FISCHER, KENNETH - Vol. Iltcrisklegalforum.com/wp-content/uploads/2019/09/Deposition-of-Kenneth... · 2013/9/24 · [email protected] 5 BY: MATTHEW W. SOWELL, ESQUIRE 6 7 On

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IN THE CIRCUIT COURT OF THE FOURTH JUDICIAL CIRCUIT,

IN AND FOR DUVAL COUNTY, FLORIDA

CASE NO. 2011-CA-007017

MARGARET ROBERTS, an incapacitated

Adult, and her husband DARRELL ROBERTS,

individually and as the guardian of

Margaret Roberts,

Plaintiffs,

vs.

ST. VINCENT'S MEDICAL CENTER, INC.,

a Florida Corporation, et al.

Defendants.

_______________________________________/

DEPOSITION OF KENNETH C. FISCHER, M.D.

Volume I

Pages 1 through 209

Tuesday, September 24, 2013

9:20 a.m. to 2:25 p.m.

Offices of Kenneth C. Fischer, M.D.

1190 N.W. 95th Street, Suite 402

Miami, FL 33150

Reported by:

DENISE MARIE STEWART, RPR

Registered Professional Reporter

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1 On Behalf of the Defendants: Marks Gray, P.A.

2 1200 River Place Boulevard, Suite 800 Jacksonville, FL 32207

3 (904)398-0900 [email protected]

4 BY: JEPTHA BARBOUR, ESQUIRE5

6 On Behalf of the Defendants: Childs, Hester & Love, P.A.

7 1551 Atlantic Boulevard, 2nd Floor Jacksonville, FL 32207


9 BY: LINDA M. HESTER, ESQUIRE10

11 VIA TELEPHONE:12 On Behalf of the Defendants:

Smith, Hulsey & Busey13 225 Water Street, Suite 1800

Jacksonville, FL 3220214 (904)359-7700

[email protected] BY: WILLIAM E. KUNTZ, ESQUIRE16

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1 APPEARANCES2 On Behalf of the Plaintiffs:

Terrell Hogan Ellis Yeglewel, P.A.3 233 E. Bay Street, 8th Floor

Jacksonville, FL 322024 (904)632-2424

[email protected] BY: MATTHEW W. SOWELL, ESQUIRE6

7 On Behalf of the Plaintiffs: Terrell Hogan Ellis Yeglewel, P.A.

8 233 E. Bay Street, 8th Floor Jacksonville, FL 32202


10 BY: BRUCE ANDERSON, JR., ESQUIRE11

12 On Behalf of the Defendants: Dennis, Jackson, Martin & Fontela, P.A.

13 1591 Summit Lake Drive, Suite 200 Tallahassee, FL 32317


15 BY: TIFFANY ROHAN-WILLIAMS, ESQUIRE16

17 On Behalf of the Defendants: Smith, Hulsey & Busey

18 225 Water Street, Suite 1800 Jacksonville, FL 32202


20 BY: MICHAEL H. HARMON, ESQUIRE21

On Behalf of the Defendants:22 Saafield, Shad, Jay, Stokes, Inclan,

Stoudemire & Stone, P.A.23 50 N. Laura Street, Suite 2950

Jacksonville, FL 3220224 (904)355-3503

[email protected] BY: F. DUKE REGAN, ESQUIRE

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1 INDEX OF PROCEEDINGS2 Deposition of Kenneth C. Fischer, M.D. Page3 Direct Examination by Ms. Rohan-Williams 5

Cross-Examination by Mr. Harmon 1424 Cross-Examination by Mr. Regan 167

Cross-Examination by Mr. Barbour 1695 Cross-Examination by Ms. Hester 184

Cross-Examination by Mr. Sowell 1856 Redirect Examination by Ms. Rohan-Williams 192

Further Cross-Examination by Mr. Harmon 1947 Further Cross-Examination by Mr. Sowell 197

Further Redirect Examination by Ms. Rohan-Williams 1978 Further Cross-Examination by Mr. Barbour 198

Further Cross-Examination by Mr. Harmon 2019 Further Cross-Examination by Mr. Barbour 203

10 Certificate of Oath 206 Certificate of Reporter 207

11 Read and Sign Letter 208 Errata Sheet 209

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13 DEFENDANT'S EXHIBITS14

No. Description Page15

1 Patient Ledger Dated September 24, 2013 2316 2 Neurological Consultation Report

Re: Margaret Roberts Dated August 12, 2013 2317 3 Curriculum Vitae of Kenneth C. Fischer, M.D. 14718

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1 Deposition taken before Denise Marie Stewart,

2 Registered Professional Reporter and Notary Public in and

3 for the State of Florida at Large in the above cause.

4 *********

5 THE COURT REPORTER: Do you swear the testimony

6 you are about to give will be the truth, the whole

7 truth and nothing but the truth?

8 THE WITNESS: Yes, I do.

9 THEREUPON,

10 KENNETH C. FISCHER, M.D.,

11 having been first duly sworn, was examined and testified

12 as follows:

13 DIRECT EXAMINATION

14 BY MS. ROHAN-WILLIAMS:

15 Q. Good morning, sir. Would you state your name for

16 the record?

17 A. Good morning. My name is Dr. Kenneth Fischer.

18 Q. Okay. Dr. Fischer, my name is Tiffany Williams.

19 I represent Dr. Benjamin Moore in a lawsuit brought by

20 Margaret Roberts and her husband Darrell Roberts, and I'm

21 here to take your deposition today as you've been

22 identified by the plaintiffs as an expert witness in their

23 case in the field of neurology.

24 Is that your understanding as well?

25 A. Yes, ma'am.

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1 Q. What does certification in vascular neurology2 mean practically speaking?3 A. It's typically an academic setting. Practically4 it has no significance. People treat strokes as5 neurologists whether they're board certified in vascular6 neurology or not.7 It's people particularly in the last -- I think8 it was starting in 2006, people who were in training do an9 extra year and train in vascular neurology, and take a

10 subspecialty board that was not available nor even11 contemplated back in the '70s when I was in training.12 Q. I'm sorry. You said it came into being in what13 year?14 A. In 2006 to my understanding.15 Q. But you never considered taking that examination;16 correct?17 A. No.18 Q. Do you agree that those neurologists that have19 such certification in vascular neurology are expertise in20 the field of stroke?21 A. Sure. It does not mean to say that people who22 aren't certified aren't expertise. In other words, if you23 need to go back in training at age 60, they would not24 contemplate that. Again, that specialty was not25 available -- the subspecialty training was not available

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1 Q. Okay. I'm aware you've been deposed before, so I2 won't belabor any rules that go with the situation. But3 if you don't understand my question, could I get you to4 please let me know that and I'll be glad to rephrase it?5 A. I'll do that, ma'am.6 Q. Okay. And if you answer my question, is it fair7 for me to assume that you understood it?8 A. That is fair.9 Q. Okay. Are you a board certified neurologist?

10 A. Yes.11 Q. Okay. And beginning at what point in time did12 you become so certified?13 A. April 1978.14 Q. Okay. And did you pass your test the first time15 around?16 A. I did.17 Q. Was that both the oral and the written?18 A. Correct.19 Q. Are you boarded in psychiatry?20 A. No.21 Q. Do you have sub-certification in vascular22 neurology?23 A. No.24 Q. Okay. Have you ever tried to attain that?25 A. No.

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1 back in the '70s when I was in my residency.2 Q. And when you say you would have to do further3 training at the age of 60 years old, is that something4 that you decided not to pursue?5 A. Certainly. I'm in practice for about 38 years.6 Back then it was 32 years. There's no way -- I'm not7 going to stop my practice and go back into the residency8 program.9 Q. Yes, sir.

10 That would take quite a bit of time, would it11 not?12 A. Sure.13 Q. Are you a member of the American Academy of14 Neurology?15 A. No.16 Q. Okay. Did you used to be?17 A. Yes.18 Q. Okay. For what for period of time?19 A. 1973 through 2007.20 Q. Okay. And did you resign from it?21 A. I did.22 Q. For what reason?23 A. They put in a mandatory dues for a political24 action committee. I was philosophically opposed to that.25 Q. What committee was that, sir?

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1 A. It was a political action committee.2 Q. Oh. Okay. And what was the nature of the3 committee?4 A. Things they felt -- endeavors they felt were5 important when it was, quote, stamping out malpractice.6 Q. Okay. Is that the only reason that you resigned7 from the academy?8 A. Correct.9 Q. What is the American Academy of Neurology?

10 A. It's a guild. In other words, it's not a11 certification authority. People in neurology who want to12 belong to it for educational and collegial purposes. It13 has some good educational aspects to it, actually. They14 do some nice training programs, and courses, and15 publications, including the Journal of Neurology and16 including Continuum which are excellent journals.17 Q. Can that academy discipline its members if18 appropriate?19 A. It can.20 Q. Okay. For example, if one neurologist complained21 or had filed a grievance against another neurologist in22 that academy, it could be investigated, and potentially23 the neurologist who had the complaints against him could24 be sanctioned or disciplined?25 A. That could happen.

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1 at other facilities in this area as well?2 A. Yes.3 Q. Okay. What other hospitals that you can recall?4 A. Oh, gee. When I was with a group we had like 115 hospitals. So those -- a hospital called North Miami6 General which is now closed. A hospital called -- it was7 called Parkway then, now it's called Jackson North.8 Q. Okay.9 A. Palmetto General, South Miami Hospital, Baptist

10 Hospital, Dorking Hospital. I'm trying to think of11 anything else. Oh, Aventura Hospital.12 Q. All right. And this North Shore Hospital is on13 the campus where your office is; correct?14 A. It is.15 Q. And how long, if you know, has North Shore16 Hospital been?17 A. It started in 1953.18 Q. And, sir, do you take call as a neurologist at19 any hospitals?20 A. Not in the last number of years, no.21 Q. Okay. Well, approximately how many?22 A. Let's see. I got grandfathered out at this23 hospital -- then it was called Cedars, now University of24 Miami hospital -- probably around 10 years ago.25 Q. Okay. So you have not taken calls in neurology

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1 Q. Okay. But the American Academy of Neurology has2 no such authority over a nonmember neurologist; is that3 right?4 A. That's correct.5 Q. The address that we are here at today is what,6 sir?7 A. I'm sorry?8 Q. The address we are here at today?9 A. 1190 Northwest 95th Street, Suite 402, Miami,

10 Florida 33150.11 Q. And that is your practice; correct?12 A. Yes.13 Q. And that's a solo practice?14 A. It is.15 Q. And how long have you been practicing in Miami?16 A. Since -- well, my residency started in 1971. I17 have been in practice since 1975 when I was on the18 faculty. So I've been in actual practice 38 years and19 I've been in Miami as a physician for 42.20 Q. And at which hospitals do you currently have21 privileges at?22 A. North Shore Medical Center, University of Miami23 Hospital, Jackson Memorial Hospital, and St. Catherine's24 Rehabilitation Hospital.25 Q. Okay. And over the years have you had privileges

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1 for about 10 years?2 A. When you say "taking call," I take calls every3 night.4 Q. Okay.5 A. However, I don't have obligatory emergency room6 call. I see patients every day in the emergency room.7 I'm not obliged to. I can pick and choose who I see or8 don't see.9 Q. Okay. Is that because they're your patients?

10 A. No. I don't want to -- certain doctors I don't11 want to deal with, certain insurances I don't accept.12 Q. I see.13 A. If I have call, I have to take -- I take all14 comers. I don't want to do that.15 Q. I see.16 A. So I just -- I take -- I see patients in the17 emergency room from select doctors and select insurances.18 I'm not obliged to take people I don't -- I don't want to19 deal with.20 Q. Okay. So how was it that it would come to your21 attention that a patient in the E.R. would like to have22 your services?23 A. Typically what happens is a patient comes into24 the emergency with a neurological problem. Uniformly25 they're admitted to an internal medicine person and a

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1 hospitalist.2 Q. Okay.3 A. And there's a large cadre of doctors who utilize4 my services, and have done so for many years, and they'll5 call me even though I'm not on the call list.6 Q. Okay. So you are actually specifically contacted7 by another physician in order to go perform a consult on a8 patient; is that right?9 A. That is correct, ma'am.

10 Q. Okay. And that's really the only manner in which11 you see on-call patients?12 A. The only other manner is -- I've been in this13 community a long time and well-known in the community, and14 family members who I've seen as patients have someone come15 in the hospital with a neurological problem and will16 insist I see the patient as opposed to someone else.17 Q. Okay. All right. Sir, when were you first18 retained in this case?19 A. I guess about -- I can't give you the exact time.20 I'd say probably about a year and a half ago.21 Q. And by whom were you retained?22 A. Attorney Matthew Sowell.23 Q. And had you worked with Mr. Sowell before?24 A. Yes.25 Q. Okay. How many other occasions?

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1 A. Initially, that's correct.2 Q. Okay. All right. And you kindly brought a box3 of materials here today, and I was able to go through them4 before the start of your deposition. And just for5 purposes of the record, and the other attorneys in the6 room, I'll go ahead and enumerate everything that I7 counted. And if you think of something else that you8 received, that isn't here, if you'd let me know that at9 the end, I would appreciate that.

10 A. That's fine.11 Q. Okay. So you brought your CV. And --12 A. Oh, I'm sorry.13 Q. Yes, sir.14 A. I don't mean to interrupt you.15 Q. No problem.16 A. I did receive simultaneously the records -- the17 films of that hospitalization.18 Q. Okay.19 A. The disks over there that incorporate that.20 Q. Okay. Terrific. Thank you for that.21 I also note you brought two volumes of22 St. Vincent's Medical Center records for the 8/23/201023 admission. You have records from Mayo Clinic, records24 from Baptist Medical Center Downtown.25 As far as this particular radiology studies, I

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1 A. I can think of two other occasions.2 Q. All right. Did Mr. Sowell telephone you?3 A. Yes.4 Q. Okay. And what did he say as best you can5 recall?6 A. He was very brief. He had a stroke case he'd7 like me to review. Could he send the records. I said,8 "Sure."9 We didn't discuss the particulars of the case.

10 It was just -- something was neurological, something in11 strokes. So I was -- accepted to reviewing it.12 Q. Okay. And at that time what materials were sent13 to you?14 A. Well, afterwards -- our conversation -- I15 received Ms. Roberts' records. I think the initial16 submission. Let's see.17 Q. Sure. Sure.18 A. You had it all moved around. In these manila19 folders. All these manila folders. It was basically --20 basically the records at the hospital, the admission of21 8/23/10 --22 Q. Okay.23 A. -- to St. Vincent's.24 Q. And at that time, initially, is that really all25 you recall receiving?

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1 note you have CT of the head from St. Vincent's Medical2 Center which would be 8/23, 8/24, 8/25, 8/28, 8/31/2010.3 And then you have Baptist CT head studies from4 9/21/09 and 1/20/11. And then from Mayo Clinic CT head5 studies from 12/23/10, 1/4/11 and 10/15/11.6 Also, you have deposition transcripts from7 Drs. Pavlat, Moore, Szwed, S-z-w-e-d, and Pilcher.8 And in addition, you provided your chart on9 Ms. Roberts as I understand you performed a consultation

10 on her; correct?11 A. Yes.12 Q. Okay. As far as deposition transcripts, did you13 receive any of the plaintiffs'?14 A. Yeah, I think it's down here. It's in here15 somewhere. Mr. Roberts.16 Q. Mr. Roberts' deposition also?17 A. Yes.18 Q. Okay. What about Mrs. Roberts?19 A. I don't recall that.20 Q. Okay. Have you seen any picture, photograph, or21 DVD of Mrs. Roberts?22 A. No.23 Q. Are you aware of the identity of other -- of24 plaintiffs' experts in this case?25 A. No, I'm not.

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1 Q. Have you --2 A. Wait. I do. Also, I -- Dr. Pressman. I3 reviewed his deposition. I know he's an expert for the4 plaintiff.5 Q. Okay. All right. Great.6 And have you been provided any medical literature7 from Mr. Sowell?8 A. No, I have not.9 Q. Have you performed any medical literature in

10 coming to your opinions in this case?11 A. "Performed"? How do you mean by "performed"?12 Q. Gone online, Google or PubMed.13 A. I mean, I'm familiar with some medical literature14 which is pertinent in the case, but I have not done any15 research with respect to this case specifically.16 Q. Okay. All right. Let me ask you about your17 consult. Unfortunately, I didn't really get to read all18 of it yet, but how did it come about that you performed a19 neurological consult on Mrs. Roberts?20 A. I discussed with Mr. Sowell that I might be --21 use it for damages in the terms of patient. I suggested22 the best way for me to assess her damages would be to23 examine her physically.24 Q. Okay.25 A. So he agreed and Ms. Roberts came.

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1 Q. For how long has that been the case?2 A. Well, prior to her hospitalization in 2010, for3 some years.4 Q. Okay. Were you provided Dr. Sackett's deposition5 transcript?6 A. No, I have not been.7 Q. All right. Do you know -- well -- strike that.8 Are all the entirety of the records that you have9 received in this case on this table?

10 A. Yes, they are.11 Q. Okay. So would you agree with me, then, any12 records that you have of Dr. Sackett are probably very13 small?14 A. It's not substantial, I agree with you.15 Q. Okay. All right. Do you know at what point in16 time the records from Dr. Sackett, that you have received,17 cover?18 A. I think in the short period of time prior to the19 hospitalization of 2010.20 Q. Okay. Do you think that would be more than one21 or two visits to Dr. Sackett?22 A. I don't recall, madam.23 Q. Okay. Is it possible for you to locate the24 envelope --25 A. It may be. I'm sorry to interrupt you.

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1 Q. Okay. Was that your suggestion to Mr. Sowell,2 then, that you might be able to assist him with damages?3 A. Yes.4 Q. Okay.5 A. Well, I mean, he discussed with me damages, and I6 reviewed some records dated back to 2011 at the Mayo7 Clinic, Dr. E-i-e-d-e-l-m-a-n [sic], I guess, Eidelman or8 Eidelman.9 Q. Okay.

10 A. But that was 2011. So I didn't have any ideally11 up-to-date situation with her. He said she hadn't been12 seen neurologically since then. So then we came to the13 conclusion it might be worthwhile for her to come from14 Jacksonville to see me.15 Q. Have you been in contact with Dr. Paul Deutsche16 in this case?17 A. I have not.18 Q. Do you know he is?19 A. He is a rehabilitation specialist.20 Q. Okay. Have you been provided any medical records21 of Dr. Ellen Sackett?22 A. Yes. I think it's in there somewhere. The23 answer is yes.24 Q. Okay. Who is Dr. Ellen Sackett?25 A. She is the primary physician for Ms. Roberts.

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1 Q. Sure.

2 A. It may be that the records I have are after the

3 hospitalization.

4 Q. Right.

5 A. I don't remember very much of Dr. Sackett prior

6 to -- in fact, I don't remember too much interceding at

7 all to these hospitalizations.

8 Q. Okay.

9 THE WITNESS: I'm sorry?

10 MS. HESTER: I'm fine.

11 Q. (BY MS. ROHAN-WILLIAMS) So probably then, if I'm

12 understanding you correctly, the records that you have

13 from Dr. Sackett are after stroke?

14 A. I believe that's the case.

15 Q. Okay. Did you ask, for the purpose of assessing

16 damages in this case, for the records of Dr. Sackett that

17 preceded the stroke?

18 A. I did not.

19 Q. Do you think those might be helpful to your

20 valuation as far as damages and -- as far as damages are

21 concerned?

22 A. No.

23 Q. Okay. All right. All the materials, sir, that

24 you received, did you review them all?

25 A. Of course.

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1 Q. Okay. Did you prepare any type of written

2 report?

3 A. Yes, that you have.

4 Q. Okay. Yes, sir.

5 Apart from the three-page typed record dated

6 8/12/13, did you prepare any other type of written report

7 in this matter?

8 A. This is so-called verified written medical expert

9 opinion, which I participated in its production.

10 Q. Okay. And what would the date of that have been,

11 sir?

12 MR. SOWELL: It's the pre-suit.

13 Q. (BY MS. ROHAN-WILLIAMS) And that would be it;

14 correct?

15 A. Yes.

16 Q. All right. Terrific.

17 A. You want the date of that? That's 2-16-11.

18 Q. Thank you.

19 A. So I have to amend the previous answer. It's

20 about two years -- two and a half years.

21 Q. Sure. I appreciate that.

22 All right. In the records, the paper and

23 materials that we have on the table, have you marked or

24 made notes in them?

25 A. There are stickies and underlining in some of the

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1 A. I asked my assistant to prepare -- let me see if

2 they --

3 Q. Sure.

4 (Interruption.)

5 A. Looks about, prior to today, about 18 hours.

6 MS. ROHAN-WILLIAMS: Okay. All right. And I'm

7 going to go ahead and mark that billing information as

8 Exhibit 1.

9 (The document referred to was marked for

10 identification as Defendant's Exhibit 1.)

11 Okay. And then I will mark Dr. Fischer's

12 three-page type written consult as Exhibit 2.



15 Q. (MS. ROHAN-WILLIAMS) And what is your rate for

16 review of records, sir?

17 A. $500 an hour.

18 Q. Is that the same rate for telephone conferences

19 and in-person meetings?

20 A. No.

21 Q. What's the rate for a telephone conference?

22 A. $800 an hour.

23 Q. Okay. And what about for an in-person meeting?

24 A. Same, $800 an hour.

25 Q. And what about for deposition?

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1 medical records.2 Q. Okay. What's the purpose of the stickies?3 A. Well, obviously, it's a voluminous amount of4 material here. When I review a case over two and a half5 years there isn't not much activity, to go back and read6 everything again in preparation for deposition is not7 conducive. For example, this packet right here has the8 crux of what happened and a few other things marked. It's9 easier for me to go back over the last several days to

10 prepare for discussion as opposed to reading the whole sum11 of things again.12 Q. Sure. And so these manila envelopes that we have13 here on the table are something that you prepared from14 documents received from Mr. Sowell?15 A. See you -- my staff -- I got a pile that comes16 in.17 Q. Yes, sir.18 A. It's not conducive to keep them like that. So19 one of any assistants puts it in the envelope -- just fits20 a certain amount per envelope.21 Q. Okay. All right. And approximately how much22 time have you spent reviewing matters from Mr. Sowell23 and/or speaking to him and/or meeting with him?24 A. In this particular matter?25 Q. Yes, sir.

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1 A. $800 an hour.2 Q. Okay. And for a deposition you require3 prepayment; correct?4 A. Correct.5 Q. Okay. How many days in advance of the actual6 deposition?7 A. I think it's three business days or something8 like that. I have to ask my assistance what we do. We've9 written policy. I've forgotten what it is actually.

10 Q. Okay.11 A. It could be five business days. I think that's12 correct.13 Q. All right. And do you require payment in order14 to hold the day for your deposition?15 A. In other words -- yes. In other words, if five16 business days comes and it has not been paid for or17 canceled, I put somebody else in. I'm very busy with18 patients. I don't want to have slack time.19 Q. Okay. In the event that you were to come to20 trial, which is in Jacksonville, Florida in February of21 next year, what rate would you charge for that?22 A. $5,000 for the visit, plus airfare and lodging if23 I stay overnight. I've tried to come in the morning and24 come out in the evening. So probably it would be no25 lodging, but one never knows.

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1 Q. If lodging were required, i.e., you would have to2 spend the night, would you then be charging $5,000 times3 two for two days?4 A. No. No. It's just $5,000 for the visit.5 Q. For the trial appearance?6 A. Regardless, I'm not going to charge -- unless I7 stay the second day to testify, it would be $5,000 even8 though it's a little more than 24 hours.9 Q. Okay. And prior to the trial appearance, would

10 you need to be paid beforehand?11 A. Yes.12 Q. How far in advance?13 A. A week ahead of time.14 Q. Have you been asked to come to this trial?15 A. Yes.16 Q. Okay. Are you planning to do so?17 A. Yes, I am.18 Q. Have you testified in Jacksonville or Duval19 County before?20 A. Yes, many times. I would not say "many." I21 mean, half a dozen times.22 Q. Okay. All right. Can you tell me, please, a23 little bit about your personal practice, what you do in24 your business, what's encompassed by your practice?25 A. Sure. I'm an adult clinical neurologist. I

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1 Q. How many bed facility is North Shore Medical2 Center?3 A. 305.4 Q. Do you know how large the ICU is?5 A. Yes.6 Q. How many?7 A. Well, it's a moving target because we have two8 fixed ICUs with a component of 22 beds. However, we have9 several areas of ICU which open and close depending on

10 need. That could be an additional 20 beds, and typically11 they're open. So I'd say it's about 42 beds of ICU we12 have.13 Q. Okay. And how frequently are you actually in the14 hospital seeing patients? How many days of the week?15 A. Every day, 7 days a weak. I can't think of a16 day, other than when I am on vacation, that I have not17 been in the hospital for seeing patients in many, many18 years.19 Q. Okay. And how frequently do you see patients,20 days out of the week, in your office?21 A. Every day. I should not say that. Monday22 through Friday.23 Q. Okay. Are there certain hours in your office24 that you see patients?25 A. Sure.

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1 don't see pediatric cases. I don't take a child typically2 below 12 years of age, occasionally 10, but not below3 that. Because of the area where I practice and the4 demographics of the area, my practice is a substantial5 component of stroke.6 Half the patients I see in the hospital are7 stroke victims. About 25 percent of them are in the8 office. What I do see is the entire gamut of neurological9 issues; epilepsy, migraine, multiple sclerosis, back and

10 neck problems. But again, stroke, because of the11 community -- it's an Afro-American, Haitian American,12 older community -- stroke is a tremendous issue in this13 area. It's one of the largest percentages of patients14 with stroke in the country, this ZIP code.15 I'm Director of the North Shore Medical Center16 Stroke Center. It's an accredited Primary Stroke Center.17 We've been that since about 2008 and I'm the director of18 that. So I spend a lot of time dealing with the19 administration of that and the stroke program here, as20 well as my own practice.21 Q. All right. You said the North Shore Medical22 Center is a Primary Stroke Center?23 A. Yes, we are.24 Q. Okay. And that's been so since 2008?25 A. Correct.

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1 Q. When?2 A. 9:00 to 5:00.3 Q. 9:00 to 5:00, Monday through Friday?4 A. Yes.5 Q. So typically when you're at the hospital each6 day, when is that? What time of day?7 A. 7:00 to 9:00.8 Q. 7:00 to 9:00 a.m.?9 A. Yeah.

10 Q. Okay.11 A. What I do is I look at how many patients I have.12 I get up early enough each day to see all of my patients13 prior to office. I like to see everybody before I start14 office hours. It could be 6:30 in hospital. It could be15 seven o'clock. Rarely later than seven o'clock.16 I see them again at lunch hour. We close from17 12:00 to 12:30. But I eat lunch in about two minutes, so18 if there's a consult that comes in in the morning, I'll19 see them at 12:02. And after five o'clock I'll see20 patients, or whoever comes in during the afternoon I'll21 see before I leave for the hospital.22 Q. So after you see patients in the office, do you23 go back to the hospital?24 A. Yes.25 Q. Okay. And is there any way of telling me an

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1 average number of patients you have in the hospital on a2 daily basis?3 A. Sure. Sure.4 Q. What is that? What would you suspect that --5 A. The average is -- my sense is it's typically6 between five and seven in the hospital.7 Q. Okay. Okay. If I'm understanding your prior8 testimony, are half of those patients stroke patients --9 A. That's correct.

10 Q. -- typically?11 A. That's right.12 Q. Okay. And then what type of medical care or13 treatment are you rendering to those stroke patients that14 are inpatient?15 A. Well, first of all, the whole thrust of our16 service is to see if they are candidates for thrombolysis.17 Q. Okay.18 A. So when they come in on an expedited process, a19 stroke alert is called. And the protocol is that a20 neurologist has to contacted in 15 minutes. The patient21 is evaluated for potential tPA administration. And22 fortunately, two or three percent are given tPA, but then23 still the stroke protocol is invoked.24 Even if they are not tPA patients that are25 certain -- vital signs need to be done and certain

31

1 requirements that the patient be evaluated by a2 neurologist in 15 minutes, we employ teleneurology. We3 have a service based out of Boston. I think it's called4 telemedicine. I can't remember the name of the company.5 But they, by contract, will have within 15 minutes a board6 certified, Florida licensed, hospital accredited7 neurologist on a -- we have a big screen TV. We wheel it8 up to the bedside and that doctor will evaluate the9 patient, with the emergency room physician, within

10 15 minutes of the patient's arrival.11 Sometimes since I'm so -- I'm contiguous to the12 hospital, if they call me, I'll waive off that fellow or13 lady and do it myself. But in the middle of the night14 it's conducive to have that facility. So that in 1515 minutes, somebody can be seen and the process is started16 to enable us to fulfill the requirement and give the17 patient the proper care.18 Q. And those four other neurologists, do they take19 calls at night?20 A. I'm the only one that doesn't take calls.21 Q. Okay.22 A. But I get called in in the manner I said. If the23 doctor has a preference for me, they will call me.24 Q. Okay.25 A. This way I can see those patients I want to see

30

1 monitoring needs to be done in the stroke units which is a2 set aside place in the hospital. We have special nurses3 who are trained in stroke management. They are given -- a4 certain protocol that must be fulfilled immediately with a5 provision of antiplatelet drugs of statins, liquid6 profile, initiation of physical therapy, occupational7 therapy and speech therapy and the like.8 So we really try very hard to get maximum9 benefits accrued to the stroke patients. We have really

10 very good what's called door-to-needle time. In other11 words when we give tPA, the national standard is the12 patient -- from the time he hits the door, if they're13 candidates, get the tPA started in 45 minutes. We average14 36 minutes which is very, very good for a community15 hospital. We're superior to almost everybody in the area16 in that regard.17 Q. Okay. You said you're the director of that18 stroke program; right?19 A. Yes. That's correct.20 Q. And how many neurologists work at North Shore as21 it regards to the stroke unit and tending to stroke22 patients?23 A. There are two layers. First, we have I would say24 1, 2, 3 -- 4 other neurologists who regularly attend the25 hospital. But to satisfy the state and joint community

32

1 and certain doctors I don't want to deal with, I don't2 have to deal with.3 Q. And if the doctor that you like to deal with4 calls you at 1:00 a.m. regarding a patient he has concerns5 about, do you get up and come in the middle of the night?6 A. Oh, absolutely.7 Q. All right. If a patient arrives at the E.R. here8 at North Shore and they're suspicion of stroke, do they go9 right to the stroke unit?

10 A. No. What happens is a stroke alert is called.11 Q. Okay.12 A. Immediately the E.R. physician will see the13 patient at that moment and we get the CAT scan done within14 the next five minutes. And as the patient is being15 wheeled to the CAT scan, he or she will get the blood work16 done. So at the end of 15 minutes, the CAT scan will be17 done, the blood work will be done, and the emergency room18 doctor will assess, and the neurologist is called.19 Q. Okay.20 A. And that by that time the teleneurology person is21 on the scene and the CT is transmitted to him or her to22 review. So that doctor will have the CT, the blood work23 and the patient in front of him.24 Now simultaneously they'll call an indigenous25 neurologist -- a house neurologist.

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1 Q. Okay.2 A. Who may or may not be there before the3 teleneurologist. If it's me, typically I am. I'm right4 here.5 Q. Okay.6 A. See, other people are not on-site. So they come7 in in a half hour or so. So usually the teleneurologist8 will do the initial evaluation.9 Q. Is that true, then, a neurologist is not

10 physically in the unit at all times?11 A. That's correct. He or she may or may not be.12 Q. Correct.13 A. It depends whether it's a teleneurologist or a14 local person. It could be another local person is right15 around the hospital at ten o'clock in the morning --16 Q. Right?17 A. -- and they'll walk over and see the patient, but18 that's random. At three o'clock in the morning typically19 no one's going to be here, and the teleneurologist will be20 the first person to see the patient.21 Q. All right. And you said within that first few22 minutes of the stroke alert being called a CT scan is23 done; correct?24 A. That's correct.25 Q. And what's the purpose for that?

35

1 high, if your glucose is over 500 and lower than 50.2 Those things are exclusionary criteria. You can eliminate3 most of them with certain routine blood test. Also, if a4 person has a very high -- low platelet count or has a very5 high INR, those things would make the patient a high risk6 for bleeding and we don't want to use tPA.7 Q. Okay. And so have you been treating patients8 with acute ischemic strokes for 42 years then?9 A. Yes.

10 Q. And how often is it that you, here at the11 hospital North Shore -- that's your primary hospital;12 correct?13 A. It is.14 Q. Okay. And the other ones that you told me15 about --16 A. University of Miami Hospital --17 Q. Thank you.18 A. -- Jackson Memorial Hospital and St. Catherine's19 Rehabilitation.20 Q. Yes, sir.21 Okay. How frequently are you at University of22 Miami Hospital?23 A. Rarely. I mean, it used to be my primary24 hospital 20 years ago, but I moved my office here. It's25 more conducive to be here. I'm still on the staff there

34

1 A. Well, if a patient has a stroke, it could be2 hemorrhagic or it could be ischemic. If it's hemorrhagic,3 immediately tPA is not a consideration, a neurosurgeon4 needs to called, and a different protocol is invoked.5 Even if it's not hemorrhagic, there's certain6 kinds of strokes -- it could be a brain tumor, it could be7 a malformation, it could be some kind of cyst. Those8 structural lesions preclude the provision of9 thrombolytics.

10 Q. Okay.11 A. Also very large strokes. In other words, if you12 do a CT and it's ischemic, and that encompasses more than13 one-third of the hemisphere, that is an exclusionary14 factor for tPA administration. Also something called the15 middle cerebral artery sign. You could see a lighting up16 in a plain CT scan that indicates a pour prognosis with17 tPA administration and they won't give it.18 So there's a whole bunch of reasons why you do a19 CT immediately. It allows you to determine whether the20 patient continues to be a candidate for thrombolysis or21 not.22 Q. Okay. And what's the purpose of doing the blood23 work right away?24 A. Certain factors would inhibit use of tPA; renal25 failure, hepatic failure, if your sodium is too or too

36

1 and I go there maybe once a month. Not that often.2 Q. And then when you go there once a month, you're

3 actually seeing patients?

4 A. Yes.5 Q. Okay. And what about Jackson Memorial, how often

6 are you there?

7 A. It's almost exclusively teaching purposes. I'm8 on the teaching faculty at the University of Miami and my9 role is to go to Jackson the months of April, August and

10 December.11 Q. Okay.

12 A. During every Wednesday of those months I'll be at13 Jackson Memorial Hospital.14 Q. And predominantly your patient base by and far is

15 here at North Shore?

16 A. That is correct.17 Q. Okay. All right. And how often is it that you

18 are actually the physician diagnosing stroke on these

19 stroke patients at North Shore?

20 A. Well, I come -- I see patients every day just21 about. We try to make it diffuse, so maybe I'll see22 maybe -- I'll personally see maybe a quarter or a fifth of23 the stroke patients. I'll review every single stroke24 patient.25 In other words, one of my missions is whether I

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1 see a patient or not, I review every stroke admission and2 determine if the -- are we meeting the criteria. Did the3 neurologist come on time? Did the teleneurologist come on4 time? Was the proper criteria exercised for tPA or not?5 Was the nursing appropriate? Did the emergency room6 person do the right thing? Was the CAT scan done within7 15 minutes? Was the blood work done in 15 minutes? Was8 the door-to-needle time less than 45 minutes?9 I'll review each case to determine that. If we

10 have a fallout, then we'll assess why that was and counsel11 the individual or individuals responsible.12 Q. And why is it that you have that role or duty, if13 you will, to review all the stroke cases?14 A. That's my job as stroke director.15 Q. Okay. Of the stroke patients that are seen, and16 treated at North Shore, what percentage of those have17 ischemic strokes as opposed to hemorrhagic strokes?18 A. 85 percent.19 Q. All right. And how do you go about making the20 diagnosis of ischemic stroke?21 A. Initially a brain -- a plain brain CT scan is the22 standard. Typically it's followed up by other testing23 including MRI, MRA, CTA, and sometimes angiography.24 Q. Okay. And what is it about the plain brain CT25 that helps you make the diagnosis of ischemic stroke?

