Nursing Home Deposition 4-Plaintiff's Deposition of Pschologist and Nursing Home Administrator - Part 3
Q. Okay. Now, the sessions of psychotherapy that you told us about that were designed to help Jerry Wattron cope with his brain injury that you had diagnosed ended in about early 1999; correct?
A. Yes. February 11, 1999 was the discharge session.
Q. Did you have occasion to conduct a later evaluation or reevaluation of Jerry Wattron to focus on the status of his deficits from that brain injury?
A. Yes. I saw him again beginning on October 9 of 2001.
Q. So that would be roughly three years after the first evaluation that you did; correct?
Q. Can you tell us whether you conducted essentially the same type of evaluative steps that you have told us about that you performed in 1998 when you saw him?
A. Yes. There were a few refinements to the battery, so a couple of the tests were different.
I also sought a few more medical records. I spoke to the same significant others, and the rest of the process of the battery was similar.
Q. Okay. What I would like to do is have you focus for us on the differences or changes that you saw when you conducted each of these steps when compared to the time that you saw Jerry Wattron in October of 1998.
So let's look at first, when you talked to him, what did he tell you?
A. Overall, I was seeing indications of improvement in his symptoms over time, as is typical and would be expected for a head trauma.
For example, he was mentioning that he was no longer having trouble with dizziness, that his concentration seemed better, that his headaches had largely resolved.
He did note that he was continuing to have some problems. He mentioned that he still had that tingly sensation on the top of his head, almost a pressure feeling, that he was still having some trouble with his thinking being slow and hard, some problems with forgetfulness, memory, things of that nature, some difficulty with word findings.
He talked about an example where he said to someone, “I don't usually drink toast in the morning.”
Some -- still a little problem with reading it and having to reread things to understand it.
Emotionally he mentioned that he still is having some difficulty with irritability, but that overall, he had seen an improvement in his symptoms over time.
Q. Okay. Now, you mentioned that this is consistent with the traumatic brain injury.
Can you tell us whether that helps you when you see that type of progress -- helps you distinguish a deficit or deficits due to traumatic brain injury from deficits that are due to some other causes of brain dysfunction?
A. Yes. One of the advantages of a reevaluation is that you get an opportunity to look at changes in symptoms.
One of the things that's characteristic of a change in symptoms for a head trauma is an improvement over time, and then a plateauing or an evening out of mild symptoms.
He clearly showed improvement both in his report, as well as the reports of significant others, and in his testing results, along with some lessened but lingering symptoms, particularly in regard to his thinking and emotions.
Q. So if you have somebody who is having a brain dysfunction because of something like -- I may be using wrong terms, and feel free to correct me, but senility or a premature senility or Alzheimer's disease, those type of things -- does the fact that the patient improved from 1998 to 2001 have any bearing on determining whether it's more consistent with the type of thing that you diagnosed as opposed to one of those kinds of things?
A. Well, certainly, as I mentioned, the course of head trauma is a healing, an improving, and then a stabilization, sometimes, of lingering symptoms.
This is opposite of the course of something like a dementia such as Alzheimer's where you would expect to see slow but steady decline, and over the course of three years you would clearly see a decline in things such as memory and cognitive performance.
In general, I found his test scores to be either stable or improving over time, and the reports of himself and his significant others and his behavior with me during testing also suggested a lessening of his symptoms.
Q. Okay. What about when you talked to the same two significant others, what differences and similarities did they give you with respect to his progress of his situation?
BY THE WITNESS:
A. His girlfriend noted that she had seen some improvement, that his concentration seemed to be okay, that he was no longer confusing names, that he didn't seem moody or depressed.
She did note some ongoing symptoms, including the discomfort pressure in his head, that it is still a little slower and harder for him to think, that he was still having problems with memory, that she would tell him something and later he would say that they hadn't talked about it, and that he did tend to become agitated more easily.
He would get up, walk around, act out his agitation and that that was unusual for him, that wasn't something that he had done before the trauma.
She mentioned that the changes she saw were not like him, but that as I described, she was noting improvement in him.
