Dr. Walker's Deposition on Bone Scan -- 11/21/2003

1 IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT OF THE STATE OF FLORIDA IN AND FOR PINELLAS COUNTY PROBATE ACTION

RICHARD LEE REPORTING Registered Professional Reporters (813) 229-1588 TAMPA: email: rlr@fdn.com ST. PETERSBURG: 501 East Jackson Street, Suite 200 535 Central Avenue Tampa, Florida 33602 St. Petersburg, Florida 33701 2 APPEARANCES:

PATRICIA FIELDS ANDERSON, ESQUIRE Patricia Fields Anderson, P.A. 447 Third Avenue Suite 405 St. Petersburg, Florida 33701 Appeared for Petitioners

SCOTT P. SWOPE, J.D., ESQUIRE Merricks, Hale & Swope, P.A. 2450 Sunset Point Road Suite D Clearwater, Florida 33765 Appeared for Respondent

Examination by Ms. Anderson 3 Examination by Mr. Swope 35 Examination by Ms. Anderson 64 Examination by Mr. Swope 66 Examination by Ms. Anderson 67

5 Mediplex Rehab - Bradenton Monthly Summary dated February 15, 1991 - March 15, 1991 46

3 1 The deposition, upon oral examination, of 2 WILLIAM CAMPBELL WALKER, M.D., taken by counsel for 3 Petitioner, on the 21st day of November 2003, at 311 4 Rye Road East, Bradenton, Florida, beginning at 9:40 5 a.m., before Sherry L. Frain, Notary Public, State 6 of Florida at Large. 7 * * * * * * * * * * 8 WILLIAM CAMPBELL WALKER, M.D., 9 having been duly sworn to tell the truth, the whole 10 truth, and nothing but the truth, was examined and 11 testified as follows: 12 EXAMINATION 13 BY MS. ANDERSON: 14 Q Would you state your name, please, for 15 the record? 16 A It's William Campbell Walker. 17 Q And, Dr. Walker, would you briefly state 18 your educational background for me? 19 A Well, I went to the University of South 20 Florida, College of Medicine, and did my internship 21 and residency at University of South Florida 22 affiliated hospitals and became a board-certified 23 radiologist in 1980 in diagnostic radiology. 24 Q What year did you get your medical 25 degree? 4 1 A It would have been '76, I believe. I 2 gave a copy of the CV to the court reporter. 3 MS. ANDERSON: Why don't we mark that, 4 then, and attach the CV as Exhibit 1? 5 (Exhibit 1 marked for identification.) 6 Q Dr. Walker, after you finished your 7 internship and residency, where did you go to work? 8 A I went to work at Manatee Memorial 9 Hospital. 10 Q How long did you work there? 11 A From 1980 to June of this year. 12 Q June of 2003? 13 A Correct. 14 Q How does diagnostic radiology differ from 15 other types of radiology? 16 A Well, there initially were two classes of 17 radiologists. There were therapeutic radiologists 18 who provided radiotherapy treatment for cancer, and 19 then there was diagnostic radiology, which 20 encompassed all the other branches, specifically 21 utilizing the imaging studies to detect the presence 22 or absence of disease. 23 Recently there's been yet another 24 subcategory called interventional radiology, which 25 is sort of a cross between surgery and radiology. 5 1 And those radiologists do therapeutic kinds of 2 things to patients; open blocked arteries, for 3 example. 4 Q Using -- 5 A Little balloons and metal stents 6 typically. 7 Q That's done by radiologists? 8 A Well, it's done by radiology, it's done 9 by general surgery, and it's done by cardiology. So 10 it's sort of a turf war there. 11 Q Is that subspecialty an area that is 12 subject to board certification? 13 A There isn't a specific interventional 14 board that I'm aware of. There is an area of 15 expertise in interventional radiology which you can 16 get. 17 Q Dr. Walker, in the course of your duties 18 at Manatee Memorial Hospital, did you have occasion 19 to prepare a bone-scan report dated March 5th, 1991? 20 A When you pointed that out to me, yes, I 21 did. 22 Q You have no independent recollection of 23 this report? 24 A I do not. 25 MS. ANDERSON: Let's have a copy of the 6 1 report marked as Exhibit 2. 2 (Exhibit 2 marked for identification.) 3 MR. SWOPE: May I see that after it's 4 marked? 5 Q I want to go over this in some detail 6 with you, if we can. I have a lot of questions 7 about it. 8 A Certainly. 9 Q There are two sets of initials down at 10 the bottom. Do you see those? 11 A Yes, I do. 12 Q Is one of those sets your initials? 13 A No. 14 Q Do you know whose initials they are? 15 A Well, the one set appears to be "FH," 16 which would be Florence Heimberg, who was an 17 associate of mine at that time. 18 Q Was she a radiologist? 19 A Yes. 20 Q How do you spell her last name? 21 A H-e-i-m-b-e-r-g. 22 Q And would that be the top or bottom set 23 of initials? 24 A That would be the top set. 25 Q Do you know where Dr. Heimberg is today? 7 1 A Yes, I do. 2 Q Where is she? 3 A She is employed by another radiology 4 group in Bradenton and works at several different 5 hospitals and clinics in this area. 6 Q What is the name of her radiology group? 7 A It used to be called Baron and 8 Stoutamyer, but they've gone through some changes. 9 I think it's Stratos. 10 Q S-t-r-a-t-o-s? 11 A Yes. Stratos and some other names after 12 that. They were based out of Blake Hospital. 13 Q Blake? 14 A Yes. 15 Q Do you recognize the bottom set of 16 initials? 17 A I do not. 18 Q At this time, were you the head of 19 radiology at Manatee Memorial? 20 A Not at this time. 21 Q What would the significance of Dr. 22 Heimberg's initials being on there be? 23 A Well, it's customary for someone to 24 review and sign the report before it becomes 25 official. 8 1 Q Is this your report, then countersigned 2 by Dr. Heimberg? 3 A As best I can recollect from that time 4 period. It's not impossible that it could be the 5 wrong signature attached. It's happened before, but 6 I doubt it, because that sounds like my format of a 7 report. 8 Q Typically if your name were typed at the 9 bottom as it is here, W. Campbell Walker, M.D., 10 would that indicate that this is a report that you 11 have dictated? 12 A Typically, unless, as I mentioned, the 13 transcriptionist appended the wrong name, which has 14 happened, because they have in their computer system 15 a button for each doctor's signature, and sometimes 16 they hit the wrong button. But I would say, again, 17 based on the format -- because we all have our own 18 dictating style -- that sounds like my dictating 19 style. 20 Q There's nothing in this report that jumps 21 off the page at you and says, "I would never have 22 dictated that"? 23 A No. 24 Q I notice there is a slash and then "mjt" 25 in lowercase initials after your typed name. Do 9 1 you know who that refers to? 2 A That would be the transcriptionist that 3 actually did this. 4 Q Okay. Now, I notice also on this report 5 that it's dated up at the top 3/5/91. 6 A Correct. 7 Q And also down at the bottom "Dictated 8 3/5/91" and "Transcribed 3/5/91"? 9 A Correct. 10 Q Would that indicate to you that the image 11 was done on March 5th, 1991, the report was dictated 12 and transcribed on that same day? 13 A Yes. 14 Q Would that in any way be unusual with the 15 way things were done at that hospital? 16 A No. That's typical. 17 Q Now, up at the top the patient's name is 18 Theresa Schiavo. Do you see that? 19 A Yes, I do. 20 Q This appears to be a form that was 21 xeroxed onto this page, the form that contains her 22 name. Am I reading that correctly? 23 A Typically, no. This was a multi-page 24 form. The original form is a multi-page form at 25 that time, and Radiology retains one copy of that. 10 1 And it's one of those carbonless copies. So this 2 obviously is a reproduction of that original 3 radiology form. But that block of material on there 4 is part and parcel of that multi-page form. 5 Q So it was nothing that was laid on top of 6 a piece of paper? 7 A No. 8 Q Now, in that top block there, it says, 9 "closed head injury." Do you see that? 10 A Yes, I do. 11 Q Where would that information have come 12 from? 13 A Typically the clerk, the intake clerk, 14 puts that information there. 15 Q And I see that James Carnahan is 16 underneath Theresa Schiavo's name in the upper 17 right? 18 A Correct. 19 Q Do you know Dr. Carnahan? 20 A Yes, I do. 21 Q Do you recall where he was at the time? 22 A Not at that specific time. But, as a 23 general rule, he was the rehab physician for a 24 number of the rehab facilities such as Mediplex. 25 Q Did he typically refer patients to 11 1 Manatee Memorial if they needed a total-body bone 2 scan? 3 A Yes. 4 Q How unusual is it to order a total-body 5 bone scan for a patient in your experience? 6 A I don't think it's unusual at all. 7 Q In any given week, how many would you do? 8 A At that time? 9 Q Yes. 10 A Myself or the department? Because I did 11 not read all the studies done every day. There were 12 several radiologists there. 13 Q Let's say the whole department. 14 A In a week, probably about 20. 15 Q What is a total-body bone scan used for 16 typically? 17 A It's to look for abnormalities of the 18 bone, whether they -- if they would be recent 19 abnormalities. 20 Q Recent -- 21 A Recent. 22 Q -- abnormalities? 23 A Correct. 24 Q Is it also a technique to diagnose 25 osteoporosis? 12 1 A No. 2 Q Explain to these lay ears what a bone 3 scan is. 4 A Okay. The patient is injected with a 5 small amount of a radioactive material which acts 6 the same as calcium and phosphate and bone. So 7 metabolically this material exchanges with the 8 normal bone material. So the body thinks it's the 9 same as bone material and processes it the same way 10 as bone material. And wherever there is an increase 11 in bone turnover in the skeleton, this material will 12 go as would normal bone material. 