39

1 of Radiology has. There's a board in diagnostic radiology2 and a special qualification in neuroradiology. He has the3 latter.4 Q. Okay.5 A. In addition to being board certified in6 diagnostic radiology, he has a special qualification in7 neuroradiology.8 Q. Okay. So do you have more than one of those here9 at North Shore or just one?

10 A. He's the only gentleman. When he's on vacation11 there's a firm which supplies radiologist to the hospital.12 When he's on vacation, they supply somebody else.13 Q. Okay. And does -- the North Shore radiologist14 ultimately render the report; correct?15 A. Yes.16 Q. And do you rely upon the radiologist's report in17 treating your patients?18 A. What happens is this, in a pinch I'm there. I19 look at the scan. In other words, I don't need to ask the20 radiologist on a plain brain CT scan is there a21 hemorrhage. That's something I know.22 Q. Right?23 A. So in retrospect I'll go over and look with him24 on it, make sure there isn't anything strange on it. But25 at three o'clock in the morning I'm not going to wait for

38

1 A. Well, it's excluding -- you don't see a stroke2 most times. But if you see a hemorrhage, it's not3 ischemic stroke. If you see a malformation, it's not4 ischemic stroke. If you see a tumor, it's not ischemic5 stroke.6 So it doesn't necessarily rule it a stroke. It7 rules out those factors which will preclude you from using8 thrombolysis based on the clinical presentation.9 Q. Okay. And with regard to Ms. Roberts is tPA an

10 issue at all for you?

11 A. Not at all.12 Q. Okay.

13 A. Excluded by her specific presentation.14 Q. All right. Okay. And do you read your own CT

15 studies?

16 A. Yes.17 Q. Okay.

18 A. Of course, we have a board qualified19 neuroradiologist here, but I see them on my own and I walk20 down the hall to look at them with him as well.21 Q. When you say "board qualified," do you mean board

22 certified, or no?

23 A. It's not a certification.24 Q. Okay.

25 A. It's a special qualification the American Board

40

1 the radiologist. The radiologist will read the study. If2 he's not here, it gets done remotely by somebody. But I3 don't need to wait for that interpretation to do what I4 need to do.5 Q. Okay. And on occasion you go down and talk to6 the radiologist about the stroke patients?7 A. Oh, sure.8 Q. Bounce ideas off one another?9 A. I respect his ability substantially. So maybe

10 some subtle things, particularly on the CTA or the MRA,11 which I'm not as cognizant as he is. So I want to look at12 some subtleties and say, "What percentage of stenosis is13 there? Do you see a little malformation here or not?"14 So I'll utilize his expertise in that regard.15 Q. Okay. And you might even ask him if he has16 thoughts on whether additional imaging studies might be17 helpful; correct?18 A. Sure.19 Q. Okay. And is that true because you're working20 together as a team in the patient's best interest?21 A. That's exactly right.22 Q. Okay. Once -- tell me if you have a patient that23 comes in, stroke is being considered, CT scan is done,24 blood studies are done, there's no obvious hemorrhage on25 the CT. Tell me about the further workup of that patient.

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1 A. MRI, either MRA or CTA. That's for the2 vasculature. We prefer at this hospital using CTA,3 because we get better images of the arteries than with an4 MRI. Angiography is rarely used. We use if we think5 there's an aneurism, or perhaps there's a vasculitis, or6 perhaps a dissection. Those are the primary imaging7 techniques.8 Then, of course, blood studies. We look to see9 if there's some coagulopathy or connective tissue process,

10 particularly in a younger individual which might be11 causing them to stroke prematurely.12 Q. All right.13 A. And cardioembolic. In other words, you look to14 see if there's a large vessel involvement. Again, the MRA15 or CTA will take care of that. We use simultaneously16 carotid ultrasound and Transcranial Doppler Analysis, the17 echocardiography, and perhaps even a transesophageal18 echocardiogram.19 Q. All right?20 A. I'm sorry. And also --21 Q. That's okay.22 A. -- one of the large causes of -- frequent causes23 in this population here, and nationally as well, is atrial24 fibrillation, another rhythm disorder. So the patient25 would be on telemetric monitoring to look for such a

43

1 Q. Okay. But if there is documentation that the2 patient has DVT, heparin would be utilized?3 A. Yes, that's correct.4 Q. And why is that?5 A. It's thought to be more effective.6 Q. At what?7 A. At combatting deep vein thrombosis and pulmonary8 embolization.9 Q. All right. And is heparin a proper medication to

10 use if the patient's documented as having not only DVT but11 also PE?12 A. Yes, of course.13 Q. And you said that heparin is utilized because14 it's believed to be more efficient at combatting DVT and15 PE. Did I get that right?16 A. Yes, sir.17 Q. Okay. And what do you mean, sir, by combatting?18 A. If you have documentation of those conditions --19 Q. Okay.20 A. -- it appears that's more affective than Lovenox21 would be.22 Q. Okay.23 A. This is a little beyond my scope as a24 neurologist, but that's my understanding as far as the25 reasons why and the studies there are. I could not cite

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1 process.2 Q. All right. So is the patient admitted then to3 either the telemetry unit or the ICU?4 A. Yes.5 Q. Okay. Are any medications started if you know6 there is no hemorrhagic stroke, but you're considering7 ischemic stroke?8 A. Yes.9 Q. Okay. Well, what medications?

10 A. Immediately an antiplatelet medication is11 administered. That would be either aspirin, Plavix, or12 Aggrenox. If there is no contraindication, a statin would13 be administered.14 Q. Okay.15 A. And the patient would be placed on deep vein16 prophylaxis and is typically started on Lovenox or one of17 those other agents. Unless there is some reason not to18 use that.19 Q. Okay. Do you ever use heparin?20 A. Yes, I use heparin. I think typically just for a21 spate of DVT prophylaxis we use Lovenox, unless the22 patient has documentation of pulmonary emboli, or23 something like that, or documentation of deep vein24 thrombosis. But typically in a prophylactic manner, use25 Lovenox.

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1 them for you.2 Q. Sure. Sure. And maybe that was a poor question.3 I understand what you're saying.4 What is it about the heparin that combats the DVT5 and the PE?6 A. Well, heparin prevents the formation of7 additional clots. So if you have a clotting problem and8 you have the documentation of a DVT, you're concerned that9 DVT will extend itself and further block additional veins

10 and further -- progress and go into the pulmonary11 circulation and so forth. Heparin is effective in12 preventing that.13 Q. So it prevents formation of additional clots?14 A. Yes.15 Unlike tPA, it does not lyse clots.16 Q. Okay. The body has its own way, given time, of17 lysing clots; does it not?18 A. Yes.19 Q. Okay. What is that process called?20 A. Thrombolysis. I guess internal thrombolysis as21 opposed to chemical thrombolysis.22 Q. Okay. All right. Apart from the North Shore23 facility, have you ever been a director of a stroke24 program at any other facility?25 A. No.

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1 Q. Okay. All right. Moving on to Mrs. Roberts.

2 A. Sure.3 Q. Finally got there.

4 A. Okay.5 Q. Is it your understanding that on the morning of

6 August 23rd Ms. Roberts was taken to the ER at

7 St. Vincent's Medical Center?

8 A. Yes.9 Q. Do you know about what time she arrived to the

10 hospital?

11 A. About 5:00-ish in the morning.12 Q. And what was the nature of her complaint?

13 A. Severe shortness of breath and chest pain.14 Q. Okay. Did you understand at that time she had

15 been approximately 10 days postop following a total

16 abdominal hysterectomy?

17 A. Correct.18 Q. Okay. And what was your understanding as to the

19 reason why Ms. Roberts had a hysterectomy?

20 A. Uterine carcinoma.21 Q. And are you aware of one way or the other as to

22 whether she had been experiencing severe bleeding over the

23 years?

24 A. Severe over when?25 Q. Over the years.

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1 Q. Okay. Would it surprise you if she had, given2 the amount of bleeding you understood she had over the3 years?4 A. It would not surprise me.5 Q. All right. In addition to a history of severe6 bleeding and anemia and uterine cancer, are you aware of7 any other comorbidities Ms. Roberts had when she entered8 St. Vincent's on August 23, 2010?9 A. Yes.

10 Q. Okay. What other ones, sir?11 A. Morbid obesity.12 Q. And what is morbid obesity?13 A. It's defined as having a body weight greater than14 50 percent above your ideal body weight.15 Q. All right. Do you know what Ms. Roberts' weight16 was at that time?17 A. At time of admission?18 Q. Yes, sir.19 A. I've seen some numbers. I'm not sure if it's20 correct. It's 327 pounds. I'm not sure how they derived21 at that, but I've seen that number in some of the records22 or depositions.23 Q. And if some of the records indicate it's24 340 pounds, would you have any reason to quarrel with25 that?

46

1 A. Oh, yes. She had been, yes.2 Q. Okay. Because I do note, now that I think about

3 it, you were not provided any records from Drs. Nowicki

4 and Robertson; is that correct?

5 A. That is correct.6 Q. And that would be Ms. Roberts' GYN oncologist and

7 GYN caretaker.

8 A. Correct.9 Q. Do you know those names?

10 A. Yes.11 Q. Okay. But you didn't receive any of those

12 records?

13 A. That's correct.14 Q. Okay. And it is your understanding, then, that

15 for years -- not the number four but f-o-r -- for years

16 leading up to the hysterectomy Ms. Roberts had problems

17 with severe menorrhea?

18 A. That's my understanding.19 Q. Okay. Are you aware of one way or the other as

20 to whether Ms. Roberts had a history of anemia in

21 August 2010?

22 A. She did.23 Q. Okay. And do you know if she required blood

24 transfusions on occasions for that anemia?

25 A. I don't know that.

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1 A. I would not.

2 Q. Do you know what her BMI was alternatively?

3 A. I don't know. It was grossly excessive, but I

4 don't know the exact number.

5 Q. Sure. That's fine.

6 And I know I've already asked this, but just to

7 clarify, you've not seen a picture of Ms. Roberts at all?

8 A. I've seen her personally, but not in pictures.

9 Q. Okay. Okay. I forgot about that.

10 A. I'm sorry. There may be a picture. I think we

11 took a picture of her when she came in.

12 Q. Okay.

13 A. Here's her driver's license picture, yeah.

14 Q. I had forgotten you had seen her.

15 A. Here's her picture. See?

16 Q. Okay. Did you document the weight that

17 Ms. Roberts was when she came to see you this past August?

18 A. I couldn't because our scales don't accommodate

19 wheel chairs.

20 Q. Okay.

21 A. And she is too unsteady to walk on her own to a

22 regular scale. So the answer is no.

23 Q. Again, not having reviewed your report, did they,

24 Mr. or Mrs. Roberts, tell you what her weight was?

25 A. I asked -- I asked her husband --

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1 Q. Okay.2 A. -- and he was uncertain. I asked when was the3 last time Ms. Roberts was weighed and he was not clear on4 that.5 Q. All right. Do you have an opinion, one way or6 the other, whether or not Ms. Roberts, when you saw her7 this past August, weighed about 340 pounds, or more than8 340, or less than 340?9 A. I mean, it's like, you know, in fair guessing

10 like --11 Q. Right. You don't have to have an opinion. I'm12 just asking.13 A. She looked to be over 300 pounds. Whether it was14 340, or 350, or 330, I couldn't determine. I would say15 she's probably in that range.16 Q. All right. In addition to the other17 comorbidities we just discussed, did you understand if18 Ms. Roberts had hypertension in August 2010?19 A. I believe she did.20 Q. Okay. And do you know if she took medication for21 the hypertension?22 A. She did.23 Q. All right. And is it your understanding that24 while Ms. Roberts was in the E.R., at St. Vincent's that25 she was diagnosed with bilateral pulmonary embolism?

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1 admitted to the hospital?

2 A. She was.3 Q. To what unit?

4 A. Intensive Care.5 Q. Was that appropriate?

6 A. Absolutely.7 Q. All right. And once admitted, was the heparin

8 continued?

9 A. It was.10 Q. And did you find that it was actually continued

11 all the way through lunchtime on August 25, 2010?

12 A. Yes.13 Q. And it was appropriate, was it not, to continue

14 the heparin for that duration of time?

15 A. I would agree to that, yes.16 Q. All right. And then Dr. Pavlat, he ordered

17 several consults; correct?

18 A. Yes.19 Q. Okay. One of which was for neurology?

20 A. Correct.21 Q. And that was performed by Dr. Benjamin Moore, my

22 client; correct?

23 A. Correct.24 Q. All right. And pursuant to Mr. Sowell's

25 disclosure in this case of experts, it's my understanding

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1 A. Yes.2 Q. And the deep vein -- deep vein thrombosis as3 well; correct?4 A. Correct.5 Q. And was any medication provided in the E.R. in6 response to that diagnosis?7 A. Heparin.8 Q. Okay. And was that an appropriate medication to9 be prescribed to her?

10 A. Yes.11 Q. And then a CT of the brain was performed that12 morning as well; right?13 A. It was.14 Q. Okay. And is that because, if you know, there15 was suspicion of TIA or a possible cerebral vascular16 accident?17 A. Yeah. In other words, specifically Dr. Pavlat,18 who was the admitting physician, documented the presence19 of left -- upper left, lower extremity weakness and20 numbness, suggesting some right cerebral process. In view21 of that symptomatology, appropriately a brain CT scan was22 ordered and performed.23 Q. Okay. And what did you understand it revealed?24 A. When I looked at it, it looked to be normal.25 Q. Okay. All right. And was Ms. Roberts ultimately

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1 that you have criticisms against Dr. Moore as the2 neurologist in this case from your expertise as a3 neurologist; is that right?4 A. Yes, I do.5 Q. Okay. And can you go ahead and tell me what6 those criticisms are?7 A. Certainly. I'll start with the beginning.8 Dr. Moore was consulted on Ms. Roberts the morning of9 8/23/10. He did not see her until sometime about

10 6:50 p.m.11 Q. At 6:50 p.m. -- I'm sorry. Is it okay if I stop12 you occasionally?13 A. Surely. I'll speak slowly --14 Q. We'll see how it goes.15 A. That's okay. So this way you can comment on16 anything that I'm saying as we go.17 Q. Perfect.18 You said you thought that he saw her at 6:50 p.m.19 And what's the basis for that?20 A. The hospital records.21 Q. Okay. And 6:50 equals 1850?22 A. Yes.23 Q. Okay. All right. So if his note is actually24 written at earlier than that, do you have a reason to25 quarrel with the time that's recorded on his

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1 documentation?2 A. No, I don't.3 Q. Okay.4 A. If I have to look at it to see exactly where it5 is.6 Q. Sure. If you know where it is readily in your7 stack, that would be great.8 A. It's 1084. Let me see.9 Okay. It's dictated at 7:05 p.m.

10 Q. Okay.11 A. That's pretty close to what I said.12 Q. Okay. Well, let me ask you if you would look13 at -- I'm trying to make it easier, not pulling any14 punches at all when I'm asking you questions. The15 progress record, does this -- in your understanding is16 this Dr. Moore's progress record?17 A. Yes. That would suggest at 5:50 p.m.18 Q. Okay. And you read his testimony; correct?19 A. Yes.20 Q. Okay. And he spent I believe it was about21 50 minutes with the patient?22 A. You said "50" or "15"?23 Q. "50."24 A. Yes, 50. That's my recollection.25 Q. And he documented his record after consultation

55

1 document.2 MS. ROHAN-WILLIAMS: I'm sorry. 2546.3 MR. SOWELL: Thank you.4 Q. Okay. So he showed up around approximately5 6:00 p.m. for the sake of our discussion right here?6 A. In any case, Ms. Williams --7 Q. Yes, sir.8 A. -- I believe it's too long a latency in the time9 the consult was rendered to him. Again, there's some

10 disparity between what the records say, what he says when11 he got the consult. I think he says he got it about12 12:30. The records suggest it was sent about ten o'clock.13 So even to take the best case scenario for14 Dr. Moore, at 12:30 receipt of the consult, and doing it15 around six o'clock, that's five and a half hours. This16 really would be considered a "stat consult."17 Now, the fact that Dr. Pavlat didn't designate it18 a stat consult is not material because neurologists, when19 he or she receives a consult, has the responsibility to20 check on this patient, find out the acuity of it, either21 by calling where the patient is, be it the ICU or the22 E.R., wherever, if it's not clear from speaking to the23 nurse, or speaking to the emergency room doctor, or24 speaking to the attending doctor and determine what the25 acuity is.

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1 with the patient; correct?2 A. Okay.3 Q. Is that yes?4 A. Yes.5 Q. So in other words, maybe his consult took place6 around 1700 pursuant to this record?7 A. Well, yes, it's a little bit of disparity --8 Q. Okay.9 A. -- because typically a physician dictates right

10 away. And his dictation was rendered at 7:05. Again, I11 wasn't there. I don't know. But this would suggest that12 perhaps that was the time he first came on the scene.13 Most doctors put a time that they first start.14 When I see a patient, I put down the time I start15 seeing the patient. I may see the patient and come out16 and write, but I use the time I first saw the patient as17 the time of my interaction.18 Q. Okay.19 A. So this number is more consistent with the20 dictation rendered at 7:05 p.m.21 Q. Okay. So if the dictation is rendered at 7:0522 and he spent approximately 50 minutes with the patient, is23 it fair to say he probably saw the patient close to 6:00?24 A. Yes.25 MR. SOWELL: Excuse me. Could we identify the

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1 A 37-year-old woman with bilateral pulmonary2 emboli, and having deep vein thrombosis, having frequent3 neurological dysfunction is a "stat consult." So4 Dr. Moore should have seen this patient earlier as opposed5 to whatever time it was, 5:00 or six o'clock. And that's6 my first criticism of the doctor.7 Q. Okay. As a practicing neurologist in a hospital8 is there a difference between a stat and a routine9 consult?

10 A. There is.11 Q. Okay. And doctors that work in a hospital know12 that; correct?13 A. Of course.14 Q. And they choose to make the order whether stat or15 routine; correct?16 A. That's true.17 What I'm saying is the neurologist knows better18 than anyone else what the acuity is of a neurological19 issue.20 Q. Okay. And was Dr. Pavlat's order for a neurology21 consult of a routine nature?22 A. He did not designate.23 Q. He did not designate it as "stat"?24 A. That's correct.25 Q. And is this time latency, to use your word,

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1 somehow causative of the damages that Ms. Roberts2 ultimately sustained?3 A. Perhaps. I'll tell you why.4 Q. Okay.5 A. Because at some point in time Ms. Roberts had6 focal neurological dysfunction.7 Q. Okay.8 A. That included left upper and left lower extremity9 weakness and sensory loss.

10 Q. I'm sorry. Left upper extremity what now?11 A. Left upper and left lower extremity weakness and12 sensory loss.13 Q. Okay.14 A. Now, by the time Dr. Moore eventually arrived on15 the scene, those findings had dissipated --16 Q. Okay.17 A. -- and caused Dr. Moore to erroneously diagnose18 possible carpal tunnel syndrome.19 Now, certainly carpal tunnel syndrome is not an20 appropriate diagnosis to explain left upper and left lower21 extremity sensory loss. Had Dr. Moore arrived in a timely22 fashion -- even if he didn't look at the chart, which23 obviously he didn't to make this erroneous diagnosis -- he24 would have seen Ms. Roberts in the throws of having right25 cerebral dysfunction, and would have arrived on the 23rd

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1 A. I don't know that.2 Q. Okay.

3 A. It was more likely to be there at 10:00 or eleven4 o'clock then it was at 6:00 or seven o'clock that's for5 sure.6 Q. And what's your basis for that?

7 A. The lady got better. So a TIA does get better8 usually over a couple of hours. She was certainly -- by9 the time he came, she had normalized. He did not find any

10 residual weakness.11 Q. The way you stated your answer initially was you

12 don't know that they wouldn't have dissipated within the

13 hour; correct?

14 A. That's correct. I don't know that.15 Q. All right. And had he come at, let's just say,

16 11:30 a.m. as opposed to 6:00 p.m., somehow are you saying

17 the treatment that he provided would have been different?

18 A. I would think his thinking processes would have19 been different.20 Q. Okay.

21 A. In other words, he came there -- when he came22 there, the patient had no focal motor deficits and no23 lower extremity complaints. So he said, okay, this is a24 left upper extremity sensory problem. And he said, okay,25 she may have carpal tunnel. She may have cervical

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1 of August as opposed to the 25th of August as to the2 nature of her problem.3 In other words, what I'm saying to you is he4 erroneously considered this to be a peripheral process.5 Carpal tunnel syndrome or possibly cervical radiculopathy6 had misled him in the appropriate management and treatment7 for Ms. Roberts. So his latency in seeing the patient was8 likely contributory to his inappropriate care.9 Q. And how quickly for this routine order was

10 Dr. Moore in your opinion to have seen this patient.11 MR. SOWELL: Objection to form.12 A. Within the hour.13 Q. (BY MS. ROHAN-WILLIAMS) Okay.14 A. If he was unable to fulfill that -- which15 sometimes it happens. You're in the middle of some16 matter. You just simply say, I decline the consult; call17 someone else, or whoever is on call. Whatever. I don't18 know he was on call, whether he was just being chosen to19 see the patient because of some relationship he had with20 Dr. Pavlat or whatever. I don't know that. It's not21 clear to me.22 Q. Okay. And how do you know if he had seen her in23 an hour, the findings of left upper extremity and left24 lower extremity, and weakness, and sensory loss that you25 described would not have dissipated?

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1 radiculopathy. He was thinking a peripheral process. So2 his thought processes were skewed in that direction.3 Whereas, had he appreciated either historically4 or by examination that she had left upper and lower5 extremity weakness, that would have taken out of the box6 for those problems. It would have had to have been a7 right cerebral process.8 Again, that's my second criticism. Had he just9 looked at the charts and noted Dr. Pavlat's evaluation at

10 9:35 in the morning, he would have seen at that time the11 patient historically, by a physician, had been documented12 to have left-sided weakness and sensory loss. And that13 makes it impossible to tender the diagnosis of either14 carpal tunnel syndrome or cervical radiculopathy as15 explicatory of that process.16 Q. For the findings that Dr. Moore made in his17 record at the time he saw the patient, were his diagnoses18 in line with those findings then?19 A. I didn't understand your question. Could you20 repeat that?21 Q. Sure. Sure.22 You said that -- basically what I heard you to23 say or understood you to say is when Dr. Moore saw this24 patient in the evening, that the left upper extremity and25 left lower extremity weakness and sensory loss had

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1 dissipated --2 A. That's correct.3 Q. -- which led him to believe -- utilize a thinking4 process, you said, of a peripheral problem; correct?5 A. Correct. That's right.6 Q. I'm asking you based upon what Dr. Moore saw and7 evaluated and assessed at the time of his examination of8 this patient, were his diagnoses in line with those9 findings?

10 MR. SOWELL: Objection to the form.11 Q. (BY MS. ROHAN-WILLIAMS) Okay.12 A. If you isolate out the historical explanation13 that he had at his disposal -- in other words, just look14 at the examination, yes, is the answer to your question.15 Q. Thank you. All right.16 Your second criticism is that you said he didn't17 look at the chart.18 A. Well, if he looked at the chart, he didn't look19 at it sufficiently to ascertain what other doctors had20 written earlier in the day.21 Q. Okay.22 A. Which should have affected, again, his thinking23 process. In other words, he had a couple ways to make the24 right diagnosis by examination contemporaneous to her25 problem which didn't happen. And by a third, review of

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1 her.2 MR. SOWELL: Objection to form.3 MS. ROHAN-WILLIAMS: Why?4 MR. SOWELL: The record is there. So when you're5 talking about evidence, that would have to deal with6 solely physical examination.7 MS. ROHAN-WILLIAMS: Okay.8 Q. (BY MS. ROHAN-WILLIAMS) So do you admit,9 Dr. Fischer, that when Dr. Moore saw the patient at

10 approximately 6:00 p.m. on the evening of 8/23/2010 there11 was no physical evidence indicative of a clear-cut right12 cerebral dysfunction?13 A. I agree with that.14 Q. Thank you.15 A. So he has historically that aspect.16 Q. I understand.17 A. And he has a woman who has deep vein thrombosis18 which is documented, bilateral pulmonary emboli which is19 documented, and has risk factors for struck including20 hypertension, morbid obesity and family history of stroke.21 Q. Okay.22 A. Again, I'm going to just go back for a second.23 Dr. Moore, in his history taking, did not elicit that.24 Now maybe the patient did not tell him, but patients often25 don't know what's important. A neurologist should.

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1 the chart demonstrating clear-cut right cerebral2 dysfunction. He didn't mention that. So either he looked3 at the chart and didn't notice it, or didn't look it the4 chart. I don't know that. But it's not there, and it was5 available for him to know and he didn't know for whatever6 reason.7 Q. When you say in the chart contained a "clear-cut8 right cerebral dysfunction" evidence, what is it that is9 contained in the chart that demonstrates the "clear-cut

10 right cerebral dysfunction"?11 A. The documentation by Dr. Pavlat that the patient,12 on his examination, had left upper and left lower13 extremity weakness and sensory loss.14 Q. Okay. So that left upper and lower extremity15 weakness and sensory loss is clear-cut evidence of right16 cerebral dysfunction?17 A. Correct.18 Q. Okay. And what is the treatment or the remedy19 that the neurologist is supposed to do for that?20 A. Okay. Let's go with that. Okay. Now we have --21 Dr. Moore, whenever he comes in, six o'clock, we'll say,22 has a patient who had right cerebral dysfunction that's23 gone.24 Q. Okay. And do you admit that, the evidence of25 right cerebral dysfunction is gone at the time he sees

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1 So if a doctor comes to see a patient who has2 these risk factors -- well, what did your mother and3 father die of? Anybody have stroke in your family? No.4 My brother was 19 and had a stroke. That's a crucial5 aspect to know. He didn't know that because he didn't6 ask.7 Q. Okay. Let me ask you this. Dr. Sackett, she8 treated Ms. Roberts for 10 years prior to the stroke. Did9 she know there was a family history of stroke?

10 A. I have not seen those records. I couldn't say.11 Even if she didn't --12 Q. I have another question for you.13 A. I'm sorry.14 Q. Did you read my deposition of Mr. Roberts?15 A. Yes.16 Q. Okay. Did I ask him if Ms. Roberts' brother had17 a stroke?18 A. Yes.19 Q. And what was his answer?20 A. He wasn't sure.21 Q. Exactly.22 Okay. Go ahead.23 A. In any event, with that constellation of24 symptoms --25 Q. Right.

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1 A. -- and history, he, Dr. Moore should have been2 thinking, okay, this is cerebral vascular disease. What3 are the possibilities? Well, he already had a CT scan4 which was negative. Perhaps he could not do an MRI scan5 because of the patient's weight and her instability. I'll6 grant him that.7 Q. You don't have a criticism about that?8 A. No.9 Q. Okay.

10 A. There's too many factors here. I don't know11 exactly what her weight was, what her physiognomy was at12 that time, how unstable she was medically. Perhaps she13 was -- so I'll grant that maybe an MRI scan was not14 possible.15 Q. Okay.16 A. He could have done a CTA. We know that because17 there's no problem putting her in the CTA machine. The18 CTA is fast. That would have ruled out some large vessel19 occlusive problem of the vertebral or carotid arteries.20 That wouldn't have demonstrated it, but he would have21 ruled it out at least.22 And then he would have been thinking strongly of23 cardioembolic disease. And particularly in this case with24 the severe venous disease and pulmonary emboli he would25 have been thinking of some process with a right to left

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1 A. I said cerebral cardioembolic disease.

2 Q. Okay. Cardioembolic disease. Okay. Large

3 vessel disease.

4 A. Yeah. The CTA would be useful for that.

5 And then you do studies of -- coagulation studies

6 and studies for connective tissue disease.

7 Q. Okay. Hadn't Ms. Roberts had an echocardiogram?

8 A. I know it was ordered that day. I'm not sure

9 whether it was completed and read by the time Dr. Moore

10 saw her.

11 Q. Is it possible for you to review the chart?

12 A. I will do that.

13 Q. Thanks.

14 A. He has the book. Here it is. Page 1106.

15 MR. SOWELL: Tiffany, do you mind if I point this

16 out?

17 MS. ROHAN-WILLIAMS: Not at all.

18 MR. SOWELL: All right. So here's the worksheet,

19 B001284, and then the final report, B002392.

20 Q. (BY MS. ROHAN-WILLIAMS) Is that what you were

21 looking for, Doctor?

22 A. Yeah. It was done here. It was performed at

23 1:45 p.m.

24 Q. Okay. On 8/23?

25 A. Yes, ma'am.

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1 shunt, and the possibility of a venous problem causing an2 arterial disease. So those are -- or an alternative would3 be some process, either vasculitis or premature clotting4 disorder which could have been ruled out by appropriate5 laboratory tests in a few hours.6 So he had there a differential diagnosis7 established on the day he first saw the patient of the8 afternoon or evening of 8/23. Well, he should have. And9 that's my next criticism.

10 Q. That differential should have been what?11 A. Cerebral vascular disease and he should have gone12 through the thought processes I just demonstrated for you.13 Okay. Could it be large vessel disease? I'll do a CTA to14 find that out. Could it be cardioembolic disease? We15 need to start an echocardiogram. And even if the16 echocardiogram does not show something, this well could be17 a PFO which is a common phenomenon.18 Something is causing massive venous disease and19 now we have cerebral arterial disease. And that20 combination would suggest a possibility of a PFO. So in21 other words, he could have arrived that evening, 8/23, of22 the proper presumptive diagnosis.23 Q. Well, which I'm understanding you to have24 indicated was cerebral vascular disease for which a stat25 echocardiogram should have been done?

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1 Q. All right.2 A. I don't see it. The interpretation was signed3 8:23 a.m. on 8/24. So it was done but it was not4 interpreted by the cardiologist until the following5 morning.6 Q. And what was the result?7 A. Technically difficult study. Chamber size was8 normal. Left ventricular ejection fraction 55 to9 60 percent. It was trace tricuspid regurgitation.

10 Estimated pulmonary pressure around 55 to 60 millimeters,11 consistent with moderate pulmonary hypertension. There12 was a trivial cardiac effusion.13 Q. Okay. And does that -- did I allow you to14 finish?15 A. Yes, that's it.16 Q. Does that echocardiogram report -- is that17 indicative to you of cardioembolic disease?18 A. You can't tell. There's no valve disease.19 There's no ventricular appendage. There's moderate20 pulmonary hypertension. It might be indicative of a right21 to left shunt. Again, you're beyond my capabilities of22 interpreting an echocardiogram any further.23 Q. But you had indicated that cardioembolic disease24 should have been on the differential on the evening of25 8/23 and hence a stat echocardiogram order.

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1 A. Correct.2 Q. And my question is is the echocardiogram3 indicative of cardioembolic disease as a neurologist?4 A. Not definitively, no.5 Q. Okay. All right. Were coag studies done?6 A. They were done.7 Q. Okay. And what did they reveal?8 A. They were negative.9 Q. Okay. And then you said a CTA is what else

10 should have been done.11 A. Yes.12 Q. You said -- I wrote it down, but I don't think I13 got this right. Cerebral arterial disease should have14 been on the differential?15 A. I'm not sure.16 Q. I might not have done a good job with that one.17 A. No, not on that one.18 Q. Okay. Anything else that you can recall that you19 stated he should have done or considered on the evening of20 8/23?21 A. Yes.22 Q. Okay.23 A. He should have done laboratory work to rule out a24 coagulation disorder or connective tissue disorder.25 Q. Okay. Was that done?

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1 to arterial shunting as the cause of the stroke, which was2 a substantial possibility based on the fact that she had3 focal neurological dysfunction, coupled with deep vein4 thrombosis and large pulmonary emboli.5 So let's assume Dr. Moore had done all these6 things systematically on the 23rd as I suggested.7 Q. Okay.8 A. He would have been left with that is the likely9 presumptive cause of the stroke.

10 Q. Okay. And isn't the treatment for that heparin?11 A. Well, that's -- heparin is a treatment.12 Q. Okay.13 A. And if the patient continues to have14 symptomatology, then you have to think about putting in a15 filter.16 Q. Okay. So if the consideration had been, by17 Dr. Moore, venous to arterial shunting on the evening of18 August 23rd, then heparin, if I'm understanding your19 testimony correctly, would have been the treatment of20 choice?21 A. Initial treatment of choice, yes.22 Q. Okay. All right. So what's the next criticism23 that you have of Dr. Moore?24 A. Okay. The next day --25 Q. Okay.

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1 A. No, not -- at least not at that time. It was2 done later on but not done then.3 Q. Were they ultimately revealing?4 A. No, they were not.5 Q. Okay. Just to backtrack for just a minute.6 Haven't you testified in other cases that family history7 of stroke is not a risk factor for stroke?8 A. Is not what?9 Q. A risk factor for stroke.

10 A. I have not testified that way, no.11 Q. So in other words, in your opinion it is a risk12 factor for stroke?13 A. Yes, it is.14 Q. Okay. All right. So apart from performing the15 CTA, as you suggested, on 8:23 p.m., the other studies you16 indicated were performed and ultimately nonrevealing for17 the conditions that you set forth on your differential; is18 that true?19 A. That's correct.20 Q. Okay.21 A. But he needed to know the results of those22 studies immediately --23 Q. Okay.24 A. -- because once he eliminated all of those facets25 in a differential diagnosis, that leaves him with venous

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1 A. Again, this is a very sick patient, Ms. Roberts2 was.3 Q. Okay.4 A. So one would reasonably expect the neurologist to5 come back the next morning. In other words, if I see a6 patient like this on the evening of the 23rd, I come back7 7:00 or eight o'clock in the morning. Any reasonable --8 not just me, any reasonable neurologist would come back in9 the morning to see what was going on.

10 Q. Okay.11 A. To my surprise he doesn't come back that morning.12 Q. When does he come back?13 A. In the afternoon when he's recalled by14 Dr. Pavlat.15 Q. Okay.16 A. Now the patient was now having a different17 symptom, headaches.18 Q. Okay.19 A. And it's also documented the patient was having20 nausea and dizziness.21 Q. Okay.22 A. So that is -- also, now we have headaches in this23 setting. Now Ms. Roberts did have a history of migraines.24 So the headaches, per se, well -- they're not necessarily25 specific, but headaches are also a symptom of embolic

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1 stroke. In other words, typical thrombotic stroke is --2 usually doesn't give you headaches. Hemorrhagic stroke3 obviously does. Embolic stroke frequently does.4 When you have nausea and dizziness, that suggests5 something in the posterior fossa, the back of the brain.6 So first we have, if you remember, right cerebral7 dysfunction. The right side of the brain. And now we8 have on the 24th when he comes, since then she has had9 headaches and she has had nausea and dizziness. So that

10 should make him think about something in the back of the11 brain.12 Now of course, he still can't do an MRI scan13 which would be likely demonstrative of these things. He'd14 do another CT scan which doesn't show anything or --15 actually, I must say something. There was a subtle defect16 on that CT scan. I didn't see it myself.17 Q. Which one are we talking about now?18 A. The 24th.19 Q. The 24th. Okay.20 A. I looked at those scans and I didn't see it. So21 I don't blame Dr. Moore for not seeing it, because it was22 not appreciated by the radiologist at the hospital. It23 wasn't appreciated by him. It wasn't appreciated by me.24 Q. Then how do you know it wasn't appreciated?25 A. Dr. Pressman sees it retrospectively.

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1 A. Yes, from the front part of the legs and the2 pulmonary arteries.3 Q. Okay. What's the purpose of the filter?

4 A. To prevent clots. In other words, it filters the5 clots from coming from the venous system into the arterial6 system. It's not perfect, but it reduces the burden of7 clots, reduces large clots. Some small clots will pass8 through to be sure, but it will substantially reduce the9 chance of clotting occurring.

