DR. WALKER'S DEPOSITION-----11/21/2003



                                             1
 IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT
               OF THE STATE OF FLORIDA
              IN AND FOR PINELLAS COUNTY     
                    PROBATE ACTION
               
 In Re: The Guardianship of
 THERESA MARIE SCHIAVO,
       Incapacitated,
                          FILE NO.:  90-2908GD-003
                                 /
 ROBERT SCHINDLER, et al.,
                        
       Petitioners,
 v.
 MICHAEL SCHIAVO,
       Respondent.
                                 /
 DEPOSITION OF:      WILLIAM CAMPBELL WALKER, M.D.
 TAKEN:              By Counsel for Petitioner
 DATE:               November 21, 2003
 TIME:               9:40 a.m.
 PLACE:              311 Rye Road East      
                     Bradenton, Florida
               
 REPORTED BY:        Sherry L. Frain
                     Notary Public
                     State of Florida at Large
                    RICHARD LEE REPORTING
              Registered Professional Reporters
                       (813) 229-1588
 TAMPA:              email: rlr@fdn.com      ST. PETERSBURG: 
 501 East Jackson Street, Suite 200       535 Central Avenue 
 Tampa, Florida  33602        St. Petersburg, Florida  33701 
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 APPEARANCES:
      PATRICIA FIELDS ANDERSON, ESQUIRE
      Patricia Fields Anderson, P.A.
      447 Third Avenue
      Suite 405
      St. Petersburg, Florida  33701 
            Appeared for Petitioners
      
      SCOTT P. SWOPE, J.D., ESQUIRE
      Merricks, Hale & Swope, P.A.   
      2450 Sunset Point Road
      Suite D                      
      Clearwater, Florida  33765
            Appeared for Respondent
                          INDEX
                                             PAGE
 Examination by Ms. Anderson                    3
 Examination by Mr. Swope                      35
 Examination by Ms. Anderson                   64
 Examination by Mr. Swope                      66
 Examination by Ms. Anderson                   67
                        EXHIBITS
 NO.  DESCRIPTION                            PAGE
 1    Curriculum Vitae                          4
 2    Bone Scan dated 3/5/91                    6
 3    Mediplex Rehab - Bradenton
      Dated February 15, 1991 -
      March 15, 1991                           41
 4    X-Ray Report dated 2/5/91                42
 5    Mediplex Rehab - Bradenton
      Monthly Summary dated
      February 15, 1991 -
      March 15, 1991                           46
 6    Mediplex Rehab Bradenton
      Doctor's Progress Notes                  48
 7    Affidavit                                50
 8    Affidavit                                52
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1                The deposition, upon oral examination, of
2     WILLIAM CAMPBELL WALKER, M.D., taken by counsel for
3     Petitioner, on the 21st day of November 2003, at 311
4     Rye Road East, Bradenton, Florida, beginning at 9:40
5     a.m., before Sherry L. Frain, Notary Public, State
6     of Florida at Large.
7                 *  *  *  *  *  *  *  *  *  *
8                 WILLIAM CAMPBELL WALKER, M.D.,
9     having been duly sworn to tell the truth, the whole
10    truth, and nothing but the truth, was examined and
11    testified as follows:
12                        EXAMINATION
13    BY MS. ANDERSON:
14         Q     Would you state your name, please, for
15    the record?
16         A     It's William Campbell Walker.
17         Q     And, Dr. Walker, would you briefly state
18    your educational background for me?
19         A     Well, I went to the University of South
20    Florida, College of Medicine, and did my internship
21    and residency at University of South Florida
22    affiliated hospitals and became a board-certified
23    radiologist in 1980 in diagnostic radiology.
24         Q     What year did you get your medical
25    degree?
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1          A     It would have been '76, I believe.  I
2     gave a copy of the CV to the court reporter.
3                MS. ANDERSON:  Why don't we mark that,
4          then, and attach the CV as Exhibit 1?
5                (Exhibit 1 marked for identification.)
6          Q     Dr. Walker, after you finished your
7     internship and residency, where did you go to work?
8          A     I went to work at Manatee Memorial
9     Hospital.
10         Q     How long did you work there?
11         A     From 1980 to June of this year.
12         Q     June of 2003?
13         A     Correct.
14         Q     How does diagnostic radiology differ from
15    other types of radiology?
16         A     Well, there initially were two classes of
17    radiologists.  There were therapeutic radiologists
18    who provided radiotherapy treatment for cancer, and
19    then there was diagnostic radiology, which
20    encompassed all the other branches, specifically
21    utilizing the imaging studies to detect the presence
22    or absence of disease.
23               Recently there's been yet another
24    subcategory called interventional radiology, which
25    is sort of a cross between surgery and radiology.
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1     And those radiologists do therapeutic kinds of
2     things to patients; open blocked arteries, for
3     example.
4          Q     Using --
5          A     Little balloons and metal stents
6     typically.
7          Q     That's done by radiologists?
8          A     Well, it's done by radiology, it's done
9     by general surgery, and it's done by cardiology.  So
10    it's sort of a turf war there.
11         Q     Is that subspecialty an area that is
12    subject to board certification?
13         A     There isn't a specific interventional
14    board that I'm aware of.  There is an area of
15    expertise in interventional radiology which you can
16    get.
17         Q     Dr. Walker, in the course of your duties
18    at Manatee Memorial Hospital, did you have occasion
19    to prepare a bone-scan report dated March 5th, 1991?
20         A     When you pointed that out to me, yes, I
21    did.
22         Q     You have no independent recollection of
23    this report?
24         A     I do not.
25               MS. ANDERSON:  Let's have a copy of the
?                                             6
1          report marked as Exhibit 2.
2                (Exhibit 2 marked for identification.)
3                MR. SWOPE:  May I see that after it's
4          marked?
5          Q     I want to go over this in some detail
6     with you, if we can.  I have a lot of questions
7     about it.
8          A     Certainly.
9          Q     There are two sets of initials down at
10    the bottom.  Do you see those?
11         A     Yes, I do.
12         Q     Is one of those sets your initials?
13         A     No.
14         Q     Do you know whose initials they are?
15         A     Well, the one set appears to be "FH,"
16    which would be Florence Heimberg, who was an
17    associate of mine at that time.
18         Q     Was she a radiologist?
19         A     Yes.
20         Q     How do you spell her last name?
21         A     H-e-i-m-b-e-r-g.
22         Q     And would that be the top or bottom set
23    of initials?
24         A     That would be the top set.
25         Q     Do you know where Dr. Heimberg is today?
?                                             7
1          A     Yes, I do.
2          Q     Where is she?
3          A     She is employed by another radiology
4     group in Bradenton and works at several different
5     hospitals and clinics in this area.
6          Q     What is the name of her radiology group?
7          A     It used to be called Baron and
8     Stoutamyer, but they've gone through some changes.
9     I think it's Stratos.
10         Q     S-t-r-a-t-o-s?
11         A     Yes.  Stratos and some other names after
12    that.  They were based out of Blake Hospital.
13         Q     Blake?
14         A     Yes.
15         Q     Do you recognize the bottom set of
16    initials?
17         A     I do not.
18         Q     At this time, were you the head of
19    radiology at Manatee Memorial?
20         A     Not at this time.
21         Q     What would the significance of Dr.
22    Heimberg's initials being on there be?
23         A     Well, it's customary for someone to
24    review and sign the report before it becomes
25    official.
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1          Q     Is this your report, then countersigned
2     by Dr. Heimberg?
3          A     As best I can recollect from that time
4     period.  It's not impossible that it could be the
5     wrong signature attached.  It's happened before, but
6     I doubt it, because that sounds like my format of a
7     report.
8          Q     Typically if your name were typed at the
9     bottom as it is here, W. Campbell Walker, M.D.,
10    would that indicate that this is a report that you
11    have dictated?
12         A     Typically, unless, as I mentioned, the
13    transcriptionist appended the wrong name, which has
14    happened, because they have in their computer system
15    a button for each doctor's signature, and sometimes
16    they hit the wrong button.  But I would say, again,
17    based on the format -- because we all have our own
18    dictating style -- that sounds like my dictating
19    style.
20         Q     There's nothing in this report that jumps
21    off the page at you and says, "I would never have
22    dictated that"?
23         A     No.
24         Q     I notice there is a slash and then "mjt"
25    in lowercase initials after your typed name.  Do
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1     you know who that refers to?
2          A     That would be the transcriptionist that
3     actually did this.
