Nursing Home Deposition 4-Plaintiff's Deposition of Pschologist and Nursing Home Administrator - Part 4

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BY MR. DOMBROWSKI:
Q. I'm asking you, do you see any indication that there is any contusion to Mr. Wattron's head from review of the emergency room records?
A. Other than the doctor using it as a discharge diagnosis, it's difficult for me to say what his basis for that was, but they generally won't give that without some basis.
BY MR. DOMBROWSKI:
Q. Doctor, do you see anywhere in the emergency room record, other than the discharge diagnosis of contusion, that there was any evidence of any type of contusion on Jerry Wattron's head 15 days after the accident?
A. Not from what I can tell, but I don't know what the doctor was thinking in making that discharge diagnosis.
BY MR. DOMBROWSKI:
Q. Doctor, did Mr. Wattron ever complain or is there any indication that he ever complained to anyone at the emergency room that he was having any memory problems?
A. No.
Q. Moving on, Doctor, you had sent a letter to Dr. Jerry Sweet, another psychologist, on December 17, 2002; right?
A. Yes, I believe that was the cover letter for the release of the raw data.
Q. Okay. What were you pointing out to Dr. Sweet in that cover letter? I can hand it to you.
A. Thank you. That would help. I have a copy of it in here somewhere.
I was noting some minor corrections in the data because I had gone through it thoroughly in my transmitting of it to him. None of them impacted my interpretation of the results and they were all minor.
Q. Okay. So you noted some errors; correct? How many errors did you note?
A. I wouldn't say errors. I would say that there were a few corrections that I wanted to clarify.
Some of them were, for example, that I had reported one score to be in a slightly higher range than it actually was.
Another was that, for example, one subtest was in the average, not the high average range. One was that his verbal memory span ranged from the second to the 50th percentile.
Just a minute. And so, as I said, those -- I do that for the record because I want everything to be as completely accurate as possible.
There are hundreds of scores in these, and it's not unusual for me to find a few that I want to clarify when I go over the raw data.
Q. Do you have any clarifications or corrections today --
A. No.
Q. -- further?
A. No, and I noted for Dr. Sweet that those were corrected in the text that I was transmitting to him along with the raw data.
BY MR. DOMBROWSKI:
Q. Now, Doctor, with suspected brain injuries that don't have swelling of the brain or bleeding into the brain or that apparently are without complications such as here, isn't the resulting condition of the brain considered stable or unchanging after a few months?
A. Not necessarily. I think there's a great deal of variability in that, and certainly not everyone who has had a mild head trauma has lingering symptoms. A certain proportion do.
Q. Well, Doctor, in fact, once a person is three months away from an actual mild brain injury, if there are persistent effects present, isn't it true that the brains of these individuals do not deteriorate?
A. As I mentioned before, brains don't deteriorate after a head trauma, assuming that you don't have any subsequent injuries.
A head trauma is an injury not an illness, and, therefore, the course is uphill, not downhill.
Q. Now, Doctor, as far as some of the complaints that the plaintiff had initially when you saw him or when Dr. Eilers saw him in September, October, November of 1998, some of the things that he's talking about, “Difficulty finding words or searching for words or sleep deprivation” --
A. I don't believe I said sleep deprivation.
Q. I'm talking about difficulty sleeping that he noted with Dr. Eilers.
Did you see that?
A. That wasn't something he mentioned to me.
Q. Okay. But you did review Dr. Eilers' notes?
A. Yes.
BY MR. DOMBROWSKI:
Things like memory change or altered concentration or difficulty finding words or difficulty sleeping can be experienced by someone who has not had trauma or any type of brain injury; correct?
A. That is possible, although improbable as a constellation of symptoms.
BY MR. DOMBROWSKI:
Q. Now, these type of things that I just mentioned, you've had patients attribute these type of things to trauma and it turns out that trauma was not the cause at all; correct?
A. Generally when patients come in, they aren't always attributing their symptoms to anything, and so I'm not sure how to answer that question.