10 MS. ROHAN-WILLIAMS: Okay. Is this a good time11 to stop you or do you want to keep going?12 THE WITNESS: You don't have to stop. I am okay13 where we are.14 MS. ROHAN-WILLIAMS: Okay.15 MR. SOWELL: At one point could we maybe have16 like 10 minutes just to stand or walk?17 MS. ROHAN-WILLIAMS: I'll give you five.18 MR. SOWELL: That's fine too.19 MS. ROHAN-WILLIAMS: I'm just saying I'm on the20 clock.21 (Off the record.)22 MS. ROHAN-WILLIAMS: Going back on the record.23 Q. (BY MS. ROHAN WILLIAMS) All right. Doctor, to

24 pick apart some of what you just said on the -- what I

25 would call "the third criticism against Dr. Moore," you

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1 Q. On the 24th?2 A. Yes.3 Q. Okay.4 A. He is a board certified neuroradiologist. He has5 more acumen perhaps than most. So I'm not going to6 criticize Dr. Moore for not seeing that cerebellar7 infarct.8 Q. Nor Dr. Brown?9 A. Anybody.

10 Q. Okay.11 A. Okay. But still the clinical situation has12 become more complicated. She's having -- she has another13 occurrence. She still has some numbness of the left hand,14 but that's not major. But now she's having other15 symptomatology.16 Again, Dr. Moore should say, okay, if a lady who17 has right cerebral dysfunction is now having symptoms of18 posterior fossa dysfunction, and still on the heparin, and19 still having the -- again, he should have reconsidered at20 that point, or didn't considered the first time, the21 provision of a filter. Again, the purpose of the filter22 would be to prevent cerebral embolization stemming from23 the venous defects. He didn't do that.24 Q. "From the venous defects," does that mean in the25 legs? What do you mean by "from the venous defects"?

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1 indicated that headache is symptom of embolic stroke.2 A. Could be.3 Q. Could be. Okay.4 A. I'm sorry. It's not definitive. In other words,5 headache could be many things. It could be migraine. It6 could be tension. It could be -- in terms of stroke it's7 almost always present with hemorrhagic stroke.8 Q. Right.9 A. It's usually not present with thrombotic stroke.

10 Q. Okay.11 A. And it may be present with embolic stroke.12 Q. Okay. All right. Thank you for that13 clarification.14 And headache, you would agree, is a very15 nonspecific symptom?16 A. Yes.17 Q. Okay. You also stated that nausea and dizziness18 suggested that posterior fossa or back of brain19 involvement; correct?20 A. Correct.21 Q. Was that borne out to be the situation with22 regard to Ms. Roberts' stroke?23 A. Eventually she was found to have a right24 cerebellar stroke which was probably explicatory of those25 symptoms.

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1 Q. And right cerebellar stroke would be in the back2 of the brain?3 A. Yes.4 Q. Would you agree that both nausea and dizziness5 are also vague symptoms?6 A. Yes.7 Q. Okay. And couldn't both of those be attributable8 to narcotic medication?9 A. Nausea, yes; dizziness, less likely.

10 Q. Okay. All right. Was Ms. Roberts taking11 narcotic medication during this admission?12 A. Yes.13 Q. All right. Let's go to the IVC filters or the14 Greenfield Filters. Can we use those terms15 interchangeably in our conversation?16 A. Practically, yes.17 Q. Ms. Roberts ultimately had a Greenfield Filter18 placed?19 A. Yes.20 Q. And that's a type of IVC filter?21 A. Yes. Developed by Joe Greenfield, actually, one22 of my professors at Duke.23 Q. Okay.24 A. He is diseased now but he was a very nice man.25 Q. I hope he made a lot of money.

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1 order. See, usually you'll get a consult for the person2 to put it in and that person will agree or not.3 Q. I see.4 A. It's not like a blood test or an x-ray. If5 something has to be done by another physician, that6 physician doesn't -- like an automaton just does it. He7 or she will have to see why it's being done and if it's8 appropriate and agree to it or not.9 A neurologist may recommend it if the neurologist

10 feels that a venous problem is causing secondary arterial11 stroke.12 Q. If a venous problem is causing a secondary13 arterial stroke?14 A. That's correct.15 Q. Okay. All right. And approximately how many16 times have you ordered or recommended this filter in say17 the past five years?18 A. In five years?19 Q. Uh-huh.20 A. Two or three.21 Q. Two or three times?22 A. Yes.23 Q. Only?24 A. Yes.25 Q. Okay. Do you believe in the last five years you

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1 A. No, he didn't.2 Q. Do you personally order these filters?3 A. Yes, in conjunction with typically a4 cardiological and a pulmonary consultant or intensivist.5 In other words, it's unusual for a neurologist to6 unilaterally do these things.7 Q. Okay.8 A. We are usually in communication with the other9 doctors involved and say, okay, look, neurologically this

10 appears to be the cause of the problem; I would recommend11 that you have that installed.12 Q. Okay.13 A. I wanted to make sure that we get this in. This14 is an additional criticism of Dr. Moore. I don't want to15 break up your --16 Q. You're fine.17 A. We can go back later to the communication issues18 between him and the other physicians, particularly during19 the onset of his care. We will go back to that later. I20 want to finish this stream here with the daily visits.21 Q. Okay. All right. Typically you said you will22 order these in conjunction with a cardiologist and23 pulmonologist for what?24 A. See, order isn't good. I'll recommend them as25 opposed to ordering them. "Order" means I am writing the

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1 have had more than two or three patients with ischemic

2 stroke you believe was resultant of cardioembolic disease?

3 A. Oh, no. Many more than that. Most of4 cardioembolic disease is not due to PFO.5 Q. Okay.

6 A. It's due to atrial fibrillation or some other7 cardio -- cardiac valvular disease. That is much more8 common statistically than PFOs. PFOs are common, but PFOs9 causing large strokes are less common than atrial

10 fibrillation or cardiac valvular disease.11 Q. Okay. And why is it -- help me to understand why

12 you believe on the 24th, as my understanding, that

13 Dr. Moore should have considered or recommended an IVC

14 filter? Did I say that correctly?

15 A. You did correctly express that.16 Q. Should he have considered or recommended it on

17 the 24th?

18 A. The latter.19 Q. Recommended?

20 A. Yes.21 Q. Okay. All right. And why is it that now?

22 A. Okay. If we go back over the last 36 hours of23 Ms. Roberts' presentation --24 Q. Okay.

25 A. -- I don't mean to be repetitive, but she had

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1 deep vein thrombosis, pulmonary embolization, clear-cut2 right cerebral dysfunction which resolved or improved, and3 then posterior fossa dysfunction and headaches. So this4 suggests multifocal embolization.5 Again, he had ruled out or could have ruled out6 the other coherent causes of stroke. In other words, we7 talked about it was no malformation, there was no8 hemorrhage. He had two CT scans by this time. He could9 have ruled out large vessel disease, but didn't, with a

10 CTA. He could have ruled out then, but didn't, a11 coagulopathy or connective tissue process.12 In other words, he did have an echocardiogram13 which by this time was read by the 24th, which showed no14 significant valvular process, or ventricular appendage, or15 atrial appendage, anything like that. So he's ruled out16 most of the other causes of stroke and the differential17 diagnosis would then focus on a venous arterial process,18 like a PFO causative of her recurrent symptoms or19 multifocal systems.20 Q. Okay. And in -- pardon me if I already asked you21 this. Wasn't treatment in August of 2010 for a PFO22 heparin?23 MR. SOWELL: Objection to form.24 A. Heparin is a treatment.25 Q. (BY MS. ROHAN-WILLIAMS) Okay.

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1 A. No, I don't.2 Q. Okay. All right. So the two to three times in3 the past five years that you ordered the IVC filter was4 for what reason? Or recommended. Sorry.5 A. It was similar situation to this where the person6 was having episodes of focal cerebral dysfunction. We had7 either documented or suspected PFO. The patient either8 could not take heparin or was having symptoms despite9 heparin.

10 Q. Okay. How many of those two to three cases was11 the patient unable to have heparin?12 A. At least one of them I remember specifically, she13 had a so-called heparin allergy.14 Q. Okay. So we might really only be talking about15 one patient in the past five years?16 A. I believe there were two. I think there was17 three all told. One of them I exclude from consideratio18 because it was a different set of circumstances. Heparin19 could not be used.20 Q. Okay. All right. The specific filter actually21 placed in Ms. Roberts on the 25th, is that the type of22 filter you're saying should have been placed earlier?23 A. Yes, ma'am. That's correct.24 Q. And when are you saying that filter should have25 been recommended by Dr. Moore?

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1 A. She was on heparin, but she was having2 symptomatology despite the heparin.3 Q. Okay. All right. Isn't it true that IVC filters4 are used as an alternative to heparin for suspicion of PFO5 and paradoxical emboli?6 A. Alternatively it is, but heparin is precluded.7 There are people who can't take heparin and have active8 bleeding deficits, or they have either heparin allergies.9 There are reasons that people can't take heparin.

10 Ms. Moore -- I'm sorry.11 Q. That's okay.12 A. Ms. Roberts did not have exclusionary criteria13 for heparin at that point. I mean, she had some anemia14 and later on she had some bleeding. But the point is on15 the 23rd and 24th heparin was not excluded. She was on16 heparin full strength, but she was still having symptoms.17 So this -- it's not one or the other necessarily.18 I mean, sometimes it is if heparin can't be used. But19 this was the case where heparin was being used and the20 patient remained symptomatic. Therefore, they had to go21 beyond the heparin. It was not sufficient to deal with22 her problem.23 Q. Okay. Have you any criticism as to the24 therapeutic level of heparin that Ms. Roberts was on from25 8/23 to the time of lunch on 8/25?

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1 A. Surely by his visit of the afternoon of the 24th.2 Q. Okay. So any specific time I can attach to that?3 A. Well, when he came -- again, I criticized him for4 not coming the morning of the 24th.5 Q. Right.6 A. He did come about two o'clock in the afternoon.7 Q. Okay.8 A. So we takes that time. When he came there and he9 looked at the chart, and he should have seen -- he didn't

10 address this, but Dr. Pavlat had recalled him earlier that11 day because Ms. Roberts was having headaches which12 concerned Dr. Pavlat.13 In other words, Dr. Moore had said she could be14 transferred to telemetry from ICU, and Dr. Pavlat nixed15 that, because he felt she was still unstable. That was16 appropriate. But Moore either did not realize she was17 having headaches or didn't comment on it. I don't know.18 He didn't comment on it. There was no right cerebral19 dysfunction, but she had the headache and the additional20 symptoms of the nausea and dizziness. So again -- okay.21 Q. Okay.22 A. The right cerebral radio process had not23 reappeared, but she was having headaches now and was also24 having nausea and dizziness. So that should have made him25 consider a brain stem process in addition to previous

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1 right cerebral process despite the heparin being in full2 force.3 Again, by two o'clock in the afternoon of the4 24th certainly he was in the position to appreciate this,5 or should have been, and had recommended at that time the6 provision of the filter.7 Q. Okay. And so did you read -- oh, you didn't read8 testimony from the nurses, did you? Not from Merlinda9 Pilapil or Sue Riley or Carrie Ann King? You weren't

10 provided with those?11 A. I have not seen those, ma'am, no.12 Q. Okay. Did you discuss their testimony with the13 plaintiffs' attorneys?14 A. Discuss with the nurses?15 Q. Their testimony.16 A. No, I have not heard about them.17 Q. Okay. Do you have any knowledge, whether it be18 from the records or otherwise, that nurses described19 Ms. Roberts' headache on the 24th as intermittent?20 A. Yes, that's right. I do recall that.21 Q. Okay. And do you have any reason to quarrel with22 that characterization of the headache being intermittent23 on the 24th?24 A. I don't.25 Q. Okay. So then if I'm understanding what you're

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1 could be caught by the IVC filter that was placed in2 Ms. Roberts on August 25th?3 A. I believe less than half a centimeter.4 Q. How many millimeters?5 A. Anything greater than half a centimeter would6 be -- you know, again, I think some studies have shown7 clots less than 2 millimeters will be excluded by these8 devices.9 Q. Does that mean -- just changing the word -- that

10 2-millimeter clots would be able the pass through that IVC11 filter?12 A. Yes, they would be able to do that.13 Q. Okay. What about 3-millimeter sized clots?14 A. They'd probably be blocked off.15 Q. Upon what do you base that?16 A. Just my previous reading about these things and17 my experience. I have not looked at anything for this18 case.19 Q. So you think 3-millimeter clots would be blocked20 by the IVC filter?21 A. Yes.22 Q. Okay. And larger?23 A. Correct.24 Q. All right. Okay. The occlusion of Ms. Roberts'25 left middle cerebral artery on the 25th, that's seen on

86

1 saying, that by about 2:00 p.m. on the 24th Dr. Moore

2 should have recommended placement of an IVC filter despite

3 the fact that therapeutic heparin was still being provided

4 to this patient, because of the new symptoms of

5 intermittent headache plus nausea and dizziness?

6 A. Plus the earlier picture we had described. I

7 don't want to be repetitive. The composite of what

8 happened the day before, between the 23rd and 24th and two

9 o'clock there was enough information that Dr. Moore had,

10 or could have had, to exclude other causes of cerebral

11 vascular disease and to have recommended the provision of

12 the filter despite the fact she was already on heparin.

13 Q. Okay. But the new symptoms on the 24th were

14 simply intermittent headache, nausea and dizziness?

15 A. That's correct.

16 Q. And in your opinion those warranted his

17 consideration of placement of an IVC filter despite the

18 therapeutic heparin being provided?

19 A. That is correct.

20 Q. Okay. So is it ultimately your opinion that if

21 Dr. Moore had recommended by 2:00 p.m. on the 24th, and

22 thereafter the general surgeon agreed, and placed the IVC

23 filter, that the stroke of 8/25 would not have occurred?

24 A. That is exactly right.

25 Q. Okay. What is the smallest diameter clot that

88

1 CT?2 A. Yes.3 Q. Do you have an opinion as to -- well, did a clot4 cause that occlusion?5 A. Yes, it did.6 Q. Okay. Do you have an opinion as to the size of7 that clot?8 A. I would go with what Dr. Pressman said in his9 deposition since he's the expert. I think he said it's

10 half by 1 centimeter.11 Q. What does that equate to in millimeters?12 A. 5 by 10. It may be a little bit larger, maybe13 it's 5 by 12.14 Q. 5 to 10 millimeters?15 A. Yes.16 Q. So would a clot of that size, 5 to 1017 millimeters, have been caught by the IVC filter placed in18 Ms. Roberts?19 A. That's correct. That's correct.20 Q. Okay. Do you defer to a neuroradiologist on the21 size of the clots that would occlude the vessels in22 Ms. Roberts' brain that you believe were occluded?23 MR. SOWELL: Objection to form.24 A. I'm a little confused by your question, madam.25 Q. (BY MS. ROHAN-WILLIAMS) Okay.

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1 A. Are we going to defer to him, to a2 neuroradiologist, on the reading of the x-rays? Yes, I3 would.4 Q. No. I'm trying to figure out if you5 independently, as Dr. Fischer, board certified6 neurologist, have opinions as to the size of the clot or7 clots that obstructed vessels or vasculature in8 Ms. Roberts' brain.9 MR. SOWELL: Objection to form.

10 A. I looked through the x-rays myself. That being11 said, I'll defer to a radiologist on measuring that clot12 exactly.13 Q. (BY MS. ROHAN-WILLIAMS) Okay. Thank you.14 Well, the subtlety that you discussed earlier15 that was seen I believe, you said, on the 8/24 CT scan.16 A. Yes.17 Q. Okay. What is that subtlety? Tell me what that18 is.19 A. It was a right cerebellar infarction. It was20 retrospectively diagnosed. Again, I personally didn't see21 it when I looked at the films.22 Q. Okay.23 A. Retrospectively I think I see it, but it was very24 subtle, and I think it was missed by the radiologist in25 the hospital. It was missed by Dr. Moore. But I would

91

1 necessarily? I don't know that. Possibly.2 Q. Okay. So in other words then, yes, as I3 understand your answer to my question, a 2-millimeter clot4 in diameter could have caused the right cerebellar5 infarction you understand Dr. Pressman saw on the6 8/25/2010 CT films?7 A. Exactly.8 MR. SOWELL: Object to the form.9 Q. (BY MS. ROHAN-WILLIAMS) Similarly could a

10 1-millimeter clot cause that same infarction?11 A. That's rather small. The answer's probably not.12 I couldn't say categorically no. Within medical13 probability, no.14 Q. Okay. Why not? What do you base that on?15 A. The ultimate size. You see the -- you see the16 infarction better as time goes on. That's not unusual.17 Particularly with an MRI as opposed to a CT. But looking18 at the size of the infarction eventually a 1-millimeter19 clot will be unlikely to cause such an infarction.20 Q. Because the vasculature it would have traveled21 through is larger than that?22 A. Yes.23 Q. The lumen in the vasculature?24 A. Correct.25 Q. Okay. And what specific vein or vessel are we

90

1 not blame them. I could not really consciously blame them2 since I did not see it myself.3 Q. Do you have an opinion as to the size of the --4 well, strike that.5 Was the right cerebellar infarction in your6 opinion caused by a clot?7 A. Yes.8 Q. Okay. Do you have an opinion as to the size of9 the clot -- the smallest size of the clot that could have

10 caused that infarction?11 A. No, you don't see a clot. You see, unlike the12 middle cerebral artery lesion where you see the clot13 itself, the cerebellar infarction, you see the14 ramifications of the clot. You don't see the clot.15 Q. Okay. Would a clot the size of 2 millimeters be16 able to cause an infarction of the -- of that right17 cerebellar infarction?18 A. Possibly. I'd be speculating. The answer is19 possibly. I don't know.20 Q. Why don't you know?21 A. I don't know the -- I don't know the size of that22 particular clot because it was not visualized. Could it23 be, yes.24 Q. Okay.25 A. Do I know whether one of that size would do it

92

1 talking about there?

2 A. It will be a tributary of a vertebral artery. It

3 wouldn't be a vertebral artery per so. It will be a

4 tributary of the vertebral artery.

5 Q. A tributary --

6 A. Yeah.

7 Q. -- of the vertebral artery?

8 A. Right.

9 Q. Okay. In other words, has a lumen that is larger

10 than 1 millimeter?

11 A. To get an infarct of that size.

12 Q. All right. Now would a 2-millimeter clot be

13 caught by the IVC filter that Ms. Roberts had placed?

14 A. No.

15 Q. Okay.

16 A. It might be but not necessarily.

17 Q. Okay.

18 MR. SOWELL: I'm going to object to the form.

19 Q. (BY MS. ROHAN-WILLIAMS) Not likely; correct?

20 MR. SOWELL: Objection to the form.

21 A. Not likely.

22 Q. (BY MS. ROHAN-WILLIAMS) Isn't the main purpose

23 of these IVC filters to block DVTs from lower extremities

24 from going to the lungs?

25 A. That's one purpose of it, yes.

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1 Q. Is that the main purpose?2 A. Yes.3 Q. Where anatomically was the IVC filter placed in4 Ms. Roberts?5 A. In the groin area I believe.6 Q. In the groin?7 A. Yes.8 Q. Okay. So in other words, anatomically once9 again, the filter would not stop clots that were above

10 placement of that filter; correct?11 A. That's correct, it would not.12 Q. Okay. Is placement of an IVC filter an invasive13 procedure?14 A. Yes.15 Q. Does it have risks associated with it?16 A. Yes.17 Q. What are those risks, sir?18 A. Infection, anesthesia risk, hypotension.19 Q. And general anesthesia is required for placement20 of that?21 A. Yes.22 Q. Well, tell me a little about the hypotension.23 How does that occur?24 A. When you have anesthesia, it lowers the blood25 pressure.

95

1 with Ms. Roberts here.2 Would the IVC filter of Ms. Roberts, placed on3 August 25th, prevent emboli that are already in the heart4 from going to the brain?5 A. No, they would not.6 Q. Okay. Thus, if Ms. Roberts had the IVC filter7 placed and already had a clot in her heart, it would not8 have prevented ischemic stroke resultant of a paradoxical9 emboli?

10 A. That's correct. That's correct.11 Q. Okay. And is there anyway for you to know12 whether or not on August the 24th Ms. Roberts had a clot13 in her heart?14 A. Well, we know from the echocardiogram after the15 23rd she didn't. We don't know what happened between the16 23rd and 24th. That we don't know. But at least we know17 as of the 23rd, with the echocardiogram, there was no18 obvious clot in the heart.19 Q. Okay. "No obvious clot in the heart."20 Could there be small clots that don't appear on21 the echocardiogram?22 A. Sure.23 MR. SOWELL: Object to the form.24 MS. ROHAN-WILLIAMS: What's the nature of the25 objection?

94

1 Q. Okay. Related to the anesthesia.2 A. Yes.3 Q. Okay. And who is the physician, or what type of4 physician places an IVC filter?5 A. A general surgeon typically.6 Q. Okay. Are there any contraindications associated7 with the use of IVC filter?8 A. None I'm aware of. No specific ones. Obviously,9 the patient's clinical condition. The patient is

10 clinically ill, he's having severe hypotension or high11 fever, you may want to withhold doing it at that time.12 But other than that, no.13 Q. When those filters are placed, they're not14 removed are they?15 A. They're not what?16 Q. Removed.17 A. No. They're usually left in indefinitely.18 Q. Right.19 And isn't it true that they indeed can become20 situs for clot formation in the future?21 A. Possibly.22 Q. And they themselves can cause clotting problems23 and hence potential embolic problems for the patient?24 A. Possibly.25 Q. Okay. Okay. Does an IVC filter -- we will stick

96

1 MR. SOWELL: Vague. Ambiguous.

2 Q. (BY MS. ROHAN-WILLIAMS) Okay. Can there have

3 been on August the 23rd, despite the finding of the

4 echocardiogram report of August 23rd, a clot 2 millimeters

5 in the heart that wasn't seen?

6 A. See, now you're asking me questions about

7 definitions of echocardiogram. That's beyond my scope.

8 So I don't feel comfortable answering that.

9 Q. Thank you very much.

10 Okay. Anytime I do that, you feel free to let me

11 know.

12 A. Thank you, ma'am.

13 Q. Similarly, same question with regard to the IVC

14 filter being placed on the 25th. That would not have

15 prevented a clot or thrombi anywhere anatomically above

16 that from causing Ms. Roberts an ischemic stroke?

17 A. Correct.

18 Q. Okay. If the patient is experiencing an evolving

19 stroke, the medical literature supports administration of

20 heparin; correct?

21 A. Evolving stroke?

22 Q. Right. And it's not contraindicated.

23 A. No, that's not correct.

24 Q. Okay. What's incorrect about that?

25 A. That was correct up until 2002.

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1 Q. Okay.2 A. A body of literature came out at that time,3 2002-2003, suggesting use of heparin for arterial4 sclerotic stroke was not indicated, unless special5 circumstances. Those circumstances being atrial6 fibrillation --7 Q. Okay.8 A. -- or dissection, but not for typical arterial9 sclerotic stroke. So you said "evolving stroke" in

10 general. Most are not arterial sclerotic and, therefore,11 it would not -- heparin would not be utilized.12 Q. Understood. Thank you.13 All right. Well, what could have been -- what14 are the possibilities, the differential diagnoses, for the15 etiology of Ms. Roberts' stroke?16 A. Okay. I think I alluded to that before.17 Q. Okay.18 A. So we'll go over it.19 Q. Okay. Thank you.20 A. Cardioembolic. When you say "cardioembolic,"21 valvular.22 Q. Okay. Encompassed in cardioembolic is valvular?23 A. Well, it's one type of cardioembolic --24 Q. Okay.25 A. -- within disorder of atrial fibrillation.

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1 A. No. No. That's not my impression. I read his2 deposition. That's not my impression, no.3 Q. Okay. So you believe that Dr. Pressman's4 deposition testimony is she didn't have atherosclerotic5 disease because he could tell that visually from the6 imaging studies done?7 A. That's my impression.8 Q. All right. And do we know -- I believe we do --9 that Ms. Roberts didn't have a coagulopathy?

10 A. She did not.11 Q. Okay. I know you saw Mayo Clinic records12 subsequent to the stroke; correct?13 A. Yes.14 Q. She still has clotting issues, does she not?15 A. Well, to be more specific, she had deep vein16 thrombosis from a PICC line in her axilla, and she had17 pulmonary emboli secondary to that in late 2010 when she18 was treated at Baptist downtown.19 Q. And did you see in any of those subsequent20 records any indication of coagulopathy problems?21 A. No, I did not.22 Q. Okay. Was a connective tissue disorder ruled out23 for Ms. Roberts?24 A. Yes.25 Q. Okay. And she didn't have a dissection; correct?

98

1 Q. Okay.2 A. In this case it was a PFO.3 Q. Okay.4 A. Other causes would be a coagulopathy --5 Q. Okay.6 A. -- or a connective tissue disorder, dissection,7 large vessel disease. That would be of the carotid or8 vertebral arteries.9 Q. Okay.

10 A. That's basically it.11 Q. All right.12 A. I mean, things like sickle cell she didn't have.13 Q. Sure. Sure. And that was specific to14 Ms. Roberts.15 A. Yes.16 Q. Okay. What about atherosclerotic disease for17 her?18 A. That's a consideration but that was not present.19 In other words, I looked at her x-rays, and Dr. Pressman20 specifically commented as a neuroradiologist, that she did21 not have significant atherosclerosis.22 Q. If I'm not mistaken, didn't Dr. Pressman really23 indicate that he didn't think that she had atherosclerotic24 disease because of her age not because he had seen any25 particular films?

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1 A. She did not.2 Q. Okay. Has large vessel disease been ruled out?3 A. Yes.4 Q. And how so?5 A. Carotid ultrasound.6 Q. Okay. Subsequent to this stroke?7 A. During the course of this hospitalization.8 Q. Okay. And can you exclude thrombotic episode as9 causing Ms. Roberts' stroke?

10 A. Well, "thrombotic episode" means insight to11 arterial sclerosis. The answer is yes. Again, she does12 not demonstrate that on her X-rays.13 Q. And by that you mean the CT studies?14 A. Yes.15 Q. And is that an independent opinion of yours from16 looking at the studies, or is it reliant upon17 Dr. Pressman?18 A. Both. Again, I reached that conclusion of my own19 review and it's confirmed by Dr. Pressman.20 Q. And is it your testimony that Ms. Roberts had21 more than one stroke?22 A. Yes.23 Q. Okay. How many strokes?24 A. She had three clinical -- okay. She had one --25 when you say "stroke," she had TIA, a stroke episode. It

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1 was no permanent damage from that, because the symptoms2 improved and there was no radiographic correlate of it.3 And she had a right cerebellar infarct that's there, and4 she had a left neuro cerebral artery infarct that you can5 see radiographically as well as clinically.6 So two well-defined permanent clinical problems7 and one transient problems. So three different episodes8 of stroke.9 Q. And is it your opinion that the TIA was on

10 August 23rd?11 A. I'm sorry, ma'am?12 Q. Is it your opinion that the TIA or the stroke13 episode occurred on August 23rd?14 A. That is correct.15 Q. And the right cerebellar infarct, do you have a16 date for that?17 A. Well, it wasn't seen on the 23rd, but it was seen18 on the 24th. So I'd say the 24th.19 Q. Okay. And the left middle cerebral artery on20 8/25?21 A. That's correct.22 Q. Is it true in your experience that most cerebral23 vascular accidents are secondary to atherosclerosis.24 MR. SOWELL: Objection to form.25 A. In history that's true.

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1 A. It's your statement I take exception to.2 Q. Okay.3 A. The first line of defense in what kind of4 situation, an arterial sclerotic stroke, or what kind of5 stroke are you referring to?6 Q. Well, I was refer to an ischemic stroke.7 A. Again, I have to tried to express heparin in the8 last 10 years or so -- 11 years actually -- has not been9 considered appropriate for typical arterial sclerotic

10 stroke. There's certain -- some types of stroke for which11 it's utilized still, mainly cardioembolic disease and12 dissection. It's not used for typical atherosclerotic13 stroke, because the studies do not show its benefits.14 Any benefit, which is slight, is overcome by the15 incidence of cerebral hemorrhage.16 Q. I appreciate the clarification.17 Then heparin is the first line of defense for18 stroke caused by cardioembolic disease?19 A. That I agree with, yes, ma'am.20 Q. All right. Super.21 And similarly heparin, in a patient with22 cardioembolic disease, is useful in preventing recurrent23 stroke.24 A. Yes, it is.25 MR. SOWELL: Objection to form.

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1 Q. (BY MS. ROHAN-WILLIAMS) Is it true in your

2 experience that most cerebral vascular accidents are

3 secondary to hypertension.

4 MR. SOWELL: Objection to form.

5 A. Well, hypertension is the most common causative

6 factor of atherosclerosis so that is true.

7 Q. (BY MS. ROHAN-WILLIAMS) And in your opinion have

8 sufficient studies been performed on Ms. Roberts for you

9 to rule out atherosclerosis as causative of her stroke?

10 A. Yes.

11 Q. Would you agree that other experts might have a

12 difference of opinion on that?

13 A. Certainly.

14 Q. Okay. And that would at least include their

15 interpretation of the same studies you looked at?

16 A. I suppose that's going to happen, yes.

17 Q. Okay. Have you ever heparinized a patient

18 following an initial stroke that went on to have a second

19 stroke the following day?

20 A. Yes.

21 Q. That's happened more than once?

22 A. Many times.

23 Q. Okay. And although heparin is a first line of

24 defense, it's not 100 percent; is that correct, at

25 preventing ischemic --

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1 Q. (BY MS. ROHAN-WILLIAMS) And not only is that

2 your consensus, but that's the consensus -- not only is

3 that your opinion, that's the consensus of practicing

4 neurologists in the United States; correct?

5 MR. SOWELL: Objection to form.6 A. I think so.7 Q. (BY MS. ROHAN-WILLIAMS) You think so?

8 A. Yes, it is.9 Q. And is it true that in patients with fluctuating

10 strokes or TIAs resultant of cardioembolic disease, those

11 patients typically benefit from heparin.

12 MR. SOWELL: Objection to form.13 A. Yes, I think so.14 Q. (BY MS. ROHAN-WILLIAMS) In fact, heparin,

15 potentially in a patient experiencing TIAs from

16 cardioembolic disease, can allow that patient to avoid all

17 neurologic deficits.

18 MR. SOWELL: Objection to form.19 A. Possibly. I mean, yes.20 Q. (BY MS. ROHAN-WILLIAMS) I said "potentially."

21 A. Potentially, yes.22 Q. Okay. Is heparin -- well, let me ask you this.

23 I should allow you to finish your criticism. I'm sorry.

24 I got a little bit away.

25 We were on what I called "No. 3," which was the

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1 24th, and I believe you were telling me that Dr. Moore2 should have recommended placement of an IVC filter at3 about 2:00 p.m.4 A. Yes.5 Q. Okay.6 A. Again, "recommended" you said?7 Q. I said that actually.8 A. I thought you said ordered again.9 Q. Recommended.

10 A. Okay.11 Q. I think I got it that time, bu I understand what12 you're saying. I worked really hard to get that right.13 A. Well, the other -- the other criticism I alluded14 to before and I will complete it --15 Q. Okay.16 A. -- is his initial lack of direct discussion with17 the other physicians. In other words, in the beginning18 Dr. Moore appeared to be treating this patient in19 isolation. Okay. He gets called for the consult. As I20 said, he didn't check personally on the acuity of the21 case.22 He could have called doctor -- the primary23 physician, Dr. Pavlat. He could have called Pavlat and24 said look, Pavlat, what is the story with Ms. Roberts?25 Any reasonable neurologist would have appreciated this was

107

1 He decided to embark on the provision of the filter. All2 that should have been done on the 23rd and 24th. He3 shouldn't have waited. So I'm criticizing his4 communications with the other physicians.5 Q. Okay. Well, on the 24th wasn't Dr. Moore's6 testimony that he went in to see the patient and he went7 back in after being reconsulted with Dr. Pavlat?8 A. Apparently he came back in. There was no9 documentation of that, but I'm not dismissing that. He

10 said he came back on the 24th.11 Q. Right.12 A. But I think there's one point in time he was in13 the same unit as Dr. Pavlat and they didn't talk to each14 other. That to me is amazing. Again, a separate15 criticism is the lack of communication between Dr. Moore16 and other treating physicians, specifically Dr. Pavlat.17 Q. And Dr. Moore's criticism, in your opinion, that18 he didn't speak with Dr. Pavlat on the 24th, was that19 causative of the stroke?20 A. It's has causation affects because it didn't21 enable Dr. Moore to appropriately appreciate the entirety22 of her neurological process, her evolution. In other23 words, he was not aware, apparently, of the left-sided24 weakness of her upper and lower extremities. He was not25 aware of the headaches.

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1 an urgent situation and not to the wait six or seven hours2 before seeing the patient.3 Once -- then he didn't come the next morning. He4 gets called again by Dr. Pavlat for reconsultation. Well,5 if a doctor gets called for reconsultation, one would6 typically know, well, why am I being called back? I saw7 her yesterday. It's just carpel tunnel. Why is he8 calling me?9 If he spoke to Dr. Pavlat either on the first

10 occasion, he would have realized the patient had clear-cut11 findings of right cerebral dysfunction. If he'd spoken to12 him the second time he called for the consult on the13 morning of the 24th, he would have realized now the14 patient was having significant headaches.15 But he didn't appreciate those facets because he16 didn't either look at the chart nor speak with Dr. Pavlat.17 Had he communicated with Dr. Pavlat, then he would have18 realized that, and had a better appreciation of the whole19 scenario which was expressly Ms. Roberts'.20 Okay. After his consultation on the 24th, it21 would have been useful of him to speak with Dr. Pavlat and22 say, okay -- and discuss on the 24th what he did on the23 25th. Now, on the 25th he did communicate. He talked to24 the other doctors. He talked to Pilcher. He talked to --25 I'm not sure Dr. Pavlat. He talked to Szwed I believe.

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1 Had he said, okay, she has headaches now, coupled2 with dizziness and nausea, and right cerebral dysfunction3 on the 23rd which had gone by the time I saw her on the4 23rd, he might have had a better idea of what was going5 on; that she was -- she had recurrent embolic disease,6 despite the heparin, and would have done the proper thing7 on the 24th as opposed to waiting on the 25th.8 Q. Didn't Dr. Moore testify that he read9 Dr. Pavlat's record of the 23rd and was specifically aware

10 of why he was being consulted.11 MR. SOWELL: Objection to form.12 A. He states that.13 Q. (BY MS. ROHAN-WILLIAMS) Okay.14 A. But despite that statement, he acted as if he15 didn't. In other words, there's a disconnect here between16 that deposition testimony some years after the fact, and17 his contemporaneous activity of calling this carpal tunnel18 syndrome.19 No neurologist in his right mind would say a20 person who had left-sided upper and lower extremity21 weakness and numbness, which got better, could be carpal22 tunnel. It just can't be. The fact he documented that23 demonstrates he was apparently was unaware of that24 finding.25 Q. And similarly on the 24th, Dr. Moore was aware

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1 that Mrs. Roberts was complaining to Dr. Pavlat about2 headaches, because he went back in to check on it himself;3 correct?4 A. Again, madam, typically when the doctor comes5 back to see a patient the second time in a day, he or she6 documents that.7 Q. So you're saying --8 A. I'm not saying he didn't do it. It's unusual and9 it's something, again, that comes in a deposition years

10 after the fact. It's a little bit strange. Again, I11 don't see anything in the chart to demonstrate that.12 Q. Well, you're not accusing Dr. Moore of lying, are13 you?14 A. I'm not saying that at all. I'm just saying I15 don't see any corroboration of that.16 Q. And indeed, if Dr. Moore had gone in and then he17 talked or understood he was being reconsulted for18 headache -- his testimony was indeed he was aware she was19 experiencing headaches; correct, on the 24th?20 A. Yes.21 Q. And similarly you didn't get the nurses'22 testimony. But there is at least testimony that's23 provided in depositions that you have not seen and I24 believe record evidence in the chart, that you already25 testified to, of the fact that Ms. Roberts indeed

111

1 necessarily.2 Q. "Not necessarily." So sometimes yes?3 A. Yes.4 Q. Okay. And the utilization of heparin with5 cardioembolic disease, one of the purposes is to try to6 prevent additional emboli from forming; correct?7 A. That's correct.8 Q. Okay. What is a TEE?9 A. Transesophageal echocardiogram.