4          Q     Okay.  Now, I notice also on this report
5     that it's dated up at the top 3/5/91.
6          A     Correct.
7          Q     And also down at the bottom "Dictated
8     3/5/91" and "Transcribed 3/5/91"?
9          A     Correct.
10         Q     Would that indicate to you that the image
11    was done on March 5th, 1991, the report was dictated
12    and transcribed on that same day?
13         A     Yes.
14         Q     Would that in any way be unusual with the
15    way things were done at that hospital?
16         A     No.  That's typical.
17         Q     Now, up at the top the patient's name is
18    Theresa Schiavo.  Do you see that?
19         A     Yes, I do.
20         Q     This appears to be a form that was
21    xeroxed onto this page, the form that contains her
22    name.  Am I reading that correctly?
23         A     Typically, no.  This was a multi-page
24    form.  The original form is a multi-page form at
25    that time, and Radiology retains one copy of that.
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1     And it's one of those carbonless copies.  So this
2     obviously is a reproduction of that original
3     radiology form.  But that block of material on there
4     is part and parcel of that multi-page form.
5          Q     So it was nothing that was laid on top of
6     a piece of paper?
7          A     No.
8          Q     Now, in that top block there, it says,
9     "closed head injury."  Do you see that?
10         A     Yes, I do.
11         Q     Where would that information have come
12    from?
13         A     Typically the clerk, the intake clerk,
14    puts that information there.
15         Q     And I see that James Carnahan is
16    underneath Theresa Schiavo's name in the upper
17    right?
18         A     Correct.
19         Q     Do you know Dr. Carnahan?
20         A     Yes, I do.
21         Q     Do you recall where he was at the time?
22         A     Not at that specific time.  But, as a
23    general rule, he was the rehab physician for a
24    number of the rehab facilities such as Mediplex.
25         Q     Did he typically refer patients to
?                                             11
1     Manatee Memorial if they needed a total-body bone
2     scan?
3          A     Yes.
4          Q     How unusual is it to order a total-body
5     bone scan for a patient in your experience?
6          A     I don't think it's unusual at all.
7          Q     In any given week, how many would you do?
8          A     At that time?
9          Q     Yes.
10         A     Myself or the department?  Because I did
11    not read all the studies done every day.  There were
12    several radiologists there.
13         Q     Let's say the whole department.
14         A     In a week, probably about 20.
15         Q     What is a total-body bone scan used for
16    typically?
17         A     It's to look for abnormalities of the
18    bone, whether they -- if they would be recent
19    abnormalities.
20         Q     Recent --
21         A     Recent.
22         Q     -- abnormalities?
23         A     Correct.
24         Q     Is it also a technique to diagnose
25    osteoporosis?
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1          A     No.
2          Q     Explain to these lay ears what a bone
3     scan is.
4          A     Okay.  The patient is injected with a
5     small amount of a radioactive material which acts
6     the same as calcium and phosphate and bone.  So
7     metabolically this material exchanges with the
8     normal bone material.  So the body thinks it's the
9     same as bone material and processes it the same way
10    as bone material.  And wherever there is an increase
11    in bone turnover in the skeleton, this material will
12    go as would normal bone material.
13         Q     Bone turnover, what does that mean?
14         A     Well, the cells of your bones are always
15    being exchanged.  The calcium is being absorbed and
16    then redeposited.  That's a normal thing.  And that
17    gives us a normal background pattern of activity on
18    a bone scan.
19               If the bone is abnormal, then it often is
20    involved in abnormal bone turnover.  Either lots of
21    bone is being removed and not too much is being put
22    back or, on the other hand, more bone is being
23    deposited than is being removed.  So it's a dynamic
24    process.
25         Q     Is the bone scan then done over a period
?                                             13
1     of time?  You take a series of images?
2          A     Well, no.  It's pretty much done all at
3     once.  You inject the patient, you wait three hours
4     typically.  And that may be variable for different
5     institutions, but three hours is typical.  And then
6     you place the patient under the imaging camera, it's
7     called, and the radioactive material is slowly
8     decaying and giving off radioactive particles which
9     are detected by this camera, and that's recorded on
10    film.
11               Probably I should say at this point to
12    clarify also, there are different kinds of imaging
13    cameras.  At the time that this was done, you
14    couldn't fit the whole body under the camera all at
15    once.  So the images -- you do record several images
16    over a period of a few minutes, one that has the
17    head and neck typically, the skull; another that has
18    the shoulders and rib cage; another that has the
19    pelvis and hips; another that has most of the legs.
20               It wasn't customary when you had to do
21    those multiple images to include the hands or
22    sometimes even the forearms and sometimes not the
23    feet.  So I want to clarify that.  There are other
24    imaging systems where you can get the whole skeleton
25    in there from head to toe and then you have all the
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1     bones.
2                When I read this report, it says that
3     there were multiple images, which suggest to me that
4     this was done as a series of pictures and probably
5     did not include parts of the forearms.  Probably did
6     not include the hands.  May not have included the
7     feet completely.  So I wanted to clarify that.
8          Q     But it would be one set of images?
9          A     It would be one set of images.  They were
10    all recorded on one film, one piece of film, as
11    several small images of the various parts of the
12    skeleton.
13         Q     Okay.  At the top right under the date
14    appear the words "Bone Scan, Indication:  Evaluate
15    for trauma."
16         A     Correct.
17         Q     What does that line indicate?
18         A     Well, in the best of all possible worlds
19    when we are asked to produce an imaging study,
20    there's a question that's been asked for which we
21    are being asked to provide an answer.  And in
22    medicine there are many, many different questions
23    that can be asked, and the examinations are tailored
24    to answer those questions.  And the report we want
25    to tailor to bring up those possibilities which
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1     would most likely relate to the question that's
2     being asked.
3                So if somebody comes in with a history
4     that says "closed head injury," belongs to Dr.
5     Carnahan, for example, who's a known rehab doc, and
6     the indication that was given to us is "evaluate for
7     trauma," then our mind-set is to look for those
8     things that are most likely related to trauma and to
9     possibly give some additional possibilities if we
10    don't see something that fits what we expect.
11         Q     So the question that's being asked would
12    come from outside your department?
13         A     Correct.
14         Q     The first sentence says, "Multiple gamma
15    camera images of the axial and proximal appendicular
16    skeleton."  What is an appendicular skeleton?
17         A     The appendages constitute the
18    appendicular skeleton.  So it would be the arms and
19    legs.  And that refers to what I mentioned before,
20    is that this wasn't done as one contiguous image of
21    the whole skeleton but, rather, was a composite of a
22    set of images of various areas.
23         Q     And the sentence goes on to say, "in the
24    anterior and posterior projections."
25         A     Correct.  We normally have the camera
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1     over the chest, you know, the anterior part of the
2     body, to obtain one set of images, and then over the
3     back, over the posterior half of the body, to obtain
4     another set of images.  Because the closer the part
5     is to the camera, the more radioactive counts you
6     get, and so the sharper the image.  So you try to
7     make sure that you're getting images from both sides
8     of the body as close to the camera as you can.
9          Q     Given the equipment that you were using
10    at the time, how many individual images would you
11    expect to see if we had been able to recover this
12    scan?
13         A     Well, it would depend on the size of the
14    patient.  Because the closer you can get the camera
15    to the patient, the more of the body you can get on
16    any individual image.  But typically it would be
17    about six images, I would say.
18         Q     Front and back?
19         A     Correct.
20         Q     Together?
21         A     Correct.
22         Q     And the "technetium"?  Is that how you
23    say that?
24         A     Correct.
25         Q     That's your tracer?
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1          A     Correct.  Technetium is handled by the
2     body like calcium.
3          Q     And the next sentence, "There are an
4     extensive number of focal abnormal areas of nuclide
5     accumulation of intense type."  What does that mean?
6          A     Well, that means that there are a lot of
7     areas that look black on the images because lots of
8     that radioactive decaying material was happening at
9     those points and was being recorded by the imaging
10    system.
11         Q     Okay.  "These include multiple bilateral
12    ribs."  What would that mean to you?
13         A     Well, you know, there's left ribs and
14    right ribs.  And that would mean that more than two
15    ribs on each side were involved.
16         Q     Would it necessarily mean that the first
17    rib, left and right, as opposed to the first rib on
18    the left side and say the fifth rib on the right
19    side?