People don't come in and say, “I think I have a head trauma.” They come in and say, “I've had these problems since then.”
Q. Well, it's true in your practice that sometimes people attribute certain things or pains or problems to a traumatic event and it turns out later that that is not the case. You've had that happen; correct?
A. In rare experience.
Q. Now, doesn't that happen more so when there's, in fact, litigation involved?
A. Not necessarily, and I've seen studies that have gone both ways in terms of that question.
Q. Now, Doctor, isn't there substantial literature in your community, neuropsychological community, that demonstrates that a vast majority of symptoms caused by head injury begin very close to the time of the trauma?
A. Yes, although there's often a difference between when a symptom is experienced and when it is first either acknowledged or reported.
Q. Well, here the first medical evidence of any complaints from Mr. Wattron was 15 days after the accident; correct?
A. That's the first time that he sought medical treatment following the trauma.
Q. Now, isn't it also true that symptoms complained of much later are probably not caused by any type of brain injury, and when I say “much later,” I'm talking much later from the traumatic event itself?
BY THE WITNESS: A. That's not -- actually not unusual in my experience that patients become more aware of, and, in particular, more concerned of symptoms over time that they've been experiencing since the time of the trauma, but they do not always acknowledge or report those then, and that they become more aware of those over time.
BY MR. DOMBROWSKI:
Q. Now, Doctor, in this case, wouldn't you agree that it is likely the plaintiff did not suffer a loss of consciousness?
A. I'm unsure about that question. At this point the only information we have regarding that is the patient himself and he's not sure.
Q. He did tell you that he thought he remembered the impact; correct?
A. Yes, but that, also, he didn't remember all of what was going on at the time, and that he clearly stated to me that he didn't know whether or not, for example, he had hit his head.
BY MR. DOMBROWSKI:
Q. And didn't Mr. Wattron actually describe specific details of the accident to you and to Dr. Eilers?
A. Specific details in terms of he told me how he was hit, but he also told me that he felt sketchy in his recall and that he doesn't think he remembered everything that happened at the time.
Q. Okay. Did you see in Dr. Eilers' records where he actually described miles per hour and how the actual hit of the vehicles happened?
A. To some extent, although it was difficult for me to say if that was information he received afterwards from police reports, for example.
Q. Okay. But you --
A. That's common for me.
Q. But you did see that noted by Dr. Eilers; correct?
A. I believe so.
Q. Do you know how Mr. Wattron behaved at all after the accident?
A. He stated that he had gotten out of the car, that he, as I said, felt somewhat dazed, I guess, is a good word for it, didn't remember everything that was happening.
The police came, I believe because the neighbors had summoned them because of the noise of the crash, and I don't know if it was -- yeah, the police, and at that point he declined an ambulance and went on.
Q. Did he ever relate to you his conversations or his demeanor towards the other driver in any fashion?
A. I don't recall that.
Q. Now, Doctor, after your first evaluation back in 1998, your diagnostic impression, your diagnosis then was actually “Dementia due to head trauma, mild, resolving”; is that right?
A. Yes.
Q. Now, as you sit here today, was that the correct diagnosis?
A. Yes. I felt comfortable with that at the time. I had a different diagnosis on the second evaluation because I felt that I had seen significant improvement in his symptoms.
Q. So you felt looking at the DSM that we've talked about, that Diagnostic Statistical Manual, that given what you knew at the point in 1998, that a diagnosis of dementia due to head trauma was appropriate?
A. Yes, with the qualifiers of “mild” and “resolving.”
Q. Okay. So at that point even in 1998, you thought that Mr. Wattron's problems were resolving; correct?
A. Yes, I did.
Q. And when you say “mild,” is mild the lowest range within head trauma or traumatic brain injuries?
A. Yes. The generally recognized classification system used in terms of communicating results clearly is mild, moderate, and severe, and within that system I felt that mild was most appropriate for Mr. Wattron.