I also spoke to his employee again, Mr. Vondewalker. He mentioned at that point he had known Jerry for 10 years and saw him every day.
He continued to note some difficulty in terms of being forgetful, that he is somewhat irritable, that his emotions seem more quick and he is easily upset, that he did see specific improvements in his physical symptoms in terms of that he wasn't describing anything like fatigue or dizziness, and generally some stability in the other symptoms over time.
BY MR. KNIGHT:
Q. You mentioned that you conducted the neuropsychological testing, and that overall it showed improvement.
Let me ask you whether there were some test results that varied from the earlier tests when you used the same tests, some showing better results and some showing worse? Is that true or not?
A. Yes. In terms of the neuropsychological testing portion of this, I mentioned that he was currently showing mild problems with his fine motor coordination and with his visual scanning speed, but that overall, he had shown improvement in his neuropsychological functioning, particularly for the tests that were consistent evaluation to evaluation, such as the subtests of the Halsted-Reitan.
Q. In your experience, is some variation perfectly natural when someone takes the same tests three years apart, and let's just assume a person who doesn't even have any kind of improving or worsening brain dysfunction, but if you take them, are you going to have some variation from over three years in those tests?
A. Yes. You don't expect someone to have exactly the same performance.
What you look for is a general trend in terms of improving or declining over time.
Q. Okay. So if, in fact, some specific test scores were lower in '01 than they were in '98, is that in any way inconsistent with your evaluation that the patient had improved overall?
A. No, because you would expect to see some variability in the test scores.
You would look more for an overall trend of the test as a whole in terms of improvement or stability versus decline.
Q. Okay. Now, you mentioned that there was still some lingering deficits, and you've explained what some of those were; correct?
Q. Can you tell us to a reasonable degree of medical -- or excuse me, a reasonable degree of neuropsychological certainty as to whether those deficits which existed in '01 as a result of the motor vehicle accident in May of '98 were -- are permanent or will continue to resolve and go away?
A. At this point I expect the deficits to be permanent for a couple of reasons. One is because it's been over three years since the time of the trauma, and from what we know of the natural course of healing of a brain trauma, that is above and beyond the natural course of healing.
The other is that he already had a course of psychotherapy and was, at the time I was seeing him at the reevaluation, consistently implementing strategies which were helping him to minimize the impact of his deficits, and, so, therefore, I felt that he was functioning and coping very well and that as a result of that, I expected -- and his healing had concluded, and so as a result of that, I expected any mild deficits to linger over time.
Q. Can you give us to a reasonable degree of neuropsychological certainty a prognosis for Jerry Wattron's future?
What's in store for him with respect to these deficits which remained at the conclusion of your '01 inter -- your '01 evaluation?
A. I felt that he would likely continue to experience mild problems with things such as his memory, his emotional control, things of that nature, that he was more aware of those and compensating more effectively for them, but that those would be -- likely to be problematic for him and would also be likely to be worse under the conditions we described earlier; stress, fatigue, hunger, pain, things of that nature.
Q. Okay. When you evaluated Jerry Wattron, did you see any signs of a person who was predisposed or prone to depression or anxiety?
A. No. In fact, I found no indication of significant depression, anxiety in either evaluation, either on the self-report inventory, such as the Beck Inventories, or on the MMPI-II. He had a very normal and psychologically healthy looking profile for all of those measures on both occasions.
Q. Is it true that any person can end up suffering from depression or anxiety given enough stress? As a neuropsychologist, can you tell me whether that's an accurate statement or not?
A. Certainly, anyone can be prone to depression and anxiety.
People with head traumas are somewhat more predisposed towards that, which is one of the reasons that that's evaluated as part of the process of evaluation.
The reason for that is that head traumas tend to lessen tolerance for stress and increase frustration, and, as a result of that, some people have a little more difficulty coping with the regular ups and downs of life following a head trauma.
Q. Okay. You had recommendations after that second evaluation for him to engage in certain behaviors long term; is that correct?