13 Q Bone turnover, what does that mean? 14 A Well, the cells of your bones are always 15 being exchanged. The calcium is being absorbed and 16 then redeposited. That's a normal thing. And that 17 gives us a normal background pattern of activity on 18 a bone scan. 19 If the bone is abnormal, then it often is 20 involved in abnormal bone turnover. Either lots of 21 bone is being removed and not too much is being put 22 back or, on the other hand, more bone is being 23 deposited than is being removed. So it's a dynamic 24 process. 25 Q Is the bone scan then done over a period 13 1 of time? You take a series of images? 2 A Well, no. It's pretty much done all at 3 once. You inject the patient, you wait three hours 4 typically. And that may be variable for different 5 institutions, but three hours is typical. And then 6 you place the patient under the imaging camera, it's 7 called, and the radioactive material is slowly 8 decaying and giving off radioactive particles which 9 are detected by this camera, and that's recorded on 10 film. 11 Probably I should say at this point to 12 clarify also, there are different kinds of imaging 13 cameras. At the time that this was done, you 14 couldn't fit the whole body under the camera all at 15 once. So the images -- you do record several images 16 over a period of a few minutes, one that has the 17 head and neck typically, the skull; another that has 18 the shoulders and rib cage; another that has the 19 pelvis and hips; another that has most of the legs. 20 It wasn't customary when you had to do 21 those multiple images to include the hands or 22 sometimes even the forearms and sometimes not the 23 feet. So I want to clarify that. There are other 24 imaging systems where you can get the whole skeleton 25 in there from head to toe and then you have all the 14 1 bones. 2 When I read this report, it says that 3 there were multiple images, which suggest to me that 4 this was done as a series of pictures and probably 5 did not include parts of the forearms. Probably did 6 not include the hands. May not have included the 7 feet completely. So I wanted to clarify that. 8 Q But it would be one set of images? 9 A It would be one set of images. They were 10 all recorded on one film, one piece of film, as 11 several small images of the various parts of the 12 skeleton. 13 Q Okay. At the top right under the date 14 appear the words "Bone Scan, Indication: Evaluate 15 for trauma." 16 A Correct. 17 Q What does that line indicate? 18 A Well, in the best of all possible worlds 19 when we are asked to produce an imaging study, 20 there's a question that's been asked for which we 21 are being asked to provide an answer. And in 22 medicine there are many, many different questions 23 that can be asked, and the examinations are tailored 24 to answer those questions. And the report we want 25 to tailor to bring up those possibilities which 15 1 would most likely relate to the question that's 2 being asked. 3 So if somebody comes in with a history 4 that says "closed head injury," belongs to Dr. 5 Carnahan, for example, who's a known rehab doc, and 6 the indication that was given to us is "evaluate for 7 trauma," then our mind-set is to look for those 8 things that are most likely related to trauma and to 9 possibly give some additional possibilities if we 10 don't see something that fits what we expect. 11 Q So the question that's being asked would 12 come from outside your department? 13 A Correct. 14 Q The first sentence says, "Multiple gamma 15 camera images of the axial and proximal appendicular 16 skeleton." What is an appendicular skeleton? 17 A The appendages constitute the 18 appendicular skeleton. So it would be the arms and 19 legs. And that refers to what I mentioned before, 20 is that this wasn't done as one contiguous image of 21 the whole skeleton but, rather, was a composite of a 22 set of images of various areas. 23 Q And the sentence goes on to say, "in the 24 anterior and posterior projections." 25 A Correct. We normally have the camera 16 1 over the chest, you know, the anterior part of the 2 body, to obtain one set of images, and then over the 3 back, over the posterior half of the body, to obtain 4 another set of images. Because the closer the part 5 is to the camera, the more radioactive counts you 6 get, and so the sharper the image. So you try to 7 make sure that you're getting images from both sides 8 of the body as close to the camera as you can. 9 Q Given the equipment that you were using 10 at the time, how many individual images would you 11 expect to see if we had been able to recover this 12 scan? 13 A Well, it would depend on the size of the 14 patient. Because the closer you can get the camera 15 to the patient, the more of the body you can get on 16 any individual image. But typically it would be 17 about six images, I would say. 18 Q Front and back? 19 A Correct. 20 Q Together? 21 A Correct. 22 Q And the "technetium"? Is that how you 23 say that? 24 A Correct. 25 Q That's your tracer? 17 1 A Correct. Technetium is handled by the 2 body like calcium. 3 Q And the next sentence, "There are an 4 extensive number of focal abnormal areas of nuclide 5 accumulation of intense type." What does that mean? 6 A Well, that means that there are a lot of 7 areas that look black on the images because lots of 8 that radioactive decaying material was happening at 9 those points and was being recorded by the imaging 10 system. 11 Q Okay. "These include multiple bilateral 12 ribs." What would that mean to you? 13 A Well, you know, there's left ribs and 14 right ribs. And that would mean that more than two 15 ribs on each side were involved. 16 Q Would it necessarily mean that the first 17 rib, left and right, as opposed to the first rib on 18 the left side and say the fifth rib on the right 19 side? 20 A No. There wouldn't be any meaning of 21 that nature. Typically if it's one or two ribs, 22 we'll actually specify, you know, rib approximately 23 the second on the left. If you have large numbers 24 of areas of activity, then it's superfluous to label 25 each one in the report. And we would say 18 1 "multiple." 2 Q And by "bilateral," you mean on each side 3 of the sternum? 4 A It would be, yes, on each side of the 5 body's midline. 6 Q Right. What does the word costovertebral 7 mean? 8 A That's where the posterior part of the 9 rib joins the spine. The rib on each side comes out 10 from the spine and joins the spine by an articulated 11 joint. And so that refers to where the ribs butt 12 against the spinal vertebral bodies. 13 Q "Several of the thoracic vertebral 14 bodies, the L1 vertebral body, both sacroiliac 15 joints." These are all areas that were abnormal on 16 the scan? 17 A That's what this indicates, yes. 18 Q "The distal right femoral diaphysis," 19 what area of the body is that? 20 A That would be the right leg, the upper 21 part of the right leg. 22 Q Distal? 23 A Above the knee. 24 Q Okay. What is the diaphysis portion? 25 A That's the shaft of the bone. 19 1 Q And distal is? 2 A Away from the center of the body. So 3 that would be near the knee part of the leg, the 4 upper leg. Femur is the upper leg. 5 Q So on the thigh bone above the kneecap 6 but not involving the joint? 7 A That's what that particular thing says, 8 but I think somewhere in there also, it mentioned 9 that both knees -- 10 Q Right. Right after that. 11 A Right after that. So that's different 12 from the knee activity. 13 Q And, "Both ankles, right greater than 14 left." Those are two additional areas that showed 15 up as abnormalities on the scan? 16 A That's correct. Correct. 17 Q Okay. "Correlative radiographs are 18 obtained of the lumbar spine and of the right femur 19 which reveal compression fracture, minor, superior 20 end plate of L1 and shaggy irregular periosteal 21 ossification along the distal femoral diaphysis." 22 And what is that next word? 23 A Metaphysis. 24 Q "Metaphysis primarily ventrally." What 25 is the metaphysis? 20 1 A The metaphysis is that portion of the 2 bone which is closer to the joint than the 3 diaphysis. The diaphysis is the shaft, and then the 4 metaphysis is a continuum from the diaphysis to the 5 epiphysis, which is just below the joint. 6 Q Now, that sentence contains a reference 7 to "correlative radiographs." What are radiographs? 8 A Those are typically called x-rays. 9 Q X-rays. So in addition to the bone scan, 10 the nuclear imaging, you also did x-rays? 11 A That would be what would be indicated by 12 this report, yes. 13 Q Would that have been a step that you 14 would have taken had the bone scan been normal? 15 A We do not normally do x-rays of normal 16 bone scan areas. 17 Q Are x-rays done to provide additional 18 information to what you have seen on the bone scan? 19 A Correct. 20 Q Is it of a confirming type of 21 information? 22 A It refines the diagnosis. 23 Q What kind of information does the x-ray 24 give you that the bone scan does not? 25 A Well, the bone scan is based on the 21 1 body's metabolism. 2 Q Okay. 3 A And an x-ray is a shadow of the bone at a 4 given moment which doesn't involve metabolism. It's 5 just a picture. 6 Q Now, because of the sentence structure, 7 I'm not sure if there is a single compression 8 fracture at L1 or a second compression fracture also 9 in the femur. 10 A What this says is there's a compression 11 fracture of the lumbar vertebral body at L1 and an 12 additional radiographic abnormality, irregular 13 periosteal ossification along the femoral bone. 14 Periosteal ossification is not a compression 15 fracture. It's a different kind of abnormality. 