Q. Are there ranges or categories within that mild range?
A. Not that I generally use. I generally use those three categories because my purpose is to communicate information to patients and their significant others, and those seem the most effective for me.
Q. Doctor, you testified earlier that in order to actually have a traumatic brain injury, you either have to have a loss of consciousness or a change of consciousness; right?
A. Yes, an alteration of consciousness.
Q. Okay. So if it's determined that Mr. Wattron did not have a change in consciousness or loss of consciousness, it's, therefore, unlikely he suffered a traumatic brain injury; correct?
A. Yes, that would be true.
Q. Doctor, what is a post-traumatic amnesia?
A. Post-traumatic amnesia is a loss of memory for a period of time following a trauma.
Q. It's fair to say that we don't really know if that occurred with Mr. Wattron; correct?
A. No. One of the disadvantages of his not seeking medical care earlier is that we have no medical documentation of his state of mind and symptoms at the time of the trauma.
Q. But even if he did suffer some type of post-traumatic amnesia, it would be, it appears, just for a few seconds; correct?
A. I don't have that information to be able to tell you that.
Q. Didn't Mr. Wattron tell you back in 1998 that “I don't know if I was unconscious. Maybe for just a few seconds.”
A. Yes, but post-traumatic amnesia and unconsciousness are two different concepts.
Q. Okay. Well, with the post-traumatic amnesia, can you gauge whether he did have for seconds or minutes -- can you put any type of analysis on that?
A. No. I don't have that information.
Q. Now, Doctor, in your 1998 evaluation, apparently I think under “Recommendations,” I think No. 3, you stated “All symptoms will be reduced when physical and emotional stress, fatigue, pain, hunger, and time pressure are minimized”; correct?
A. Yes.
Q. You also stated that “Adequate rest, good nutrition, regular exercise, and a healthy lifestyle will be important in the healing process”; correct?
A. Yes.
Q. Now, you've talked before about Mr. Wattron's eating habits and emotional stress and things like that.
Things like that can actually have a negative effect on the symptoms that you diagnosed him with; correct?
A. Meaning that they can maximize as opposed to minimize those symptoms. That's one of the reasons that we focused on those in the follow-up.
Q. Now, Doctor, in your 2001 evaluation, your diagnosis was “Cognitive disorder, not otherwise specified, largely resolved”; correct?
A. Yes. “Mild and largely resolved.”
Q. Okay. So we're still in the mild range, and so you've seen him go from in 1998 to resolved to largely resolved; correct?
A. Yes. I think in the first -- in '98 I called it resolving, and in '011 called it largely resolved.
Q. You also stated in 2001 that he does not need further services from you; correct?
A. Yes. I mentioned that at the time I felt that he was coping effectively, implementing compensatory strategies appropriately, and not in significant emotional distress, and as a result of that, I did not feel a need for further psychotherapy at this point.
Q. Okay. As we sit here today in 2003, it's obviously possible that Mr. Wattron could be suffering from no mild traumatic brain injury given his improvement; correct?
BY THE WITNESS:
A. I wouldn't say that he would not be suffering from a brain injury.
I would say that his symptoms are largely resolved and he is compensating for them effectively.
BY MR. DOMBROWSKI:
Q. Well, today is it possible that his symptoms can be completely resolved?
A. Unlikely since at the time that I saw him he was already three years post-trauma and he was already implementing the type of strategies that would help to resolve those symptoms, but I have no further information regarding his functioning after the conclusion of the 2001 evaluation.
Q. Now, Doctor, your recommendations, both in 1998 and 2001, can actually be helpful to people who do not have a mild brain injury of any type; correct?
A. Certainly. It's not that these recommendations are exclusively for people who have had traumatic brain injury, they're just more important for that group because of the problems that they're having.
Q. Okay. Doctor, given the large number of findings that you had that were in the average range during your evaluations --
A. Yes.
Q. -- isn't it probable that the plaintiff's problem is not, in fact, brain injury but rather perception?
A. No, I don't believe that's true. I believe that, again, you don't look at the testing in isolation. You look at it in combination with everything else that you know of the patient, and the -- that entire picture was extremely consistent with a mild traumatic brain injury.