10 Q. Is that an invasive procedure?11 A. Yes.12 Q. There are risks associated with it?13 A. Yes.14 Q. Okay. What are those risks?15 A. Bleeding, esophageal tearing, hypotension.16 Q. So in a patient that already has issues17 associated with bleeding, TEE might put her at even more18 risk of bleeding?19 MR. SOWELL: Objection to form.20 A. Potentially. The cardiologist typically does it21 while taking into consideration the patient's situation,22 whether the benefits of it outweigh the risks.23 Q. (BY MS. ROHAN-WILLIAMS) And that's in the24 cardiologist's purview?25 A. That's correct.

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1 experienced intermittent headache on the 24th; correct?2 A. Sure. But that does not negate anything. The3 fact that she had headaches, intermittent or constant, is4 significant coupled with the nausea and the dizziness.5 None of which are documented by Dr. Moore.6 Q. It seemed to me that you were disputing, as one7 of your criticisms, that he was not aware she was8 experiencing headache on the 24th?9 A. I see no evidence he incorporated that into his

10 thinking.11 Q. Okay. All right. I was calling that criticism12 No. 4.13 A. Okay.14 Q. Are there more?15 A. No, ma'am.16 Q. Okay. All right. Then let me see if I can't get17 wrapped up here.18 Just curious. Does MRI examination require a19 patient be off heparin?20 A. No, it does not.21 Q. Okay.22 A. If you have a certain kind of pumps with metallic23 things, you may need to clamp it for that 15 or 20 minutes24 the patient is in the machine. It depends on the type of25 delivery system that's being utilized, but not

112

1 Q. As he or she is the one performing that test;

2 correct?


4 Q. Would you agree that patients who are critically

5 ill are not appropriate candidates for a TEE?


7 A. Again, it depends. It's a case-by-case scenario,

8 and I would defer to a cardiologist making that

9 determination.

10 Q. (BY MS. ROHAN-WILLIAMS) Very good.

11 Would you agree that if there's a thrombus in the

12 heart which has emboli in it or potential emboli, that

13 condition is treated by giving heparin?


15 A. Yes.

16 Q. (BY MS. ROHAN-WILLIAMS) And that purpose of the

17 heparin is to reduce the chances of provocation of that

18 emboli coming off the thrombus and going into the

19 bloodstream?



22 Q. (BY MS. ROHAN-WILLIAMS) Would you agree that

23 despite the length of time the thrombus has been sitting

24 in the heart, the sooner you give heparin the more likely

25 you'll prevent production of emboli?

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1 A. Yes.2 Q. You agree, sir, that stroke has low incidents3 before the age of 50 years?4 MR. SOWELL: Objection to form.5 A. Low?6 Q. (BY MS. ROHAN-WILLIAMS) Yes.7 A. Much lower than after 50. In other words,8 starting at age 50, the incident of stroke doubles every9 10 years. So certainly at age 50 and below, the incidents

10 are relatively small compared to the general population.11 Q. Okay. What are the signs and symptoms of stroke?12 A. Okay. Confusion, speech difficulty, loss of13 consciousness; visual change, either blurring or loss of14 vision unilaterally or bilaterally; diplopia which is15 double vision, facial numbness, facial weakness,16 swallowing difficulty, slurred speech; aphasia, which is17 inability to express one's self or understand; weakness18 typically unilaterally of an extremity, arm or leg, or19 often the arm or it could even bilaterally; trouble with20 gait and balance. Those are the primary symptomatologies.21 Q. Okay.22 A. And headache, of course. More likely for23 hemorrhagic stroke, but also for embolic, and less likely24 for thrombotic stroke. Dizziness. If I did not mention25 that, I'll add that to the mix.

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1 record is inconsistent as to complaints of dizziness for2 Ms. Roberts on August 23rd and 24th?3 A. Inconsistent. If you're asking me did she have4 it consistently, no. She had it only periodically.5 Q. Okay.6 A. If that's your condition -- I'm sorry. She did7 not have dizziness consistently in those two days. She8 had it intermittently.9 Q. Right. Because sometimes dizziness would be

10 assessed and it would be there, and sometimes it would be11 assessed and it wasn't there; correct?12 A. I agree with that statement, madam.13 Q. Similar to a headache?14 A. Yes.15 Q. Okay. And numbness, that is not weakness, is it?16 A. No, it's not.17 Q. They're different?18 A. Absolutely.19 Q. Okay. As a neurologist is there a distinction to20 you between dizziness and vertigo?21 A. Yes.22 Q. Tell me about that distinction, please.23 A. Dizziness is less specific. It's typically a24 sensation of -- could be one feels they're passing out, or25 where vertigo is typically a whirling sensation. So it's

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1 Q. Okay. Does a decrease in blood flow to the2 brain, or ischemia, cause headache?3 A. Typically that description you've given is -- if4 it's from atherosclerotic, thrombotic stroke, typically5 not.6 Q. Okay. And the brain, it does not have any nerve7 endings in it; correct?8 A. Say that again.9 Q. The brain -- I'm sorry -- does not have nerve

10 endings, does it?11 A. Well, the brain has nerves throughout -- through12 it. It's not nerve endings. It's different than the13 peripheral nerves. The brain is the master.14 Q. Does the brain feel pain?15 A. The thalamus. In other words, the thalamus and16 the cortex feel pain.17 Q. Okay. Are there nerve endings in the thalamus18 and the cortex?19 A. Yeah. They're nerve nuclei. They're nerve20 centers.21 Q. Okay. And you would agree that dizziness is a22 symptom that can range from very serious conditions to23 benign conditions; correct?24 A. Yes.25 Q. Would you agree that the record -- hospital

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1 usually -- could be suggesting something in their2 vestibular nuclei or in the inner ear, one of those two3 areas.4 Q. Is vertigo more specific to the probability of a5 defect in the nervous system as opposed to general6 dizziness.7 MR. SOWELL: Objection to form.8 A. One has to inquire of the patient more9 specifically what he or she means by dizziness. It may

10 be. Verdict could be an inner ear process also. So the11 answer is you can't necessarily say which is more likely12 to be of essential origin just by the two names.13 Q. Well, if you as a neurologist are assessing a14 patient, a neurologic patient, and you find dizziness but15 not vertigo, are they less likely in your opinion as a16 neurologist to have a neurologic problem than if you were17 to elicit what you determined was vertigo?18 A. No.19 Q. So it could be either one?20 A. That's correct.21 Q. Okay. Is it -- is it -- can I take from that,22 that dizziness is a broad category as opposed to vertigo23 being a type of dizziness?24 A. Yes, I think that's a fair statement.25 Q. Okay. All right. Now dizziness and nausea

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1 together could be consistent with inner ear infections; is2 that right?3 A. That could be, yes.4 Q. Okay. And together with that constellation you5 might even have headache?6 A. It's unusual to have headache with inner ear7 problems. Anything is possible, but usually not.8 Q. Might one have other problems with an inner ear9 infection such as a cold or upper respiratory infection,

10 thereby having headache?11 A. Yeah. I mean, that potentially is true.12 Q. Okay. Is there any aspect of neurology that you13 are not comfortable opining about?14 A. Yeah, there may be some things. Neurology has15 become very specialized.16 Q. Okay.17 A. And some things -- very complicated neuromuscular18 things, I would defer to a neuromuscular specialist.19 Neuro-ophthalmology certainly -- there's some complicated20 things there which I didn't see in everyday practice.21 But other things like stroke, brain tumor,22 epilepsy, which I deal with on an everyday basis, I feel23 comfortable about opining.24 Q. Okay. Have you testified at trial, do you think,25 more than 100 times?

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1 Q. Do you believe that you committed any aspect of

2 negligence in any of those cases?

3 A. I do not.

4 MR. SOWELL: Objection.

5 Q. (BY MS. ROHAN-WILLIAMS) Did any of those four

6 suits or matters involve the issue of stroke?

7 A. Yes.

8 Q. How many of them?

9 A. One.

10 Q. Okay. Was that patient's name Marie Joseph?

11 A. It was.

12 Q. Okay. All right. Is Dr. Moore the only

13 defendant in this case of whom you have criticisms?

14 A. None of the other physicians.

15 Q. Okay.

16 A. Potentially the hospital on some credentialing

17 issues, but I have not formulated opinions because the

18 things I have asked for I have not received.

19 Q. Okay.

20 A. I've asked Mr. Sowell to inform me -- I'm not

21 sure whoever represents them -- once those things are

22 obtained and I review them, and I form additional

23 opinions, he will make me available for further inquiry.

24 Q. Okay. Well, what have you asked for that you

25 have not received?

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1 A. Yes, I think I have now.2 Q. Okay. You've certainly given hundreds of3 depositions.4 A. Yes.5 Q. You think it's reached a 1,000?6 A. No.7 Q. How much of your income currently is derived from8 medical-legal work such as this?9 A. 15 to 20 percent.

10 Q. What's the highest it's been in your career?11 A. About 12 years ago there was one year or parts of12 a year -- it spanned, like, from part of one year to13 another where I had a huge number of reviews for motor14 vehicle accident cases. It was one of the major insurance15 carriers was clamping down on excessive use of diagnostic16 studies like EMG -- nerve conductions.17 I had a whole slew -- I mean, every day five or18 ten cases to review. So maybe that year it was 25 percent19 of my income. That was a one-year period of time and20 that's dissipated, and it's been very consistent21 otherwise.22 Q. All right. And have you been, yourself, the23 subject of medical negligence?24 A. Four times, all dismissed, no payments. Most25 recently 1997.

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1 A. Their policies and procedures, their2 credentialing criteria, about Dr. Moore particularly3 because Dr. Moore was not a board certified neurologist.4 He was credentialed. He was probably Director of5 Neurology which is peculiar.6 It's unusual for a hospital of this size to have7 a non-board certified physician in charge of a department.8 So I wanted to see the criteria of the hospital's rules9 and regulation, things of that sort, and the credentialing

10 criteria to opine on that further.11 Q. How long ago did you ask for that information?12 A. I'm sorry, ma'am?13 Q. How long ago did you ask for that information?14 A. Let's see. We had a conversation, Mr. Sowell and15 I, several weeks ago. So I can't give you the exact date16 but...17 Q. Okay. You did not review any imaging studies18 evidencing embolus originating or being present in19 Ms. Roberts' heart, did you?20 A. If you're asking me did I look at echocardiograms21 and stuff, no, I couldn't.22 Q. I'm not asking you to do it. I'm just asking if23 you did.24 A. No.25 Q. Did you look at --

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1 A. I wouldn't anyway. But the answer is no, I did2 not.3 Q. Okay. In looking at imaging studies of4 Ms. Roberts, did you see any evidence of small vessel5 disease?6 A. Minimal.7 Q. And what is it that you saw that allows you to8 say you saw minimal evidence?9 A. I didn't -- I didn't see it. In other words,

10 usually you see areas of multiple areas of ischemia and11 drop out. You don't see that. You see a very specific12 area of the right cerebellar infarction. You see a very13 specific large area of encephalomalacia from the left14 middle cerebral artery infarction. You don't see multiple15 areas of small stroke other than that.16 Q. Can a small vessel disease lead to ischemic17 stroke?18 A. Sure.19 Q. What causes cerebral thrombosis?20 A. Well, again, differential of that is embolic21 versus thrombotic.22 Q. Okay.23 A. Embolic is either large vessel disease,24 cardioembolic disease. And thrombotic is arterial25 sclerosis primarily. Other considerations would be

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1 That's the scenario that happened.2 Q. Okay. Would you say that your review -- excuse3 me -- your consultation of Ms. Roberts equated to an IME?4 A. Yes, it was.5 Q. Okay. And were you paid separate and apart from6 that as opposed to --7 A. It's in that billing and $800.00 was the charge8 for that visit.9 Q. So Ms. Roberts flew down here?

10 A. Let's see. Yes, she and her husband came in by11 plane.12 Q. Okay. And I believe your note said "with a13 13-year-old niece."14 A. Yes.15 Q. You don't know her name, do you?16 A. No, I don't know her name.17 Q. Okay. Was she actually seen on the 12th of18 August of this year?19 A. That's correct.20 Q. Was she seen here where we are currently?21 A. My examining room is right across there22 (indicating).23 Q. Okay. All right. And she was in a wheelchair at24 that time, did you say?25 A. She was.

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1 dissection and vasculitis and coagulopathy.2 Q. Now you actually did examine Ms. Roberts;3 correct?4 A. Yes, ma'am.5 Q. Okay. And now tell me -- you might be6 reiterating, but tell me how that came about?7 A. At some point in time Mr. Sowell and I discussed8 damages and gotten me additional records. Neurologically9 these went up to late 2011. And I asked Mr. Sowell

10 whether he would be talking about damages. He said,11 "Yes."12 I said, "Well, what was her neurologic13 examination subsequent to that?"14 I mean, the reason why that -- well, she had the15 episode in August 2010. Therefore, you reach likely16 maximum medical improvement from the stroke by about 18 to17 24 months, which would take us no later than August 2012.18 But I only saw an examination by a doctor in 2011.19 Therefore, I really did not have a full idea of the extent20 of her damages.21 I said it would be useful to see -- "Well, who22 has seen her since then?"23 He said, "Nobody."24 Then it came about it may be worthwhile for me to25 see her, so I can see directly what her damages were.

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1 Q. Okay. And tell me -- first off, how long was2 your examination?3 A. You say "examination." The time I spent with her4 was over an hour.5 Q. Okay.6 A. I can't tell you -- I can't compartmentalize how7 much was talking to her, how much was examining her8 physically.9 Q. Sure. And of course, you would have the benefit

10 of looking at her records prior to even seeing her because11 you had them for a year and a half; correct?12 A. That's correct.13 Q. And had you asked, in anticipation of this IME14 from Mr. Sowell, for any current records?15 A. Well, that's what came about. I wanted to know16 her neurological status.17 Q. Okay. So the last neurological assessment you'd18 seen was by Dr. Eidelman at Mayo Clinic; right?19 A. That's correct.20 MS. ROHAN-WILLIAMS: Did we ever find Helen21 Sackett's records in here?22 MR. SOWELL: I have not looked.23 MS. ROHAN-WILLIAMS: Okay.24 MR. SOWELL: I don't see them, because it was a25 pretty significant notebook.

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1 MS. ROHAN-WILLIAMS: Okay.2 Q. (BY MR. ROHAN-WILLIAMS) All right. Do you3 actually recall seeing Dr. Sackett's records?4 A. Yes, I did.5 Q. Okay. But you don't know the time frame that6 they span?7 A. That was probably in the last couple of months.8 Remember, at some point in time I wanted to get an update.9 Q. Okay.

10 A. And he sent me those records. That being11 Dr. Sackett's, and there was no neurological thing in it.12 And her neurological examination was very pithy. It did13 not really say much. So that's when it came back and we14 determined I would cease. So it probably was sometime in15 July of this year. I couldn't say with specificity.16 Q. Did you ever ask for Dr. Sackett's deposition17 transcript?18 A. Mr. Sowell mentioned to me that it was taken, but19 I guess he didn't think it was significant enough for me20 to read. The answer is I didn't ask for it.21 Q. And you weren't provided it?22 A. That's right.23 Q. All right. Did you ever ask to speak to24 Dr. Sackett?25 A. No, I did not.

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1 come from the records.2 And basically, I would say, the last paragraph on3 the second -- I'm sorry. If you go to the second page,4 the third paragraph down, that came from Mr. Roberts5 himself.6 Q. Okay.

7 A. I asked, "How is she doing now?" And he just8 voiced to me how she was doing.9 Q. Okay.

10 A. By the way, I did ask him about the weight, and11 he said, "about 400 pounds" is what he thought.12 Q. All right. Back to page 1 which says,

13 "Unfortunately, the morning" -- which I'm pretty far down

14 the page. I guess it's the second up from the bottom.

15 "Unfortunately, the morning of 8-25-10 Ms. Roberts

16 deteriorated with aphasia and right-sided weakness."

17 The aphasia really occurred around lunchtime;

18 correct?

19 A. Yes.20 Q. Okay. And it was acute onset, was it not?

21 A. That's correct.22 Q. Okay. Okay. And your -- top of page 2, your

23 first paragraph talks about "TEE performed 8-31-10

24 confirmed a PFO" -- "It was decided to utilize Coumadin

25 eventually. After stabilization, Ms. Roberts was

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1 Q. Okay. Prior to seeing the Roberts on August the2 12th of this year, had you spoken to Mr. Roberts?3 A. No, I had not.4 Q. Okay. So tell me -- kind of take me through this5 note which I really honestly have not had a chance to6 fully review.7 A. Basically the first -- the first page and a half8 is history. So there's nothing in there that you don't9 know.

10 Q. Okay. Is the history -- is it written by you11 strictly pursuant to review of the records and your12 knowledge about this case or did you take some of this13 from the Roberts?14 A. Both. In other words, I wanted to know from him15 what he remembered.16 Q. Okay.17 A. Mrs. Roberts herself really couldn't give much18 history. She was aphasic and he was her spokesperson.19 Q. Anyway, let's just take page 1 of record.20 Is there any way to parse out what was told to21 you by Mr. Roberts versus what you know from the case?22 A. No. It was a composite of what he told me -- he,23 Mr. Roberts, told me when I had seen him previously. I24 couldn't say -- anything that's medical in names,25 Mr. Roberts is not particularly sophisticated. That would

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1 transferred to rehab. The patient never received any2 intervention for the PFO itself."3 To what are you referring? What intervention?4 A. Closure.5 Q. To date she has not received closure of the PFO?6 A. That's correct.7 Q. Is that something you have an opinion on one way8 or the other, whether it should have been closed or not9 closed?

10 A. Studies have been negative about that. So I11 probably would not recommend any intervention of it.12 Q. Okay.13 A. I'm not saying it's a negative. I'm saying14 there's no definite evidence that closure of the PFO would15 reduce the chances of stroke.16 Q. Correct. Exactly. No benefit.17 "Subsequent to her hospitalizations,"18 paragraph 2, "Ms. Roberts has stabilized with slow very19 partial improvement in her status. This year she has had20 2 admissions to Baptist for respiratory complaints. She21 has had no new stroke episodes."22 So this year being 2013?23 A. May I see this? He, Mr. Roberts, was very vague.24 When I got this, I asked Mr. Sowell for the -- I received25 the Jackson -- I'm sorry, not Jackson -- the Baptist main

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1 records which you have.2 Q. Okay.

3 A. I was trying to get an idea of what was going on4 in these admissions. He is not very sophisticated. And I5 got them. It's not quite what he suggested to me. It's6 not for lack of being cooperative, he is just not a very7 sophisticated man.8 Q. In other words, it's hard to get information from

9 Mr. Roberts?

10 A. Not hard. He is not a physician. He is not a11 professional individual. So he'll give you a history.12 It's a little diffuse.13 Q. The information he provides is not always

14 accurate; is that you're finding?

15 MR. SOWELL: Objection to form.16 A. It's not that. He's not that articulate. He's a17 nice man but he is not sophisticated.18 Q. (BY MS. ROHAN-WILLIAMS) Sure.

19 And as a result, does he give you information on

20 occasion that is inaccurate?

21 MR. SOWELL: Objection to form.22 A. I would say more inexact than inaccurate.23 Q. (BY MS. ROHAN-WILLIAMS) Okay. "The current

24 situation is" -- so Ms. Roberts continues with difficulty

25 with her speech?

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1 this. I could tell she was alert and comprehended, but2 beyond that you really can't do a good exam because of the3 severe aphasia.4 Q. Okay. If that's true, why would you write, "She5 has good comprehension and cognition," if you didn't think6 that was the case.7 MR. SOWELL: Objection to form.8 A. I said, quote, mental status: Alert,9 comprehended well. Difficult to have detailed assessment

10 because of her aphasia, which is what I'm trying to11 express to you.12 Q. (BY MS. ROHAN-WILLIAMS) Okay.13 A. Now before that, I'm saying what he says,14 Mr. Roberts, he thinks that she understands pretty well.15 I think it's less than that, because based on my16 evaluation I can't do a detailed examination for the17 reasons I expressed to you.18 Q. Okay.19 A. Then the cranial nerves -- she had reduced facial20 sensation and corneal responses. She had right facial21 asymmetry. She had reduced swallowing and reduced22 shoulder shrug. Her motor examination was very abnormal23 with a spastic right-sided weakness, graded 1 over 5 in24 the arm, and 2 to 3 over 5 in the right leg with25 significant increased tone. Her strength in the left side

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1 A. Yes.2 Q. Okay. Is she able to write -- handwrite things?3 A. Very minimally. As I try to have her do that,4 she would just put her pencil on the paper and she would5 be all over the place.6 Q. Okay. All right. How did you find, physically,7 Ms. Roberts to be when you evaluated her in August?8 A. Morbidly obese. She comprehended pretty well,9 but you couldn't do subtle things. When a person is that

10 aphasic, you can't do typical mental status testing. You11 can't do numbers. You can't do calculations. You can't12 do repeated objects. So I get the feeling that while she13 was alert and she comprehended, at least superficially, it14 was at a low level. Like a juvenile level so to speak.15 Again, I could not do a typical kind of cognitive16 examination I normally do with severe aphasia.17 Q. Nonetheless you found in your examination,18 however, as you documented, that Ms. Roberts had good19 comprehension and good cognition?20 A. She seemed -- she was alert.21 Q. Okay.22 A. But, again, one cannot do a typical mental status23 examination. You cannot do a mini-mental status test with24 30 questions, things like that. So maybe a25 neuropsychologist can do a better job than I can limiting

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1 was normal.2 On the sensory examination all modalities on the3 right side were reduced. Her reflexes were abnormal with4 a right Babinski, and she had what's called cortical5 release signs.6 Coordinating examination -- you could not test7 coordination on the right because of weakness. Left side8 coordination was normal.9 The gait -- she was in a wheelchair. I attempted

10 to get her up. I could get her up, but she couldn't walk11 on her own. She needed to be helped, and she was a very12 heavy person. So I didn't want to hurt my back.13 Q. Did Mrs. Roberts she was able to walk on her own14 at home?15 A. She walks with a cane, but he has to be there16 with her because she's very unstable is what he told me.17 Q. I note on page 2 where it says, "Operations," you18 say "total abdominal hysterectomy, revision of IVC19 filter."20 A. It should be provision. That's a typo. I'm21 sorry.22 Q. Okay. So --23 A. P-r-o-v-i-s-i-o-n.24 Q. Sometimes when you chart on your patients you25 make typographical errors?

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1 A. Yes.

2 Q. And that happens with neurologists sometimes;

3 correct?

4 A. All doctors.


6 Q. (BY MS. ROHAN-WILLIAMS) All doctors.

7 A. Even lawyers, too, maybe.

8 MR. HARMON: Object to form.

9 Q. (BY MS. ROHAN-WILLIAMS) Let's go down to your

10 impression, then. All right.

11 Okay. Can you read your impression for me into

12 the record, please, sir?

13 MR. SOWELL: It's typed.

14 A. Sure.

15 MS. ROHAN-WILLIAMS: I am paying five hours of

16 his time. I think he could give me at least three.

17 MR. SOWELL: That's fine. But at the end of five

18 hours I don't want to hear this wow, you know --

19 MS. ROHAN-WILLIAMS: I will be done in about 10

20 minutes.

21 A. "Ms. Margaret Roberts is an unfortunate young

22 woman with risk factors for stroke who entered

23 St. Vincent's Hospital 8-23-10 after a recent hysterectomy

24 with DVT, pulmonary emboli, and focal neurological

25 findings. Unfortunately, the treating physicians failed

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1 Q. And why is that?

2 A. Because she still has the same PFO sitting there.3 Q. Okay.

4 A. And she has the propensity for developing more5 clots. She'll need to have modifications to her home. I6 mean, the husband told me there's been some but he can't7 forward to do more. And she can't fit into a lot of the8 rooms and it's very difficult for her to navigate.9 Q. What kind of modifications does she need to the

10 home?

11 A. I don't know. She needs to have an analysis of12 her home. This is something beyond my scope. I'm not a13 physiatrist. So I would not -- I need to see what she14 has, what she needs, what her bathroom sizes are. There15 are things like that which need to be measured. I guess16 the life care planner and a physiatrist would do that.17 Q. I'm specifically asking you, the neurologist

18 who's looked at Ms. Roberts, for the purpose of damages,

19 performing an IME, you said if Dr. Deutsch were to contact

20 you, would have some opinions with regard to significant

21 treatment needed to avoid further episodes and improve the

22 quality of her life.

23 A. Okay.24 Q. I'm asking you if Dr. Deutsch were to contact

25 you, Dr. Kenneth Fischer, what would you indicate

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1 to appreciate in a timely fashion the possibility of

2 paradoxical cerebral embolization stemming from a PFO and

3 effective treatment was not instituted. This allowed the

4 development of a major left middle cerebral artery

5 infarction manifest 8-25-10 which has left Ms. Roberts

6 with the symptoms and findings delineated above. As this

7 episode was nearly 3 years ago, the patient has already

8 achieved any possible spontaneous recovery and will be

9 left with her current symptomatology and neurological

10 deficit. She will need significant treatment to avoid

11 further episodes and to improve the quality of her life,

12 which has been severely diminished by the major stroke

13 sustained."

14 Q. (BY MS. ROHAN-WILLIAMS) Have you been asked or

15 will you be making any recommendations as to the

16 quote-unquote significant treatment needed to avoid

17 further episodes and to improve the quality of her life?

18 A. Well, if indeed her life care planner

19 Dr. Deutsche were to contact me, I would be glad to speak

20 with him in terms of my considerations for her needs. I

21 have not had that opportunity. I'm not sure what's going

22 to happen.

23 Q. Okay. And if indeed Dr. Deutsche were to so

24 contact you, what recommendations would you make?

25 A. She needs to have ongoing anticoagulation.

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1 Ms. Roberts needs for those purposes?2 A. Okay. We're talking about anticoagulation and3 someone to monitor it. I guess Dr. Sackett or somebody4 else. Okay. She would need to have an accessible5 bathroom. She'd need to have proper wheelchairs,6 motorized and simple, a van or some car which is easily7 accessible to her.8 She would need to have aid and attendants 24/7,9 be it her husband, or someone else if she is not

10 available. Probably the current situation is he is there11 most of the time. He gets respite from some neighbors or12 friends.13 She'll need to have a visiting nurse14 periodically, either to draw blood from her if Dr. Sackett15 is not drawing the blood regularly, or to just see her --16 check her situation.17 She'll need to have a -- she doesn't need18 long-term physical therapy, and occupation therapy, and19 speech therapy. She probably should have an evaluation.20 If she did have some in a truncated fashion after stroke21 but not that much, it may be worthwhile to do an22 evaluation and have someone review the evaluation to see23 if a short-term period of therapy would be useful.24 It's not going to effectuate a major structural25 change in the status at this stage, but at least get her

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1 to a little better state. It may or may not be useful.2 An evaluation would be a start and someone -- a doctor3 would look at those evaluations to determine if additional4 efforts are useful.5 There may be some durable medical equipment.6 She'll need shower adjustments and special grab rails in7 the house. Again, she needs an analysis of her home to8 see what -- whether the home itself can be modified to9 accommodate her or whether she needs a new home. I don't

10 know. Maybe the home itself is fine. Certain things need11 to be done in terms of ramps. I think Mr. Roberts told me12 he built some kind of a ramp to help her wheelchair --13 getting out of the house. What that is exactly, I don't14 know.15 Q. Okay. And is that exhaustive?16 A. Again, those are the main things.17 Again, when someone does a home analysis of her,18 I'll be able to comment more on what she would need.19 Q. And what are -- Ms. Roberts has always had the20 PFO; correct?21 A. Sure. It was congenital.22 Q. And despite the strokes that occurred during the23 St. Vincent's hospitalization, arguably she would always24 have needed anticoagulation for the propensity to develop25 clots; correct?

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1 addition to her other problems.2 Q. Well, sure. And if her body size were reduced,3 in all likelihood she would need less modifications to her4 home and her bathroom; correct?5 A. Maybe. Someone should do an analysis of the size6 and I have not seen that.7 Q. Okay. As far as this visiting nurse8 periodically, are you specifying any more specific time9 frame periodically?

10 A. I would need to know how often she sees11 Dr. Sackett on a regular basis. That may not be necessary12 if she sees Dr. Sackett every two weeks.13 Q. Sure.14 And don't you think Dr. Sackett's record and/or15 deposition testimony might be helpful in that regard?16 A. It might be, yes.17 Q. All right. What is a positive Tinel's sign?18 A. Positive Tinel's sign?19 Q. Yes, sir.20 A. The physician takes the patient, extends the21 wrist, as I'm doing, takes the reflex hammer and taps on22 the wrist. And if a positive Tinel's sign occurs, the23 patient will experience a burning-tingling sensation,24 emanating from the wrist and spreading into the thumb,25 index and the -- part of the middle finger. That's

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1 A. Well, you wouldn't know that until the stroke. I2 see what you're saying. Let's put it this way, PFOs are3 not that uncommon. Often they're small. A quarter of the4 American population has them. You don't necessarily5 coagulate them. If you're symptomatic -- and this lady is6 symptomatic -- then you anticoagulate. You wouldn't know7 until she -- after something had happened to her.8 Q. Okay.9 A. Is it because of Dr. Moore or anybody else's

10 negligence that she had to be?11 Q. Right.12 A. No, it's not.13 Does she need anticoagulation because of14 Dr. Moore? No.15 Q. Exactly. She would have needed it independent of16 these parties -- defendants' actions; correct?17 A. I would agree with that.18 Q. All right. And I believe you said -- and you can19 correct me if I'm wrong -- part of the difficulty20 Ms. Roberts' has experienced in moving about her home is21 due to her weight?22 A. That's a factor. I think she may need to have23 consideration of bariatric surgery. Now, again, that's24 endogenous problem. I would not attribute that to the25 malpractice. Nonetheless, that's a need she has in

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1 suggestive strongly of carpal tunnel syndrome.2 MR. SOWELL: Tiffany, I don't mean to interrupt.3 Did you have an appointment at 12:15? We were4 told you had an appointment.5 THE WITNESS: No, it's all right. I'll go on.6 MS. ROHAN-WILLIAMS: Okay.7 THE WITNESS: It will make it easier on everybody8 and we could finish. We may briefly stop at some9 point.

10 Q. (BY MS. ROHAN-WILLIAMS) By all accounts11 Ms. Roberts was alert, oriented and fluent on August 23rd12 and 24th, and even on the 25th prior to lunch; correct?13 A. According to who, madam?14 Q. According to the chart.15 A. Oh, yes. Yes, I agree with that.16 Q. Okay. If a patient reports to you tingling and17 numbness in an upper extremity from the fingers to the18 shoulder, is that indicative of any condition or19 conditions to you as a neurologist?20 A. Yes.21 Q. What?22 A. Just from that it could be right cerebral, or23 cervical, or brachial plexus.24 Q. What is cervical?25 A. Neck.

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1 Q. Cervical radiculopathy?2 A. Possible.3 Q. Because you told me before that numbness is not4 weakness?5 A. That's correct.6 Q. Okay. Okay. Have I covered all of the7 criticisms that you have against Dr. Moore?8 A. Yes, ma'am.9 Q. Okay. And I've covered all of the causation

10 arguments you expect to render in this case as well;11 correct?12 A. Yes, ma'am.13 MS. ROHAN-WILLIAMS: Okay. I believe I am done14 for now, and I thank you for your time.15 THE WITNESS: Thank you, madam.16 MR. HARMON: I might have a lot of question to17 follow-up probably. So if we need to take a break,18 let's take one.19 THE WITNESS: You said a lot?20 MR. HARMON: Yes.21 THE WITNESS: Okay. That's okay.22 Who do you represent, sir?23 MR. HARMON: The hospital.24 THE WITNESS: Okay.25 (Deposition adjourned at 12:15 p.m. and resumed

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1 a vote. There may be others. The one for brain injury is2 proposed. It's not approved yet.3 Q. Is what's been proposed going to include the4 diagnosis, treatment of stroke?5 A. No. Well, there's some overlap in the brain6 injury -- stroke is a form of brain injury.7 THE WITNESS: Maybe that's Mr. Kuntz. Yes, it8 is.9 MR. HARMON: Hello.

10 (Interruption.)11 THE WITNESS: I was starting to say, sir, there's12 some overlap in terms of brain injury that would13 encompass stroke. That subspecialty contemplated in14 2014, I have not seen the particulars of it. I just15 recently heard about it. It's different than the16 stroke certification.17 I'm not sure exactly if it's an approved18 subspecialty of the American Board of Neurology and19 Psychiatry. It may be some other board. I'm just not20 sure.21 (Interruption.)22 THE WITNESS: Mr. Kuntz?23 MR. KUNTZ: Yes.24 THE WITNESS: We gotcha. Good.25 MR. KUNTZ: Thank you.

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1 at 12:55 p.m.)2 MR. HARMON: Counsel, I think Mr. Kuntz was on3 the phone. He signed off at some point.4 MR. BARBOUR: I think he left it all to you,5 Mike.6 MR. HARMON: Yeah. But he just texted me, "Like,7 when are you starting?"8 I'm like, "Right now."9 CROSS-EXAMINATION

10 BY MR. HARMON:11 Q. If everybody's ready, we better get started.12 All right. Dr. Fischer, my name is Michael13 Harmon. I represent St. Vincent's Medical Center. Good14 afternoon.15 A. Good afternoon, sir.16 Q. Thanks.17 Earlier you were asked some questions about the18 subspecialty certifications that you could obtain as a19 neurologist. Is there also one called brain injury20 medicine? Are you familiar with that subspecialty?21 A. That's in process. It's not an approved -- in22 other words, it's an American Board of Psychiatry and23 Neurology and Neurology, and they have certain approved24 subspecialty things like child neurology, cognitive25 neurology. I think it's -- EMG, nerve conduction study's

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1 Q. (BY MR. HARMON) And so I take it you're not that

2 familiar with that subspecialty?

3 A. Well, I'm familiar with what the subspecialty is.4 I'm not familiar with the exact board delegation that has5 been formulated.6 Q. Is that something that you've looked into for

7 purposes of possibly obtaining?

8 A. No, I've not personally.9 Q. When you first joined North Shore Medical Center,

10 was there a requirement that you be board certified in

11 some sort of area of medicine?

12 A. It was required to either be -- at that time it13 was either "board certified" or so-called "board14 eligible." The hospital subsequently has required either15 as board certification -- if you were not board certified,16 they gave you a particular time frame in which you can17 become board certified.18 I was not board certified when I got to staff. I19 was just finishing my residency. I became board certified20 within a year of applying here. So that's -- it didn't --21 it never really pertained to me after that.22 Q. To become board eligible you have to have

23 practiced as a neurologist for a while and have peer

24 reviews done that are submitted to the board; is that

25 correct?

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1 A. No, that's not correct, sir.2 Q. What is it then that's required to become board3 certified currently as a neurologist?4 A. Completing an approved residency.5 Q. And you had to take an exam?6 A. To become board eligible or board certified?7 Q. Board certified.8 A. Yes. Now it's changed again. Now it's only a9 written examination. It used to be first an oral

10 examination and the following year a written examination.11 Q. And you don't have to have any kind of peer12 reviews submitted to the board from anyone?13 A. No, not in neurology.14 Q. And to sit for the exam you don't have to have15 practiced as a neurologist for a while; you just come16 straight out of training?17 A. Finish your residency and on day one -- it works18 out chronologically. There's some latency. Board's are19 in April. If you finish your residency in June, it's like20 an eight-month wait most times to get your exam.21 Q. Who are the four neurologists that you spoke22 about earlier that practice at North Shore?23 A. Dr. Goldberg, Dr. Maldonado, Dr. Landess, spelled24 L-a-n-d-e-s-s, and Dr. Saldanha, S-a-l -- S-a-l-d-a-n-h-a.25 Q. And I noticed there are some other neurologists

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1 consulting role for rehabilitation, but he didn't practice

2 neurology here.