16 Q And the ossification referred to in the 17 femur is primarily ventrally? 18 A Ventral is that surface of the body 19 related to the belly. Ventral is belly. Dorsal is 20 back. 21 Q So it was on the front side of the femur? 22 A Correct. 23 Q The abnormality was? 24 A It would be on that side facing closer to 25 you if the patient was standing in front of you 22 1 looking at you. 2 Q Okay. And by "shaggy irregular 3 periosteal ossification," you are speaking there of 4 the information you got from the bone scan or from 5 the x-ray? 6 A The radiograph. 7 Q What does that word "shaggy" refer to? 8 A It's just a descriptor like the shaggy 9 dog. 10 Q Just means that the ossification is 11 not -- 12 A The opposite of smooth. 13 Q Would you draw any conclusions from that 14 how old the ossification was? 15 A You could say that it wasn't real old, 16 because typically, as we mentioned, the bone is a 17 dynamic structure, and it's constantly being 18 remodeled normally. So the body tends to take away 19 extra bone eventually to remodel it to look like 20 normal bone. So typically old bone injuries are 21 remodeled so that eventually they may almost 22 disappear, particularly in young people. In the 23 very young, a fracture you won't even see in three 24 or four years, it will be totally erased. 25 Q By "young," you mean? 23 1 A Say a six- or eight- or ten-year-old. As 2 you get older, the bone remodeling process slows 3 down, and so those injuries may persist for longer 4 and longer times, but it depends on the individual 5 too. But I would say it would be more recent than 6 less recent; same with the bone scan. 7 Q In an adult female in her twenties, would 8 a bone fracture be capable of being aged by a 9 radiologist? In other words, could you look at an 10 image of a fracture and say is it a new fracture or 11 an old fracture? 12 A I would have to refine that to say that 13 the bone scan actually gives you more information on 14 fracture age than a plain radiograph. A plain 15 radiograph may give you some gross indication of 16 age. 17 Q If this patient were to today have a bone 18 scan, would there likely be traces of these 19 abnormalities in her skeleton? 20 A It would depend on the cause of the 21 abnormality. 22 Q And that brings us to the next sentence 23 in the report, which is, "The patient has a history 24 of trauma." What likely led you to that conclusion? 25 A As I mentioned before, the indication 24 1 "evaluate for trauma" and the history of closed-head 2 injury and the fact that Dr. Carnahan is a rehab 3 doctor who typically works with patients who have 4 been severely injured and need to be rehabilitated. 5 Q Anything else? 6 A Not that I could speculate on at this 7 point in time, no. 8 Q Then you go on to say, "Most likely the 9 femoral periosteal reaction reflects a response to a 10 subperiosteal hemorrhage." Would that be a bone 11 bruise? 12 A Correct. 13 Q Leading to ossification? 14 A Correct. The periosteum is a fibrous 15 layer that covers the bone, and blood vessels run 16 underneath that. And in certain kinds of trauma, 17 blood accumulates between the bone surface itself 18 and that fibrous periosteum and displaces the 19 periosteum away from the bone. And then the body 20 repairs that by putting more bone there to replace 21 the blood. 22 Q To bridge the gap? 23 A Yes. Under the periosteum, the body lays 24 down more bone, so that makes the cortex of the bone 25 thicker. And that's what that periosteal reaction 25 1 is. 2 Q Is that an unusual phenomenon, in your 3 experience? 4 A It's the body's normal way of repairing 5 the bone. 6 Q Did you see it frequently when you were 7 practicing? 8 A Yes. 9 Q In what kinds of situations? 10 A Well, trauma and also in bone 11 malignancies. The body attempts to repair the 12 malignancy also by adding new bone to it. And in 13 certain metabolic processes, the body also puts down 14 new bone. So it's fairly common skeletal response 15 to a lot of different diseases. 16 Q Then you go on to say, "And the activity 17 in L1 correlates perfectly with the compression 18 fracture which is presumably traumatic." 19 A That's what it says. 20 Q In other words, the x-ray confirmed the 21 L1 fracture? 22 A The x-ray shows an abnormality at L1 23 which happens to correspond with the abnormal bone 24 turnover on the bone scan at that point. 25 Q What is a compression fracture? 26 1 A It's a loss of the mechanical structure 2 of the vertebral body along what we call the end 3 plates of the vertebral body. And the end plates 4 are those portions that are adjacent to the 5 cartilages that separate each vertebral body, the 6 cartilages being the body's shock absorbers. 7 Q Is this compression fracture, then, in 8 common parlance, a broken back? 9 A Yes. 10 Q Is there any way to tell how old that 11 fracture would be? 12 A Well, as I've alluded to, the bone scan 13 gives some suggestion of that. 14 Q More recent rather than less recent? 15 A Correct. Typically in trauma the rule of 16 thumb is that a traumatic fracture is not active on 17 the bone scan after 12 to 18 months. That's the 18 typical rule of thumb. Now, bodies being very 19 variable, there's a lot of variation there, but 20 that's the typical rule of thumb. So if a fracture 21 shows up active on the bone scan, then one makes the 22 presumption that it is relatively recent; i.e., 23 within 18 months. 24 Q And after that, it becomes relatively 25 undetectable on the bone scan? 27 1 A If it's a simple fracture not related, 2 say, to a malignancy and if it is given the 3 opportunity to heal, then, yes. Typically after 18 4 months you'll see that it's getting so inactive that 5 you may not pick it out. 6 So let's say you did a series of bone 7 scans on an individual who had a simple fracture. 8 Typically the bone scan won't be active in the first 9 24 hours because the body hasn't had time to start 10 turning over the bone there to make the body repair. 11 So the first 24 hours, you won't see anything 12 typically on a nuclide bone scan. And I qualify 13 that because there's other kinds of bone scans now. 14 Q Right. 15 A Then from one day to some period of time, 16 it gets increasingly intense activity as the body 17 lays down more and more bone. Then once the repair 18 work is fairly finished as to laying down the bone, 19 then the body starts to remodel that repair work to 20 try to make it look like normal bone again. So it 21 starts taking away some of what it's laid down. 22 Q Sloughing off? 23 A Well, it actually just resorbs it. The 24 cells of the body -- each individual cell picks up a 25 little bit of that calcium and takes it away. So 28 1 you'll have, then, a declining activity phase as the 2 body does that remodeling. And at some point the 3 body decides that that's all it's able to do for 4 that particular spot, and then the activity will 5 typically return to normal background. 6 Q So the skeleton is sort of a work in 7 progress? 8 A It's always turning over, yes. 9 Q The report goes on to say, "The 10 presumption is that the other multiple areas of 11 abnormal activity also relate to previous trauma." 12 A That's what it says. 13 Q And, again, that's based on the fact that 14 Dr. Carnahan is a rehab physician, that you were 15 asked to evaluate for trauma? 16 A And the pattern of activity is fairly 17 typical of multiple traumatic injuries of relatively 18 recent origin. 19 Q I realize you can't assign a cause to 20 these injuries that you picked up in this report. 21 But typically in your experience, what would be the 22 causes of this pattern of abnormality? 23 A In somebody her age, an auto accident is 24 by far the most typical cause. 25 Q Assume that she was not in an auto 29 1 accident but that she had suffered an anoxic or 2 hypoxic encephalopathy type of injury from a cardiac 3 arrest and had been bedridden for a year at this 4 point. What might account for these abnormalities? 5 A In my knowledge, that type of injury 6 would not account for this pattern of abnormalities. 7 Q Now, the last sentence says, "Additional 8 possibility would be neoplastic bone disease, 9 widespread disseminated infectious bone disease or 10 multiple bone infarcts from abnormal hemoglobin." 11 Those are all other possible diagnoses to rule out? 12 A Correct. We typically give what we think 13 is the most common explanation for what we see based 14 on the information that we're given and the pattern 15 of disease that we see, and then we'll throw out 16 some other possibilities in case the clinical 17 picture doesn't fit because we rarely know anything 18 about what happened to the patient. I mean, we're 19 peeking through the keyhole of the patient's 20 clinical condition. So we tend to throw in a few 21 other things that might be something to think about. 22 Q Might account for? 23 A We don't attempt to be exhaustive because 24 there is a list of probably 30 or 40 things that 25 could cause abnormal bone scans of this wide nature. 30 1 And because the body is very variable, nothing is 2 ever classic, which is why attorneys make such a 3 good living at malpractice, because nothing is ever 4 typical. 5 Q Nothing is ever perfect either, is it? 6 A Yes. I had to throw that in. 7 Q Thanks for doing that. Do you recall 8 ever having a conversation with Dr. Carnahan about 9 this patient? 