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1 are not manifest by convulsive movements that are

2 overt. It may manifest by alterations in level

3 of alertness. And a way of determining that, the

4 severity of that, is via SPECT scanning. That is

5 one instance in which I used it.

6 Q. About how many years ago did that

7 incident occur where you used the SPECT scan?

8 A. That was probably about eight years

9 ago.

10 Q. About eight years?

11 A. Yes.

12 Q. And I know that you requested that a

13 PET scan be done on Ms. Schiavo?

14 A. Yes.

15 Q. Would that be typically, if she had

16 presented to you, would that be typically the

17 test that you would have ordered the scan?

18 A. I felt a PET scan would have been

19 preferable because my understanding is there's

20 more literature with regard to the utility of a

21 PET scan. There's more literature that PET

22 scanning is maybe a bit more helpful in assisting

23 a person in a persistent vegetative state as

24 opposed to SPECT scanning.

25 Q. Now, when you did your literature




332



1 search, when did you do that?

2 A. There would have been a literature

3 search done in approximately June of this year.

4 Q. Okay. And what were your search

5 parameters?

6 A. Well, first of all, the parameters were

7 with regard to the utility of hyperbaric

8 treatment and management of patients in a

9 persistent vegetative state.

10 Q. And you, yourself, have never tried

11 hyperbaric in a patient who's been out a long

12 time?

13 A. Not in a persistent vegetative state,

14 although, I have referred one patient to

15 hyperbaric, if I remember, and that was an

16 unusual case.

17 Q. Did you tell us before that was a wound

18 healing situation?

19 A. No. That was a woman who had an air

20 embolism going to the brain and this was when I

21 was up in Rochester, Minnesota, and they had a

22 hyperbaric chamber, I believe, at the University

23 of Minnesota.

24 And we felt that we may have been able

25 to help that particular situation by transferring




333



1 air for that. I never found out how the thing

2 turned out.

3 Q. Does the Cleveland Clinic have a

4 hyperbaric; do you know?

5 A. That I don't know.

6 Q. Now, what else did you search, if

7 anything?

8 A. Well, basically that. In looking to my

9 own particular files with regard to issues

10 concerning the diagnosis of a persistent

11 vegetative state in terms of what the diagnostic

12 parameters are for diagnosing a patient in a

13 persistent vegetative state.

14 Q. And that's something that you already

15 had in your file?

16 A. That's something that I already had

17 available.

18 Q. Where was it available?

19 A. In my personal library that I have in

20 my office.

21 Q. In a book?

22 A. Well, actually there are practice

23 parameters in the American Academy of Neurology

24 that deal with the diagnosis of a persistent

25 vegetative state.




334



1 Q. And did that include the Multi-Society

2 Task Force Report of diagnosis?

3 A. My recollection is that those

4 particular recommendations overlapped quite well

5 with the recommendations that were contained in

6 the practice parameters by the American Academy

7 of Neurology.

8 Q. As you sit here today, have you ever

9 read the Multi-Society Task Force Report in its

10 entirety?

11 A. I believe I have, yes.

12 Q. Do you remember when that was?

13 A. It would have been within the last few

14 months.

15 Q. In preparation for this case?

16 A. Indirectly, yes. But it's important,

17 obviously, for most physicians to know that in

18 terms of dealing with patients in a persistent

19 vegetative state.

20 Q. Well, you had never read it before,

21 right?

22 A. Well, I had referred to it -- I

23 referred to the essence of that before.

24 Q. No, that's not my question. My

25 question is: Had you read it in its entirety




335



1 before?

2 A. I can't recall whether I had or had

3 not, but I made it a point to read it in

4 preparation for this.

5 Q. All right. And who suggested that you

6 read that?

7 A. Nobody.

8 Q. How did you know then to read it?

9 A. Because I felt that it was something

10 that was important.

11 Q. Were you --

12 A. And I knew that it existed, obviously.

13 Q. You knew of its existence?

14 A. Correct.

15 Q. But you had never read it before

16 because?

17 A. No, that's not what I said. I said, I

18 may have read it before. I knew of its

19 existence, but I'm not certain as to whether or

20 not I had read it previously.

21 Q. You have no independant recollection

22 sitting here today if, in fact, you had read it

23 before you were asked to participate in this

24 case?

25 A. That's correct.




336



1 Q. All right. Even though before you had

2 diagnosed patients as being in PVS?

3 A. Correct.

4 Q. So, in those cases, you would have

5 relied on your practice and diagnostic guidelines

6 from the American Academy of Neurology?

7 A. Correct.

8 Q. Mr. Felos never mentioned the

9 Multi-Society Task Force to you?

10 A. He may have. It sounds familiar.

11 Q. I see. Did you read the report after

12 he mentioned it to you the first time?

13 A. No.

14 Q. Did you have to look it up?

15 A. Excuse me?

16 Q. Did you have to look it up?

17 A. My -- it was eventually cited, I

18 believe, in the American Academy of Neurology

19 Parameters as a reference.

20 Q. Do you subscribe to the New England

21 Journal of Medicine?

22 A. Not currently, no.

23 Q. Where did you get your copy of it?

24 A. Well, it may have been part of the

25 literature search that I had done. In fact, it




337



1 probably was.

2 Q. On hyperbaric medicine?

3 A. No. No. That was an additional

4 literature search that I had done also on matters

5 on persistent vegetative state.

6 Q. And are you familiar with any research

7 studies being done on animals with hyperbaric

8 oxygen therapy at big research universities in

9 the United States like Harvard?

10 A. I know that there are those that are

11 being done, yes.

12 Q. Are you familiar with the research

13 that's being done at the University of Pittsburg

14 about hyperbaric --

15 A. Not specifically, no.

16 Q. Are you aware that hyperbaric medicine

17 is used in Western Europe and Russia?

18 A. It doesn't surprise me.

19 Q. And that it's also being used in Latin

20 America?

21 A. (Witness indicates.)

22 Q. You need to answer audibly.

23 A. Yes.

24 Q. Have you ever heard of Dr. Richard

25 Neubauer?




338



1 A. Yes.

2 Q. Have you ever met him?

3 A. No.

4 Q. Do you know anything about his work?

5 A. I know a little bit about his work.

6 Q. How do you know anything about his work

7 in hyperbaric therapy?

8 A. Well, I know because there have been

9 some articles that I have looked at that have

10 been written by Dr. Neubauer.

11 Q. Neubauer.

12 A. Neubauer, correct.

13 Q. We're talking about the man who has a

14 practice down at Lauderdale By the Sea, the same

15 person?

16 A. I believe so, yes.

17 Q. Okay. So when you did your literature

18 research on hyperbaric is that when you turned up

19 the article by Dr. Richard Neubauer?

20 A. Yes.

21 Q. Did you find them intriguing or

22 interesting?

23 A. Well, there are lots of things that are

24 interesting.

25 Q. Did you find them intriguing or




339



1 interesting?

2 A. Interesting in a way, yes.

3 Q. I see. Did it inspire you to use

4 hyperbaric with your patients?

5 A. No, it did not.

6 Q. I see. Now, let me ask you if you

7 would agree with this statement. The diagnosis

8 of --

9 MR. FELOS: Excuse me. Excuse me.

10 Where are we reading from?

11 MS. ANDERSON: We're reading from the

12 International Working Party Report on the

13 Vegetative State.

14 MR. FELOS: Is that an exhibit number?

15 MS. ANDERSON: No.

16 MR. FELOS: Well, Your Honor, if

17 counsel intends to cross-examine the witness

18 through an authoritative text she has to

19 establish that they are authoritative and I

20 don't believe she's done that.

21 THE COURT: She's not cross-examining

22 him about the text. She's just reading --

23 what's the difference in reading that or

24 reading something she wrote on a piece of

25 paper?




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1 MS. ANDERSON: Right.

2 MR. FELOS: Well, that's the whole

3 point of the rule, Your Honor. You can't

4 read from a text and use it for

5 cross-examine purposes with an

6 authoritative -- an article or writing

7 that's deemed -- an article or writing in

8 the field unless the witness agrees it's

9 authoritative or the Court so finds.

10 THE COURT: That's right. You can't

11 impeach with it --

12 MR. FELOS: No, you can't.

13 THE COURT: -- unless the witness

14 agrees, but she can read any statement she

15 wants to, Mr. Felos, and ask him if he

16 agrees with it; can she not?

17 MS. ANDERSON: And that's exactly what

18 I'm doing, Judge.

19 BY MS. ANDERSON:

20 Q. Let me ask you if you agree or disagree

21 with this statement, The diagnosis of the

22 cognitive status is time dependent and cannot be

23 made in a short single assessment even by

24 competent and experienced clinicians?

25 A. I would agree with it to a point, but




341



1 it is incomplete. We need to know what the time

2 parameters are, when the person did it, for how

3 long they were followed.

4 Q. Would you agree with this statement,

5 There are no tests which can confirm whether the

6 patient has any inner awareness?

7 A. That's correct.

8 Q. Would you agree with this, Assessments

9 are best based on a series of behavioral

10 patterns?

11 A. It's hard for me to agree with that

12 without knowing more about what the person means.

13 Q. Okay.

14 A. Which behavioral patterns?

15 Q. The patient's behavioral patterns.

16 A. In response to what?

17 Q. Well, I think --

18 A. You see, it's hard for me to agree

19 without knowing more about it.

20 Q. The patient's behavioral patterns, is

21 there something -- some question in your mind

22 about what that means?

23 A. Yes.

24 Q. Okay. Would you agree with this

25 statement, The ability to generate a behavioral




342



1 response fluctuates from day to day and hour to

2 hour and even minute to minute?

3 A. To some degree that's true.

4 Q. That would be true as well for people

5 without brain damage; would it not?

6 A. Well, yes, that's very true.

7 Q. We all have good days and bad days,

8 correct?

9 A. The variability factor is always there,

10 that's true.

11 Q. Un-huh. For example, if we had the flu

12 we're not going to function at top notch, with

13 top notch brain power, are we?

14 A. Often that's true. Often I find

15 personally it's the opposite. It seems to be a

16 rush of adrenaline and at least one has the

17 impression one is being more efficient. Whether

18 that's true and actually a fact, that's another

19 issue.