A. Yes. I was basically stating that I felt that the compensatory strategies he was using were effective, but that he would need to continue to consistently implement them in order for them to continue to reduce the impact of his lingering symptoms.
Q. Do you have an opinion, to a reasonable degree of neuropsychological certainty, as to whether Jerry Wattron might or could incur future medical expense as a result of the permanent deficits from his traumatic brain injury?
BY THE WITNESS:
A. In regard to medical expenses, his physicians would probably be a better source of information in terms of that.
In terms of psychological expenses, he -- he is at somewhat greater risk for needing professional assistance in dealing with things such as life traumas, however, I felt at the time that I completed this evaluation that he was coping well.
BY MR. KNIGHT:
Q. Okay. And when talk you about -- I'm sorry, I said medical by mistake instead of psychological, but when you talk about psychological expenses, would we be talking about such things as the psychotherapy sessions that you worked with him in to help him develop those coping strategies in the first place?
A. I felt that I needed to keep that door open because it is my experience that persons who have had this problem often do need future treatment, but at the time that I concluded the evaluation, I felt comfortable that he was not in unusual emotional distress and was compensating effectively for his symptoms.
So I didn't feel a need for future treatment at this point.
BY MR. KNIGHT:
Q. You have told us that this traumatic brain injury resulted in certain deficits which are consistent -- several times you said consistent with traumatic brain injury.
Q. Are you familiar, based on your education and training and experience as a neuropsychologist, with the mechanism by which traumatic brain injury occurs and the dynamics of that injury, and its natural course?
Q. Can you tell us whether with respect to this traumatic brain injury there is a mechanism that's referred to as acceleration-deceleration injury? Are you familiar with that?
Q. And can you tell the Ladies and Gentlemen of the Jury what that is insofar as it relates to the kind of injury that you found that Jerry Wattron had?
A. Certainly. The brain itself is not very hard. It's about the consistency of firm Jell-O.
Generally within the skull it's fairly well protected because it's surrounded by several different layers and then by the skull, which is very hard, however, in the course of something such as a motor vehicle accident, what happens is what they call an acceleration-deceleration type of injury, meaning that if you're driving along at 30 or 40 miles an hour, your head is also going 30 or 40 miles an hour, and if you stop very abruptly, as can happen when two things hit each other and suddenly stop, your brain keeps traveling forth at that same speed, and it bounces, first off the front of your head and then off the back of your head, as a result of those physical forces.
There's also a rotational type of thing that can happen because of other laws of physical force.
As a result of that, the brain itself is pulled and torn. The axons, which are the -- kind of the long string part of the nerve fibers, can be pulled apart and damaged, as well as the brain striking the inside of the skull, which isn't always smooth because your facial bones are there, and so the parts of the brain are basically rubbed and scraped against the bony inside of the skull, and the brain itself is shaken violently within the skull.
As a result of that, the nerve cells can be damaged, the brain can swell. In more extreme cases, the brain can bleed and lead to something like coma, for example.
Q. Okay. You talked about rotational --
Q. -- movement, as well as the acceleration and deceleration.
Is that because of the fact that the head -- it sounds like an old song, the head is connected to the neck, which is connected to the rest of your body?
A. Yes, and the head can pivot around, as well as back and forth, and in the course of something such as a motor vehicle accident, that frequently occurs.
Q. Now, you mentioned that -- it sounded like you were talking about two different ways -- at least two or three different ways that the brain can be injured during this acceleration-deceleration; is --
Q. -- that correct?
A. That is true. In addition, there is also the additional injury if the head is struck in some way.
You don't need to strike your head in an acceleration-deceleration injury to sustain a mild brain injury, but many times people also do, and at that point there's one more mechanism of injury, which is the point of impact on the brain and on the opposite side of the brain when someone strikes their head.
Q. Okay. Incidentally, is this traumatic brain injury that you diagnosed, is that a recognized diagnosis within the fields of medicine and neuropsychology?
A. Yes. Certainly all fields acknowledge that there is such a thing as hurting the brain and that hurting the brain has a recognized constellation of symptoms.
