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Nursing Home Deposition 4-Plaintiff's Deposition of Pschologist and Nursing Home Administrator - Part 2
BY MR. KNIGHT:
Q. I'll ask you whether the interviewing of significant others as part of the neuropsychological evaluation is a standard -- or a part of the standard professional approach that good professionals in the field of neuropsychology engage in, in order to conduct a complete and thorough evaluation.
A. I do think that's done somewhat routinely, particularly in regard to traumatic brain injury, and the reason for that being that you're looking at changes in things such as emotions, behavior, and thinking, and it's helpful to talk to someone who knows the patient well, sees them on a regular basis, both before and afterwards, particularly because I've only had the benefit of seeing the patient after the trauma and not before.
In addition to that, the significant others are in a position to be helpful to my patient if they can understand the problems and work with them on implementing some of the recommendations, and so it's also part of my therapeutic approach to involve significant others.
Q. Okay. With patients who have brain dysfunction, are they sometimes, to some extent, handicapped in their ability to perceive the precise nature of their deficits?
A. Sometimes because it's a somewhat complex thinking process to be able to step back and look at yourself realistically and be able to notice changes in yourself, for example.
Generally, the more severe the brain injury, the less insight a patient has and the more of a problem that is.
Q. All right. And with that standing objection continuing, let me ask you who you spoke to as significant others in order to perform your neuropsychological evaluation of Jerry Wattron.
A. For both the evaluation and the reevaluation I spoke with his girlfriend, Ms. Schorle, and his employee, Mr. Vondewalker.
Q. Okay. Do you have a spelling for Schorle and Vondewalker that you can give to us?
A. Schorle, S-C-H-O-R-L-E. Vondewalker, V-O-N-D-E-W-A-L-K-E-R.
Q. All right. And do you recall when it was that you spoke to -- let's take Ms. Schorle first?
A. It was in the course of the evaluation.
Do you need an exact date?
Q. To the best of your ability -- when you said “in the course of the evaluation,” you said earlier that you conducted that evaluation on 10/1, 10/7, and 11/5 of '98?
Q. Is that the best you can tell us at this point from your memory as to when you spoke to her, that it was during the course of that evaluation?
A. Well, I spoke to Ms. Schorle on 10/27/98, and I spoke to Mr. Vondewalker on 11/3/98.
Q. Thank you. And was there anyone else who participated in the conversations that you had with those individuals other than you and each of them on the occasion that you spoke to them?
Q. What, if anything, did Ms. Schorle tell you that was significant to your efforts to evaluate Jerry Wattron?
A. She noted that she had known him since 1993 and saw him regularly, and that's important because I want to get a sense of how well the patient is known by the person I'm talking to.
She was describing physical thinking and emotional symptoms in Mr. Wattron that were quite consistent with his own report, and, also, with the classic symptoms of head trauma.
That included things like discomfort in his head, slowed thinking, difficulty with staying focused, memory not as good.
She talked about they were supposed to meet, that he told her one time, thought he had told her another one, that she saw some difficulty with confusion. He would call her his secretary's name.
He would -- he would get the names of her sons wrong, that it was hard for him to put his thoughts into words, that he'll think one thing, say another, that he meant to say something totally different.
Emotionally she mentioned that he was shorter on patience, seemed less tolerant, more easily agitated, seemed more moody, moods going more from high to low, and a little depressed.
She also noted that he -- she thought he was experiencing symptoms but not admitting them, that he doesn't really complain, and he wanted her to believe that everything was fine, but that she was seeing some things that were of concern to her.
She mentioned that the changes were noted after the trauma, that he hasn't really felt like himself since the accident, that they seemed very different for him, and that he seemed to be becoming more aware of those and more realizing of them over time.
Q. Again, you made some detailed notes concerning those things that you've just related to us that you learned from Ms. Schorle; correct?
Q. Did you have to ask questions of her to get some of these examples that you've given us or was it the type of thing where she just rattled them all off to you?
A. A little of both. I start with a very broad question, “What, if any, changes have you seen,” so that the person I'm talking to has the ability to say, “He's fine,” or “I haven't seen any changes at all,” and then at that point they'll generally talk about some things spontaneously.
If I need further information, I'll question more specifically.