20 Q. Would you accept the notion that most

21 people do not operate that way?

22 A. That is reasonable to accept that, yes.

23 Q. Did Terri have a cold the evening you

24 examined her?

25 A. Not to my knowledge.




343



1 Q. Did you hear any sounds of congestion?

2 A. There were some upper area sounds on

3 her lung examination, but those are common in

4 persons who may have some difficulty with

5 clearing their secretions.

6 Q. Were those in the bronchial tubes?

7 A. Yes.

8 Q. Okay. Did she appear to be in

9 distress?

10 A. To me she did not.

11 Q. Did she appear to you to be in imminent

12 danger of death?

13 A. No.

14 Q. Would you agree with this statement,

15 There is a clear need for further research using

16 neurophysiological tests and behavioral

17 measurements to help identify or predict the

18 possible degree of recovery?

19 A. In general I would agree with that

20 because there is an inherent difficulty in

21 evaluating patients who are in a persistent

22 vegetative state.

23 It is based on clinical examinations

24 which are not always reliable and perfect.

25 That's why we utilize frequently supplementary




344



1 testing some of which we've dealt with in the

2 course of this matter to help shed more light

3 into the person's neurological status.

4 Q. That would be laboratory tests, such as

5 blood tests and imaging tests?

6 A. Imaging in particular as well as other

7 physiologic medicine, an EEG, yes.

8 Q. Now, would you agree with this

9 statement, Neuro diagnostic tests alone can

10 neither confirm the diagnosis of a vegetative

11 state nor predict the potential for recovery from

12 awareness?

13 A. If you say "alone" that is correct.

14 Q. Now, did you and Mr. Schiavo when you

15 took the history discuss the issue of Terri's

16 contractures?

17 A. I don't believe we discussed that

18 specifically.

19 Q. When he and Mr. Felos were waiting for

20 you in the lobby of Hospice, did they brief you

21 on anything before you actually went into Terri's

22 room?

23 A. No.

24 Q. And they walked back with you

25 immediately to her room and you started your




345



1 examination?

2 A. No. We sat down. I took the history.

3 I'm not sure if it was then that I looked at the

4 EEG or afterwards, but, in any event, following

5 the history I went in and examined her

6 essentially the same way that I would examine a

7 patient in my own practice in a similar

8 situation.

9 Q. Do you typically when you have a

10 patient with a severe brain injury suggest or

11 order that the patient get physical therapy?

12 A. It depends on the nature of the

13 situation and what the family's wishes are at

14 that particular situation, yes.

15 Q. So if the family says no physical

16 therapy it's okay?

17 A. Well, that's not what I said. What I

18 say is that in order to promote patient comfort

19 and to also perceive along those lines with the

20 assumption that it's something that could be

21 manageable in a reasonable way, then that would

22 certainly be a reasonable thing to do.

23 Q. And, in fact, don't many neurologists

24 always order physical therapy to avoid the

25 creation of contractures?




346



1 A. Oftentimes, yes.

2 Q. It's a pretty standard practice among

3 neurologists, isn't it?

4 A. Well, I don't know if it's -- it

5 depends on their population that they see. If

6 they see a lot of rehabilitation patients that

7 have a lot of spasticity, physical therapy and

8 other methods are employed. So that would be a

9 fair statement.

10 Q. Now, in terms of the long-term patient,

11 is it more or less likely that the principal care

12 given is going to be in the rehabilitation area

13 of medicine?

14 A. It's more likely that it would be

15 rehabilitation.

16 Q. And so neurologists treat in the acute

17 phase generally and then turn the patient over

18 once the patient has maxed out on improvements

19 and turn the patient over to the rehab

20 specialists who work their magic?

21 A. Well, it's misleading in a sense

22 because there are many neurologists that also

23 practice actively rehab --

24 Q. I understand.

25 A. -- neuro rehabilitationist. Plus not




347



1 infrequently neurologists are asked by the

2 rehabilitation medicine colleagues to assist them

3 in evaluating a patient. So it's not as

4 though --

5 Q. It's not a --

6 A. -- the neurologist just sort of

7 abandons the patient completely on the

8 rehabilitationist.

9 Q. But at some point the neurologist has

10 done everything he can and then it becomes a

11 question of rehabilitation?

12 A. Yes.

13 Q. Correct?

14 A. Yes.

15 Q. You would agree with that?

16 A. I would agree with that, in general.

17 Q. And so perhaps the more experienced

18 physicians in terms of treatment of PVS patients

19 would be the rehab doctors?

20 A. Certainly they are very experienced

21 with them often.

22 Q. Dr. Bambakidis, do you have a colleague

23 at the Cleveland Clinic whose name is Robert

24 Kurkel, K-U-R-K-E-L? Do you recognize that name

25 at all?




348



1 A. Kunkel?

2 Q. Excuse me?

3 A. Kunkel?

4 Q. Right.

5 A. And the first name, are you sure you

6 have it correct because there are two people

7 there who have names that are very similar and I

8 want to make sure we're talking about the same

9 person.

10 Q. This physician is in the headache?

11 A. Yes, that's Robert Kunkel.

12 Q. Robert Kunkel, K-U-N-K-E-L?

13 A. Yes.

14 Q. Is Dr. Kunkel an experienced physician

15 in areas of the migraine headache?

16 A. Yep, he is a full-time headache doctor

17 which doesn't mean that he gives his patients

18 headaches, but rather that he treats them for

19 that.

20 Q. Do you know if he treats migraines with

21 vasodilators?

22 A. Yes, many neurologists do as well as

23 myself included.

24 Q. Now, it used to be that migraines were

25 treated with vasoconstrictors.




349



1 A. Still is actually, in a way.

2 Q. So this is an area where the Cleveland

3 Clinic's treatment is different than the majority

4 of physicians who treat migraine headaches?

5 A. I wouldn't say that's accurate at all.

6 Q. Do you know the underlying therapy of

7 why you treat a migraine with vasodilation?

8 A. Well, the role of calcium channels --

9 the etiology of migraines is the issue here. It

10 used to be that migraines were thought to relate

11 somehow with the blood vessel was either

12 vasodilating them or constricting them.

13 Now it's thought that the use of the

14 pathogenesis migraine calcium channel activity,

15 as I just mentioned, is a factor. That's why

16 calcium channel blockers which do dilate are

17 utilized.

18 Q. To relieve a vasospasm?

19 A. No, not to relieve a vasospasm. It's

20 not believed, to my knowledge, that the role of

21 calcium channel blockers and prophylactics of

22 migraine has anything necessarily to do with

23 dilatation itself and may have to do with the

24 role on the calcium channel and that the

25 dilatation or constriction, if you're talking




350



1 about other agents may, in fact, be a

2 epiphenomenon --

3 Q. Be a what?

4 A. Epiphenomenon.

5 Q. Epiphenomenon?

6 A. In other words, if you give somebody a

7 vasodilator it certainly dilates the blood

8 vessels, but the actual reason for its efficacy

9 may be another action that it has.

10 Q. And if you gave the patient another

11 class of vasodilation, spasms, for example, which

12 I think are a different kind, they are not

13 calcium channel blockers, are they?

14 A. No, they're not calcium channel

15 blockers.

16 Q. If you give statins, that also would

17 have a vasodilating effect; would it not?

18 A. I'm not an expert on statins. I

19 wouldn't venture an opinion there.

20 Q. In addition to your literature search

21 on hyperbaric and vegetative state, did you do

22 any other literature searches?

23 A. No.

24 Q. So you didn't do any research on

25 vasospasm or vasodilation as it relates to




351



1 treatment of the long-term brain injury?

2 A. No.

3 Q. Now, when you say you watched the

4 entire videotape of Dr. Hammesfahr, did you get

5 all the way to the end ultimately, once you

6 straightened out your misunderstanding about it?

7 A. Ultimately we got there, yes.

8 Q. Did you see Terri yawn while you were

9 examining her during that 30-minute period?

10 A. Yes -- no. When I was examining her?

11 Q. Yes.

12 A. No.

13 Q. Yes. I'm talking now about your

14 examination.

15 A. My exam? No.

16 Q. Yes. Did you see her laugh?

17 A. No.

18 Q. Did you see her cry?

19 A. No.

20 Q. Did you see her cough?

21 A. I may have seen her cough, yes.

22 Q. Was she relatively quiet during your

23 examination of her?

24 A. Relatively so.

25 Q. Did she moan any?




352



1 A. There was some vocalization.

2 Q. What were you doing at the time?

3 A. I believe it was actually spontaneous

4 that she vocalized.

5 Q. What were you doing at the time?

6 A. When I say "spontaneous" this means I

7 was not doing anything at the time.

8 Q. What were you doing at the time? You

9 must have been doing something.

10 A. I was in the room.

11 Q. You were in the room?

12 A. It could have been between various

13 aspects of the examination.

14 Q. Did you not have your hands on her?

15 A. Not to my recollection, no.

16 Q. What commands did you give her, verbal

17 commands?

18 A. I asked her to look at me when I was

19 off to her side.

20 Q. Which side?

21 A. Off on her left side and then off to

22 her right side.

23 Q. Did Mr. Schiavo tell you that she had a

24 lazy eye?

25 A. I ran across that.




353



1 Q. Where did you run across that?

2 A. I ran across that in the chart. It

3 says -- there's one designation in the records

4 that I reviewed that says the lazy eye was on the

5 left and then the other one says it was on the

6 right. And the (inaudible) on the right eye,

7 it's hard to tell which side it's on.

8 Q. So the records are confusing?

9 A. A bit.

10 Q. In that regard anyway?

11 A. But it shouldn't interfere with a

12 person turning her eyes in response to noise.

13 Q. Did she do that?

14 A. No.

15 Q. She did not turn her eyes to you?

16 A. No.

17 Q. How much time did you give her to look

18 at you?

19 A. Well, let's see, I asked her on each

20 side to -- I called her name and asked her to

21 turn her eyes.

22 Q. Okay.

23 A. Then I gave her, I would say,

24 approximately 30 seconds or so.

25 Q. Now, when you observed Terri on the




354



1 Hammesfahr examination videotape, does she appear

2 to be fixated on Dr. Hammesfahr?

3 A. At times.

4 Q. Throughout the whole exam she appeared

5 to turn her head and her eyes toward the sounds

6 of his voice, correct?