3 Q. Do you know why he is listed on the -- and still

4 is listed on the website as a neurologist?

5 A. He is a neurologist, but he was acting as

6 neurorehabilitation. I think he's board certified in a

7 separate -- called neurorehabilitation.

8 Q. I noticed on your CV which I would like to attach

9 as another exhibit to your deposition.

10 MS. ROHAN-WILLIAMS: No. 3.

11 MR. HARMON: Exhibit 3 to your deposition. We

12 were provided one earlier.



15 Q. (BY MR. HARMON) Do you know when this was last

16 updated?

17 A. In January of 2013. Eight months ago --

18 nine months ago.

19 Q. I think there's four articles listed here that

20 you've authored.

21 A. Yes, sir.

22 Q. Do any of them have anything to do, or touch on

23 the subjects that are part of your opinions you provided

24 today?

25 A. They do not.

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1 listed on the hospital's website as well.

2 Do you know why they are listed or do they not

3 practice here but just have some privileges?

4 A. Yes. Those are the only ones who practice here

5 besides me.

6 Q. Do you know Pedro Cardich?

7 A. He's in Oklahoma.

8 Q. He's in Oklahoma?

9 A. Yes.

10 Q. Do you know why his name is still on the

11 hospital's website?

12 A. They are slow in taking him off.

13 MR. SOWELL: May I have a standing objection to

14 anything about North Shore Medical Center? It will

15 prevent me from interrupt you.

16 MR. HARMON: I'm not sure what's the basis.

17 MR. SOWELL: It's completely irrelevant to the

18 pleadings as they stand right now.

19 Q. (BY MR. HARMON) Okay. In any event, do you know

20 whether or not Dr. Cardich is board certified in

21 neurology?

22 A. To my knowledge he is not.

23 Q. Did he ever practice at North Shore Medical

24 Center?

25 A. Not in recent years. He was -- had some sort of

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1 Q. Have you ever been disciplined by any of the2 organizations that you are a part of or were a part of in3 the past?4 A. No, sir.5 Q. Have you ever had your license suspended or6 revoked?7 A. No, sir.8 Q. Have you ever been disciplined by a hospital?9 A. No, sir.

10 Q. Have you ever been convicted of any crimes?11 A. No, sir.12 Q. What's the percentage currently of your work for13 plaintiff versus defendants in medical malpractice14 lawsuits?15 A. I'd say in the last five years it's been 90/10.16 I would say this year I've had four new defense cases. So17 this year it's about 40 percent defense, which is unusual.18 It's been new cases. Typically in the last five years I'm19 90 percent plaintiff.20 Q. And earlier I think you said you've testified in21 hundreds of deposition but not a 1,000. Is that over 500?22 A. I think someone -- in fact, I was in court23 recently and somebody had an IDEX and it said I had 65224 depositions. I don't quarrel with that. That sounds25 about right.

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1 Q. All right. Do you know about how many states2 you've testified in?3 A. Either in deposition or in person, 30 states.4 Q. All right. Do you keep a list of testimony?5 A. Of the last three years, yes. Excuse me. I have6 2009 -- sorry -- 2010, 2011, 2012. We have not compiled7 2013 yet.8 Q. Is that something here we have in the office that9 we could attach as Exhibit 4 to your deposition?

10 A. Absolutely.11 Q. Thanks.12 I know that you said earlier that you've done --13 I can't remember if you said two or three cases with14 Mr. Sowell in the past.15 A. Yes, sir.16 Q. Have you done any for other members of the law17 firm of Terrell Hogan?18 A. Recently I received two cases from the other19 lawyer in Mr. Sowell's new firm. Ms. Dodson her name is.20 Q. Do you know how you were originally found by21 Mr. Sowell?22 A. I don't know that.23 Q. Do you advertise at all?24 A. I advertised in 1993 for a 4-month period of25 time, not since then.

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1 A. I've not seen those.

2 Q. Is that something you would like to see?

3 A. Not particularly because it does not -- whatever

4 she had -- I know how she is now. It's not germane to her

5 current state and what she might need currently.

6 Q. Okay. Other than the visit with Mr. and

7 Mrs. Roberts, have you spoken to anyone other than the

8 attorneys about this case?

9 A. No, sir, I have not.

10 Q. Is there anything about the medical records that

11 you do not believe is true and accurate?


13 A. I've no particular section that I could say that.

14 Q. (BY MR. HARMON) Are there any deposition

15 testimony that you don't think is true and accurate?

16 A. We discussed with Dr. Moore there's some

17 inconsistencies between when he states in the deposition

18 and what is documented in the record. I'm not saying it's

19 inaccurate. I'm just saying it's not consistent.

20 Q. I understand.

21 Earlier you testified that you had not and were

22 not planning on reviewing the echocardiogram performed on

23 August 23rd?

24 A. That's for sure. That's beyond my capability.

25 Q. You are relying on the report, then?

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1 Q. All right. Are you a member of any legal2 organizations?3 A. Legal, no, sir.4 Q. Earlier you mentioned some things that you had5 asked for from Mr. Sowell. Are there any other materials6 you asked for from him that you have not received?7 A. I may have asked him for the deposition of8 Dr. Sackett and make sure I have all her records. I9 didn't ask for that before. No, nothing else I can think

10 of.11 Q. The report that we were talking about earlier12 refers to some admissions this year, 2013, at Baptist. Do13 you have those records?14 A. No, if they were to exist -- again, I'm not sure15 if that's accurate from the patient's husband. If they16 were to have been, I would like to see them.17 Q. Okay. And are you aware of any therapist that18 Mrs. Roberts is currently seeing?19 A. To my knowledge she is not.20 Q. Have you reviewed the records of any past therapy21 that she has obtained?22 A. In the hospital she had therapy. I say "in the23 hospital." I'm talking about in St. Vincent's. I don't24 think I have seen any "outpatient" of her records.25 Q. Okay. Or inpatient rehabilitation records?

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1 A. That's right. I have no way of independently2 confirming or denying the report. It's not something I'm3 trained to do.4 Q. Okay. I take it there was nothing seen on the

5 August 23rd CT scan, or even the August 24th CT scan, that

6 would have -- from based on your opinion changed any of

7 the treatment provided to Mrs. Roberts, in and of itself

8 those CT scans?

9 A. That's correct.10 Q. Other than the notations made by follow-up

11 radiologists with regards to their findings regarding the

12 right cerebellar infarction, is there anything that you

13 relied upon with regards to your opinions about the

14 subsequent CTs obtained at other facilities?

15 A. I'm not understanding your question, sir. Maybe16 you could restate it.17 Q. Sure.

18 I think earlier you testified that the -- there

19 was some follow-up studies done where there were some

20 notations about the right cerebellar infarction.

21 A. Yes, sir, that's correct. I don't think I22 testified. That's accurate what I'm saying, but I didn't23 testify to that effect.24 Q. Okay. And so other than that issue, do you rely

25 on any of the findings on the subsequent CT scans at all?

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1 A. Well, I'm relying on -- I've actually seen the CT2 scans.3 Q. Okay.4 A. And I agree with their reports.5 Q. Okay.6 A. I'm talking about she had some -- in October7 of 2010 and January 4, 2011 additional CT scans were8 performed demonstrative of the right cerebellar9 infarction, which in retrospect appears to be there on

10 8/24/10. Although I didn't see it and it was not noted11 contemporaneously. I agree with what they are saying in12 retrospect. It is currently and are in those latest scans13 the right cerebellar visualized and it was one which is14 hard to see, but it was there on 8/24/10.15 Q. What permanent deficits if any does Mrs. Roberts16 have relating to the right cerebellar infarction?17 A. She doesn't.18 Q. Okay. So the exam that you did and the results19 that you put in your report are based on the -- or you20 would attribute to the left NCA in part?21 A. Yes, sir, that's correct.22 Q. As far as the -- earlier you testified about the23 TIA that had occurred first on August 23rd. Is there any24 radiological evidence of that?25 A. There is not.

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1 And what exactly does sensory loss mean?2 A. Loss of sensation, numbness.3 Q. Are you aware of -- well, first of all, are you4 aware that certain organizations put out guidelines to its5 members? For instance, the American Academy of Chest6 Physicians has guidelines that they put out for their7 members.8 A. I would assume so. I'm not familiar with that9 particular academy.

10 Q. How about the American of Neurology you used to11 be a member of, do they put out guidelines and12 recommendations, et cetera?13 A. Sure.14 Q. Are you familiar with any guidelines, whether15 it's from the American Academy of Neurology or any other16 organization, that would suggest putting an IVC filter in17 in the case of a patient that has a PFO, and a DVT, and18 PE?19 A. I've not seen guidelines, no, sir.20 Q. Would you agree that there aren't any21 guidelines -- there are not any guidelines from any22 organization that suggests putting an IVC filter in for a23 patient who has a PFO, and a DVT, and a PE?24 MR. SOWELL: Objection to form.25 A. I have not seen -- I am not saying they're any.

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1 Q. And is there anything other than the symptoms you2 mentioned earlier that you relied upon to say that that3 was a TIA?4 A. The fact that it resolved.5 Q. Okay.6 A. The symptoms that were expressed by the patient,7 that were documented by Dr. Pavlat, and affectively8 resolved, and not seen subsequently either then or now9 that confirms it's a TIA.

10 Q. Okay. Versus a stroke?11 A. Correct.12 Q. What about TI versus something unrelated to the13 brain? Is there something you relied upon outside of14 those symptoms?15 A. Just the symptoms, that's all.16 Q. Okay. And do you have an opinion as to what part17 of the brain that TIA was occurring?18 A. The right interior circulation.19 Q. And that's different from where the two strokes20 are?21 A. That's correct, sir.22 Q. And what's the basis for that opinion?23 A. The distribution of her symptoms of having left24 upper and left lower extremity weakness and sensory loss.25 Q. Right.

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1 I've just seen them personally. They may exist. I would2 not say they existed.3 Q. Okay. Your position as the director of the4 stroke program at North Shore Medical Center, that's an5 administrative position?6 A. Yes, it is.7 Q. Did you assist in the hospital becoming a primary8 stroke center?9 A. Yes, sir.

10 Q. I thought I had seen somewhere that that occurred11 in 2010, but I think earlier you said it was 2008.12 A. That's right. In other words, what happens is13 you request permission from the state to become a stroke14 center. With certain prerequisites it's granted. And you15 accumulate data over two years and the state and Joint16 Commission individually come and visit you and certify17 you.18 We started our program in 2008 accumulating data.19 And 2010 arrived, and then it's after that period they20 come over in the course of that year to evaluate you. It21 turned out it was slow. It didn't come in until 2008 --22 2010.23 Q. And that's the -- is the way the process works at24 every hospital in Florida --25 A. Yes.

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1 Q. -- that's becoming a primary stroke center?2 A. We renewed it again in 2012.3 Q. Earlier you testified about an IVC filter. I4 think you used the word substantially reducing the chance5 of, I guess, a paradoxical stroke from occurring?6 A. That's correct. I stated that.7 Q. What's the basis for that statement?8 A. I think just clinical knowledge and use. I've9 seen that procedure utilized in this setting for a long

10 period of time. I don't think there's any controlled11 studies quite frankly, but it's something that's been used12 in this setting.13 Q. Have you had patients that did not have an IVC14 filter that had a stroke and you're comparing that to15 ones, then, who did have it?16 A. If there were -- again, I don't think there are17 any controlled studies in that matter. If there was one,18 that's how you would conduct it. It's something that's19 hard to do, because it's an accepted procedure, and you20 would not deprive a person of that. So it's hard to do a21 controlled study. It's like saying if a person has22 pneumonia and you've giving them nothing but penicillin --23 you wouldn't do that because lack of medication would be24 deleterious.25 Q. Are you aware of any studies or case reports

159

1 migraine headaches come from when the brain is compressed.2 In other words, a migraine headache is a mechanism in3 which arteries dilate, swell up, and cause compression of4 brain tissue and the patient feels pain. So there5 certainly has to be pain sensors. The meninges, which is6 the covering -- if it's perforated or touched, it does7 cause pain.8 So the answer is yes, there are pain sensors in9 and around the brain substance.

10 Q. What's the mechanism for an embolic stroke

11 causing a headache?

12 A. Probably a sudden edema coming from a foreign13 body basically, causing swelling in the blood vessel and14 causing ischemia in that area around that blood vessel.15 Q. And just to make sure I understand, the

16 August 23rd CT scan doesn't show any embolus in the right

17 cerebellar region; is that correct?

18 A. That's correct.19 Q. And it does not show any ischemia in that area?

20 A. It does not.21 Q. And it does not show any dead tissue infarct in

22 that area either?

23 A. That's correct, sir.24 Q. And the 8/24 scan -- I understand what your

25 testimony is with regard to what Dr. Pressman sees, but do

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1 involving patients who suffered a stroke while2 anticoagulated, and at therapeutic levels, and had an IVC3 filter in?4 A. I've not seen particular studies on that, no,5 sir.6 Q. Would that surprise you if that's happened in the7 past?8 A. No. I mean, it certainly could be. That9 situation does arise.

10 Q. All right. I wanted to make sure I understood11 what you were talking about earlier with regards to12 headache and pain. If I understood you correctly, there's13 parts of the brain that would sense pain; is that right,14 that will tell you that there's -- your body is feeling15 pain?16 A. There are processing centers in the brain. The17 cortex and the thalamus. There's some controversy. In18 fact, that's coming into a lot of consideration now in19 terms of neonates and abortions and so forth, how we feel20 pain, what parts are there necessary to develop.21 Certainly there are pathways in the thalamus and the22 cortex which sense and interpret pain for us.23 Q. And does the brain tissue itself have pain24 sensors?25 A. Good question. I would think, yes, because

160

1 you have an understanding as to whether there's any2 ischemia as well in that area?3 A. There is ischemia in the right cerebellar4 visualized by the neuroradiologist and subsequent5 radiologists in the 8/25 scan.6 Q. How about edema?7 A. I don't think so, sir.8 Q. Okay. Earlier you mentioned that -- something9 about a physiatrist. You know what a physiatrist is

10 obviously.11 A. Sure.12 Q. Somebody in physical medicine and rehabilitation.13 A. Yes, sir.14 Q. Okay. And that's a physician; correct?15 A. It is.16 Q. All right. And that is somebody who you think17 would be qualified to examine Mrs. Roberts and give18 opinions with regards to her future medical needs?19 A. A neurologist could do that too. A physiatrist20 is typically one who engages in the rehabilitative aspects21 of a person poststroke.22 Q. Do you ever personally write life care plans?23 A. Sure.24 Q. Do you have patients that you write life care25 plans for?

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1 A. Yes, I do.2 Q. All right. Including stroke patients?3 A. Yes, sir.4 Q. Who do you give the life care plans to?5 A. To the life care planner.6 Q. What does this life care planner use them for?7 A. To formulate a plan and the insurance company to8 cover it and the patient undergoes it.9 Q. Do they get submitted to the insurance companies

10 for review --11 A. Yes.12 Q. -- and approval?13 A. Right.14 Q. And then do the insurance companies follow those15 plans to the "T"?16 A. No, it's always a battle.17 Q. Okay. And an insurance company's standard is18 whether something is medically necessary?19 A. Yes, sir.20 Q. Why is it that Mrs. Roberts is unable to write?21 She is left-handed; correct?22 A. Yes.23 Q. And she suffered injury on her right side of her24 body, and she can't more her arm?25 A. I think she has mixed dominance. Because if she

163

1 Q. So it has to be an R.N. that does that?2 A. Better to make the check because if she's on3 blood thinners and so forth, an R.N. would be better than4 an LPN to do that.5 Q. And if Dr. Sackett is already doing that for6 Mrs. Roberts, then would an R.N. still be needed?7 A. It depends on the frequency of Dr. Sackett's8 visits. In other words, if she saw Dr. Sackett every9 two weeks, that would be sufficient. If she saw

10 Dr. Sackett once a month, at two week intervals, the RN11 could come out and check and report to Dr. Sackett.12 Q. Are you saying that if Dr. Sackett is not doing13 it every two weeks, that she should be doing it every two14 weeks?15 A. No. A person of lesser credentials than16 Dr. Sackett could see her every two weeks. If Dr. Sackett17 were to see her every two weeks, that will be sufficient.18 What I'm saying is if she were not to see19 Dr. Sackett, then someone should come in the interval to20 make sure everything is appropriate with Mrs. Roberts.21 Q. Are you talking strictly about the anticoagulants22 and getting blood work for that?23 A. That's correct.24 Q. And of course, Mrs. Roberts does not actually25 have to see Dr. Sackett. She could go into the office or

162

1 is left-handed, you would not expect aphasia. Yet she has2 a profound nonfluent aphasia.3 Now right-handed people are -- 95 percent of them4 are left-brain dominant. Left-handed people only5 60 percent are right-brain dominant. There's a lot of6 mixed dominance. So, therefore, she has some abilities to7 determine speech, and probably the dysgraphia stems from8 her left cerebral dysfunction. She is not pure9 left-handed.

10 Q. And it's your understanding currently that11 Mrs. Roberts is being taken care of by her husband?12 A. Primarily and he gets some respite from some13 neighbors and friends.14 Q. And you know that Mr. Roberts has no background15 or training in medical care?16 A. None whatsoever. That's right.17 Q. So I assume when you talked about attendant care18 earlier, you were talking about someone similar to him,19 somebody that can be taught to take care of somebody like20 that but does not need to have a medical license of any21 type?22 A. Well, she would need someone like a certified23 nurse assistant, whatever, 24/7. And she would need an24 R.N. to come in periodically to supervise that person a25 few hours a week.

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1 even go to a different lab and give blood, or have2 somebody take it at home, and then Dr. Sackett could get3 the results and review them at her office?4 A. That could be done.5 Just to step back for a second. The gravity of6 Mrs. Roberts medical conditions are such that a monthly7 visit with an internal medicine or family practice person8 is necessary.9 Q. When you met with Mrs. Roberts, you mentioned

10 that she came in a wheelchair. Did you discuss with11 Mr. Roberts any of her other medical equipment that she12 had?13 A. She had some -- I think he had installed some14 grab bars in the house, and I think she had some kind of a15 cane in the house she used with his assistance. But she16 didn't have the cane with her, so I didn't see that.17 Q. Are you familiar with what mode of transportation18 that Mrs. Roberts and Mr. Roberts had?19 A. Yes. I think they have a car or something. It's20 not a specialized van. He just got her -- he would lift21 her up and get her from the wheelchair. He is a big22 man -- strapping man himself. He needs to be to get in23 her in there. But he would get her into the vehicle by24 himself with assistance from his friends and his25 neighbors.

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1 Q. Your note that you made -- I think it's Exhibit 22 maybe.3 MS. ROHAN-WILLIAMS: I think so.4 Q. (BY MR. HARMON) It was about your exam of5 Mrs. Roberts.6 A. Yes, sir.7 Q. I note some handwritten changes were made on8 there.9 A. After I had done the -- I noticed some errors. I

10 wrote them in.11 Q. When did you make those changes?12 A. Week ago. I was preparing for this matter. I13 pulled my stuff out to look at it and I saw it when I read14 it, and I said, 'This is not write.'15 Q. Based on your memory of the facts?16 A. Yes. I missed one as I mention to your17 colleague. It was on the second page which says18 "revision." It should be "provision."19 Q. And that -- I don't think I had a chance to look20 at that one folder you're looking at now.21 MS. ROHAN-WILLIAMS: I was thinking that.22 A. It's the same as you have.23 Q. (BY MR. HARMON) So you setup a patient file for24 Mrs. Roberts?25 A. That's correct.

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1 legal examination. Mostly are compulsory medical2 examinations as opposed to this being voluntary.3 Q. Right. Okay. Earlier you were asked some4 questions about the purpose -- the main purpose of an IVC5 filter to prevent pulmonary embolism; correct?6 A. That's correct.7 Q. And really it's to prevent fatal pulmonary8 embolism, right? Big clots that could go like a9 straddling embolus that could cause death?

10 A. That's correct.11 Q. And when these big clots get caught by the12 filter, they can fragment and little clots can shower off13 of that too; correct?14 A. That's correct, sir.15 MR. HARMON: Dr. Fischer, I thank you for your16 time.17 THE WITNESS: Thank you, sir.18 MR. HARMON: I'll pass you down to the next one.19 MR. SOWELL: I need to make a telephone call. If20 you don't mind, Bruce is going to make the objections.21 (Mr. Sowell exited the room.)22 CROSS-EXAMINATION23 BY MR. REGAN:24 Q. Dr. Fischer, my name is Duke Regan. We met this25 morning. I represent Dr. Szwed.

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1 Q. Do you intend to see her again as a patient?2 A. Well, logistically it's somewhat difficult. I3 have no objection to it, but I'm not going to ask her to4 come from Jacksonville to see me. It's expense for them5 and it's no easy trip.6 Q. Do you intend to examine her prior to trial?7 A. I don't think I need to. The answer is I've no8 necessity to. Again, her situation is not going to change9 neurologically. So I do know what her current status is.

10 I wouldn't expect it to be different from now to February11 of year.12 Q. And you mentioned that it cost $800 for the exam.13 Has that been paid?14 A. Yes, it has.15 Q. Was that paid by -- did you try to obtain any16 third-party pay?17 A. No. It's Mr. Sowell responsibility.18 Q. And I know the term "IME" got used earlier. It's19 written here in your term chart. That is the legal term20 for an independent medical examination. That's21 technically not what was done here; correct?22 A. I guess not, yes.23 Q. Yeah. You were retained by the plaintiffs --24 Mr. Sowell to do that exam; correct?25 A. Correct. Of course, I use it in any kind of

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1 We have been doing fine this morning. Fair to2 say if I ask you a question you don't understand, you'll3 let me know?4 A. That's fine, sir. I will do that.5 Q. You're aware from your review of the records that6 Dr. Szwed was responding to a consultation for7 pulmonology?8 A. That's my understanding.9 Q. And am I correct that you have no criticisms of

10 the care Dr. Szwed provided?11 A. That's correct, sir.12 Q. Your letter, which I think is -- was it13 Exhibit 2?14 MS. ROHAN-WILLIAMS: Yeah.15 Q. (BY MR. REGAN) If you want to take a look at it,16 look at the last page, "Impression."17 A. Which page, sir?18 Q. The last page.19 A. Yes, sir. I'm with you.20 Q. In the last paragraph, "Impression," the second21 sentence reads -- I won't read the whole thing --22 "Unfortunately, the treating physicians failed to23 appreciate in a timely fashion" -- it would be incorrect24 then to construe that as a criticism of Dr. Szwed?25 A. Since I'm a neurologist and he's a pulmonologist,

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1 I have no criticisms of Dr. Szwed.2 Q. We talked about anticoagulation today. From her3 admission 8/23 to what we call "lunchtime" 8/25, is it4 correct that the patient was therapeutically5 anticoagulated the entire time?6 A. Yes, she was.7 Q. Dr. Pavlat noted some left extremity -- call them8 generally "symptoms" on 8/23; correct?9 A. Yes, sir.

10 Q. Can you say when those -- and those resolved11 later?12 A. It did resolve.13 Q. Can you say when?14 A. If you look at the time Dr. Moore examined her,15 6:00 or seven o'clock on the 23rd, they basically had16 resolved.17 Q. So that at least gives us a time frame. We know18 when they were ongoing and we have a point when they19 weren't. At some point in between they resolved?20 A. Yes, sir.21 MR. REGAN: Thank you, sir. That's all the22 questions I have.23 THE WITNESS: Thank you.24 CROSS-EXAMINATION25 BY MR. BARBOUR:

171

1 in the deposition you were talking about the various file2 folders and packets of records you have. And I thought3 you held up one and you said this packet has the crux of4 the case, and it has certain tabs on it.5 A. Yeah.6 Q. What is that?7 A. That's the initial first several days -- right8 here. I will hand it to you to take a look at.9 Q. Thank you.

10 A. That has the first several days of her11 hospitalization. In terms of the standard of care12 deviations I've discussed of Dr. Moore, they occurred13 between 8/23 and 8/25 and they are in that period of time14 in that package.15 Q. Okay. All right. Thank you sir.16 Have you ever been to St. Vincent's Medical17 Center Riverside, the hospital?18 A. I passed it many times. I've never been inside19 of it.20 Q. Okay. I assume you have not spoken to any21 physicians that may practice at St. Vincent's Medical22 Center Riverside, as now what it's referred to as, about23 this case or any of the physicians involved?24 A. I have not, sir.25 Q. You've talked about some of Ms. Roberts'

170

1 Q. Doctor, my name is Jep Barbour. I represent2 Dr. William Pilcher in this case, a cardiologist. I3 assume based upon what you just told Mr. Regan, that you4 have no opinions regarding any physician outside of your5 specialty; is that correct?6 A. That's correct, sir.7 Q. And so nothing in your letter report of 8/12/138 is an implied criticism of Dr. Pilcher. Is that fair to9 say?

10 A. That is fair to say.11 Q. Have you been in solo practice your entire12 practice?13 A. No, sir.14 Q. How many years were you with a group?15 A. Well, I was -- one year I full-time faculty. I16 was 17 years in a group and 20-plus years in solo17 practice.18 Q. So the last 20 years have been solo practice?19 A. Since February of 2000 -- 1993, yes.20 Q. You mentioned you spent 18 hours on the case21 before today. Did you spend sometime this morning on the22 case?23 A. Just before you all arrived, about 15 minutes, I24 spoke with plaintiffs' attorneys.25 Q. I'm at the other end of the table. But earlier

172

1 preexisting stroke risk factors and comorbidities, her2 hypertension, and other things, and her weight which was3 well over 300 pounds, prior to August 23, 2010. Do you4 have an opinion as to whether Ms. Roberts would have5 probably experienced a stroke at some point in time had6 she not experienced one in this August 2010 time frame?7 MR. ANDERSON: Object to the form.8 A. That's pure speculation. She had greater9 likelihood than the average individual for several

10 reasons. She had hypertension, morbid obesity, and is11 Afro-American. So those confer higher risks than -- there12 are many people who are obese, Afro-American, and,13 hypertensive, and don't get strokes. Her chance was14 higher than the average individual because of those15 factors.16 Q. Do you have an opinion, based upon your review of17 the records and your examination of Ms. Roberts, as to her18 life expectancy?19 A. Okay. She is now 38. And based on the recent20 tables, a 38-year-old Afro-American woman would have a21 life expectancy of about 42 years. However, hers is22 reduced by her comorbidities, including the morbid obesity23 and including the hypertension, and the fact that she has24 a previous stroke deficit, probably by about 10 years. So25 therefore, I would say she would -- unless anything else

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1 happens, a 32-year life -- no, a 42-year life expectancy,2 sir.3 (Mr. Sowell entered the room.)4 Q. (BY MR. BARBOUR) What are the tables you are

5 referring to? It looked like you looked at something.

6 A. No. It's just her chart, just for her age.7 Just recently I had seen some articles on life8 expectancy that were just updated in the United States9 where it has increased a little bit. Whereas minority

10 groups had more of a disparity in their life expectancy,11 that's narrowed because of better treatment of certain12 underlying conditions.13 Q. Can you tell me what table you're referring to

14 when you're referring to the like expectancy table?

15 A. I think it's CDC. Not CDC. I think it's NIH.16 It's some governmental organization which publishes17 periodically. It just came out about two months ago.18 Q. From what you said previously, it appears that

19 even if she had not had a stroke, based upon her obesity,

20 hypertension and other comorbidities, she would have had a

21 reduced from normal life expectancy?

22 A. Yes, sir.23 Q. Do you know when the filter was ultimately

24 placed?

25 A. The exact date, I think it was -- it would have

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1 A. It's a little bit long. I mean, it could have2 been a -- I'm not sure exactly. There's no documentation3 in the chart of the discussions. So it could have been4 less than that. I just don't know.5 Let's assume the worst case scenario, as soon as6 he looked at the CAT scan he decided to do that. But I7 don't think it happened quite that way. The CAT scan was8 reviewed and revealed the stroke and the discussion9 ensued. So it was probably less than four hours. It was

10 probably more like three hours, but that's not11 unreasonable.12 Q. And so if we look at that time frame and apply it13 to the day before, on the 24th, you have indicated that14 you thought that Dr. Moore should have recommended a15 filter around two o'clock p.m. or shortly after that?16 A. Using that same time frame, by six o'clock on the17 24th it could have been installed.18 Q. So if things had gone as you would expect them to19 go in the usual course of things in discussing a filter20 and placing a filter, you would have expected it would21 have been in place by about 6:00 p.m. on August 24th?22 A. Yes, that's correct, sir.23 Q. You were asked some questions earlier about the24 size of clot that might be able to get through a filter25 that was in place inferior vena cava, and you gave us some

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1 been 25th -- August 25th.

2 Q. Do you know when on the 25th?

3 A. What time?

4 Q. Yes.

5 A. Not a part of the day. It was evening hours.

6 MR. ANDERSON: Is he allowed to look at his

7 records?

8 MR. BARBOUR: Sure.

9 THE WITNESS: It looks like six o'clock,

10 18 hours -- 1800 hours, six o'clock p.m.

11 Q. (BY MR. BARBOUR) And the stroke was appreciated,

12 I think we referred to, around lunchtime on August 25th?

13 A. That's correct, sir.

14 Q. And sometime after that there was a discussion

15 about whether to place a filter. Is that your

16 understanding?

17 A. Yes, sir.

18 Q. And so from the time the filter was discussed

19 until it was placed was about five hours or so?

20 A. It was a CAT scan performed 1:46. It was after

21 that. I think the discussion was sometime after two

22 o'clock. So between two and -- about four hours.

23 Q. Okay. And is that time period a reasonable time

24 period, from discussion of a filter until it's actually

25 put in place, would you say?

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1 sizes.2 Did you do any research to arrive at those3 opinions?4 A. No, sir, I did not.5 Q. Can you refer us to any articles, book chapters,6 or any other source that addresses the size of clot that7 might be able to make it through a filter?8 A. No, sir, I cannot.9 Q. You may have been asked this question earlier, so

10 I apologize. But you refer to the right cerebellar11 infarction that you could see on CT scan in retrospect.12 You didn't see it initially yourself.13 Are you able to tell us what symptoms she had14 that you believe were attributable to the right cerebellar15 infarction?16 A. Yes, the nausea and the dizziness.17 Q. And what permanent sequelae or injury or damage18 does she have from the right cerebellar infarction?19 A. As I mentioned earlier I don't find any.20 Q. How is it that she had a right cerebellar21 infarction sufficient to cause symptoms, and in your22 opinion to be called a stroke, yet there's no damage or23 injury that's resulted?24 A. That's not uncommon. For whatever reason the25 cerebellum may be a redundant structure, and we often see

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1 people with cerebellar infarcts that have total recovery

2 function.

3 Q. Again, you may have been asked this earlier. I

4 don't recall. But are you aware of any of the other

5 experts who have been retained by plaintiffs in this case?

6 A. I understand Dr. Deutsch has been retained. I

7 don't know anybody else.

8 Q. Have you heard it mentioned that a Dr. Cherish

9 has been retained?

10 A. Oh, yes. I'm sorry. He's an internal medicine

11 doctor.

12 Q. Have you been involved or on behalf of plaintiffs

13 in other cases in which Dr. Cherish has been an expert as

14 well?

15 A. One case about eight years ago.

16 Q. Do you know Dr. Cherish?

17 A. Only by his deposition. I've never met him or

18 spoke with him.

19 Q. And the information that you have regarding

20 Dr. Cherish's involvement came to you from Mr. Anderson or

21 Mr. Sowell?


23 Q. What did they tell you about his opinions?

24 A. I don't know that they did. I don't recall.

25 They just mentioned he was an expert. I don't know his

179

1 was very short of breath. I was scared and I took her to2 the hospital."3 So part of that was confirmed by what he told me.4 Q. So that paragraph, other than what you've just

5 said, came from your review of the medical records; right?

6 A. Yes, sir, that's correct.7 Q. The next paragraph that begins, "Because of her

8 symptomatology" came from your review of the reports?

9 A. That's correct.10 Q. And would it be fair to say that all the

11 remaining paragraphs on page 1 below that came from your

12 review of the records as well?

13 A. That's exactly right.14 Q. And the same with the top or first paragraph on

15 page 2?

16 A. Yes.17 Q. In the second paragraph on page 2 that begins,

18 "Subsequent to her hospitalizations," it says,

19 "Ms. Roberts has stabilized with slow very partial

20 improvement in her status."

21 Did that come from you or Mr. Roberts?

22 A. That came from Mr. Roberts.23 Q. You mentioned she had had two admissions to

24 Baptist Hospital for respiratory complaints. Do you see

25 that?

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1 opinions at all.2 Q. Okay. Is nausea considered a focal neurological3 deficit?4 A. No, sir, it's not a deficit. It's a symptom.5 Q. Is dizziness a focal neurological deficit?6 A. I'm sorry, sir?7 Q. Is dizziness a focal neurological deficit?8 A. No, sir, it's not. Again, it's a symptom as9 opposed to a finding.

10 Q. How about an intermittent headache?11 A. Again, it's a symptom. It's not a finding.12 Q. You mentioned when you did your August 12, 201313 report that some of the information contained here came14 from your review of the medical records and some of the15 information came from Mr. Roberts; is that correct?16 A. That's correct.17 Q. If you could take a look at the first page, would18 it be fair to say that the paragraph beginning -- it's I19 guess the fourth paragraph that begins, "In the early-20 morning hours of 8-23-10, Ms. Roberts had difficulty21 breathing, headache," et cetera.22 Did that paragraph come from your review of the23 medical records?24 A. Yes. Although, I asked Mr. Roberts specifically25 what happened that morning. And he said, "Well, my wife

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1 A. Yes.2 Q. Do you have any information that those

3 respiratory complaints and the admissions were in any way

4 caused by her stroke injury or symptoms?

5 A. No, sir. I'm not sure this is accurate. Again,6 when I had this information, I asked plaintiffs' counsel7 for any admissions, and they said the only ones they had8 were the Baptist main admissions of late 2010, which one9 was for a pulmonary embolism stemming from her PICC

10 filter.11 Actually, she had like four hospitalizations in12 the latter part of 2010. Three at Baptist and one at13 Mayo. None of them were the -- like he described. She14 had respiratory symptoms. Maybe he was just lumping them15 all together. He, being Mr. Roberts.16 Q. The two recent cases that you've been asked to

17 review by Patty Dodson of Mr. Sowell and Mr. Anderson's

18 firm, are those medical malpractice cases?

19 A. They are, sir.20 Q. Involving neurology issues?

21 A. Yes, sir.22 MR. SOWELL: Excuse me. I have to assert work23 product on behalf of Ms. Dodson.24 MR. BARBOUR: I'm not asking anything further25 about it.

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1 MR. SOWELL: That's fine. I don't know even know2 what they are.3 Q. (BY MR. BARBOUR) Doctor, I'd seen in some of4 your prior depositions that you give depositions on5 Tuesdays and Thursdays?6 A. No, that's not -- maybe years and years ago.7 That was true maybe 20 years ago. Now it's whenever.8 Q. With what frequency on average are you giving9 depositions on a monthly basis?

10 A. Actually two a month. It could be three11 sometimes. I'd say two or three a month.12 Q. And when is the last time you testified at trial?13 A. I'm not sure you'd call it a trial. I testified14 in an arbitration hearing Thursday last.15 Q. A medical malpractice case?16 A. No. It was a shipboard defense witness.17 Q. What percent of your professional time do you18 devote to medical legal review and involvement?19 A. 15 to 20 percent.20 Q. You've told us you've been deposed about 650-plus21 times, and testified at trial a lot as well. And you22 reviewed far more medical malpractice cases -- well,23 strike that.24 Your 650 depositions, are those in all different25 types of cases?