Q. Is there a phenomenon known as “Attribution error,” in neuropsychological literature?
A. Yes. That refers to people who mistakenly attribute symptoms to one cause as opposed to another.
In neuropsychological literature, it means people who mistakenly attribute symptoms to things such as a stroke or a head trauma when in actuality that is not true.
Q. Okay. Now, Doctor, I would like to go over some of your reports briefly with you to talk about them.
Your first report in '98, the pages aren't numbered but I numbered a Page 4. It looks like the first full paragraph.
You state, “Jerry showed performance within the perfectly normal range for perceiving speech sounds, perceiving bilateral tactile, auditory, and visual stimulation, and simple sensory perceptual functions”; correct?
A. Yes.
Q. What did you mean by that?
A. That meant that for this particular test, performance is divided into perfectly normal, normal, mildly impaired, and seriously impaired.
There are two categories of normal to acknowledge that there is a certain variability in normal that is not uncharacteristic.
He showed performance for those particular tasks in the perfectly normal range.
Q. You also go on to state that “Performance was in the normal range for complex problem solving and complex sensory perceptual functions”; correct?
A. Yes.
Q. And you also go down to state that “Screening of visual fields indicated no restrictions”; correct?
A. Yes.
Q. And also, “A simple hearing screening was passed bilaterally”?
A. Yes.
Q. That means both ears?
A. Yes.
Q. Okay. And then, Doctor, moving on to Page 7 of that first report, second full paragraph under “Clinical/Projective,” it states, “The results of the Beck Hopelessness Scale were in the normal/age symptomatic range with no significant feelings of hopelessness, pessimism or expectation of failure/disappointment noted.”
A. Yes.
Q. Now, why is that significant?
A. The Hopelessness scale is related to depression. It can also be related to things such as suicidal ideation, and so it was a positive thing that at that point he was not feeling negatively about the future.
He also wasn't assuming that, for example, the head injury was going to get worse or was going to be an awful thing in his life.
Q. Just below that, the next paragraph, it states “The Beck Anxiety Inventory was also administered to assess symptoms of anxiety. The results were in the normal asymptomatic range”; correct?
A. Yes.
Q. Now, below that there's something called “The Minnesota Multiphasic Personality Inventory II.” I think we may have touched on that.
You go on to state, the next page from that, Page 8, that “The analysis of the validity scales indicated a valid profile --
A. Yes.
Q. -- with typical test taking responding, independence and self-confidence, and sufficient resources for intervention.”
A. Yes.
Q. What did you mean by that?
A. What I meant by that is there are validity scales in the MMPI-II in order to see if somebody is trying to present either better or worse than they actually are, and my analysis of those scales for Mr. Wattron showed that he was presenting in a forthright way, and was neither minimizing, nor exaggerating his psychological issues.
Q. Now, Doctor, in the scores in 1998 and the scores in 2001, as far as I.Q. is concerned, both Mr. Wattron's scores were in the normal range on both tests; correct?
A. Yes. Average is what we use --
Q. Right.
A. -- as oppose to normal.
Q. Okay. And they were -- that was consistent with his educational background?
A. In general in an average intelligence, completion of high school, are consistent.
Q. Doctor, looking at the scores in 1998 and also 2001, you've actually -- or have you had patients with these scores who suffered no head injury at all?
A. Yes. An average score is not one that you would want to overly interpret.
BY MR. DOMBROWSKI:
I'm referring to the 1998 and the 2000 tests, the whole tests. You've obviously had patients with these scores who suffered no head injury at all; correct?
A. By “these scores,” do you mean on the Wechsler Adult Intelligence Scale or do you mean the entire evaluation as a whole?