20         A     No.  There wouldn't be any meaning of
21    that nature.  Typically if it's one or two ribs,
22    we'll actually specify, you know, rib approximately
23    the second on the left.  If you have large numbers
24    of areas of activity, then it's superfluous to label
25    each one in the report.  And we would say
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1     "multiple."
2          Q     And by "bilateral," you mean on each side
3     of the sternum?
4          A     It would be, yes, on each side of the
5     body's midline.
6          Q     Right.  What does the word costovertebral
7     mean?
8          A     That's where the posterior part of the
9     rib joins the spine.  The rib on each side comes out
10    from the spine and joins the spine by an articulated
11    joint.  And so that refers to where the ribs butt
12    against the spinal vertebral bodies.
13         Q     "Several of the thoracic vertebral
14    bodies, the L1 vertebral body, both sacroiliac
15    joints."  These are all areas that were abnormal on
16    the scan?
17         A     That's what this indicates, yes.
18         Q     "The distal right femoral diaphysis,"
19    what area of the body is that?
20         A     That would be the right leg, the upper
21    part of the right leg.
22         Q     Distal?
23         A     Above the knee.
24         Q     Okay.  What is the diaphysis portion?
25         A     That's the shaft of the bone.
?                                             19
1          Q     And distal is?
2          A     Away from the center of the body.  So
3     that would be near the knee part of the leg, the
4     upper leg.  Femur is the upper leg.
5          Q     So on the thigh bone above the kneecap
6     but not involving the joint?
7          A     That's what that particular thing says,
8     but I think somewhere in there also, it mentioned
9     that both knees --
10         Q     Right.  Right after that.
11         A     Right after that.  So that's different
12    from the knee activity.
13         Q     And, "Both ankles, right greater than
14    left."  Those are two additional areas that showed
15    up as abnormalities on the scan?
16         A     That's correct.  Correct.
17         Q     Okay.  "Correlative radiographs are
18    obtained of the lumbar spine and of the right femur
19    which reveal compression fracture, minor, superior
20    end plate of L1 and shaggy irregular periosteal
21    ossification along the distal femoral diaphysis."
22    And what is that next word?
23         A     Metaphysis.
24         Q     "Metaphysis primarily ventrally."  What
25    is the metaphysis?
?                                             20
1          A     The metaphysis is that portion of the
2     bone which is closer to the joint than the
3     diaphysis.  The diaphysis is the shaft, and then the
4     metaphysis is a continuum from the diaphysis to the
5     epiphysis, which is just below the joint.
6          Q     Now, that sentence contains a reference
7     to "correlative radiographs."  What are radiographs?
8          A     Those are typically called x-rays.
9          Q     X-rays.  So in addition to the bone scan,
10    the nuclear imaging, you also did x-rays?
11         A     That would be what would be indicated by
12    this report, yes.
13         Q     Would that have been a step that you
14    would have taken had the bone scan been normal?
15         A     We do not normally do x-rays of normal
16    bone scan areas.
17         Q     Are x-rays done to provide additional
18    information to what you have seen on the bone scan?
19         A     Correct.
20         Q     Is it of a confirming type of
21    information?
22         A     It refines the diagnosis.
23         Q     What kind of information does the x-ray
24    give you that the bone scan does not?
25         A     Well, the bone scan is based on the
?                                             21
1     body's metabolism.
2          Q     Okay.
3          A     And an x-ray is a shadow of the bone at a
4     given moment which doesn't involve metabolism.  It's
5     just a picture.
6          Q     Now, because of the sentence structure,
7     I'm not sure if there is a single compression
8     fracture at L1 or a second compression fracture also
9     in the femur.
10         A     What this says is there's a compression
11    fracture of the lumbar vertebral body at L1 and an
12    additional radiographic abnormality, irregular
13    periosteal ossification along the femoral bone.
14    Periosteal ossification is not a compression
15    fracture.  It's a different kind of abnormality.
16         Q     And the ossification referred to in the
17    femur is primarily ventrally?
18         A     Ventral is that surface of the body
19    related to the belly.  Ventral is belly.  Dorsal is
20    back.
21         Q     So it was on the front side of the femur?
22         A     Correct.
23         Q     The abnormality was?
24         A     It would be on that side facing closer to
25    you if the patient was standing in front of you
?                                             22
1     looking at you.
2          Q     Okay.  And by "shaggy irregular
3     periosteal ossification," you are speaking there of
4     the information you got from the bone scan or from
5     the x-ray?
6          A     The radiograph.
7          Q     What does that word "shaggy" refer to?
8          A     It's just a descriptor like the shaggy
9     dog.
10         Q     Just means that the ossification is
11    not --
12         A     The opposite of smooth.
13         Q     Would you draw any conclusions from that
14    how old the ossification was?
15         A     You could say that it wasn't real old,
16    because typically, as we mentioned, the bone is a
17    dynamic structure, and it's constantly being
18    remodeled normally.  So the body tends to take away
19    extra bone eventually to remodel it to look like
20    normal bone.  So typically old bone injuries are
21    remodeled so that eventually they may almost
22    disappear, particularly in young people.  In the
23    very young, a fracture you won't even see in three
24    or four years, it will be totally erased.
25         Q     By "young," you mean?
?                                             23
1          A     Say a six- or eight- or ten-year-old.  As
2     you get older, the bone remodeling process slows
3     down, and so those injuries may persist for longer
4     and longer times, but it depends on the individual
5     too.  But I would say it would be more recent than
6     less recent; same with the bone scan.
7          Q     In an adult female in her twenties, would
8     a bone fracture be capable of being aged by a
9     radiologist?  In other words, could you look at an
10    image of a fracture and say is it a new fracture or
11    an old fracture?
12         A     I would have to refine that to say that
13    the bone scan actually gives you more information on
14    fracture age than a plain radiograph.  A plain
15    radiograph may give you some gross indication of
16    age.
17         Q     If this patient were to today have a bone
18    scan, would there likely be traces of these
19    abnormalities in her skeleton?
20         A     It would depend on the cause of the
21    abnormality.
22         Q     And that brings us to the next sentence
23    in the report, which is, "The patient has a history
24    of trauma."  What likely led you to that conclusion?
25         A     As I mentioned before, the indication
?                                             24
1     "evaluate for trauma" and the history of closed-head
2     injury and the fact that Dr. Carnahan is a rehab
3     doctor who typically works with patients who have
4     been severely injured and need to be rehabilitated.
5          Q     Anything else?
6          A     Not that I could speculate on at this
7     point in time, no.
8          Q     Then you go on to say, "Most likely the
9     femoral periosteal reaction reflects a response to a
10    subperiosteal hemorrhage."  Would that be a bone
11    bruise?
12         A     Correct.
13         Q     Leading to ossification?
14         A     Correct.  The periosteum is a fibrous
15    layer that covers the bone, and blood vessels run
16    underneath that.  And in certain kinds of trauma,
17    blood accumulates between the bone surface itself
18    and that fibrous periosteum and displaces the
19    periosteum away from the bone.  And then the body
20    repairs that by putting more bone there to replace
21    the blood.
22         Q     To bridge the gap?
23         A     Yes.  Under the periosteum, the body lays
24    down more bone, so that makes the cortex of the bone
25    thicker.  And that's what that periosteal reaction
?                                             25
1     is.
2          Q     Is that an unusual phenomenon, in your
3     experience?
4          A     It's the body's normal way of repairing
5     the bone.
6          Q     Did you see it frequently when you were
7     practicing?
8          A     Yes.
9          Q     In what kinds of situations?
10         A     Well, trauma and also in bone
11    malignancies.  The body attempts to repair the
12    malignancy also by adding new bone to it.  And in
13    certain metabolic processes, the body also puts down
14    new bone.  So it's fairly common skeletal response
15    to a lot of different diseases.
16         Q     Then you go on to say, "And the activity
17    in L1 correlates perfectly with the compression
18    fracture which is presumably traumatic."
19         A     That's what it says.
20         Q     In other words, the x-ray confirmed the
21    L1 fracture?
22         A     The x-ray shows an abnormality at L1
23    which happens to correspond with the abnormal bone
24    turnover on the bone scan at that point.
25         Q     What is a compression fracture?
?                                             26
1          A     It's a loss of the mechanical structure
2     of the vertebral body along what we call the end
3     plates of the vertebral body.  And the end plates
4     are those portions that are adjacent to the
5     cartilages that separate each vertebral body, the
6     cartilages being the body's shock absorbers.
7          Q     Is this compression fracture, then, in
8     common parlance, a broken back?
9          A     Yes.
10         Q     Is there any way to tell how old that
11    fracture would be?