7 A. At times.

8 Q. And do you think that was random?

9 A. Yes.

10 Q. Now, you saw in Dr. Hammesfahr's tape

11 the way that -- at the very beginning of the

12 tape, the way she reacted to her mother, correct?

13 A. Yes.

14 Q. Did she look that way at you?

15 A. No.

16 Q. Let's show H01. There will be an image

17 here on your screen. I want you to look at it

18 and I'll ask you a question about it.

19 Is this the way Terri appeared when you

20 examined her?

21 A. Yes.

22 Q. Yes?

23 A. Yes.

24 Q. Is her head oriented to the right?

25 A. Yes, it is.




355



1 Q. Now, when you examined her was it

2 oriented to the right?

3 A. Yes, it was.

4 Q. Did you greet Terri when you entered

5 the room?

6 A. I believe I did, yes.

7 Q. Did she have no response to you?

8 A. No response.

9 Q. You saw she had no response to

10 Dr. Hammesfahr?

11 A. No, I don't think she had any response

12 to Dr. Hammesfahr.

13 Q. Okay. Does it appear from this image

14 on the screen that Terri is looking at her mother

15 with a changed expression?

16 A. It appears that way, yes.

17 Q. And how would you describe that

18 expression?

19 A. Well, the expression seems to be that

20 she is smiling.

21 Q. And what else?

22 A. And she moaned.

23 Q. She vocalized a little to her mother?

24 A. Yes, she did.

25 Q. And what else?




356



1 A. That's all.

2 Q. Does she appear to be looking at her

3 mother with love?

4 A. That's a question that I can't answer

5 because it begs another question and that

6 question is one of recognition.

7 Q. Do you think she doesn't recognize her

8 mother?

9 A. I'm not convinced that she does.

10 Q. Why is that?

11 A. Because a very similar expression was

12 noted by me during the examination of

13 Dr. Cranfield (sic) that apparently occurred

14 spontaneously that drew this into question. I

15 want the Court to pay particular note to this

16 fact, that I looked at this particular

17 phenomenon.

18 Q. This phenomenon of smiling?

19 A. That's right, in response to her

20 mother, certainly not once, but several times.

21 It was noted, actually, at the beginning of the

22 examination by Dr. Cranford as well.

23 Q. The way she responds to her mother the

24 first time she comes into the room?

25 A. Yes. And the issue that it raises,




357



1 again, is one is this, in fact, a recognition.

2 And if it, in fact, is recognition, then it

3 suggests that there's at least some element of

4 the cerebral cortex that may, in fact, be

5 functioning.

6 Q. Now, you did not see her react in the

7 same fashion, did you, to her father?

8 A. No, I did not.

9 Q. And you did not see her react in the

10 same fashion to Mr. Schiavo?

11 A. That's correct.

12 Q. Correct. And she certainly did not

13 respond in the same fashion to you?

14 A. That's correct.

15 Q. And yet on all three of these

16 videotapes the first time her mother presents

17 herself on a visit --

18 A. Yes.

19 Q. -- you observed this phenomenon; did

20 you not?

21 A. That's correct.

22 Q. Okay. Did you not also observe on the

23 tape of Dr. Cranford's examination that when

24 Terri smiled she was looking at the balloon?

25 A. That specifically I don't remember, but




358



1 I do remember her attending to the balloon.

2 Q. She actually tracked it; did she not?

3 A. Yes.

4 Q. And she actually turned her head toward

5 Dr. Cranford's voice; did she not?

6 A. That I do not recall. I think she may

7 have.

8 Q. Let's play Cranford 02. Was that a

9 startled reflex?

10 A. You could refer to it as that.

11 Q. Is that what she did for you?

12 A. Yes.

13 Q. Did her expression change when the

14 balloon was introduced?

15 A. It may have been. It's hard to know if

16 it was random or purposeful.

17 Q. I see. Continue, please. Pause it,

18 please. Do you think Terri's vision is affected?

19 A. Well, if it's affected it's not

20 affected to the point where she cannot see.

21 Q. She's not totally blind?

22 A. No, she's not.

23 Q. Now she appears to be looking up here.

24 A. Uh-huh.

25 Q. Searching for something, correct?




359



1 A. Yes.

2 Q. Resume, please. Pause, please. If you

3 had to say right now based on this clip up to

4 this point which side of the bed is Dr. Cranford

5 standing on?

6 A. I would have to say he's on the right

7 side of the bed.

8 Q. The right side of the bed?

9 A. Her right.

10 Q. Right. And so she's looking -- she's

11 turned her head to the right there, correct?

12 A. She's tracking him to some degree with

13 her eyes.

14 Q. I see. Now, Dr. Bambakidis, when you

15 go home in the evening you will usually see your

16 wife, correct?

17 A. Sometimes. Sometimes I get home pretty

18 late.

19 Q. Okay. Assuming that she's awake, she

20 is there?

21 A. She is there.

22 Q. When you come in you greet her in a

23 particular fashion at the end of the day?

24 A. Yes.

25 Q. The second time you see her that




360



1 evening, do you greet her the same way?

2 A. It depends.

3 Q. Every time on these videotapes that you

4 see Terri encounter her mother for the first time

5 during the visit she pretty much reacts the same

6 way, doesn't she?

7 A. I'm not sure about every time. I have

8 seen it more than once, certainly.

9 Q. Okay. The second time you see your

10 wife during the evening you don't say, Honey, I'm

11 home, do you?

12 A. Well, I don't think -- you're not

13 suggesting that's really analogous, but I

14 appreciate your point.

15 Q. Resume, please. When you are dealing

16 with the brain-injured patient and you're in the

17 part of the examination where you're giving the

18 patient commands, you have to make allowances,

19 don't you, for the brain injury, the difficulty

20 the patient may have in processing the command?

21 A. In many instances that's appropriate,

22 yes.

23 Q. The mere fact that the patient cannot

24 respond to rapid fire commands would only be

25 indicative of brain damage, correct? It would




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1 not be indicative of persistent vegetative state,

2 correct?

3 A. Repeat that again, please.

4 Q. The mere fact that a brain-injured

5 patient cannot respond or does not respond to

6 rapid fire commands, commands given right

7 after -- one right after the other, is not

8 indicative of persistent vegetative state, is it?

9 A. It depends on how you're defining rapid

10 fire. How are you defining that?

11 Q. The speed in which Dr. Cranford was

12 giving commands on this videotape.

13 A. Well, now, I would disagree with that,

14 actually. Commands may be rapid fire, but you

15 see they are repetitive.

16 Q. No, what I'm suggesting --

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

18 object. Again, the witness --

19 MS. ANDERSON: Mr. Felos, he is

20 finished.

21 MR. FELOS: -- the witness should be

22 allowed to complete his answer.

23 THE COURT: Well, we have -- have you

24 completed your answer, Doctor?

25 THE WITNESS: Frankly, I'm not sure




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1 because I was interrupted toward the end.

2 THE COURT: Okay.

3 BY MS. ANDERSON:

4 Q. I'm not suggesting the same command

5 given over and over and over again, look at me,

6 look at me, look at me, look at me. I'm

7 suggesting changing rapid fire commands, look to

8 your left, look to your right, look up, look

9 down.

10 Wouldn't you not when dealing with a

11 brain-injured patient want to take into account

12 the delay factor process?

13 MR. FELOS: Your Honor, I object. If

14 that's a hypothetical question there's no

15 basis for the hypothetical in this

16 situation. I see no evidence or basis of

17 the commands were other than what

18 Dr. Bambakidis said was the same command

19 repeated over and over again.

20 THE WITNESS: There's actually more to

21 it than that --

22 THE COURT: Wait just a second, Doctor.

23 Let me deal with his objection. I didn't

24 notice anything in any of these tapes like

25 your hypothetical, Ms. Anderson, did I miss




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1 something?

2 MS. ANDERSON: Let's start this clip

3 again.

4 THE COURT: Because you had four

5 commands quickly stated in a row, four

6 different commands. Are you suggesting that

7 there is something like that on one of those

8 tapes?

9 MS. ANDERSON: This clip.

10 THE COURT: Okay.

11 MS. ANDERSON: Take it from the top.

12 (Thereupon, the tape was played.)

13 THE COURT: I must have missed it again

14 because I didn't hear any one, two, three

15 four --

16 MS. ANDERSON: I want to ask this next

17 question, if I may, Judge.

18 THE COURT: Okay.

19 BY MS. ANDERSON:

20 Q. If you had to guess when the camera

21 pulled back, would you guess that Terri is

22 looking in his general direction?

23 A. I would guess that to be correct.

24 Q. Okay. Resume, please. Is that a

25 startled response, startled reflexes?




364



1 A. She's blinking in response to a loud

2 stimulus, correct.

3 Q. That would be a reflex?

4 A. Yes.

5 Q. Dr. Bambakidis, when you were examining

6 Terri, did you raise your voice to her?

7 A. I don't believe that I did.

8 Q. Okay. Resume. When he said, look to

9 your right, did she briefly turn her head and her

10 eyes to the right?

11 A. Briefly.

12 Q. Okay. Did you hear Dr. Cranford say,

13 focus up here and then focus down here?

14 A. Yes.

15 Q. Back to back?

16 A. But you're misinterpreting what he's

17 actually doing, if I may say.

18 Q. I am? How am I misinterpreting?

19 A. From a neurologist's perspective what

20 he's basically done is he's assessing her

21 response to various stimuli. First visual, and I

22 assume, although it's hard to tell with his face,

23 assessing what factors may be involved with

24 regard to tracking.

25 So when he's saying, this is my




365



1 interpretation and it's hard to be certain, but

2 when he's saying, Look at me, look up here, look

3 down here, he's trying to give a stimulus either

4 in his face or by clicking his fingers. That is,

5 coupling his image with a sound to see if that

6 makes a difference.

7 Q. I'm not following you. Has he moved

8 his face when he says look up here his face is

9 high and then when he says look down here --

10 A. Or he could be doing this or doing that

11 (indicating). Admittedly it's hard to tell

12 because it's focusing on her face.

13 Q. Right.

14 A. You're not seeing what he's doing. So

15 that compromises how to evaluate this particular

16 phenomenon exactly what the strategy is.