Q. I'm talking about the entire evaluation itself.
A. No, generally I'm not seeing some of the problems I saw in the 2001 evaluation unless someone has had a head trauma.
Q. Well, you have seen patients who have had no head trauma and have had similar scores; correct?
A. Not on everything. Certainly if we're talking about the intelligence scale, I've seen people of average intelligence that have not had a head trauma, but I haven't seen people without a head trauma who had some of the problems I was seeing on the second evaluation.
Q. Now, Doctor, in the neuropsychological literature, there's some addressing of reporting of patients of post-concussion symptoms among pain patients who have, in fact, suffered no brain injury; is that right?
A. Depending upon what you talk of as post-concussion syndrome, sometimes people who have had an injury but not a brain injury can report things like fatigue, for example.
Q. Okay. Now, in this case, have you ever seen a diagnosis at all at any point of Mr. Wattron that he, indeed, did suffer a concussion?
A. I don't believe from the limited medical follow-up that he had, that that term was used.
Dr. Eilers talked about traumatic brain injury, which is the equivalent of a concussion.
Q. But you never saw any diagnosis of post-concussion syndrome or a concussion, did you?
A. No. As I said, Dr. Eilers diagnosed traumatic brain injury, which is another word for concussion.
BY MR. DOMBROWSKI:
Q. Okay. Now, Doctor, you talked with plaintiff's counsel regarding the movement of the brain, and neurons, and microscopic fibers; correct?
A. Yes.
Q. Now, you do not know how Mr. Wattron's body moved the day of the accident, do you?
A. Yes. There are laws of physics that are assumed to be in force at all times, and so the fact that he was in an acceleration-deceleration incident means that we do know how his head moved.
Q. Well, our heads don't move exactly the same way during automobile accidents, do they? Your body can move in different directions at different times; correct?
A. Certainly there is variability.
Q. Okay. Now, when you were handling the skull and the brain, you were actually making assumptions about what you believe Mr. Wattron experienced during the accident; correct?
A. Well-based assumptions as opposed to assumptions without a basis.
Q. Okay. Assumptions nonetheless; correct?
A. I guess I'm a little uncomfortable with that word because it implies that there is no basis for that, and clearly there is a substantial knowledge base regarding what happens to someone's head during a motor vehicle accident such as the one Mr. Wattron experienced.
Q. Well, there's no medical records, that you know of in this case, that talk about fibers or neurons or microscopic things within the brain, are there?
A. No, but that doesn't mean that that isn't what occurred.
Q. Well, there's no testing done in this case that would indicate any tearing of any fibers or anything like that; correct?
A. The medical testing that we have at this point was not specifically indicative of that, although could not rule it out.
Q. Doctor, the prognosis, in general, of healthy individuals like the plaintiff with possible mild head injury is normally good; correct?
A. Yes, and, in fact, I think that Jerry has had a very good recovery.
Q. Doctor, during your course of treatment, did you ever recommend to the plaintiff at any point that he stop driving?
A. No. If I had concerns about that, I would refer him back to his physician. That's not generally a recommendation that I would make.
Q. Did you ever recommend he stop lifting weights or going to a health club?
A. Again, those would be more medical recommendations that his physician would make as opposed to myself.
Q. Did you ever recommend that he take a break from work or take some time off?
A. Now, that is an area that I would normally address if I felt it necessary.
At that point the patient was describing adequate functioning with compensation in his work, and so I would have no reason to tell him not to work.
I'm a great believer in work. I think it's good for my patients and I always encourage them to work in any way possible.
Q. Doctor, did you ever take a look at Dr. Sweet's report or evaluation of Mr. Wattron?
A. No.
BY MR. DOMBROWSKI:
Q. You have no plans to see Mr. Wattron; correct?
A. Not at this point.
Q. Now, the second neuropsychological evaluation, Mr. Wattron actually contacted you; correct?
A. Yes.
Q. Now, in your opinion, were both of these neuropsychological evaluations actually medically necessary or necessary for his treatment?
