122

1 rule. So the fact that he reads it into the record

2 didn't pertain to anything except that it takes us

3 longer to conclude his testimony.

4 BY MR. FELOS:

5 Q. Do you see any notation in that report

6 specifically regarding the amounts of brain matter in

7 Teresa Schiavo's cerebral hemisphere?

8 A. Yes.

9 Q. What is that in the discussion provided by the

10 radiologist?

11 A. He reports there is a small amount of brain

12 substance remaining in the cerebral hemisphere, mainly

13 in the anterior temporal lobes.

14 Q. Thank you, Dr. Gambone.

15 Now, would you call yourself a general

16 practitioner, Dr. Gambone?

17 A. I would call myself a specialist in internal

18 medicine and geriatric medicine.

19 Q. Do you consider yourself a specialist in

20 neurology?

21 A. No, I do not.

22 Q. And is it common for an internist to rely on

23 the opinions of expert doctors in the course of their

24 treatment of a patient?

25 A. That is correct, extremely in unusual






123

1 conditions.

2 Q. I believe you were -- I believe you testified

3 on cross-examination that you partially relied on

4 Dr. Barnhill's opinion as to Terry Schiavo being in a

5 vegetative state. In your review of your medical

6 records, prior to your and Dr. Barnhill seeing the

7 patient, had you ever seen any other reference to that

8 event?

9 A. Yes, I believe I did. And if you asked me

10 where I saw that, I'd probably have difficulty without

11 having the record.

12 Q. I would like to show you Petitioner's Exhibit

13 4 marked for identification, which is a discharge

14 summary from Mediplex Rehab in Bradenton.

15 MS. ANDERSON: Judge, I move to strike that

16 last bit of testimony from Mr. Felos. He needs to

17 approach the witness with the document and ask him

18 if he recognizes the document and ask him how he

19 recognizes it. He doesn't need to make a speech

20 about what they are ahead of time.

21 MR. FELOS: Your Honor, I'm not giving a

22 speech. I'm just identifying the title of the

23 document I am showing him.

24 THE COURT: A normal question is, do you

25 recognize this? What is it? Then, it's






124

1 identified. You have already identified it in your

2 question. Say what it is.

3 I am going to grant the Motion to Strike and

4 allow to you rephrase the question.

5 BY MR. FELOS:

6 Q. Do you recognize the document I just handed

7 you which is marked Petitioner's Exhibit 4?

8 A. Vaguely. This happens to be part of the

9 documents that I reviewed when I took over her care in

10 1998.

11 Q. Do you recognize that as part of

12 Terry Schiavo's medical chart and records?

13 A. Yes, I do.

14 Q. Thank you.

15 MS. ANDERSON: Mr. Felos, I would like to have

16 a copy of that exhibit.

17 MR. FELOS: Your Honor, I'd move to introduce

18 Petitioner's Exhibit 4 into evidence.

19 THE COURT: Is there an objection?

20 MS. ANDERSON: If I may take a moment, Your

21 Honor, to look at this.

22 THE COURT: Yes, ma'am.

23 MS. ANDERSON: These are -- part of this

24 exhibit that I have been handed is a duplicate.

25 There are two copies of the discharge summary.






125

1 It's also jumbled up there, actually.

2 No objection, Your Honor.

3 THE COURT: Thank you. It would be so

4 received.

5 (Whereupon, the document referred to was

6 received in evidence as Petitioner's Exhibit Numbers 3

7 and 4.)

8 BY MR. FELOS:

9 Q. Now, I believe you mentioned that -- we

10 discussed on your cross-examination that you discussed

11 Terry's additional care with the staff at the Hospice;

12 is that correct?

13 A. That's correct.

14 Q. Do you recall -- you were asked a question, I

15 believe, "Do you ever see Terry's mother with Terry",

16 and you said no.

17 A. That's correct.

18 Q. Do you recall seeing any record in the -- any

19 record in the Hospice medical notes regarding Terry's

20 mother visiting her?

21 A. I do not recall offhand.

22 Q. Let me show you part of Respondents' exhibit

23 introduced into evidence, Hospice medical records, and

24 ask you if that refreshes your recollection?

25 MS. ANDERSON: Judge, that's a problem. This






126

1 is not the way you refresh somebody's recollection.

2 If he has a question about a specific page in

3 Respondents' Exhibit 12, he needs to draw

4 Dr. Gambone's attention to it and ask the question.

5 But he is asking -- he's, in effect, suggesting to

6 refresh of his recollection, and that's improper

7 because Dr. Gambone hasn't indicated that looking

8 at that would refresh any recollection he might

9 have that he no longer has. It's a different

10 animal, is what he is doing.

11 THE COURT: He is asking him to look at this

12 and see if he can refresh his recollection.

13 MS. ANDERSON: He hasn't indicated that his

14 recollection needs refreshing, which is a necessary

15 predicate.

16 THE COURT: He said, "I don't remember."

17 That's the standard predicate answer to may I

18 refresh your recollection.

19 MS. ANDERSON: And, then, there is the

20 intermediate step, "if you look at this record,

21 would it refresh your recollection." I haven't

22 heard him say that it would.

23 THE COURT: Okay. Why don't you say that,

24 Mr. Felos?

25 BY MR. FELOS:






127

1 Q. Regarding Page 58 of Respondents' Exhibit, I

2 would like you to take a look at this and ask you if it

3 would refresh your recollection?

4 A. This is -- I don't recall this particular

5 passage.

6 Q. Okay. Would you be surprised, Dr. Gambone,

7 that there are many entries in the hospital's medical

8 records regarding visits of Mrs. Schindler to her

9 daughter?

10 A. It would not surprise me.

11 Q. Would it surprise you there are many entries

12 in the Hospice medical notes regarding Mrs. Schindler's

13 visits with her daughter?

14 A. I would think, yes.

15 Q. Would it surprise you that those records

16 reflect that Terry is not responsive to the mom?

17 A. On the video, it's not what I would expect.

18 Q. Regarding Terry's teeth, you testified that a

19 dentist saw Terry; is that correct?

20 A. Yes.

21 Q. And you received a report of his findings?

22 A. Yes.

23 Q. Did the report evidence any problems with her

24 teeth?

25 A. No.






128

1 Q. Now, I believe you testified on

2 cross-examination that you didn't believe that a

3 hygienist, dental hygienist, came out afterwards and

4 cleaned her teeth. Are you aware that a dentist -- do

5 you know whether or not the dentist came out afterwards

6 and cleaned her teeth?