17 Q. Of course the issue is quick

18 back-to-back differing commands?

19 A. Well, no. The issue here is what

20 exactly is being assessed by Dr. Cranford at this

21 point. Is it so much commands or is it response

22 to stimuli both visual and/or auditory.

23 Q. Now, if Dr. Cranford who, of course,

24 knows better what he was doing, if he says, I

25 interpret her inability to quickly look up and




366



1 quickly look down to be an inability to reproduce

2 an action or follow commands?

3 A. Well, which is it, because there's a

4 big difference.

5 Q. Either one. I know they're different.

6 Either one?

7 A. Okay.

8 Q. Would that be consistent with your

9 understanding of what he was doing?

10 A. Now I'm a little confused. Could you

11 repeat that again to make sure that I understand

12 it?

13 Q. Uh-huh. Sure. If Terri's failure to

14 look up and then quickly look down in response to

15 whatever it was Dr. Cranford was doing, would you

16 view that as a sign of inability to reproduce the

17 behavior on command?

18 A. Yes, because reproducibility is an

19 important parameter when assessing somebody --

20 Q. I understand. I understand it's

21 important.

22 A. -- in a persistent vegetative state,

23 but it's only part of the picture because it's

24 very important also to answer that meaningfully

25 to know exactly what it was -- what he was trying




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1 to do and what he was assessing, whether it was

2 following his command or attending to a stimulus

3 by tracking with her eyes. I think it was the

4 latter, but it's hard to be certain.

5 Q. Now, when you looked at this videotape

6 did you conclude that she did track the balloon?

7 A. Yes.

8 Q. Did you consider that to be

9 reproducible behavior?

10 A. Inconsistent. It's not perfectly

11 reproducible.

12 Q. Really? How so?

13 A. Well, the thing is visual tracking

14 commonly occurs spontaneously in people in a

15 persistent vegetative state and even in response

16 to it may incur with one stimulus, but not with

17 another.

18 Q. True, right?

19 A. So my observation, on not just on this

20 tape, but on the other tape, is that it was not a

21 perfectly consistent response that she was

22 having.

23 Q. So she has to exhibit a perfectly

24 consistent response --

25 A. No. No, that's not what I said. And




368



1 that's not to imply that that's the only criteria

2 that I used in coming to the determination that I

3 felt she was in a persistent vegetative state.

4 That's just one of many.

5 Q. Uh-huh. What would a perfectly

6 consistent response be? Where she follows the

7 balloon without fail every time left and right,

8 up and down, forward and backward always?

9 A. Yes.

10 Q. On command?

11 A. On command, assuming that she's

12 perfectly alert.

13 Q. And if she can't do that she is -- that

14 goes against her in terms of being in a

15 persistent vegetative state?

16 A. Well, no. No. It raises -- no. You

17 don't necessarily say, if she doesn't do that

18 that goes against her being in a persistent

19 vegetative state --

20 Q. No. That goes -- that's a checkmark in

21 column of PVS?

22 A. Well, no, I wouldn't characterize it

23 that way. That's not what people are doing.

24 That's not what I have seen. It's one of the

25 several criteria that you look at in assessing a




369



1 person in a persistent vegetative state.

2 Then you put all of that data together

3 at the end, okay. It's not like a person says,

4 Oh, she's not following the command perfectly,

5 therefore, on the basis of this only she is in a

6 persistent vegetative state.

7 Q. Because there are other factors? You

8 look at the patient in its totality, correct?

9 A. That is true.

10 Q. Did you lift up Terri's leg the way

11 Dr. Hammesfahr did?

12 A. No. Wait a minute. To assess tone I

13 manipulated the leg, but I did not lift up the

14 leg in that same fashion.

15 Q. Did Michael Schiavo tell you that she

16 has not had any physical therapy at all for the

17 last four-and-a-half years?

18 A. That entire conversation did not come

19 up. I never asked him about physical therapy or

20 things like that.

21 Q. If she was your patient, would you have

22 ordered physical therapy for her?

23 A. Well, that's a question that -- that's

24 a hypothetical question that's probably

25 inappropriate for me to answer.




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1 Q. I see. Does Terri Schiavo have to

2 prove to you that she's not in a persistent

3 vegetative state?

4 A. No, I wouldn't characterize it that

5 way, Ms. Anderson. I would characterize it --

6 may I continue, Judge? I would characterize it

7 as looking at all the data as best you can, the

8 history of all the records, examining the person,

9 looking at the examinations of other people,

10 looking at all the tests and coming to the best

11 diagnosis that fits. I went to the best

12 diagnosis that she has.

13 Q. In decerebrate posturing the limbs are

14 rigid, aren't they?

15 A. Yes.

16 Q. So she can't be in decerebrate

17 posturing because her leg is bent, right?

18 A. No. Well, this is not decerebrate

19 posturing that we're seeing here, but not so much

20 it goes to the issue of spasticity. The posture

21 that she has in her upper extremities is more

22 consistent with decorticate posturing and not

23 decerebrate.

24 Q. And in decorticate posturing the limbs

25 are hyperflexed, aren't they?




371



1 A. The upper extremities are flexed. The

2 typical description of a decorticate posture the

3 lower limbs are extended and adducted.

4 Q. And adducted?

5 A. Yes.

6 Q. And rigid?

7 A. Yes.

8 Q. So how could she be in decorticate

9 posturing when her lower limbs are not rigid?

10 A. They are rigid.

11 Q. Did you see Dr. Hammesfahr lift her leg

12 up and her leg bent at the knee?

13 A. Excuse me?

14 Q. You didn't see that?

15 A. Describe for me once again what you are

16 referring to.

17 Q. He put his hands under her leg, lifted

18 it up and her knee bent. Did you see that on the

19 tape?

20 A. What I saw was the leg bending and then

21 having him release his hand and the leg come up

22 this way straight. Was that what you were

23 referring to?

24 Q. I'll show you what I'm referring to,

25 okay.




372



1 A. All right. Show me.

2 Q. Leg 1, please. Now, do you see how

3 flexible her leg is?

4 A. Yes.

5 Q. Is that consistent with decorticate

6 posturing?

7 A. It could be perfectly consistent with

8 decorticate posturing.

9 Q. So decorticate posturing then the lower

10 limbs could either be rigid --

11 A. No. No. That's not what I'm saying.

12 What I'm saying is the lower extremities, the

13 tone is increased the -- there is spastic in the

14 lower extremities. That does not mean that it

15 cannot be overcome, okay.

16 Number two, the degree just as tendon

17 reflexes can vary from time to time, the rigidity

18 can vary.

19 Q. Does her leg appear rigid?

20 A. Excuse me?

21 Q. Does her leg appear rigid?

22 A. Now, does it appear rigid -- you assess

23 rigidity on the basis of actually feeling the

24 extremity, not by looking at it in a situation

25 like this.




373



1 Q. You can't -- you can't, you, Peter

2 Bambakidis, can't tell?

3 A. I cannot tell what he is feeling.

4 Q. I understand. I don't think we need to

5 continue. Did you watch this part of the tape on

6 Sunday? This is right at the end.

7 A. Is that -- that would have been tape

8 two?

9 Q. Yes.

10 A. I saw part of that. I saw tape two on

11 Sunday, yes.

12 Q. H12, please. Did you get any sort of

13 response like that where you touched her toes?

14 A. It was a different response. It was

15 abnormal extension. This is an abnormal flexion.

16 Well, there's both flexion and extension in that

17 situation.

18 Q. So when you touched her toes on the

19 left side --

20 A. No, on both sides, actually.

21 Q. You got an abnormal response?

22 A. Yes.

23 Q. And was it to noxious stimuli?

24 A. Yes.

25 Q. Did you pinch her a bit?




374



1 A. Yes, a little bit.

2 Q. And in your case she pushed her foot

3 down?

4 A. More extension, an exaggeration of the

5 extended --

6 Q. What would be a normal response?

7 A. Move the leg completely.

8 Q. Jerk it back, right?

9 A. Jerk to back.

10 Q. Okay. So that response, of course, is

11 what would be consistent with brain damage,

12 right?

13 A. Generically, yes, a particular type of

14 brain damage we've seen. This is something that

15 I would anticipate in encountering a situation

16 like this.

17 Q. You've encountered that before?

18 A. Yes.

19 Q. And does that abnormal response mean

20 that she's in a persistent vegetative state?

21 A. Not in and of itself, no.

22 Q. In fact, she had a response. It was an

23 abnormal response, but she responded to the pain,

24 correct?

25 A. Well, I wouldn't say that. This was a




375



1 spinal mediated reflex to a painful stimulus.

2 This does not mean a conscious appreciation of

3 the pain necessarily at all.

4 Q. I see. So when we saw what we just saw

5 in the tape where she raised her leg straight up

6 in response to Dr. Hammesfahr putting his hand on

7 top of her left toes what do you think that was?

8 A. That's an abnormal -- that's a

9 combination of an abnormal extension and an

10 abnormal flexor response.

11 Q. Did you watch how Dr. Hammesfahr

12 massaged Terri's shoulder and elbow at the

13 beginning?

14 A. Yes.

15 Q. And got her arm extended?

16 A. Yes.

17 Q. Did you do anything like that for her?

18 A. Usually the physical therapist would do

19 that.

20 Q. Right. If you had wanted to take her

21 blood pressure that evening, where would you have

22 put your cuff?

23 A. Well, I would have put it on the arm,

24 certainly. That would have been preferable.

25 Q. Now, the evening you examined her both




376



1 of her arms were clenched with her hands close to

2 her chin, correct?

3 A. Yes.

4 Q. Would the fact that there was spastic

5 tone in her arms, would that kind of a position

6 have interfered with her ability to take a blood

7 pressure?

8 A. Yes, it would have.

9 Q. Is that why you didn't do one? Is that

10 why you did not take a blood pressure?

11 A. No, that's not why.

12 Q. Is blood pressure important to you?

13 A. It is. It's usually done by the

14 nurses. I usually rely on them.

15 Q. I see.

16 MS. ANDERSON: I may be nearing the

17 end, Judge.

18 THE COURT: Thank you.

19 BY MS. ANDERSON:

20 Q. Dr. Bambakidis, what is penumbra as

21 that term is used with regard to brain injury?