Q. Okay. So is it a common thing for you to have to say, well, can you give me an example of what you mean when you say he, whatever? Is that the way it works?
A. Sometimes, or I'll say, “You know, tell me what you mean,” if it's somewhat vague.
Q. Okay. In the things that you've just told us about, you told us about things that were like memory and difficulty finding words and so forth, and then you said on the -- from an emotional standpoint or something like that.
Can you tell us why you were looking for information on an emotional side, as well as mental activities side, as part of your effort to evaluate the patient?
A. Certainly. In terms of the symptoms of head trauma, there certainly are a constellation of emotional symptoms that are characteristic of head trauma.
Your head doesn't just control what you think. It also controls what you feel and your behavior related to that, and so because of that, things such as irritability, moodiness, quick, intense, inchangeable emotions, reduced tolerance for frustration, things of that nature, are very consistent with head trauma and very common symptoms of that, and so, therefore, that is an area that I'm interested in finding out about.
Q. Can you tell me what you learned from Mr. Vondewalker in that -- in your conversation you mentioned that you had in -- on a certain date that I've now lost but it's on the record. Can you tell us about that conversation, and the objection still stands to it.
A. He mentioned that he was Jerry's employee, that he had seen him regularly, knows him well.
He had also noted some changes in Jerry at the time of the trauma. He talked about some pain in his head and his wrist, that he seemed more irritable, that there's been a couple of instances where he had gotten very angry, high strung, that he seemed more emotional, that his emotions were more quick.
He hadn't noted very significant cognitive changes, but did talk about forgetting -- Jerry forgetting to give him messages, that he mentioned that he thought the changes occurred after the trauma, and that he had been noticing them more over time.
Q. Okay. Now, you mentioned earlier that as part of your evaluation you perform neuropsychological testing; correct?
Q. Are there a large number of available instruments or tests -- types of tests that you can choose from to conduct an evaluation as a neuropsychologist?
Q. Does the earlier part of your evaluative effort, the clinical interview, looking at the medical records, prior history, and interviews with significant others -- do those things help you decide what tests you should include in the battery that you're going to use?
A. Yes, to some extent.
I have a somewhat standard battery in terms of that the same type of areas need to be evaluated in each patient, things like intellectual functioning, memory, learning, academic achievement, emotional functioning.
And, so, therefore, I have a fairly standard battery that evolves over time, and the battery I did on the reevaluation has somewhat different tests than the initial evaluation.
Q. Okay. Can you tell us, in general, what these tests that you give measure?
A. Certainly. Because the brain is so comprehensive in its function, it's important to measure a number of different functions of the brain, and so they measure things such as neuropsychological functioning, which is tasks related to brain functioning; intellectual assessment, which is I.Q.; learning and memory; academic achievement, which is reading, spelling, arithmetic, things like that; emotional functioning in terms of looking for things like depression, anxiety, psychiatric symptoms, things of that nature.
Q. Okay. So you're having the patient perform different tests, and I know you're going to wince when I say this, but sort of like they do when they're in school. They're doing some math things and some verbal things; is that correct?
A. Yes. It's a little bit more intensive in one on one than most school experiences, but it does look more like school than medical testing.
Q. Okay. And the reason I said you'll probably wince is you're -- you're attempting to learn a lot more than just how well he can add things up and what his vocabulary is, I take it; is that correct?
A. Yes. These are more intensive because more specific information is needed than would be needed in an academic setting.
Q. Well, how do you know when you give these tests that you're going to be able to learn things about the patient compared to other people?
A. The tests are what they call normed, and that's an important part of the testing process.
What that means is that I will be comparing the patient's performance to a large group of people who are similar to him in some way, generally who are similar in terms of age, and that's especially important in testing memory, for example, that you would want to compare an 80-year-old to other 80-year-olds and a 30-year-old to other 30-year-olds in order to take into account normal changes in memory over time.
Q. So in this case you noted very early in your report Jerry Wattron's age at the time that you were treating him; correct?
Q. And so were the parts of the tests or the tests that you used comparing him to other people in his age group?
A. And that way you can get a better sense of what he can do versus what he should be able to do by looking at his performance compared to the average of that large group of people his age.
Q. Would it be fair to say that it would be complicated and probably take us a considerable amount of time to go through each of those tests and how they are implemented?