10 A No, ma'am. 11 Q Now, your conclusion is, "Multiple areas 12 of abnormal scintigraphic accumulation some of which 13 are radiograph for differential as discussed above." 14 What do you mean "radiograph for differential"? 15 A I think that sort of got butchered in the 16 translation there. But what that attempts to say is 17 that there are radiographic correlatives for some of 18 the bone scan abnormalities. 19 Q And scintigraphic accumulation just 20 refers to the tracer action in the skeleton? 21 A Correct. Scintigraphy is another word 22 for nuclear imaging. 23 Q Have you done bone scans on other 24 bedridden patients? 25 A I'm sure that I have. 31 1 Q Now, are you just given the images to 2 read? 3 A Yes. We're just given the images. We do 4 not typically see the patient. 5 Q Okay. Would you typically have called 6 the referring physician to report this type of an 7 abnormal bone scan? 8 A No. And further, when I do call a 9 physician, it's my custom almost exclusively to 10 annotate the report that it was called. But we 11 typically only call for life-threatening, unexpected 12 findings. And bone-scan abnormalities are not 13 typically considered to be life-threatening 14 abnormalities, particularly ones of this nature. 15 If I saw a bone scan on a hip that was 16 positive in somebody that we were worried about a 17 hip fracture, then I would call, because that has 18 implications for treatment. You don't want them 19 walking around. You want the orthopedics to 20 evaluate them. But in this case, no, I didn't feel 21 that that was an emergent, life-threatening 22 condition, so I would not have typically called it. 23 Q If you look at the bottom of Exhibit 2, 24 which is probably a better copy in some regards, 25 you see there's some notation down there in 32 1 handwriting? 2 A Yes. I see that. 3 Q It says "Mediplex," and I can't read the 4 rest of it. 5 A It looks like it says "Mediplex 3/91." 6 And then I can't read the remainder of it either. 7 Q Is that your handwriting? 8 A No. 9 Q Do you know what that would have been put 10 on there for? 11 A It might refer to the transcription 12 department sending the report. That would be my 13 guess, but that's just speculation. 14 Q Would it have been unusual, then, for you 15 to have called Dr. Carnahan and say, "Hey, I've got 16 this bone scan over here"? 17 A It would be very unusual if I didn't make 18 a note on here. And I would normally dictate in the 19 report, the report was called in to Dr. Carnahan at 20 such and such a time on such and such a date. So I 21 would not say that that was called. 22 Q Since you and I chatted the other day, 23 have you had occasion to look into heterotrophic 24 ossification? 25 A Yes, I have. 33 1 Q And is this bone scan consistent with 2 what you have learned about that condition? 3 A I'm not sure I understand the format of 4 that question. 5 Q Okay. Is this a pattern of heterotrophic 6 ossification as reported in the literature that you 7 looked at? 8 A Not typically. 9 Q What makes it atypical? 10 A Well, if I were to pick one thing, I 11 would say the activity in the ribs is not typical. 12 And typically heterotrophic ossification occurs 13 around the joints because they're not being moved. 14 And typically you will see on the radiographs 15 calcium deposits actually sitting there. And they 16 don't look like periosteal reaction typically 17 either; they have a different appearance. 18 Q The periosteal is where the membrane that 19 covers -- I guess that's the periosteum. Right? 20 A Right. 21 Q That covers the bone, separates from the 22 bone? 23 A Correct. 24 Q And then calcium ossification occurs 25 between those two? 34 1 A Correct, right. And heterotrophic 2 ossification usually involves the actual joint and 3 the anatomic structures in and around the joint. 4 Q Can you say, then, within a reasonable 5 degree of medical certainty whether this bone scan 6 is consistent with heterotrophic ossification? 7 A In my knowledge, it's not consistent with 8 heterotrophic ossification as I typically see it. 9 Q Do you know how heterotrophic 10 ossification is treated, if at all? 11 A I don't know. That's outside my area of 12 expertise. Speculatively I don't think that you can 13 really treat that as a condition. But, rather, you 14 try to keep the joints mobile, which is where rehab 15 comes in. 16 Q Physical therapy? 17 A Correct, physical therapy. Because it's 18 the immobility of the joints that cause that 19 reaction to occur. 20 MS. ANDERSON: I have no further 21 questions. 22 MR. SWOPE: Can we take a brief break 23 before we get started? 24 MS. ANDERSON: Certainly. 25 MR. SWOPE: Is that all right? 35 1 THE WITNESS: Fine with me. 2 (Recess from 10:22 a.m. to 10:25 a.m.) 3 EXAMINATION 4 BY MR. SWOPE: 5 Q Dr. Walker, my name is Scott Swope, and 6 I'm one of the attorneys representing Michael 7 Schiavo, who's the guardian in this case. There was 8 some discussion during the direct examination 9 regarding the total-body bone scan looking for 10 recent abnormalities. Do you remember that? 11 A Not specifically. But you can certainly 12 elaborate, I'm sure. 13 Q All right. I believe you said that one 14 of the things that you're looking for when you 15 review the photos on a total-body bone scan is for 16 recent abnormalities. Is that one of the things 17 that you look for? 18 A That would be the thing that we look for 19 is for disease that's active, because that's all 20 that shows up on a bone scan, is active disease. 21 Q Okay. And later on in your direct 22 examination you were saying that traumatic fractures 23 typically are not active on a bone scan after 12 to 24 18 months. Is that correct? 25 A That's correct. 36 1 Q Now, would that hold true for only 2 traumatic fractures, or does that 12-to-18-month 3 time period hold true for any kind of occurrence? 4 A I would not say that it holds true for 5 any kind of occurrence, no. Because many things 6 that give you an abnormal bone scan don't have a 7 finite date where they stop. 8 A fracture occurs in a single moment of 9 time, and then hopefully it's treated and heals. 10 Whereas other things that give rise to abnormal bone 11 scans may be metabolic, for example, and they're an 12 ongoing process that don't stop. And if that 13 process doesn't stop, the bone scan may be abnormal 14 forever. 15 Malignancies, unless you treat the 16 malignancy, that bone scan is always abnormal. So 17 only things that have the opportunity to undergo 18 healing will result in a bone scan improving. 19 Q Okay. Is there any way for you to say 20 from looking at this report when any of these 21 occurrences took place that caused the abnormality 22 to appear on the bone scan? 23 A I can only say that if they were 24 traumatic that they probably occurred within 18 25 months. 37 1 Q I think you mentioned that you had no 2 personal recollection of dictating this particular 3 report. Is that right? 4 A That's correct. 5 Q And you didn't sign the report? 6 A I don't see my signature on this copy, 7 no. 8 Q Okay. Now, since Dr. Florence Heimberg 9 put her initials on the report, it possible that she 10 is the one who actually dictated this report? 11 A No. 12 Q It's not possible? 13 A No. Had she dictated the report, she 14 would have had the transcription issue a corrected 15 copy that would have had her name typed as the 16 dictating physician. 17 Q Okay. 18 A So if she looked at it and she didn't do 19 that, then she didn't dictate this. 20 Q I see. Were there any other radiologists 21 besides yourself and Dr. Heimberg who worked 22 together at this time? 23 A Yes. 24 Q Is it possible that one of the other 25 radiologists besides yourself or Dr. Heimberg 38 1 dictated this report? 2 A As I said before, it's possible but not 3 probable because I recognize my dictating style 4 here. And we all have our own dictating styles. We 5 all phrase things differently, set things in 6 different order. And almost always you can 7 recognize your own dictating style as opposed to 8 someone else's. So based on the dictating style 9 here, I would say it was a very high probability 10 that this was something that I dictated, that Dr. 11 Heimberg reviewed and signed off on. 12 Q Okay. There was a part in the report 13 that refers to shaggy, irregular periosteal 14 ossification. And I believe you indicate -- you 15 said during your direct that that indicated to you a 16 relatively recent injury. Is that accurate? 17 A I think what I said was that -- if memory 18 serves me, I gave a fairly long discussion of how 19 bone is remodeled and that given enough time, 20 particularly in young people, that that will go 21 away, but that you can't date it very precisely. 22 I think I said my guess would be it would 23 be more recent rather than old but that it can't be 24 precisely dated, and the bone scan is more accurate 25 at giving some indication of a date. 39 1 Q Okay. So when you say "more recent," 2 you're not able to say within a reasonable degree of 3 medical certainty whether it was a month old, six 4 months old or two years old? 5 A Are you speaking about the radiograph or 6 the bone scan? 7 Q I'm referring about your reference in the 8 report to "shaggy irregular periosteal 9 ossification." 10 A I don't think I drew a conclusion in the 11 report as to how old it was. But if you're asking 12 me could I date a radiograph, an injury on a 13 radiograph, by the amount of periosteal reaction, 14 within that time frame of a month to two years, no, 15 I couldn't date that. 16 Q Okay. Do you have any way of knowing how 17 the compression fracture at L1 occurred? 