Deposition 3 - Expert Doctor Witness in car accident case
MR. ELMAN: Let the record reflect this is the evidentiary deposition of Dr. Stephen Gryzlo, M.D. taken on today's date, October 11, 2001. The time is now 3:43 p.m. exactly, and the attorney for the defense is not here nor has he called my cell phone that has been previously provided to him as well. The doctor has an obligation of a lecture. So in light of that fact, we have to start right now because of the time pressure and because I haven't ... heard from the attorney.
Doctor, I will be asking you a series of questions throughout this evidentiary deposition. If there are any questions you don't understand, please feel free to ask me to repeat them for you. Fair enough?
THE WITNESS: Fair.
MR. ELMAN: Also it is important that you give your answers in a yes-no format so the court reporter can transcribe them, fair enough? THE WITNESS: Yes.
MR. ELMAN: This evidentiary deposition will be taken pursuant to the rules of the Supreme Court, Civil Procedure and Evidence.
Stephen M. Gryzlo, M.D., called as a witness herein, having been first duly sworn, was examined and testified as follows:
BY MR. ELMAN:
Q. Doctor, please state your full name for the ladies and gentlemen of the jury.
A. Stephen M. Gryzlo, G-r-y-z-1-o. Q. Doctor, you have tendered to me, which I am going to now mark as Plaintiff's Exhibit No. 1 is your curriculum vitae which is also known as your resume, fair enough? A. Yes.
Q. Is it true and accurate as you sit here today?
Q. Is it a business record made in the ordinary course of your business practice? A. Yes.
Q. Is it usual and customary for you to prepare this? A. Yes.
MR. ELMAN: At this time plaintiff moves to admit Exhibit No. 1 into evidence and publish it to the jury.
BY MR. ELMAN:
Q. Really just going over briefly in summary, your background, it seems like you went to Loyola University and you received a bachelor of science and biology in 1981, correct?
Q. You went to Loyola Medical School and graduated in 1985, correct?
Q. You are board certified in orthopedic surgery?
Q. You obtained those boards in 1983. correct?
Q. Are all doctors certified in a specialty like yours?
A. We would like to be. That's sort of the highest ranking you can achieve to suggest that the governing body of orthopedic surgeons think you do good work.
Q. You passed your boards, correct?
Q. What is an orthopedic surgeon in general? A. He is a physician who takes care of musculoskeletal injuries, bone and joints, soft tissues injuries, fractures, dislocations.
Q. And I also note here that you are duly licensed both in Illinois from 1987 as a medical doctor and in California since 1990, correct?
Q. And what hospitals, if any, are you affiliated with?
A. I am affiliated with Northwestern Memorial Hospital and Lakeside VA Hospital adjoining it.
Q. And what areas of concentration have you dedicated your practice in orthopedic surgery to?
A. I did a sports fellowship after the completion of my residency, so I would say the majority of things I like to see are more sports-related injuries, shoulder, knee, ankle, elbow injuries. But any orthopedic injury that is seen in the emergency room or comes from the office, I can see.
Q. How often do you perform surgeries on a weekly basis on average?
A. Twice a week.
Q. Now, Doctor, turning our attention away from your credentials, which we briefly talked about, into your care and treatment of Sheri Holloman-McKinney, first of all, was she a patient of yours? A. Yes.
Q. When was she a patient of yours? A. Is it okay to look at my files?
(Discussion off the record.)
BY MR. ELMAN:
Q. Doctor, before you look at your records, can you tell me if you are looking at your records through past recollection recorded which is the history of medical records as you recorded them in an accurate and true way?
Q. And did you record the history of the patient's medical treatment and office visit at the time they were undertaken? A. Yes.
Q. Please feel free to look at your file. A. Thank you. Sheri Holloman-McKinney, I first saw her in January of 1997 from a referral. of a Dr. Fred Fishman and subsequently saw her in February 10 of 1997, March 24 of ‘98, April 29 of 1998, May 20 of 1998, June 15 of 1998, and that was the last time I saw her.
Q. The first time you saw this patient, though, after the January - strike the question.
The first time you saw this patient after the January 1998 automobile accident would be when? A. March 24, 1998.
Q. Fair enough, Now, what is contained in your medical file, in general, so the ladies and gentlemen of the jury know what you will be referring to?
A. Office notes, in this case, many of them are letters sent to Dr. Fred Fishman, an internist here at Northwestern, who referred Sheri to us in regards to her treatment and care. Many of the studies that we ordered would have been in here, so X-ray evaluations, MRI reports, EMG reports, notes from the physical therapist and how she was doing would be contained in our chart as well as insurance information and information packets of that nature.
Q. What other medical records, if any, from other medical providers have you reviewed as well?
A. A letter from a neurologist here at Northwestern.
Q. That would be doctor who, Fagan?
A. Yes, Dr. Kevin Fagan, correct.
Q. And what other medical history have you reviewed?
A. There was an X-ray report from the chiropractic surgeon who saw her before I saw her following that automobileaccident and a report from his X-ray was enclosed in our chart file too.
Q. Now, Doctor, could you please state what the patient's history was the first time you saw her in March of 1998?
A. Certainly, I had seen her on the 24th of March 1998 after she had exacerbated neck complaints that she stated followed a rear-end collision she had sustained in January of 1998. She had explained to me that she tried going to a chiropractor for roughly 20 visits and not much headway was being made in that effort.
Her neck was still stiff and sore. She came in for me to take a look at her. She also had a report, as I said earlier, from her chiropractor about the degenerative changes seen in her neck that were seen on her X-ray.
Q. Now, Doctor, are all your opinions today based upon a reasonable degree of medical and orthopedic certainty?
Q. After you noted the patient's history, did you then examine her?
Q. What examination results, if any, did you note concerning her condition as it relates to the automobile accidentthat she told you about?
A. My examination was focused on her cervical spine, neck area. In that regard her range of motion or ability to bring her chin down, chin up, tilt her head to the right and left and turn were all slowed and reduced in range. She had tenderness as well as increased tone or spasticity in her neck muscles called the trapezius. There was a difference in the height of her shoulders, the left being lower than the right. Her shoulders, themselves, however, had good range of motion.
Her upper extremity neurovascular exam, her ability to sensate, feel sensation of soft touch and provide strength were good, though, in both upper extremity. There was, when I compressed her spine in the cervical area, reproduction of her pain in the neck region.
Q. And, Doctor after you noted her complaints, after the examination, did you then render a diagnosis of her condition initially or did you wait and do some more diagnostic tests before you did a final impression?
A. I had a report from the chiropractor on her cervical spine suggesting there was some degeneration between the fifth and sixth cervical vertebrae. So that entered into my thought process at that time. And my impression following my visit with her on the 24th of March was that she had a cervical strain brought on by the rear-end collision and exacerbated pre-existing neck problems she had.
Q. And your opinion is based upon a reasonable degree of medical certainty that these conditions that you just described are a result of the automobile collision?
Q. And when you say strain, what does that mean?
A. It is a term we use for a soft tissue injury to ligaments or, in this case, muscles about the neck region. We believe that there is soft tissue damage and injury to muscles and surrounding soft tissues, in this case, the neck. No fractures were seen on the X-ray, so it wasn't a bony injury but more the soft tissues of the areas surrounding the neck.
Q. When you use the term exacerbation of the degenerative conditions, which is seen in the cervical spine X-ray which is the neck X-ray, what is the significance of that finding in exacerbation or aggravation of something degenerative?
A. Well, typically when X-rays do show some signs of degeneration, we feel in the past sometime, there may have been a previous injury or a problem that occurred in the neck region so that the bones have changed their configuration. There may be some spurs. There may be some sclerosis. There may be some narrowing of spaces consistent with degeneration or aging.
When that is seen, it is typically something that takes a while to develop. So an immediate accident, three months prior, would not have caused X-ray changes. We certainly can note that the problem she has probably did not cause the bone changes but more in the soft tissue strain region.
Q. Why were her symptoms from the January 19, 1998, automobile accident not resolved when she saw you on that first visit?
A. Sometimes they can remain quite symptomatic from months to years in situations. Q. Does it depend upon the patient? A. Sometimes depends on the patient. Sometimes it depends on how violent the injury was. Sometimes it depends on what soft tissues were injured. If it is mostly muscular, it probably will resolve. If there is underlying disk and
sort of damage, it may not.
Q. What was the treatment plan for her on that first visit?
A. Following that first visit I thought we would step away from the chiropractic interventions and go with formal physical therapy. I reinstituted the anti-inflammatory regimen to reduce inflammation and wanted to see her back in about a month to see if that was going to make her better.
Q. Were you still concentrating on her neck at that time?
Q. The next visit a month later was where?
A. The next visit was here in our office. That was April 29, 1998.
Q. And your office is here in Water Tower Place, correct?
Q. That's where we are having the evidence deposition?
Q. Incidentally, you are here pursuant to subpoena?
Q. That's because you were not available to testify live at trial because of your surgical and patient schedule?
Q. On the next visit, then, on April of 1998, what if anything, did you note?
A. That her visit at that time really hadn't improved much. She explained to me that she really wasn't better following therapy. I took X-rays at that time because I had not seen the X-rays from the chiropractor's office and agreed that there was some degenerative changes in the area between the fifth and sixth cervical vertebrae as well as some disk space narrowing. Her exam continued to show slow range of motion and soreness primarily into the right shoulder region and right upper arm area with discomfort.
And with this soreness it even extended down into her hand towards her thumb and index finger which I thought was in the area of what we call the C6 dermatome. That's the enervation of the sixth cervical nerve down into the hand. Because of that and the persistence of problems now for four months of so, I wished to do an MRI on her neck.
Q. Based upon a reasonable degree of medical certainty, is it your opinion that these right upper extremity symptoms that went into her arm and hand from her neck area is related to the automobile collision?
Q. And why do you believe it was related?
A. Well, she had saw her a month earlier when she had problems with her neck stemming from this automobileaccident. She had seen a chiropractor without much improvement and things seemed to focus at the time of theautomobile accident which are consistent with neck trauma.
Q. Did she then have that MRI at Northwestern Memorial Hospital in May of 1998?
A. That is correct.
Q. What significant findings, if any, were noted based upon a reasonable degree of medical certainty that alerted your attention and would be related to the automobile accident?
A. Well, they saw three abnormalities. The one that rides home most significant is the tiny disk herniation seen between the third and fourth cervical vertebrae on the right-hand side. Typically disk herniations are from trauma and certainly could have stemmed from a rear car collision and a swinging forward.
She did demonstrate stenosis in the four, five, C4-C5 and C5-C6 region with osteophytes which again are more consistent with the pre-existing or underlying degeneration that occurs. So I wasn't - that didn't surprise me. I was expecting that. And the good news overall on her cervical spine was that there was no stenosis or narrowing of the entire canal.
Q. Do you believe that the right
neuroforaminal disk herniation in the C3-C4 area of her neck was probably related to the automobile accident?
A. More likely than not, yes. Q. And what is a disk herniation as opposed to a simple soft tissue injury. What makes this a little bit more severe?
A. The disk is the cushion in between vertebral bodies. On X-ray we don't have a real good look at what a disk does, but on MRI we can get a picture of what position the disk is in. In this particular case a disk herniation means that the soft cushion between the ends of the bone has actually expelled itself into an area where it shouldn't be and is putting pressure on the nerve that exits the neck and in this case goes down the arm.
Q. And the stenosis and the osteophytes, which are degenerative conditions, were those aggravated by theautomobile collision?
A. Undoubtedly, yes.
Q. Did they help the disk herniation in producing the severity of the symptoms that became chronic and lasting for this patient in her neck region?
A. More than likely the combination of a disk
herniation superimposed on degeneration would be worsened by an automobile accident, yes.
Q. And after you noted her MRI results which were taken on May 9 of 1998, what did you then do for this patient next?
A. When she returned to see us with the MRI and the MRI report on May 20 and with those findings, the right-handed abnormalities, the osteophytes and the disk herniation and the persistence of discomfort down into her hand region, I thought that a nerve study now would be needed.
She had an abnormality on her exam, her X-rays were not normal and MRI certainly showed some injuries. I next did an EMG test to determine the function of her nerves in that right upper extremity and that we did here at Northwestern with the Rehab Institute.
Q. And why was an EMG important after an MRI was already taken?
A. MRI shows a static change of the disk in this particular case. It gives us no ability to understand if the nerve is significantly damaged or partially damaged. So an EMG test gives us further
understanding of nerve function and takes the place
of the MRI from the standpoint of giving us information about the function of the nerve, where the MRI just gives us a situation of the picture of the disk, not telling us about the nerve.
Q. Is that a crucial component in determining whether surgery is needed or not?
A. In my opinion, yes. As an orthopedic surgeon, I would like to have everything, abnormality in X-ray, abnormality in MRI, and then maybe a really significant abnormality on EMG before surgery is considered, yes.
Q. So when and where - strike the question. When and where was the EMG taken?
A. The EMG was taken at the Rehab Institute of Chicago in the downtown region.
Q. That was by your order?
A. By my order, yes. She had it scheduled, and it was performed on May 22, 1998.
G. What was the result of the EMG test?
A. This is done by Dr. Marciniak who felt that there was no electrical diagnostic evidence of right cervical radiculopathy. She essentially felt that the EMG study showed no significant or permanent damage to the nerves.
Q. Just because the EMG ruled out any nerve damage, does that mean there wasn't any other damage, though, in the right arm extremity?
A. No, I tried to explain that to Sheri as well. Many times we do this for gross pathology or gross injury. Despite a normal EMG, that doesn't necessarily negate the possibility of some nerve irritation that is not being registered on the EMG test.
Q. After the EMG, what was the next course of treatment for her?
A. We saw her back after the EMG; and I elected to, her exam was unchanged. She still had the pain down her arm. Despite a normal EMG, I felt that further evaluation from a neurologist would be helpful in this particular problem to see if they felt similarly as did I, that she needed some treatment although surgical treatment was not deemed necessary at this time.
Q. And during that time that you were seeing her from March of 1998 up until June 15 of 1998, was she getting physical therapy at the Healthsouth physical therapy department?
A. Yes, it had begun in March of 1998; and, I believe, it continued to the point that I had seen her in June.
Q. Now, what is the whole purpose of your orders for her to get physical therapy and soft tissue mobilization, mechanical traction, hot packs, how is that helpful in remedying her symptoms?
A. Ideally with neck pain there is a vicious cycle with pain, spasm, more pain, more spasm, that can be elicited. The idea with physical therapy or chiropractic intervention or even with acupuncture is you try to resolve the spasm that's going on with soft tissue massage, with heat, with traction in an effort to try to decrease the pain. If nothing is done at all, the patient many times can be deconditioned or start to use faulty ways of doing things and aggravate the situation even more. So ideally it is designed to condition the patient to try and generate a more normal neck function and more normal ability to operate during the day.
Q. And it looks like a lot of her physical therapy is centered around her shoulder region in this right side? A. Yes.
Q. Is that related to the automobile accident?
Q. How is the neck and right shoulder and right arm, how is that all interconnected, if you could explain real briefly to the ladies and gentlemen of the jury?
A. The nerves of our neck exit and form a conglomeration of nerves called the brachial plexus which enervate the shoulder, the elbow and the right, in this case the right side. Injuries to the neck may take on appearance of shoulder symptomatology, soreness behind the shoulder blade, near the back, at the top of the shoulder, towards the base of the neck or even down the arm all the way to her fingers and in this case her thumb and index finger. So it is a radiation or referral of pain coming from her neck.
Q. So after the EMG was performed and after you reviewed some of her physical therapy findings, what was then next done for this patient?
A. She was made an appointment to see the neurologist at Northwestern, Dr. Fagan, who saw her in July, I believe. I have a letter dated July 14. 1 am not sure exactly what day she saw her.
Q. What findings, if any, did Dr. Fagan make that you would relate to the automobile collision in your opinion?
A. He felt that the discomfort down her right arm was most likely sensory radiculopathy, so radiating pain in the sensory mode of the nerves that we just talked about and chronic muscle spasm that was present. And he felt that a change in the medicines would be more appropriate for her and I believe did change her medicines around a little bit and felt that continuation of physical therapy would be helpful and agreed that the motor vehicle accident had exacerbated her pre-existing problem.
