241



1 Q. Dr. Bambakidis, in -- will you agree or

2 disagree with the proposition that the 2002 CT

3 scans shows a marked improvement over the 1996 CT

4 scan?

5 MS. ANDERSON: Objection, leading.

6 MR. FELOS: I said would you agree or

7 disagree, Your Honor. That is not a leading

8 question.

9 THE COURT: I think that's okay.

10 THE WITNESS: I would tend to disagree,

11 Mr. Felos.

12 BY MR. FELOS:

13 Q. Is there anything on these CT scans, in

14 your opinion, which would support the conclusion

15 that Terri Schiavo's brain has regenerated from

16 1996 to 2002?

17 A. Let me take a closer look, if you don't

18 mind, to be certain.

19 Q. Go ahead.

20 A. I'm showing the cuts may not be the

21 same, so it makes it more difficult, from my

22 perspective, to interpret. Again, Mr. Felos,

23 within the limitations of the fact that these are

24 two separate scans of different qualities, I

25 don't see any evidence of improvement or




242



1 regeneration by the tissue.

2 Q. Thank you, Dr. Bambakidis. You can

3 resume your seat in the witness box.

4 A. (Witness complies.)

5 Q. Dr. Bambakidis, when cells die in the

6 brain can they regenerate themselves?

7 A. The best answer is no, although that's

8 an area of ongoing research. But for all

9 practical intents and purposes, the answer is no.

10 Q. Now, I want to talk about the EEGs.

11 First the ones taken in -- excuse me -- the one

12 performed in July of 2002 in which you read the

13 report and also -- you read the report and also

14 the tracings?

15 A. That's correct.

16 Q. Well, excuse me. Let me backtrack a

17 second.

18 Regarding the report on the 2002 CT

19 scan, did you concur with that report?

20 A. Yes, I did.

21 Q. Now, how would you interpret the

22 tracings of Terri Schiavo's 2002 EEG?

23 A. Well, I disagree with the

24 interpretation that was provided by the

25 electroencephalogram with that study.




243



1 Q. In what respect?

2 A. I believe, and please correct me if I'm

3 wrong, that that particular study and that

4 particular interpretation, rather, suggested that

5 there was no electrical activity in the cerebral

6 origin.

7 I disagreed with that for two reasons:

8 Number one, there were significant technical

9 difficulties there were encountered, artifacts

10 that we previously discussed. That compromises

11 the ability to meaningfully interpret that

12 particular tracing.

13 Number two, if my recollection serves

14 me correct, and I don't see why it wouldn't in

15 this particular situation, the activity that I

16 saw that I was convinced was coming from the

17 brain was, in fact, insufficient to state that

18 there was no activity coming from the brain.

19 In other words, there was electrical

20 activity coming from the brain itself.

21 Q. And from the electrical activity that

22 you determined was coming from the brain, how

23 would you read the scan?

24 A. Within the limitations of the study my

25 interpretation would be that it shows low




244



1 amplitude, diffuse slowing of the background

2 activity with little in the way of spontaneous

3 variability --

4 THE COURT REPORTER: I'm sorry, I

5 couldn't hear you. Could you please repeat

6 that?

7 THE WITNESS: With little in the way of

8 spontaneous variability or response to

9 external stimuli.

10 BY MR. FELOS:

11 Q. What does that mean in layman's terms?

12 A. I'm sorry, I'm probably being too

13 technical. Please forgive me. It means that the

14 electrical activity is low amplitude, abnormally

15 low amplitude, not as prominent as it should be

16 in a normal person.

17 That the frequencies are slower than

18 normal. And that the frequencies and the

19 amplitudes don't change spontaneously the way

20 they would in a normal individual. And they

21 don't respond to stimulus such as eye opening or

22 the application of painful stimulus that they

23 would in a normal individual.

24 Q. Now, did you give special

25 instructions -- I believe you had requested an




245



1 EEG to be performed. Did you include special

2 instructions with that?

3 A. Yes, I believe that I did, Mr. Felos.

4 Q. What were those special instructions?

5 A. Well, the response to eye opening, if,

6 in fact, that had to be passive eye opening. In

7 other words, having a technician open the

8 person's eyes to see if there was any change in

9 the electro cerebral rhythms.

10 And the other one would be the

11 application of a painful stimulus. Unfortunately

12 we have to do that sometimes in order to properly

13 assess the level of cerebral functioning. I

14 believe those were the two things that I

15 specifically requested.

16 Q. So what would the technician do to

17 follow up with your instruction?

18 A. Well, as I mentioned, passively opening

19 the eyes when the machine was running. And the

20 other would be to apply a painful stimulus such

21 as taking a person's Achilles tendon or ankle

22 tendon and squeezing it gently, but sufficient to

23 cause discomfort to see if there's a change in

24 the rhythms coming from the brain.

25 Q. And, as I understand it, in this EEG




246



1 there were no change in the rhythms when those

2 noxious stimuli were applied?

3 A. My best recollection is that there was

4 not, but, again, subject to the limitations of

5 the study.

6 Q. Now, in a normal EEG, if a noxious

7 stimulus was applied to the patient, what would

8 you see in the tracer?

9 A. Well, we frequently see if the person

10 is drowsy an alerting response. In other words,

11 there's a dropoff in amplitude of the normal

12 background and a flattening of the background

13 which we did not see here, if my memory serves me

14 correctly.

15 Q. In -- do you have an opinion -- do you

16 have an opinion based upon the EEG as to what

17 Terri Schiavo's capacity is to consciously

18 interact with her environment?

19 A. With all due respect, Mr. Felos, that's

20 probably an unfair question because -- and it's

21 not that you would know that. It's probably --

22 it's beyond the scope of meaningful

23 interpretation of electroencephalography to

24 answer a question like that because we want to

25 tie it to the clinical status of the patient.




247



1 What I can say is this is a very

2 typical EEG who is -- that is encountered with a

3 person with a history such as Ms. Schiavo's.

4 Q. Now, you also talked about the SPECT

5 scan?

6 A. Yes.

7 Q. What is a SPECT scan, Dr. Bambakidis?

8 A. A SPECT scan is a method of imaging the

9 brain that you also use a radioactive substance

10 that's injected. And my understanding is that it

11 is primary to assess flow and not necessarily

12 metabolism. So its primary purpose, again,

13 certainly I'm not an expert in the SPECT scan, is

14 to assess blood flow to certain regions of the

15 brain.

16 Q. Uh-huh. And you reviewed the test

17 results and the films of the SPECT scan?

18 A. Yes, I did.

19 Q. Did you concur with the results of the

20 test results?

21 A. Yes.

22 Q. Were there any differences that you had

23 with the results?

24 A. A bit of difference. When I looked at

25 the report I mistakenly -- what was written was




248



1 that there was activity in the frontal lobes in

2 the cerebellum.

3 In my mind I assumed that there was

4 activity in the cerebral cortex in the frontal

5 lobes. When I looked at the scan, actually there

6 is activity in the frontal lobes, but it's not in

7 the cortex, that upper-most portion of the very

8 surface of the brain where those vital nerves

9 are.

10 Q. How would you describe the SPECT scan

11 that you read?

12 A. Well, I'm not certainly an expert in

13 SPECT, as I already mentioned, anymore

14 necessarily than I'm an expert in CT

15 interpretation, although I do more of that than

16 the SPECT scan specifically, but my

17 interpretation is that that's clearly an abnormal

18 study. That's clearly an abnormal study, the

19 SPECT scan.

20 Q. Now, you've also reviewed the results

21 of the ultrasound of the carotid artery; is that

22 correct?

23 A. That's correct, Mr. Felos.

24 Q. Did you concur with the results of that

25 test?




249



1 A. Well, since I didn't have the

2 ultrasound films to review, I accepted the

3 results at face value which there is no way that

4 I could tell if it is correct or incorrect. But

5 it seems reasonable and I wouldn't be surprised

6 if it showed any significant abnormality in a

7 person of her age.

8 Q. All right. Now, in reviewing the

9 bloodwork performed on Theresa Schiavo, did you

10 find any abnormalities there?

11 A. No.

12 Q. The -- in fact, I want to discuss with

13 you your examination of the patient. On what

14 date did that occur, Dr. Bambakidis?

15 A. That was, I believe, on July 9th of

16 this year.

17 Q. And can you walk us through your

18 examination and tell us what you did, what you

19 observed -- or what you did, why you did it and

20 what you observed?

21 A. Briefly, the examination consisted of,

22 in this particular case, observing her posture as

23 she was actually lying in bed. And more

24 specifically after that, assessing her responses

25 to various stimuli, both visual, tactile and




250



1 noxious and auditory.

2 That then follows an evaluation of the

3 cranial nerves, that is to say the muscles that

4 are responsible for moving the eyes, controlling

5 the power of the muscles in the face.

6 An assessment of the tendon reflex,

7 which is what neurologists and physicians

8 typically do with the little hammers that they

9 get out and pound on the limbs.

10 An assessment of the tone, that is, the

11 normal resistence or the appropriateness of the

12 resistance offered by the limbs as to movement.

13 And part and parcel, assessing the

14 response to stimuli, as I mentioned, the

15 application of a painful stimulus to observe the

16 patient's pattern of response to that.

17 Q. Now, let's start at the beginning

18 again. I believe you mentioned that you first

19 observed the position in which Theresa Schiavo

20 was lying in bed?

21 A. Yes.

22 Q. Was there anything of significance in

23 that?

24 A. Yes. From the onset, the posture of

25 her limbs was abnormal. It could be




251



1 characterized as contracting in a sense that

2 there was flexion at the elbow, at the wrist, and

3 the upper extremities, relatively fixed posture.

4 And extension of the lower legs, including the

5 feet. And aversion, that is the legs coming

6 together and the feet more or less pointing

7 towards each other at the lower extremities.

8 Although not mentioned in the report,

9 there was a -- in the position of her head, it

10 seemed to be leaned slightly to the right and

11 turned a bit to the right as well.

12 Q. What significance, if any, would be the

13 patient's body position like that have on a

14 diagnosis or opinion as to the patient's

15 condition?

16 A. Well, it has a great deal of

17 significance because the posture in which she was

18 seen, that I observed, and I observed

19 subsequently is a posture called classic

20 decorticate posturing. That is a posture that is

21 seen in individuals whom the cerebral cortex,

22 that vital area of the brain, the surface, has

23 been essentially disconnected from the rest of

24 the brain.