7 A. If the dentist did, I wasn't aware of it.

8 Q. Now, you were asked about the will to live.

9 This is this part of the survival instinct?

10 A. I would think so.

11 Q. Now, you were asked questions about

12 responsiveness and whether responsiveness in a patient

13 indicated or contraindicated a vegetative condition.

14 Would it make a difference in that answer as to whether

15 the response was involuntary as opposed to meaningful?

16 A. Yes, it would make a difference.

17 Q. Would an involuntary response to a stimulus,

18 which is the environment, contraindicate a vegetative

19 condition?

20 A. No.

21 Q. Now, I believe you were asked "would you be

22 surprised if Terry lifted her leg on demand if I pressed

23 her leg," and I believe you stated you would. Would you

24 be surprised that -- would you be surprised if that --

25 let me rephrase that.






129

1 Could a press of her leg coincide with an

2 involuntary action or movement on the part of Terry?

3 A. That's correct.

4 Q. Would that be particularly surprising?

5 A. No.

6 Q. You mentioned that there is a DNR order in

7 Terry's chart.

8 A. That's correct.

9 Q. Do you know whether there was a DNR order in

10 her chart before you took over her care?

11 A. I believe that there was a DNR order before I

12 took over her care. I am not positive.

13 Q. Do you know a presumptive audio oriented

14 process?

15 A. No.

16 Q. Now, you were shown various portions of the

17 videotape examinations on Terry. Do you recall when the

18 video starts that music is playing?

19 A. Yes.

20 Q. Did you see any reaction of Terry initially

21 when the music was playing?

22 A. Movements of her head and eyes are movements

23 which I have observed her make without any music or

24 interaction.

25 Q. To your knowledge, does Terry have a -- to

130

1 your knowledge does Terry have a startle reflex?

2 A. Yes.

3 Q. What is a startle reflex, Dr. Gambone?

4 A. To respond to stimuli, to loud sounds or a

5 painful reaction is a startle response.

6 Q. There is a portion of the tape where Terry was

7 moaning while her mother was by the bedside. Do you

8 recall that?

9 A. Yes, there was a noise. On one video, there

10 was nasal sounds. I wasn't clear if -- I called it

11 snoring. I wasn't sure if it was related to her cold,

12 if it was a moan, or snore or nasal congestion.

13 Q. Do you know for a fact whether Terry had a

14 cold in 2002?

15 A. No, I don't know that for a fact.

16 Q. During the time that -- and correct me if I am

17 wrong, but was Terry's -- was Terry's mom making

18 physical contact with Terry during the time that you saw

19 her moan?

20 A. I believe so. She was off to the left of the

21 screen. I failed to see where her hands were at times.

22 Q. Would it surprise you that these tapes review

23 numerous occasions where Terry's mother kisses her and

24 asks her questions when there is no moaning?

25 A. Yes. According to the nurses, she does moan






131

1 all the time.

2 Q. Now, you were asked to listen to her carotid

3 arteries?

4 A. Yes.

5 Q. And what was the result of listening to her

6 carotid arteries? Did you find anything wrong?

7 A. No, I did not.

8 MR. FELOS: I have no further questions, Your

9 Honor.

10 THE COURT: Thank you.

11 Anything further, Ms. Anderson.

12 MS. ANDERSON: Just a few, Judge.

13 RECROSS-EXAMINATION

14 BY MS. ANDERSON:

15 Q. Would it be unusual if the dentist cleaned a

16 Hospice patient's teeth?

17 A. I couldn't answer that.

18 Q. Has that ever happened, in your experience?

19 A. Has the dentist come in and cleaned the person

20 in Hospice's teeth?

21 Q. Yes.

22 A. I haven't had that much experience with

23 Hospice. I couldn't comment on what their policy is to

24 clean the teeth.

25 Q. I can't hear you.






132

1 A. I don't know what their policy is, procedure

2 on teeth cleaning, the dentist.

3 Q. At nursing homes, would it be unusual for a

4 dentist to clean the patient's teeth?

5 A. No. Again, not unusual, because some of the

6 patients are very difficult and would require the

7 dentist's expertise.

8 Q. As the attending physician, would you be

9 informed if the patient's teeth were cleaned?

10 A. Only if medication were required for sedation.

11 Q. Have you ever --

12 A. Or antibiotics, or something that involved an

13 order. But just routine cleanings that are done on a

14 routine basis, I'm not sure.

15 Q. I think you said earlier that you are not sure

16 if the State's regulation are not the same for nursing

17 home?

18 A. They are not. As far as the dental, I'm not

19 sure what their policy and procedure is. I know they

20 are not regulated by the State, so they are different.

21 Q. Has anyone at Hospice ever informed you that

22 Terry's teeth were cleaned?

23 A. No.

24 Q. Did you ever see a chart notation that Terry's

25 teeth were cleaned as a result of this examination in






133

1 2002?

2 A. No.

3 Q. Okay. You said here that they received a

4 report from the physical therapist suggesting the

5 viability of therapy for her?

6 A. That's correct.

7 Q. Has the physical therapist ever seen Terry?

8 A. Yes, the physical therapist has seen Terry.

9 Q. No. I'm talking about -- forgive me. I

10 confused you.

11 While she has been at Hospice, has a physical

12 therapist ever seen Terry?

13 MR. FELOS: Your Honor, I have got -- this may

14 be within the scope of cross-examination, but not

15 recross. The scope of recross are just new matters

16 that are brought up on redirect. I didn't bring up

17 any new matters on redirect.

18 MS. ANDERSON: He certainly did. That

19 particular item right there was on his item of

20 redirect.

21 MR. FELOS: That was not on the subject that

22 was redirect from cross-examination. Recross is

23 limited to new matters that I brought up.

24 THE COURT: Well, new matters aren't supposed

25 to be brought up in redirect. I'm giving both






134

1 sides fair latitude in this proceeding. I examine

2 that you certainly brought up physical therapy.

3 BY MS. ANDERSON:

4 Q. Let me make sure that we are communicating.

5 I'm speaking about Terry's time at Hospice.

6 A. Correct.

7 Q. Since she has been at Hospice, has she been

8 seen, and by seen, I mean evaluated by a physical

9 therapist?

10 A. I believe that she was seen for an evaluation

11 for therapy.

12 Q. Now, was she has not received any physical

13 therapy?