Q. And is there a generally accepted catalog of mental disorders and brain dysfunctions that doctors and neuropsychologists and psychologists use in their work as professionals?
A. There are several different volumes. The psychiatrists and psychologists are generally using the Diagnostic and Statistical Manual of the American Psychiatric Association.
The medical profession is generally using a different sort of text.
Q. Okay. Is that Diagnostical and Statistical Manual, edition number -- or Roman Numeral IV, is that the one that's up-to-date or not?
Q. And does that DSM-IV contain the traumatic brain injury as a recognized diagnosis or mental disorder of brain dysfunction?
A. Yes, in that it has a diagnosis of cognitive disorder, meaning difficulties with thinking which can be due to traumatic brain injury.
They're in the process of standardizing a psychological definition of postconcussion syndrome, which contains the physical, cognitive, and emotional symptoms that I've discussed so far.
Q. Now, one of the things that I think I heard you tell us is that the -- when the head moves forward rapidly or backward, and when the vehicle suddenly stops, that the -- part of the brain may actually come in contact with some bony structures that can injure it. Is that what you said?
BY THE WITNESS:
A. Yes. The inside of the skull is not smooth. It contains many of the facial bones, for example, and as a result of that, when the brain is thrown violently back and forth, it is scraped along these bony ridges, and that is one mechanism of injury.
BY MR. KNIGHT:
Q. Okay. Would it help to illustrate your testimony as to this -- these bony structures that you're referring to, to -- to use a model representation of the -- of the human skull that would show the inside of the skull that contains those bony structures you're talking about?
A. That may be helpful for the Jury to see what the inside of the skull looks like and why the brain rubbing against it could potentially damage it.
BY MR. KNIGHT:
Q. Okay. Then I would like you to take a look at what has been marked as Plaintiff's Exhibit No. 18, and this is just for demonstrative purposes, as you've just indicated, which is a represent -- appears to be to any of us, a representation of a human skull, and I'll ask you to look at it, and we've opened the connection so that you can lift the top of that skull off to look at the inside at the bony structures and perhaps turn it around there.
(Plaintiff's Exhibit No. 18 marked.)
BY THE WITNESS:
BY MR. KNIGHT:
Q. And --
A. This is the inside of the skull. You'll notice that there is a bony ridge here which cradles the bottom of the brain.
The temporal lobes --
Q. Can you do this --
A. -- go in there.
Q. -- can you stand up and tilt the lower part of that skull toward the camera a little better and then tell us what -- you can use my pen here if it will help to point to what you're referring to as those bony structures that part of the brain may come in contact with in a traumatic brain injury due to acceleration-deceleration.
A. This is the bottom inside of the skull. The top inside of the skull is pretty smooth, as you'll notice, but the bottom inside of skull has ridges here, here, here, which -- in which the brain sits. (Indicating.)
When the brain is pushed forward rapidly and bounces back rapidly, it scrapes along those bony ridges, and that's the reason that you often find, for example, damage to the temporal lobes which have to do with memory because those lobes are contained there and they're being scraped along those bony ridges.
Q. Okay. In the course of your study of anatomy as a neuropsychologist and in the work that you've done as an intern, have you become familiar with that anatomy of the skull, in the human skull?
Q. And is this a fair representation for illustrative purposes of those bony prominences?
A. Yes. That seems very accurate, and in looking at it you can see why, if the brain is resting in there and it suddenly is pushed forward, that bottom pieces will be scraped by those ridges.
Q. Okay. Now, there are certain parts of the brain in all of us that are resting in that particular part of the skull; is that correct?
Q. And is it true that the functions of the brain -- you can be seated if you're more comfortable or you can stand, but I think for now we might be through with that, and I'll push it over here.
Q. We'll reassemble the poor fellow.
Are there certain functions of the brain that are associated with certain parts of the brain?
A. Yes, in general. The brain has both focal and diffuse functions, so, for example, the function of memory is focally, meaning locally, in the temporal brain, but it is also distributed throughout the brain as a whole.