22 A. Excuse me?

23 Q. What does the term penumbra mean with

24 regard to brain injury?

25 A. What type of brain injury?




377



1 Q. What type of what?

2 A. What type of brain injury?

3 Q. Let's say hypoxic encephalopathy?

4 A. So ischemic penumbra?

5 Q. Uh-huh.

6 A. That refers to the area, for example,

7 surrounding an area of an infarction or dead

8 brain tissue where there are cells that are

9 malfunctioning, but could go either way in terms

10 of whether they survive or not.

11 Q. They're still viable?

12 A. Still viable.

13 Q. But they're dysfunctional?

14 A. Correct.

15 Q. And why wouldn't increasing oxygenation

16 to those cells bring them back online?

17 A. Well, that's what you try to do in an

18 acute stroke in the first five to seven days.

19 That's why we routinely do not reduce the blood

20 pressure so that we could produce those

21 adequately.

22 Q. In fact, the treatment of strokes has

23 changed pretty dramatically in response to the

24 progress, hasn't it?

25 A. Our thinking about it has changed. I




378



1 don't know if the outright practice, but

2 management had changed as much.

3 Q. But Project HOPE as well, is that

4 also --

5 A. Project?

6 Q. Project HOPE, are you familiar with

7 that?

8 A. Tell me about it.

9 Q. Well, that is the use of vasodilators

10 to prevent heart complications and also to

11 prevent secondary strokes that are secondary to

12 heart attack. Are you familiar with that Project

13 HOPE?

14 A. Now that you mentioned it I am.

15 Q. Would you consider the New England

16 Journal of Medicine to be authoritative?

17 A. Generally, yes.

18 Q. And Lancet?

19 A. Yes.

20 Q. Stroke?

21 A. Yes.

22 Q. Do you read Stroke?

23 A. Depending on the article, yes.

24 Q. That's sort of in your area, isn't it?

25 A. Well, it's in the province of every




379



1 neurologist's area.

2 Q. I'm sorry, I couldn't hear you.

3 A. It's in the province of any neurologist

4 to see stroke patients.

5 Q. Right. The Journal of Neurosurgery, do

6 you --

7 A. I don't usually read that, no.

8 Q. You don't look at it?

9 A. Not usually.

10 Q. Would you say that it's authoritative?

11 A. Well, you would have to ask a

12 neurosurgeon for a more meaningful opinion.

13 Q. Is Stroke authoritative?

14 A. Generally, with all of these they are

15 not 100 percent authoritative.

16 Q. So none of the journals are

17 authoritative?

18 A. No, that's not what I said. I said --

19 Q. All the time.

20 A. All the time. There's nothing that is

21 100 percent.

22 Q. What would be your qualifier on

23 authoritative for any of the academic journals?

24 A. Well, I wouldn't necessarily put a

25 qualifier on it. What I would probably do would




380



1 be irregardless of the journal look at it, look

2 at the particular article in question and then

3 make an assessment on that basis.

4 It is true, however, that various

5 journals have more or less rigorous requirements

6 in terms of peer review of the particular

7 articles in order to determine whether or not

8 they'll allow them to be published in their

9 journal.

10 Q. So you're saying that within peer

11 review journals there's a hierarchy? Some peer

12 review journals are tougher to get into?

13 A. Well, that's true, yes.

14 Q. And that's certainly true of the New

15 England Journal, for example?

16 A. True.

17 Q. True of Lancet, I would guess?

18 A. I would guess.

19 Q. Is the British Medical Journal

20 authoritative?

21 A. Well, they're all authoritative up to

22 at point. I think -- well, I don't know how I

23 would compare Lancet to the British Medical

24 Journal.

25 Q. Are you familiar with them at all?




381



1 A. Yes.

2 Q. Do you know who publishes them? The

3 Royal Medical Society?

4 A. I don't usually read the British

5 Medical Journal.

6 Q. Have you ever looked at them? Have you

7 ever had an occasion to look at them?

8 A. On a few occasions, yes.

9 Q. The Internet has really revolutionized

10 medical research, hasn't it? Literature

11 searches, medical literature searches?

12 A. Yes.

13 Q. In the sense that the smallest town

14 general practitioner if he has Internet access

15 can now search outward; isn't that so?

16 A. It's helpful. I don't know if I would

17 say it's revolutionized the practice of medicine

18 because it's one thing to read a particular

19 article and another thing to determine how that

20 would influence your practice.

21 Q. Right. I didn't mean to say practice

22 of medicine, I meant to say it revolutionized the

23 medical searches --

24 A. Oh, certainly.

25 Q. -- and the literature searches?




382



1 A. Yes.

2 Q. You no longer have to live near a large

3 medical library, correct?

4 A. That's correct.

5 Q. Have you ever heard of the Journal of

6 Human Hypertension?

7 A. No.

8 Q. You are familiar with that at all?

9 A. That's the name of it, Journal of

10 Human Hypertension?

11 Q. Human Hypertension?

12 A. No.

13 Q. The Journal of Hypertension?

14 A. That sounds familiar.

15 Q. The Journal of Cardiovascular

16 Pharmacology; are you familiar with that?

17 A. I've heard of it.

18 Q. Would you consider the Annals of

19 Neurology to be authoritative?

20 A. Again to a point, certainly.

21 Q. I'm sorry?

22 A. Again, up to a point.

23 Q. Up to a point?

24 A. Yes.

25 Q. Now, The Annals of Neurology, is that




383



1 published once a year?

2 A. No, the Annals of Neurology is actually

3 published on a bi-monthly basis.

4 Q. Bi-monthly?

5 A. Yes.

6 Q. Did I ask you about Circulation?

7 A. No, but that journal I know.

8 Q. Do you know it?

9 A. Yes.

10 Q. Have you had occasion to look at it

11 every once in a while?

12 A. A lot of these journals I think over

13 the years I may have gone to an article there.

14 Q. Have you concluded with these articles

15 or with these journals that we've mentioned that

16 in terms of being a reliable source of medical

17 research literature, they're authoritative?

18 A. Up to a point. Although, the whole

19 area of medical research has come under fire

20 lately in terms of the quality of the research

21 that's been going on.

22 Q. And that's an outgrowth of the publish

23 or perish syndrome; is it not?

24 A. Well, I think it is plus the

25 involvement of the pharmaceutic companies and the




384



1 research itself, so we have to be careful.

2 Q. And, in fact, JAMA, the Journal of the

3 American Medical Association, devoted virtually

4 an entire issue of June of this year to this

5 topic; did it not?

6 A. I believe so, yes.

7 Q. Do you remember seeing it?

8 A. I remember other articles written by

9 Casler (phonetic) for example, about those

10 particular issues.

11 Q. Well, in the New England Journal I

12 think last year addressed this topic, the -- is

13 the peer review system working?

14 A. Uh-huh.

15 Q. Correct?

16 A. Well, yes, plus there are people that

17 have left the editorship of the New England

18 Journal over this issues.

19 Q. I think I remember the hoopla.

20 MS. ANDERSON: I have no further

21 questions of this witness, Your Honor.

22 THE COURT: Thank you. Mr. Felos, how

23 much redirect do you anticipate?

24 MR. FELOS: Just a minute or two, Your

25 Honor.




385



1 THE COURT: Okay. You may proceed.

2 REDIRECT EXAMINATION

3 BY MR. FELOS:

4 Q. Dr. Bambakidis, did Terri Schiavo have

5 a stroke?

6 A. No.

7 Q. Dr. Bambakidis, had Attorney Anderson

8 called you at any time and requested that you

9 speak with Terri's parents over the phone about

10 her medical history would you have been agreeable

11 to do that?

12 A. Yes.

13 Q. I believe you stated that you don't

14 treat or you've given no treatment to your

15 patients who are in persistent vegetative states

16 to improve their neurological function.

17 My question is: Before a diagnosis of

18 permanency is made do you offer treatments to

19 your patients?

20 A. Yes.

21 Q. Do you believe that Dr. Cranford was

22 thorough in his examination?

23 A. Excuse me?

24 Q. Do you believe that Dr. Cranford was

25 thorough in his examination?




386



1 A. Yes.

2 Q. You mentioned when talking about the

3 CAT scans the words generation of scanner, what

4 did you mean?

5 A. The clarity and the definition of the

6 images on the older scanners is not generally as

7 good as the more recent scanners.

8 Q. Thank you. I believe you stated that

9 when the brain is not getting enough oxygen

10 damage may occur after four minutes; is that

11 correct?

12 A. Correct.

13 Q. If the brain is receiving no oxygen,

14 how long would it take for damage to begin to

15 occur?

16 A. Well, for the same period of time

17 basically when I said not enough oxygen and no

18 oxygen it's essentially the same once you reach

19 that threshold.

20 Q. You were asked about an article by

21 Dr. Neubauer and I think the question was: Were

22 you moved to use -- as a result of reading that

23 article, were you moved to use hyperbaric oxygen

24 therapy for treatment of brain damage?

25 And your answer was: No.




387



1 Why weren't you -- why weren't you

2 moved to use hyperbaric oxygen therapy?

3 A. Mr. Felos, I'm not quite sure that that

4 was the exact question, was it?

5 Q. Well, what do you recall the question

6 to be?

7 A. Somehow the connection seemed to be

8 would I attempt to use hyperbaric oxygen in a

9 situation such as this and I think my answer was

10 no.

11 Q. Okay. On the second tape played, which

12 was the Dr. Cranford tape.

13 A. Yes.

14 Q. Do you recall that portion of the tape

15 where Terri appears to smile and moan?

16 A. Yes.

17 Q. Did you note that she did that when

18 Dr. Cranford moved her head?

19 A. I note that she -- yeah, I believe that

20 she had done that during that examination, now

21 that you mention it. And I believe one other

22 time as well, maybe.

23 Q. Did you note in the first tape with the

24 mother that the mother also moves Terri's head?

25 MS. ANDERSON: Leading. Leading.




388



1 Leading. Also Mr. Felos is testifying.

2 MR. FELOS: It's a proper question,

3 Your Honor.

4 THE COURT: I'm going to overrule the

5 objection?

6 THE WITNESS: Yes, I noticed that.

7 MR. FELOS: Thank you. I have no other

8 questions.