A. Most likely, although I would be happy to answer any questions that would clarify that.
Q. Okay. Well, what I'm going to try to do is to -- is to in some way be a little more general about it.
Let's -- let me take an example. I'm looking at a copy of what looks like the “Instruments Used” section of your evaluation report from the first evaluation --
Q. -- and there's one there called “California Verbal Learning Test.”
Q. Can you tell me what that test -- we'll use this for illustration purposes -- what the test consists of and what you're trying to learn with that test?
A. The test consists of -- it's a verbal learning test, meaning that there is a list of 16 items which is repeatedly presented to the patient verbally and they're asked to give back as many of those items as they can.
After that's done a number of times, there is then what they call an interference list, meaning that they are given a different list and asked to recall items from just that list. Then without hearing the original list again, they're asked to recall the items, and then they're asked to recall the items with cues as to categories that the items were in such as fruits or tools.
Then after about 20 minutes, there is a free recall, meaning that they're asked to recall that original list that was done over and over again one more time, and then recall it again with those same categorical cues, and then the last part is that a list of items is presented and the patient is asked, “Was this one of the items that was seen on the first list,” and -- and that's to look at their ability to recognize or discriminate those words.
Q. And is this one of those tests that is given to like huge numbers of people and their scores are collated and collected for professionals like you to be able to see what the norms are?
A. Yes. This is a test that's also normed and standardized in the way that I described.
Q. Okay. What types of things are you trying to find out about the patient's functioning when you administer this California Verbal Learning Test?
A. This particular test looks at new learning. I find it especially helpful for patients with head trauma because it relates to a problem that they often relate to me, which is difficulty remembering what they've heard, and this is a test that is basically asking you to remember things that you've heard without benefit of being able to write them down or asking for repeats when you need it.
Q. So you introduce some new things to them, and then see how well they do at recalling them right away, and then a little bit later and things like that?
A. Yes, and with or without cues, the idea being that this is a new learning type of task that would most effectively tap into a skill which is often impacted by head trauma, as opposed to something like a test of vocabulary, which is looking at old learning things that a patient has known for a long time before the trauma.
Q. When you -- when you evaluate the results of the tests, do you consider the whole battery of tests that you've given or do you just stop after one test and say, well, this guy is good or not good or something like that?
A. No. As I mentioned, the way that I come to a diagnostic impression is to evaluate all of my information simultaneously at the conclusion of the evaluation. That includes not just the testing results, but the patient's behavior, the clinical interview, the interviews of significant others, things of that nature.
Q. Okay. Well, while we are on this one example, though, can you tell me relative to the norms how the plaintiff, Jerry Wattron, scored with respect to this test trying to learn about his ability to remember newly learned information?
A. Overall his results were significantly impaired, meaning that he did poorly in comparison to a group of people his age.
His short delay free recall was within normal limits, meaning the first time I said tell me how this is, but the -- but the cued recall was mildly impaired, meaning that he didn't benefit from the cues, and his long delay free recall and cued recall were impaired, meaning that he forgot a lot over the period of time.
Q. Which you said was something like 20 or so minutes later?
A. About 20 minutes, approximately, and so his initial recall was within normal limits, however his memory faded rather quickly over time.
Q. All right. Are there parts of this battery of tests that are designed to determine whether a patient is giving it good effort or whether the patient is trying to fake responses? Is there anything about this battery of tests that tries to focus in on that?
BY THE WITNESS:
A. Yes. There are several things. One is in the first battery, for example, the 15-item memory task is a screening for -- to see if someone is putting forth their full efforts.
Also, the MMPI-II, which is the psychiatric screening inventory, has a number of validity scales.
In the reevaluation, there was also the 15-item memory test and MMPI-II validity scales. In addition to that, I also added the test of memory malingering, which is one way that the battery has evolved over time.
BY MR. KNIGHT:
Q. Okay. And when I refer to it -- and I think you understood it that way from your answer, but to make sure we're on the same page, I'm talking now about the battery you actually administered to Jerry Wattron, correct --
Q. -- not just your custom and practice.
Okay. What were the results of these parts of the tests that are designed to determine whether the patient is giving a good effort and whether the patient is being honest and forthright as opposed to malingering?
A. In both evaluations I saw no indication of malingering. His performance on the test specifically designed for malingering was quite good.