A. I'm not sure how you would be defining “medically necessary.”
As I said, I'm a psychologist. I do feel that they were necessary in regard to initially the diagnosis and treatment, and over time, determining the course and existence of continuing symptoms.
Q. Now, Doctor, counsel talked about labyrinthitis that apparently Dr. Eilers mentioned once in a record in October of '98.
So this is actually a condition of the ear. It does not implicate the brain at all; correct?
A. Yes, that's true. It's a condition of the balance system within the inner ear.
Q. And, actually, in your experience, if a doctor actually diagnosed labyrinthitis, there is actually a test that can find out whether that phenomenon is actually happening; correct?
A. Yes, and I've seen that ordered occasionally for patients, especially those with severe dizziness.
I believe it's called an ENG.
Q. Okay. No one in this case ordered that test; correct?
A. Not that I am aware of. You would want to ask Dr. Eilers specifically about that.
Q. Doctor, how much do you charge for a neuropsychological evaluation?
A. It varies depending upon the number of hours needed for it.
Q. Okay. What did you charge in this case?
A. Just a minute. I have the billing.
The 2001 evaluation was a total of 13 hours and was billed by the Paulson Center at $1,800.50.
BY MR. DOMBROWSKI:
Q. Now, Doctor, the first test, how much did that cost?
A. Just a minute. $1,939 for 14 hours.
Q. And then you also charge for the follow-up visits?
A. Yes. Again, these are charges by the Paulson Center as opposed to me since I'm a contractor here.
The follow-up visits, I believe, were charged at $117.50 an hour. I think that was the going rate at that time.
Q. Doctor, you're being compensated for your time today?
A. Yes.
Q. And at what rate?
A. At the rate of $250 an hour, which includes preparation and review.
Q. And did you meet with the plaintiff's attorneys before your testimony?
A. Yes, yesterday.
MR. DOMBROWSKI: Thank you, Doctor. I don't have anything further.
MR. KNIGHT: Doctor, I have a few questions on redirect.

REDIRECT EXAMINATION

BY MR. KNIGHT:

Q. You were asked early in your cross-examination whether you are Board-certified.
Is there any Board-certification that is recognized by the State of Illinois in your field of neuropsychology?
A. No. You need to be licensed as a clinical psychologist to practice neuropsychology, but the Illinois Board of Professional Regulation doesn't have anything like a Board-certification such as is common for medical doctors, for example.
Q. Okay. Are there some either societies or independent groups within -- among psychologists who created their own board or group or something like that that certifies people?
A. Yes. Two different groups of psychologists appointed themselves as a board and purport to board-certify, however, that is not, as I said, endorsed by my licensing agency.
Q. You were asked early in your cross-examination whether you had received a number of different referrals from Dr. Eilers over a period of years.
Can you explain whether the -- how many referrals there have been within the last two or three years from Dr. Eilers?
A. Within the last two or three years, there have been very few. About, I guess, a year-and-a-half to two years ago, Dr. Eilers moved his practice out of the Paulson Center building.
I believe he is now in Sugar Grove, and I also think that the scope of his practice has changed, and so since then I've had, I think, two or three new referrals and a few referrals for reevaluations from him, but significantly less than prior to that.
Q. Okay. And you have a full-time practice in neuropsychology yourself; correct?
A. Yes, both neuropsychology and developmental disability. Those overlap somewhat because the patients that I see at the pediatric nursing homes pretty much all have significant brain damage.
Q. And so you receive referrals of patients from many different sources, many different doctors, and many different entities; is that correct?
A. Yes. As I said, I work for pediatric nursing homes, as well as receiving referrals from neurologists in the community, as well as the State of Illinois, Department of Rehab.
Q. You were asked on cross-examination whether you had reviewed any school records for Jerry Wattron.
Was there any necessity, as you saw it, for purposes of your evaluation to obtain and review school records?
A. No. I always ask the patients if they had any problems with school, any diagnosis of learning difficulties, any need for special services, and whether or not they had graduated high school.