9 RECROSS-EXAMINATION

10 BY MS. ANDERSON:

11 Q. Now, Dr. Bambakidis, the day after you

12 examined Terri at Hospice we were here in this

13 courtroom on July 10th, correct?

14 A. That's correct.

15 Q. An Mr. and Mrs. Schindler were here in

16 the courtroom; do you remember?

17 A. Yes.

18 MR. FELOS: Mr. and Mrs. Schindler.

19 MS. ANDERSON: I said Mr. And Mrs.

20 Schlinder.

21 MR. FELOS: I thought you said Schiavo.

22 BY MS. ANDERSON:

23 Q. And do you recall that I asked you at

24 the conclusion of the hearing if you wanted to go

25 back down to Hospice in the presence of the




389



1 parents?

2 A. Yes.

3 Q. And you had to make your flight?

4 A. That's correct.

5 Q. Now, the arrangement had been for Mr.

6 and Mrs. Schindler to be present during your

7 examination, correct?

8 A. That's correct.

9 Q. And the way you knew that was that you

10 had a copy of my letterhead, correct?

11 A. Yes.

12 Q. So you could have called me, right?

13 A. Well, I could have -- my anticipation

14 when I went to Hospice was that they were there

15 and I fully intended to take a history from them.

16 Then it turned out that they had gone. Was I

17 supposed to call you at that time?

18 Q. After July 10th, after you had returned

19 to Cleveland, you could have taken a history from

20 them over the telephone, couldn't you?

21 A. I could have.

22 Q. And why didn't you call me to get their

23 phone number?

24 A. Well, you know -- I mean, I didn't know

25 what their particular perspective would have been




390



1 with regard to this whether they were able to or

2 not. Certainly if they expressed a desire to do

3 that I would have gladly done that.

4 Q. They did, they expressed a willingness

5 to be present during your exam?

6 A. Ms. Anderson, I mean, this is I could

7 have called them, they could have called me. I

8 would have been happy however it could have been

9 done to obtain a history from them. I would have

10 addressed the whole issue in the same fashion and

11 the same way I have addressed it with

12 Mr. Schiavo. I have no bias or ill-will against

13 anybody in this particular case.

14 Q. Do you have any information that

15 different scanners were involved in these two

16 different CT scans?

17 A. No, but I can tell by the quality of

18 the scans that they are different. I'm

19 experienced enough to know that.

20 Q. Are you also experienced enough to know

21 that they were done at two different

22 institutions?

23 A. I noticed that.

24 MS. ANDERSON: No further questions.

25 MR. FELOS: No further questions.




391



1 THE COURT: Thank you very much,

2 Doctor. I appreciate you coming down. I

3 hope you have a safe flight home.

4 THE WITNESS: Thank, you Judge.

5 (Thereupon, testimony was concluded for October

6 16th, 2002.)

7 OCTOBER 17TH, 2002

8 MR. FELOS: Good morning, Your Honor.

9 THE COURT: Okay. Are we ready for

10 Dr. Greer?

11 MR. FELOS: Yes, Your Honor.

12 MS. ANDERSON: Your Honor, I got two

13 faxed orders from Mr. Felos. Do you want to

14 take it up at the first break because I do

15 have a problem with one of the proposed

16 orders, but we don't need to attend to that

17 now.

18 THE COURT: Okay. We could do that.

19 Doctor, come on up, please.

20 THE BAILIFF: Stand here. Raise your

21 right hand. Face the Judge and take the

22 oath, please.

23 THEREUPON,

24 MELVIN GREER, M.D.

25 WAS ADDUCED AS THE WITNESS HEREIN AND AFTER




392



1 BEING DULY SWORN ON OATH WAS EXAMINED AND

2 TESTIFIED AS FOLLOWS:

3 THE COURT: Thank you, Doctor. Have a

4 seat over here.

5 MR. FELOS: If I may, Your Honor?

6 THE COURT: Yes, sir.

7 MR. FELOS: Thank you.

8 DIRECT EXAMINATION

9 BY MR. FELOS:

10 Q. Could you state your name, please.

11 A. Melvin Greer.

12 Q. And how are you employed, sir?

13 A. I'm a professor at the University of

14 Florida College of Medicine in Gainesville,

15 Florida in neurology.

16 Q. Are you licensed to practice medicine

17 in the state, sir?

18 A. Yes.

19 Q. And what states are those?

20 A. Florida.

21 Q. Okay. Dr. Greer, are you of any

22 relation to the presiding judge in this case?

23 A. No.

24 Q. Dr. Greer, can you briefly describe to

25 the Court what your educational background is?




393



1 A. I graduated from New York University

2 College of Arts and Pure Science in 1950. I

3 graduated from New York University College of

4 Medicine in 1954. I was an intern and resident

5 for two years in Bellevue Hospital.

6 I then was a naval officer for two

7 years in the South Pacific, following which I was

8 a fellow in neurology at Columbia in New York

9 City for three years.

10 Then I came to the University of

11 Florida in 1961 as an assistant professor. I

12 became chairman of the department after having

13 been chief since 1962 relinquishing that position

14 in the year 2000 and just assumed my

15 responsibility as a full professor after that.

16 Q. Uh-huh. What year was it that you

17 assumed chairmanship of the Department of

18 Neurology at the University of Florida College of

19 Medicine?

20 A. This was a division of the Department

21 of Medicine that I undertook responsibility for

22 in 1962. It was made a formal department in

23 1974.

24 Q. How does one become the chairman of a

25 Department of Neurology? Is that an elected




394



1 position or an appointed position?

2 A. It's appointed by the dean of the

3 College of Medicine based on the qualifications

4 of the candidate for the opportunities that exist

5 in an academic environment where the candidate

6 has to have shown expertise in the field of

7 neurology, which is a clinical expertise, in

8 addition to having experience and pursuing

9 research and teaching activities. These are the

10 three major legs of the school that appoints a

11 person in an academic position.

12 Q. What is the Bob Paul Family Professor

13 of Neurology? What does that post describe?

14 A. During the time that I was seeing Mr.

15 Paul who has been a patient with Alzheimer's

16 disease. His family in their gratitude donated

17 an amount of money which was placed in the

18 Florida Foundation. It is still used currently

19 to assist with regard to my salary as well as for

20 other research activities that are undertaken by

21 me within the department.

22 Q. By the year 2000, how many physicians

23 were there in the Department of Neurology?

24 A. There were about 15 staff physicians,

25 nine residents and I would suspect about six




395



1 fellows.

2 Q. Now, regarding some appointments you've

3 had, sir, what did you do as a special consultant

4 to the director of the National Institute of

5 Health?

6 A. For the NIH I was a consultant, which

7 meant that I was involved with reviewing grant

8 requests that came from other individuals who

9 wished to pursue research where the funding would

10 come from the federal government.

11 I would often travel to evaluate the

12 program. The research request was then presented

13 by me before the counsel of the NIH and there

14 would be a vote. I was one of the participants.

15 And I was, if you will, the spokesperson for the

16 individuals who submitted the grant.

17 Q. Dr. Greer, what work or services, if

18 any, did you provide to the National Board Of

19 Medical Examiners?

20 A. The National Board of Medical Examiners

21 which makes up an examination that all medical

22 students need to pass to qualify to take further

23 exams such as state licensure was -- has asked me

24 to participate in preparing the examination which

25 I did for several years.




396



1 Q. Regarding written examinations, did you

2 also perform any light services for the American

3 Board of Psychiatry and Neurology?

4 A. Yes, the American Board of Psychiatry

5 and Neurology, which is the board that awards

6 certification or diplomat status to people who

7 have concluded their neurology training and

8 wished to become specialists with the certificate

9 behind them, had asked me to get involved. The

10 same year that I passed my boards, I became an

11 assistant examiner and had done so for about 30

12 times.

13 I not only helped make up the written

14 portion of the examination which came

15 subsequently, but I was one of the people who

16 travelled around the country three or four times

17 a year to all the major hospitals and I gave oral

18 examinations to candidates.

19 Q. Uh-huh. What is the American Academy

20 of Neurology?

21 A. This is the largest organized body of

22 neurologists in the United States and Canada. It

23 must be about 18,000 now. This organization

24 serves as a major function, a continuing

25 educational type of activity for its membership




397



1 so that they can be upgraded with regard to

2 neurological knowledge. It puts out a major

3 journal called Neurology.

4 It also represents the, if you will,

5 the essential bodies so that in case there's

6 somebody who has to speak for Neurology that's

7 where this is accomplished, by having someone do

8 so from the executive committee of the American

9 Academy of Neurology.

10 Q. Dr. Greer, have you held any positions

11 within the American Academy of Neurology?

12 A. Yes.

13 Q. Could you please tell the Court what

14 those positions were?

15 A. Well, in addition to being the

16 secretary treasurer for several years and being

17 on various committees, I also was the president

18 of the American Academy of Neurology in 1985 to

19 1987.

20 Q. Is that an elected or appointed

21 position?

22 A. That's an elected position.

23 Q. Dr. Greer, what's the Royal Society of

24 Medicine?

25 A. That's the British society of




398



1 physicians who organize an educational program.

2 I belong to them. And they awarded me a

3 fellowship.

4 Q. And are you a member or hold a position

5 with that organization?

6 A. No, just a fellow.

7 Q. Uh-huh. Now, have you served either as

8 a consultant or contributing editor on the

9 editorial boards of any specialty medical

10 journals?

11 A. Yes.

12 Q. Could you explain to the Court first

13 what you mean by the term specialty medical

14 journal?

15 A. These are journals that are put forth

16 by various groups of health care providers

17 whether it's surgery or obstetrics and in our

18 case it's neurology where the editorial board is

19 involved with receiving articles.

20 And the editorial board looks at the

21 articles and decides, yes, it is appropriate to

22 be published or not or there are revisions that

23 are necessary before it's published.

24 In other words, the editorial board

25 sits and judges the articles of scientific




399



1 interest that are being submitted for purposes of

2 consideration for publication.

3 I was on editorial boards and I've also

4 been a consultant where I would receive

5 individual papers from other journals that were

6 interested in my particular input.

7 And I've also been a contributing

8 editor where I would be asked by the senior

9 editor to contribute an article to the particular

10 journal. I continue to do that at the present.

11 Q. The process that you described before

12 about receiving articles and reviewing articles,

13 is that commonly known as peer review?

14 A. Yes.

15 Q. I was going to call you Judge Greer and

16 if I do, I apologize in advance.

17 Dr. Greer, what is the value of peer

18 review in terms of publication of medical

19 journals?

20 A. Peer review implies that one's

21 colleagues in the area will have reviewed the

22 article and found that it can be published. It

23 doesn't necessarily mean it's an outstanding

24 article. It may be an article that's presented

25 for interest. An article that's presented to




400



1 stimulate controversy.

2 The purpose is to have someone outside

3 of the individual who is submitting the article

4 to review it and then determine whether

5 publication should be undertaken.

6 Q. Could you name some of the medical

7 journals in which you have served as contributing

8 editor or consultant?

9 A. As contributing editor I'm currently on

10 Geriatrics. I have been on Alzheimer Disease,

11 Parkinson's Disease Digest. I've been a reviewer

12 for the New England Journal of Medicine or the

13 Journal of American Medical Association or JAMA,

14 Southern Medical Journal, American Journal of

15 Pediatrics. These are some of the journals where

16 I have been a reviewer.

17 Q. Have you also been a reviewer for

18 Archives of Neurology?

19 A. Yes.

20 Q. And also Neurology?

21 A. Yes.

22 Q. Dr. Greer, have you written or

23 coauthored with another individuals any books?

24 A. Yes.

25 Q. What books are those?




401



1 A. There are two books; one is a basic

2 book dealing with biochemical matters that are

3 involved with illnesses effecting the nervous

4 system. This is a book that has to do with

5 aromatic acids and amines.

6 The general area that we're talking

7 about, for example, is a child who happens to

8 have mental retardation associated with something

9 like PKU that was our effort in this book to

10 identify compounds that need to be considered and

11 then measured.

12 The other book was a handbook of

13 neurological science and symptoms so that the

14 reader would be able to recognize based on the

15 presentation of the patient what to think about,

16 what tests to order or what direction should one

17 go in terms of treatment approaches and so forth.

18 Q. Now, aside from the books that you

19 wrote or coauthored, have you written chapters

20 for other medical books?

21 A. Yes.

22 Q. I don't mean to go through them. Could

23 you approximate how many chapters?

24 A. I would suspect that my contribution in

25 standard text in neurology amounts to about 70 or




402



1 so chapters.

2 Q. What is Merits Textbook of Neurology?

3 A. This is one of the standard textbooks

4 that is available and was used as a reference by

5 neurologists as well as other specialists in the

6 area interested in understanding disease

7 entities. And it's like any other textbook, it

8 begins with, this is the nature of the problem.

9 This is what one does to understand it. This is

10 how to treat it and so forth.

11 Q. Have you authored any chapters in

12 Merits Textbook of Neurology?

13 A. Yes.

14 Q. I think you've touched on this before,

15 but have you written any articles that have been

16 published in medical specialty journals?

17 A. Yes.

18 Q. Can you approximate how many?

19 A. I would suspect 90 to 100.

20 Q. Can you name some of the -- can you

21 name some of the medical journals in which your

22 articles have been published?

23 A. Neurology, Archives of Neurology,

24 Journal of the American Medical Association. And

25 then there are more esoteric journals like




403



1 Clinica Chemica Acta where we published on the

2 topics of some of these metabolic changes and

3 recognize and the body fluids in patients with

4 retardation. These are some of the journals.

5 Q. Did you ever write a journal that was

6 published in Radiology?

7 A. Yes.

8 Q. Dr. Greer, did you have an opportunity

9 to examine -- let me backtrack. You may have

10 touched upon this, but I want to make sure.

11 Are you board certified?

12 A. Yes.

13 Q. Please tell the Court under what boards

14 you are certified?

15 A. I'm certified by the American Board of

16 Pediatrics, the American Board of Psychiatry and

17 Neurology and I'm also certified with special

18 competence in child neurology by the American

19 Board of Psychiatry and Neurology.

20 Q. Thank you. Did you have an opportunity

21 to examine Theresa Schiavo?

22 A. Yes.

23 Q. Could you tell the Court on what date

24 you did that?

25 A. June 14th, 2002.




404



1 Q. Dr. Greer, prior to your examination of

2 Theresa Schiavo, what materials, if any, did you

3 review regarding the patient?

4 A. I reviewed the medical summaries of the

5 patient from Humana Hospital 2/20/90 to May of

6 '90. Medical summaries from Bayfront Medical

7 Center from June through September '90. Medical

8 summaries from Medical -- Bradenton in January of

9 '91 through July of '91.

10 Palm Gardens Nursing Home records from

11 '94 through 2000. Hospice of the Florida

12 Suncoast records from the year -- from March 2000

13 to the present or at least when I examined the

14 patient.

15 These were some of the records. In

16 addition, I also looked at other reports and so

17 forth which came to me from you.

18 MS. ANDERSON: I'm sorry, I didn't

19 catch that answer.

20 THE WITNESS: Some reports that came

21 from Mr. Felos and sent to me.

22 BY MR. FELOS:

23 Q. Did you review the comprehensive

24 physical examination performed by the Ward's

25 treating physician, Dr. Gambone?




405



1 A. Yes, I did.

2 Q. Did you also, before you examined

3 Theresa Schiavo, have an opportunity to review

4 any tests such as EEGs or CT scans or reports

5 thereof?

6 A. Yes.

7 Q. And what were those?

8 A. I reviewed the CT scan of 7/2/02 and

9 its report. The EEG report of 7/8/02. The

10 carotid ultrasound report of 7/30/02.

11 Q. After your examination of Theresa

12 Schiavo, Dr. Greer, did you receive any other

13 materials concerning the patient that you

14 reviewed?

15 A. Yes.

16 Q. What were those?

17 A. Following my evaluation of the patient,

18 I did review the assessments undertaken by other

19 physicians including Dr. Bambakidis,

20 Dr. Maxfield, Dr. Cranford, Dr. Hammesfhar, and I

21 also looked at the videos of three of those four

22 physicians whose material I reviewed.

23 Q. Dr. Greer, based upon your examination

24 of the patient and the other materials that you

25 have reviewed, were you able to reach an opinion,




406



1 within a reasonable degree of medical certainty,

2 as to whether or not Theresa Schiavo was in

3 persistent vegetative state?

4 A. Yes.

5 Q. And what was your opinion?

6 A. I felt that she fit into the clinical

7 category of the persistent vegetative state.

8 Q. Okay. Dr. Greer, I would like to have

9 you take a look, if you can, at the 1996 CT scan

10 of Theresa Schiavo, which is enlarged in front of

11 you.

12 With the Court's permission if you need

13 to walk down and examine it, that's perfectly

14 okay.

15 Just for purposes of identification,

16 Dr. Greer, the larger picture is the blowup of

17 the images from the 1996 CT scan. The smaller

18 blowup are the images of the July 2002 CT scan.

19 A. Yes, I see those dates identified.

20 Q. Okay. Take a moment, please, to review

21 that.

22 A. Yes.

23 Q. Okay. Dr. Greer, first of all, how

24 would you describe the 2002 CT scan?

25 A. The brain is significantly altered from




407



1 normal. It has shrunken from the standpoint that

2 the tissue, and one sees a very large collection

3 of fluid which is over the surface of the brain

4 filling the crevices, but also in the center of

5 the brain which represents really the shrinkage

6 of the brain from within, as well as the

7 shrinkage of the brain from without. This is

8 what one would call profound atrophy of the

9 brain.

10 Q. Is the 2002 CT scan consistent or

11 inconsistent with the diagnosis of persistent

12 vegetative state?

13 A. It's consistent with it.

14 Q. Now, what is your impression, sir, of

15 the 1996 CT scan?

16 A. In essence, it reveals the same

17 features of marked brain impairment with atrophy

18 or shrinking of the brain tissue and the fluid

19 accumulates and takes the place of the tissue

20 which is both over the surface of the brain as

21 well as the inside of the brain. The cavities of

22 the brain or ventricles are dilating to

23 compensate for the lack of brain tissue.

24 Q. Is the 1996 CT scan consistent or

25 inconsistent with a diagnosis of persistent




408



1 vegetative state?

2 A. It is consistent with the diagnosis of

3 persistent vegetative state.

4 Q. Okay. Do you have an opinion,

5 Dr. Greer, as to whether or not there is any

6 improvements in the brain shown in the 2002 CAT

7 scan as opposed to the 1996 CAT scan?

8 A. Yes, I have an opinion.

9 Q. What is that?

10 A. There is no change.

11 Q. Thank you. If you would resume your

12 witness box.

13 A. (Witness complies.)

14 Q. Dr. Greer, what is a persistent

15 vegetative state?

16 A. The essence of the condition is that it

17 reflects a patient who will have suffered injury

18 to the brain which is rather profound, whether it

19 be related to trauma or lack of oxygen or

20 poisoning.

21 When the term is used to identify the

22 patient's clinical manifestation, that's what the

23 patient demonstrates under these circumstances.

24 This is a patient who exhibits a problem where

25 there is a loss of a distinction between self and




409



1 environment so that the individual is not able to

2 acknowledge what is going on about him or her.

3 There is preservation of autonomic

4 bodily function -- correction, autonomic function

5 of the body because the brain stem function is

6 still preserved. That's the portion of the brain

7 that controls respiration and heartbeat and so

8 forth.

9 The patient will have sleep/wake

10 cycles. There is a circumstance in such a

11 patient where not only is there a problem with

12 regard to their interactions that imply a

13 conscious reaction, but in many patients there

14 are features that imply that perhaps there is a

15 reaction that does take place, but it's not

16 sustained.

17 A patient with a persistent vegetative

18 state can vocalize, they can tear, they can

19 laugh, they can cry. These are individuals who

20 even have been described as saying random single

21 words from time to time, but this is not a

22 sustained type of process.

23 And in such an individual who has these

24 features, the nature of their reaction; the

25 crying, the laughter, even the occasional




410



1 reaction that implies the presence of some type

2 of sensory input is temporary.

3 It's not something that one can rely

4 upon as a reaction that is going to continue

5 implying perhaps that there is a potential for

6 improvement.

7 Q. Uh-huh. Would you agree or disagree

8 that one of the aspects of a persistent

9 vegetative state is absence of cognition?

10 A. Yes.

11 Q. Dr. Greer, do you have an opinion,

12 within a reasonable degree of medical certainty,

13 as to whether or not there is any treatment

14 available that can improve the neurological

15 condition of Theresa Schiavo?

16 A. Yes, I have such an opinion.

17 Q. And what is that opinion?

18 A. There is no treatment that is available

19 that can help this unfortunate young woman.

20 Q. Dr. Greer, have you ever heard of

21 hyperbaric oxygen treatment or hyperbaric oxygen

22 therapy?

23 A. Yes.

24 Q. What is that?

25 A. This is the pushing of oxygen into a




411



1 body at higher atmospheric pressure so that there

2 is an ability of the blood stream to acquire

3 dissolved oxygen where an atmospheric

4 temperature, which is normal atmospheric

5 pressure, one can only have a 20 percent

6 dissolving ability of oxygen. Whereas, if you

7 put the patient into a hyperbaric chamber, one

8 can increase the tension and you can put gases

9 into solution much easier.

10 It is effectively used in many patients

11 who have the bends where because they're

12 submerged for a period of time in water the

13 nitrogen bubbles may, if they ascend too rapidly,

14 will escape and cause problems.

15 So if you could get the nitrogen back

16 into the solution and then have the patient

17 breath and it will come out with the expired air

18 this is the way of treating such a patient.

19 Q. Is that commonly known as the bends

20 that you are describing?

21 A. Yes.

22 Q. Why would hyperbaric oxygen --

23 MS. ANDERSON: Leading, and assumes --

24 MR. FELOS: I haven't finished my

25 question, Your Honor.




412



1 THE COURT: Please complete your

2 question and then we'll see if she has an

3 objection.

4 BY MR. FELOS:

5 Q. Dr. Greer, if I haven't asked you, do

6 you believe hyperbaric oxygen treatment would be

7 of any benefit to Theresa Schiavo?

8 A. No.

9 Q. And why not?

10 A. It's never been shown to be able to

11 help a patient who has marked tissue destruction.

12 Even if you push oxygen into a solution in the

13 blood, the brain is not able to accept oxygen no

14 less use oxygen for the enhancement of brain

15 function so that you can produce more brain

16 cells.

17 In the circumstance of the persistent

18 vegetative state, we're talking about dead brain

19 cells. These are not cells that are just lying

20 around waiting for somebody to stimulate them.

21 That's the evidence of the enlarged cavities and

22 the shrinkage of the brain.

23 The brain cells have gone away or

24 they've become just scarring and putting oxygen

25 into the blood is not going to revive these




413



1 cells.

2 Q. Is the treatment of such brain injury

3 by hyperbaric oxygen therapy a prevailing

4 practice in the medical community?

5 A. No.

6 Q. Now, Dr. Greer, what is vasodilation

7 therapy?

8 A. Vasodilation implies that you want to

9 dilate blood vessels. That is vasodilatation.

10 Q. Would dilating the blood vessels in

11 Theresa Schiavo's brain or increasing the blood

12 flow to Theresa Schiavo's brain improve her

13 neurological condition?

14 A. No, it would not.

15 Q. Why not?

16 A. Well, if anything, whatever brain

17 tissue is functioning to the extent that this is

18 a patient who is able to breath and her heart is

19 beating implying that there is adequate blood

20 flow and profusion to the brain stem, that's

21 where the centers are located, you run a great

22 risk.

23 If you're going to vasodilate you're

24 going to lower the pressure force of the blood

25 getting into the brain and these critical areas




414



1 in the brain stem may be jeopardized and a change

2 with regard to the respiratory function as well

3 as the heart rate may ensue.

4 So it's a very risky thing to consider.

5 Certainly it's not something that is often

6 therapeutical except in circumstances of a

7 hypothetical patient who comes in with enormous

8 hypertension and you want to use some type of

9 vasodilatation to lower the blood pressure.

10 Q. Well, aside from the risks of

11 vasodilation therapy in the brain, what might be

12 the corresponding benefit to a patient like

13 Theresa Schiavo?

14 A. None.

15 Q. Do you have an opinion, Dr. Greer, as

16 to whether or not hormone replacement therapy

17 could benefit Theresa Schiavo's neurological

18 condition?

19 A. Yes, I have an opinion.

20 Q. What's that opinion?

21 A. It would not.

22 Q. And why not?

23 A. There is no deficiency that exists

24 either clinically or even as a result of some of

25 the studies that Dr. Gambone did to seek the




415



1 presence of something like a deficiency of

2 thyroid or problems with regard to other

3 metabolic parameters having to do with, for

4 example, with calcium metabolism or glucose

5 metabolism. These are normal. There is no

6 indication that any hormone therapy would be

7 beneficial.

8 Q. Would the administration of calcium

9 channel blockers or statins be of any benefit to

10 Theresa Schiavo's neurological condition?

11 A. No.

12 Q. And why is that?

13 A. Calcium channel blockers are -- is the

14 term that is used for patients who are on certain

15 anti-hypertensive medication where, once again,

16 the operation of the drug is at the blood vessel

17 and it relaxes blood vessels.

18 It's used again in patients who do have

19 hypertension as the typical treatment. And for

20 the same reason that hypotensive therapy is not

21 going to work so true in a patient who has normal

22 blood pressure is the calcium channel blocker

23 going to be effective. And it has no other value

24 in a circumstance where you're dealing with a

25 patient who is being treated where their concern




416



1 is the blood vessels.

2 But the other drug grouping that you

3 called are the statins. The statins is the

4 general terms that is used for cholesterol

5 lowering drugs like Lipitor or Pravachol. It's

6 used in patients who do have hyperlipidemia or

7 high cholesterol and it's used as an adjunct to

8 diet and exercise and weight reduction of the

9 patient who is at risk of heart attack or a

10 stroke.

11 It is of no value in a circumstance

12 such as Ms. Schiavo particularly when there's no

13 indication that her lipids or her cholesterol are

14 elevated.

15 Q. Is the treatment of brain injuries like

16 Theresa Schiavo's with vasodilation therapy a

17 prevailing practice in the medical community?

18 A. No.

19 Q. What's a stem cell, Dr. Greer?

20 A. A stem cell is a cell that's the

21 primitive cell in the evolution of a particular

22 formative type of tissue. One will see stem

23 cells in various organs and the fetus that's

24 developing.

25 And if it's in the area of the liver




417



1 the stem cell which is a primitive cell will go

2 on and develop a liver cell. And if it's in the

3 brain it will go on as the fetus develops to

4 develop a brain cell.

5 Q. Dr. Greer, is there any available

6 treatment or therapy with stem cells that can

7 improve Theresa Schiavo's neurological condition?

8 A. No.

9 MR. FELOS: I have no further

10 questions, Your Honor.

11 THE COURT: Thank you.

12 Cross-examination, Ms. Anderson?

13 MS. ANDERSON: Yes, Judge.

14 CROSS-EXAMINATION

15 BY MS. ANDERSON:

16 Q. Dr. Greer, when Mr. Felos asked you to

17 define "persistent vegetative state" I noticed

18 you were reading from something. May I take a

19 look at that, please?

20 A. Sure.

21 MS. ANDERSON: May I approach, Your

22 Honor?

23 THE COURT: Yes, ma'am.

24 THE WITNESS: These are notes. And

25 this is a --




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1 BY MS. ANDERSON:

2 Q. Where were you reading from?

3 A. Over here, as well as my deposition

4 which I had given for you and my notes are in

5 here.

6 Q. Was this the page you were reading

7 from?

8 A. Down here. This is the area that I was

9 referring to. These are notes that I had made in

10 the course of review and reading.

11 Q. Dr. Greer, what did you consult when

12 you made these notes?

13 A. What, ma'am?

14 Q. What did you consult when you made

15 these notes?

16 A. A series of articles as well as my own

17 experience.

18 Q. What articles were they? Would you

19 need this back?

20 A. Yes. The Medical Aspects of the

21 Persistent Vegetative State, New England Journal

22 of Medicine 1994. Volume 330, 1499.

23 Q. Did Mr. Felos provide that to you?

24 A. No, ma'am.

25 Q. Is that something that you keep at




419



1 hand?

2 A. Yes, ma'am.

3 Q. How many -- over the years, how many

4 patients have you had occasion to diagnose as

5 being PVS?

6 A. Approximately one every year or two.

7 Q. Okay. What else did you consult?

8 A. I'm sorry, ma'am?

9 Q. What else did you consult?

10 A. The Journal of Neuropathology and

11 Experimental Neurology, Volume 53, Page 548,

12 1994.

13 Q. '94?

14 A. '94.

15 Q. Let's see. That was the same year the

16 Multi Force or the Multi-Society Task Force

17 report came out?

18 A. Yes.

19 Q. Was there a comment on that report?

20 A. No. It's an article that was, in fact,

21 Neuropathology of Persistent Vegetative State.

22 The senior author was Kinney.

23 Q. Okay. What else did you consult?

24 A. The Epidemiological Studies on Patients

25 With a Persistent Vegetative State which appeared




420



1 in the Journal of Neurology and Neurosurgery and

2 Psychiatry, Volume 40, Page 876. 1977.

3 Q. 1977?

4 A. Yes.

5 Q. Okay. What else?

6 A. Residual Cerebral Activity in

7 Behavioral Fragments Can Remain in the Persistent

8 Vegetative State, article by Shift appearing in

9 Brain 2002. Volume 125, page 1210 to 1234.

10 Neuropathology in Vegetative and

11 Severely Disabled Patients after Head Injury,

12 Neurology, 2001. Volume 56, Page 486.

13 Prediction of Recovery from

14 Post-Traumatic Vegetative State with Cerebral

15 Magnetic Resonance Imaging. Lancet. Volume 351.

16 Q. Do you consider Lancet and these other

17 journals to be authoritative sources for

18 information of this type?

19 A. It depends upon the article in Lancet.

20 If it's a letter to the editor, not particularly,

21 but this was an article that went through peer

22 review, so I would recognize it.

23 Q. I'm sorry, you were -- what did the

24 letter to the editor have to do with it?

25 A. Yes. The letter to the editor is an