The consistency of his complaints, his behavior, the reports of his significant others, they were all quite consistent, and so at that point I felt comfortable that he was giving me a credible presentation.
Q. Okay. You know, you may have included it in that last answer, and if so I apologize, but I didn't pick up on how it is that these measurements --
Q. -- give you information that the person is being forthright and trying hard.
A. Well, for example, with the test of memory malingering, the way that this works is that it's a task that is actually much easier than it looks.
During this task, the patient is shown 50 pictures one at a time, which is a lot, and they are then shown pictures two at a time and asked to pick out the one that they saw in those original 50 pictures.
It seems like a very difficult task, but in actuality it's a rather simple one, and because of that, patients that are trying to do poorly will do so in a way that is obvious.
So the idea being that if someone comes into the testing, especially for something like a head trauma, they'll be -- and is trying to be somehow malingering or deceptive, that they will think this is a test of memory, I should be getting some of these wrong, and so, therefore, will answer in a wrong way even when they know the right answer, but by the second try of this, almost everyone gets 100 percent, and if you get more than five errors in the second try of this, then it is suspicious for malingering, and so, therefore, someone who is trying to look like they're having memory problems would be likely to deliberately make more than five mistakes out of 50 items.
Q. Do you have a note or memory as to how the plaintiff performed on that particular example you've just given us of the test?
A. Yes. He made three errors out of 50 items for the first trial and he had no errors at all for the second trial, and that would be -- indicate excellent motivation for testing.
Q. All right. Can you summarize for us the conclusions that you reached based upon the neuropsychological testing that you performed with the plaintiff, Jerry Wattron, during that period that you've described for us?
A. In the initial evaluation I noted that he was having difficulty with things such as his sensory motor integration speed, maintaining attention and concentration, the speed of his hands, his cognitive flexibility.
In addition to that, I noted that he was having some significant weaknesses in his attention, concentration, and working memory during the I.Q. testing, as well as somewhat lower performance than I would expect given his intelligence on the learning and memory testing with the weakness in new learning that we described previously.
Academic achievement was generally consistent with what I would expect from his education, with a relative weakness in spelling.
I noted that he was not showing or reporting significant signs of depression or anxiety, and that his psychiatric screening inventory was entirely within normal limits, that he and his girlfriend were reporting problems with things like concentration, memory, irritability, and quick, intense, inchangeable emotions.
His employee was reporting the irritability and inchangeable emotions, that the data was consistent with what I called a partially resolved mild traumatic brain injury as a result of the motor vehicle accident, and I noted that it wasn't clear at that point which of any of the symptoms would linger since we were within the first six months following the trauma, and that there's a usual 18-month to two-year post-trauma recovery period for head trauma.
I did note that his youth, health, motivation, and social support were going to be important aspects in his recovery.
Q. Okay. Some of the terms you used I have some difficulty understanding.
When you, for instance, talked about integration speed of something, can you give us an explanation in layman's terms as to what that finding meant?
A. Yes. That particular finding came from a task in which a patient does a form board blindfolded, and the sensory motor integration speed was how long it took him to do that, first with one hand, then with the other, then with both hands, as compared to other peers.
Q. Okay. You mentioned, at least with respect to some of these items, the comparison to things you had been told by Mr. Vondewalker --
Q. -- but overall, how did the results of the neurological testing -- neuropsychological testing compare with the history of the problems that Jerry was experiencing as given to you both by him and by the significant others that you interviewed?
A. The results of the testing were consistent with their reports and with the diagnosis of mild and partially resolved traumatic brain injury.
I was calling it partially resolved because I was seeing him six months after the trauma, which meant that he had had six months of healing and lessening of the symptoms before the time that I tested him.
Q. Okay. As far as your evaluation goes, does that conclude the steps that you told me about that you performed in order to reach that evaluation; the clinical interview, the interviews with significant others, reviewing the medical records, and performing the psychological testing?
A. Yes, and the last part of that is to sit down with the patient in a feedback session, and to give them a copy of the report, and to go over the results and recommendations.
Q. Okay. Before we get to that part, were you able to reach an opinion to a reasonable degree of neuropsychological certainty as to whether Jerry Wattron was, in fact, suffering from a brain dysfunction?