On the other hand, the functioning of the right hand, for example, is in one very specific part of the brain, and if that part of the brain isn't damaged, there will be no change in the functioning of the right hand.
Q. So earlier when you told us that there were certain deficits that you saw in Jerry Wattron which were consistent with traumatic brain injury, was that, in part, based upon your knowledge of the fact that certain brain functions are associated with certain parts of the brain that are more often involved in this acceleration-deceleration injury?
A. Yes, and as I mentioned, part of the brain is very focal, meaning that there are certain functions that are localized in a very small piece of the brain, and if that small piece of the brain isn't hurt, they'll be fine.
There are other functions such as concentration, for example, that are distributed through the brain as a whole, and so a diffuse injury, such as the injury that would come from a motor vehicle accident in which the brain as a whole is involved, will often have problems with things like concentration and memory.
Focal injury would be something like a stroke, for example. So you might notice that someone who has a stroke on the right side of their brain will have problems with the motor part of the left side of their body, but the right side of their body would be much better or would not be affected.
And so, as I said, some parts of the brain are very specific and there are some functions which are more generally distributed throughout the brain.
Q. Now, when you talk about this diffuse type of injury, the first thing we've just talked about here where the certain part of the brain hits these bony structures, that's more of a focal injury; right?
Q. Why wouldn't something like that be seen on an MRI or a CT scan?
A. Again, for the same reason, that the damage is microscopic, and the CT and the MRI are looking at the structure of things, not function, and changes that are microscopic generally are not seen on a CT or an MRI.
One of the mechanisms of injury is what is called axonal shearing, axons being the long part of the nerve fibers that because the parts of the brain move at somewhat different rates, the two parts of the brain can move like this, for example, and when that happens, the dangling axons can be pulled and torn, and as a result of that, the patient can receive what's called a diffuse injury, and that's a common mechanism of injury in a trauma in which the brain as a whole is affected, such as a motor vehicle accident, as opposed to something in which only a part of the brain is affected, such as a stroke, for example.
BY MR. KNIGHT:
Q. When you talk about this diffuse axonal shearing, these axons, how -- how big is an axon and the neuron it's connected to, if you know?
A. They're microscopic --
A. -- itty bitty. There's millions of them.
Q. I mean, when we studied cells in high school and things like that, is a neuron basically a cell?
A. A neuron is a nerve cell. It consists of a cell body, then a long fiber thing called the axon, and then an end part that helps to connect to the next nerve cell.
It's that long fiber part called the axon that is vulnerable to that type of a shearing injury.
Q. And would it -- what I want to ask you is, when you talk about the shearing injury, does that shearing injury occur because of different rates of movement of different parts of the brain?
A. Yes. The reason a shearing injury occurs is because different parts of the brain move at somewhat different rates, meaning that one part will slide over the other, and it's that sliding that can pull apart and damage the axons of the nerve fibers.
Q. Well, which direction do these axons generally run in? I mean, do they -- do you know?
A. They generally run downward because they're helping to bring messages from the brain to the rest of the body, and so they run up and down.
Q. So if you have neurons in an upper part of the brain, then these axons kind of dangle downward and through the lower part of the brain towards the brainstem?
Q. Would it help to illustrate this for the Ladies and Gentlemen of the Jury to have a little representation of the brain that you can refer to?
A. If they would find that helpful.
Q. And let me show you what has been marked as Plaintiff's Exhibit No. 17, a model here, and I'll let you take the top off of the skull of that model to see if there is, in fact, a model of the brain inside.
(Plaintiff's Exhibit No. 17 marked.)
BY THE WITNESS:
A. All right.
BY MR. KNIGHT:
Q. And it does; is that correct?
A. The two hemispheres, the right and the left hemisphere.
Q. Okay. Would you take that one hemisphere that has the entire half of the brain in one piece -- I know the other one is in a couple of pieces -- and hold that up in a way that perhaps the jurors can see the inside of it, and can you tell us -- and feel free to use that pen that I have there -- when you talked about different parts of the brain that may move at different rates, can you illustrate for the Ladies and Gentlemen of the Jury which parts of the brain you're referring to there?