14 A. No.

15 Q. Okay. And the chart that I directed your

16 attention to earlier where you signed it and said that

17 the husband declined the evaluation, is that the second

18 evaluation?

19 MR. FELOS: Your Honor, if I can object. I

20 asked him a question on redirect about the husband

21 and physical therapy. That was a matter on

22 cross-examination. I didn't bring it up on

23 redirect. She is just cross-examining the witness

24 again.

25 MS. ANDERSON: He has opened the door about






135

1 this physical therapy by asking this question.

2 MR. FELOS: That does not open the door for

3 her repeating cross-examination.

4 THE COURT: Well, it's -- I'm going to give

5 her a little latitude, Mr. Felos. I am not going

6 to allow her to go right back through her

7 cross-examination, of course.

8 BY MS. ANDERSON:

9 Q. You are saying you think Terry was evaluated

10 by physical therapist when she came into the hospital?

11 A. Yes.

12 Q. And sometime after that you have this

13 conference in which the husband declined the evaluation

14 for physical therapy?

15 A. The note that you referred to were date

16 April 20, 1998, okay.

17 Q. Right.

18 A. And that's when I had indicated that after

19 speaking with Michael, he declined another evaluation.

20 That was not Hospice.

21 Q. Now, you said that she did have some

22 swallowing tests.

23 A. Yes.

24 Q. What year?

25 A. I don't recall the exact year.






136

1 Q. More than ten years ago?

2 A. Again, I don't recall the exact dates or times

3 so I'm not going to guess.

4 Q. You haven't ordered any swallowing tests,

5 though, in the last four, four-and-a-half years?

6 A. No. Now, she has been evaluated by a speech

7 therapist who did not recommend a swallowing test

8 because the bedside examination suggested she was high

9 risk for aspiration. That's why the tests were not

10 ordered.

11 Q. And there is a charted entry on that?

12 A. Yes.

13 Q. What's the date of that chart entry?

14 A. I would have to go back in the record and pull

15 it out.

16 Q. That was since she has been at Hospice?

17 A. The -- I definitely -- this was when she was

18 at the Gardens, and I don't believe it was revisited at

19 Hospice.

20 Q. Basically, she hasn't seen any therapists

21 since she has been at Hospice, right?

22 A. I can't answer that question.

23 Q. To your knowledge?

24 A. It's not -- it's not a matter of not seeing,

25 but did she receive therapy because evaluations are done






137

1 and screenings are done to see if someone will benefit

2 from therapy.

3 Q. Has she been evaluated?

4 A. Yes, she received evaluations.

5 Q. When she got to Hospice?

6 A. Yes.

7 Q. But she received no therapy since then?

8 A. Yes, that's correct.

9 Q. My last question, Doctor. The second

10 urinalysis that was just done, you know, was done

11 because Terry made complaints of pain. The nurses

12 called you or --

13 MR. FELOS: There was no testimony, Your

14 Honor, that Terry made complaints of pain.

15 THE COURT: Well, she can ask the question and

16 the witness may say yes or no depending upon the

17 question that she is entitled to frame.

18 BY MS. ANDERSON:

19 Q. And by complaints of pain, I'm talking about

20 her moaning.

21 A. What I can tell you is, first of all, it was

22 the nurse practitioner who was involved. So I wasn't

23 involved in some of this transmittal of information.

24 But beyond that, the complaint was of moaning. And the

25 nurse who reported the increase moaning felt there was a






138

1 change in condition that should be reported for a

2 medical evaluation. And after discussions with the

3 nurses, I found they were concerned about the feeding

4 tube, problems with the feeding tube. They had it

5 checked for connection problems. That was noted. And

6 then, after some adjustments in the tube, it did seem to

7 change the situation. And urine was collected and

8 infection was found.

9 Q. Well, somewhere along the line, some medically

10 trained person interpreted that change in her condition

11 as evidencing pain or discomfort, correct?

12 A. As a response to irritation in the bladder.

13 This moaning could be, you know, ideal with bringing

14 treatment for many causes. And in long-term care, the

15 various individuals may have different responses in her

16 care. Moaning suggested there was a change of

17 condition.

18 Q. That somebody interpreted as a pain response?

19 A. Yes, that was her interpretation.

20 MS. ANDERSON: That was my question. Thank

21 you.

22 No further questions, Your Honor.

23 THE COURT: Anything further of this witness?

24 MR. FELOS: No, Your Honor.

25 THE COURT: Thank you. Dr. Gambone, you may






139

1 stand down.

2 Okay. Anything further for us to pick up this

3 afternoon?

4 MS. ANDERSON: Not this afternoon, Your Honor.

5 THE COURT: Who would be your witness on

6 Monday.

7 MS. ANDERSON: Dr. Hammesfahr.

8 THE COURT: Due to the fact that we would

9 probably be playing the entire video of his

10 examination, would it be prudent to start it at

11 9:00.

12 MS. ANDERSON: It's entirely up to you, Judge.

13 Immaterial to me.

14 THE COURT: Well, I'm trying to be

15 accommodating to the lawyers.

16 MS. ANDERSON: Are we having the time change

17 this weekend?

18 THE COURT: No. I don't think so.

19 MS. ANDERSON: It's next weekend then.

20 THE COURT: Mr. Felos, what are your thoughts

21 about Monday?

22 MR. FELOS: Your Honor, if we are to see two

23 hours and 50 minutes of the videotape, it might be

24 a good idea to start a little bit earlier. If

25 Ms. Anderson has no objection, why don't we stand






140

1 in recess until 9:00 a.m. Monday morning.

2 I would like to enter Petitioner's Exhibits 3

3 and 4 that were accepted into evidence and also

4 introduce into evidence Petitioner's Exhibits 1 and

5 2 which were Dr. Gambone's Comprehensive Medical

6 Examination and the report.

7 MS. ANDERSON: Wait a minute. What are we

8 doing?

9 THE COURT: He is wishing to place Exhibits 3

10 and 4, which I have already received into evidence;

11 although, I don't have physical possession of them.

12 I was going to ask you about your Exhibit 12,

13 although I don't have physical possession of it.

14 MS. ANDERSON: It's in the book and copy that

15 Dr. Gambone testified from right there.

16 THE COURT: Do you wish me to have this copy?

17 MS. ANDERSON: Judge, the duplicates are in

18 the book. And for your convenience - so I can take

19 this copy back - if you wish, we could take the

20 ones in the notebooks as the official ones.

21 THE COURT: So let me have your Exhibits 3 and

22 4, which I have already received.