If they tell me that they graduated high school, describe themselves as an average or above student, and deny any problems with learning or any special services received, at that point that's adequate information for me to establish a baseline to interpret their testing results.
Q. Okay. You were asked some questions about whether Jerry Wattron was experiencing certain problems when he went to the ER, according to the records that you examined as part of your evaluation.
Was he experiencing certain problems at the time of his visit to the ER which were related to your evaluation, and if so, what?
A. At the time he went to the ER, he was stating that he was concerned about persistent dizziness.
He also mentioned specifically that he was having numbness on the top of his head, and that he was having trouble staying focused. The quote is that it's hard to stay focused.
That was consistent to his report of me that over the first couple of weeks following the trauma, that he was becoming increasingly concerned about difficulties with his thinking and with dizziness, and that's the reason that he eventually went for medical follow-up in the ER.
Q. Among the patients that you have seen who have had mild traumatic brain trauma, is it unusual for them not to seek medical attention immediately or within the first week or so following their trauma?
A. Not in my experience.
Certainly, I always advise people after the fact that if they have -- they had any experience with a motor vehicle collision, that they should get themselves checked out at a hospital.
It certainly is possible, for example, to have something like bleeding in the brain where someone doesn't feel well, goes home, goes to sleep and never wakes up.
I find that for my patients, especially with mild head injury, it's not unusual for them to become increasingly concerned about physical thinking and emotional problems over time, particularly as these persist because they think that they may be due to the stress of the trauma, but as time goes on, it becomes obvious that they are still existing and at that point they are more concerned and then seek help later.
BY MR. KNIGHT:
Q. So did the fact that the plaintiff, Jerry Wattron, did not immediately seek care for his brain dysfunction in any way indicate to you that he was not actually suffering the injury that you diagnosed him with later after your evaluation?
A. No, I don't believe so. In fact, I think it's further indication that he was minimizing rather than exaggerating or maximizing the symptoms.
Q. You were asked on cross-examination about certain individual symptoms and as to whether those symptoms can exist in a person who doesn't have a mild traumatic brain injury.
Can you tell me whether your evaluation in this case or in general is ever based on a single symptom as opposed to the full constellation of signs and symptoms, history, and physical examination presented by a patient?
A. As I mentioned, because traumatic brain injury has a number of symptoms and can in many ways be subtle, I think it's extremely important to do a comprehensive evaluation process and not to jump to conclusions prematurely.
Certainly some of the symptoms of head trauma taken individually can be caused by other things, things such as people can get headaches for a lot of different reasons. People can be fatigued for a lot of different reasons. People can have trouble with concentration for a lot of different reasons, but when you put together that particular constellation of physical thinking and emotional symptoms that I've described so far, that particular set of symptoms existing simultaneously, and, in particular, the coming on abruptly in a person without a history of it and then resolving slowly over time, is very characteristic of a head trauma.
Q. You were asked on cross-examination whether the plaintiff, Jerry Wattron, had experienced any of these symptoms prior to the time when he went to the emergency room.
Is there a difference between when a patient experiences or may be suffering from a sign or symptom and the time when a patient recognizes that they are suffering from such a sign or symptom?
A. Yes, and, in fact, it's not unusual in my experience to have a patient notice things like dizziness or that their head doesn't feel right or that they're having trouble concentrating and either to assume that this will clear up shortly or to make an attribution error, as using a term we had used before, that this is not due to head trauma, but instead due to the stress of the accident, for example.
Q. On cross-examination you were asked whether you were unsure -- or I believe you testified that you were unsure of whether there was an actual loss of consciousness as opposed to altered consciousness.
Can you tell us what you relied on in the way of information from the plaintiff to reach your opinion to a reasonable degree of neuropsychological certainty that he, indeed, did have a period of altered consciousness?
A. At that point the only information available was the patient's report because there was not medical information available at the time of the trauma.
His description was quite typical of what I would expect of someone who had had a mild head trauma.