A. For example, the top of the brain can move at a different rate, while the bottom of the brain can stay a little more still. As a result of that, the nerve fibers can be pulled and torn.
Q. So would the nerve fibers -- if I can use the pen and you hold that toward the Jury.
These nerve fibers that you talked about, if they exist -- they exist throughout the brain; correct?
Q. But those that are up above in this upper part of the brain, would tend to descend down toward the brainstem area?
Q. So if this upper part of the brain shifts and those dangling axons are there, they can actually tear apart?
A. Yes. They've done studies where they took a Jell-O made into the consistency of the human brain and bashed it really hard, and what they found is basically small tears, almost looking like stretch marks than tears, in the brain itself because of that axonal shearing.
Q. How many of these neurons with axons are there in the brain?
A. There are millions of them.
Q. Okay. And go ahead, you can try to put our fellow back together there, if you will.
Q. And when we talk about, as you have, a head trauma or brain injury, is it -- is the function of the brain made up of the effective millions of neurons that carry messages?
A. Yes. The brain basically works by conducting messages back and forth through the brain and the rest of the body.
The neurons are the mechanism by which that is accomplished, and so when they are damaged, that is the reason for changes and things such as thinking and emotion and behavior after a head trauma.
Q. Okay. And how good are those neurons at healing and repairing themselves, if you know?
A. Generally it's thought that the neurons don't have the ability to replace themselves, and so, therefore, that's one of the reasons that you sometimes have lingering symptoms of head trauma.
The brain does have the ability to make new connections between existing neurons, bring dormant or not used brain cells into function, and so, therefore, the brain does have some ability to heal itself after a trauma.
BY MR. KNIGHT:
Q. Okay. So the brain can develop new connections, but the old connections once broken, are broken?
A. Are broken.
Q. Okay. And then even though the brain has the ability to develop new connections, from a functional standpoint it can't -- does that take a considerable amount of time?
A. It can take some time, and, also, things like bruising and swelling of the brain can also resolve with time, and that's one of the reasons that you see improvement after a head trauma despite the fact that the brain is not replacing the cells that were damaged.
Q. Okay. But in addition to the fact that taking considerable amount of time, there are some deficits that linger because the brain simply doesn't -- isn't able to replace that function?
BY MR. KNIGHT:
Q. I want to ask just a couple of things to complete the -- complete the direct examination here.
Back at the time we were talking about the neuropsychological testings, was one of them called a Picture Completeness Test or something like that? Did I get that right?
A. That's one of the subtests of the Wechsler Adult Intelligence Scale.
Q. Oh, I see. And did his scores -- Jerry Wattron's scores change from the evaluation to the revaluation on that part of the intellectual assessment test?
A. Yes. That was, I believe, the one score that had a significant decline.
Q. Can you explain that decline and why that is not inconsistent with your evaluation that he had a brain dysfunction due to traumatic brain injury which had improved between the two evaluations but still had some lingering deficits?
A. Well, his initial score on that was quite high, and it's not unusual when a score is retested that's quite high for it to come closer to the norm.
They call that regression to the mean, and it's a statistical concept.
In addition, this had to do with basically discriminating fine visual detail. It's also possible that he was having some mild trouble with that over time.
Q. Earlier when you told us that you made a determination as part of your evaluation that Jerry Wattron did have a brief period of altered consciousness at the time of the motor vehicle accident, is that also an opinion that you hold to a reasonable degree of certainty as a neuropsychologist?
MR. KNIGHT: Thank you. That concludes the direct examination.
MR. DOMBROWSKI: Hi, Doctor, my name is Jerry Dombrowski. I represent Erik Crompton in this case. I would like to ask you some questions.
THE WITNESS: Yes.
BY MR. DOMBROWSKI:
BY MR. DOMBROWSKI:
Q. Doctor, have you published any articles or written any book chapters on head trauma?
Q. And, Doctor, you work at the Paulson Center now?
A. That's one of my current contracts.
Q. And Dr. Eilers was back in '98, and still is, the director at the Paulson Center?
A. I'm not sure if he's still the director. He hasn't had an office here for a couple of years now. I'm not sure of his current status.