12         A     Well, as I've alluded to, the bone scan
13    gives some suggestion of that.
14         Q     More recent rather than less recent?
15         A     Correct.  Typically in trauma the rule of
16    thumb is that a traumatic fracture is not active on
17    the bone scan after 12 to 18 months.  That's the
18    typical rule of thumb.  Now, bodies being very
19    variable, there's a lot of variation there, but
20    that's the typical rule of thumb.  So if a fracture
21    shows up active on the bone scan, then one makes the
22    presumption that it is relatively recent; i.e.,
23    within 18 months.
24         Q     And after that, it becomes relatively
25    undetectable on the bone scan?
?                                             27
1          A     If it's a simple fracture not related,
2     say, to a malignancy and if it is given the
3     opportunity to heal, then, yes.  Typically after 18
4     months you'll see that it's getting so inactive that
5     you may not pick it out.
6                So let's say you did a series of bone
7     scans on an individual who had a simple fracture.
8     Typically the bone scan won't be active in the first
9     24 hours because the body hasn't had time to start
10    turning over the bone there to make the body repair.
11    So the first 24 hours, you won't see anything
12    typically on a nuclide bone scan.  And I qualify
13    that because there's other kinds of bone scans now.
14         Q     Right.
15         A     Then from one day to some period of time,
16    it gets increasingly intense activity as the body
17    lays down more and more bone.  Then once the repair
18    work is fairly finished as to laying down the bone,
19    then the body starts to remodel that repair work to
20    try to make it look like normal bone again.  So it
21    starts taking away some of what it's laid down.
22         Q     Sloughing off?
23         A     Well, it actually just resorbs it.  The
24    cells of the body -- each individual cell picks up a
25    little bit of that calcium and takes it away.  So
?                                             28
1     you'll have, then, a declining activity phase as the
2     body does that remodeling.  And at some point the
3     body decides that that's all it's able to do for
4     that particular spot, and then the activity will
5     typically return to normal background.
6          Q     So the skeleton is sort of a work in
7     progress?
8          A     It's always turning over, yes.
9          Q     The report goes on to say, "The
10    presumption is that the other multiple areas of
11    abnormal activity also relate to previous trauma."
12         A     That's what it says.
13         Q     And, again, that's based on the fact that
14    Dr. Carnahan is a rehab physician, that you were
15    asked to evaluate for trauma?
16         A     And the pattern of activity is fairly
17    typical of multiple traumatic injuries of relatively
18    recent origin.
19         Q     I realize you can't assign a cause to
20    these injuries that you picked up in this report.
21    But typically in your experience, what would be the
22    causes of this pattern of abnormality?
23         A     In somebody her age, an auto accident is
24    by far the most typical cause.
25         Q     Assume that she was not in an auto
?                                             29
1     accident but that she had suffered an anoxic or
2     hypoxic encephalopathy type of injury from a cardiac
3     arrest and had been bedridden for a year at this
4     point.  What might account for these abnormalities?
5          A     In my knowledge, that type of injury
6     would not account for this pattern of abnormalities.
7          Q     Now, the last sentence says, "Additional
8     possibility would be neoplastic bone disease,
9     widespread disseminated infectious bone disease or
10    multiple bone infarcts from abnormal hemoglobin."
11    Those are all other possible diagnoses to rule out?
12         A     Correct.  We typically give what we think
13    is the most common explanation for what we see based
14    on the information that we're given and the pattern
15    of disease that we see, and then we'll throw out
16    some other possibilities in case the clinical
17    picture doesn't fit because we rarely know anything
18    about what happened to the patient.  I mean, we're
19    peeking through the keyhole of the patient's
20    clinical condition.  So we tend to throw in a few
21    other things that might be something to think about.
22         Q     Might account for?
23         A     We don't attempt to be exhaustive because
24    there is a list of probably 30 or 40 things that
25    could cause abnormal bone scans of this wide nature.
?                                             30
1     And because the body is very variable, nothing is
2     ever classic, which is why attorneys make such a
3     good living at malpractice, because nothing is ever
4     typical.
5          Q     Nothing is ever perfect either, is it?
6          A     Yes.  I had to throw that in.
7          Q     Thanks for doing that.  Do you recall
8     ever having a conversation with Dr. Carnahan about
9     this patient?
10         A     No, ma'am.
11         Q     Now, your conclusion is, "Multiple areas
12    of abnormal scintigraphic accumulation some of which
13    are radiograph for differential as discussed above."
14    What do you mean "radiograph for differential"?
15         A     I think that sort of got butchered in the
16    translation there.  But what that attempts to say is
17    that there are radiographic correlatives for some of
18    the bone scan abnormalities.
19         Q     And scintigraphic accumulation just
20    refers to the tracer action in the skeleton?
21         A     Correct.  Scintigraphy is another word
22    for nuclear imaging.
23         Q     Have you done bone scans on other
24    bedridden patients?
25         A     I'm sure that I have.
?                                             31
1          Q     Now, are you just given the images to
2     read?
3          A     Yes.  We're just given the images.  We do
4     not typically see the patient.
5          Q     Okay.  Would you typically have called
6     the referring physician to report this type of an
7     abnormal bone scan?
8          A     No.  And further, when I do call a
9     physician, it's my custom almost exclusively to
10    annotate the report that it was called.  But we
11    typically only call for life-threatening, unexpected
12    findings.  And bone-scan abnormalities are not
13    typically considered to be life-threatening
14    abnormalities, particularly ones of this nature.
15               If I saw a bone scan on a hip that was
16    positive in somebody that we were worried about a
17    hip fracture, then I would call, because that has
18    implications for treatment.  You don't want them
19    walking around.  You want the orthopedics to
20    evaluate them.  But in this case, no, I didn't feel
21    that that was an emergent, life-threatening
22    condition, so I would not have typically called it.
23         Q     If you look at the bottom of Exhibit 2,
24    which is probably a better copy in some regards,
25    you see there's some notation down there in
?                                             32
1     handwriting?
2          A     Yes.  I see that.
3          Q     It says "Mediplex," and I can't read the
4     rest of it.
5          A     It looks like it says "Mediplex 3/91."
6     And then I can't read the remainder of it either.
7          Q     Is that your handwriting?
8          A     No.
9          Q     Do you know what that would have been put
10    on there for?
11         A     It might refer to the transcription
12    department sending the report.  That would be my
13    guess, but that's just speculation.
14         Q     Would it have been unusual, then, for you
15    to have called Dr. Carnahan and say, "Hey, I've got
16    this bone scan over here"?
17         A     It would be very unusual if I didn't make
18    a note on here.  And I would normally dictate in the
19    report, the report was called in to Dr. Carnahan at
20    such and such a time on such and such a date.  So I
21    would not say that that was called.
22         Q     Since you and I chatted the other day,
23    have you had occasion to look into heterotrophic
24    ossification?
25         A     Yes, I have.
?                                             33
1          Q     And is this bone scan consistent with
2     what you have learned about that condition?
3          A     I'm not sure I understand the format of
4     that question.
5          Q     Okay.  Is this a pattern of heterotrophic
6     ossification as reported in the literature that you
7     looked at?
8          A     Not typically.
9          Q     What makes it atypical?
10         A     Well, if I were to pick one thing, I
11    would say the activity in the ribs is not typical.
12    And typically heterotrophic ossification occurs
13    around the joints because they're not being moved.
14    And typically you will see on the radiographs
15    calcium deposits actually sitting there.  And they
16    don't look like periosteal reaction typically
17    either; they have a different appearance.
18         Q     The periosteal is where the membrane that
19    covers -- I guess that's the periosteum.  Right?
20         A     Right.
21         Q     That covers the bone, separates from the
22    bone?
23         A     Correct.
24         Q     And then calcium ossification occurs
25    between those two?
?                                             34
1          A     Correct, right.  And heterotrophic
2     ossification usually involves the actual joint and
3     the anatomic structures in and around the joint.
4          Q     Can you say, then, within a reasonable
5     degree of medical certainty whether this bone scan
6     is consistent with heterotrophic ossification?
7          A     In my knowledge, it's not consistent with
8     heterotrophic ossification as I typically see it.
9          Q     Do you know how heterotrophic
10    ossification is treated, if at all?
11         A     I don't know.  That's outside my area of
12    expertise.  Speculatively I don't think that you can
13    really treat that as a condition.  But, rather, you
14    try to keep the joints mobile, which is where rehab
15    comes in.