23 MR. FELOS: That's Exhibit 3, and I have to

24 locate 4, Your Honor.

25 MS. ANDERSON: Judge, you have admitted






141

1 Petitioner's 3 and 4.

2 THE COURT: Yes, ma'am, and your 12. Now

3 Mr. Felos wishes also, at this time, to introduce

4 Petitioner's Exhibits 1 and 2, which I believe he

5 said Dr. Gambone had identified.

6 MR. FELOS: Yes, his Comprehensive Medical

7 Evaluation of the results of the recent health

8 screening.

9 THE COURT: Is there an objection?

10 MS. ANDERSON: I have no objection to their

11 coming in.

12 THE COURT: Thank you.

13 (Whereupon, the document referred to was

14 received in evidence as Petitioner's Exhibit Numbers 1

15 and 2.)

16 THE COURT: Okay. Anything further?

17 MR. FELOS: No, Your Honor.

18 THE COURT: All right.

19 MS. ANDERSON: Will this room be secured over

20 the weekend or no?

21 THE COURT: My guess is nobody is going to

22 leave anything anyway. Are you? I'm talking about

23 your files.

24 MS. ANDERSON: No. I will take the files out

25 of the courtroom.






142

1 THE COURT: You are going to take yours?

2 MR. FELOS: Yes.

3 THE COURT: I will take mine, also. Until

4 9:00 a.m. on Monday.

5 THEREUPON, the hearing terminated until
9:00

6 a.m. Monday morning.

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25






143

1 CERTIFICATE OF REPORTER

2 STATE OF FLORIDA )

3 COUNTY OF PINELLAS)

4 I, TONYA H. MAGEE, RPR, Registered Professional
Reporter, Notary Public, State of Florida at Large:
5
DO HEREBY CERTIFY that the foregoing proceedings
6 were taken before me at the time and place set forth
in the caption thereof; the proceedings were
7 stenographically reported by me in shorthand, and the
foregoing pages, numbered 1 through 142 inclusive,
8 constitute a true and correct transcript of my said
stenographic notes.
9
I further certify that I am not a relative,
10 employee, attorney, or counsel of any of the parties,
nor relative or employee of such attorney or counsel,
11 nor financially interested in the outcome of the
foregoing action.
12

13 IN WITNESS WHEREOF, I have hereunto affixed my
official signature this 23rd day of January, 2003,
14 at Clearwater, Pinellas County, Florida.

15 _________________________
TONYA H. MAGEE, RPR
16 Court Reporter and
Notary Public, State of
Florida
17

18 Acknowledged before the undersigned
this day of January, 2003,
19 by Tonya H. Magee, who is personally
known to me.
20
_______________________________
21 Notary Public, State of Florida

22

23

24

25






144

1

2 IN THE CIRCUIT COURT OF THE
SIXTH JUDICIAL CIRCUIT IN AND FOR
3 PINELLAS COUNTY, FLORIDA
PROBATE DIVISION
4

5 IN RE: THE GUARDIANSHIP OF File No.90-2908-
GD-003
THERESA MARIE SCHIAVO,
6 Incapacitated. APPEAL
___________________________________// VOLUME II
7
MICHAEL SCHIAVO, as Guardian of the
8 person of THERESA MARIE SCHIAVO,

9 Petitioner/Appellee,

10 vs.

11 ROBERT SCHINDLER and MARY SCHINDLER,

12 Respondents/Appellants.
________________________________________________//
13

14 BEFORE: The Honorable GEORGE W. GREER

15 PLACE: Pinellas County Courthouse
315 Court Street North
16 Clearwater, Florida

17 DATE: October 14, 2002

18 TIME: Morning Session

19 REPORTED BY: TONYA H. MAGEE, RPR
Court Reporter and Notary
Public
20 Sixth Judicial Circuit
___________________________________________
21
HEARING
22 ___________________________________________

23 Pages 144 - 273

24 ROBERT A. DEMPSTER & ASSOCIATES
P.O. BOX 35
25 CLEARWATER, FLORIDA 34618-0035
(727) 443-0992






145

1 A P P E A R A N C E S:

2

3 GEORGE J. FELOS, ESQUIRE
595 Main Street
4 Dunedin, Florida 34698

5 Attorney for the Petitioner/Appellee.

6

7

8 PATRICIA FIELDS ANDERSON, ESQUIRE
447 Third Avenue North, Suite 405
9 St. Petersburg, Florida 33701

10 Attorney for the Respondents/Appellants.

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25






146

1

2 P R O C E E D I N G S

3 THE COURT: Yes, ma'am?

4 MS. ANDERSON: Are you ready?

5 THE COURT: Yes, sir.

6 MS. ANDERSON: The Respondents call Dr.

7 William Hammesfahr.

8 MR. FELOS: Your Honor, before we take

9 testimony, I want to address something.

10 THE COURT: Very well, Mr. Felos.

11 MR. FELOS: Your Honor, before we embark on

12 today's adventure, I'm a little concerned about the

13 timing, and I think it would be wise and helpful to

14 have a little blueprint.

15 As the Court knows, under the unique situation

16 of this proceeding, we have one day allocated for

17 each physician. It's my understanding that we're

18 going to be seeing the entirety of Dr. Hammesfahr's

19 examination, which was two hours 50 minutes, on the

20 second day. I believe Dr. Maxfield was there on

21 the next day and so was Dr. Hammesfahr. That was

22 an extra 40 minutes. That's part of his

23 examination. We may be seeing three-and-a-half

24 hours of tape.

25 Of course, I'm sure we will not be seeing it

147

1 continuous; the tape is going to break, questions

2 are going to be asked. I think it would be

3 extremely unfair to the Petitioner to turn over

4 cross-examination at seven or eight o'clock tonight

5 when you have had eight or nine hours taken on

6 direct examination.

7 I think before we start, perhaps we can hear

8 how long the expected direct examination will be

9 and get a little idea of how we're going to proceed

10 time-wise today. I just don't think it's fair to

11 have nine or ten hours of direct and redirect

12 examination, which leaves me only a couple hours of

13 cross-examination sometime in the wee hours.

14 THE COURT: I thought we had this discussion a

15 few days ago.

16 MS. ANDERSON: Now, if it helps the Court --

17 we did, Your Honor. We did discuss this. If it

18 helps, Dr. Maxfield will be testifying tomorrow and

19 I do not expect his testimony to be as lengthy.

20 But I do predict turning Dr. Hammesfahr over to

21 Mr. Felos for cross-examination sometime probably

22 mid afternoon. He'll have time for cross.

