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









In Re: The Guardianship of



FILE NO.: 90-2908GD-003










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


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

? 2



Patricia Fields Anderson, P.A.

447 Third Avenue

Suite 405

St. Petersburg, Florida 33701

Appeared for Petitioners



Merricks, Hale & Swope, P.A.

2450 Sunset Point Road

Suite D

Clearwater, Florida 33765

Appeared for Respondent



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



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

? 3

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 * * * * * * * * * *


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:



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?

? 4

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.

? 5

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

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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.

? 8

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

? 9

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.

? 10

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?

? 12

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?

? 17

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

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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

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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

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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.)



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?


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.



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.



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.



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.


7 THE REPORTER: Do you want a copy of the

8 transcript?

9 MR. SWOPE: Can I let you know?


11 (At 11:18 a.m. no further questions were

12 propounded to the witness.)