16         Q     Physical therapy?
17         A     Correct, physical therapy.  Because it's
18    the immobility of the joints that cause that
19    reaction to occur.
20               MS. ANDERSON:  I have no further
21         questions.
22               MR. SWOPE:  Can we take a brief break
23         before we get started?
24               MS. ANDERSON:  Certainly.
25               MR. SWOPE:  Is that all right?
?                                             35
1                THE WITNESS:  Fine with me.
2                (Recess from 10:22 a.m. to 10:25 a.m.)
3                         EXAMINATION
4     BY MR. SWOPE:
5          Q     Dr. Walker, my name is Scott Swope, and
6     I'm one of the attorneys representing Michael
7     Schiavo, who's the guardian in this case.  There was
8     some discussion during the direct examination
9     regarding the total-body bone scan looking for
10    recent abnormalities.  Do you remember that?
11         A     Not specifically.  But you can certainly
12    elaborate, I'm sure.
13         Q     All right.  I believe you said that one
14    of the things that you're looking for when you
15    review the photos on a total-body bone scan is for
16    recent abnormalities.  Is that one of the things
17    that you look for?
18         A     That would be the thing that we look for
19    is for disease that's active, because that's all
20    that shows up on a bone scan, is active disease.
21         Q     Okay.  And later on in your direct
22    examination you were saying that traumatic fractures
23    typically are not active on a bone scan after 12 to
24    18 months.  Is that correct?
25         A     That's correct.
?                                             36
1          Q     Now, would that hold true for only
2     traumatic fractures, or does that 12-to-18-month
3     time period hold true for any kind of occurrence?
4          A     I would not say that it holds true for
5     any kind of occurrence, no.  Because many things
6     that give you an abnormal bone scan don't have a
7     finite date where they stop.
8                A fracture occurs in a single moment of
9     time, and then hopefully it's treated and heals.
10    Whereas other things that give rise to abnormal bone
11    scans may be metabolic, for example, and they're an
12    ongoing process that don't stop.  And if that
13    process doesn't stop, the bone scan may be abnormal
14    forever.
15               Malignancies, unless you treat the
16    malignancy, that bone scan is always abnormal.  So
17    only things that have the opportunity to undergo
18    healing will result in a bone scan improving.
19         Q     Okay.  Is there any way for you to say
20    from looking at this report when any of these
21    occurrences took place that caused the abnormality
22    to appear on the bone scan?
23         A     I can only say that if they were
24    traumatic that they probably occurred within 18
25    months.
?                                             37
1          Q     I think you mentioned that you had no
2     personal recollection of dictating this particular
3     report.  Is that right?
4          A     That's correct.
5          Q     And you didn't sign the report?
6          A     I don't see my signature on this copy,
7     no.
8          Q     Okay.  Now, since Dr. Florence Heimberg
9     put her initials on the report, it possible that she
10    is the one who actually dictated this report?
11         A     No.
12         Q     It's not possible?
13         A     No.  Had she dictated the report, she
14    would have had the transcription issue a corrected
15    copy that would have had her name typed as the
16    dictating physician.
17         Q     Okay.
18         A     So if she looked at it and she didn't do
19    that, then she didn't dictate this.
20         Q     I see.  Were there any other radiologists
21    besides yourself and Dr. Heimberg who worked
22    together at this time?
23         A     Yes.
24         Q     Is it possible that one of the other
25    radiologists besides yourself or Dr. Heimberg
?                                             38
1     dictated this report?
2          A     As I said before, it's possible but not
3     probable because I recognize my dictating style
4     here.  And we all have our own dictating styles.  We
5     all phrase things differently, set things in
6     different order.  And almost always you can
7     recognize your own dictating style as opposed to
8     someone else's.  So based on the dictating style
9     here, I would say it was a very high probability
10    that this was something that I dictated, that Dr.
11    Heimberg reviewed and signed off on.
12         Q     Okay.  There was a part in the report
13    that refers to shaggy, irregular periosteal
14    ossification.  And I believe you indicate -- you
15    said during your direct that that indicated to you a
16    relatively recent injury.  Is that accurate?
17         A     I think what I said was that -- if memory
18    serves me, I gave a fairly long discussion of how
19    bone is remodeled and that given enough time,
20    particularly in young people, that that will go
21    away, but that you can't date it very precisely.
22               I think I said my guess would be it would
23    be more recent rather than old but that it can't be
24    precisely dated, and the bone scan is more accurate
25    at giving some indication of a date.
?                                             39
1          Q     Okay.  So when you say "more recent,"
2     you're not able to say within a reasonable degree of
3     medical certainty whether it was a month old, six
4     months old or two years old?
5          A     Are you speaking about the radiograph or
6     the bone scan?
7          Q     I'm referring about your reference in the
8     report to "shaggy irregular periosteal
9     ossification."
10         A     I don't think I drew a conclusion in the
11    report as to how old it was.  But if you're asking
12    me could I date a radiograph, an injury on a
13    radiograph, by the amount of periosteal reaction,
14    within that time frame of a month to two years, no,
15    I couldn't date that.
16         Q     Okay.  Do you have any way of knowing how
17    the compression fracture at L1 occurred?
18         A     No.
19         Q     Is it possible that the abnormalities
20    occurring on the bone scan with respect to the
21    fracture of L1, the compressions fracture of L1 --
22    could that have occurred when the patient -- or if
23    the patient fell onto the floor from a standing
24    position?
25         A     That's possible.
?                                             40
1          Q     Is it possible that the abnormalities
2     that you noted on the right femoral diaphysis and
3     metaphysis could have occurred if the patient was
4     standing and suffered a cardiac arrest and fell to
5     the floor?
6          A     Probably not.  That wouldn't be a typical
7     mechanism of injury that would cause a periosteal
8     bruise.  Typically you need a direct blow of some
9     kind.  I suppose one could speculate that she fell
10    on a piece of furniture, that that could produce
11    that injury.  But just typically falling on the
12    floor would not do that.
13         Q     Okay.  Is there any way to tell from the
14    information in this report how many months or years
15    prior to the bone scan and the radiographs that the
16    bruise on the right femur occurred?
17         A     Because it is active on the bone scan, if
18    it were traumatic, it would probably would have
19    occurred within 18 months.
20         Q     You mentioned that the report indicates
21    multiple bilateral rib abnormalities and that that
22    was not consistent with heterotrophic ossification.
23    Is that right?
24         A     I mentioned that in this deposition, yes,
25    but not in the report.
?                                             41
1          Q     Okay.  Were you looking for heterotrophic
2     ossification when you read the bone scan and the
3     radiographs?  Do you know?
4          A     I think that's in our mind when we see a
5     rehabilitation patient because we don't know from
6     the history how old the injury was.  And, of course,
7     heterotrophic bone is something that occurs
8     particularly in people who are immobilized for long
9     periods of time.  So that would be something that we
10    would mention were we to see a typical pattern for
11    that, yes.
12         Q     Okay.  The abnormalities in the multiple
13    bilateral ribs, could that have occurred during an
14    attempt at resuscitation by the paramedics or
15    hospital staff?
16         A     A vigorous resuscitation could do that,
17    yes.
18               MR. SWOPE:  I have a fairly poor copy of
19         an x-ray report that I would like to have
20         marked as Respondent's -- well, we'll just mark
21         it as Exhibit 3.  That would be the easiest way
22         to do it.
23               Do you want to take a look at that?
24               MS. ANDERSON:  Yes.
25               (Exhibit 3 marked for identification.)
?                                             42
1                MR. SWOPE:  And another x-ray report that
2          I would like to have marked as No. 4.
3                (Exhibit 4 marked for identification.)
4          Q     Dr. Walker, have you ever seen the x-ray
5     report that has been marked as Deposition Exhibit 3?
6          A     Not to my knowledge.
7          Q     Do you know Dr. Donald Durrance?
8          A     Yes, I do.
9          Q     Do you know what kind of a physician he
10    is?
11         A     He's a diagnostic radiologist with a
12    specialty in neuroradiology.
13         Q     His report indicates there that his
14    impression is "no evidence of fracture"?
15         A     That would be what it says, yes.
16         Q     What do you understand that to mean?
17         A     It means he didn't see an alteration of
18    the radiographic anatomy that would suggest that
19    there was a broken bone there.
20         Q     Okay.  Do you know when that report was
21    written or when the x-ray was taken?  Can you tell
22    from the report?