A. Yes. I believe that he was suffering from the classic symptoms of a mild head trauma, and that I came to that conclusion as a result of integrating all of the information that we've discussed so far.
Q. And as part of your evaluation, do you attempt to decide diagnostically what caused that brain dysfunction?
A. Yes. In part by ruling out other potential causes, such as severe depression, prior brain trauma, malingering, and, also, by looking at his symptoms in relation to the known symptoms of head trauma, and by also looking at both the onset and course of symptoms, which is an abrupt onset of symptoms which were uncharacteristic for him at the time of the trauma, following -- followed by persistence and, over time, some improvement of those symptoms.
Q. Based on all of those things -- excuse me -- with respect to the plaintiff, Jerry Wattron, do you have an opinion to a reasonable degree of neuropsychological certainty as a neuropsychologist as to what caused his mild traumatic brain injury that you've diagnosed?
A. I believe it was a direct result of the motor vehicle accident on May 11 of '98.
Q. Okay. And although you've given us the results of the neuropsychological testing, based on your entire evaluation, can you for the Ladies and Gentlemen of the Jury try to identify in layman's terms what the deficits were that he was experiencing when you saw him in 1998 as a result of the mild traumatic brain injury that was caused by the accident, and, of course, I'm asking that that be an opinion that you have to a reasonable degree of certainty as a neuropsychologist?
A. Certainly. In a practical day-to-day sense, he was having difficulty with his thinking being slower and harder, which meant that the same amount of effort was not resulting in the same amount of productivity.
He was having trouble staying focused, more difficulty with remembering details of things that he needed to remember in terms of following through on his work.
Emotionally he was more irritable, more easily upset. His emotions were more up and down, more quick and intense.
Physically at that point he was describing things such as dizziness, headaches, things of that nature.
That constellation of symptoms is characteristic and classic for a traumatic brain injury.
Q. Okay. You know, you mentioned earlier that in the neuropsych testing that you did, there was something to do with his either speed or fine motor coordination using his -- it sounded like hands or fingers or something --
Q. -- like that.
How does that relate to the findings that you're telling us that are find -- or things that he was suffering from as a result of the brain dysfunction?
A. His hands were somewhat slower and clumsier, not an unusual finding after a mild head trauma, and, in fact, in my reevaluation, I looked more specifically at fine motor coordination and found that same difficulty, that his hands were not as well coordinated as I would expect.
Q. Okay. I want to cover one more thing before we take a break. We've been going kind of hard here, but logically if we can finish with these recommendations that you had for his next step in his effort to rehabilitate, can you tell us what you determined that he should do and why?
A. I recommended some brief follow-up psychotherapy to assist him in implementing some of the strategies I was proposing, as well as to reduce his irritability and intense emotions, and to increase insight into the difficulties he was having.
And so I recommended a brief course of psychotherapy, which we proceeded with after the completion of the evaluation.
I also noted a number of suggestions in terms of reducing the impact of his problems with things like concentration and memory; things about minimizing distractions; planning more demanding tasks earlier before his mental and physical fatigue became more problematic; allowing for a prolonged response time because of his difficulty with verbal elaboration; avoiding time pressure because that seemed to negatively impact his performance; focusing on one task at a time; using normal memory aids; schedules, calendars, list of things to do, writing down what he has been promising; spotting and correcting his own errors; writing down arithmetic problems, things of that nature; keeping important items in one place so he doesn't spend a lot of time looking for them; using visual cues; demonstration, written notes, things of that nature to learn.
I also made some general lifestyle recommendations in terms of things such as that minimizing physical and emotional stress, fatigue, pain, hunger, and time pressure would also minimize his symptoms, and that he needed things, especially now in his life, such as exercise, rest, good nutrition in terms of the healing process, as well as reduced exposure to glare and harsh noise which might help to reduce the headaches.
I also noted that it was important for him to be less self-critical and to focus on prevention of recurrence of error rather than criticism of himself when he was making mistakes, that I was going to give him information about head trauma, and that I recommended a reevaluation in about a year to see the course of his symptoms.
Q. Are these recommendations that you made things that you have learned during the course of your professional career that are helpful to a patient who suffers from the traumatic brain injury, mild traumatic brain injury, that you concluded that Jerry Wattron had?