Q. Okay. Prior to this referral in 1998, it's fair to say that Dr. Eilers referred at least 100 cases to you?
A. I would say that would be accurate, at least 100.
Q. And after 1998, is it fair to say that Dr. Eilers referred numerous cases to you?
BY MR. DOMBROWSKI:
Q. And when we say referrals from Dr. Eilers, we're talking about the same type of workup you did with the plaintiff here; right?
A. Generally. I've gotten other types of referrals from Dr. Eilers, for example, patients with chronic pain, but not suspected brain dysfunction.
Q. Okay. When you started at Paulson or started working at Paulson, you treated exclusively children?
Q. And then over a period of time you started treating adults, and today you treat adults and children?
Q. And you first saw the plaintiff here in 1998?
Q. Before your treatment of the plaintiff or during your treatment back in 1998, did you ever actually review the MRI report or CT report?
A. No. At that point I had the information that those were unremarkable. I didn't see that any other information from them would be helpful.
Q. Okay. Back in 1998, before you saw Mr. Wattron or during your treatment, did you ever actually review the emergency room records?
A. No, not at that time. That was one of the refinements to the battery, that I did that more extensively over time and I reviewed those in his reevaluation.
Q. Did you ever at any point review any of Mr. Wattron's school records?
A. He had stated that he graduated, was an average student, did not have any history of learning disability or need for special services.
At that point that was adequate information for me and I didn't need the original records.
BY MR. DOMBROWSKI:
Q. Is your answer no to that question?
BY MR. DOMBROWSKI:
Q. Doctor, you talked about the emergency room records themselves, and the first time you looked at those, actually, was 2001?
Q. Okay. Now, it's fair to say that emergency room physicians have training and experience with treating patients who actually have a head trauma or traumatic brain injury?
A. As a general rule, depending on the doctor.
Q. But normally in a busy emergency room, you would expect an emergency room doctor to come across many patients who do complain of headaches or indeed do have traumatic brain injury; correct?
A. I imagine so, although I am sure there is variability in that.
Q. As far as the emergency room records that we previously talked about on May 26, 1998, when Mr. Wattron came into the emergency room, he actually was not experiencing any symptoms of dizziness when he came in; correct?
A. That was his report, that he was in because he was concerned about those persistent symptoms, but not at the moment.
Q. Okay. And when the emergency room physician stated, “Orientated times 3,” what did that mean?
A. That meant that he was oriented to person, place, and time. He knew who he was, where he was, the general time.
Q. Okay. And “HEENT,” H-E-E-N-T, what does that mean?
A. That's a medical abbreviation. My best thought on that is head, eye, ears, nose, and throat --
A. -- I believe.
Q. And after the emergency room doctor put HEENT, he put “Normocephalic and atraumatic.”
Do you know what that means?
A. Normocephalic meaning that his head was not an unusual size, that it was not too big or too small, as opposed to microcephalic or macrocephalic.
Q. How about atraumatic, what does that mean?
A. Atraumatic generally means without trauma. I'm not sure how the doctor was applying it in that way.
Q. All right. And down a ways on that emergency room record, the doctor noted “No battles, no raccoons, no lesions, no facial tenderness”; correct?
A. Uh-huh, yes.
Q. Okay. Now, what does it mean, no battles and no raccoons?
A. I don't know what that means. I haven't heard those expressions before.
Q. Okay. Below that, the doctor indicated, “There is no nystagmus noted on the ocular examination.”
What does that mean?
A. Nystagmus is generally an abnormal eye movement that is tested for by the doctor, for example, having the patient follow his finger.
Q. And this doctor found no evidence of that?
A. That's what he wrote.
Q. Okay. And then it goes on to say “The tympanic membranes are normal.”
Do you know what that means?