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1 wise?2 A. Leading cause of stroke?3 Q. Yes.4 A. Atherosclerotic and thrombotic.5 Q. Have you discussed this case with any of your6 colleagues, other doctors here at the hospital?7 A. No, sir, I have not.8 Q. Would you agree that 25 to 40 percent of all9 strokes have no identifiable cause?

10 A. That's an old figure. I think it's less than11 that now. I think we are realizing a significant12 percentage of those so-called cryptogenic strokes may be13 cardiac in origin. And a more intensive evaluation of14 patients' rhythm, and more intensive coag evaluation,15 yielded a lower percentage of so-called cryptogenic16 stroke. I think still in all 20 to 25 percent of strokes17 are of unknown cause.18 Q. You say 20 to 25 percent?19 A. Yes.20 Q. And that's despite physicians and modern testing21 examining the issue, they are unable to determine the22 actual cause of a stroke in 20 to 25 percent?23 A. Can't definitely pinpoint it. We could surmise24 something is most likely, but we can't definitely pinpoint25 it.

182

1 A. That's correct, sir.

2 Q. How long have you been reviewing medical

3 malpractice cases?

4 A. 1976 was the first time.

5 Q. Can you give me a ballpark range of the number of

6 medical malpractice cases you've reviewed?

7 A. Okay. It's about 15 -- sorry -- about 12 a year

8 the last 20 years, that would take us to about 340. And

9 before that it was less. So I'd say -- I'd say 500.

10 Q. 500 medical malpractice cases?

11 A. Yes, sir.

12 Q. And have any of those prior medical malpractice

13 cases you reviewed involved a PFO and paradoxical embolism

14 to your knowledge?

15 A. No, sir, they have not.

16 Q. You mentioned the incidents in the general

17 population of a PFO.

18 Do you know the incidents of paradoxical embolus?

19 A. I do not know the incidents of -- of all strokes?

20 I'm not clear on what you mean.

21 Q. Let's start with this. Of all strokes, what are

22 the incidents or rate or percentage of those that are due

23 to a paradoxical embolus?

24 A. Probably 2 percent.

25 Q. What's the leading cause of stroke percentage

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1 Q. And I understand that you have characterized this2 stroke as presumptive paradoxical embolism?3 A. Yes. It's strongly presumptive in view of her4 clinical course and in view of her findings; having PFO,5 having pulmonary emboli, having deep vein thrombosis,6 having imaging demonstrating multifocal embolic lesions.7 Q. But this is not a proven or established8 paradoxical embolus; correct?9 A. Well, I think true. I think there was a

10 presumptive diagnosis of the treating physicians and I11 agree with that.12 MR. BARBOUR: All right, sir. I don't think I13 have anything else at this time.14 THE WITNESS: Thank you, Mr. Barbour.15 MS. HESTER: Dr. Fischer --16 THE WITNESS: Last but not least.17 MS. HESTER: Thank you.18 CROSS-EXAMINATION19 BY MS. HESTER:20 Q. My name is Linda Hester and I represent21 Dr. Pavlat. I have what I hope will be very few questions22 for you.23 Do you have any criticisms of any of the care and24 treatment render by Dr. Pavlat?25 A. I do not.

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1 Q. Okay. Do you have any opinions that you intend

2 to express at trial regarding any of the care and

3 treatment provided to Mrs. Roberts by Dr. Pavlat?

4 A. I will express no such opinions.5 Q. Okay. And just to be clear, with regard to your

6 August 12, 2013 neurological consultation report, there's

7 nothing in this report that you mean as a criticism at all

8 of Dr. Pavlat; correct?

9 A. No such is intended.10 MS. HESTER: That's all the questions I have.11 Thank you.12 THE WITNESS: Thank you.13 MS. ROHAN-WILLIAMS: Do you have any?14 MR. SOWELL: Yeah.15 MS. ROHAN-WILLIAMS: Go ahead.16 MR. SOWELL: Okay. I'll try to be quick.17 CROSS-EXAMINATION18 BY MR. SOWELL:19 Q. Mrs. Roberts did not have a cryptogenic stroke,

20 did she?

21 A. No.22 MR. HARMON: Form.23 Q. (BY MR. SOWELL) Mrs. Roberts did not suffer any

24 hemorrhagic conversion?

25 A. She did not.

187

1 complete recovery?

2 MS. ROHAN-WILLIAMS: Object to Form.

3 MR. HARMON: Form.4 MS. HESTER: Form.5 Q. (BY MR. SOWELL) Neurologically?

6 A. That's true. The only deficit she has is related7 to that left middle cerebral artery infarction.8 Q. Do you believe agree that Mrs. Roberts is

9 permanently and totally disabled?

10 A. She is.11 MR. HARMON: Form.12 Q. (BY MR. SOWELL) The transthoracic echo done in

13 August 23rd, that did not rule in or rule out right to

14 left shunt, did it?

15 MR. BARBOUR: Form and lack of foundation.16 A. I'm sorry. I missed the first part.17 Q. (BY MR. SOWELL) The transthoracic echo that was

18 performed on August 23rd, you read the report earlier?

19 A. Yes.20 Q. It did not rule in or rule out right to left

21 shunt, did it?

22 MR. BARBOUR: Same objection.23 A. It did not.24 Q. (BY MR. SOWELL) In your corroborating opinion,

25 you talked about, "Dr. Moore was negligent in at least the

186

1 Q. When it comes to treatment of stroke, you can't

2 wait for a CT to confirm the stroke; isn't that true?

3 MS. ROHAN-WILLIAMS: Object to form.

4 MR. HARMON: Join.

5 MR. REGAN: Join.

6 A. The CT is done to rule out hemorrhagic process --

7 allows you to treat the stroke. The answer is, no, you

8 don't wait for CT evidence of stroke to treat it.

9 Q. (BY MR. SOWELL) The symptoms would trump any

10 imaging studies for an embolic or ischemic stroke?

11 A. Since this is a hemorrhage the answer is, yes,

12 that's correct.

13 MR. BARBOUR: I have one objection and note a

14 belated form objection.

15 Q. (BY MR. SOWELL) Migraines are not treated with

16 Dilaudid, are they?

17 A. No, they are not.

18 MS. ROHAN-WILLIAMS: Objected to form.

19 Q. (BY MR. SOWELL) Is a relationship between a TIA

20 and a subsequent stroke?

21 A. There is. Specifically there's a sixteenfold

22 increased risk of stroke in the first two weeks after a

23 patient has a TIA. Particularly in the first 48 hours.

24 Q. Would you agree that but for the left middle

25 cerebral artery stroke Mrs. Roberts would have made a

188

1 following respects: Dr. Moore failed to order testing2 specifically for the explicitly stated purpose of3 determining whether Mrs. Roberts had right-to-left4 shunting across a patent foramen ovale."5 Would that include a transthoracic echocardiogram6 with a bubble study?7 MS. ROHAN-WILLIAMS: Object to form.8 MR. HARMON: Is this report now admissible since9 you're referring to it now?

10 MS. ROHAN-WILLIAMS: Exactly.11 MR. SOWELL: You guys use it anyway you want.12 MR. HARMON: Okay.13 MR. SOWELL: No, it's not admissible. I'm trying14 to get you his opinions that you did not touch upon.15 MS. ROHAN-WILLIAMS: I asked the man twice if I16 had all of his opinions.17 MR. SOWELL: I mean, don't people come back and18 follow-up just -- you do whatever you want to with the19 information. Okay? I'm trying to make sure you get20 an opportunity to cover it all today.21 MS. ROHAN-WILLIAMS: Okay.22 MR. SOWELL: Just so we're clear, I'm not23 consenting to admissibility of the pre-suit affidavit.24 MR. BARBOUR: But for the record you just read25 from it, his prior affidavit?

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1 MS. ROHAN-WILLIAMS: And referred to it.2 MR. ANDERSON: He put you on notice of his3 opinions.4 MR. SOWELL: I will concede to that part I read5 being introduced into evidence, that paragraph.6 You're okay with that?7 MR. BARBOUR: You're saying you're withdrawing8 your objection?9 MR. SOWELL: What objection.

10 MR. BARBOUR: You stated an objection to the use11 of it.12 MR. SOWELL: I don't believe it's admissible at13 trial. To the extent that I screwed up, you got that14 one paragraph which accurately states this witness'15 opinions. I'm trying to give you guys a --16 MR. BARBOUR: I understand. I'm just trying to17 indicated for the record and make the record clear18 what you've read from. So we are clear on that.19 MR. SOWELL: Paragraph 8(c) of the Verified20 Written Medical Expert Opinion of Dr. Fischer from the21 pre-suit. I don't believe I read any other part of22 that.23 Q. (BY MR. SOWELL) You were asked about medical24 literature. You have not done any search for the25 existence of any medical literature in this case, have

191

1 Q. (BY MR. SOWELL) What kind of future neurological

2 care do you think Mrs. Roberts needs?

3 A. She needs to be seen periodically by a

4 neurologist to make sure no new strokes occurred, and also

5 because people who have had major strokes of her nature

6 have a significant potential for having poststroke

7 epilepsy. So I think she'll need to be seen by a

8 neurologist about every six months.

9 MR. SOWELL: Let me go through this one more

10 time. I may be done.

11 I'm going to furnish Dr. Fischer with the

12 deposition of Dr. Sackett and a set of her medical

13 records, as well as the records from Baptist. And I

14 will let you all know if they make any changes in the

15 opinions he expressed.

16 MR. HARMON: Okay.

17 MR. SOWELL: I will let you know one way or the

18 other.

19 MR. HARMON: Great.

20 MR. SOWELL: Okay.

21 THE WITNESS: And how about the hospital's policy

22 and procedures for St. Vincent's in case we discuss

23 credentialing?

24 MR. SOWELL: That depends on another ruling from

25 the Judge first.

190

1 you, sir?

2 A. I have not, sir.

3 Q. So if there was any implication that none exist

4 because you couldn't identify it, that would be

5 inaccurate?

6 A. Absolutely. I did not look.

7 Q. You were asked earlier about the timing of the

8 IVC placement by Mr. Barbour. His question to you was

9 assume that it was two o'clock in the afternoon of the

10 24th and Dr. Moore had admitted standard of care, and then

11 you placed it three or four hours later.

12 MR. BARBOUR: Form.

13 A. Yes.

14 Q. (BY MR. SOWELL) You criticized Dr. Moore earlier

15 for not seeing Mrs. Roberts earlier that morning?


17 Q. And if Dr. Moore admits the standard of care in

18 seeing Mrs. Roberts earlier on the morning of August 24th,

19 what time would you think would be reasonable to expect

20 placement of the IVC filter on that date?

21 MS. ROHAN-WILLIAMS: Object to form.

22 A. Let's assume that Dr. Moore's done as I suggested

23 he should, he'd come in the morning 8:00 or nine o'clock

24 and by 11:00 or 12:00, at the latest, the filter could

25 have been installed.

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1 THE WITNESS: Okay. Fine.2 MR. SOWELL: I'm done. Thank you.3 REDIRECT EXAMINATION4 BY MS. ROHAN-WILLIAMS:5 Q. Dr. Fischer, despite my asking earlier if I've6 exhausted your criticisms against Dr. Moore, do you in7 fact hold yet another criticism against Dr. Moore?8 A. I think it goes back to what we talked about,9 communication.

10 Q. Okay.11 A. Let's step back a second. He was consulted and12 reconsulted by Dr. Pavlat, and the echocardiogram was13 done. And Dr. Moore should have realize by the 23rd, and14 certainly earlier on the 24th, that most of the other15 explanations of stroke had been ruled out or could have16 been ruled out, particularly the possibility of17 paradoxical embolism.18 By this time the echocardiogram was done and it19 was read on the early morning of the 24th, and it was not20 definitive enough. It did not rule in or rule out PFO.21 He could have said to Pavlat, okay, now we're worried22 about possibly the PFO causing paradoxical embolization23 from the deep vein thrombosis and the pulmonary emboli.24 Maybe we could do a bubble study and an angio. It's25 another lack of communication that he exercised, Moore

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1 did, by not conveying that possibility to Pavlat and

2 having that accomplished by the cardiologist.

3 Q. So is your criticism against Dr. Moore in that

4 regard about not discussing with Dr. Pavlat the

5 possibility of ordering a TEE with bubble study?

6 A. Right.

7 Q. Okay. And did you read Dr. Pilcher's deposition

8 testimony?

9 A. Yes.

10 Q. Okay. And if in fact a TEE with bubble study had

11 been ordered on August 24th, would it have been performed?

12 A. I don't know that. I don't know how quickly they

13 do those things at St. Vincent's. I can't answer that

14 question.

15 Q. Okay. Is TEE with bubble study performed in

16 critically ill patients?

17 A. Again, it's risk-reward, similar to other things

18 we talked about. The cardiologist has to evaluate the

19 patient, to make a determination whether it's able to be

20 done logistically or not.

21 Q. And it's up to the -- the decision, once again,

22 of the cardiologist as to when the patient is an

23 appropriate candidate for TEE with bubble study, correct?

24 A. Yes, that's correct. Yes, that's correct.

25 MS. ROHAN-WILLIAMS: Okay. Thank you.

195

1 bubble study should have been done on Mrs. Roberts sooner,

2 that's based on just your experience, not on any medical

3 literature that you're aware of?


5 Again, whether or not that could be done

6 logistically is beyond my scope.

7 Q. Okay. And with regards to the placement of an

8 IVC filter in a patient who has had a stroke and a PFO

9 with DVT -- excuse me. Strike that.

10 In terms of the decision to place an IVC filter

11 in a patient who has a PFO with a DVT and PE, that's also

12 based upon your experience, not based on any medical

13 literature that you're aware of?

14 A. Yes, sir. That's correct.

15 Q. Are there any hospital committees that you

16 currently serve on?

17 A. Currently, no. Other than the stroke -- I mean,

18 the chairman of the stroke committee.

19 Q. And in the past have you served on any other

20 hospital committees?

21 A. Yes.

22 Q. What hospital committees?

23 A. Department of Medicine, the Board of Trustees on

24 three occasions, Quality Assurance for about 25 years.

25 Utilization -- it used to be called Quality Assurance and

194

1 MR. HARMON: Doctor, I do have a follow-up2 question for you here, too.3 FURTHER CROSS-EXAMINATION4 BY MR. HARMON:5 Q. Earlier you were asked about the risks of a TEE

6 with regards to the bubble study part of it. I don't

7 think we talked about that.

8 There's also a risk of the actual saline that's

9 being injected. Those bubbles could cross over and go to

10 the brain and cause a stroke as well; is that correct?

11 A. It's a theoretical possibility. How often it12 happens, I don't know. I think it's very rare, but it's a13 theoretical possibility.14 Q. And as far as the medical literature issue

15 questions you were asked by me and then by Mr. Sowell, I

16 take it that all of your opinions are based on your own

17 background, training, and experience, not upon any medical

18 literature or research you've done?

19 A. That's correct, sir. I mean, some opinions --20 for example, Ms. Williams asked me about heparin and so21 forth in the use of stroke. That's based on literature.22 But most of the questions are based -- on the so-called23 PFO and the paradoxical embolization are not based on24 literature but based on my experience.25 Q. So specifically your suggestion that a TEE with

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1 Utilization Review from 1978 through about 2005.2 Q. Okay. Any other committees?3 A. Let's see. Neurology. Credentials. I have4 served like six times on credentials, yes.5 Q. When was the last time you served on the6 credentialing committee?7 A. I think four to six years ago.8 Q. Have you ever served as the chief of the section9 or division of neurology at the hospital?

10 A. Yes.11 Q. How many times have you done that?12 A. It used to be called Cedars, several times, and13 here as well.14 Q. What effect does Dilaudid have if any on a15 headache that's caused by an embolic stroke?16 A. It would reduce it.17 Q. Why is that or how is that?18 A. Dilaudid is a very high-powered analgesic, one of19 the most strongest analgesics there is. It reduces pain20 of any sort, whether caused by stroke or migraine. It's21 very potent one, but it is a very powerful pain reducer.22 Q. Okay. So Dilaudid will have the effect of23 treating a migraine, but it's not typically used for that?24 A. It's not a specific migraine medication, but will25 reduce temporarily migraine pain.

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1 MR. HARMON: Thanks.2 MR. BARBOUR: I'm going to pass for now.3 MS. HESTER: I don't have anything else.4 MR. SOWELL: I have something.5 FURTHER CROSS-EXAMINATION6 BY MR. SOWELL:7 Q. Isn't it true that a bubble study can be8 performed with a transthoracic echo?9 A. Yes.

10 Q. That is something you defer to the cardiology11 consulted on it, would you not?12 MR. BARBOUR: Form.13 A. Yes. When do you do it, how to do it, that's14 beyond my scope.15 MR. SOWELL: Thank you.16 FURTHER REDIRECT EXAMINATION17 BY MS. ROHAN-WILLIAMS:18 Q. Doctor, I guess I should have asked you do you19 recall correctly from Dr. Moore's deposition transcript20 Mr. Sowell took him at length through records post-21 August 25th, during the hospitalization where Dr. Moore22 continued to provide care for Mrs. Roberts?23 Do you have any criticisms about the care that24 Dr. Moore provided poststroke?25 A. I do not.

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1 bubble study can be done and that's beyond your expertise;2 correct?3 A. Yes, it is.4 Q. You don't know -- well, do you yourself order5 transthoracic or transecho -- transesophageal6 echocardiograms?7 A. To answer I'll break that up in segments. As far8 as transthoracic, absolutely. It's a benign procedure.9 It's done at the bedside. There's no invasion. So I

10 order them all the time. I don't read them, but I would11 get it done and have the cardiologist take a look at them.12 Often it's not definitive.13 Now if I want TEE, I typically don't order it14 unilaterally. I recommend it and I'll call the internal15 medicine person on the case and discuss it. If there is a16 cardiologist on the case, I would call that individual and17 discuss it. It's an invasive test. I'd want to make sure18 that the other people involved in the care are on board19 both with it being done if it's a critical situation. I20 often recommend it when I suspect cardioembolic stroke.21 Q. When you say if you "expect [sic] cardioembolic22 stroke," you're talking about a stroke that emanates in23 the heart itself?24 A. Yes, sir. A clot is coming from the heart and25 travelling from the great vessels into the brain.

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1 MS. ROHAN-WILLIAMS: Thank you.2 MR. BARBOUR: All right.3 MR. SOWELL: I have one other thing. It doesn't4 affect you. Go ahead.5 MR. BARBOUR: If you want to go ahead and do it6 while you're thinking about it.7 MR. SOWELL: I want to make sure we're clear. We8 anticipate to elicit testimony from Dr. Fisher9 critical of the analysis of Mrs. Roberts' headaches by

10 Dr. Fisher -- Dr. Moore. Pardon me. Sorry. I don't11 know if that's come out clear enough today. I am just12 making sure about that.13 MS. ROHAN-WILLIAMS: Okay.14 MR. SOWELL: So we have criticism with the15 physical exam and the history done, whether he saw her16 on the 23rd and 24th.17 MS. ROHAN-WILLIAMS: Okay.18 MR. SOWELL: All right. That's it, Jep.19 MR. BARBOUR: You have anything?20 MS. ROHAN-WILLIAMS: No. Thank you.21 MR. BARBOUR: All right.22 FURTHER CROSS-EXAMINATION23 BY MR. BARBOUR:24 Q. Dr. Fischer, you've indicated that a cardiologist25 can determine, under certain circumstances, whether a

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1 Q. If you have reason to believe that a patient may2 have a -- may have, or may have had, or may be at risk for3 a paradoxical embolism, is that something that you would4 discuss with a cardiologist?5 A. That's right.6 Q. And is that --7 A. Excuse me. Backup for a second. It may be8 there's no cardiologist on the case. In other words, I'm9 called to see a patient who's in stroke and there's an

10 internal medicine person who is the primary doctor who11 calls me, and I suspect that's the case, I may go to the12 internal medicine person first and say, look, we need to13 get a cardiologist on this case if there is not one, and14 we need to discuss that with that individual that you15 select, the possibility of doing a TEE.16 Q. And you have no opinion in this case as to17 whether a TEE should have been done initially as opposed18 to transthoracic echocardiogram?19 A. Almost always start -- the transthoracic20 echocardiogram can be done -- you order it and it could be21 done in 15 minutes. So there's no reason to delay on22 that. That's something that may help you or may not. If23 that's definitive, that's something you go ahead and do as24 a matter of course, and you may get the answer from that25 and you may not. If not, you go to a more invasive

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1 procedure, a more complicated procedure.2 Q. And you're aware from the record that when3 Ms. Roberts presented to the hospital, she had elevated4 troponin levels?5 A. She did.6 Q. That could be indicative of a patient who's7 having a heart attack?8 A. Could be.9 Now in this case Dr. Pilcher did not feel that

10 was the case. He felt that was not significant.11 Q. Dr. Pavlat was the one who requested the12 cardiology consult?13 A. That's correct.14 Q. Dr. Pavlat ordered the transthoracic15 echocardiogram?16 A. That's accurate.17 Q. To your knowledge -- strike that.18 MR. BARBOUR: All right. Sir, that's all I have.19 THE WITNESS: Thank you, sir.20 MS. HESTER: I don't have anything.21 THE WITNESS: You want the me to read,22 Mr. Sowell?23 MR. HARMON: I was waiting.24 FURTHER CROSS-EXAMINATION25 BY MR. HARMON:

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1 A. That's correct.2 MR. HARMON: Thanks. That was it.3 MR. BARBOUR: Let me just follow-up on a couple4 of things if I could.5 FURTHER CROSS-EXAMINATION6 BY MR. BARBOUR:7 Q. When you did your exam of August 12, 2013, you8 didn't prescribe any medications for Ms. Roberts, did you?9 A. I did not.

10 Q. You did not provide any treatment therapy of any11 kind, did you?12 A. That's correct.13 Q. You were seeing her at the request of her14 attorney and with your input as well, not as an ongoing15 treating physician; is that fair to say?16 A. That's fair.17 Q. Are you aware that a PFO was not observed when a18 transesophageal echocardiogram was done subsequently at19 Mayo Clinic?20 A. I don't recall that Mr. Barbour. You may be21 accurate.22 Q. Are you aware that a transesophageal23 echocardiogram at Baptist Medical Center Downtown in24 January 2011 did not reflect a PFO?25 A. Did not reflect. I think that's correct.

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1 Q. You indicated, Doctor, that you reviewed2 Dr. Eidelman's records from Mayo Clinic, Jacksonville.3 A. Yes.4 Q. And did you find any different findings on your5 exam than what Dr. Eidelman found?6 A. Actually it's remarkably similar. Unfortunately7 I don't see any progressive improvement from his8 examination in 2011 versus mine in 2013.9 Q. Dr. Eidelman noted that she has bladder control

10 and does not appear to have fecal incontinence, but you11 noted that she has both; correct?12 A. That's not a finding on exam. That's a symptom13 that the husband reported to me.14 Q. Reported to you by Mr. Roberts?15 A. That's correct.16 Q. Okay. Do you know why Mrs. Roberts had not been17 seen since then by a neurologist?18 A. I think there's some insurance issues.19 I asked him why he didn't return to Dr. Eidelman,20 and he said they're no longer covered by the Mayo Clinic.21 Q. Do you know -- did he say why they have not gone22 to another facility to be seen by a neurologist?23 A. He did not say, no.24 Q. So for the past two years almost she has not been25 seen by a neurologist other than you obviously?

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1 Q. I take it you've not spoken with any cardiologist2 here at your hospital or in the South Florida area about3 this case, have you?4 A. As I indicated earlier, I have not spoken to5 anybody other than the patient, her husband and the6 attorneys.7 Q. And have we covered all of the opinions that you8 have and that's been indicated you may be asked about at9 trial?

10 A. At this point in time as Mr. Sowell indicated11 additional records being forwarded to me, and perhaps12 additional material from the hospital and if there are13 other opinions, he will let you know.14 MR. BARBOUR: Okay. All right. Thank you, sir.15 MR. SOWELL: Why don't we read this?16 (Interruption.)17 MS. ROHAN-WILLIAMS: I'm ordering. Absolutely.18 MR. HARMON: Copy.19 MR. REGAN: Handwritten copy and E-tran, please.20 MR. ANDERSON: We'll take a copy and E-tran and21 send it to my e-mail.22 MS. HESTER: We will take a copy and an E-tran.23 MR. BARBOUR: I'd like a condense, numbered top24 to bottom not side to side, a word index. And would25 you also send me an E-tran? You have my card.

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1 (Deposition was concluded at 2:25 p.m.)2 (Reading and signing of the deposition was not3 waived by the witness and all parties.)4

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1 CERTIFICATE OF REPORTER2

3 STATE OF FLORIDA4 COUNTY OF MIAMI-DADE5

6 I, DENISE M. STEWART, Registered Professional7 Reporter, certify that I was authorized to and did8 stenographically report the deposition of KENNETH C.9 FISCHER, M.D., pages 1 through 205; that a review of the

10 transcript was requested; and that the transcript is a11 true record of my stenographic notes.12

13 I Further Certify that I am not a relative,14 employee, attorney, or counsel of any of the parties, nor15 am I a relative or employee of any of the parties'16 attorneys or counsel connected with the action, nor am I17 financially interested in the action.18

19 DATED this 7th day of October 2013.20

21

22 _________________________________

DENISE MARIE STEWART, RPR23 Registered Professional Reporter24

25

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1 CERTIFICATE OF OATH2 STATE OF FLORIDA )3 COUNTY OF MIAMI-DADE )4

5 I, DENISE M. STEWART, RPR, Notary Public, State6 of Florida, certify that Kenneth C. Fischer, M.D.7 personally appeared before me on 24th day of September8 2013, and was duly sworn.9

10 Signed this 7th day of October 2013.11

12

13 _____________________________________

DENISE MARIE STEWART, RPR14 Notary Public, State of Florida

Commission No. EE 10712915 Commission Expires: June 27, 201516

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1 October 7, 20132

3 Kenneth C. Fischer, M.D. 1190 N.W. 95th Street, Suite 402

4 Miami, FL 331505 In Re: Margaret Roberts/Darrell Roberts vs. St. Vincent's

Medical Center, Inc., et al.6 Deposition of Kenneth C. Fischer, M.D.

Taken on September 24, 20137 U.S. Legal Support Job No. 10413138 The transcript of the above-referenced proceeding has been

prepared, and a courtesy copy is enclosed here for your9 review.

10 Any corrections you wish to make to the transcript should be made on the errata sheet. Please do not write on the

11 transcript itself.12 Please complete review of your transcript within a

reasonable amount of time and return the errata sheet to13 our office. You need not return the entire transcript.14 Sincerely,15

16

Denise Marie Stewart, RPR17 Registered Professional Reporter

U.S. Legal Support, Inc.18 One Southeast Third Avenue, Suite 1250

Miami, FL 3313119 (305)373-840420 CC via transcript:21 Tiffany Rohan-Williams, Esq.

Michael Harmon, Esq.22 P. Duke Regan, Esq.

Jeptha Barbour, Esq.23 Linda Hester, Esq.

Bruce Anderson, Esq24 Matthew W. Sowell, Esq.25

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1 ERRATA SHEET2

DO NOT WRITE ON TRANSCRIPT~ENTER ANY CHANGES ON THIS PAGE3

IN RE: MARGARET ROBERTS/DARRELL ROBERTS VS. ST. VINCENT'S4 MEDICAL CENTER, INC., ET AL.

KENNETH C. FISCHER, M.D.5 SEPTEMBER 24, 2013

U.S. Legal Job No. 10413136

__________________________________________________________7

PAGE NO. LINE NO. CHANGE REASON8 __________________________________________________________9 __________________________________________________________10 __________________________________________________________11 __________________________________________________________12 __________________________________________________________13 __________________________________________________________14 __________________________________________________________15 __________________________________________________________16 __________________________________________________________17 __________________________________________________________18 __________________________________________________________19 __________________________________________________________20 __________________________________________________________21 __________________________________________________________22

Under penalties of perjury, I declare that I have read the23 foregoing document and that the facts stated in it are

true.24

25 DATE: ________________ ____________________________

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busy 24:17

C

C 1:14,19 4:2,175:10 206:6 207:8208:3,6 209:4

cadre 13:3calculations130:11

call 11:18 12:2,612:13 13:5,531:12,23 32:2458:16,17,1875:25 167:19169:3,7 181:13199:14,16

called 11:5,6,7,711:23 29:1930:10 31:3,2232:10,18 33:2234:4,14 44:19104:25 105:19,22

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105:23 106:4,5,6106:12 132:4142:19 147:7176:22 195:25196:12 200:9

calling 55:21106:8 108:17110:11

calls 11:25 12:231:19,20 32:4200:11

campus 11:13canceled 24:17cancer 47:6candidate 34:20193:23

candidates 29:1630:13 112:5

cane 132:15 164:15164:16

capabilities 68:21capability 151:24car 136:6 164:19carcinoma 45:20card 204:25cardiac 68:12 80:780:10 183:13

Cardich 146:6,20cardio 80:7cardioembolic41:13 65:2366:14 67:1,268:17,23 69:380:2,4 97:20,2097:22,23 103:11103:18,22 104:10104:16 111:5121:24 199:20,21

cardiological 78:4cardiologist 68:478:22 111:20112:8 170:2193:2,18,22198:24 199:11,16200:4,8,13 204:1

cardiologist's111:24

cardiology 197:10201:12

care 29:12 31:1741:15 51:4 58:878:19 134:18135:16 160:22,24161:4,5,6 162:11162:15,17,19168:10 171:11184:23 185:2

190:10,17 191:2197:22,23 199:18

career 118:10caretaker 46:7carotid 41:1665:19 98:7 100:5

carpal 57:18,1958:5 59:25 60:14108:17,21 140:1

carpel 106:7Carrie 85:9carriers 118:15case 1:2 5:2313:18 14:6,916:24 17:10,1417:15 18:16 19:119:9 20:14,1622:4 37:9 51:2552:2 55:6,1365:23 82:1987:18 98:2105:21 119:13126:12,21 131:6141:10 151:8155:17 157:25170:2,20,22171:4,23 175:5177:5,15 181:15183:5 189:25191:22 199:15,16200:8,11,13,16201:9,10 204:3

case-by-case 112:7cases 26:1 37:1370:6 83:10118:14,18 119:2148:16,18 149:13149:18 177:13180:16,18 181:22181:25 182:3,6182:10,13

CAT 32:13,15,1637:6 174:20175:6,7

categorically91:12

category 116:22Catherine's 10:2335:18

caught 87:1 88:1792:13 167:11

causation 107:20141:9

causative 57:181:18 102:5,9107:19

cause 5:3 71:1,9

78:10 88:4 90:1691:10,19 94:22114:2 159:3,7167:9 176:21182:25 183:2,9183:17,22 194:10

caused 57:17 90:690:10 91:4103:18 180:4196:15,20

causes 41:22,2281:6,16 86:1098:4 121:19

causing 41:11 66:166:18 79:10,1280:9 96:16 100:9159:11,13,14192:22

cava 175:25CC 208:20CDC 173:15,15cease 125:14Cedars 11:23196:12

cell 98:12center 1:8 10:2215:22,24 16:226:15,16,16,2226:22 27:2 45:7142:13 144:9146:14,24 156:4156:8,14 157:1171:17,22 203:23208:5 209:4

centers 114:20158:16

centimeter 87:3,588:10

cerebellar 74:676:24 77:1 89:1990:5,13,17 91:4101:3,15 121:12152:12,20 153:8153:13,16 159:17160:3 176:10,14176:18,20 177:1

cerebellum 176:25cerebral 34:1550:15,20 57:2560:7 62:1,8,1062:16,22,2563:12 65:2 66:1166:19,24 67:169:13 73:6 74:1774:22 81:2 83:684:18,22 85:186:10 87:25

90:12 101:4,19101:22 102:2103:15 106:11108:2 121:14,19134:2,4 140:22162:8 186:25187:7

certain 12:10,1122:20 27:2329:25,25 30:432:1 34:5,2435:3 103:10110:22 137:10142:23 155:4156:14 171:4173:11 198:25

certainly 8:5 52:757:19 59:8 85:4102:13 113:9117:19 118:2158:8,21 159:5192:14

Certificate 4:104:10 206:1 207:1

certification 7:17:19 9:11 38:23143:16 144:15

certifications142:18

certified 6:9,127:5,22 31:638:22 39:5 74:489:5 120:3,7144:10,13,15,17144:18,19 145:3145:6,7 146:20147:6 162:22

certify 156:16206:6 207:7,13

cervical 58:559:25 60:14140:23,24 141:1

cetera 155:12178:21

chairman 195:18chairs 48:19Chamber 68:7chance 75:9 126:5157:4 165:19172:13

chances 112:17128:15

change 113:13136:25 166:8209:7

changed 145:8152:6

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changes 165:7,11191:14 209:2

changing 87:9chapters 176:5characterization85:22

characterized184:1

charge 24:21 25:6120:7 123:7

charging 25:2chart 16:8 57:2261:17,18 62:1,362:4,7,9 67:1184:9 106:16109:11,24 132:24140:14 166:19173:6 175:3

charts 60:9check 55:20 105:20109:2 136:16163:2,11

chemical 44:21Cherish 177:8,13177:16

Cherish's 177:20chest 45:13 155:5chief 196:8child 26:1 142:24Childs 3:6choice 71:20,21choose 12:7 56:14chosen 58:18chronologically145:18

CIRCUIT 1:1,1circulation 44:11154:18

circumstances83:18 97:5,5198:25

cite 43:25clamp 110:23clamping 118:15clarification76:13 103:16

clarify 48:7clear 49:3 55:2258:21 182:20185:5 188:22189:17,18 198:7198:11

clear-cut 62:1,7,962:15 63:11 81:1106:10

client 51:22Clinic 15:23 16:4

18:7 99:11124:18 202:2,20203:19

clinical 25:2538:8 74:11 94:9100:24 101:6157:8 184:4

clinically 94:10101:5

clock 75:20close 27:9 28:1653:11 54:23

closed 11:6 128:8128:9

closure 128:4,5,14clot 86:25 88:3,788:16 89:6,1190:6,9,9,11,1290:14,14,15,2291:3,10,19 92:1294:20 95:7,12,1895:19 96:4,15175:24 176:6199:24

clots 44:7,13,1544:17 75:4,5,7,775:7 87:7,10,1387:19 88:21 89:793:9 95:20 135:5137:25 167:8,11167:12

clotting 44:7 66:375:9 94:22 99:14

coag 69:5 183:14coagulate 138:5coagulation 67:569:24

coagulopathy 41:981:11 98:4 99:999:20 122:1

code 26:14cognition 130:19131:5

cognitive 130:15142:24

cognizant 40:11coherent 81:6cold 117:9colleague 165:17colleagues 183:6collegial 9:12combats 44:4combatting 43:7,1443:17

combination 66:20come 12:20 13:1417:18 18:13

24:19,23,2425:14 29:18 32:533:6 36:20 37:337:3 54:15 59:1572:5,6,8,11,1284:6 106:3 127:1145:15 156:16,20156:21 159:1162:24 163:11,19166:4 178:22179:21 188:17190:23 198:11

comers 12:14comes 12:23 22:1524:16 28:18,2040:23 62:21 64:173:8 109:4,9186:1

comfortable 96:8117:13,23

coming 17:10 75:584:4 112:18158:18 159:12199:24

comment 52:1584:17,18 137:18

commented 98:20Commission 156:16206:14,15

committed 119:1committee 8:24,259:1,3 195:18196:6

committees 195:15195:20,22 196:2

common 66:17 80:880:8,9 102:5

communicate 106:23communicated106:17

communication 78:878:17 107:15192:9,25

communications107:4

community 13:13,1326:11,12 30:1430:25

comorbidities 47:749:17 172:1,22173:20

companies 161:9,14company 31:4 161:7company's 161:17compared 113:10comparing 157:14compartmentalize