25 And we can also say that by




252



1 extension -- or I would say by extension the same

2 certainly applies when that is no longer

3 applicable, no longer present to any appreciating

4 degree.

5 That is when the brain is functionally

6 decorticate or the cortex is not there any

7 longer. This is a very typical posturing that's

8 encountered.

9 Q. What is H-E-E-N-T, Doctor?

10 A. Well, it's shorthand. Sometimes I wish

11 we never used them because it would be easier in

12 avoiding questions like this, but it means, head,

13 eyes, ears, nose and throat.

14 Q. And what type of head, ear, eyes, nose

15 throat examination did you perform?

16 A. In overlaps with the neurological

17 examination. We look at the way the eyes move.

18 And I might mention that when I was observing her

19 spontaneously a blinking of eyes was noted as

20 well as rapid movements of the eyes from side to

21 side.

22 We also do perform a funduscopic

23 examination, look behind the eye to assess the

24 retina, macula, optic nerves.

25 Since the face is part of the head, we




253



1 also look at the facial musculature to see if

2 it's symmetric. In this particular instance, the

3 ears I do not believe were examined by me nor did

4 I examine her throat. I do believe that I

5 examined her tongue, but that would not have been

6 commented on in the report. But that's

7 essentially what we did.

8 Q. What were your particular findings with

9 Theresa Schiavo?

10 A. Well, her eyes did move conjugately,

11 although she does have a --

12 Q. Excuse me, what do you mean when you

13 use the word conjugately?

14 A. I'm sorry. I apologize. In other

15 words, her eyes moved together. They were

16 connected when they moved, although not mentioned

17 in the examination, actually in the report there

18 was an ergotrophy of the right eye.

19 In other words, the right eye tended to

20 be deviated a bit laterally and that was a

21 consistent finding. The optic nerve appeared to

22 be normal when I examined it. There was no

23 facial weakness.

24 Q. Okay. Did you listen to her lungs?

25 A. Yes.




254



1 Q. And what was the result of that?

2 A. There was some airway sounds, but no

3 abnormalities that I could detect on her lung

4 examination.

5 Q. Now, how about the cardiovascular

6 system, did you examine that in any way?

7 A. Yes, I did.

8 Q. Please tell us what you did and what

9 your findings were?

10 A. Well, basically I palpated her chest to

11 feel where the point of maximum impulse was for

12 her heart. Then I listened with a stethoscope to

13 the various heart sounds and those were normal.

14 Q. Did you examine -- do an examination of

15 the abdomen area?

16 A. Yes.

17 Q. What did you do and what were those

18 results?

19 A. I palpated the abdomen to see if there

20 was any abnormal enlargement of any of the

21 organs. Also before doing that listened to make

22 sure that there were bowel sounds in all of the

23 quadrants putting a stethoscope on the surface of

24 the abdomen and listening to make sure that the

25 bowel sounds were appropriate.




255



1 Q. Now, tell us now how you proceeded with

2 the neurological aspect of your examination.

3 A. As I already mentioned, some of the

4 neurological examinations are already entailed in

5 the EEG, EMG description but, again, observing

6 the patient in terms of opening and closing the

7 eyes and movements of the eyes that was

8 definitely observed.

9 I also provided a loud auditory -- I

10 clapped my hands to which she would blink. I

11 attempted to call her name. In fact, I did call

12 her name to see if she would turn and attend to

13 the stimulus, which she did not.

14 The tendon reflexes for me were --

15 tended to be reduced probably as a result of the

16 degree of contraction and increased tone. Those,

17 however, can vary.

18 I also assessed her for extensor

19 plantar response. That's stroking the bottom of

20 the foot in order to see if an abnormal reflex is

21 present. It was not on that particular day when

22 it was done.

23 Q. It was, excuse me?

24 A. It was not present.

25 Q. The reflex was not present?




256



1 A. The extensor planter response or the

2 Babinski response was not present.

3 Q. What would that indicate to you?

4 A. The extensor planter response, that's

5 used with the term Babinski response, but the

6 term Babinski is named after a neurologist, it

7 merely referred to a method of eliciting that

8 response. That's all it really means.

9 But the important thing is that the

10 extensor plantar response is an abnormal finding

11 in an adult and suggests an injury to what's

12 called the upper motor neuron pathways of the

13 brain.

14 The pathway of motor function beginning

15 in the cerebral cortex, travelling all the way

16 down into the spinal cord and then connecting

17 with the nerve cells on the spinal cord

18 (unintelligible).

19 That, however, can be absent in people

20 who are very contracted, who have a significant

21 degree of weakness. So its absence in this

22 instance is not surprising.

23 Q. Did Theresa Schiavo -- did you give her

24 any directions? Did you ask her to follow a

25 command?




257



1 A. Yes.

2 Q. And did she?

3 A. She did not.

4 Q. Now, is there anything else about your

5 examination itself that you wanted to mention

6 that you deemed significant?

7 A. Well, just to say that this was a

8 markedly abnormal examination. And it's always

9 very disconcerting and very sad to examine

10 individuals in this particular condition.

11 The examination is replete with the

12 findings consistent with a severe insult to the

13 brain. It is typical of findings that one would

14 see in an individual in a vegetative state.

15 Q. Okay. Dr. Bambakidis, what is a

16 persistent vegetative state?

17 A. It could be briefly defined as a state

18 of eyes open unconsciousness. That is to say,

19 the person is awake and, in fact, typically shows

20 normal awake sleep cycles, but there is no

21 awareness of one's self or the external world.

22 So they're awake, but they're not aware.

23 Q. Now, can an organism involuntarily

24 respond or react to the environment?

25 A. Yes.




258



1 Q. Now, do you do any gardening,

2 Dr. Bambakidis?

3 A. I know my limitations, Mr. Felos.

4 Q. Ever notice a plant by the window sill

5 grows toward the light?

6 A. Well, I'm aware.

7 Q. Is that a tropistic response?

8 A. Now you will have to educate me,

9 Mr. Felos.

10 Q. Because the plant grows to the light as

11 a response to the environment, does it mean it

12 has consciousness?

13 A. No, it does not in the conventional

14 sense.

15 Q. Now, what type of involuntary or

16 unconscious responses to the environment can

17 human beings have?

18 A. Well, they can startle to a stimulus.

19 For example, if you tap their corner of their eye

20 they will blink. That is a brain stem response

21 that does not involve the cortical surface.

22 If you shine a light in their eye

23 barring an ocular abnormality to explain it or

24 nerve problem involving the pupils they will

25 constrict. That also is not passed through the




259



1 cortex.

2 They can yawn. They can swallow.

3 Interestingly they may even laugh or may cry or

4 even -- that is often done spontaneously for no

5 particular reason. I have my own theory as to

6 what that probably means, but...

7 Q. Now, you've mentioned startled?

8 A. Yes.

9 Q. That would be obviously a -- could that

10 be an auditory -- involuntary auditory response

11 to the environment?

12 A. Yes.

13 Q. Can a person respond involuntarily to

14 an auditory source by moving their eyes or head?

15 A. That can happen, yes.

16 Q. Now, is there any degree of visual

17 response that is mediated through the brain stem

18 or subcortical level?

19 A. Yes, actually, there is. There are

20 pathways for vision of travelling from the retina

21 through the brain that go through the white

22 matter of the brain which is subcortical, so a

23 person can, in fact, see, but in terms of

24 appreciating and understanding what they are

25 seeing, that's another question.




260



1 Q. Uh-huh. Now, the fact that Terri

2 Schiavo moans on occasion, does that necessarily

3 mean that she has cognition?

4 A. It does not.

5 Q. The fact that she exhibits facial

6 expressions or grunts or moves her limbs on

7 occasion, does that necessarily mean she has

8 cognition?

9 A. It does not.

10 Q. Now, if Terri Schiavo could

11 consistently in a reproducible manner follow

12 commands, would that be indication of cognition?

13 A. That would certainly suggest some level

14 of cognition.

15 Q. Now, does -- you mentioned before that

16 you observed Terri Schiavo move her eyes; is that

17 correct?

18 A. Yes.

19 Q. Now, if Terri Schiavo -- if you're

20 observing Terri Schiavo and she is not blinking

21 her eyes, will she blink her eyes sooner or

22 later?

23 A. Yes, in all probability.

24 Q. So if Terri is not blinking her eyes

25 and you say, Terri, blink your eyes, eventually




261



1 that will occur, won't it?

2 A. Yes.

3 Q. How would you know, then, whether

4 her -- the blinking of her eyes was a cognitive

5 act or not?

6 A. Well, in a situation like that you

7 don't. What you rely on in situations like that

8 it's persistent and that it is reproducible and

9 that these responses to stimuli are voluntary.

10 That's very important.

11 Q. Uh-huh. Dr. Bambakidis, do you have an

12 opinion, within a reasonable degree of medical

13 certainty, as to whether or not Theresa Schiavo

14 is in a persistent vegetative state?

15 A. Yes, I do.

16 Q. What's your opinion?

17 A. Well, I want to stress before I answer

18 this after a great deal of soul searching because

19 in situations like this you have to both in

20 assessing the patient and in assessing all the

21 data, you have to try to come to a conclusion.

22 And you want to give the patient every

23 doubt that you possibly can, the benefit of every

24 doubt that you possibly can in a situation like

25 this.




262



1 In other words, I was concerned as to

2 whether or not there may have been some minimal

3 consciousness there, but when you look at all of

4 the data and the results of the examinations, and

5 my examination certainly a preponderance of the

6 evidence supports that she's, in fact, in a

7 persistent vegetative state.

8 Q. Un-huh. Now, there are times -- did

9 you notice on the videotapes that Terri's mother

10 went up to her a number of times?

11 A. Yes.

12 Q. And did you recall she often puts a,

13 Hi, Terri, it's your mother?

14 A. Yes.

15 Q. And would kiss her?

16 A. Yes. That was a source of the concern

17 on my part, how does one interpret a situation

18 like that.

19 Q. Okay. Now, there is an occasion on the

20 tape where Terri, I believe, makes -- appears to

21 make a facial expression?

22 A. Yes.

23 Q. And moans when the mother does that; is

24 that correct?

25 A. Yes.




263



1 Q. But would you agree that there are also

2 many instances on the tape where the mother says,

3 Hi, Terri, and kisses her where Terri doesn't

4 moan?

5 A. That's true.

6 Q. And doesn't make a facial expression?

7 A. That's true.

8 Q. When Terri's mother interacts with her,

9 did you notice on the tapes whether she makes any

10 physical contact with Terri?

11 A. I believe she does on occasion.

12 Q. What type of physical contact?

13 A. Well, I think she's touching her arm,

14 if I recall correctly, and I may be mistaken.

15 She touches her face. Strokes her face.

16 Q. Did you ever see her put her hand under

17 her head?

18 A. I don't recall that specifically.

19 Q. Now, you mentioned that Terri Schiavo's

20 limbs were in contracture; is that correct?

21 A. Yes, you could characterize them that

22 way.

23 Q. Would pressure on these contracted

24 limbs, could that constitute a noxious stimulus?

25 A. It could if you did it with enough




264



1 force. I would probably use another method to

2 elicit a response in order to a noxious stimulus.

3 Q. Dr. Bambakidis, do you have an opinion,

4 within a reasonable degree of medical certainty,

5 as to whether there is any treatment that can

6 improve Terri Schiavo's condition?

7 A. Yes, I do.

8 Q. And what is that opinion, sir?

9 A. Unfortunately I know of no single

10 treatment or combination of treatments that could

11 result in any meaningful improvement in her

12 current situation.

13 Q. And let's center in on a neurological

14 improvement.

15 A. Yes.

16 Q. Okay. Why -- what factors do you take

17 into account that leads you to that conclusion?

18 A. I have never heard of or seen

19 personally, particularly of an individual in this

20 particular situation for this period of time,

21 improve to the degree of having any meaningful

22 quality of life in terms of awareness of one's

23 self and others.

24 Q. Uh-huh. Do you know what hyperbaric

25 oxygen therapy is or hyperbaric oxygen treatment?




265



1 A. Yes.

2 Q. What is that, Dr. Bambakidis?

3 A. My understanding is that it's a method

4 of using oxygen at high atmospheric pressure to

5 treat a variety of conditions.

6 Q. What type of conditions does it treat?

7 A. It's been taught as being used in

8 patients who had certain types of cancer, for

9 example, in prostate cancer it's been used. It's

10 also taught to be effective in acute management

11 of patients who had strokes.

12 It's also reputed by some to be

13 effective in people who are in coma of varying

14 causes, particularly anoxic encephalopathy, and

15 also some individuals who are in a persistent

16 vegetative state.

17 Q. Now, I believe you used the word

18 reputed, do you think hyperbaric oxygen treatment

19 is a viable therapy for Terri Schiavo?

20 A. I really don't think it is.

21 Q. Is hyperbaric oxygen treatment

22 generally accepted in the medical community as a

23 treatment for coma patients?

24 A. I do not believe it is, no.

25 Q. Or for patients that have the type of




266



1 brain injury of Terri Schiavo?

2 A. It is not.

3 Q. Dr. Bambakidis, what is vasodilation

4 therapy?

5 A. Presumably it's a method of treatment

6 that focuses on pharmacologically dilating the

7 blood vessels that serve various parts of the

8 body including the brain in order to enhance

9 delivery of blood and oxygen.

10 Q. And why wouldn't vasodilation therapy

11 be of any benefit to Terri Schiavo?

12 A. Because the parts of the brain that

13 are -- that have been lost that are responsible

14 for her status, current clinical status, could

15 not be brought back to life no matter how much

16 blood and oxygen you deliver to it because it is

17 dead.

18 Q. Would that be the same reason why you

19 would Believe hyperbaric oxygen therapy wouldn't

20 work as well?

21 A. In essence, yes.

22 Q. Now, what is glial or neuroglial

23 tissue?

24 A. Excuse me?

25 Q. What are glial cells?




267



1 A. Glial cells function in the brain as

2 sort of the equivalent of a fibroblast in other

3 parts of the body which are responsible for

4 the -- for scar formation. They are supporting

5 cells in the brain, essentially. That's why when

6 you talk about scarring of the brain you talk

7 about gliosis occurring.

8 Q. Now, is there any brain matter left in

9 Terri Schiavo's cerebral --

10 A. Oh, there is. Yes.

11 Q. -- cerebral hemispheres?

12 A. Yes, there is.

13 Q. And, in your opinion, would any of that

14 tissue be glial cells?

15 A. Yes.

16 Q. Do you have an opinion as to whether or

17 not hormone replacement therapy would be of any

18 benefit to Terri Schiavo's neurological

19 condition?

20 A. Yes, I do.

21 Q. What is that opinion?

22 A. It would be of no benefit whatsoever.

23 Q. And why is that?

24 A. I cannot understand how any imbalance

25 of the endocrine system could be responsible for




268



1 an individual in this state. And in the absence

2 of any underlying condition that could be

3 conceivably, that is an underlying condition of

4 an endocrine type, that could have conceivably

5 contributed to this, why hormone replacement

6 therapy would be appropriate.

7 MR. FELOS: Thank you, Doctor. I have

8 no further questions at this time, Your

9 Honor.

10 THE COURT: Thank you. This seems like

11 a good time for a break. Let's take 15

12 minutes. Doctor, you are technically still

13 on the stand. Please don't discuss your

14 testimony in this case with anybody. You

15 can talk to the folks, but talk about the

16 weather, things that are not connected with

17 this case.

18 We'll stand in recess for 15 minutes.

19 (Thereupon, there was a 15-minute break.)

20 THE COURT: Ms. Anderson, you may

21 proceed with your cross-examination.

22 MS. ANDERSON: Thank you.

23 CROSS-EXAMINATION

24 BY MS. ANDERSON:

25 Q. Doctor, you were originally scheduled




269



1 to examine Terri at six o'clock on the evening of

2 July 9th; were you not?

3 A. That's correct.

4 Q. And your plane was delayed I think you

5 said three hours on the ground in Charlotte?

6 A. Yes, it was.

7 Q. So what time did you actually begin

8 your examination on the evening of July 9th?

9 A. If I recall correctly, it was probably

10 around seven or seven-thirty. I believe

11 something like that.

12 Q. Seven or seven-thirty?

13 A. Seven or seven-thirty.

14 Q. Where did you make up that -- half of

15 that three --

16 A. Well, there was a layover anyway. And,

17 you know, it may have been later. Mr. Felos may

18 have a better idea, if he remembers.

19 Q. How would Mr. Felos know?

20 A. Well, because Mr. Felos -- I wanted to

21 take a history from Mr. Schiavo and also from

22 Terri's parents who my understanding was

23 everybody was going to be there. So I was going

24 to take the history from Mr. Schiavo, which I

25 did, take a history from the parents to get the




270



1 collateral history, to get a full history and

2 then examine her.

3 Q. And you did not meet with the parents;

4 is that correct?

5 A. No, that's correct.

6 Q. In fact, I think you said that they

7 were unavailable?

8 A. That's correct.

9 Q. What efforts did you make to speak with

10 the parents?

11 A. Well, I believe I got there and shortly

12 before I started taking the history I was advised

13 they had actually had left and that was the first

14 indication I had that they weren't going to be

15 there.

16 Q. No, my question was: What efforts did

17 you make to interview the parents?

18 A. I couldn't meet the parents after that

19 because --

20 Q. Well, you saw them in court the next

21 day, correct?

22 A. Yes.

23 Q. Did you speak with them then to

24 supplement your understanding of her history?

25 A. No.




271



1 Q. Have you called me or written to me in

2 a subsequent time to try and interview the

3 parents?

4 A. No.

5 Q. Now, what did Mr. Schiavo tell you

6 about Terri's history?

7 A. Basically, I had approached this the

8 way I would approach examining any patient. In

9 other words, the history of the present illness,

10 what exactly happened back in 1990.

11 Q. So you got his description of the

12 underlying incident?

13 A. The events that occurred at that

14 particular point in time.

15 Q. Did he tell you that she had had a

16 heart attack?

17 A. No, I don't remember -- I do not recall

18 that.

19 Q. You concluded that she did have a heart

20 attack, though, correct?

21 A. No, I did not.

22 Q. It's not in your report?

23 A. No, I don't believe it is.

24 Q. What is your understanding of what

25 happened to her?




272



1 A. Well, my understanding is that she did

2 have a cardiac arrest.

3 Q. Okay.

4 A. My understanding is further that there

5 seems -- it's still not definite exactly what the

6 cause of the cardiac arrest was.

7 Q. It was definitely not a heart attack

8 because her enzymes were not elevated, correct?

9 A. Well, I'm not going to answer that

10 directly. Suffice it to say that the diagnosis

11 of MI was not made or myocardial infarction was

12 not made.

13 Q. If you started your examination at

14 seven or seven-thirty, were Mr. Felos and

15 Mr. Schiavo both present?

16 A. Yes, they were both there.

17 Q. Were they present throughout the exam?

18 A. Yes, they were.

19 Q. Were they the only ones present besides

20 yourself?

21 A. No, I don't believe they were because

22 we enlisted -- I think there was a nurse who

23 helped me out with part of the examination with

24 positioning and things like that.

25 Q. What was Terri's blood pressure when




273



1 you examined her?

2 A. I didn't take the blood pressure.

3 Q. Did you inquire about her blood

4 pressure?

5 A. I'm pretty sure that I did.

6 Q. Do you remember what it was? Did you

7 record it in any way?

8 A. No.

9 Q. No? And when did you conclude the

10 exam?

11 A. I would have -- the exam itself

12 including the evaluation of the EEG and looking

13 at the CT scan, it was probably about an hour,

14 probably a little bit more than that with the

15 history.

16 Q. Well, I'm speaking about your actual

17 examination of Terri; how long did that take?

18 A. I would estimate it was probably about

19 30 minutes.

20 Q. Thirty minutes?

21 A. Yes.

22 Q. Then you spent another 30 minutes

23 talking to Mr. Schiavo and reviewing some

24 reports?

25 A. It was probably a little bit more than




274



1 that.

2 Q. Okay.

3 A. It wasn't actually reviewing a report,

4 it was actually looking at the CT scan and

5 looking at the EEG.

6 Q. Okay. Is there any reason you did not

7 request this exam to be videotaped?

8 A. My understanding was that it was going

9 to be videotaped, in fact, that it could be

10 videotaped.

11 Q. Yes.

12 A. And --

13 Q. Is there any reason you did not request

14 that?

15 A. Well, I don't know that it's up to me

16 to request that. My understanding as to whether

17 or not there was going to be a videotape that was

18 passed on by Mr. Felos and I had no objection to

19 that.

20 Q. You were led to believe that it would

21 be videotaped?

22 A. That it could be videotaped, I think

23 would be a better characterization or did I have

24 any objection to having it videotaped and my

25 answer was, no, I did not.




275



1 Q. But, in any event, it was not

2 videotaped?

3 A. It was not.

4 Q. Did you inform Mr. Felos that you had

5 no objection to the exam being videotaped?

6 A. Yes, I believe I did during that

7 conversation.

8 Q. About how many conversations had you

9 had with him?

10 A. Let me see. Oh, I would say probably

11 anywhere from -- oh, I would say about 10

12 conversations.

13 Q. When did they start?

14 A. They started around about the time that

15 the list of recommended tests to be performed was

16 due in court. And I believe that was back in

17 May.

18 Q. So in May you started speaking with

19 Mr. Felos?

20 A. He phoned me in May or actually a

21 little bit before then because I had requested

22 from the Judge that I receive some records that I

23 could review those. And actually the first

24 conversation was a conversation that I had with

25 him with regard to what records I would want to




276



1 review and that he would send those off to me.

2 Q. Who initiated that first conversation?

3 A. Well, Mr. Felos contacted me.

4 Q. I see.

5 A. And identified himself.

6 Q. How is it that you happened to be here

7 on the witness stand today? Why you and not a

8 colleague?

9 A. That's a good question. I know that

10 the Judge telephoned me and asked me if I would

11 be interested in serving as an independent expert

12 to the Court in this particular matter. I gave

13 it some thought and said that I would and sent

14 him the information that he requested, the CV, et

15 cetera.

16 Q. So that was the first that you heard of

17 it, a phone call from Judge Greer?

18 A. Yes. It was unsolicited by me.

19 Q. Do you know how it was he happened to

20 phone you as opposed to one of your colleagues?

21 A. No. No. Except they said that they

22 wanted somebody for -- I believe his comment was

23 that they wanted somebody who worked for the

24 Cleveland Clinic.

25 Q. Who is they?




277



1 A. I don't know. You would have to ask

2 the judge.

3 Q. Does the Cleveland Clinic have a stroke

4 team?

5 A. Yes, they do.

6 Q. Are you on the stroke team?

7 A. I'm on the stroke team in Fairview

8 Hospital which is a Cleveland Clinic Hospital.

9 Q. Now, the clinic itself is a separate

10 facility, isn't it? Isn't there a Cleveland

11 Clinic Foundation Hospital?

12 A. There is the main campus.

13 Q. Right.

14 A. That's right.

15 Q. And Fairview is one of the

16 clinic-operated hospitals?

17 A. Yes, that's owned by the clinic.

18 Q. Is it also in Cleveland?

19 A. Yes.

20 Q. The Cleveland Clinic bought that

21 hospital a few years ago; did it not?

22 A. Yes, it did.

23 Q. Now, you work in the hospital setting;

24 is that correct?

25 A. Well, both in the hospital setting and




278



1 in the office, which is directly attached to the

2 hospital where I do most of my work.

3 Q. What kind of office work do you do?

4 What do you mean?

5 A. Well, I see patients in the office.

6 Q. Oh, I see what you mean. So you have a

7 private practice attached to the hospital, your

8 staff position at the hospital with a private

9 practice; would that be a proper way to describe

10 it?

11 A. I think the best way of making it clear

12 is to state that I'm a member of the Department

13 of the Cleveland Clinic Foundation. My office is

14 an off-site location next to Fairview Hospital.

15 I see patients in my office and also

16 see consultations in the hospital. And I also

17 perform neurophysiological testing in the

18 hospital, that is, perform nerve conduction

19 studies and EMG and read electroencephalogram.

20 Q. Do you have any patients in nursing

21 homes?

22 A. I have a few in nursing homes. They do

23 come to my office to see me. I used to go to

24 nursing homes on occasion a few years back, but

25 I've stopped doing that because I'm so busy.




279



1 Q. Are you presently concerned in your

2 practice with acute care as oppose to long term

3 chronic care?

4 A. Well, it's actually both because we

5 have to bear in mind that chronic care also has

6 to deal with seeing patients with Parkinson's

7 disease over the years, Alzheimer's disease,

8 multiple sclerosis, as well as the more acute

9 things such as anoxic encephalopathy, people who

10 are in comas for other reasons, strokes, things

11 like that.

12 Q. Now, have you ever treated a patient

13 who was say 14 years out from an injury that

14 resulted in anoxic encephalopathy?

15 A. It's the first one that I've seen 14

16 years out. I've treated them I believe out to

17 four to five years. I think the question came up

18 before in July and I think it was four to five

19 years.

20 Q. Now, by treatment I mean a medical

21 regimen designed to increase recovery of

22 cognitive function. So, have you ever treated a

23 patient with a long-term anoxic encephalopathy?

24 A. If you're asking me have I tried a

25 particular method that may be touted as being




280



1 effective in improving cognitive functioning in a

2 person in that situation the answer would be no

3 because it's not effective.

4 Q. So, in terms of treatment of a

5 long-term PVS patient given my definition --

6 A. Uh-huh.

7 Q. -- you have never treated a long-term

8 patient in this condition?

9 A. Yes, but I must say that your question

10 is a bit misleading because --

11 Q. How so?

12 A. -- there are lots of things that we do

13 in terms of treatment in trying to help people in

14 this situation that do not fit into the treatment

15 that you are referring to.

16 Q. Well, that's what I'm interested in,

17 the treatment that's designed to help a patient

18 recover cognitive functioning. Do you have a

19 treatment protocol?

20 A. No, not for that.

21 Q. Now, how many patients over the years

22 in PVS have you treated in the sense of trying to

23 help them recover cognitive functioning? Would

24 that also be none?

25 A. That would also be none within the




281



1 strict confines of the question.

2 Q. I understand. Would you agree then

3 that you're not very experienced in the long-term

4 patient in the treatment of recovery of cognitive

5 function?

6 A. The way you're phrasing it I would not

7 agree with that because I care very much for my

8 patients. Just because I don't believe that

9 there's a treatment available that would -- that

10 has not Been -- that I would not use because it's

11 not been shown to result in significant

12 improvement does not mean that I am not actively

13 trying to take care of my patients in that

14 situation.

15 Q. I think we have a misunderstanding. I

16 think you thought I asked some question about

17 whether or not you cared about a patient and

18 that's not it.

19 A. No. No.

20 Q. My question is: Would you consider

21 yourself very experienced in the treatment of

22 long-term PVS patients?

23 A. Management, yes. Treatment as you're

24 defining it, no.

25 Q. And how would you define management as




282



1 distinct from treatment?

2 A. Well, I would define management as

3 doing what you can to keep the person

4 comfortable. Certainly working with the nursing

5 staff to minimize the things that are common in

6 individuals in situations like this, pressure

7 sores, for example, urinary tract infections,

8 pneumonias, trying to reduce the contractures and

9 spasticity pharmacologically that are involved.

10 Q. I understand. Trying to make sure the

11 patients don't deteriorate?

12 A. Yes, and being on the lookout for any

13 intercurrent problem that could develop that

14 might compromise them.

15 Q. I understand. Now, Dr. Bambakidis, did

16 you have any preexisting social relationships

17 with any of the parties or attorneys in this

18 case?

19 A. No.

20 Q. Do you have any professional

21 relationships with any of the other physicians

22 who are associated with this case?

23 A. No, I do not.

24 Q. Do you know any of them?

25 A. Not personally, no. I know of some of




283



1 them.

2 Q. Who do you know of?

3 A. Well, I know of Dr. Hammesfahr,

4 Dr. Maxfield and Dr. Cranford.

5 Q. How do you know of them?

6 A. On the basis of the hearing that we had

7 back here in July.

8 Q. Oh, you mean just -- not outside the

9 courtroom --

10 A. That's correct.

11 Q. Do you know any of the physicians from

12 outside the courtroom?

13 A. No, I do not.

14 Q. What did you understand your mission to

15 be in this case?

16 A. Essentially my mission was to, as I

17 understand it, was to provide an independant

18 opinion with regard to the questions that are

19 being presented at these proceedings.

20 Q. Would you agree that there really is no

21 test that will tell a physician whether a patient

22 is in PVS and by test I mean laboratory test?

23 A. If you're asking me if you can diagnose

24 PVS on the basis of a laboratory test alone the

25 answer is no.




284



1 Q. And, in fact, aren't clinical findings

2 more important than laboratory tests in the

3 diagnosis of PVS?

4 A. Generally, yes, that's the useful rule

5 of thumb in clinical medicine in general, but you

6 have to adapt it certainly to the particular

7 case. But in general I think that's a fair

8 statement.

9 Q. Okay. Was the 30-minute exam that you

10 performed on Terri routine, a routine exam, that

11 you would perform on a severely brain-injured

12 patient?

13 A. Well, with the understanding that my

14 routine exams are not typically performed in a

15 situation such as this particular purpose, okay,

16 that's not -- it was not a routine exam in that

17 sense.

18 If you're asking me if the approach,

19 the history and examination that I took in that

20 particular situation was typical of my practice,

21 the answer would be yes.

22 Q. The history that you took?

23 A. The history and examination is typical

24 of my practice.

25 Q. Is there anything, had you examined




285



1 Terri in Cleveland, is there anything that you

2 would have done during your clinical examination

3 of her that you didn't do at Hospice?

4 A. In terms of the clinical examination,

5 probably not. In terms of laboratory

6 examination, I probably would have.

7 Q. What were the lab tests?

8 A. Well, I would have tried to get as good

9 as quality electroencephalogram tracings as I

10 possibly could.

11 Q. Does the scalp generate an electrical

12 signal?

13 A. No, the scalp is part of the problem

14 with the electroencephalography because it's part

15 of the intervening tissue between the surface of

16 the brain and the cortex. If you're sweating on

17 the scalp of course that could cause all sorts of

18 artifacts.

19 Q. Now, I think you said that you reviewed

20 the '96 scan earlier this morning?

21 A. That's correct.

22 Q. And did you have it with you when you

23 flew in?

24 A. No. The scan that I reviewed, as

25 indicated by Mr. Felos, was the scan that was




286



1 reproduced in that posture there.

2 Q. This blowup that's been in the

3 courtroom?

4 A. That's what I reviewed.

5 Q. So you got here early and took a look

6 at it?

7 A. No, I happened to be here. Mr. Felos

8 wanted me to have a look at it so I looked at it.

9 Q. So, when was the last time you spoke to

10 Mr. Felos before he began asking you questions

11 this morning?

12 A. The last time I spoke with Mr. Felos

13 was -- you mean before this morning?

14 Q. Yes.

15 A. It was probably earlier in the day

16 yesterday because I phoned him because I wanted

17 to make sure that I had the complete videotape of

18 Dr. Hammesfahr's examination and I did.

19 Q. Did you watch it?

20 A. Yes, I did.

21 Q. And how long was it?

22 A. Oh, that was over two -- close to three

23 hours in duration, actually.

24 Q. Okay. Is there any reason that you

25 performed a much shorter exam?




287



1 A. Oh, there are probably many reasons for

2 that, but I think every physician approaches

3 history and examination a little bit differently.

4 What might suffice for one physician in a

5 particular situation and be perfectly accurate,

6 another physician may do in a different fashion.

7 Q. So it's a just difference in styles; is

8 that what you mean?

9 A. Well, I wouldn't -- well, again, I was

10 going to say -- I wouldn't exactly say style. I

11 would say different approach. People learn to

12 approach certain problems in different ways in

13 different situations.

14 Q. Now. Did you think Dr. Hammesfahr was

15 thorough in his exam, methodology?

16 A. He was fairly thorough, I thought.

17 Q. Do you think he was exceptionally

18 thorough?

19 MR. FELOS: Your Honor --

20 THE WITNESS: No, I wouldn't say that.

21 MR. FELOS: -- I object for the same

22 reason that there was an objection before, I

23 don't think the witness can comment on the

24 activities and opinions of another expert

25 witness.




288



1 MS. ANDERSON: A comment on methodology

2 is not an opinion. Methodology is the one

3 exception to that and I happen to have

4 Ehrhardt with me. And I have --

5 THE COURT: Are you talking --

6 MR. FELOS: Your Honor --

7 THE COURT: -- or literally?

8 MS. ANDERSON: In spirit.

9 THE COURT: Okay.

10 MS. ANDERSON: In spirit.

11 MR. FELOS: I have him with me as well.

12 THE COURT: And I don't.

13 MS. ANDERSON: We have it --

14 THE COURT: I think I agree with that.

15 I think the methodology --

16 MS. ANDERSON: In fact, there's just a

17 new Fifth DCA case on this very point.

18 THE COURT: Well, we're still in the

19 Second.

20 MS. ANDERSON: I mean, it's the most

21 recent reported opinion on this particular

22 point.

23 THE COURT: We'll allow the comment as

24 to methodology.

25 BY MS. ANDERSON:




289



1 Q. The question was: Do you think

2 Dr. Hammesfahr was exceptionally thorough in his

3 examination of Terri?

4 A. I wouldn't necessarily say that.

5 Q. But you would agree that he was

6 thorough?

7 A. Yes, the way that many physicians are

8 thorough in their own way.

9 Q. What did Mr. Felos tell about why you

10 needed to look at that CT scan?

11 A. I think that he wanted me to have the

12 opportunity to review that since it was -- since

13 he was here and since attention had been drawn to

14 this earlier this week in the proceedings and I

15 had not seen it.

16 Q. I didn't catch that answer. Since

17 there was -- did you say drama?

18 A. No. No. No. It wasn't drama. He

19 wanted --

20 Q. I didn't hear what you said.

21 A. And I asked you before if you could

22 hear me okay and you said you could, okay.

23 Q. I could hear you before.

24 A. Okay. He wanted -- I had not seen this

25 scan before. The only CT scan that I had seen




290



1 was the one that was done earlier this year and

2 he wanted me to have the opportunity to see this.

3 Q. Okay. Dr. Bambakidis, can you see this

4 image, which is Number 13 on the '02 scan, well

5 enough or do you need to come down?

6 A. The answer is no.

7 Q. Okay.

8 A. I think I need to come down.

9 Q. Come down and take a look at it. I

10 will tell you specifically what I want you to do,

11 I want you to look at Image Number 13 from the

12 '02 scan, particularly this area of the brain and

13 compare it to Image Number 6 in the '96 scan.

14 Just compare them and then you could get back on

15 the stand and I will ask you a question, okay?

16 A. Thirteen and six?

17 Q. This one and that one. This area.

18 That area right there.

19 A. Okay.

20 Q. Have you made that examination and

21 comparison?

22 A. Yes.

23 Q. Do you see a difference in the brain

24 tissue?

25 A. Yeah, but they're not really at the




291



1 same level.

2 Q. Not at the same level?

3 A. They're not.

4 Q. Now, certainly there are more images in

5 the '02 scan?

6 A. Yes.

7 Q. Is there another one-to-one comparison

8 that would be more apt if you believe that is an

9 in-apt comparison?

10 A. Probably the one just above it.

11 Q. (Indicating).

12 A. Not that one.

13 Q. (Indicating.)

14 A. No, to your right.

15 Q. (Indicating).

16 A. That's it.

17 Q. Okay. This is Image 7.

18 A. Uh-huh.

19 Q. This Image 7 on the '96 scan would be

20 more comparable to Image 13?

21 A. Let me look at it again to be

22 absolutely sure.

23 Q. So you believe that Image Number 13 on

24 the new scan --

25 A. I believe that this image --




292



1 Q. Which is Image 13.

2 A. -- is more comparable to this image.

3 Q. Which is Number 7.

4 A. But they're not perfect. It's not a

5 perfect comparison.

6 Q. Right. In fact, there's no precise

7 recipe for -- when you do a CT scan --

8 A. Not unless when you -- if you do them

9 with the same scanner, with the same generation

10 scanner, with the same meticulous attention shown

11 to position and the level of the cuts.

12 Q. Do you see differences on the

13 right-hand side along the front of the skull

14 between those two scans?

15 A. Are we talking right there?

16 Q. Right here, yes.

17 A. Right there?

18 Q. Right there.

19 A. I don't see any appreciable difference.

20 Q. You don't see what?

21 A. I don't see any appreciable difference.

22 Q. Any appreciable difference?

23 A. Yes.

24 Q. But you've also said that certainly you

25 are not a neuroradiologist?




293



1 A. Well, certainly not.

2 Q. Would you defer to the opinion of

3 someone who is?

4 A. Generally speaking, yes.

5 Q. Okay. Did you make any assessment

6 about her visual and hearing acuity?

7 A. Yes. If, in fact, she responds to a

8 loud noise reproducibly by blinking presumably

9 she is. Now there may be methods using audiology

10 techniques in order to determine more precisely

11 what the frequency response is, but, as you can

12 imagine, it's difficult.

13 And likewise, with regard to her vision

14 certainly on the basis of the fact that, although

15 not for me, in the examination by other

16 physicians and I believe in response to

17 appearance that she does track from time to time

18 with her eyes it's probably safe to assume that

19 she does see at least to some degree.

20 Q. And, of course, in order to visually

21 track she would have to have at least some

22 vision; would she not?

23 A. Correct.

24 Q. And visual -- sustained visual pursuits

25 is one of those medical markers that




294



1 distinguishes the non-PVS patient from the

2 patient who is in PVS, correct?

3 A. That's part of it, but that's not all

4 of it.

5 Q. No, I understand. That's one of the

6 markers, correct?

7 A. One.

8 Q. Okay.

9 A. It depends on how you define sustain

10 and sustain for what period of time.

11 Q. Well, what is a reflex?

12 A. Well, a reflex essentially is a

13 stereotyped response of the nervous system to a

14 particular stimulus.

15 Q. Of what duration?

16 A. Typically not in the cortical level.

17 Q. Right.

18 A. It occurs during the course of the

19 particular stimulus. Now, at times it may not be

20 present and other times it may be more dramatic.

21 Q. Is that because at times the person has

22 overcome the reflex action?

23 A. I'm not sure that I understand your

24 question.

25 Q. Well, for example, you might startle if




295



1 someone clapped a pair of symbols behind you the

2 first time you did it, but your -- the tenth time

3 they did it, your response, your reflex response,

4 would be quite a bit more blunted; would it not?

5 A. Yes.

6 Q. And, likewise, a reflex response might

7 also be a function of the novelty of the

8 stimulus, might it?

9 A. If your -- it depends on how you're

10 using the term novelty. If you're using the term

11 novelty in a certain sense it implies a cortical

12 level of awareness. That's not usually what

13 we're concerned about or focussing on when we

14 talk about reflex actions.

15 Q. Well, for example, in a darkened room

16 if you flash a bright light there's going to be

17 some sort of --

18 A. Reflex response.

19 Q. -- reflex response; is there not?

20 A. Uh-huh.

21 Q. The first time you do it?

22 A. Uh-huh. And subsequent times you do it

23 provided that you allow dark adaptation to occur.

24 Q. Now, by your comment about the damage

25 to Terri's cortical areas, that's the area of the




296



1 brain that makes us human. You are not

2 suggesting that Terri Schiavo is not a human, are

3 you?

4 A. Certainly not.

5 Q. You are not suggesting that she lacks

6 personhood, are you?

7 A. Certainly not. But those are -- to be

8 fair, those are perhaps more ethical questions

9 than certainly moral questions, particularly with

10 regard to personhood.

11 Q. They are also legal questions, are they

12 not?

13 A. Certainly.

14 Q. Are you particularly interested in the

15 efficacy of the practice of medicine? I'm sure

16 you're interested, but are you particularly

17 interested in this new bioethics movement?

18 A. Well, in recent years the way Medicare

19 is going, it's hard not to be interested in the

20 bioethics.

21 Q. Is that because bioethics focuses on

22 the allocation of resources on a society alone?

23 A. That's part of the equation.

24 Q. And that is that it's very expensive to

25 keep patients like this alive over the long haul,




297



1 isn't it?

2 A. Well, it is costly to society and it's

3 a dilemma.

4 Q. It is a what?

5 A. It is a dilemma for society.

6 Q. Right. But you're not suggesting that

7 we stop feeding Terri because it's expensive to

8 maintain her?

9 MR. FELOS: Your Honor, I object to the

10 form of the question. The witness has

11 offered no opinion as to whether Terri

12 Schiavo should be stopped -- we should stop

13 feeding her -- people should stop feeding

14 Terri Schiavo.

15 That was not the focus of his

16 examination or opinion. That's the legal

17 question ultimately for the Court. It was

18 not a question for the witness or brought up

19 on his direct examination.

20 THE COURT: I think she's entitled to

21 show if there may be some bias or --

22 BY MS. ANDERSON:

23 Q. You are not suggesting, are you, that

24 because it's expensive to keep her alive that she

25 should be starved and dehydrated to death?




298



1 A. Oh, I'm not suggesting that.

2 MR. FELOS: Your Honor, I object to the

3 form of the question. There's been no

4 evidence and no foundation that if tube

5 feeding was withdrawn that the ward would

6 starve to death. In fact, the evidence is

7 to the contrary.

8 MS. ANDERSON: What?

9 THE COURT: Well, this witness isn't

10 being asked anything about what may or may

11 not be done as a result of the testimony.

12 You might --

13 MS. ANDERSON: Oh, no. Right.

14 THE COURT: So the form of the question

15 I think is improper and I will sustain the

16 objection as to the form of the question.

17 MS. ANDERSON: Actually he's already

18 answered the question and I'm through and

19 I'm satisfied with the answer so I'll just

20 move onto something else.

21 THE COURT: Very well. Thank you.

22 BY MS. ANDERSON:

23 Q. Doctor, what is the difference between

24 hypoxic and anoxic?

25 A. Anoxic means without oxygen. Hypoxic




299



1 means with little oxygen, but not no oxygen.

2 Q. So it's a question of degree and not

3 kind?

4 A. Yes, although the terms are often used

5 interchangeably.

6 Q. Now, Terri has a diagnosis of anoxic

7 encephalopathy?

8 A. Uh-huh.

9 Q. I'm sure you've seen that in her

10 records; have you not?

11 A. Yes, I have.

12 Q. And really what that means is no-oxygen

13 brain damage, right?

14 A. Well, I'm not sure that I would exactly

15 put it so bluntly as that, but in essence you're

16 correct.

17 Q. Now, encephalopathy is sort of a

18 generic term, isn't it?

19 A. It is.

20 Q. I mean, it doesn't yield any

21 information about what structures in the brain

22 are damaged, how extensive the damage is. It

23 just means brain damaged, correct?

24 A. I would agree except for your first

25 comment, it doesn't -- when you said it doesn't




300



1 indicate the area of the brain that's effected.

2 In common usage the term encephalopathy is used

3 to refer to a history and examination that

4 suggests dysfunction of the brain in a diffused

5 fashion.

6 Q. In a diffused fashion?

7 A. That's correct.

8 Q. I see. So hypoxic encephalopathy would

9 be also diffused, but less severe?

10 A. Not necessarily less severe, it's

11 because the terms are often used interchangeably.

12 Once there is a certain threshold below which

13 oxygen delivery to the brain does not occur, the

14 damage occurs irregardless of whether it's still

15 being delivered, but some oxygen is not being

16 delivered at all.

17 Q. And the two words anoxic and hypoxic

18 are causative terms, that is they describe a

19 cause of the brain damage, correct?

20 A. Yes.

21 Q. Okay. So, no-oxygen brain damage would

22 be a good layman's translation, wouldn't it?

23 A. Yes, if it's no oxygen for long enough

24 certainly, yes.

25 Q. How long is long enough for it to




301



1 change from hypoxic to anoxic?

2 A. Well, actually when I said long enough

3 if you're not delivering enough oxygen to the

4 brain so that the cells can function you start to

5 see damage after about four minutes.

6 Q. Now, when you were examining Terri, did

7 you palpate her neck?

8 A. I don't believe that I did, no.

9 Q. Did you observe Dr. Hammesfahr's

10 palpation of her neck on the videotape?

11 A. Yes.

12 Q. Did you observe him lifting her head,

13 neck and upper shoulders off the bed simply by

14 lifting up with his hand behind her head?

15 A. Yes, I observed that.

16 Q. Would you consider that an abnormal

17 finding?

18 A. Yes, and consistent with her current

19 neurological status.

20 Q. Now, why is her neck so rigid?

21 A. Well, it's like asking me why is her

22 entire body so rigid. You know, this sort of

23 injury to the brain, as I've mentioned

24 previously, one of the characteristics is

25 dramatic increase in tone in various muscle




302



1 groups of the body. Part of what we refer to by

2 the term spasticity.

3 And, in fact, it could be so profound

4 that it can lead to the development of

5 contractures as it has in her case. This also

6 applies to the neck itself and the term

7 opisthotonus is used to describe this --

8 Q. Would you spell that for the court

9 reporter.

10 A. I anticipated that.

11 O-P-I-S-T-H-O-T-O-N-U-S.

12 Q. M or N-U-S?

13 A. N-U-S.

14 Q. Opisthotonus.

15 A. Opisthotonus. Now, that's a term

16 that's used to describe her other conditions.

17 For example, individuals who have received a

18 certain -- excessive amount, sometimes a standard

19 amount of a certain medication they can also

20 develop that.

21 Q. Did you happen to be provided with an

22 admission record at Northside Hospital when she

23 had her collapse back in February of '90 that

24 noted that on admission she presented with a

25 rigid neck?




303



1 A. I believe I do recall that, correct.

2 Q. So she may, in fact, have had this

3 rigid neck all these years?

4 A. Yes, she may have.

5 Q. Do you treat patients with spinal cord

6 injury in addition to patients with brain

7 disorders?

8 A. On occasion, yes.

9 Q. Is excessive sweating and facial rashes

10 and cyanosis in the extremities, are those

11 symptoms of a cord injury or can they be?

12 A. They can be.

13 Q. Okay. Did you notice whether Terri's

14 toes were cyanotic?

15 A. My recollection was they were pale when

16 I saw her and that her limbs seemed to be a bit

17 on the cool side.

18 Q. Was she asleep when you got there?

19 A. No, she was not actually.

20 Q. Was she being fed?

21 A. No.

22 Q. When you got to Hospice was Mr. Schiavo

23 or Mr. Felos in her room?

24 A. No, they were not.

25 Q. Were they waiting for you out in the




304



1 lobby area?

2 A. They were in the lobby, as I recall.

3 Q. At the time you developed the joint ENG

4 and EEG --

5 A. EMG.

6 Q. EMG.

7 A. I had to correct those. There is an

8 ENG, actually, to make matters more complicated.

9 Q. You said that you were asked along with

10 some other residents to devise this test?

11 A. We had input --

12 Q. Wait, listen to my question.

13 A. All right.

14 Q. I want to make sure that I understand

15 what you were saying. You were a resident

16 physician at Mayo when you did that?

17 A. Yes.

18 Q. So it's a way of hooking together the

19 electrical study of the brain with an electrical

20 study of the extremities; is that it in a

21 nutshell?

22 A. No. I'm glad you asked the question

23 because now I could explain it.

24 Q. Great. Do you use this?

25 A. No. Please let me explain.




305



1 Q. All right. Go ahead.

2 A. There are two disciplines in

3 neurophysiology, one is electroencephalography

4 and another one is nerve conduction such as an

5 EMG. The purpose of the committee was to form a

6 curriculum where people that are residents would

7 be trained in both of these for a certain period

8 of time.

9 Q. Oh, so it was a curriculum task and not

10 a --

11 A. It was a curriculum task.

12 Q. I misunderstood totally.

13 A. That's okay.

14 Q. And you did as instructed being a

15 resident physician, correct?

16 A. We all do when we are residents.

17 Q. Was she being fed when you got there?

18 A. She was not.

19 Q. Have you had occasion previously to

20 diagnose a patient as being in a persistent

21 vegetative state?

22 A. Yes.

23 Q. How far out from the injury was the

24 patient?

25 A. Well, in one case I diagnosed the




306



1 patient was out about four to five years.

2 Q. Okay.

3 A. In other cases I frequently see them as

4 they're evolving from the initial insult into a

5 persistent vegetative state. That is to say,

6 they have been comatose for a number of days or a

7 few weeks and they are starting to open their

8 eyes.

9 Q. And, in fact, coma is sort of a

10 continuum; is it not?

11 A. Well, it depends on how you want to --

12 well, I thought you were going to ask me if coma

13 and a vegetative state are synonymous and they're

14 not.

15 Why don't you just ask me the question.

16 Go ahead.

17 Q. Great. That way we all know our roles.

18 Is coma part of a continuum of

19 consciousness?

20 A. Yes, it is.

21 Q. Okay. So a patient can start out in a

22 coma and perhaps be on a respirator?

23 A. Yes.

24 Q. Because he can't breathe on his own

25 beyond a feeding tube or an IV line, be a total




307



1 care patient?

2 A. Yes.

3 Q. Maybe because of the, you know, the

4 general trauma to the nervous system. And

5 gradually gets better. At some point the patient

6 stops getting better, correct?

7 A. That's correct.

8 Q. Sometimes patients fully recover from a

9 coma, correct?

10 A. That is true.

11 Q. Now, are you familiar with the study

12 that was published in the British Medical Journal

13 in 1996 done by Professor Andrews out of the

14 Royal Neuro Disability Hospital on the

15 misdiagnosis rate of PVS?

16 A. I'm not familiar with it, but it's not

17 surprising it is misdiagnosed.

18 Q. Do you think it's misdiagnosed

19 frequently? Now he found a 43 percent error

20 rate?

21 A. Well, that's a valid point. And the

22 point is that these definitions even of coma,

23 what constitutes a coma, terms like stupor,

24 obtundation, lethargy, these are terms that are

25 used standard and quite freely and oftentimes not




308



1 particularly accurately.

2 Q. And also they're subject to change as

3 thoughts in the medical community changes; are

4 they not?

5 A. I will agree that the -- I would agree

6 with that.

7 Q. Okay.

8 A. Some more than others, certainly.

9 Q. Because just like medical technology,

10 medical knowledge also changes and expands?

11 A. Well, certainly, because we don't know

12 everything. There's always something to learn.

13 Q. In fact, stem cell research is an area

14 that is a very hot area right now in the

15 expansion of medical knowledge; is it not?

16 A. Yes, and controversial.

17 Q. And very controversial, too, of course.

18 Did you do any literature searches in

19 conjunction with this case?

20 A. I did a few. I did one literature

21 search, I believe.

22 Q. Did you? Did you go on PubMed?

23 A. I don't believe so.

24 Q. Or MedLine?

25 A. I think it was MedLine, actually.




309



1 Q. Did you happen to review or are you

2 familiar with in any way the Multi-Society Task

3 Force report on the medical aspects of a

4 persistent vegetative state?

5 A. I am.

6 Q. Now, that was published in the New

7 England Journal of Medicine, I believe, in two

8 separate parts. Would you consider the New

9 England Journal to be an authoritative source for

10 the research that it publishes?

11 A. I would say that's accurate with the

12 understanding that nothing in life is 100 percent

13 authoritative.

14 Q. Yes. Of course. In fact, none of the

15 journals give you absolutely up-to-date

16 scientific information, do they?

17 A. Well, I avoid the term none, Ms.

18 Anderson, because the problem is there would be

19 one that you would find and it would be

20 completely up to date, but I understand what you

21 are saying.

22 Q. As a general matter, medical knowledge

23 is shared first at symposiums and conferences and

24 conventions, correct?

25 A. Often, yes.




310



1 Q. That is really the conventional start

2 of the process. And when it's presented, comment

3 is invited from the floor, correct?

4 A. Correct.

5 Q. Because in keeping with the scientific

6 method there is this dialog that goes on, this

7 testing, testing, testing, correct, of the

8 hypothesis?

9 A. Correct.

10 Q. Sort of a dialectic as the ideas and

11 information evolves?

12 A. You could say that.

13 Q. And, in fact, the publication itself is

14 part of that dialect, that our knowledge is

15 always evolving; isn't that so?

16 A. Yes, I would say so.

17 Q. So, assuming that it takes some time,

18 even if you skip the presentation step, it takes

19 some time to get research results into print?

20 A. Uh-huh.

21 Q. There's going to be some lag time

22 there; is there not? From the time the scientist

23 makes the discovery in the laboratory to the time

24 your issue of say Circulation or Stroke arrives

25 on your desk?




311



1 A. Yes, with the understanding that even

2 after it's in print and there are those that have

3 been published for years it's still often rid

4 with controversy.

5 Q. In fact, many times it sparks

6 controversy; does it not?

7 A. It?

8 Q. Sparks?

9 A. Yes.

10 Q. Promotes -- provokes controversy?

11 A. Yes, that's true.

12 Q. And that's all part of the process of

13 changing, evolving medical knowledge?

14 A. That's correct.

15 Q. Are you aware of the International

16 Working Party's paper that was published by the

17 Royal Medical Society published in London in 1996

18 partly in response to the Multi-Society Task

19 Force Report?

20 A. I'm not familiar with it.

21 Q. Were you aware that there was a British

22 response?

23 A. It's not surprising.

24 Q. Okay. Is that because there are

25 different philosophies that prevail between




312



1 England and the United States?

2 A. Well, I don't know. In discussing

3 these issues generically with colleagues many of

4 whom I trust and admire, these whole issues and

5 particularly their implications are fraught with

6 all sorts of shifting of sands, gray areas,

7 contentiousness because it is such an important

8 issue. How much observation is enough, for

9 example, with a person in a persistent vegetative

10 state.

11 Q. And what one person -- what one

12 physician might think of as medically a

13 persistent vegetative state another physician

14 might reject; isn't that so?

15 A. That's correct.

16 Q. There's really no right and wrong in

17 this diagnosis, is there?

18 A. Well, I would disagree.

19 Q. Do you think that persistent vegetative

20 state is more of a prognosis?

21 A. Well, it's both, actually. That's two

22 aspects of it. If you're asking me -- and I

23 believe your comment was there is no right or

24 wrong with regard to that; is that what you've

25 said?




313



1 Q. Right. I mean, when it's right on the

2 line. Obviously you're not in a persistent

3 vegetative state and I'm not.

4 A. Yes.

5 Q. Mr. Felos isn't and I'm sure Judge

6 Greer isn't.

7 A. No. In all honestly, and you have to

8 be honest, I mean, these are diagnoses I was

9 mentioning before that has such profound

10 implications not only for the person, but for

11 society in general and of course for the family,

12 friends and loved ones.

13 The diagnosis has to be arrived at

14 very, very carefully and you want to give them

15 every benefit of the doubt in making that

16 diagnosis.

17 Q. Do you feel that you had the adequate

18 opportunity to observe Terri with a 30-minute

19 exam?

20 A. I would state that on the basis of the

21 records that I reviewed, the examination that I

22 performed, and on observing the examinations of

23 the other physicians that examined Terri, all the

24 data that I had available to me, that to a

25 reasonable degree of medical certainty, she is in




314



1 a persistent vegetative state.

2 Q. Now, you gave us a list of an

3 unconscious response and I think you mentioned

4 startling, correct?

5 A. What list are you --

6 Q. Startle?

7 A. Yes.

8 Q. Did you --

9 MR. FELOS: Your Honor, I believe that

10 mischaracterizes the testimony. I believe

11 it was involuntary response.

12 MS. ANDERSON: That's what I said,

13 involuntary response.

14 MR. FELOS: You said unconscious.

15 MS. ANDERSON: Or I said unconscious --

16 actually you said unconscious, did you not,

17 Doctor?

18 THE COURT: I don't think it matters.

19 MS. ANDERSON: Does it matter?

20 THE WITNESS: Well, it depends on how

21 you want to use the words. I would prefer

22 the term involuntary. That's more accurate.

23 THE COURT: Then it does matter.

24 BY MS. ANDERSON:

25 Q. And you would consider a startle in




315



1 response to your clapping your hands to be a

2 reflexive response and it is of a short duration;

3 is it not?

4 A. Correct.

5 Q. A fleeting duration?

6 A. Yes.

7 Q. It would not be a behavior that would

8 last for two or three or five minutes; would it

9 not?

10 A. Ordinarily not, certainly.

11 Q. It's an instantaneous jump when you

12 hear a loud noise, correct?

13 A. Yes.

14 Q. And it indicates that the brain stem is

15 intact, right?

16 A. That's correct.

17 Q. And you shine a light in the patient's

18 eye and the patient's eye the pupil contracts.

19 That is also an involuntary and instantaneous

20 response --

21 A. It's not instantaneous. Sometimes it

22 takes a little while, but --

23 Q. In the brain-damaged patient it will,

24 wouldn't it?

25 A. Yes, it could often.




316



1 Q. As a general matter, do responses in

2 brain-damaged patients take a little more time?

3 A. Well, it depends on how severely

4 injured they are and the nature of the stimulus.

5 For example, a person who has had a cardiac

6 arrest and who is comatose may have very brisk

7 corneal responses, that is, blinking of the eye,

8 so it all depends.

9 Q. Now, Mr. Felos asked you that if you

10 asked Terri to blink her eyes eventually she is

11 going to blink her eyes and that will not be

12 indicative of cognitive behavior, correct? Do

13 you remember that testimony?

14 A. Yes.

15 Q. That question?

16 A. Yes.

17 Q. How about if you asked her to squeeze

18 her eyes shut and resist the attempt to open

19 them, would that be -- and she does this

20 successfully; would that be an involuntary

21 response?

22 A. It could be, actually.

23 Q. Really?

24 A. On the basis of the stimulus that's

25 being applied by applying the hands there -- the




317



1 hands on the head to the eyes --

2 Q. Trying to pull apart the eyes could

3 turn it into an involuntary response?

4 A. No, but the type of stimulus itself --

5 Q. No, you're misunderstanding me. The

6 command is given --

7 MR. FELOS: Excuse me, Your Honor. I

8 would request the witness be allowed to

9 answer the question rather than having his

10 answer interrupted.

11 MS. ANDERSON: I think you have

12 completed it, hadn't you? I think we

13 miscommunicated.

14 THE WITNESS: Well -- may I, Judge? In

15 order to minimize miscommunication, could

16 you please just ask the question again.

17 MS. ANDERSON: Oh, absolutely.

18 BY MS. ANDERSON:

19 Q. The question I'm asking is this: If

20 the command is given, Terri, squeeze your eyes

21 shut and hold them shut and she closes her eyes

22 and squeezes them and you're unable, you, the

23 examiner, are unable doing this, the finger on

24 the upper part of the eye and the lower part of

25 the eye, to pull apart her eyelids?




318



1 A. Yes.

2 Q. Would that be cognitive behavior?

3 A. It could be, but you couldn't state yes

4 on the basis of the solitary instance that you

5 described. Because when we're talking about the

6 making the diagnosis of a persistent vegetative

7 state, the responses to stimuli including a

8 verbal stimulus, for example, it has to be

9 reproducible, and it has to obviously be

10 voluntary and it has to be a continuance

11 phenomenon.

12 In other words, there has to be a

13 consistent link that you observe between the

14 stimulus and the response that you cannot explain

15 alternatively.

16 Q. So if Terri -- are you finished?

17 A. No.

18 Q. Go ahead.

19 A. And that's what makes it difficult

20 often.

21 Q. So if Terri were able to follow 10

22 different commands that would indicate cognitive

23 responsiveness, but did not reproduce all 10 of

24 them a second time --

25 A. The issue is one --




319



1 Q. Well, let me ask the question.

2 A. All right.

3 Q. -- would that indicate to you that if

4 she failed on reproducibility that she must be in

5 PVS?

6 A. It certainly draws into question.

7 Q. Okay. You mean it would draw the

8 diagnosis into question?

9 A. No, it would draw into question as to

10 whether or not that actually represented

11 cognition.

12 THE COURT: Okay. Let us stop now.

13 I'm told by the bailiff that some folks have

14 meters that are going to expire at noon and

15 I assure you if they expire you will get a

16 ticket.

17 So we will take a lunch break and we

18 will come back at one o'clock. And, Doctor,

19 the same admonition as the prior break, you

20 may talk to these folks, but not about the

21 case, okay?

22 THE WITNESS: Yes, sir.

23 THE COURT: Thank you.

24 THE BAILIFF: All rise, please. Court

25 stands in recess for lunch until one p.m.




320



1 This afternoon.

2 (Thereupon, there was a one-hour lunch break.)

3 MS. ANDERSON: Your Honor, the specific

4 section in Ehrhardt is 702.5.

5 THE COURT: I ruled with you.

6 MS. ANDERSON: Yes. I know. I'm just

7 putting it in the record.

8 THE COURT: Thank you. You know

9 Professor Ehrhardt invites us to call him.

10 MS. ANDERSON: He does?

11 THE COURT: And I have.

12 MS. ANDERSON: He is extremely

13 knowledgeable.

14 THE COURT: Can you imagine taking an

15 entire evidence course from him?

16 MS. ANDERSON: I would like to.

17 THE COURT: It would be just a

18 wonderful experience, I'm sure. Okay.

19 Continuing on with cross-examination of

20 Dr. Bambakidis.

21 MS. ANDERSON: Yes, enough about us.

22 BY MS. ANDERSON:

23 Q. Dr. Bambakidis, you've said that the CT

24 scans have been drawn into question; is that what

25 you said when I thought you said drama?




321



1 A. You know, I'm not quite sure what

2 exactly I said. If you could give me the context

3 maybe I can.

4 Q. I think it was when Mr. Felos was

5 asking you about the CT scans and you said that

6 they had been drawn into question earlier this

7 week?

8 A. Well, it was mentioned that comments

9 had been made with regard to the 1996 CT scan of

10 the brain which I had not had an opportunity to

11 review.

12 Q. And who mentioned that to you?

13 A. Mr. Felos mentioned that to me.

14 Q. When did he mention that to you?

15 A. Well, he mentioned that to me briefly

16 before the testimony that started today, this

17 morning.

18 Q. I see. And when you talked with him

19 yesterday he asked you to examine the CT scan,

20 the '96 CT scan --

21 A. No.

22 Q. -- the day before your testimony?

23 A. No. No. No. Yesterday -- the

24 conversation yesterday morning stemmed from the

25 fact that I had concerns that I had not received




322



1 the entire videotape of Dr. Hammesfahr's

2 examination and I wanted to make sure that I had

3 that.

4 Q. I see. And so that was yesterday

5 morning?

6 A. Yes.

7 Q. Where were you yesterday morning when

8 you had that conversation?

9 A. I was in my home in Rocky River, Ohio.

10 Q. And so somehow between then that

11 conversation yesterday morning and this morning

12 when you took the stand you watched the entire

13 Hammesfahr examination, all three hours?

14 A. No. I had actually reviewed that on

15 Sunday, but I had concerns that I had not had the

16 entire examination. It turns out it was my error

17 in the fact that the videographer said, I had to

18 change tapes and I assumed that I had to change

19 tapes. Not so.

20 Q. Okay.

21 A. Not so.

22 Q. I see.

23 A. So feeling a little silly I went back

24 to that and the rest of the examination was on

25 there.




323



1 Q. So you watched from that point forward?

2 A. Yes.

3 Q. And you also on Sunday looked at the

4 entire examination of Dr. Maxfield and

5 Dr. Cranford?

6 A. That is correct.

7 Q. All right. Now, before yesterday's

8 conversation with Mr. Felos, you say you had not

9 examined the '96 scan?

10 A. That is correct. I had seen reports --

11 well, I'm not sure if there's a report of the '96

12 scan in the records that I reviewed. I don't

13 think there is.

14 Q. Who did you get your records from?

15 A. I get them from Mr. Felos.

16 Q. Let me make sure I have this down. The

17 first contact you had on the case Judge Greer

18 called you?

19 A. That's correct.

20 Q. And he said, would you like to

21 participate in this case?

22 A. Yes.

23 Q. You're not sure why he called you as

24 opposed to the neurologist down the hall?

25 A. Essentially that's correct.




324



1 MR. FELOS: Excuse me, Your Honor,

2 haven't we already gone through this line of

3 questioning in cross-examination?

4 MS. ANDERSON: No, we haven't finished

5 this.

6 THE COURT: Well, we've certainly gone

7 through these specific questions. Let's

8 wait and see where she's going before we

9 worry about it.

10 BY MS. ANDERSON:

11 Q. And did you tell Judge Greer at that

12 time you wanted to think it over before you said

13 yes or did you say yes right away?

14 A. If I recall correctly, the initial

15 conversation was that I would think about it.

16 Then I believe I got back to him relatively

17 promptly with regard to that.

18 Q. So you called him?

19 A. Yes.

20 Q. And you said in that second

21 conversation, I need to see medical records to

22 review; is that right?

23 A. Well, yes. It was either during the

24 conversation or actually a letter that I sent to

25 the judge. Then consequent to that I received a




325



1 telephone call from Mr. Felos asking me what

2 particular records he should send.

3 Q. I see.

4 A. And I indicated in general terms what

5 would be helpful.

6 Q. Did you make the assumption when

7 Mr. Felos called you that he was calling you on

8 the Judge's instruction?

9 A. That's my assumption that either one of

10 the attorneys would contact me in that regard.

11 It just happened that Mr. Felos contacted me.

12 Q. Now, is it your impression that you

13 represent Mr. Felos and Mr. Felos' client in this

14 case?

15 A. No, that's not my impression at all.

16 Q. Okay. So Mr. Felos sent you records

17 and that would have been -- that first contact

18 was some time in May; is that correct?

19 A. Probably a little bit earlier than

20 that. Since the deadline, I believe the initial

21 deadline for submitting a notification for the

22 tests that each expert would want to perform was

23 in May, so it was probably a few weeks before

24 that that I received the records and, you know, a

25 few days at least before that that this




326



1 conversation with Mr. Felos took place.

2 Q. Okay. And counting that conversation,

3 do you think you've had about 10 conversations

4 since then?

5 A. That's a very rough estimate.

6 Q. Okay. And --

7 A. I would say conversations or

8 communications. I mean, some of them are just,

9 you know, directions from the airport to get to a

10 hotel and things like that.

11 Q. Now, when did you get the '96 scan?

12 When did you get access to it?

13 A. I had access to the '96 scan this

14 morning.

15 Q. And how did you gain access to it?

16 A. Mr. Felos mentioned to me that there

17 was a scan from 1996 that I had not reviewed.

18 Q. And where were you when he mentioned

19 this to you?

20 A. Sitting outside in the hall.

21 Q. Did you have the scan?

22 A. No.

23 Q. I mean, you had never seen it?

24 A. I had never seen the scan.

25 Q. At all?




327



1 A. No.

2 Q. Did Mr. Felos provide you the film?

3 A. No. No. He told me essentially this

4 display of the scan, this poster, if you will, of

5 the scan from 1996 was available.

6 Q. So he asked you to step into the

7 courtroom and look at it?

8 A. Yes.

9 Q. I see.

10 A. That's all.

11 Q. Now, did he tell you how the scans had

12 been drawn into controversy regarding the --

13 A. Not really. The only thing that was

14 mentioned or implied was that light had been made

15 of this particular scan and that I had not had

16 the opportunity to look at it.

17 Q. That what had been made?

18 A. Well, in some way during the course of

19 this trial that this scan had been presented and

20 comments had been made on it, presumably. This

21 is my assumption. But I had not had an

22 opportunity to look at that scan.

23 Q. Did Mr. Felos at any time since this

24 hearing began share with you the testimony?

25 A. No.




328



1 Q. He's not shared with you any of the

2 opinions or observations of the other physicians

3 who have testified?

4 A. No.

5 Q. And you have had no contact with him?

6 A. Certainly not.

7 Q. All right. Now, you told us about a

8 patient who was four or five years out from the

9 insult whom you diagnosed to be in a persistent

10 vegetative state.

11 Do you remember that testimony before

12 lunch?

13 A. Yes.

14 Q. Is that the only patient you've

15 diagnosed besides Terri Schiavo to be in a PVS

16 condition?

17 A. I've seen other patients over the years

18 in a persistent vegetative state.

19 Q. Was this an initial diagnosis for this

20 person who was four or five years out?

21 A. No, it was not.

22 Q. So it was a confirmatory diagnosis?

23 A. Confirmatory diagnosis, there were also

24 other issues involved as well.

25 Q. Could you estimate about how many for




329



1 me?

2 A. I would say 20 to 30 at least that

3 would be considered.

4 Q. And were these patients referred to you

5 for a confirmatory diagnosis?

6 A. It's variable. Often times the reason

7 for the referral is more vague than that.

8 Sometimes it's as vague as a neurologic

9 evaluation.

10 Q. Did you ever wind up managing the care

11 of any of those PVS patients on a long-time

12 basis, by long term maybe more than one year?

13 A. I would say so, yes.

14 Q. How many?

15 A. And it was -- well, it was probably a

16 handful. I would say no more than four or five.

17 Q. So four or five patients you've managed

18 their care for more than one year who have been

19 in PVS?

20 A. That would be a rough estimate, yes.

21 Q. Would you describe yourself as a

22 generalist in neurology?

23 A. That's part of the designation. I do a

24 lot in general neurology. I also have a special

25 interest and expertise, as I've already mentioned




330



1 to you, with regard to neurophysiology.

2 Q. And neurophysiology consumes about how

3 much of your work week in terms of percentage?

4 A. Percentage? I would say it's about 20

5 percent.

6 Q. Would you like to do more?

7 A. Not necessarily.

8 Q. Does it remain an area of special

9 interest for you?

10 A. Yes, it does.

11 Q. Okay. Now, isn't it a fact that SPECT

12 scans, in fact, measure brain metabolism, glucose

13 metabolism?

14 A. Maybe, but not as effectively as what I

15 understand as PET scanning.

16 Q. Do you use SPECT scans at all in your

17 practice?

18 A. I have used them on occasion.

19 Q. Routinely you use a PET scan, I think

20 more frequently, the PET than a SPECT scan, don't

21 you?

22 A. Actually I used a SPECT scan once in a

23 patient that I had -- it was, I believe,

24 non-convulsive status and let me explain that.

25 There are forms of ongoing seizure activity that