A. Tympanic membranes are the membranes of the eardrum.
Q. And then he went on to say that “The neck was supple and a full range of motion of the neck”; is that right?
A. I'm sorry, I'm not looking at that. If that's what you say it says.
MR. KNIGHT: I have a copy if you want.
MR. DOMBROWSKI: Thank you.
MR. KNIGHT: The other one, remember, was on the screens, so I'll just give you a copy.
BY MR. DOMBROWSKI:
Q. Okay, Doctor, it's toward the middle. It says, “Neck supple, full range of motion.”
Do you see that?
Q. And that means, apparently, that he -- the doctor had Mr. Wattron have his neck go all the way around and there was no limitation on that range in that particular motion; right?
A. That's generally what full range of motion means.
Q. Now, under “Neurologic,” the doctor stated “Reflexes are symmetrical. The patient is ambulatory without ataxia.”
Do you know what that means?
A. Reflexes symmetrical meaning that the reflexes were similar on both the right and left side of the body.
Ambulatory meaning he could walk without ataxia, meaning that he wasn't having significant problems with severe balance problems, for example.
Q. Okay. And, Doctor, up a ways it says “Review of systems,” and then it's got a colon, and it says, “No other symptoms and/or complaints at this time.”
Do you see that?
Q. So that would mean apparently the only complaints Mr. Wattron had 15 days after the accident was intermittent dizziness, that he wasn't even experiencing at the time, and apparently on the next page, pain on the top of his head; right?
A. Well, they also referred back to the initial triage evaluation. At that point he was also complaining of hard to stay focused, numbness on the top of his head, and headache.
Q. But he was not experiencing headache at that time; correct?
A. No. He was saying that that's one of the symptoms that he had had since the trauma but not at the time.
Q. Right. Now, this phenomenon of pain on the top of the head, that's not an indication of traumatic brain injury, is it?
A. It depends on more specifically what the patient means by that.
He could be describing a sensory change, which would be more medical.
He could be describing a pressure headache problem, which could be related to head trauma.
Q. Well, I'm just talking -- when he says he had pain on the top of his head, that is not an indication of traumatic brain injury; rather it's an indication that he might have stiffness or a problem in the neck; correct?
A. Again, I think that there can be a number of reasons for that.
I don't think he was talking about pain on the top of his head as much as he was numbness on the top of his head. That's more likely to be nerve and sensory related.
Q. Okay. Have you seen records where Mr. Wattron actually did complain about pain on the top of his head?
A. Not pain. He talked of headaches and he talked of a pressure -- it felt like a band around his head -- and of numbness on the top of his head.
I don't know if he ever talked specifically of pain on the top of his head. I don't recall that specifically.
Q. Now, on that triage page, counsel did not go through this with you, but there's a “Revised trauma score.”
Do you see that?
Q. What is a revised trauma score, do you know?
A. I don't know. It might be idiosyncratic to that particular triage.
Q. Okay. So you don't know -- when he circles 12, you don't know what that means?
A. I don't know if he's talking about a Glasgow Coma Scale. That sometimes uses those same numbers.
I don't know what -- how -- what their basis for the revised trauma score is.
Q. Okay. Now, to the right of that there's a pain scale; correct?
Q. And I'm assuming that pain scales go from one, minimal pain, to 10, a lot of pain; correct?
A. Yes, that's generally how those mean.
Q. And it appears that either the doctor or whoever was doing the initial triage evaluation put a zero with a line through it; correct?
A. Yes, and it -- which is consistent with Jerry's report that he was not having pain at the time that he went to the emergency room.
Q. Right. So there was no pain at that time?
Q. Now, with the diagnoses, there's no diagnosis there of traumatic brain injury; correct?
A. No. “Head contusion and persistent dizziness.”
Q. Okay. Now, as far as the head contusion itself is concerned, there was actually no head contusion found; correct?
A. That was the discharge diagnosis from the doctor in the emergency room.
Q. Right. But there was no cuts or bruises or anything on Mr. Wattron's head; correct?
A. You would have to ask the doctor what he meant by head contusion. He is obviously using it as a discharge diagnoses, and so --
A. -- he must have some basis for it.