18 A No. 19 Q Is it possible that the abnormalities 20 occurring on the bone scan with respect to the 21 fracture of L1, the compressions fracture of L1 -- 22 could that have occurred when the patient -- or if 23 the patient fell onto the floor from a standing 24 position? 25 A That's possible. 40 1 Q Is it possible that the abnormalities 2 that you noted on the right femoral diaphysis and 3 metaphysis could have occurred if the patient was 4 standing and suffered a cardiac arrest and fell to 5 the floor? 6 A Probably not. That wouldn't be a typical 7 mechanism of injury that would cause a periosteal 8 bruise. Typically you need a direct blow of some 9 kind. I suppose one could speculate that she fell 10 on a piece of furniture, that that could produce 11 that injury. But just typically falling on the 12 floor would not do that. 13 Q Okay. Is there any way to tell from the 14 information in this report how many months or years 15 prior to the bone scan and the radiographs that the 16 bruise on the right femur occurred? 17 A Because it is active on the bone scan, if 18 it were traumatic, it would probably would have 19 occurred within 18 months. 20 Q You mentioned that the report indicates 21 multiple bilateral rib abnormalities and that that 22 was not consistent with heterotrophic ossification. 23 Is that right? 24 A I mentioned that in this deposition, yes, 25 but not in the report. 41 1 Q Okay. Were you looking for heterotrophic 2 ossification when you read the bone scan and the 3 radiographs? Do you know? 4 A I think that's in our mind when we see a 5 rehabilitation patient because we don't know from 6 the history how old the injury was. And, of course, 7 heterotrophic bone is something that occurs 8 particularly in people who are immobilized for long 9 periods of time. So that would be something that we 10 would mention were we to see a typical pattern for 11 that, yes. 12 Q Okay. The abnormalities in the multiple 13 bilateral ribs, could that have occurred during an 14 attempt at resuscitation by the paramedics or 15 hospital staff? 16 A A vigorous resuscitation could do that, 17 yes. 18 MR. SWOPE: I have a fairly poor copy of 19 an x-ray report that I would like to have 20 marked as Respondent's -- well, we'll just mark 21 it as Exhibit 3. That would be the easiest way 22 to do it. 23 Do you want to take a look at that? 24 MS. ANDERSON: Yes. 25 (Exhibit 3 marked for identification.) 42 1 MR. SWOPE: And another x-ray report that 2 I would like to have marked as No. 4. 3 (Exhibit 4 marked for identification.) 4 Q Dr. Walker, have you ever seen the x-ray 5 report that has been marked as Deposition Exhibit 3? 6 A Not to my knowledge. 7 Q Do you know Dr. Donald Durrance? 8 A Yes, I do. 9 Q Do you know what kind of a physician he 10 is? 11 A He's a diagnostic radiologist with a 12 specialty in neuroradiology. 13 Q His report indicates there that his 14 impression is "no evidence of fracture"? 15 A That would be what it says, yes. 16 Q What do you understand that to mean? 17 A It means he didn't see an alteration of 18 the radiographic anatomy that would suggest that 19 there was a broken bone there. 20 Q Okay. Do you know when that report was 21 written or when the x-ray was taken? Can you tell 22 from the report? 23 A Well, it's a pretty bad copy. I see a 24 date of 6/24/91 at 7:11 a.m. underneath the 25 signature line. Whether that was the date the 43 1 examination was taken or whether that was the date 2 it was transcribed or dictated, I can't be sure. 3 But one would speculate within some two or three 4 days of the time that the x-ray was taken would be 5 that date. 6 Q Okay. So the report is dated June of 7 1991 -- 8 A Correct. 9 Q -- as far as we can tell? And your 10 report is dated March of 1991. Correct? 11 A Correct. 12 Q And your report indicates that a 13 compression fracture at L1 was noted on the 14 radiographs, and Dr. Durrance's report shows no 15 evidence of fracture. 16 A Well, I think that's simply explained in 17 that this is a radiograph of the right humerus, 18 whereas that compression fracture was in the 19 vertebral body of the spine. So they don't involve 20 the same area. This is the arm. 21 Q So this x-ray report relates to her right 22 upper arm? 23 A That's correct. 24 Q So he's saying he didn't see any evidence 25 of a fracture in her right upper arm? 44 1 A He's saying not only did he not see any 2 evidence of a fracture but that the soft tissues 3 are, quote, intact, yes. 4 Q Now, Deposition Exhibit 4 is an x-ray 5 report which indicated Steven Ricciardello. 6 A Ricciardello. 7 Q Are you familiar with Dr. Ricciardello? 8 A I am. 9 Q What kind of a physician is he? 10 A He's also a diagnostic radiologist with a 11 specialty in neuroradiology. 12 Q And his report indicates, as far as the 13 left knee conclusion, "no acute injury," and right 14 knee conclusion, "no acute injury." 15 A Correct. 16 Q And the date on that report? 17 A 2/05/91 is the date on the top on the 18 right, which would suggest that was a date that this 19 study was obtained. And 2/8/91 is the date below 20 the signature line which suggests that that's when 21 it was either dictated or transcribed. 22 Q Okay. Now, Dr. Ricciardello's indication 23 that there is no acute injury in either of the knees 24 is consistent with your findings and is not 25 inconsistent with your findings on the compression 45 1 fracture of L1. Correct? 2 A That's a -- I don't understand that 3 question. 4 Q Okay. His indication that there is no 5 acute injury on either of Ms. Schiavo's knees, 6 that's consistent with the radiographic report that 7 you issued on March 1991. Correct? 8 A I would have to say no, that's not 9 consistent, because the bone scan shows that there 10 is activity at the knees of some type. The bone 11 scan can't be more specific than that because it 12 doesn't show anatomy. 13 Now, I don't know if this right-knee 14 image included the area that we're talking about as 15 the periosteal reaction or not. I don't know 16 whether that includes that area or not. And the 17 other problem with this is that these are obtained 18 portably in the nursing extended-care facility, and 19 these quality x-rays are typically of bad quality, 20 "quality" being a misnomer here. 21 So the fact that this doesn't even 22 describe periosteal reaction doesn't surprise me, 23 because that's a subtle finding that you probably 24 would not expect to see in this radiograph but that 25 I would expect to see in a hospital-based radiograph 46 1 because of the different equipment and the different 2 techniques. So this -- except to the extent that it 3 doesn't show a big fracture -- is fairly 4 meaningless. 5 Q Okay. 6 A I think it probably is -- it doesn't show 7 any calcium in the joints, which you would expect to 8 see with heterotrophic ossification. It does 9 describe osteopenia. But, again, osteopenia is a 10 loss of bone substance, which is a fairly judgmental 11 call on a radiograph and depends a lot on the 12 technique too. Osteopenia is, however, something 13 typically seen in someone who is bedridden because 14 the body tends to put more calcium in areas that are 15 stressed. 16 And if you're bedridden, your legs are 17 not under any stress anymore, so the body tends to 18 take some of the mineral away from those areas. So 19 the osteopenia is consistent with someone who is 20 bedridden. Beyond that, because I know the quality 21 of these films because I read them at that time too, 22 I wouldn't make a lot of judgment call on those. 23 MR. SWOPE: For Exhibit 5, I have a 24 two-page exhibit which is a "Mediplex Rehab - 25 Bradenton Monthly Summary from February 15, 47 1 1991 to March 15, 1991." 2 (Exhibit 5 marked for identification.) 3 Q Dr. Walker, have you ever seen that 4 monthly summary? 5 A No. 6 Q All right. Would you go to the second 7 page, please? 8 A (Witness complying.) 9 Q At the top there is a statement that 10 says, "An increase in bone growth has been noted in 11 the right thigh secondary to heterotrophic 12 ossification making passive range increasingly 13 difficult." Do you see where it says that? 14 A Yes, I do. 15 Q Is that indication in the medical records 16 consistent with the report that you wrote on the 17 bone scan, or is it consistent with your findings 18 and reading of the bone scan? 19 A I think it's an apples-and-oranges kind 20 of comparison, in that this is a clinical finding. 21 And I wouldn't make any speculation as to how to 22 relate that to the bone-scan finding. I just don't 23 think you can do that. Basically they're saying 24 there that the joint doesn't have as much mobility 25 as it used to. You can't make clinical 48 1 determinations off of bone scans, so I wouldn't know 2 where to go with that. 3 Q Okay. The person who wrote the summary 4 indicates that the increase in bone growth was 5 secondary to heterotrophic ossification. Would you 6 say that the abnormalities on the bone scan that you 7 reviewed would be consistent with that? 8 A I think I mentioned already that they're 9 not typical of heterotrophic ossification, based on 10 my experience. 11 Q Is it possible that the abnormality was 12 an indication of heterotrophic ossification? 13 A I suppose with respect to the knee where 14 it refers to the diaphysis of the distal femur only, 15 I'm going to qualify my response referring only to 16 that anatomic area, it's not inconceivable that it 17 could be, but it's not typical. 