23         A     Well, it's a pretty bad copy.  I see a
24    date of 6/24/91 at 7:11 a.m. underneath the
25    signature line.  Whether that was the date the
?                                             43
1     examination was taken or whether that was the date
2     it was transcribed or dictated, I can't be sure.
3     But one would speculate within some two or three
4     days of the time that the x-ray was taken would be
5     that date.
6          Q     Okay.  So the report is dated June of
7     1991 --
8          A     Correct.
9          Q     -- as far as we can tell?  And your
10    report is dated March of 1991.  Correct?
11         A     Correct.
12         Q     And your report indicates that a
13    compression fracture at L1 was noted on the
14    radiographs, and Dr. Durrance's report shows no
15    evidence of fracture.
16         A     Well, I think that's simply explained in
17    that this is a radiograph of the right humerus,
18    whereas that compression fracture was in the
19    vertebral body of the spine.  So they don't involve
20    the same area.  This is the arm.
21         Q     So this x-ray report relates to her right
22    upper arm?
23         A     That's correct.
24         Q     So he's saying he didn't see any evidence
25    of a fracture in her right upper arm?
?                                             44
1          A     He's saying not only did he not see any
2     evidence of a fracture but that the soft tissues
3     are, quote, intact, yes.
4          Q     Now, Deposition Exhibit 4 is an x-ray
5     report which indicated Steven Ricciardello.
6          A     Ricciardello.
7          Q     Are you familiar with Dr. Ricciardello?
8          A     I am.
9          Q     What kind of a physician is he?
10         A     He's also a diagnostic radiologist with a
11    specialty in neuroradiology.
12         Q     And his report indicates, as far as the
13    left knee conclusion, "no acute injury," and right
14    knee conclusion, "no acute injury."
15         A     Correct.
16         Q     And the date on that report?
17         A     2/05/91 is the date on the top on the
18    right, which would suggest that was a date that this
19    study was obtained.  And 2/8/91 is the date below
20    the signature line which suggests that that's when
21    it was either dictated or transcribed.
22         Q     Okay.  Now, Dr. Ricciardello's indication
23    that there is no acute injury in either of the knees
24    is consistent with your findings and is not
25    inconsistent with your findings on the compression
?                                             45
1     fracture of L1.  Correct?
2          A     That's a -- I don't understand that
3     question.
4          Q     Okay.  His indication that there is no
5     acute injury on either of Ms. Schiavo's knees,
6     that's consistent with the radiographic report that
7     you issued on March 1991.  Correct?
8          A     I would have to say no, that's not
9     consistent, because the bone scan shows that there
10    is activity at the knees of some type.  The bone
11    scan can't be more specific than that because it
12    doesn't show anatomy.
13               Now, I don't know if this right-knee
14    image included the area that we're talking about as
15    the periosteal reaction or not.  I don't know
16    whether that includes that area or not.  And the
17    other problem with this is that these are obtained
18    portably in the nursing extended-care facility, and
19    these quality x-rays are typically of bad quality,
20    "quality" being a misnomer here.
21               So the fact that this doesn't even
22    describe periosteal reaction doesn't surprise me,
23    because that's a subtle finding that you probably
24    would not expect to see in this radiograph but that
25    I would expect to see in a hospital-based radiograph
?                                             46
1     because of the different equipment and the different
2     techniques.  So this -- except to the extent that it
3     doesn't show a big fracture -- is fairly
4     meaningless.
5          Q     Okay.
6          A     I think it probably is -- it doesn't show
7     any calcium in the joints, which you would expect to
8     see with heterotrophic ossification.  It does
9     describe osteopenia.  But, again, osteopenia is a
10    loss of bone substance, which is a fairly judgmental
11    call on a radiograph and depends a lot on the
12    technique too.  Osteopenia is, however, something
13    typically seen in someone who is bedridden because
14    the body tends to put more calcium in areas that are
15    stressed.
16               And if you're bedridden, your legs are
17    not under any stress anymore, so the body tends to
18    take some of the mineral away from those areas.  So
19    the osteopenia is consistent with someone who is
20    bedridden.  Beyond that, because I know the quality
21    of these films because I read them at that time too,
22    I wouldn't make a lot of judgment call on those.
23               MR. SWOPE:  For Exhibit 5, I have a
24         two-page exhibit which is a "Mediplex Rehab -
25         Bradenton Monthly Summary from February 15,
?                                             47
1          1991 to March 15, 1991."
2                (Exhibit 5 marked for identification.)
3          Q     Dr. Walker, have you ever seen that
4     monthly summary?
5          A     No.
6          Q     All right.  Would you go to the second
7     page, please?
8          A     (Witness complying.)
9          Q     At the top there is a statement that
10    says, "An increase in bone growth has been noted in
11    the right thigh secondary to heterotrophic
12    ossification making passive range increasingly
13    difficult."  Do you see where it says that?
14         A     Yes, I do.
15         Q     Is that indication in the medical records
16    consistent with the report that you wrote on the
17    bone scan, or is it consistent with your findings
18    and reading of the bone scan?
19         A     I think it's an apples-and-oranges kind
20    of comparison, in that this is a clinical finding.
21    And I wouldn't make any speculation as to how to
22    relate that to the bone-scan finding.  I just don't
23    think you can do that.  Basically they're saying
24    there that the joint doesn't have as much mobility
25    as it used to.  You can't make clinical
?                                             48
1     determinations off of bone scans, so I wouldn't know
2     where to go with that.
3          Q     Okay.  The person who wrote the summary
4     indicates that the increase in bone growth was
5     secondary to heterotrophic ossification.  Would you
6     say that the abnormalities on the bone scan that you
7     reviewed would be consistent with that?
8          A     I think I mentioned already that they're
9     not typical of heterotrophic ossification, based on
10    my experience.
11         Q     Is it possible that the abnormality was
12    an indication of heterotrophic ossification?
13         A     I suppose with respect to the knee where
14    it refers to the diaphysis of the distal femur only,
15    I'm going to qualify my response referring only to
16    that anatomic area, it's not inconceivable that it
17    could be, but it's not typical.
18         Q     Okay.  I don't have any other questions
19    on that document.  
20               I have a document here which is Mediplex
21    Rehab Bradenton Doctor's Progress Notes, which is
22    comprised of five pages, and the dates appear to go
23    from January 31, 1991 to March 21, 1991.
24               MR. SWOPE:  If we could mark that as
25         Exhibit 6.
?                                             49
1                (Exhibit 6 marked for identification.)
2          Q     Dr. Walker, if you could take a look at
3     that and tell me if you have ever seen that
4     document.
5          A     Not to my knowledge.
6          Q     Okay.  Now, those are doctor's notes, and
7     I have a section there with a bracket.  Can you read
8     what that says?
9          A     No.  I see "knees" there.  But beyond
10    that, I can't really read it.
11         Q     I'm not making a doctor's joke.
12         A     It's true.  We all admit it.  It's so
13    attorneys can't read it.  I can't read it either.
14    Perhaps you can read it for me.
15         Q     Well, does it look like it says, "Some
16    warmth in knees, monitor for H.O."?
17         A     That would be a possibility.
18         Q     Now, "monitor for H.O.," would that be,
19    do you think, heterotrophic ossification?
20               MS. ANDERSON:  Objection.  Calls for
21         speculation.
22         A     I agree, that calls for speculation.  It
23    could be hypertrophic osteoarthropathy too, which is
24    another bone condition that you can get from various
25    things.  So I couldn't say specifically what he was
?                                             50
1     thinking.
2          Q     All right.  So, "Warmth in the knees,
3     monitor for H.O.," you can't say what that means?
4          A     I can't differentiate from two likely
5     diagnoses because hypertrophic osteoarthropathy also
6     gives you warmth in the knees and is seen with
7     people with certain chronic conditions.  So, no, I
8     can't tell you to what specifically he refers there.
9          Q     Okay.  I don't have any other questions
10    on that document.  
11               I have an affidavit signed by Dr. James
12    Carnahan, 14 November 2002.
13               MR. SWOPE:  If I could have that marked
14         as Exhibit 7.
15               (Exhibit 7 marked for identification.)
16         Q     Dr. Walker, have you ever seen the
17    affidavit from Dr. Carnahan that's been marked as
18    Exhibit 7?
19         A     No.
20         Q     All right.  Would you take a moment to
21    read through the statements that Dr. Carnahan makes
22    in the affidavit, please?
23         A     Certainly.
24         Q     You can just read it to yourself.  You
25    don't have to read it out loud.