He was not saying, “I remember everything clearly and continuously and everything is clear in my mind.”
He was saying, “I'm not exactly sure about this. I don't know if I was unconscious. Maybe I don't remember hitting my head but I'm not sure. I don't really remember everything that happened at the time.”
That's very typical of the alteration of consciousness that would be consistent with a mild head trauma.
Clearly he did not have the type of prolonged unconsciousness which is associated with a more severe head trauma.
Q. On cross-examination you were asked about your diagnosis in 1998 that included the term “dementia.”
Can you tell us what you meant by the term dementia in the context of that diagnosis?
A. At that point I was describing difficulties with things such as his concentration, as well as personality changes related to an injury to the brain, and I was noting that those were mild and that they appeared to be resolving, meaning decreasing over time.
Q. And why is it that you believe that the term dementia is appropriate to describe that degree of deficit?
A. Because that's the diagnostic term used for that particular issue, for changes in thinking and behavior and emotions which come as a direct result of a physical change to the brain such as occurs in a head trauma.
Q. You were asked whether there was any evidence of -- or medical evidence of an indication that there were damage to the neurons.
Can you tell us whether the neuropsychological testing that you performed in 1998 and in 2001 on the plaintiff, Jerry Wattron, was or was not an indication that there were damage -- that there was damage to neurons in his brain?
A. Yes, I believe it was.
The question I was asked is medical testing, and at that point I assumed we were talking about a CT or an MRI.
Those were unremarkable, however, I did find some specific deficits and problems in my two neuropsychological evaluations.
Q. All right. You were asked on cross-examination whether you had reviewed a report of a Dr. Sweet, another doctor who was not a treating physician in this case.
What is your role with respect to this patient and this case as opposed to someone who would review someone else's -- other doctor's report who is not a treating physician?
BY THE WITNESS:
A. I'm a treating psychologist, which means that my practice is clinical and therapeutic.
People come to me referred generally by their physician because they are experiencing problems and symptoms, and my purpose is to clarify those and to try to help them to work around those more effectively.
I'm not an expert witness. I have been asked by both sides. I dislike being involved in litigation intensely and would never do this voluntarily.
The only time I'm ever brought into this is after the fact when my -- I've treated a patient and my records and testimony are subpoenaed.
BY MR. KNIGHT:
Q. Is it fair to state that as a treating physician --
A. Psychologist, please.
Q. I'm sorry, my apologies.
As a treating -- I wrote it in my notes wrong. In fact, I just wrote something that I just read wrong.
As a treating neuropsychologist, do you see your role as one of reviewing any party's expert witness's reports about the case?
A. Not generally. I've occasionally been requested to do that, again, after the fact by patients' attorneys, but in general, that's not information that I would seek out.
At this point my treatment of this patient is completed, so I would have no reason to seek out further information regarding him.
Q. And you were not requested by us to step outside that role as a treating --
A. No, I was not.
Q. -- neuropsychologist in this case; correct?
MR. KNIGHT: Thank you. That's all I have on redirect.
MR. DOMBROWSKI: Doctor, just a follow-up.

RECROSS-EXAMINATION

BY MR. DOMBROWSKI:

Q. When the plaintiff went to the emergency room on May 26, 1998, he did not present with what you call a constellation of symptoms, did he?
A. Yes, he did. He was reporting physical and cognitive symptoms.
Q. Well, let's back up a little.
He said he had some intermittent dizziness, but he told the doctor he did not have dizziness when he was at the emergency room; correct?
A. Yes.
Q. And he did complain of numbness at the top of the head but he said he did not -- was not experiencing headaches at that time; correct?
A. Yes.
Q. And that his pain scale was zero, meaning no pain; correct?
A. Yes.
Q. And the physician who examined him at the time did not diagnose him with any type of brain injury whatsoever; correct?
A. The terms he used was “Head contusion and persistent dizziness.”
He did not use the term “brain injury.”
MR. DOMBROWSKI: Thank you. I have nothing further.
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