18 Q Okay. I don't have any other questions 19 on that document. 20 I have a document here which is Mediplex 21 Rehab Bradenton Doctor's Progress Notes, which is 22 comprised of five pages, and the dates appear to go 23 from January 31, 1991 to March 21, 1991. 24 MR. SWOPE: If we could mark that as 25 Exhibit 6. 49 1 (Exhibit 6 marked for identification.) 2 Q Dr. Walker, if you could take a look at 3 that and tell me if you have ever seen that 4 document. 5 A Not to my knowledge. 6 Q Okay. Now, those are doctor's notes, and 7 I have a section there with a bracket. Can you read 8 what that says? 9 A No. I see "knees" there. But beyond 10 that, I can't really read it. 11 Q I'm not making a doctor's joke. 12 A It's true. We all admit it. It's so 13 attorneys can't read it. I can't read it either. 14 Perhaps you can read it for me. 15 Q Well, does it look like it says, "Some 16 warmth in knees, monitor for H.O."? 17 A That would be a possibility. 18 Q Now, "monitor for H.O.," would that be, 19 do you think, heterotrophic ossification? 20 MS. ANDERSON: Objection. Calls for 21 speculation. 22 A I agree, that calls for speculation. It 23 could be hypertrophic osteoarthropathy too, which is 24 another bone condition that you can get from various 25 things. So I couldn't say specifically what he was 50 1 thinking. 2 Q All right. So, "Warmth in the knees, 3 monitor for H.O.," you can't say what that means? 4 A I can't differentiate from two likely 5 diagnoses because hypertrophic osteoarthropathy also 6 gives you warmth in the knees and is seen with 7 people with certain chronic conditions. So, no, I 8 can't tell you to what specifically he refers there. 9 Q Okay. I don't have any other questions 10 on that document. 11 I have an affidavit signed by Dr. James 12 Carnahan, 14 November 2002. 13 MR. SWOPE: If I could have that marked 14 as Exhibit 7. 15 (Exhibit 7 marked for identification.) 16 Q Dr. Walker, have you ever seen the 17 affidavit from Dr. Carnahan that's been marked as 18 Exhibit 7? 19 A No. 20 Q All right. Would you take a moment to 21 read through the statements that Dr. Carnahan makes 22 in the affidavit, please? 23 A Certainly. 24 Q You can just read it to yourself. You 25 don't have to read it out loud. 51 1 A Okay. I read it. 2 Q Do you have any thoughts on whether or 3 not Dr. Carnahan's affidavit is consistent or 4 inconsistent with your review of the bone scan and 5 radiographic -- 6 MS. ANDERSON: Let me object to the 7 extent that that question calls for Dr. Walker 8 to comment upon any methods or qualifications 9 of another physician. 10 MR. SWOPE: Okay. 11 Q You can answer the question. 12 A All right. My response would be that 13 this is outside my area of expertise. So I wouldn't 14 be able to comment on it. 15 Q Okay. Now, when you say that it is 16 outside the area of your expertise, what do you mean 17 by that? 18 A Well, Dr. Carnahan is a rehabilitation 19 doctor who has the patient in front of him, who 20 physically examines the patient and then looks for 21 physical findings and symptoms based on his 22 knowledge of rehabilitation medicine. And I'm not a 23 rehabilitation-medicine physician, so I wouldn't be 24 able to comment on this document because it is 25 outside of my area of knowledge. 52 1 Q Okay. I think you said during your 2 direct examination that you never saw Terri Schiavo 3 as far as you recollect. Is that correct? 4 A That is correct. 5 Q And so that would mean that you never had 6 an opportunity to examine her? 7 A That is correct. 8 Q Would you say that Dr. Carnahan, as her 9 treating rehabilitation physician, would be in a 10 better position to comment on the cause of the 11 abnormalities in the bone scan for this particular 12 patient than you? 13 A I would say he had a more complete 14 picture of the patient than I. 15 MR. SWOPE: Okay. I have a document I 16 would like to have marked as Exhibit 8. 17 (Exhibit 8 marked for identification.) 18 Q Dr. Walker, Exhibit 8 is an affidavit 19 signed by a physician Eugenio Alcazaren. Have you 20 ever seen that document? 21 A No. 22 Q Do you know Dr. Alcazaren? 23 A The name is familiar. I don't know him 24 personally. 25 Q Do you know what kind of physician he is? 53 1 A I believe he's also a rehabilitation 2 physician. 3 Q Would you take a moment to read the 4 contents of his affidavit? 5 A Certainly. Okay. I read it. 6 Q In that affidavit, Dr. Alcazaren gives 7 his interpretation of the radiologist's report dated 8 March 5, 1991 of the bone scan as an indication of 9 "heterotrophic ossification, not trauma." Do you 10 see where it says that? 11 A Yes, I do. 12 Q Would you say that Dr. Alcazaren's 13 opinion is consistent with yours or inconsistent? 14 A Again, this document was produced by a 15 physician whose area of expertise is not identical 16 with mine. His findings are based again on clinical 17 findings. He's not an imager. I'm not a 18 rehabilitation physician. So I would not be able to 19 comment on the significance of that except to say, 20 again, that the bone scan is not typical of 21 heterotrophic ossification. 22 They're saying that the clinical 23 findings, which are entirely different, may, in 24 fact, be consistent with that. And I can't make a 25 judgment on that because I'm not a clinician. 54 1 Q So you're not saying that Dr. Carnahan 2 and Dr. Alcazaren were wrong? 3 A I couldn't say that because they're 4 commenting from an area of expertise that I don't 5 have. 6 Q Okay. 7 A So I would be presumptuous to say that 8 they were wrong. 9 Q Okay. The bone scan and radiographic 10 report shows only one fracture. And that is a 11 compression fracture to L1. Correct? 12 A Well, I should clarify that by stating 13 that not all of the areas of bone-scan abnormality 14 were imaged concurrently. Okay. And that's 15 important. In other words, we didn't x-ray every 16 area that was hot on there. A couple of typical 17 areas were imaged but not all. Of those areas that 18 were imaged, the only area that showed what was a 19 clear fracture was L1. 20 Q Okay. So of the documents that you had 21 the benefit of reviewing, the only fracture that 22 showed up was a compression fracture to L1? 23 A You're speaking of the documents at the 24 time that this was interpreted? 25 Q Correct. 55 1 A Yes. That's correct. 2 Q The radiographs did not show any 3 fractures of the right femur. Correct? 4 A They don't show a typical fracture. They 5 show periosteal reaction, which could be the result 6 of a bone bruise, which is a bone injury that's not 7 a loss of continuity of the structure of the bone. 8 So to the extent that you define fracture as a loss 9 of structural continuity, then, yes, that is an 10 actual fracture as is typically described. 11 Q Okay. If there was a loss of structural 12 continuity of the femur, you would have indicated in 13 the report that there was a fracture to the femur. 14 Correct? 15 A Correct. 16 Q And when there is not a structural -- 17 A Discontinuity. 18 Q -- discontinuity of the femur, you do not 19 note that there is a fracture of the femur. Is that 20 also correct? 21 A Yes, that's correct. 22 Q When you read the bone scan and the 23 radiographs, is it your standard procedure to 24 comment on each area of abnormality that you 25 observe? 56 1 A Are you referring to the bone scan or the 2 radiographs or both? 3 Q Both. 4 A One would typically comment on any 5 abnormality that one observed, yes. 6 Q So if there is an absence of a comment in 7 the report of an abnormality in any part of her body 8 other than what is indicated in the report, would it 9 be safe to conclude that you did not observe any 10 abnormality to that particular body part? 11 A It would be safe to conclude that those 12 areas which were actually imaged did not disclose 13 any additional abnormalities. 14 Q Okay. 15 A But since we don't have the films in 16 front of us, we don't know to what extent an area 17 was imaged. 18 Q With a closed-head injury, would you 19 typically take images of the head, neck and 20 shoulders? 21 A At the time of the injury we would. 22 Q Okay. When you receive a request from 23 Dr. Carnahan to do a complete-body bone scan and the 24 indication of the injury is that it was a 25 closed-head injury, would your standard procedure be 57 1 to take images of the head, neck and shoulder area 2 as part of your standard procedures? 3 A Not unless those areas looked 4 particularly unusual on the bone scan. 5 Q Okay. Can you say whether or not those 6 areas were actually part of the bone scan? 7 A I can only say that typically the head, 8 neck and shoulders would be part of a bone scan. 9 But not having the actual images in front of me, 10 that does call for some degree of speculation. 11 Q Can you think of any time when a 12 physician would ask you for a total-body bone scan 13 and you would not take images for the bone scan of 14 the head, neck and shoulder area? 15 A If we were having technical difficulties 16 or if the patient was noncompliant, for example, 17 moved around a lot -- which some people do -- then 18 it is possible that those areas would not be imaged. 19 Q Okay. Other than that, though, generally 20 you would take images of the head, neck and shoulder 21 area? 22 A The bone scan typically includes those 23 areas, yes. 24 Q Okay. And because there is no comment in 25 your report of any abnormalities in the head, neck 58 1 or shoulder area, that is an indication that either 2 those images were taken and you observed no 3 abnormalities or that those images were not ever 4 taken. Is that an accurate statement? 