Q. What was then next done for this patient or have we covered everything up until now?
A. That was the last visit. I did not see her following her visit with the neurologist.
Q. Fair enough. I am going to wrap this up by asking the last final questions. Now globally speaking, looking back at her medical history and your care and treatment of her and relying upon Dr. Fagan's report which you have taken into consideration and the X-ray report from the chiropractor that saw her previous to you, what was your final diagnosis for this patient?
A. That she had sustained a surgical spine strain following the car accident as a result of the car accident, that she had a radiculopathy of a sensory nature that Dr. Fagan felt was present and this again was also a result of the caraccident and more likely than not the tiny disk herniation seen was a result of the car accident.
Q. And in your opinion are her conditions permanent in nature because of the automobile collision, more likely true than not?
A. Not having seen her for two years, three years now, it would be hard. If I saw her now and she still had the symptoms, I would say, yes, they were permanent. Typically, I don't render the idea of permanency until a year after surgery or a year after an injury. I had seen her for half a year but not quite a whole year.
Q. Let me ask you a more appropriate question. In Sheri Hol1oman-McKinney's case was she making progress under your care and treatment, under the neurologist and under the chiropractors after these six, seven months?
A. She had not made much progress, no. At that point, yes, we were still looking for answers and trying to decrease the discomfort she was having.
Q. Is a reason why her lack of progress was made because of the automobile collision causing these chronic conditions in your opinion?
A. They aggravated those chronic conditions and were very high on the list of why she was having pain. Again, some of the degenerative changes were there; but the automobile accident put them to a heightened level.
Q. Immediately before the automobile collision, she was not having any pain or any problems at all, would that be a factor in any of your opinions today that immediately before collision she wasn't treating with anyone?
A. She told me she was functioning well and doing good.
Q. I think we have covered everything. Thank you very much for your time.
THE WITNESS: I waive. BY MR. ELMAN:
Q. Doctor, two quick questions, based upon a reasonable degree of medical certainty, are your charges from your facility fair and reasonable treatments and customary in this time period?
A. Yes, I think it was $280 for the five visits that we saw Sheri for which is customary and reasonable for the area.
(Whereupon, Plaintiff's Exhibit No. 2 was marked for i dentification.)
MR. ELMAN: At this time plaintiff moves to admit Exhibit 2 into evidence subject to cross-exami nation.
BY MR. ELMAN:
Q. And the last couple of questions, was it fair and reasonable treatment for her to get treatment at the Healthsouth Rehab Center?
A. I thought so. I nave had very good success with Healthsouth in the care and treatment of my patients.
Q. ‘Was it fair and reasonable for her to get treatment being the MRI and EMG?
Q. Was it fair for her to get treatment because of the automobile collision as well under Dr. Fagan the neurologist?
MR. ELMAN: No further questions.
FURTHER DEPONENT SAITH NOT.
I, Deanna Amore, a notary public within and for the County of Cook County and State of Illinois, do hereby certify that heretofore, to-wit, on the 11th day of October, 2001, personally appeared before me, at 845 North Michigan, Chicago, Illinois, Stephen M. Gryzlo, M.D. in a cause now pending and undetermined in the Circuit Court of Cook County, Illinois, wherein SHERI HOLLOMAN-MCKINNEY is the Plaintiff, and DONNABEL ADAJAR is the Defendant.
I further certify that the said witness was first duly sworn to testify the truth, the whole truth and nothing but the truth in the cause aforesaid; that the testimony then given by said witness was reported stenographical1y by me in the presence of the said witness, and afterwards reduced to typewriting by Computer-Aided Transcription, and the foregoing is a true and correct transcript of the testimony so given by said witness as aforesaid.
I further certify that the signature to the foregoing deposition was waived by counsel for the respective parties.
I further certify that the taking of this deposition was pursuant to Notice, and that there were present at the deposition the attorneys hereinbefore mentioned,
I further certify that I am not counsel for nor in any way related to the parties to this suit, nor am I in any way interested in the outcome thereof,
IN TESTIMONY WHEREOF: I have hereunto set my hand and affixed my notarial seal this 12th day of October, 2001.
NOTARY PUBLIC, COOK COUNTY, ILLINOIS