124:6compiled 149:6complained 9:20complaining 109:1complaint 45:12complaints 9:2359:23 115:1128:20 179:24180:3

complete 105:14187:1 208:12

completed 67:9completely 146:17Completing 145:4complicated 74:12117:17,19 201:1

component 26:527:8

composite 86:7126:22

comprehended 130:8130:13 131:1,9

comprehension130:19 131:5

compressed 159:1compression 159:3compulsory 167:1concede 189:4concerned 20:2144:8 84:12

concerns 32:4concluded 205:1conclusion 18:13100:18

condense 204:23condition 94:9112:13 115:6140:18

conditions 43:1870:17 114:22,23140:19 164:6173:12

conducive 22:7,1831:14 35:25

conduct 157:18conduction 142:25conductions 118:16confer 172:11conference 23:21conferences 23:18confirm 186:2confirmed 100:19127:24 179:3

confirming 152:2confirms 154:9confused 88:24Confusion 113:12

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congenital 137:21conjunction 78:378:22

connected 207:16connective 41:967:6 69:24 81:1198:6 99:22

consciously 90:1consciousness113:13

consensus 104:2,2104:3

consenting 188:23consider 84:25consideratio 83:17consideration 34:371:16 86:1798:18 111:21138:23 158:18

considerations121:25 134:20

considered 7:1540:23 55:16 58:469:19 74:2080:13,16 103:9178:2

considering 42:6consistent 54:1968:11 117:1118:20 151:19

consistently 115:4115:7

constant 110:3constellation64:23 117:4

construe 168:24consult 13:7 17:1717:19 23:1228:18 54:5 55:955:11,14,16,1855:19 56:3,9,2158:16 79:1105:19 106:12201:12

consultant 78:4consultation 4:1616:9 53:25106:20 123:3168:6 185:6

consulted 52:8108:10 192:11197:11

consulting 147:1consults 51:17contact 18:15134:19,24 135:19135:24

contacted 13:629:20

contained 62:7,9178:13

contemplate 7:24contemplated 7:11143:13

contemporaneous61:24 108:17

contemporaneously153:11

contiguous 31:11continue 51:13continued 51:8,10197:22

continues 34:2071:13 129:24

Continuum 9:16contract 31:5contraindicated96:22

contraindication42:12

contraindications94:6

contributory 58:8control 202:9controlled 157:10157:17,21

controversy 158:17conversation 14:1477:15 120:14

conversion 185:24conveying 193:1convicted 148:10cooperative 129:6Coordinating 132:6coordination 132:7132:8

copy 204:18,19,20204:22 208:8

corneal 131:20Corporation 1:9correct 6:18 7:169:8 10:4,1111:13 13:9 15:116:10 21:14 24:324:4,12 26:2529:9 30:19 33:1133:12,23,2435:12 36:1639:14 40:17 43:345:17 46:4,5,846:13 47:20 50:350:4 51:17,20,2251:23 53:18 54:156:12,15,24

59:13,14 61:2,461:5 62:17 69:170:19 76:19,2079:14 83:2386:15,19 87:2388:19,19 91:2492:19 93:10,1195:10,10 96:1796:20,23,2599:12,25 101:14101:21 102:24104:4 109:3,19110:1 111:6,7,25112:2,3,20 114:7114:23 115:11116:20 122:3123:19 124:11,12124:19 127:18,21128:6,16 133:3137:20,25 138:16138:19 139:4140:12 141:5,11144:25 145:1152:9,21 153:21154:11,21 157:6159:17,18,23160:14 161:21163:23 165:25166:21,24,25167:5,6,10,13,14168:9,11 169:4,8170:5,6 174:13175:22 177:22178:15,16 179:6179:9 182:1184:8 185:8186:12 190:16193:23,24,24194:10,19 195:4195:14 199:2201:13 202:11,15203:1,12,25

corrections 208:10correctly 20:1271:19 80:14,15158:12 197:19

correlate 101:2corroborating187:24

corroboration109:15

cortex 114:16,18158:17,22

cortical 132:4cost 166:12Coumadin 127:24counsel 37:10

142:2 180:6207:14,16

count 35:4counted 15:7country 26:14County 1:1 25:19206:3 207:4

couple 59:8 61:23125:7 203:3

coupled 71:3 108:1110:4

course 20:25 38:1841:8 43:12 56:1373:12 100:7113:22 124:9156:20 163:24166:25 175:19184:4 200:24

courses 9:14court 1:1 5:5148:22

courtesy 208:8cover 19:17 161:8188:20

covered 141:6,9202:20 204:7

covering 159:6cranial 131:19credentialed 120:4credentialing119:16 120:2,9191:23 196:6

credentials 163:15196:3,4

crimes 148:10criteria 35:2 37:237:4 82:12 120:2120:8,10

critical 198:9199:19

critically 112:4193:16

criticism 56:660:8 61:16 65:766:9 71:22 75:2578:14 82:23104:23 105:13107:15,17 110:11168:24 170:8185:7 192:7193:3 198:14

criticisms 52:1,6110:7 119:13141:7 168:9169:1 184:23192:6 197:23

criticize 74:6

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criticized 84:3190:14

criticizing 107:3cross 194:9Cross-Examination4:3,4,4,5,5,6,74:8,8,9 142:9167:22 169:24184:18 185:17194:3 197:5198:22 201:24203:5

crucial 64:4crux 22:8 171:3cryptogenic 183:12183:15 185:19

CT 16:1,3,4 32:2132:22 33:2234:12,16,1937:21,24 38:1439:20 40:23,2550:11,21 65:373:14,16 81:888:1 89:15 91:691:17 100:13152:5,5,8,25153:1,7 159:16176:11 186:2,6,8

CTA 37:23 40:1041:1,2,15 65:1665:17,18 66:1367:4 69:9 70:1581:10

CTs 152:14curious 110:18current 124:14129:23 134:9136:10 151:5166:9

currently 10:20118:7 123:20145:3 148:12150:18 151:5153:12 162:10195:16,17

Curriculum 4:17CV 15:11 147:8cyst 34:7

D

daily 29:2 78:20damage 101:1176:17,22

damages 17:21,2218:2,5 20:16,2020:20 57:1 122:8122:10,20,25

135:18Darrell 1:4 5:20data 156:15,18date 21:10,17101:16 120:15128:5 173:25190:20 209:25

dated 4:15,16 18:621:5 207:19

day 12:6 24:1425:7 27:15,16,2128:6,6,12 36:2061:20 66:7 67:871:24 84:11 86:8102:19 109:5118:17 145:17174:5 175:13206:7,10 207:19

days 22:9 24:5,724:11,16 25:327:14,15,2045:15 115:7171:7,10

dead 159:21deal 12:11,19 32:132:2,3 63:582:21 117:22

dealing 26:18death 167:9December 36:10decided 8:4 107:1127:24 175:6

decision 193:21195:10

declare 209:22decline 58:16decrease 114:1deep 42:15,23 43:750:2,2 56:263:17 71:3 81:199:15 184:5192:23

defect 73:15 116:5defects 74:23,2474:25

defendant 119:13Defendant's 4:1323:10,14 147:14

defendants 1:102:12,17,21 3:1,63:12 138:16148:13

defense 102:24103:3,17 148:16148:17 181:16

defer 88:20 89:189:11 112:8

117:18 197:10deficit 134:10172:24 178:3,4,5178:7 187:6

deficits 59:2282:8 104:17153:15

defined 47:13definite 128:14definitely 183:23183:24

definitions 96:7definitive 76:4192:20 199:12200:23

definitively 69:4delay 200:21delegation 144:4deleterious 157:24delineated 134:6delivery 110:25demographics 26:4demonstrate 100:12109:11

demonstrated 65:2066:12

demonstrates 62:9108:23

demonstrating 62:1184:6

demonstrative73:13 153:8

Denise 1:23 5:1206:5,13 207:6207:22 208:16

Dennis 2:12denying 152:2department 120:7195:23

depending 27:9depends 33:13110:24 112:7163:7 191:24

deposed 6:1 181:20deposition 1:144:2 5:1,21 15:416:6,12,16 17:319:4 22:6 23:2524:2,6,14 64:1488:9 99:2,4108:16 109:9125:16 139:15141:25 147:9,11148:21 149:3,9150:7 151:14,17171:1 177:17191:12 193:7

197:19 205:1,2207:8 208:6

depositions 47:22109:23 118:3148:24 181:4,4,9181:24

deprive 157:20derived 47:20118:7

described 58:2585:18 86:6180:13

description 4:14114:3

designate 55:1756:22,23

despite 82:2 83:885:1 86:2,12,1796:3 108:6,14112:23 137:22183:20 192:5

detailed 131:9,16deteriorated127:16

determination112:9 193:19

determine 34:1937:2,9 49:1455:24 137:3162:7 183:21198:25

determined 116:17125:14

determining 188:3Deutsch 135:19,24177:6

Deutsche 18:15134:19,23

develop 137:24158:20

Developed 77:21developing 135:4development 134:4deviations 171:12devices 87:8devote 181:18diagnose 57:17diagnosed 49:2589:20

diagnoses 60:1761:8 97:14

diagnosing 36:18diagnosis 37:20,2550:6 57:20,2360:13 61:24 66:666:22 70:2581:17 143:4

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184:10diagnostic 39:1,6118:15

diameter 86:2591:4

dictated 53:9dictates 54:9dictation 54:10,2054:21

die 64:3difference 56:8102:12

different 34:459:17,19 72:1683:18 101:7114:12 115:17143:15 154:19164:1 166:10181:24 202:4

differential 66:666:10 68:2469:14 70:17,2581:16 97:14121:20

difficult 68:7131:9 135:8166:2

difficulty 113:12113:16 129:24138:19 178:20

diffuse 36:21129:12

dilate 159:3Dilaudid 186:16196:14,18,22

diminished 134:12diplopia 113:14direct 4:3 5:13105:16

direction 60:2directly 122:25director 26:15,1730:17 37:1444:23 120:4156:3

disabled 187:9discipline 9:17disciplined 9:24148:1,8

disclosure 51:25disconnect 108:15discuss 14:9 85:1285:14 106:22164:10 191:22199:15,17 200:4200:14

discussed 17:20

18:5 49:17 89:14122:7 151:16171:12 174:18183:5

discussing 175:19193:4

discussion 22:1055:5 105:16174:14,21,24175:8

discussions 175:3disease 65:2,23,2466:2,11,13,14,1866:19,24 67:1,267:3,6 68:17,1868:23 69:3,1380:2,4,7,10 81:986:11 98:7,16,2499:5 100:2103:11,18,22104:10,16 108:5111:5 121:5,16121:23,24

diseased 77:24disks 15:19dismissed 118:24dismissing 107:9disorder 41:2466:4 69:24,2497:25 98:6 99:22

disparity 54:755:10 173:10

disposal 61:13disputing 110:6dissection 41:697:8 98:6 99:25103:12 122:1

dissipated 57:1558:25 59:12 61:1118:20

distinction 115:19115:22

distribution154:23

division 196:9dizziness 72:2073:4,9 76:1777:4,9 84:20,2486:5,14 108:2110:4 113:24114:21 115:1,7,9115:20,23 116:6116:9,14,22,23116:25 176:16178:5,7

doctor 31:8,2332:3,18,22 55:23

55:24 56:6 64:167:21 75:23105:22 106:5109:4 122:18137:2 170:1177:11 181:3194:1 197:18200:10 202:1

doctors 12:10,1713:3 32:1 54:1356:11 61:19 78:9106:24 133:4,6183:6

document 23:9,1348:16 55:1147:13 209:23

documentation42:22,23 43:1,1844:8 53:1 62:11107:9 175:2

documented 43:1050:18 53:2560:11 63:18,1972:19 83:7108:22 110:5130:18 151:18154:7

documents 22:14109:6

Dodson 149:19180:17,23

doing 34:22 55:1494:11 127:7,8139:21 163:5,12163:13 168:1200:15

dominance 161:25162:6

dominant 162:4,5door 30:12door-to-needle30:10 37:8

Doppler 41:16Dorking 11:10double 113:15doubles 113:8downtown 15:2499:18 203:23

dozen 25:21Dr 5:17,18,19 17:218:7,15,21,2419:4,12,16,2120:5,13,16 23:1150:17 51:16,2152:1,8 53:1655:14,17 56:4,2057:14,17,21

58:10,20 60:9,1660:23 61:6 62:1162:21 63:9,9,2364:7 65:1 67:971:5,17,23 72:1473:21,25 74:6,874:16 75:2578:14 80:1383:25 84:10,1284:13,14 86:1,986:21 88:8 89:589:25 91:5 98:1998:22 99:3100:17,19 105:1105:18,23 106:4106:9,16,17,21106:25 107:5,7107:13,15,16,17107:18,21 108:8108:9,25 109:1109:12,16 110:5119:12 120:2,3124:18 125:3,11125:16,24 134:19134:23 135:19,24135:25 136:3,14138:9,14 139:11139:12,14 141:7142:12 145:23,23145:23,24 146:20150:8 151:16154:7 159:25163:5,7,8,10,11163:12,16,16,19163:25 164:2167:15,24,25168:6,10,24169:1,7,14 170:2170:8 171:12175:14 177:6,8177:13,16,20184:15,21,24185:3,8 187:25188:1 189:20190:10,14,17,22191:11,12 192:5192:6,7,12,13193:3,4,7 197:19197:21,24 198:8198:10,10,24201:9,11,14202:2,5,9,19

draw 136:14drawing 136:15Drive 2:13driver's 48:13drop 121:11

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Drs 16:7 46:3drugs 30:5due 80:4,6 138:21182:22

dues 8:23Duke 2:25 77:22167:24 208:22

duly 5:11 206:8durable 137:5duration 51:14duty 37:12Duval 1:1 25:18DVD 16:21DVT 42:21 43:2,1043:14 44:4,8,9133:24 155:17,23195:9,11

DVTs 92:23dysfunction 56:357:6,25 62:2,862:10,16,22,2563:12 71:3 73:774:17,18 81:2,383:6 84:19106:11 108:2162:8

dysgraphia 162:7

E

E 2:3,8 3:15E-i-e-d-e-l-m-a-n18:7

e-mail 204:21E-tran 204:19,20204:22,25

E.R 12:21 32:7,1249:24 50:5 55:22

ear 116:2,10 117:1117:6,8

earlier 52:24 56:461:20 83:2284:10 86:6 89:14142:17 145:22147:12 148:20149:12 150:4,11151:21 152:18153:22 154:2156:11 157:3158:11 160:8162:18 166:18167:3 170:25175:23 176:9,19177:3 187:18190:7,14,15,18192:5,14 194:5204:4

early 28:12 178:19

192:19easier 22:9 53:13140:7

easily 136:6easy 166:5eat 28:17echo 187:12,17197:8

echocardiogram41:18 66:15,1666:25 67:7 68:1668:22,25 69:281:12 95:14,1795:21 96:4,7111:9 151:22188:5 192:12,18200:18,20 201:15203:18,23

echocardiograms120:20 199:6

echocardiography41:17

edema 159:12 160:6educational 9:129:13

EE 206:14effect 152:23196:14,22

effective 43:544:11 134:3

effectuate 136:24efficient 43:14efforts 137:4effusion 68:12Eidelman 18:7,8124:18 202:5,9202:19

Eidelman's 202:2eight 72:7 147:17177:15

eight-month 145:20either 41:1 42:342:11 55:20 60:360:13 62:2 66:382:8 83:7,784:16 106:9,16113:13 116:19121:23 136:14144:12,13,14149:3 154:8159:22

ejection 68:8elevated 201:3eleven 59:3elicit 63:23116:17 198:8

eligible 144:14,22

145:6eliminate 35:2eliminated 70:24Ellen 18:21,24Ellis 2:2,7else's 138:9emanates 199:22emanating 139:24embark 107:1emboli 42:22 56:263:18 65:24 71:482:5 95:3,999:17 111:6112:12,12,18,25133:24 184:5192:23

embolic 72:25 73:376:1,11 94:23108:5 113:23121:20,23 159:10184:6 186:10196:15

embolism 49:25167:5,8 180:9182:13 184:2192:17 200:3

embolization 43:874:22 81:1,4134:2 192:22194:23

embolus 120:18159:16 167:9182:18,23 184:8

emergency 12:5,612:17,24 31:932:17 37:5 55:23

EMG 118:16 142:25employ 31:2employee 207:14,15enable 31:16107:21

encephalomalacia121:13

enclosed 208:8encompass 143:13encompassed 25:2497:22

encompasses 34:12endeavors 9:4endings 114:7,10114:12,17

endogenous 138:24engages 160:20ensued 175:9entered 47:7133:22 173:3

entire 26:8 169:5

170:11 208:13entirety 19:8107:21

enumerate 15:6envelope 19:2422:19,20

envelopes 22:12epilepsy 26:9117:22 191:7

episode 100:8,10100:25 101:13122:15 134:7

episodes 83:6101:7 128:21134:11,17 135:21

equals 52:21equate 88:11equated 123:3equipment 137:5164:11

ER 45:6errata 4:11 208:10208:12 209:1

erroneous 57:23erroneously 57:1758:4

errors 132:25165:9

esophageal 111:15Esq 208:21,21,22208:22,23,23,24

ESQUIRE 2:5,10,152:20,25 3:4,9,15

essential 116:12established 66:7184:7

Estimated 68:10et 1:9 155:12178:21 208:5209:4

etiology 97:15evaluate 31:8156:20 193:18

evaluated 29:2131:1 61:7 130:7

evaluation 33:860:9 131:16136:19,22,22137:2 183:13,14

evaluations 137:3evening 24:2460:24 63:10 66:866:21 68:2469:19 71:17 72:6174:5

event 24:19 64:23146:19

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everybody 28:1330:15 140:7

everybody's 142:11everyday 117:20,22evidence 62:8,1562:24 63:5,11109:24 110:9121:4,8 128:14153:24 186:8189:5

evidencing 120:18evolution 107:22evolving 96:18,2197:9

exact 13:19 48:4120:15 144:4173:25

exactly 40:21 53:464:21 65:1186:24 89:12 91:7128:16 137:13138:15 143:17155:1 175:2179:13 188:10

exam 131:2 145:5145:14,20 153:18165:4 166:12,24198:15 202:5,12203:7

examination 4:3,64:7 5:13 7:1560:4 61:7,14,2462:12 63:6110:18 122:13,18124:2,3 125:12130:16,17,23131:16,22 132:2132:6 145:9,10145:10 166:20167:1 172:17192:3 197:16202:8

examinations 167:2examine 17:23122:2 160:17166:6

examined 5:11169:14

examining 123:21124:7 183:21

example 9:20 22:7194:20

excellent 9:16exception 103:1

excessive 48:3118:15

exclude 83:1786:10 100:8

excluded 38:1382:15 87:7

excluding 38:1exclusionary 34:1335:2 82:12

exclusively 36:7excuse 54:25 123:2149:5 180:22195:9 200:7

exercised 37:4192:25

exhausted 192:6exhaustive 137:15exhibit 23:8,10,1223:14 147:9,11147:14 149:9165:1 168:13

EXHIBITS 4:13exist 150:14 156:1190:3

existed 156:2existence 189:25exited 167:21expect 72:4 141:10162:1 166:10175:18 190:19199:21

expectancy 172:18172:21 173:1,8173:10,14,21

expected 175:20expedited 29:18expense 166:4experience 87:17101:22 102:2139:23 194:17,24195:2,12

experienced 110:1138:20 172:5,6

experiencing 45:2296:18 104:15109:19 110:8

expert 5:22 17:321:8 88:9 177:13177:25 189:20

expertise 7:19,2240:14 52:2 199:1

experts 16:2451:25 102:11177:5

Expires 206:15explain 57:20explanation 61:12

explanations192:15

explicatory 60:1576:24

explicitly 188:2express 80:15103:7 113:17131:11 185:2,4

expressed 131:17154:6 191:15

expressly 106:19extend 44:9extends 139:20extent 122:19189:13

extra 7:9extremities 92:23107:24

extremity 50:1957:8,10,11,2158:23,24 59:2359:24 60:5,24,2562:13,14 108:20113:18 140:17154:24 169:7

F

F 2:25f-o-r 46:15facets 70:24106:15

facial 113:15,15131:19,20

facilities 11:1152:14

facility 27:131:14 44:23,24202:22

fact 20:6 55:1771:2 86:3,12104:14 108:16,22109:10,25 110:3148:22 154:4158:18 172:23192:7 193:10

factor 34:14 70:770:9,12 102:6138:22

factors 34:24 38:763:19 64:2 65:10133:22 172:1,15

facts 165:15209:23

faculty 10:18 36:8170:15

failed 133:25168:22 188:1

failure 34:25,25fair 6:6,8 49:954:23 116:24168:1 170:8,10178:18 179:10203:15,16

fallout 37:10familiar 17:13142:20 144:2,3,4155:8,14 164:17

family 13:14 63:2064:3,9 70:6164:7

far 15:25 16:1220:20,20 25:1236:14 43:24127:13 139:7153:22 181:22194:14 199:7

fashion 57:22134:1 136:20168:23

fast 65:18fatal 167:7father 64:3February 24:20166:10 170:19

fecal 202:10feel 96:8,10114:14,16 117:22158:19 201:9

feeling 130:12158:14

feels 79:10 115:24159:4

fellow 31:12felt 9:4,4 84:15201:10

fever 94:11fibrillation 41:2480:6,10 97:6,25

field 5:23 7:20fifth 36:22figure 89:4 183:10file 165:23 171:1filed 9:21films 15:17 89:2191:6 98:25

filter 71:15 74:2174:21 75:3 77:1777:20 79:1680:14 83:3,20,2283:24 85:6 86:286:12,17,23 87:187:11,20 88:1792:13 93:3,9,1093:12 94:4,7,25

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filters 75:4 77:1377:14 78:2 82:392:23 94:13

final 67:19Finally 45:3financially 207:17find 51:10 55:2059:9 66:14116:14 124:20130:6 176:19202:4

finding 96:3108:24 129:14178:9,11 202:12

findings 57:1558:23 60:16,1861:9 106:11133:25 134:6152:11,25 184:4202:4

fine 15:10 20:1048:5 75:18 78:16133:17 137:10168:1,4 181:1192:1

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finishing 144:19firm 39:11 149:17149:19 180:18

first 5:11 6:1413:17 29:1530:23 33:20,2154:12,13,16 56:666:7 73:6 74:20102:23 103:3,17106:9 124:1126:7,7 127:23144:9 145:9153:23 155:3171:7,10 178:17179:14 182:4186:22,23 187:16191:25 200:12

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Fischer's 23:11Fisher 198:8,10fit 135:7fits 22:19five 24:11,1528:19 29:6 32:1455:15 75:1779:17,18,25 83:383:15 118:17133:15,17 148:15148:18 174:19

fixed 27:8FL 1:20 2:3,8,132:18,23 3:2,7,13208:4,18

flew 123:9Floor 2:3,8 3:7Florida 1:1,9 5:310:10 24:20 31:6156:24 204:2206:2,6,14 207:3

flow 114:1fluctuating 104:9fluent 140:11focal 57:6 59:2271:3 83:6 133:24178:2,5,7

focus 81:17folder 165:20folders 14:19,19171:2

follow 161:14follow-up 141:17152:10,19 188:18194:1 203:3

followed 37:22following 45:1568:4 102:18,19145:10 188:1

follows 5:12Fontela 2:12foramen 188:4force 85:2foregoing 209:23foreign 159:12forgot 48:9forgotten 24:948:14

form 58:11 61:1063:2 81:23 88:2389:9 91:8 92:1892:20 95:23101:24 102:4103:25 104:5,12104:18 108:11111:19 112:6,14112:21 113:4116:7 119:22129:15,21 131:7133:5,8 143:6151:12 155:24172:7 185:22186:3,14,18187:2,3,4,11,15188:7 190:12,21197:12

formation 44:6,1394:20

forming 111:6formulate 161:7formulated 119:17144:5

forth 44:11 70:17158:19 163:3194:21

fortunately 29:22forward 135:7forwarded 204:11fossa 73:5 74:1876:18 81:3

found 76:23 130:17149:20 202:5

foundation 187:15four 31:18 46:15118:24 119:5145:21 147:19148:16 174:22175:9 180:11190:11 196:7

fourth 1:1 178:19fraction 68:8fragment 167:12frame 125:5 139:9144:16 169:17172:6 175:12,16

frankly 157:11free 96:10frequency 163:7181:8

frequent 41:2256:2

frequently 27:1327:19 35:21 73:3

Friday 27:22 28:3friends 136:12

162:13 164:24front 32:23 75:1fulfill 31:1658:14

fulfilled 30:4full 82:16 85:1122:19

full-time 170:15fully 126:6function 177:2furnish 191:11further 4:6,7,7,84:8,9 8:2 40:2544:9,10 68:22119:23 120:10134:11,17 135:21180:24 194:3197:5,16 198:22201:24 203:5207:13

future 94:20160:18 191:1

G

gait 113:20 132:9gamut 26:8gee 11:4general 11:6,986:22 93:19 94:597:10 113:10116:5 182:16

generally 169:8gentleman 39:10germane 151:4getting 137:13163:22

give 5:6 13:1930:11 31:1634:17 73:2 75:17112:24 120:15126:17 129:11,19133:16 160:17161:4 164:1181:4 182:5189:15

given 29:22 30:344:16 47:1 114:3118:2

gives 169:17giving 112:13157:22 181:8

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grab 137:6 164:14graded 131:23grandfathered11:22

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greater 47:13 87:5172:8

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grievance 9:21groin 93:5,6grossly 48:3group 11:4 170:14

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guild 9:10guys 188:11 189:15GYN 46:6,7

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H 2:20Haitian 26:11half 13:20 21:2022:4 25:21 26:629:8 33:7 55:1587:3,5 88:10124:11 126:7

hall 38:20hammer 139:21hand 74:13 171:8handwrite 130:2handwritten 165:7204:19

happen 9:25 61:25102:16 134:22

happened 22:8 86:895:15 102:21123:1 138:7158:6 175:7178:25

happens 12:2332:10 39:1858:15 133:2156:12 173:1194:12

hard 30:8 105:12129:8,10 153:14157:19,20

Harmon 2:20 4:3,64:8 133:8 141:16141:20,23 142:2142:6,10,13143:9 144:1146:16,19 147:11147:15 151:14165:4,23 167:15167:18 185:22186:4 187:3,11188:8,12 191:16

191:19 194:1,4197:1 201:23,25203:2 204:18208:21

he'll 129:11head 16:1,3,4headache 76:1,5,1484:19 85:19,2286:5,14 109:18110:1,8 113:22114:2 115:13117:5,6,10158:12 159:2,11178:10,21 196:15

headaches 72:17,2272:24,25 73:2,981:3 84:11,17,23106:14 107:25108:1 109:2,19110:3 159:1198:9

hear 133:18heard 60:22 85:16143:15 177:8

hearing 181:14heart 95:3,7,13,1895:19 96:5112:12,24 120:19199:23,24 201:7

heavy 132:12held 171:3Helen 124:20Hello 143:9help 80:11 137:12200:22

helped 132:11helpful 20:1940:17 139:15

helps 37:25hemisphere 34:13hemorrhage 38:239:21 40:24 81:8103:15 186:11

hemorrhagic 34:2,234:5 37:17 42:673:2 76:7 113:23185:24 186:6

heparin 42:19,2043:2,9,13 44:4,644:11 50:7 51:751:14 71:10,1171:18 74:1881:22,24 82:1,282:4,6,7,8,9,1382:15,16,18,1982:21,24 83:8,983:11,13,18 85:1

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high 35:1,4,5,594:10

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higher 172:11,14highest 118:10historical 61:12historically 60:360:11 63:15

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hospitals 10:2011:3,5,19

hour 23:17,22,2424:1 28:16 33:758:12,23 59:13124:4

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identified 5:22identify 54:25190:4

identity 16:23IDEX 148:23ill 94:10 112:5193:16

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immediately 30:432:12 34:3,1942:10 70:22

implication 190:3implied 170:8important 9:563:25

impossible 60:13impression 99:1,299:7 133:10,11168:16,20

improve 134:11,17135:21

improved 81:2101:2

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included 57:8including 9:15,1637:23 63:19161:2 172:22,23

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inconsistent 115:1115:3

incontinence202:10

incorporate 15:19incorporated 110:9incorrect 96:24168:23

increased 131:25173:9 186:22

indefinitely 94:17independent 100:15138:15 166:20

independently 89:5152:1

index 4:1 139:25204:24

indicate 47:2398:23 135:25

indicated 66:2468:23 70:16 76:197:4 175:13189:17 198:24202:1 204:4,8,10

indicates 34:16indicating 123:22indication 99:20indicative 63:1168:17,20 69:3140:18 201:6

indigenous 32:24individual 37:1141:10 129:11172:9,14 199:16200:14

individually 1:5156:16

individuals 37:11inexact 129:22infarct 74:7 92:11101:3,4,15159:21

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infections 117:1inferior 175:25inform 119:20information 23:786:9 120:11,13129:8,13,19177:19 178:13,15180:2,6 188:19

inhibit 34:24initial 14:15 33:871:21 102:18105:16 171:7

initially 14:2415:1 37:21 59:11176:12 200:17

initiation 30:6injected 194:9injury 142:19143:1,6,6,12161:23 176:17,23180:4

inner 116:2,10117:1,6,8

inpatient 29:14150:25

input 203:14inquire 116:8inquiry 119:23INR 35:5inside 171:18insight 100:10insist 13:16instability 65:5installed 78:11164:13 175:17190:25

instance 155:5instituted 134:3insurance 118:14161:7,9,14,17202:18

insurances 12:1112:17

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investigated 9:22invoked 29:23 34:4involve 119:6involved 78:9171:23 177:12182:13 199:18

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56:19 119:6152:24 183:21194:14

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kindly 15:2kinds 34:6King 85:9know 6:4 11:1515:8 17:3 18:1819:7,15 27:439:21 42:5 45:946:9,23,25 47:1548:2,3,4,6 49:949:20 50:14 53:654:11 56:1158:18,20,22 59:159:12,14 62:4,562:5 63:25 64:564:5,9 65:10,1667:8 70:21 73:2484:17 87:6 90:1990:20,21,21,2591:1 95:11,14,1595:16,16 96:1199:8,11 106:6123:15,16 124:15125:5 126:9,14126:21 133:18135:11 137:10,14138:1,6 139:10146:2,6,10,19147:3,15 149:1149:12,20,22151:4 160:9162:14 166:9,18168:3 169:17173:23 174:2175:4 177:7,16177:24,25 181:1181:1 182:18,19191:14,17 193:12193:12 194:12198:11 199:4202:16,21 204:13

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knows 24:25 56:17Kuntz 3:15 142:2143:7,22,23,25

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lab 164:1laboratory 66:569:23

lack 105:16 107:15129:6 157:23187:15 192:25

lady 31:13 59:774:16 138:5

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larger 87:22 88:1291:21 92:9

largest 26:13late 99:17 122:9180:8

latency 55:8 56:2558:7 145:18

latest 153:12190:24

Laura 2:23law 149:16lawsuit 5:19lawsuits 148:14lawyer 149:19lawyers 133:7layers 30:23lead 121:16leading 46:16182:25 183:2

leave 28:21leaves 70:25led 61:3Ledger 4:15left 50:19,19 57:857:8,10,11,11,2057:20 58:23,2359:24 60:4,24,2562:12,12,1465:25 68:8,2171:8 74:13 87:2594:17 101:4,19121:13 131:25132:7 134:4,5,9142:4 153:20154:23,24 162:8169:7 186:24187:7,14,20

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left-brain 162:4left-handed 161:21162:1,4,9

left-sided 60:12107:23 108:20

leg 113:18 131:24legal 150:1,3166:19 167:1181:18 208:7,17209:5

legs 74:25 75:1length 112:23197:20

lesion 90:12lesions 34:8 184:6lesser 163:15let's 11:22 14:1659:15 62:20 71:577:13 120:14123:10 126:19133:9 138:2141:18 175:5182:21 190:22192:11 196:3

letter 4:11 168:12170:7

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license 48:13148:5 162:20

licensed 31:6life 134:11,17,18135:16,22 160:22160:24 161:4,5,6172:18,21 173:1173:1,7,10,21

lift 164:20lighting 34:15likelihood 139:3172:9

limiting 130:25Linda 3:9 184:20208:23

line 60:18 61:899:16 102:23103:3,17 209:7

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literature 17:6,917:13 96:19 97:2189:24,25 194:14194:18,21,24

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logistically 166:2193:20 195:6

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lowers 93:24LPN 163:4lumen 91:23 92:9lumping 180:14lunch 28:16,1782:25 140:12

lunchtime 51:11127:17 169:3174:12

lungs 92:24lying 109:12lyse 44:15lysing 44:17

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machine 65:17110:24

madam 19:22 88:24109:4 115:12140:13 141:15

main 92:22 93:1128:25 137:16167:4 180:8

major 74:14 118:14134:4,12 136:24191:5

making 37:19 112:8134:15 198:12

Maldonado 145:23malformation 34:738:3 40:13 81:7

malpractice 9:5138:25 148:13180:18 181:15,22182:3,6,10,12

man 77:24 129:7,17

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mandatory 8:23manifest 134:5manila 14:18,1922:12

manner 13:10,1231:22 42:24

Margaret 1:4,54:16 5:20 133:21208:5 209:3

Marie 1:23 5:1119:10 206:13207:22 208:16

mark 23:7,11marked 21:23 22:823:9,13 147:13

Marks 3:1Martin 2:12massive 66:18master 114:13material 22:455:18 204:12

materials 14:1215:3 20:23 21:23150:5

matter 21:7 22:2458:16 157:17165:12 200:24

matters 22:22119:6

Matthew 2:5 13:22208:24

maximum 30:8122:16

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mean 7:2,21 15:1417:11,13 18:525:21 35:2338:21 43:17 49:974:24,25 80:2582:13,18 87:998:12 100:13104:19 117:11118:17 122:14135:6 140:2155:1 158:8175:1 182:20185:7 188:17194:19 195:17

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measuring 89:11mechanism 159:2,10medical 1:8 10:2215:22,24 16:117:6,9,13 18:2021:8 22:1 26:1526:21 27:1 29:1245:7 91:12 96:19118:23 122:16126:24 137:5142:13 144:9146:14,23 148:13151:10 156:4160:18 162:15,20164:6,11 166:20167:1 171:16,21178:14,23 179:5180:18 181:15,18181:22 182:2,6182:10,12 189:20189:23,25 191:12194:14,17 195:2195:12 203:23208:5 209:4

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medically 65:12161:18

medication 42:1043:9 49:20 50:550:8 77:8,11157:23 196:24

medications 42:5,9203:8

medicine 12:25142:20 144:11160:12 164:7177:10 195:23199:15 200:10,12

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meetings 23:19member 8:13 150:1155:11

members 9:17 13:14149:16 155:5,7

Memorial 10:2335:18 36:5,13

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mention 62:2113:24 165:16

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Miami 1:20 10:9,1510:19,22 11:5,911:24 35:16,2236:8 208:4,18