5 A Yes. 6 Q But in either one of those events, you 7 did not observe any abnormalities to the head, neck 8 or shoulder area? 9 A To the extent that they are not described 10 in the report, I would say yes. 11 Q When you read the bone scan, were you 12 aware, to your knowledge, that the patient had been 13 immobile for an extended period of time? 14 A No. 1, I would have to say, what is your 15 definition of "extended period of time"? Because 16 that's kind of a loose term. Could you give me some 17 indication of what you say by "extended"? 18 Q Were you aware at the time that you 19 reviewed the bone scan that the patient was immobile 20 for any period of time? 21 A Not specifically. 22 Q Do you know whether it is a common 23 occurrence for immobile patients to suffer fractures 24 as a result of undergoing intensive physical 25 therapy? 59 1 A That's outside of my area of expertise, 2 so I wouldn't know that for a fact. I could only 3 speculate. 4 Q A physician who would be better able to 5 answer that question would be what kind of 6 physician? 7 A A rehabilitation physician. 8 Q That would be like Dr. Carnahan and 9 Alcazaren? 10 A Yes. 11 Q I showed you some documents of her 12 medical records earlier that referred to warm 13 spots -- well, we think they referred to warm spots 14 in her knees as a result of the physical therapy. 15 Would that be consistent -- 16 MS. ANDERSON: Excuse me. "As a result," 17 did you say? 18 MR. SWOPE: As a result of the physical 19 therapy. 20 MS. ANDERSON: I don't think that's what 21 that says, so I'm going to have to object to 22 that question. It was observed during physical 23 therapy, it's not as a result of physical 24 therapy. 25 MR. SWOPE: Okay. 60 1 Q So the hot spots noted in the medical 2 records observed during physical therapy, would 3 those hot spots be consistent with the abnormalities 4 that you noted in your report in both knees? 5 A I don't think one can make that direct 6 connection because warmth in joints can be caused by 7 many, many things, some of which may show up on bone 8 scans and some of which may not. So you can't make 9 that A to B connection. 10 Q Okay. If an immobile patient is going 11 through physical therapy and part of the physical 12 therapy is to have manual manipulation of the legs, 13 particularly flexing of the knees, is it possible 14 that that physical therapy would result in an 15 abnormal appearance on a bone scan? 16 MS. ANDERSON: Objection. That question, 17 I think, is virtually unanswerable because it 18 is so vague. 19 A I could only speculate. 20 Q Okay. In your opinion, is that something 21 that would show up on a bone scan? 22 A I would think only if the joint were 23 injured would it show up on a bone scan. Just 24 simple manipulation of an injured part should not 25 show up as an abnormality on a bone scan. 61 1 Q Can you tell me when you first realized 2 that you had some involvement in the Terri Schiavo 3 case? 4 A Only when I got a phone call from Ms. 5 Anderson. 6 Q When was that? 7 A Perhaps a week or so ago, maybe. 8 MS. ANDERSON: Tuesday, I think. 9 THE WITNESS: This week. 10 MS. ANDERSON: I think it was this week. 11 THE WITNESS: It wasn't very long ago. 12 Q So you don't know what day it was -- 13 A No, I don't. 14 Q -- that you first became involved in the 15 -- first realized that you were involved in the 16 case? 17 A Not precisely. 18 Q Did you have any idea that you had read a 19 bone scan for Terri Schiavo whenever you heard any 20 of the media coverage on the case? 21 A No. 22 Q Have you spoken with anyone regarding 23 your involvement with the report or this deposition 24 other than the persons who are here? 25 A Two of my partners who have called today 62 1 wanting to talk to me, I have mentioned that I was 2 being deposed in the Schiavo matter. 3 Q Okay. After learning from Ms. Anderson 4 that you had apparently written or dictated a report 5 relating to the bone scan -- strike that. I don't 6 even know where I was going with that one. 7 Did you review any documents before your 8 deposition today after learning that you had 9 apparently dictated the report? 10 A How would you define "documents"? You 11 mean documents related to the case, or do you mean 12 medical literature? I don't understand the 13 question. 14 Q Well, in preparation for your deposition 15 today, did you review any documents? And when I say 16 "documents," I'm referring to medical literature, 17 medical records, reports, notes, things of that 18 nature. 19 A I reviewed the copy of the bone scan that 20 was provided by Ms. Anderson, and I also looked at a 21 couple of radiographic textbooks about bone disease 22 just to familiarize myself with some of this. 23 Q Okay. Do you know in particular what 24 areas you looked at specifically relating to the 25 textbooks? 63 1 A I looked at all areas covering abnormal 2 deposition of bone. 3 Q Abnormal deposition of bone? 4 A Yes. 5 Q What do you mean by "deposition of bone"? 6 A The depositing of bone. That's called 7 deposition in the medical literature. 8 Q Other than Ms. Anderson and the two 9 physicians who called you today, did you have 10 conversations with anyone else regarding your 11 deposition today? 12 A Well, you called me last night, so I 13 guess that would count. We spoke briefly. But 14 nobody else. 15 Q Okay. Well, let me say this. Did you 16 discuss the merits of the case or the issues 17 involved in your deposition, or anticipated to be 18 involved in your deposition, with anyone? 19 A I'm not sure I understand what that 20 means. 21 Q All right. Well, you indicated you spoke 22 with me briefly. You indicated you spoke with Ms. 23 Anderson when she informed you that you had 24 apparently dictated the report? 25 A Correct. 64 1 Q Other than those conversations, did you 2 have conversations with anyone regarding the merits 3 of the case -- 4 A No. 5 Q -- or issues involved in the case? 6 A No. 7 Q What led you to look at the textbooks 8 relating to the deposition of bone? 9 A I just wanted to familiarize myself with 10 those things. It's a part of a normal education 11 process. 12 Q Okay. 13 A We're always try to review the 14 literature, and this gave me a good reason to go 15 ahead and take a look at it. 16 MR. SWOPE: All right. I have no further 17 cross. 18 MS. ANDERSON: Just a couple questions, 19 Dr. Walker. 20 EXAMINATION 21 BY MS. ANDERSON: 22 Q Would a kick be the kind of direct blow 23 that would produce that femoral abnormality? 24 A That would be a possibility, yes. 25 Q Would being thrown into a sharp furniture 65 1 corner? 2 A That would be a possibility. 3 Q Would being struck with some sort of 4 blunt object like a golf club or something do it? 5 A Yes. 6 Q Have you ever encountered a situation 7 where bedridden patients have fractures or sustain 8 fractures during physical therapy? 9 A Yes. 10 Q Have you ever talked to physicians about 11 that? 12 A I have had the occasion to call a 13 physician to report that, because that would be an 14 unexpected finding, yes. 15 Q Do you caution rehabilitation physicians 16 about the fragility of the skeleton of a bedridden 17 patient? 18 A No. That would be presumptuous on our 19 part because they have more knowledge of that than 20 we. 21 Q Do you think it's possible that these 22 fractures were caused by the rehabilitation at 23 Mediplex? 24 MR. SWOPE: Object as to the form. 25 A I couldn't exclude that. 66 1 Q Do you think that might be why Dr. 2 Carnahan and Dr. Alcazaren rejected your traumatic 3 finding? 4 A That would be definite speculation there. 5 Q Can you tell from your report whether you 6 ordered x-rays of her ribs? 7 A I would say that those were not ordered. 8 We don't do all areas of abnormality if the areas on 9 the bone scan are so extensive, because, as you 10 know, there's radiation involved, and you want to 11 minimize the amount of radiation to patients. 12 Q So we don't know whether her ribs were 13 broken? 14 A We don't. And I don't believe that they 15 were imaged, based on that report. 16 MS. ANDERSON: I have no further 17 questions. 18 MR. SWOPE: I just have one follow-up 19 question on recross. 20 EXAMINATION 21 BY MR. SWOPE: 22 Q You mentioned that you have seen 23 fractures in bedridden patients before? 24 A Yes. 25 Q How frequently have you seen that? 67 1 A Rare. 2 Q It's rare? 3 A Yes. 4 Q More than once? 5 A Well, I have been in practice now since 6 1980, so I would say more than once in that period 7 of time. 8 Q Do you have any idea how many fractures 9 you've seen in bedridden patients? 10 A I would be guessing. Less than six. 11 MR. SWOPE: No other questions. 12 EXAMINATION 13 BY MS. ANDERSON: 14 Q Have those fractures occurred in elderly 15 patients? 16 A Typically, because typically those are 17 the patients that we see in this area, yes. 18 MS. ANDERSON: No further questions. 19 MR. SWOPE: And no additional recross. 20 MS. ANDERSON: I'm going to order this. 21 So would you like to look at it, review it? 22 THE WITNESS: Yes, I would love to be 23 able to look at it. 24 MS. ANDERSON: Okay. 25 THE REPORTER: I will send you the 68 1 original and the errata sheet. 2 MS. ANDERSON: Do that. 3 And I'll send you the original errata 4 sheet where you can note any changes that you 5 want to make. 6 THE WITNESS: Okay. 7 THE REPORTER: Do you want a copy of the 8 transcript? 9 MR. SWOPE: Can I let you know? 10 THE REPORTER: Yes. 11 (At 11:18 a.m. no further questions were 12 propounded to the witness.)