23 MR. FELOS: Mid afternoon would be -- that's

24 fine. I just didn't want to find myself here at

25 eight o'clock at night starting my






148

1 cross-examination.

2 THE COURT: All right. Dr. Hammesfahr.

3 THE BAILIFF: Stand here, if you would, sir,

4 face the judge and take your oath.

5 THE COURT: Do you solemnly swear the

6 testimony you will give in this cause will be the

7 truth, the whole truth, and nothing but the truth

8 so help you God?

9 THE WITNESS: I do.

10 THE COURT: Thank you, sir.

11 THE BAILIFF: Thank you. Have a seat, please.

12 Please, speak in a loud clear voice for the court.

13 MS. ANDERSON: Your Honor, may I approach the

14 witness and give him a bottle of water?

15 THE COURT: Sure.

16 DIRECT EXAMINATION

17 BY MS. ANDERSON:

18 Q. Dr. Hammesfahr, would you state your name and

19 spell your last name for the benefit of the court

20 reporter, please.

21 A. William Hammesfahr, H-A-M-M-E-S-F-A-H-R.

22 Q. Would you tell the court briefly about your

23 education.

24 A. Was accepted to medical school directly from

25 high school as part of the Northwestern Honors Program






149

1 of Medical Education, six-year medical program in which

2 we did two years of undergraduate medical work followed

3 by four years of medical school.

4 Q. When did you enter Northwestern Medical

5 School?

6 A. I entered in 1976. I graduated in 1982. From

7 there I went into training for neurosurgery and

8 neurology at Medical College of Virginia. I trained in

9 neurosurgery and neurology until approximately 1988.

10 The position including C-level positions in neurosurgery

11 as well as neurology.

12 I underwent fellowship training in EEGs at the

13 same time and also Transcranial Doppler examinations at

14 the same time.

15 Q. Is that part of your post-residency training

16 in EEG and Transcranial Doppler?

17 A. No. It was done as part of my residency

18 training because I was in both departments and we worked

19 together for much of the time. In neurosurgery we would

20 work close with neurology and vice versa. When I went

21 into neurology, I had the freedom to do post-residency

22 training work in addition to my residency duties in

23 neurology.

24 Q. And so you left the medical college in

25 Virginia in 1988 when you completed that training?






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1 A. Correct.

2 Q. Is that associated with the any university?

3 A. It is the Medical College of Virginia, which

4 is associated with Virginia Commonwealth University in

5 Richmond, Virginia.

6 Q. Are you board certified in any area of

7 medicine?

8 A. I'm board certified in pain management as well

9 as in neurology.

10 Q. Are you licensed to practice in your area of

11 specialty?

12 A. I am licensed to practice medicine in Virginia

13 and California and Florida.

14 Q. Are you presently in practice?

15 A. Yes, I am.

16 Q. Where are you in practice?

17 A. In Clearwater, Florida.

18 Q. Now, have you lectured in any field of

19 neurology?

20 A. Yes, I have.

21 Q. On what topics have you lectured?

22 A. I have lectured on spinal injuries, brain

23 injuries, stroke and mistreatment, vascular injuries of

24 the brain and mistreatment, the use of Transcranial

25 Doppler to guide therapy, and the use of computerized






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1 EEGs to guide therapy. That's the bulk of the

2 treatments, with certain minor variations. Some dealing

3 with case studies and some dealing with stroke

4 prevention crisis.

5 Q. Now, have you ever given any lectures for

6 which the attendees were awarded continuing medical

7 education credits?

8 A. Yes, I have.

9 Q. How many times?

10 A. I'm not sure. I have done it many times.

11 Q. Do you recall where?

12 A. Well, I have given it at the National Practice

13 Update Convention in Orlando. I believe that was two

14 years ago. I have given it at Family College

15 Osteopathic Practices Convention, state of Florida,

16 several times. Each of those were generally two to four

17 hours lectures. I have given it at the University of

18 Florida. I have given it at a series of other major

19 universities.

20 I have done several national conventions

21 including applied autonomic disorders, reflex sympathy

22 disorders and also International Hyperbaric Conference

23 that deals with cerebral palsy and treating cerebral

24 palsy.

25 Q. In the course of your practice, have you ever






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1 been invited to be a research grantee for the United

2 States Department of Education?

3 A. Yes, I have.

4 Q. Do you recall -- how long did you do that?

5 A. Well, I believe I'm still on the list;

6 although, I think they have dissolved that committee

7 over the last couple years. I was first on the list, I

8 think, around -- I'm not sure. In the early or mid 90s.

9 Q. Did you actually conduct random studies?

10 A. Yes, I did.

11 Q. Do you have any specialized knowledge in some

12 particular aspect of neurology?

13 A. My area of specialty is brain injury and

14 vascular diseases. Historically, it's also involved

15 pain management and also the use of ultrasound and

16 electronic monitoring of the nervous system.

17 Q. During the course of your practice, have you

18 ever had occasion to treat patients diagnosed with

19 anoxic encephalopathy?

20 A. Yes, I have.

21 Q. Can you estimate how many?

22 A. Probably about 100 that were treated for

23 technique. Before that, I have treated many over the

24 course of the years prior to using vasodilators with

25 these types of patients, but I'm not really exactly






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1 sure, you know, how many that is. It may be more.

2 Q. What does anoxic mean?

3 A. Anoxic means without oxygen.

4 Q. And how does that differ from hypoxic?

5 A. Well, it really doesn't differ from hypoxic.

6 Anoxia and hypoxic encephalopathy both deal with the

7 difficulty of getting oxygen to the brain, so there is

8 really no major difference with respect to the pathology

9 that occurs with the brain itself.

10 Q. Encephalopathy means what?

11 A. Encephalopathy means disorder or disease of

12 the brain.

13 Q. So anoxic encephalopathy does not tell you

14 what structures in the brain have been affected or

15 damaged, correct?

16 A. It's a general term. So anoxic suggests there

17 has been a lack of oxygenation of the brain for whatever

18 reason. That can be due to carbon monoxide poisoning,

19 where a person inhales a gas other than oxygen. Or, it

20 could be something like a cardiac arrest or lack of

21 blood flow to the brain.

22 Hypoxic encephalopathy is really essentially

23 the same thing. Hypoxic encephalopathy generally means

24 that diffusely in the brain, the brain has been injured.