?                                             51
1          A     Okay.  I read it.
2          Q     Do you have any thoughts on whether or
3     not Dr. Carnahan's affidavit is consistent or
4     inconsistent with your review of the bone scan and
5     radiographic --
6                MS. ANDERSON:  Let me object to the
7          extent that that question calls for Dr. Walker
8          to comment upon any methods or qualifications
9          of another physician.
10               MR. SWOPE:  Okay.
11         Q     You can answer the question.
12         A     All right.  My response would be that
13    this is outside my area of expertise.  So I wouldn't
14    be able to comment on it.
15         Q     Okay.  Now, when you say that it is
16    outside the area of your expertise, what do you mean
17    by that?
18         A     Well, Dr. Carnahan is a rehabilitation
19    doctor who has the patient in front of him, who
20    physically examines the patient and then looks for
21    physical findings and symptoms based on his
22    knowledge of rehabilitation medicine.  And I'm not a
23    rehabilitation-medicine physician, so I wouldn't be
24    able to comment on this document because it is
25    outside of my area of knowledge.
?                                             52
1          Q     Okay.  I think you said during your
2     direct examination that you never saw Terri Schiavo
3     as far as you recollect.  Is that correct?
4          A     That is correct.
5          Q     And so that would mean that you never had
6     an opportunity to examine her?
7          A     That is correct.
8          Q     Would you say that Dr. Carnahan, as her
9     treating rehabilitation physician, would be in a
10    better position to comment on the cause of the
11    abnormalities in the bone scan for this particular
12    patient than you?
13         A     I would say he had a more complete
14    picture of the patient than I.
15               MR. SWOPE:  Okay.  I have a document I
16         would like to have marked as Exhibit 8.
17               (Exhibit 8 marked for identification.)
18         Q     Dr. Walker, Exhibit 8 is an affidavit
19    signed by a physician Eugenio Alcazaren.  Have you
20    ever seen that document?
21         A     No.
22         Q     Do you know Dr. Alcazaren?
23         A     The name is familiar.  I don't know him
24    personally.
25         Q     Do you know what kind of physician he is?
?                                             53
1          A     I believe he's also a rehabilitation
2     physician.
3          Q     Would you take a moment to read the
4     contents of his affidavit?
5          A     Certainly.  Okay.  I read it.
6          Q     In that affidavit, Dr. Alcazaren gives
7     his interpretation of the radiologist's report dated
8     March 5, 1991 of the bone scan as an indication of
9     "heterotrophic ossification, not trauma."  Do you
10    see where it says that?
11         A     Yes, I do.
12         Q     Would you say that Dr. Alcazaren's
13    opinion is consistent with yours or inconsistent?
14         A     Again, this document was produced by a
15    physician whose area of expertise is not identical
16    with mine.  His findings are based again on clinical
17    findings.  He's not an imager.  I'm not a
18    rehabilitation physician.  So I would not be able to
19    comment on the significance of that except to say,
20    again, that the bone scan is not typical of
21    heterotrophic ossification.
22               They're saying that the clinical
23    findings, which are entirely different, may, in
24    fact, be consistent with that.  And I can't make a
25    judgment on that because I'm not a clinician.
?                                             54
1          Q     So you're not saying that Dr. Carnahan
2     and Dr. Alcazaren were wrong?
3          A     I couldn't say that because they're
4     commenting from an area of expertise that I don't
5     have.
6          Q     Okay.
7          A     So I would be presumptuous to say that
8     they were wrong.
9          Q     Okay.  The bone scan and radiographic
10    report shows only one fracture.  And that is a
11    compression fracture to L1.  Correct?
12         A     Well, I should clarify that by stating
13    that not all of the areas of bone-scan abnormality
14    were imaged concurrently.  Okay.  And that's
15    important.  In other words, we didn't x-ray every
16    area that was hot on there.  A couple of typical
17    areas were imaged but not all.  Of those areas that
18    were imaged, the only area that showed what was a
19    clear fracture was L1.
20         Q     Okay.  So of the documents that you had
21    the benefit of reviewing, the only fracture that
22    showed up was a compression fracture to L1?
23         A     You're speaking of the documents at the
24    time that this was interpreted?
25         Q     Correct.
?                                             55
1          A     Yes.  That's correct.
2          Q     The radiographs did not show any
3     fractures of the right femur.  Correct?
4          A     They don't show a typical fracture.  They
5     show periosteal reaction, which could be the result
6     of a bone bruise, which is a bone injury that's not
7     a loss of continuity of the structure of the bone.
8     So to the extent that you define fracture as a loss
9     of structural continuity, then, yes, that is an
10    actual fracture as is typically described.
11         Q     Okay.  If there was a loss of structural
12    continuity of the femur, you would have indicated in
13    the report that there was a fracture to the femur.
14    Correct?
15         A     Correct.
16         Q     And when there is not a structural --
17         A     Discontinuity.
18         Q     -- discontinuity of the femur, you do not
19    note that there is a fracture of the femur.  Is that
20    also correct?
21         A     Yes, that's correct.
22         Q     When you read the bone scan and the
23    radiographs, is it your standard procedure to
24    comment on each area of abnormality that you
25    observe?
?                                             56
1          A     Are you referring to the bone scan or the
2     radiographs or both?
3          Q     Both.
4          A     One would typically comment on any
5     abnormality that one observed, yes.
6          Q     So if there is an absence of a comment in
7     the report of an abnormality in any part of her body
8     other than what is indicated in the report, would it
9     be safe to conclude that you did not observe any
10    abnormality to that particular body part?
11         A     It would be safe to conclude that those
12    areas which were actually imaged did not disclose
13    any additional abnormalities.
14         Q     Okay.
15         A     But since we don't have the films in
16    front of us, we don't know to what extent an area
17    was imaged.
18         Q     With a closed-head injury, would you
19    typically take images of the head, neck and
20    shoulders?
21         A     At the time of the injury we would.
22         Q     Okay.  When you receive a request from
23    Dr. Carnahan to do a complete-body bone scan and the
24    indication of the injury is that it was a
25    closed-head injury, would your standard procedure be
?                                             57
1     to take images of the head, neck and shoulder area
2     as part of your standard procedures?
3          A     Not unless those areas looked
4     particularly unusual on the bone scan.
5          Q     Okay.  Can you say whether or not those
6     areas were actually part of the bone scan?
7          A     I can only say that typically the head,
8     neck and shoulders would be part of a bone scan.
9     But not having the actual images in front of me,
10    that does call for some degree of speculation.
11         Q     Can you think of any time when a
12    physician would ask you for a total-body bone scan
13    and you would not take images for the bone scan of
14    the head, neck and shoulder area?
15         A     If we were having technical difficulties
16    or if the patient was noncompliant, for example,
17    moved around a lot -- which some people do -- then
18    it is possible that those areas would not be imaged.
19         Q     Okay.  Other than that, though, generally
20    you would take images of the head, neck and shoulder
21    area?
22         A     The bone scan typically includes those
23    areas, yes.
24         Q     Okay.  And because there is no comment in
25    your report of any abnormalities in the head, neck
?                                             58
1     or shoulder area, that is an indication that either
2     those images were taken and you observed no
3     abnormalities or that those images were not ever
4     taken.  Is that an accurate statement?
5          A     Yes.
6          Q     But in either one of those events, you
7     did not observe any abnormalities to the head, neck
8     or shoulder area?
9          A     To the extent that they are not described
10    in the report, I would say yes.
11         Q     When you read the bone scan, were you
12    aware, to your knowledge, that the patient had been
13    immobile for an extended period of time?
14         A     No. 1, I would have to say, what is your
15    definition of "extended period of time"?  Because
16    that's kind of a loose term.  Could you give me some
17    indication of what you say by "extended"?
18         Q     Were you aware at the time that you
19    reviewed the bone scan that the patient was immobile
20    for any period of time?
21         A     Not specifically.
22         Q     Do you know whether it is a common
23    occurrence for immobile patients to suffer fractures
24    as a result of undergoing intensive physical
25    therapy?
?                                             59
1          A     That's outside of my area of expertise,
2     so I wouldn't know that for a fact.  I could only
3     speculate.
4          Q     A physician who would be better able to
5     answer that question would be what kind of
6     physician?
7          A     A rehabilitation physician.
8          Q     That would be like Dr. Carnahan and
9     Alcazaren?
10         A     Yes.
11         Q     I showed you some documents of her
12    medical records earlier that referred to warm
13    spots -- well, we think they referred to warm spots
14    in her knees as a result of the physical therapy.