Q Since you and I chatted the other day, have you had occasion to look into heterotrophic ossification?

A Yes, I have.

Q And is this bone scan consistent with what you have learned about that condition?
A I'm not sure I understand the format of that question.
Q Okay. Is this a pattern of heterotrophic ossification as reported in the literature that you looked at?

A Not typically.

Q What makes it atypical?

A Well, if I were to pick one thing, I would say the activity in the ribs is not typical. And typically heterotrophic ossification occurs around the joints because they're not being moved. And typically you will see on the radiographs calcium deposits actually sitting there. And they don't look like periosteal reaction typically either; they have a different appearance.

Thanks. I read it, but don't have time to due a full analysis or reading (I might have missed something). But what I got from the reading is this:

Most of the report is technical, but she has rib injuries on both sides, a "compression" type injury of the back, and a fracture healing above the knee.

The main question is when the scan was done.

If Terri had CPR, she could have sustained a dozen rib fracctures.

If she had been in a rehab place for awhile (e.g. one year) and developed osteoporosis, she could get this type of fracture from caregiving.

I had some very ostroporotic patients who developed rib fractures from simple transfer to a wheelchair when they lifted a person up. And a compression fracture at that level from sitting her down too hard. And in a spastic person, the leg fracture could be from opening the legs to change a diaper, and if she spasmed her muscles, the leg could break here. Or if she fell.

All of this sounds terrible, but you can see this with good caregiving.

Finally, this could be abuse. Young healthy women just don't break these bones.

However, usually beatings have one sided rib fractures. The back injury is not consistent with a beating--more common with a fall or being thrown forward in a carwreck. The leg fracture could be from a fall on ice where the leg twisted.

Beatings usually have rib fractures more on one side than another, and facial fractures, again usually on one side. And usually you see fractures on the arms or hands from "defense" posture (putting hands in front of the face) and you see twisting type fractures of the arms, or a fracture of one but not both arm bones.

So if the scan was right after she started rehab (in the first three months) then you should suspect something.

If she fell (twisting her leg), and had cardiac arrest and CPR, and the bone scan was done less than 6 months later, you could blame it on the CPR.

If she was in rehab for a year, and had osteoporosis, then the injuries probably happened in rehab.

A clue to abuse is many different injuries of different ages. So you might see these fractures, but an x ray would show older injuries--especially of the left facial bones and the arms, and more rib fractures on the left side of the body (unless the assailent was left handed, where you would see right sided injuries)

Hope this helps a bit....and don't quote me in court, because I'm only guessing....

Q Can you say, then, within a reasonable degree of medical certainty whether this bone scan is consistent with heterotrophic ossification?

A In my knowledge, it's not consistent with heterotrophic ossification as I typically see it.

Q Do you know how heterotrophic ossification is treated, if at all?

A I don't know. That's outside my area of expertise. Speculatively I don't think that you can really treat that as a condition. But, rather, you try to keep the joints mobile, which is where rehab comes in.

Q Physical therapy?

A Correct, physical therapy. Because it's the immobility of the joints that cause that reaction to occur.

Nice analysis, LadyDoc.

Extra emphasis on importance of dynamic changes,
and so not only is the actual scan impt, but the changes between scans is also paramount.

Also, since the bone scans show the RECENT cellular activity,
it is the xrays themselves which show the time-integral of all previous history and trauma.
Probably need both and changes to deconvolve actual history.

7 Q Is this compression fracture, then, in common parlance, a broken back?
A Yes.

Explain THAT one, you people trying to explain away Michael's assault and Terri's injuries. She was face down. How did her back get broken?

Michael was on top of her, that's how. He was on her back, pinning her down and asphyxiating her or pinching off the carotid blood to her brain. He broke her back.

Q Is this compression fracture, then, in common parlance, a broken back?
A Yes.

Explain THAT one, you people trying to explain away Michael's assault and Terri's injuries. She was face down. How did her back get broken? Michael was on top of her, that's how. He was on her back, pinning her down and asphyxiating her or pinching off the carotid blood to her brain. He broke her back.

Well, as Felos has been explaining it....Terri has a disease of osteoporosis, silly, that's how her back got broken, within months of being in the hospital. (barf)

Thanks for the ping. This was an explosive deposition and Dr. Walker certainly corroborates a strong possibility that Terri's injuries were caused by physical battery.

Ms. Anderson did a very good job here, and Mr. Swope appears to have been outclassed and outflanked. By the way, isn't Shiavo's attorney Swope the same attorney who was originally a police officer in Pinellas County at the time of Terri's "collapse" and admittance to the hospital? If I recall correctly, he was under Sheriff Rice at the time, the same Rice who was on the board of directors at the Hospice with Felos?

>> Well, as Felos has been explaining it....Terri has a disease of osteoporosis

Felos doubtless rushed to hire a doctor -- with Terri's money, of course -- to figure out some "innocent" explanation of the bone scan(s) report after he'd blundered and given it to Pat Anderson. He can afford to lie about Terri's osteoporosis because he has a court order to burn her body as soon as he gets her killed. (That court order to destroy the evidence of her body also came out of her therapy funds.)

Anyway, osteoporosis does not explain how a healthy young woman ended up on the floor unconscious and brain-damaged.

yes, if someone stepped on her you culd get bilateral rib fractures. But if she had CPR, there is a lot of chest pressure and often bilateral rib fractures that wuld be idenitical to being stepped on...depends on where the fractures were, and if they were in the lower or upper ribs on the side etc. then you would need a forensic pathologist, not a radiologist, to interpret the injury.

Radiologists just see fractures, but forensic pathologists have expertise on what types of fracctures come from what type of injury...

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