25 So it tends not to be localized to one specific point,






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1 although, injuries can be very severe, affect the entire

2 brain, or a very minor and swollen areas.

3 Q. And would those both be called encephalopathy?

4 A. Yes, they would. Encephalopathy correlates to

5 a diffuse injury. You could have widespread diffuse

6 injury or more localized areas, but patterned throughout

7 the brain diffusely.

8 Q. Now, have you also had occasion through the

9 course of your practice to treat patients who have

10 suffered stroke?

11 A. Yes, I have.

12 Q. How many?

13 A. Well, again, that's tough to answer. Most of

14 my work from about 1995 has been dealing with the use of

15 vasodilators and stroke patients. So from that time, I

16 would estimate two to 3,000 patients. Slightly more, if

17 possible.

18 Before that we treated a lot of stroke

19 patients through the emergency room or through general

20 referrals or in hospitals where stroke is a common

21 disorder.

22 Q. Is stroke linked in any way to a heart attack?

23 A. Stroke can be linked to heart attacks, yes.

24 Q. How could it been linked?

25 A. There are two main mechanisms that a stroke is






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1 linked to heart attacks. The first is that after a

2 heart attack, the heart is damaged. Small blood clots

3 forming can break off and cause injuries to one or many

4 different blood vessels in damage the brain tissues from

5 those blood vessels.

6 Q. Would that be called an embolic stroke?

7 A. That's usually called an embolic stroke, yes.

8 Q. Caused by a brain embolism?

9 A. Right. An embolism, being a small clot that

10 has gone off to the brain.

11 The second type of a stroke that tends to

12 occur is when you have a drop of blood pressure that is

13 sudden and beyond the ability of the body to compensate.

14 That causes a lack of blood flow to the brain, and that

15 lack of blood flow results in anoxia or hypoxia to the

16 brain or lack of oxygen delivered to the brain, which

17 causes brain injury.

18 Q. When you say "lack of oxygen" or a reduced

19 amount of oxygen to the brain causes injury, what does

20 the brain do? How does that injury manifest itself?

21 A. Well, in all strokes from any cause, whether

22 it's from cardiac arrest or it's from anoxia or hypoxia

23 or a drowning, in all strokes common things happen. The

24 first thing that happens is you have a lack of oxygen

25 delivered to the tissue. That itself causes damage to






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1 the tissue.

2 Q. What happens? Does it shrivel up?

3 A. Different areas of the brain, different things

4 happen in it. Certain areas of the brain are more

5 sensitive to lack of blood flow than other areas of the

6 brain, or lack of oxygen. So those would be injured

7 first. There is going to be areas to the brain that are

8 injured more and areas to the brain that are injured

9 less in these types of episodes.

10 Q. What are the more sensitive structures in the

11 brain with regard to blood flow?

12 A. The more sensitive areas are areas that deal

13 with memory and concentration. And then the cortex of

14 the brain in the cerebral hemispheres are less

15 sensitive. Areas that deal with communication are more

16 sensitive than areas that deal with strength. But they

17 have -- they are various different scenarios in these

18 different areas. Then what happens is that that tissue

19 itself may die. Other areas of the tissue become

20 injured and may be able to survive. And then other

21 areas will sort of go into hibernating state and other

22 areas will continue to function.

23 Then, the second thing that happens is the

24 blood vessels. The blood vessels leading to that area

25 can be damaged just like the nerves can be damaged.






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1 When the blood vessels become injured, they narrow or

2 constrict and they try to stay narrow and constricted.

3 There's a loss of normal blood flow, normal vascular

4 function, which means that the blood vessels starve the

5 brain of oxygen.

6 In the normal person, there's something called

7 autoregulation, where the blood vessels will try to open

8 up again or open up at certain times.

9 Q. Is that autoregulation the body's attempt to

10 overcome this infection?

11 A. Yes, it is. But in the injured brain, you

12 lose autoregulation. So these blood vessels don't tend

13 to open back up, nor do they tend to compensate properly

14 for poor blood flow to the area. And once the blood

15 vessels become injured, then tend to say narrow.

16 Q. The blood vessels themselves?

17 A. The bloods vessels themselves.

18 Q. Now, have you devised a therapy to expand

19 those blood vessels?

20 A. Yes, I have.

21 Q. And can you tell the court, in brief, what

22 that therapy consists of.

23 A. Well, the therapy really consists of standard,

24 time-tested, and long-term understandings of the blood

25 vessels and how they respond and how to treat them.






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1 It's well understood these blood vessel disorders that

2 arise after an injury exit. They have been identified

3 in cardio disease. They have been identified in stroke

4 and brain injury. They have been identified in skin

5 injuries, kidney injuries, everywhere in the body.

6 The principles of what I talked about, as far

7 as injury, are well identified and well observed over

8 the last 50 to 100 years.

9 Q. And is there anything special about blood

10 vessels in the brain as opposed to other parts of the

11 body?

12 A. Well, the blood vessels in the brain are

13 slightly different than -- the blood vessels themselves

14 are not different from elsewhere in the body, but there

15 are some unique characteristics to the brain that has

16 made this standard application of vasodilators to the

17 brain more difficult.

18 Q. What are those differences?

19 A. There are really several differences. The

20 first one is that there is something called the blood

21 brain barrier, which is a chemical sheeting or coating

22 around blood vessels that tends to prevent medications

23 from going into the tissue and then affecting the blood

24 vessels from the outside of the tissue.

25 Q. So if you would administer the patient






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1 medication with a shot, the blood brain barrier would

2 prevent the medication from reaching the brain tissue?

3 A. That has been the thought over the last 30 or

4 40 years that that's what's happening.

5 Q. And how did you get around this problem, if

6 you were able to get around it?

7 A. Well, we actually made a very unusual and odd

8 observation about 1994, and that was that we had an

9 large number of patients with brain injuries that were

10 part of my practice. We also had what was then and

11 still is very new technology in the office. Several

12 types of new technology. But for these purposes, what

13 turned out to be most important was a special type of

14 ultrasound that looks at the blood vessel diameter

15 inside of the brain.

16 Up until 1994, it was thought there weren't

17 many medications that could actually affect the blood

18 vessels inside of the brain other than medication that

19 narrowed blood vessels due to the oxygenation after

20 stroke patients.

21 Q. Did you determine that your patients were

22 victims of cerebral vasospasm?