15    Would that be consistent --
16               MS. ANDERSON:  Excuse me.  "As a result,"
17         did you say?
18               MR. SWOPE:  As a result of the physical
19         therapy.
20               MS. ANDERSON:  I don't think that's what
21         that says, so I'm going to have to object to
22         that question.  It was observed during physical
23         therapy, it's not as a result of physical
24         therapy.
25               MR. SWOPE:  Okay.
?                                             60
1          Q     So the hot spots noted in the medical
2     records observed during physical therapy, would
3     those hot spots be consistent with the abnormalities
4     that you noted in your report in both knees?
5          A     I don't think one can make that direct
6     connection because warmth in joints can be caused by
7     many, many things, some of which may show up on bone
8     scans and some of which may not.  So you can't make
9     that A to B connection.
10         Q     Okay.  If an immobile patient is going
11    through physical therapy and part of the physical
12    therapy is to have manual manipulation of the legs,
13    particularly flexing of the knees, is it possible
14    that that physical therapy would result in an
15    abnormal appearance on a bone scan?
16               MS. ANDERSON:  Objection.  That question,
17         I think, is virtually unanswerable because it
18         is so vague.
19         A     I could only speculate.
20         Q     Okay.  In your opinion, is that something
21    that would show up on a bone scan?
22         A     I would think only if the joint were
23    injured would it show up on a bone scan.  Just
24    simple manipulation of an injured part should not
25    show up as an abnormality on a bone scan.
?                                             61
1          Q     Can you tell me when you first realized
2     that you had some involvement in the Terri Schiavo
3     case?
4          A     Only when I got a phone call from Ms.
5     Anderson.
6          Q     When was that?
7          A     Perhaps a week or so ago, maybe.
8                MS. ANDERSON:  Tuesday, I think.
9                THE WITNESS:  This week.
10               MS. ANDERSON:  I think it was this week.
11               THE WITNESS:  It wasn't very long ago.
12         Q     So you don't know what day it was --
13         A     No, I don't.
14         Q     -- that you first became involved in the
15    -- first realized that you were involved in the
16    case?
17         A     Not precisely.
18         Q     Did you have any idea that you had read a
19    bone scan for Terri Schiavo whenever you heard any
20    of the media coverage on the case?
21         A     No.
22         Q     Have you spoken with anyone regarding
23    your involvement with the report or this deposition
24    other than the persons who are here?
25         A     Two of my partners who have called today
?                                             62
1     wanting to talk to me, I have mentioned that I was
2     being deposed in the Schiavo matter.
3          Q     Okay.  After learning from Ms. Anderson
4     that you had apparently written or dictated a report
5     relating to the bone scan -- strike that.  I don't
6     even know where I was going with that one.
7                Did you review any documents before your
8     deposition today after learning that you had
9     apparently dictated the report?
10         A     How would you define "documents"?  You
11    mean documents related to the case, or do you mean
12    medical literature?  I don't understand the
13    question.
14         Q     Well, in preparation for your deposition
15    today, did you review any documents?  And when I say
16    "documents," I'm referring to medical literature,
17    medical records, reports, notes, things of that
18    nature.
19         A     I reviewed the copy of the bone scan that
20    was provided by Ms. Anderson, and I also looked at a
21    couple of radiographic textbooks about bone disease
22    just to familiarize myself with some of this.
23         Q     Okay.  Do you know in particular what
24    areas you looked at specifically relating to the
25    textbooks?
?                                             63
1          A     I looked at all areas covering abnormal
2     deposition of bone.
3          Q     Abnormal deposition of bone?
4          A     Yes.
5          Q     What do you mean by "deposition of bone"?
6          A     The depositing of bone.  That's called
7     deposition in the medical literature.
8          Q     Other than Ms. Anderson and the two
9     physicians who called you today, did you have
10    conversations with anyone else regarding your
11    deposition today?
12         A     Well, you called me last night, so I
13    guess that would count.  We spoke briefly.  But
14    nobody else.
15         Q     Okay.  Well, let me say this.  Did you
16    discuss the merits of the case or the issues
17    involved in your deposition, or anticipated to be
18    involved in your deposition, with anyone?
19         A     I'm not sure I understand what that
20    means.
21         Q     All right.  Well, you indicated you spoke
22    with me briefly.  You indicated you spoke with Ms.
23    Anderson when she informed you that you had
24    apparently dictated the report?
25         A     Correct.
?                                             64
1          Q     Other than those conversations, did you
2     have conversations with anyone regarding the merits
3     of the case --
4          A     No.
5          Q     -- or issues involved in the case?
6          A     No.
7          Q     What led you to look at the textbooks
8     relating to the deposition of bone?
9          A     I just wanted to familiarize myself with
10    those things.  It's a part of a normal education
11    process.
12         Q     Okay.
13         A     We're always try to review the
14    literature, and this gave me a good reason to go
15    ahead and take a look at it.
16               MR. SWOPE:  All right.  I have no further
17         cross.
18               MS. ANDERSON:  Just a couple questions,
19         Dr. Walker.
20                        EXAMINATION
21    BY MS. ANDERSON:
22         Q     Would a kick be the kind of direct blow
23    that would produce that femoral abnormality?
24         A     That would be a possibility, yes.
25         Q     Would being thrown into a sharp furniture
?                                             65
1     corner?
2          A     That would be a possibility.
3          Q     Would being struck with some sort of
4     blunt object like a golf club or something do it?
5          A     Yes.
6          Q     Have you ever encountered a situation
7     where bedridden patients have fractures or sustain
8     fractures during physical therapy?
9          A     Yes.
10         Q     Have you ever talked to physicians about
11    that?
12         A     I have had the occasion to call a
13    physician to report that, because that would be an
14    unexpected finding, yes.
15         Q     Do you caution rehabilitation physicians
16    about the fragility of the skeleton of a bedridden
17    patient?
18         A     No.  That would be presumptuous on our
19    part because they have more knowledge of that than
20    we.
21         Q     Do you think it's possible that these
22    fractures were caused by the rehabilitation at
23    Mediplex?
24               MR. SWOPE:  Object as to the form.
25         A     I couldn't exclude that.
?                                             66
1          Q     Do you think that might be why Dr.
2     Carnahan and Dr. Alcazaren rejected your traumatic
3     finding?
4          A     That would be definite speculation there.
5          Q     Can you tell from your report whether you
6     ordered x-rays of her ribs?
7          A     I would say that those were not ordered.
8     We don't do all areas of abnormality if the areas on
9     the bone scan are so extensive, because, as you
10    know, there's radiation involved, and you want to
11    minimize the amount of radiation to patients.
12         Q     So we don't know whether her ribs were
13    broken?
14         A     We don't.  And I don't believe that they
15    were imaged, based on that report.
16               MS. ANDERSON:  I have no further
17         questions.
18               MR. SWOPE:  I just have one follow-up
19         question on recross.
20                        EXAMINATION
21    BY MR. SWOPE:
22         Q     You mentioned that you have seen
23    fractures in bedridden patients before?
24         A     Yes.
25         Q     How frequently have you seen that?
?                                             67
1          A     Rare.
2          Q     It's rare?
3          A     Yes.
4          Q     More than once?
5          A     Well, I have been in practice now since
6     1980, so I would say more than once in that period
7     of time.
8          Q     Do you have any idea how many fractures
9     you've seen in bedridden patients?
10         A     I would be guessing.  Less than six.
11               MR. SWOPE:  No other questions.
12                        EXAMINATION
13    BY MS. ANDERSON:
14         Q     Have those fractures occurred in elderly
15    patients?
16         A     Typically, because typically those are
17    the patients that we see in this area, yes.
18               MS. ANDERSON:  No further questions.
19               MR. SWOPE:  And no additional recross.
20               MS. ANDERSON:  I'm going to order this.
21         So would you like to look at it, review it?
22               THE WITNESS:  Yes, I would love to be
23         able to look at it.
24               MS. ANDERSON:  Okay.
25               THE REPORTER:  I will send you the
?                                             68
1          original and the errata sheet.
2                MS. ANDERSON:  Do that.
3                And I'll send you the original errata
4          sheet where you can note any changes that you
5          want to make.
6                THE WITNESS:  Okay.
7                THE REPORTER:  Do you want a copy of the
8          transcript?
9                MR. SWOPE:  Can I let you know?
10               THE REPORTER:  Yes.
11               (At 11:18 a.m. no further questions were
12         propounded to the witness.)
?