MIAMI-DADE 206:3207:4

Michael 2:20142:12 208:21

middle 31:13 32:534:15 58:1587:25 90:12101:19 121:14134:4 139:25186:24 187:7

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migraines 72:23186:15

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mind 67:15 108:19167:20

mine 202:8mini-mental 130:23minimal 121:6,8minimally 130:3minority 173:9minute 70:5minutes 28:1729:20 30:13,1431:2,5,10,1532:14,16 33:2237:7,7,8 53:2154:22 75:16110:23 133:20170:23 200:21

misled 58:6missed 89:24,25165:16 187:16

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mixed 161:25 162:6modalities 132:2mode 164:17moderate 68:11,19modern 183:20modifications135:5,9 139:3

modified 137:8moment 32:13Monday 27:21 28:3money 77:25monitor 136:3monitoring 30:141:25

month 36:1,2163:10 181:10,11

monthly 164:6181:9

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Moore's 53:16107:5,17 190:22197:19

morbid 47:11,1263:20 172:10,22

Morbidly 130:8morning 5:15,1724:23 28:1833:15,18 39:2545:5,11 50:12

52:8 60:10 68:572:5,7,9,11 84:4106:3,13 127:13127:15 167:25168:1 170:21178:20,25 190:15190:18,23 192:19

mother 64:2motor 59:22 118:13131:22

motorized 136:6moved 14:18 35:24moving 27:7 45:1138:20

MRA 37:23 40:1041:1,14

MRI 37:23 41:1,465:4,13 73:1291:17 110:18

multifocal 81:4,19184:6

multiple 26:9121:10,14

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N 2:23N.W 1:19 208:3name 5:15,17,1831:4 119:10123:15,16 142:12146:10 149:19167:24 170:1184:20

names 46:9 116:12126:24

narcotic 77:8,11narrowed 173:11national 30:11nationally 41:23nature 9:2 45:1256:21 58:2 95:24191:5

nausea 72:20 73:473:9 76:17 77:477:9 84:20,2486:5,14 108:2110:4 116:25176:16 178:2

navigate 135:8NCA 153:20nearly 134:7necessarily 38:672:24 82:17 91:192:16 111:1,2116:11 138:4

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negate 110:2negative 65:4 69:8128:10,13

negligence 118:23119:2 138:10

negligent 187:25neighbors 136:11162:13 164:25

neonates 158:19nerve 114:6,9,12114:17,19,19118:16 142:25

nerves 114:11,13131:19

nervous 116:5neuro 101:4Neuro-ophthalm...117:19

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neurological 4:1612:24 13:1514:10 17:19 26:856:3,18 57:671:3 107:22124:16,17 125:11125:12 133:24134:9 178:2,5,7185:6 191:1

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neurology 5:236:22 7:1,6,9,198:14 9:9,11,1510:1 11:25 51:1956:20 117:12,14120:5 142:23,23142:24,25 143:18145:13 146:21147:2 155:10,15180:20 196:3,9

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neuropsychologist130:25

neuroradiologist38:19 74:4 88:2089:2 98:20 160:4

neuroradiology39:2,7

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neurosurgeon 34:3never 7:15 24:25128:1 144:21171:18 177:17

new 86:4,13 128:21137:9 148:16,18149:19 191:4

nice 9:14 77:24129:17

niece 123:13night 12:3 25:231:13,19 32:5

NIH 173:15nine 147:18 190:23nixed 84:14non-board 120:7nonfluent 162:2nonmember 10:2nonrevealing 70:16nonspecific 76:15normal 50:24 68:8132:1,8 173:21

normalized 59:9normally 130:16North 10:22 11:5,711:12,15 26:1526:21 27:1 30:2032:8 35:11 36:1536:19 37:16 39:939:13 44:22144:9 145:22146:14,23 156:4

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note 15:21 16:146:2 52:23123:12 126:5132:17 165:1,7186:13

notebook 124:25noted 60:9 153:10169:7 202:9,11

notes 21:24 207:11notice 62:3 189:2noticed 145:25147:8 165:9

Nowicki 46:3nuclei 114:19116:2

number 11:20 29:146:15 47:21 48:454:19 118:13182:5

numbered 204:23numbers 47:19130:11

numbness 50:2074:13 108:21113:15 115:15140:17 141:3155:2

nurse 55:23 136:13139:7 162:23

nurses 30:2 85:885:14,18 109:21

nursing 37:5

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Oath 4:10 206:1obese 130:8 172:12obesity 47:11,1263:20 172:10,22173:19

object 91:8 92:1895:23 133:8172:7 186:3187:2 188:7190:21

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objections 167:20objects 130:12obligatory 12:5obliged 12:7,18observed 203:17obstructed 89:7obtain 142:18166:15

obtained 119:22150:21 152:14

obtaining 144:7obvious 40:2495:18,19

obviously 22:357:23 73:3 94:8160:10 202:25

occasion 40:5106:10 129:20

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opportunity 134:21188:20

opposed 8:24 13:1622:10 37:1744:21 56:4 58:159:16 78:2591:17 108:7116:5,22 123:6167:2 178:9200:17

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period 8:18 19:18118:19 136:23149:24 156:19157:10 171:13174:23,24

periodically 115:4136:14 139:8,9

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162:24 173:17191:3

peripheral 58:460:1 61:4 114:13

perjury 209:22permanent 101:1,6153:15 176:17

permanently 187:9permission 156:13person 12:25 32:2033:14,14,20 35:437:6 79:1,2 83:5108:20 130:9132:12 149:3157:20,21 160:21162:24 163:15164:7 199:15200:10,12

personal 25:23personally 36:2248:8 78:2 89:20105:20 144:8156:1 160:22206:7

pertained 144:21pertinent 17:14PFO 66:17,20 80:481:18,21 82:483:7 98:2 127:24128:2,5,14 134:2135:2 137:20155:17,23 182:13182:17 184:4192:20,22 194:23195:8,11 203:17203:24

PFOs 80:8,8,8138:2

phenomenon 66:17philosophically8:24

phone 142:3photograph 16:20physiatrist 135:13135:16 160:9,9160:19

physical 30:6 63:663:11 136:18160:12 198:15

physically 17:2333:10 124:8130:6

physician 10:1913:7 18:25 31:932:12 36:1850:18 54:9 60:1179:5,6 94:3,4

105:23 120:7129:10 139:20160:14 170:4203:15

physicians 78:18105:17 107:4,16119:14 133:25155:6 168:22171:21,23 183:20184:10

physiognomy 65:11PICC 99:16 180:9pick 12:7 75:24picture 16:20 48:748:10,11,13,1586:6

pictures 48:8Pilapil 85:9Pilcher 16:7106:24 170:2,8201:9

Pilcher's 193:7pile 22:15pinch 39:18pinpoint 183:23,24pithy 125:12place 3:2 30:254:5 130:5174:15,25 175:21175:25 195:10

placed 42:15 77:1883:21,22 86:2287:1 88:17 92:1393:3 94:13 95:295:7 96:14173:24 174:19190:11

placement 86:2,1793:10,12,19105:2 190:8,20195:7

places 94:4placing 175:20plain 34:16 37:2137:24 39:20

plaintiff 17:4148:13,19

plaintiffs 1:6 2:22:7 5:22 16:1316:24 85:13166:23 170:24177:5,12 180:6

plan 161:7plane 123:11planner 134:18135:16 161:5,6

planning 25:16

151:22plans 160:22,25161:4,15

platelet 35:4Plavix 42:11pleadings 146:18please 6:4 25:22115:22 133:12204:19 208:10,12

plexus 140:23plus 24:22 86:5,6pneumonia 157:22point 6:11 19:1557:5 67:15 74:2075:15 82:13,14107:12 122:7125:8 140:9142:3 169:18,19172:5 204:10

policies 120:1policy 24:9 191:21political 8:23 9:1poor 44:2population 41:23113:10 138:4182:17

position 85:4156:3,5

positive 139:17,18139:22

possibilities 65:397:14

possibility 66:166:20 71:2 134:1192:16 193:1,5194:11,13 200:15

possible 19:2350:15 57:1865:14 67:11117:7 134:8141:2

possibly 58:590:18,19 91:194:21,24 104:19144:7 192:22

post 197:20posterior 73:574:18 76:18 81:3

postop 45:15poststroke 160:21191:6 197:24

potent 196:21potential 29:2194:23 112:12191:6

potentially 9:22104:15,20,21

111:20 117:11119:16

pounds 47:20,2449:7,13 127:11172:3

pour 34:16powerful 196:21practically 7:2,377:16

practice 8:5,710:11,13,17,1825:23,24 26:3,426:20 117:20145:22 146:3,4146:23 147:1164:7 170:11,12170:17,18 171:21

practiced 144:23145:15

practicing 10:1556:7 104:3

pre-suit 21:12188:23 189:21

preceded 20:17preclude 34:8 38:7precluded 82:6predominantly36:14

preexisting 172:1prefer 41:2preference 31:23premature 66:3prematurely 41:11preparation 22:6prepare 21:1,622:10 23:1

prepared 22:13208:8

preparing 165:12prepayment 24:3prerequisites156:14

prescribe 203:8prescribed 50:9presence 50:18present 76:7,9,1198:18 120:18

presentation 38:838:13 80:23

presented 201:3Pressman 17:273:25 88:8 91:598:19,22 100:17100:19 159:25

Pressman's 99:3pressure 68:1093:25

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presumptive 66:2271:9 184:2,3,10

pretty 53:11124:25 127:13130:8 131:14

prevent 74:22 75:495:3 111:6112:25 146:15167:5,7

prevented 95:896:15

preventing 44:12102:25 103:22

prevents 44:6,13previous 21:1984:25 87:16172:24

previously 126:23173:18

primarily 121:25162:12

primary 18:2526:16,22 35:1135:23 41:6105:22 113:20156:7 157:1200:10

prior 19:2,18 20:523:5 25:9 28:1329:7 64:8 124:10126:1 140:12166:6 172:3181:4 182:12188:25

privileges 10:2110:25 146:3

probability 91:13116:4

probably 11:2413:20 19:1220:11 24:2449:15 54:2376:24 87:1491:11 120:4125:7,14 128:11136:10,19 141:17159:12 162:7172:5,24 175:9175:10 182:24

problem 12:2413:15 15:15 44:758:2 59:24 61:461:25 65:17,1966:1 78:10 79:1079:12 82:22116:16 138:24

problems 26:10

46:16 60:6 94:2294:23 99:20101:6,7 117:7,8139:1

procedure 93:13111:10 157:9,19199:8 201:1,1

procedures 120:1191:22

proceeding 208:8PROCEEDINGS 4:1process 29:1831:15 41:9 42:144:19 50:20 58:460:1,7,15 61:461:23 65:25 66:381:11,14,1784:22,25 85:1107:22 116:10142:21 156:23186:6

processes 59:1860:2 66:12

processing 158:16product 180:23production 21:9112:25

professional 1:245:2 129:11181:17 207:6,23208:17

professors 77:22profile 30:6profound 162:2prognosis 34:16program 8:8 26:1930:18 44:24156:4,18

programs 9:14progress 44:1053:15,16

progressive 202:7propensity 135:4137:24

proper 31:17 37:443:9 66:22 108:6136:5

prophylactic 42:24prophylaxis 42:1642:21

proposed 143:2,3protocol 29:19,2330:4 34:4

proven 184:7provide 197:22203:10

provided 16:8 17:6

18:20 19:4 46:350:5 59:17 85:1086:3,18 109:23125:21 147:12,23152:7 168:10185:3 197:24

provides 129:13provision 30:534:8 74:21 85:686:11 107:1132:20 165:18

provocation 112:17psychiatry 6:19142:22 143:19

Public 5:2 206:5206:14

publications 9:15publishes 173:16PubMed 17:12pulled 165:13pulling 53:13pulmonary 42:2243:7 44:10 49:2556:1 63:18 65:2468:10,11,20 71:475:2 78:4 81:199:17 133:24167:5,7 180:9184:5 192:23

pulmonologist78:23 168:25

pulmonology 168:7pumps 110:22punches 53:14pure 162:8 172:8purpose 20:15 22:233:25 34:2274:21 75:3 92:2292:25 93:1112:16 135:18167:4,4 188:2

purposes 9:12 15:536:7 111:5 136:1144:7

pursuant 51:2454:6 126:11

pursue 8:4purview 111:24put 8:23 24:1754:13,14 79:2111:17 130:4138:2 153:19155:4,6,11174:25 189:2

puts 22:19putting 65:1771:14 155:16,22

Q

qualification38:25 39:2,6

qualified 38:18,21160:17

quality 134:11,17135:22 195:24,25

quarrel 47:2452:25 85:21148:24

quarter 36:22138:3

question 6:3,644:2 60:19 61:1464:12 69:2 88:2491:3 96:13141:16 152:15158:25 168:2176:9 190:8193:14 194:2

questions 53:1496:6 130:24142:17 167:4169:22 175:23184:21 185:10194:15,22

quick 185:16quickly 58:9193:12

quite 8:10 129:5157:11 175:7

quote 9:5 131:8quote-unquote134:16

R

R.N 162:24 163:1,3163:6

radiculopathy 58:560:1,14 141:1

radio 84:22radiographic 101:2radiographically101:5

radiological153:24

radiologist 39:1139:13,20 40:1,140:6 73:22 89:1189:24

radiologist's39:16

radiologists152:11 160:5

radiology 15:2539:1,1,6

rails 137:6

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ramifications90:14

ramp 137:12ramps 137:11random 33:18range 49:15 114:22182:5

rare 194:12rarely 28:15 35:2341:4

rate 23:15,18,2124:21 182:22

reach 122:15reached 100:18118:5

read 4:11 17:1722:5 38:14 40:153:18 64:14 67:981:13 85:7,799:1 108:8125:20 133:11165:13 168:21187:18 188:24189:4,18,21192:19 193:7199:10 201:21204:15 209:22

readily 53:6reading 22:1087:16 89:2 205:2

reads 168:21ready 142:11realize 84:16192:13

realized 106:10,13106:18

realizing 183:11really 13:10 14:2417:17 30:8,955:16 83:14 90:198:22 105:12122:19 125:13126:5,17 127:17131:2 144:21167:7

reappeared 84:23reason 8:22 9:642:17 45:1947:24 52:24 62:683:4 85:21122:14 176:24200:1,21 209:7

reasonable 72:7,8105:25 174:23190:19 208:12

reasonably 72:4reasons 34:18

43:25 82:9131:17 172:10

recall 11:3 14:514:25 16:1919:22 69:1885:20 125:3177:4,24 197:19203:20

recalled 72:1384:10

receipt 55:14receive 15:1616:13 46:11

received 14:1515:8 19:9,1620:24 22:14119:18,25 128:1128:5,24 149:18150:6

receives 55:19receiving 14:25recollection 53:24recommend 78:10,2479:9 128:11199:14,20

recommendations134:15,24 155:12

recommended 79:1680:13,16,19 83:483:25 85:5 86:286:11,21 105:2,6105:9 175:14

reconsidered 74:19reconsultation106:4,5

reconsulted 107:7109:17 192:12

record 5:16 15:521:5 53:15,16,2554:6 60:17 63:475:21,22 108:9109:24 114:25115:1 126:19133:12 139:14151:18 188:24189:17,17 201:2207:11

recorded 52:25records 14:7,15,2015:16,22,23,2318:6,20 19:8,1219:16 20:2,12,1621:22 22:1 23:1646:3,12 47:21,2352:20 55:10,1264:10 85:1899:11,20 122:8

124:10,14,21125:3,10 126:11127:1 129:1150:8,13,20,24150:25 151:10168:5 171:2172:17 174:7178:14,23 179:5179:12 191:13,13197:20 202:2204:11

recovery 134:8177:1 187:1

recurrent 81:18103:22 108:5

Redirect 4:6,7192:3 197:16

reduce 75:8 112:17128:15 196:16,25

reduced 131:19,21131:21 132:3139:2 172:22173:21

reducer 196:21reduces 75:6,7196:19

reducing 157:4redundant 176:25refer 103:6 176:5176:10

referred 23:9,13147:13 171:22174:12 189:1

referring 103:5128:3 173:5,13173:14 188:9

refers 150:12reflect 203:24,25reflex 139:21reflexes 132:3Regan 2:25 4:4167:23,24 168:15169:21 170:3186:5 204:19208:22

regard 30:16 38:940:14 76:2296:13 135:20139:15 159:25185:5 193:4

regarding 32:4152:11 170:4177:19 185:2

Regardless 25:6regards 30:21152:11,13 158:11160:18 194:6

195:7region 159:17Registered 1:245:2 207:6,23208:17

regular 48:22139:11

regularly 30:24136:15

regulation 120:9regurgitation 68:9rehab 128:1rehabilitation10:24 18:1935:19 147:1150:25 160:12

rehabilitative160:20

reiterating 122:6related 94:1 187:6relating 153:16relationship 58:19186:19

relative 207:13,15relatively 113:10release 132:5reliant 100:16relied 152:13154:2,13

rely 39:16 152:24relying 151:25153:1

remained 82:20remaining 179:11remarkably 202:6remedy 62:18remember 20:5,631:4 73:6 83:12125:8 149:13

remembered 126:15remotely 40:2removed 94:14,16renal 34:24render 39:14141:10 184:24

rendered 54:10,2054:21 55:9

rendering 29:13renewed 157:2repeat 60:20repeated 130:12repetitive 80:2586:7

rephrase 6:4report 4:16 21:2,639:14,16 48:2367:19 68:16 96:4

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150:11 151:25152:2 153:19163:11 170:7178:13 185:6,7187:18 188:8207:8

reported 1:23202:13,14

Reporter 1:24 4:105:2,5 207:1,7,23208:17

reports 140:16153:4 157:25179:8

represent 5:19141:22 142:13167:25 170:1184:20

represents 119:21request 156:13203:13

requested 201:11207:10

require 24:2,13110:18

required 25:146:23 93:19144:12,14 145:2

requirement 31:16144:10

requirements 31:1research 17:15176:2 194:18

residency 8:1,710:16 144:19145:4,17,19

residual 59:10resign 8:20resigned 9:6resolve 169:12resolved 81:2154:4,8 169:10169:16,19

respect 17:15 40:9respects 188:1respiratory 117:9128:20 179:24180:3,14

respite 136:11162:12

responding 168:6response 50:6responses 131:20responsibility55:19 166:17

responsible 37:11restate 152:16

result 68:6 129:19resultant 80:295:8 104:10

resulted 176:23results 70:21153:18 164:3

resumed 141:25retained 13:18,21166:23 177:5,6,9

retrospect 39:23153:9,12 176:11

retrospectively73:25 89:20,23

return 202:19208:12,13

reveal 69:7revealed 50:23175:8

revealing 70:3review 14:7 20:2422:4 23:16 32:2236:23 37:1,9,1361:25 67:11100:19 118:18119:22 120:17123:2 126:6,11136:22 161:10164:3 168:5172:16 178:14,22179:5,8,12180:17 181:18196:1 207:9208:9,12

reviewed 17:3 18:648:23 150:20175:8 181:22182:6,13 202:1

reviewing 14:1122:22 151:22182:2

reviews 118:13144:24 145:12

revision 132:18165:18

revoked 148:6rhythm 41:24183:14

right 10:3 11:1213:8,17 14:215:2 17:5,1619:7,15 20:4,2321:16,22 22:7,2123:6 24:13 25:2226:21 29:1130:18 32:7,933:3,14,16,2134:23 36:17 37:6

37:19 38:1439:22 40:2141:12,19 42:243:9,15 44:2245:1 47:5,1549:5,11,16,2350:12,20,25 51:751:16,24 52:3,2354:9 55:5 57:2459:15 60:7 61:561:15,24 62:1,862:10,15,22,2563:11 64:2565:25 67:18 68:168:20 69:5,1370:14 71:22 73:673:7 74:17 75:2376:8,12,23 77:177:10,13 78:2179:15 80:21 81:282:3 83:2,2084:5,18,22 85:185:20 86:2487:24 89:19 90:590:16 91:4 92:892:12 94:1896:22 97:1398:11 99:8 101:3101:15 103:20105:12 106:11107:11 108:2,19110:11,16 115:9116:25 117:2118:22 119:12121:12 123:21,23124:18 125:2,22125:23 127:12130:6 131:20,24132:3,4,7 133:10138:11,18 139:17140:5,22 142:8142:12 146:18148:25 149:1,4150:1 152:1,12152:20 153:8,13153:16 154:18,25156:12 158:10,13159:16 160:3,16161:2,13,23162:16 167:3,8171:7,15 176:10176:14,18,20179:5,13 184:12187:13,20 193:6198:2,18,21200:5 201:18204:14

right-brain 162:5right-handed 162:3right-sided 127:16131:23

right-to-left188:3

Riley 85:9risk 35:5 63:1964:2 70:7,9,1193:18 111:18133:22 172:1186:22 194:8200:2

risk-reward 193:17risks 93:15,17111:12,14,22172:11 194:5

River 3:2Riverside 171:17171:22

RN 163:10Roberts 1:4,4,54:16 5:20,2014:15 16:9,15,1616:18,21 17:1917:25 18:25 38:945:1,6,19 46:646:16,20 47:7,1548:7,17,24 49:349:6,18,24 50:2552:8 57:1,5,2458:7 64:8,14,1667:7 72:1,2376:22 77:10,1780:23 82:12,2483:21 84:1185:19 87:2,2488:18,22 89:892:13 93:4 95:195:2,6,12 96:1697:15 98:14 99:999:23 100:9,20102:8 105:24106:19 109:1,25115:2 120:19121:4 122:2123:3,9 126:1,2126:13,17,21,23126:25 127:4,15127:25 128:18,23129:9,24 130:7130:18 131:14132:13 133:21134:5 135:18136:1 137:11,19138:20 140:11150:18 151:7

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152:7 153:15160:17 161:20162:11,14 163:6163:20,24 164:6164:9,11,18,18165:5,24 171:25172:4,17 178:15178:20,24 179:19179:21,22 180:15185:3,19,23186:25 187:8188:3 190:15,18191:2 195:1197:22 198:9201:3 202:14,16203:8 208:5209:3

Roberts/Darrell208:5 209:3

Robertson 46:4ROHAN 75:23Rohan-Williams2:15 4:3,6,75:14 20:11 21:1323:6,15 55:258:13 61:11 63:363:7,8 67:17,2075:10,14,17,1975:22 81:2588:25 89:13 91:992:19,22 95:2496:2 102:1,7104:1,7,14,20108:13 111:23112:10,16,22113:6 119:5124:20,23 125:1125:2 129:18,23131:12 133:6,9133:15,19 134:14140:6,10 141:13147:10 165:3,21168:14 185:13,15186:3,18 187:2188:7,10,15,21189:1 190:21192:4 193:25197:17 198:1,13198:17,20 204:17208:21

role 36:9 37:12147:1

room 12:5,6,1715:6 31:9 32:1737:5 55:23123:21 167:21173:3

rooms 135:8routine 35:3 56:856:15,21 58:9

RPR 1:23 206:5,13207:22 208:16

rule 38:6 69:23102:9 186:6187:13,13,20,20192:20,20

ruled 65:18,2166:4 81:5,5,9,1081:15 99:22100:2 192:15,16

rules 6:2 38:7120:8

ruling 191:24

S

S-a-l 145:24S-a-l-d-a-n-h-a145:24

S-z-w-e-d 16:7Saafield 2:22SAALFIELD.FILI...2:24

Sackett 18:21,2419:12,16,21 20:520:13,16 64:7125:24 136:3,14139:11,12 150:8163:5,8,10,11,12163:16,16,19,25164:2 191:12

Sackett's 19:4124:21 125:3,11125:16 139:14163:7

sake 55:5Saldanha 145:24saline 194:8sanctioned 9:24satisfy 30:25saw 49:6 52:1854:16,23 60:1760:23 61:6 63:966:7 67:10 91:599:11 106:6108:3 121:7,8122:18 163:8,9165:13 198:15

saying 44:3 52:1656:17 58:3 59:1675:19 83:22,2486:1 105:12109:7,8,14,14128:13,13 131:13138:2 151:18,19

152:22 153:11155:25 157:21163:12,18 189:7

says 55:10,11127:12 131:13132:17 165:17179:18

scale 48:22scales 48:18scan 32:13,15,1633:22 34:16 37:637:21 39:19,2040:23 50:21 65:365:4,13 73:12,1473:16 89:15152:5,5 159:16159:24 160:5174:20 175:6,7176:11

scans 73:20 81:8152:8,25 153:2,7153:12

scared 179:1scenario 55:13106:19 112:7123:1 175:5

scene 32:21 54:1257:15

sclerosis 26:9100:11 121:25

sclerotic 97:4,997:10 103:4,9

scope 43:23 96:7135:12 195:6197:14

screen 31:7screwed 189:13se 72:24search 189:24second 25:7 60:861:16 63:22102:18 106:12109:5 127:3,3,14164:5 165:17168:20 179:17192:11 200:7

secondary 79:10,1299:17 101:23102:3

section 151:13196:8

see 11:22 12:6,7,812:12,15,1613:11,16 14:1618:14 22:15 23:126:1,6,8 27:1927:24 28:12,13

28:16,19,19,2128:22 29:1631:25,25 32:1233:6,17,20 34:1536:20,21,22 37:138:1,2,3,4,1940:13 41:8,1448:15,17 52:9,1453:4,8 54:14,1558:19 64:1 68:272:5,9 73:16,2078:24 79:1,3,789:20,23 90:2,1190:11,12,13,1491:15,15 96:699:19 101:5107:6 109:5,11109:15 110:9,16117:20 120:8,14121:4,9,10,11,11121:12,14 122:21122:25,25 123:10124:24 128:23135:13 136:15,22137:8 138:2150:16 151:2153:10,14 163:16163:17,18,25164:16 166:1,4176:11,12,25179:24 196:3200:9 202:7

seeing 27:14,1736:3 54:15 58:773:21 74:6 106:2124:10 125:3126:1 150:18190:15,18 203:13

seen 13:14 16:2018:12 31:1537:15 47:19,2148:7,8,14 56:457:24 58:10,2260:10 64:10 84:985:11 87:2589:15 96:5 98:24101:17,17 109:23122:22 123:17,20124:18 126:23139:6 143:14150:24 151:1152:4 153:1154:8 155:19,25156:1,10 157:9158:4 173:7181:3 191:3,7202:17,22,25

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sees 62:25 73:25139:10,12 159:25

segments 199:7select 12:17,17200:15

self 113:17send 14:7 204:21204:25

sensation 115:24115:25 131:20139:23 155:2

sense 29:5 158:13158:22

sensors 158:24159:5,8

sensory 57:9,12,2158:24 59:2460:12,25 62:1362:15 132:2154:24 155:1

sent 14:12 55:12125:10

sentence 168:21separate 107:14123:5 147:7

September 1:174:15 206:7 208:6209:5

sequelae 176:17serious 114:22serve 195:16served 195:19196:4,5,8

service 29:16 31:3services 12:2213:4

set 30:2 70:1783:18 191:12

setting 7:3 72:23157:9,12

setup 165:23seven 28:15,1529:6 59:4 106:1169:15

severe 45:13,22,2446:17 47:5 65:2494:10 130:16131:3

severely 134:12Shad 2:22She'd 136:5she'll 135:5136:13,17 137:6191:7

sheet 4:11 208:10208:12 209:1

shipboard 181:16

Shore 10:22 11:1211:15 26:15,2127:1 30:20 32:835:11 36:15,1937:16 39:9,1344:22 144:9145:22 146:14,23156:4

short 19:18 179:1short-term 136:23shortly 175:15shortness 45:13shoulder 131:22140:18

show 66:16 73:14103:13 159:16,19159:21

showed 55:4 81:13shower 137:6167:12

shown 87:6shrug 131:22shunt 66:1 68:21187:14,21

shunting 71:1,17188:4

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vestibular 116:2victims 26:7view 50:20 184:3,4Vincent's 1:814:23 15:22 16:145:7 47:8 49:24133:23 137:23142:13 150:23171:16,21 191:22193:13 208:5209:3

vision 113:14,15visit 24:22 25:484:1 123:8 151:6

156:16 164:7visiting 136:13139:7

visits 19:21 78:20163:8

visual 113:13visualized 90:22153:13 160:4

visually 99:5Vitae 4:17vital 29:25voiced 127:8Volume 1:15volumes 15:21voluminous 22:3voluntary 167:2vote 143:1vs 1:7 208:5 209:3

W

W 2:5 208:24wait 17:2 39:2540:3 106:1145:20 186:2,8

waited 107:3waiting 108:7201:23

waive 31:12waived 205:3walk 33:17 38:1948:21 75:16132:10,13

walks 132:15want 9:11 12:10,1112:14,18 21:1724:18 31:25 32:135:6 40:11 75:1178:14,20 86:794:11 132:12133:18 168:15188:11,18 198:5198:7 199:13,17201:21

wanted 78:13 120:8124:15 125:8126:14 158:10

warranted 86:16wasn't 54:11 64:2073:23,23,2481:21 96:5101:17 107:5115:11

Water 2:18 3:13way 8:6 17:2228:25 31:2544:16 45:2146:19 49:5 51:11

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website 146:1,11147:4

Wednesday 36:12week 25:13 27:1427:20 162:25163:10 165:12

weeks 120:15139:12 163:9,13163:14,16,17186:22

weighed 49:3,7weight 47:13,14,1548:16,24 65:5,11127:10 138:21172:2

well-defined 101:6well-known 13:13went 102:18 107:6107:6 109:2122:9

weren't 85:9125:21 169:19

whatsoever 162:16wheel 31:7 48:19wheelchair 123:23132:9 137:12164:10,21

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woman 56:1 63:17133:22 172:20

word 56:25 87:9157:4 204:24

words 7:22 9:1024:15,15 30:1134:11 36:2539:19 41:1350:17 54:5 58:359:21 61:13,2366:21 70:11 72:573:1 75:4 76:478:5 81:6,1284:13 91:2 92:993:8 98:19105:17 107:23108:15 113:7114:15 121:9126:14 129:8142:22 156:12159:2 163:8200:8

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worksheet 67:18workup 40:25worried 192:21worst 175:5worthwhile 18:13122:24 136:21

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writing 78:25written 6:17 21:121:6,8 23:1224:9 52:24 61:20126:10 145:9,10166:19 189:20

wrong 138:19wrote 69:12 165:10

X

x-ray 79:4x-rays 89:2,1098:19 100:12

Y

yeah 16:14 28:948:13 50:17 67:467:22 92:6114:19 117:11,14142:6 166:23168:14 171:5185:14

year 7:9,13 13:2024:21 118:11,12118:12,18 123:18124:11 125:15126:2 128:19,22144:20 145:10148:16,17 150:12156:20 166:11170:15 182:7

years 8:3,5,610:18,25 11:2011:24 12:1 13:419:3 21:20,2022:5 26:2 27:1835:8,24 45:23,2546:15,15 47:364:8 79:17,18,2583:3,15 103:8,8108:16 109:9113:3,9 118:11134:7 146:25148:15,18 149:5156:15 170:14,16170:16,18 172:21172:24 177:15181:6,6,7 182:8

195:24 196:7202:24

Yeglewel 2:2,7yesterday 106:7yielded 183:15young 133:21younger 41:10

Z

ZIP 26:14

0

1

1 1:15 4:15 23:823:10 30:2488:10 92:10126:19 127:12131:23 179:11207:9

1-millimeter 91:1091:18

1,000 118:5 148:211/20/11 16:41/4/11 16:51:00 32:41:45 67:231:46 174:2010 11:24 12:1 26:245:15 64:8 75:1688:12,14,16103:8 113:9133:19 172:24

10/15/11 16:510:00 59:3100 102:24 117:251041313 208:7209:5

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12 4:16 26:2 88:13118:11 178:12182:7 185:6203:7

12/23/10 16:512:00 28:17 190:2412:02 28:1912:15 140:3 141:2512:30 28:17 55:1255:14

12:55 142:1

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1200 3:21250 208:1812th 123:17 126:213-year-old 123:13142 4:3147 4:1715 29:20 31:2,5,1031:14 32:16 37:737:7 53:22110:23 118:9170:23 181:19182:7 200:21

1551 3:71591 2:13167 4:4169 4:417 170:161700 54:618 23:5 122:16170:20 174:10

1800 2:18 3:13174:10

184 4:5185 4:51850 52:2119 64:4192 4:6194 4:61953 11:17197 4:7,71971 10:161973 8:191975 10:171976 182:41978 6:13 196:1198 4:81993 149:24 170:191997 118:25

2

2 4:16 23:12,1430:24 87:7 90:1596:4 127:22128:18,20 131:24132:17 165:1168:13 179:15,17182:24

2-16-11 21:172-millimeter 87:1091:3 92:12

2:00 86:1,21 105:32:25 1:17 205:120 27:10 35:24110:23 118:9170:18 181:7,19182:8 183:16,18183:22

20-plus 170:16200 2:132000 170:192002 96:252002-2003 97:32005 196:12006 7:8,142007 8:192008 26:17,24156:11,18,21

2009 149:6201 4:82010 19:2,19 46:2147:8 49:18 51:1181:21 99:17122:15 149:6153:7 156:11,19156:22 172:3,6180:8,12

2011 18:6,10 122:9122:18 149:6153:7 202:8203:24

2011-CA-007017 1:22012 122:17 149:6157:2

2013 1:17 4:15,16128:22 147:17149:7 150:12178:12 185:6202:8 203:7206:8,10 207:19208:1,6 209:5

2014 143:142015 206:15203 4:9205 207:9206 4:10207 4:10208 4:11209 1:15 4:1122 27:8225 2:18 3:1323 4:15,16 47:8172:3

233 2:3,823rd 45:6 57:2571:6,18 72:682:15 86:8 95:1595:16,17 96:3,4101:10,13,17107:2 108:3,4,9115:2 140:11151:23 152:5153:23 159:16169:15 187:13,18192:13 198:16

24 1:17 4:15 25:8122:17 208:6209:5

24/7 136:8 162:2324th 73:8,18,1974:1 80:12,1781:13 82:15 84:184:4 85:4,19,2386:1,8,13,2195:12,16 101:18101:18 105:1106:13,20,22107:2,5,10,18108:7,25 109:19110:1,8 115:2140:12 152:5175:13,17,21190:10,18 192:14192:19 193:11198:16 206:7

25 26:7 51:11118:18 183:8,16183:18,22 195:24

2546 55:225th 58:1 83:2187:2,25 95:396:14 106:23,23108:7 140:12174:1,1,2,12197:21

27 206:152950 2:232nd 3:7

3

3 4:17 30:24104:25 131:24134:7 147:10,11147:14

3-millimeter 87:1387:19

30 130:24 149:3300 49:13 172:3305 27:3305)373-8404208:19

32 8:632-year 173:132202 2:3,8,18,233:13

32207 3:2,732317 2:13327 47:20330 49:1433131 208:1833150 1:20 10:10208:4

340 47:24 49:7,8,849:14 182:8

350 49:1436 30:14 80:2237-year-old 56:138 8:5 10:18172:19

38-year-old 172:20

4

4 30:24 110:12149:9 153:7

4-month 149:2440 148:17 183:8400 127:11402 1:19 10:9208:3

42 10:19 27:1135:8 172:21

42-year 173:145 30:13 37:848 186:23

5

5 4:3 88:12,13,1488:16 131:23,24

5:00 28:2,3 56:55:00-ish 45:115:50 53:1750 2:23 35:1 47:1453:21,22,23,2454:22 113:3,7,8113:9

500 35:1 148:21182:9,10

55 68:8,10

6

6:00 54:23 55:559:4,16 63:10169:15 175:21

6:30 28:146:50 52:10,11,1852:21

60 7:23 8:3 68:968:10 162:5

650 181:24650-plus 181:20652 148:23

7

7 27:15 208:17:00 28:7,8 72:77:05 53:9 54:10,2054:21

70s 7:11 8:17th 206:10 207:19

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8-25-10 127:15134:5

8-31-10 127:238(c) 189:198/12/13 21:6 170:78/23 16:2 66:8,2167:24 68:2569:20 82:25169:3,8 171:13

8/23/10 14:21 52:98/23/2010 15:2263:10

8/24 16:2 68:389:15 159:24

8/24/10 153:10,148/25 16:2 82:2586:23 101:20160:5 169:3171:13

8/25/2010 91:68/28 16:28/31/2010 16:28:00 190:238:23 68:3 70:15800 3:285 37:18850)422-3345 2:148th 2:3,8

9

9/21/09 16:49:00 28:2,3,7,89:20 1:179:35 60:1090 148:1990/10 148:15904)355-3503 2:24904)359-7700 2:193:14

904)396-3007 3:8904)398-0900 3:3904)632-2424 2:4,995 162:395th 1:19 10:9208:3

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FISCHER, KENNETH - Vol. Iltcrisklegalforum.com/wp-content/uploads/2019/09/Deposition-of-Kenneth... · 2013/9/24 · [email protected] 5 BY: MATTHEW W. SOWELL, ESQUIRE 6 7 On