A. Yes. The reason I mentioned those specifically is because I found them to be helpful with my patients in regard to reducing the impact of the symptoms as they are hopefully healing over time.
Q. Okay. You know, we deal with medicine a lot in our lives, all of us.
Is this the type of injury that you can cure with, you know, medicine or operations or things like that?
A. No. Generally there is very little medical treatment, per se, for a mild head trauma.
Certainly, unless there is a pressing need, no one wants to enter the brain because that causes damage in and of itself.
There are certain medications that can help if, for example, emotional symptoms are extreme, but, generally, the medical treatment has to do more with trying to reduce impact of symptoms as opposed to actually curing the problem.
Q. So you're recommending things that enables the patient to cope with the deficits that you have learned that they have; is that the idea?
A. Yes, to help them understand and cope with them more effectively so that they aren't as inconvenient and frustrating in their day-to-day life.
Q. Well, how does a healthier lifestyle, like you talked about -- how does that relate to coping with this mild traumatic brain injury?
A. The major reason it relates to that, or two, one is because generally the patients I've seen have been in a whole body trauma and are in the process of healing and as a result of that, those type of lifestyle changes tend to facilitate healing.
Another reason that I recommend things like rest, exercise, nutrition, is that when patients are in extreme conditions, things such as fatigue, hunger, extreme emotional distress, their symptoms tend to become much worse and so one way of coping with the symptoms is to control those conditions and avoid those extremes in order to keep from aggravating their symptoms.
Q. How many sessions did you have with Jerry Wattron and over what period of time in order to perform this psychotherapy designed to facilitate his adjustment to these recommendations?
A. I saw him a total of four times, starting 11/24/98 and ending 2/11/99.
Q. Okay. And, in general, can you tell us what his progress was, that is, how well he seemed to do during those -- that time period and what he experienced in the way of any difficulties?
A. He did very well, and that was one of the reasons we were able to conclude treatment in just several months.
We went over the results and recommendations at the evaluation, talked about better ways to implement those.
He talked about stress and fatigue worsening his symptoms, and we discussed the implications of that, and ways to lesson stress and fatigue in order to lesson the expression of his symptoms.
We also deal -- dealt with some other miscellaneous topics. For example, he mentioned that he noted that he had been tending to speed and get angrier at other drivers since the trauma, and we talked quite a bit about the unsafe nature of that, particularly in regard to increasing his risk for further head trauma, and the importance of both monitoring his speed and keeping a tighter reign on his emotions when he was driving.
He was implementing the strategies that we talked about, and those seemed to be helping, and so we refined those a little bit.
He would do things such as start to leave himself more time between commitments so that he wasn't rushing and stressed everywhere that he was going, and that seemed to be helpful for him.
He mentioned that he was often too busy to eat, not just regular meals, but just to eat in general, and I discussed, again, the importance of regular nutrition, not only for healing, but in order to keep low blood sugar from worsening his symptoms.
Q. Okay. Was any part of your psychotherapy sessions that you encouraged him to have due to a concern about the impact that your diagnosis might have upon him after he learned that this is what he was suffering from?
A. Yes. In fact, in our first follow-up session we discussed specifically the emotional reaction to the diagnosis of head trauma.
My patients generally have mixed emotional reactions depending upon how worried they've been and what they thought could be causing it.
Many of my patients are secretly afraid that they're going crazy, and they're afraid to tell anybody that because they're afraid they're going crazy, and because suddenly they're memory and their concentration and their emotions are unfamiliar to them, and that's very disconcerting and at times almost panic inducing.
And so some of my patients are almost a little relieved to hear a diagnosis of head trauma simply because it gives them an explanation for what's going on with them, and it's a diagnosis that does have a somewhat positive prognosis, meaning that it's not degenerative, it's not like Alzheimer's, it's not going to go downhill until someone can no longer take care of themselves.
It's an injury and tends to have a healing course, and I do emphasize that as optimistically as I can, because I want patients to work positively towards that and to be expecting some resolution of their symptoms over time.
Q. But are there other times when that news of the diagnosis can be an emotionally traumatizing thing for a patient?
A. Certainly. It's scary to hear that there's something wrong with your brain. People depend on their brains a lot more than they think until they're injured, and to suddenly be unfamiliar to yourself in terms of your thinking and emotions and behavior can be a very frightening and distressing experience.
