involve the ascending aorta, which is the 14 number one, abnormal ascending aortic shadow.
15 important part. And I'm concerned that it moved into 15 Worrisome for aortic dissection. Recommend CT
16 the descending aorta as well. 16 angiography for further evaluation. 17 Q. Well, does that mean you believe that in 17 Number two, additional findings of
18 all probability it did involve the descending aorta 18 rightward tracheal deviation, comma, indistinctness of
19 when the patient was at Lake Hospital, or you're not 19 the aortic knob, and aortopulmonary space. May be20 sure? 20 seen with extension of an aortic dissection to the
21 A. More likely than not, yes, based on the 21 descending aorta. 22 aortopulmonary clear space and the aortic knob 22 Number three, border line cardiomegaly. 23 finding. 23 And then I'd call the referring physician, time, date, 24 Q. Do you believe that this X ray could be 24 and put that at the bottom of the report.
25 the X ray of a patient with chest pain who does not 25 Q. So I was timing that and it took two
20 ( Pages 74 to 77)
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minutes and ten seconds.
Does that sound about -- does that feel
right to you?
A. That's about right.
MR. GROEDEL: Okay. Well, I think thoseare all the questions I have for the moment. Pll go
through my notes, and it's quite possible these other
lawyers might have some questions for you as well.
MS. SANTONI: No questions here.
MR. ROSSI: Gregg Rossi. I don't have
any questions for the doctor. MR. WALTERS: None here as well.
M.R. GROEDEL: Well, then let me take a
break and look at my notes then and we'll finish it
up.
There was a pause in the proceedings.)
EXAMINATION
BY MR. WALTERS:
Q. report?
A.
Q.
Doctor, did you see Dr. Zelinski' s
I believe so, yes.
Do you feel more qualified as a board
certified radiologist with regard to your
interpretation of the CT scan than Dr. Zelinski?
MR. BERRIS: Objection.
80
1 MR. BERRIS: I'll object to that only2 because --
3 BY MR. GROEDEL:
4 Q. Do you believe we have covered all of
5 your standard of care criticisms ofDr. Semaj? 6 A. I believe so.
7 Q. I take it that you saw expert reports
8 from a number of experts who looked at the same film
9 you're looking at and felt that it was within the10 range ofnormal limits, essentially disagreed with11 your opinion? You've seen those reports?
12 A. Well, I saw two from radiologists. One
13 incorrectly said it's a rightward deviation, so a lot14 of his opinions are wrong on that basis. The other15 correctly said it was leftward deviation but came to16 wrong conclusions about what that would cause. So, 17 yeah, I saw them, but I just don't agree with them.
18 Q. So you don't believe that any reasonable19 radiologist could look at this film and consider it to
20 be within normal limits?
21 A. That' s correct.
22 Q. And that would hold true with respect to
23 a non radiologist as well who frequently interprets24 chest X rays also, I would assume?
25 A. Well, I can't talk to the standard of
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BY MR. WALTERS:
Q. Of the chest X ray? Pm sorry. MR. BERRIS: Objection.
THE WITNESS: Again, Pm not sure what
his qualifications are exactly. All I can reallyspeak to is myself as a radiologist.
BY MR. WALTERS:
Q. Okay. Do you agree or disagree with his
findings regarding the chest X ray? A. I generally agree.
MR. WALTERS: Okay. That's all I have. Thank you.
MR. GROEDEL: Pm still going to go
through my notes here. MR. ROSSI: Take a short break then,
Marc?
MR. GROEDEL: It will only take me about
two minutes to go through my notes. I may be done. A recess was taken.)
FURTHER EXAMINATION
BY MR. GROEDEL:
Q. Doctor, have we covered of all of the
opinions that you intend to offer at the time of
trial?
A. I believe so. I can't think of any.
81
1 care for them, but I would -- it would be a deviation
2 for a radiologist.
3 Q. Understood.
4 MR. GROEDEL: Okay. Those are all the5 questions I have for you. Thank you.
6 MR. BERRIS: Okay. Thank you, everybody. 7 MR. WALTERS: Doctor, just a couple more.
8 FURTHER EXAMINATION
9 BY MR. WALTERS:
10 Q. Doctor, do you know Dr. Charles White,
11 professor of radiology at the University ofMaryland? 12 A. I don't know him personally; I've heard13 the name though.
14 Q. Okay. Do you know -- do you know his
15 name by way of reviewing the medical literature? 16 A. No I think he was --
17 Q. How do you know him?
18 A. I think he was involved in another case.
19 Q. Okay. Did you review his report? 20 A. I don't believe so.
21 MR. BERRIS: I don't remember him being22 in this case.
23 THE,WITNESS: I've only seen reports from24 two radiologists.
25 MR. BERRIS: There may be another one --
21 ( Pages 78 to 81)
22 ( Page 82)
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1 THE WITNESS: Chesbrough and -- what was
2 the other one?
3 MR. BERRIS: Bruno.
4 THE WITNESS: Bruno. Dr. Chesbrough and
5 Bruno.
6 BY MR. WALTERS:
7 Q. Doctor, I'm assuming you're going to8 limit your opinions in this case to Dr. Semaj' s, 9 radiologist, correct?
10 A. Yes.
11 MR. WALTERS: That's all I have. Thanks.
12 MR. BERRIS: Okay? 13 MR. GROEDEL: All right.
14 MR. BERRIS: Thank you.
15 The deposition concluded at 3: 14 p.m.) 16
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COMMONWEALTH OF VIRGINIA AT LARGE, to wit:
I, Scott D. Gregg, RPR, a Notary Public for
the Commonwealth of Virginia at Large, of
qualification in the Circuit Court of the City of
Newport News, whose commission expires July 31, 2016,
do hereby certify that the within deponent, DARYL R.
FANNEY, MD, appeared before me at Norfolk, Virginia,
as hereinbefore set forth; and after being first duly
sworn by me, was thereupon examined upon his oath by
counsel; that his examination was recorded in
stenotype by me and reduced to typescript under my
direction; and that the foregoing transcript
constitutes a true, accurate, and complete transcript.
I further certify that by consent of counsel
and the deponent, reading thereof and signature
thereto was expressly waived.
I further certify that I am not related to
nor otherwise associated with any party or counsel to
this proceeding, nor otherwise interested in the event
thereof. Given under my hand and notarial seal at
Norfolk, Virginia this day of , 2014.
Scott D. Gregg, RPR, Notary Public
Notary Registration No. 215323
83