23 A. It was thought that these patients -- that

24 many of these patients had a brain injury but that they

25 also had vasospasm on their examination, yes. And the






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1 reason for that was that they had severe migraines.

2 Q. How did a migraine related to vasospasm?

3 A. Patients with chronic migraines after an

4 accident with brain injury, what happens in a migraine

5 is blood vessels constrict. When it constricts to a

6 very high rate, other blood vessels may actually dilate

7 and it could cause the pain of a headache.

8 Q. Why would another area dilate?

9 A. Back in 1994, the understanding of a migraine

10 was that a blood vessel would constrict, pinning off

11 some of the blood flow to the brain, then the brain

12 would release carbon monoxide around the area of the

13 blood vessel and that would cause the blood vessel to

14 dilate.

15 When the blood vessel would dilate more than

16 it was necessary to compensate for the lack of blood

17 flow to the area and that overdilation causes headache.

18 So what would happened was medications that were

19 designed to treat migraine were designed to make the

20 blood vessel narrow and cut down the pain.

21 Q. So the conventional treatment therapy for

22 migraine back in 1994 was to use vaso-constricting

23 drugs?

24 A. Correct.

25 Q. And you noticed in your patients this unusual






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1 phenomenon of migraines plus brain injury; is that what

2 happened?

3 A. Correct. What happened was we had a series of

4 patients. I did a lot of work for Social Security and I

5 also did a lot of work for people involved in severe

6 auto accidents. So there was long before treatment, an

7 evaluation stage they had gone on for many years.

8 Patient with Social Security were disabled for over one

9 year and were expected to be permanently disabled for me

10 to treat them.

11 What we found is that a lot of these patients

12 had migraines or partial paralysis or weaknesses and

13 balance problems and memory problems. We tried to find

14 a new technique to control their headache. Not new to

15 me, but, rather, there were a series of anti-migraine

16 medications, like Imitrex, that had just come to

17 market.

18 Q. Now, were those vasodilators?

19 A. These are vasoconstrictors. Now, these

20 patients who are on Social Security for chronic

21 migraines or brain injuries for up to 17 years, and they

22 have tried a lot of different medications. So at that

23 time I didn't think any of the new medications coming

24 out would treat their headaches. Rather, what I thought

25 we would do is monitor a series of these patients with






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1 different testing techniques, try out different

2 medications on them while being monitored. And we would

3 identify the proof that might be seen on one set of

4 tests and the proof that might be seen in some patients

5 in other tests, we would then generate a cocktail.

6 Q. What do you mean by "cocktail?"

7 A. In medicine, it's common when you deal with

8 patients who are having very severe problems to use two

9 or three or four medications in that patient to treat

10 the medical problem. No single medication will do the

11 trick, so you have to try to use several different

12 medications.

13 Q. In conjunction, you mean?

14 A. In conjunction, correct. We actually see that

15 in a lot of blood pressure medicines and cardiology

16 medicines where there will be two or three medicines

17 combined in a single pill.

18 Q. And your reason for devising this cocktail was

19 what?

20 A. To stop pain.

21 Q. By dilating the vessels?

22 A. No. It was to stop pain by trying to find

23 medications that would stop these people's pains. It

24 was not to dilate the blood vessel, because the standard

25 thinking at that time was that the blood vessel






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1 constricted and it later expanded and caused the

2 headache. So what we were seeing, in theory, was that

3 the blood vessels were already dilated at the time of

4 the migraine and causing the headache. So, we were

5 looking for only pain relief.

6 Q. So by the time the pain manifests itself, the

7 thinking at the time was the blood vessels were already

8 compensated and dilated?

9 A. Correct.

10 Q. So when you try these cocktails, what did you

11 discover?

12 A. Well, we never got to a cocktail. What

13 happened was we had six patients in our office at one

14 time, gave them Imitrex. Another six get a new medicine

15 called Toradol.

16 Q. Toradol?

17 A. Yes. It's T-O-R-D-A-L.

18 We use medicine that have very short onset of

19 action and they use patients who are very severely

20 disabled from the brain injuries and need help walking

21 to get to the exam table or testing table or they would

22 need to be brought in in a wheelchair.

23 Q. Was there speech discernible?

24 A. Many of them had severe difficulty speaking.

25 Many had severe weakness in one arm or leg. They had






164

1 balance problems where they couldn't walk unassisted;

2 they would fall into walls when they were walking.

3 Something of that nature.

4 Most of them are had neuropsychology tests

5 done on them before us for many years documenting severe

6 brain injuries. If you spoke to them and gave them

7 instructions, sometimes they wouldn't understand these

8 instructions when it came to caregivers.

9 Q. What happened when you began -- well, first of

10 all, how did you decide to treat these patients?

11 A. Well, what we did was put them on a monitor,

12 electronic monitor with evoked potential, or EEGs,

13 computerized EEGs, or Transcranial Doppler, and gave

14 them the medicine, the Imitrex or Toradol.

15 Q. When you say you had them on a monitor, you

16 had them hooked up on the machine and gave them the

17 drugs?

18 A. Correct.

19 Q. What was the purpose of that?

20 A. Well, this is typically a standard technique.

21 Again, my background was extensively surgery in the

22 intensive care unit and medicine. In this fields, it's

23 common to monitoring ongoing monitoring of the patient

24 or serial monitoring the patient with technology to help

25 to give you an indication early on whether or not having






165

1 proven that from a technique that you are applying to

2 that patient.

3 Q. And you would be able to tell that from the

4 monitor and device that you're using?

5 A. Sure. This is just like using an EKG monitor

6 in the emergency room or in an ICU. You might have a

7 blood oxygen monitor as well as an EKG monitor as well

8 as a blood pressure monitor. The idea of monitoring the

9 medication's effect is the standard part of the medicine

10 when you have to deal with customizing doses and also

11 trying to look what you're trying to deal with, the

12 effect of.

13 Q. So what happened?

14 A. Well, the patients who had Imitrex, we gave

15 them the medicine, we watched them, and their blood

16 vessels constricted just like which thought and

17 understood Imitrex should work. The patients with head

18 injuries, they became very confused. And

19 neurologically, they worsened.

20 Q. And what did you do for them?

21 A. That's what we expected from Imitrex.

22 Imitrex, in fact, has had a lot of research since then

23 that talks about -- that wasn't around at the time, that

24 talks about the narrowing of the blood vessels and

25 patients with heart disease, Imitrex can actually put






166

1 them into a heart attack.

2 So we got what we expected. We saw the

3 ultrasound that showed further narrowing. The headache

4 did go away quite dramatically, so that was a very

5 effective tool. But they frequently got worse in

6 minutes. They had trouble to where they couldn't get

7 onto the table and couldn't get off the table without

8 having help. They returned from normal to not normal.

9 Q. And, then, what did you decide to do?

10 A. Well, we also gave Toradol on the same day to

11 other patients. Again, this is the using the same kind

12 of monitoring. Toradol, at that time, was a shot, so it

13 had very rapid action. Toradol did something very

14 unexpected.

15 Q. What was that?

16 A. What it did was it relieved the headache

17 entirely, but it did it through a different mechanism

18 than Imitrex, which had never been reported before. The

19 mechanism was that it made the blood vessels dilate

20 inside of the brain.

21 Q. So this initial set of patients, you used a

22 vasoconstrictor among one group of patients. And on the

23 same day gave the other group of patients a vasodilator.

24 A. Correct. But that's not what we meant to do.

25 Toradol wasn't known to be a vasodilator at the time we






167

1 gave it. It was known to be a medicine like Motrin, a

2 anti-headache medicine. It was not thought to be a

3 vasodilator.

4 Q. So you had this unexpected result. And how

5 did you proceed?

6 A. Well, it was unexpected. It meant that if

7 this -- it meant that even if Toradol worked by

8 vasodilating or Toradol had a different mechanism of

9 acting, we then went to a second set of categories of

10 medicine, which were vasoconstrictors on one side, like

11 Imitrex, and were standard anti-migraine medicines,

12 Ergotamines, E-R-G-O-T-A-M-I-N-E-S, caffein. It is a

13 series of very strong, very short-acting medications

14 that are used to constrict blood vessels and relieve

15 migraines, commonly.

16 On the other hand, we used some very

17 short-acting vasodilators that were known to be

18 vasodilators for patients. We got the same exact same

19 results all over again.

20 Q. The what results?

21 A. We got the same results that we got with the

22 first one. Within ten or 15 minutes, those given the

23 vasoconstrictor, the headaches would leave. The

24 Transcranial Doppler would show worsening, meaning more

25 narrowing of the constriction, which is the understood






168

1 mechanism of how these medicines worked. The headache

2 went away, but the patient, in front of us,

3 deteriorated. They would develop abnormal reflexes,

4 balance problems, thinking problems. They were quite

5 dramatic.

6 Q. And what happened with the vasodilation

7 patients?

8 A. With the other group, we had an equally

9 dramatic effect. The ultrasound, again, showed

10 dilation of the blood vessels. The patients themselves

11 had a dramatic improvement. They would eventually clear

12 up in front of you. They could understand and follow

13 commands, which they had troubling doing before. They

14 could get up and down from chairs.

15 We do a test, which is standard in neurology,

16 called a Romberg and Tandem Gait. A Romberg examination

17 is where a person stands at attention with their heels

18 and toes together and closes their eyes. You

19 essentially see how their balance is. It's a sign of

20 neurological injury for those who sway and have balance

21 problems.

22 The other test that goes with that is a tandem

23 gait. A tandem gait is what the police officers use for

24 drunk driving tests where you have a person walking a

25 straight line. These persons, prior to getting the






169

1 vasodilator, could not do that. When they got the

2 vasodilator, 15 to 20 minutes later, were able to do

3 those tests, for the most part, without difficulty,

4 being able to walk around unassisted. Then, when they

5 eventually wore off, the ultrasound, again, worsened.

6 They couldn't do those tests again.

7 The same thing happened with the Imitrex group

8 and vasoconstrictors. They couldn't do it. When they

9 started, it got worse and then returned to their

10 baseline as the medication wore off.

11 Q. Over the years -- this happened in '94?

12 A. Yes. So this meant that you have migraine, in

13 at least these patients, was not correct. What was

14 really happening was that the migraine was more like a

15 heart attack.

16 In a heart attack, the beginning of a heart

17 attack, the patient has a narrowing in the blood

18 vessels. And the blood vessels downstream dilate to try

19 to make a vacuum to pull blood through that narrow area.

20 Q. As the bottom overcoming the narrowing?

21 A. Correct. In that heart attack, the dilation

22 causes pain, chest pain. What you do with those

23 patients is give them a vasodilator, nitroglycerin, and

24 the pain goes away. As the blockage opens up, the

25 downstream areas dilate to compensate to return to






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1 normal size. As they return to normal size, the pain

2 goes away.

3 When we use nitroglycerin on these brain

4 injured patients, we saw the same phenomenon happen. As

5 in Toradol or other vasodilators, we saw proof: The

6 heart attack patient started feeling brief better; we

7 saw the pain go away; we saw the neurological exam

8 improve.

9 Q. How, over the years, have you refined this

10 technique?

11 A. Well, mainly by very close observation of

12 patients, serial observations of patient.

13 Q. Serial observation of patients?

14 A. Observing patients for long periods of time

15 both in the office as well as months and years down the

16 road.

17 Eventually, there have been new medications

18 that have also come out. This technique has allowed us

19 to identify these medicines easily and to use them with

20 patient --

21 Q. Now, what is the -- what does the term

22 Kenombra mean with regard to blood flow to the brain?

23 A. Kenombra is an old concept, a scientific

24 concept that was first seen in wound healing, but it's

25 been seen -- as technology's gotten more sophisticated,






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1 it's been seen in every organ. It's the body's common

2 response to injury of any form. That response is that

3 you get different areas of brain tissue or heart tissue

4 or skin tissue, have different degrees of injury. The

5 areas farthest away from the site of the injury are the

6 least damaged. Sometimes they are not even damaged at

7 all, but they are thrown into a hibernating stage.

8 Areas closest to the site of the injury or at

9 the site of the area may be dead. And seeing everything

10 from hibernating tissues or even normal tissue -- you

11 know, normal tissue by definition is normal tissue

12 outside of the area damage. Everything from hibernating

13 tissue to undamaged tissue, a tissue which, for some

14 reason, cannot carry out its normal functions; either

15 there is not enough blood flow into the area for it to

16 have the energy to carry out its normal function or

17 there's been some other injured area of problem, lack of

18 glucose or sugar or protein, whatever. So its

19 undamaged cells, not active cells, not functioning

20 active cells carrying out what they are designed to do

21 all the way into the deeper areas where you actually

22 have deadened areas.

23 Q. Now, has your technique or method of treating

24 patients resulted in any insight on your part in any

25 number?