MR. KNIGHT: Well, to lessen fatigue on all of us who have been sitting here, especially you who have been doing most of the talking, let's take a break.
BY MR. KNIGHT:
Q. Okay. We've had a little break, and there are a couple of things I thought of that I wanted to cover based on things we've already talked about and then we'll move on to the next area.
When you did the neuropsychological testing that we talked about, can you tell me how long that took?
A. Just a moment. I saw him for two hours on 10/1/98, three hours on 10/7/98, and three hours on 11/5/98, and there was an hour feedback session on 11/10/98.
Q. And when you say you saw him, that meant you were with him observing him during all of that time?
Q. Okay. We used that one illustrative example of the California Learning -- Verbal Learning test, and you said that he had a result that indicated he was significantly impaired.
Have you seen worse results than that on that test in the course of your work?
Q. Okay. And better ones, of course?
Q. Is there any, to your understanding and belief as a neuropsychologist -- is there any threshold below which you would have to reject that test as being invalid when given as part of a battery of the tests as you've given it here?
A. Not generally. Now, usually if you're using the threshold, it's because below that you're assuming that the patient was not putting in full effort or somehow exaggerating his problems, but I didn't see any indication of that, and, therefore, I didn't think that that was the reason for the result on this.
In addition, during the process of the testing, it was clear to me that he was trying, that he was after a long pause coming up with more correct answers, and so that, while his performance was impaired, he obviously understood the demands of the task and appeared to be putting forth his full -- full effort on that, and, therefore, I would be unlikely to reject the results but rather interpret his poor performance as a valid performance.
Q. So if I understand correctly what you're telling us, is that the only reason you would reject a result is if there was reason to believe that the patient either was not putting forth a full effort or was faking a response or something like that; is that the idea?
A. Yes, or that there was some problem with the administration of that particular test that would cause me to feel that the administration was invalid and, therefore, to discard it.
Q. But based on your own observations of the test taker, Mr. Wattron, and the other aspects of the battery of tests which give you evidence of the effort that the person is putting in and their forthrightness, you would not reject it because you had that other evidence to indicate he was -- indicate he was doing his best effort?
A. Yes, and that he clearly understood the demand of the task.
His answers were not wrong. They were simply limited in terms of his memory, but he was clearly repeating back the words. He understood that that's what he was supposed to do, and, in fact, often he would say “Let me think,” and then have a long pause and then come up with a couple of more correct answers, which lead me to believe that he was having some trouble pulling up the words that he wanted, but that he was, indeed, trying.
Q. Okay. And then earlier I asked you about the dizziness and whether your review of Dr. Eilers' records had given you any indication of -- as to his diagnosis with respect to that aspect of the problem that Jerry Wattron was experiencing.
Let me show you what was previously marked as Plaintiff's Exhibit No. 10 -- oh, we don't need to put it up -- just No. 10, and ask you if that was one of the documents that you would have reviewed from Dr. Eilers' records.
A. Not at the time of the evaluation because this was done following that. This was a follow-up on Dr. Eilers' original evaluation.
Q. Okay. You have told us -- and we haven't gotten to it yet, but you've told us several times that there was a later evaluation that you did of Jerry Wattron; correct?
Q. Okay. Do you know whether at some point in time you've seen this or -- Exhibit 10 or not?
A. I don't believe so.
Q. Okay. Looking at it, though, about midway down where Dr. Eilers is reporting about the dizziness, if he determined that that dizziness was due to labyrinthitis, would that be in any way inconsistent with your own observations?
A. No. Dizziness due to labyrinthitis is a common related symptom that my patients experience because their whole head is in the trauma, not just their brain, but also the balance mechanisms of their inner ear, and the same motion which can damage and disrupt brain functioning can do the same to the balance system of the inner ear, which is called the labyrinthine system.
Q. So if the dizziness was due to labyrinthitis of the ear, what would that tell you with regard to the consistency of the force involved in the impact that caused the brain injury that accompanied this labyrinthitis?
BY THE WITNESS:
A. As I said, it's a common associated symptom because the brain as a whole and the head as a whole is involved in this type of a trauma, and, therefore, it's not unusual to have patients complain of things such as dizziness because the same force which can damage the brain can also damage the inner ear.
BY MR. KNIGHT: