1 A. They refuse to eat or drink, generally. They

2 become withdrawn.

3 Q. What else?

4 A. Refuse treatments, medications.

5 Q. Have you ever encountered a patient for no

6 good reason suddenly expire?

7 A. Perhaps, I have. It doesn't -- I can't recall

8 a particular instance, but I am sure that has occurred.

9 Q. Nothing comes to mind?

10 A. No.

11 Q. If Terry pressed her leg against someone's

12 hand on command, would that surprise you?

13 A. Yes.

14 Q. Does that seem consistent with your experience

15 of Terry?

16 A. Yes.

17 Q. Have you run any Evoked Sensory Potential

18 tests on her?

19 A. I have not done those tests, but I understand

20 those tests were done.

21 Q. Who ordered those?

22 A. I recall, when I first undertook her care,

23 that she had had those tests done. I vaguely remember

24 reading a report to that effect.

25 Q. Were they done --

89

1 A. And I don't know what the results were.

2 Q. Do you remember how much earlier they had been

3 done?

4 A. Yeah. It could have been shortly before I

5 undertook her care. But I do remember that those tests

6 were done, and I couldn't tell you the results. But

7 since you brought it up, there is some vague memory in

8 my mind that I have seen that in some portion of the

9 records that I reviewed.

10 Q. So there is some recorded evidence of how

11 acute her eyesight is, for example?

12 A. Perhaps, there is. Those tests were done and

13 I don't know the results, no.

14 Q. They don't really have a bearing on the orders

15 that you wrote for Terry?

16 A. The results of those tests were reviewed by

17 the neurologist, Dr. Barnhill, who gave an

18 interpretation. I do not interpret those tests or

19 understand those tests very well. It's a very

20 specialized area. I think that the neurologist would be

21 the one to answer those questions.

22 Q. Dr. Gambone, last June, June 18, 2001, you

23 filed an affidavit in this case saying that you had

24 examined Terry on June 14 and that she continued to be

25 in a persistent vegetative state. Do you remember that?

90

1 A. When was this?

2 Q. Last summer, June of 2001.

3 A. Yes, I did.

4 Q. Did Mr. Felos ask you to file this affidavit?

5 A. Yes.

6 Q. When you examined her on June 14, was that a

7 ten-minute examination where you basically just checked

8 her out again?

9 A. I don't recall the amount of time that I spent

10 on that occasion. I would have to review my notes and

11 maybe I could give you some idea how much time I spent.

12 Q. Did you bring your notes with you today?

13 A. No, I didn't.

14 Q. Is the one hour during the initial examination

15 the longest period of time that you ever spent with her?

16 A. Yes, it is.

17 Q. Was there anything unusually lengthy about

18 your examination of her on June 14, 2001?

19 A. I don't recall the amount of time spent at

20 that point in time.

21 Q. Sitting here today, you're saying you don't

22 recall?

23 A. I do not recall.

24 Q. Do you know for what purpose you were asked to

25 examine Terry on June 14, 2001?

91

1 A. Yes. To verify that there had been no change

2 in her condition since my prior examination.

3 Q. And what did you do to satisfy yourself there

4 had been no change?

5 A. Again, I would ask to review my notes and I

6 could tell you exactly what I did at that point in time.

7 Q. You physically did see her, though?

8 A. I assume. If I signed it saying I did, I did.

9 Q. You have no independent recollection today?

10 A. No.

11 Q. When you first assumed her care you entered a

12 DNR order on her chart, right?

13 A. Yes.

14 Q. What does the DNR stand for?

15 A. Do not resuscitate.

16 Q. What is the medical effect of the DNR? What

17 does it mean?

18 A. It means that if someone's heart would stop or

19 they were to stop breathing, that resuscitation would

20 not be attempted.

21 Q. Why did you enter the DNR order on her chart?

22 A. That was done at the request of Mr. Schiavo,

23 the healthcare surrogate.

24 Q. Mr. Schiavo is the healthcare surrogate.

25 Mrs. Schiavo, you mean?

92

1 A. Yes.

2 Q. And who was that?

3 A. Michael Schiavo.

4 Q. Has she experienced any sort of cardiac

5 distress or crisis since she has been under your care?

6 A. No, she has not.

7 Q. She's pretty safe, isn't she?

8 A. Yes, she is.

9 Q. If someone could be trained to feed her by now

10 and if you could concoct a sufficient nutritious routine

11 for her, would she be able to survive?

12 A. If she was able to swallow?

13 Q. Yes. Uh-huh.

14 A. If she was able to swallow and someone was

15 able to feed her, yes, she could survive.

16 MS. ANDERSON: May I have just one moment?

17 THE COURT: Yes.

18 BY MS. ANDERSON:

19 Q. Dr. Gambone, I want to show you some

20 videotape. Have you reviewed any of the videotape

21 examinations?

22 A. No, I have not.

23 Q. I want to show you some of the videotapes and

24 ask you a few questions. That is monitor right there on

25 your stand. If you would, take a look at them. I will

93

1 play segments and ask you some questions, if you don't

2 mind.

3 THE COURT: Will you identify videotape?

4 MS. ANDERSON: Yes. We are going to -- it is

5 the Hammesfahr examination, 11/25 to 11/26.

6 MR. FELOS: Excuse me, Your Honor. Stop it

7 for a second. Your Honor, these tapes were made

8 with a time code to specifically be time coded so

9 we could identify portions of the tape that were

10 being played. I don't see any time code on these

11 tapes which would give me an opportunity, then, to

12 identify them in relation to the

13 two-hour-five-minute video.

14 MS. ANDERSON: The time is 11:25 to 11:26.

15 When digitized, the time code dropped off for a

16 technical reason I don't understand.

17 THE COURT: So the master tape, if you will,

18 has the time code on them?

19 MS. ANDERSON: Yes.

20 THE COURT: So for the purpose of what you are

21 showing Dr. Gambone, you are going to supplement

22 what he is seeing with the time code?

23 MS. ANDERSON: Yes. I'm telling you that it

24 was 11:25 a.m. to 11:26 a.m.

25 MR. FELOS: Your Honor, I do notice something

94

1 not on the tape itself on the pause. It's there on

2 the upper right, which I didn't see when the type

3 was played first. I request that the tape be

4 continued to play in this format so it will just

5 play with the time code as it is now.

6 MS. ANDERSON: I cannot command electronics,

7 Mr. Felos. It is what it is. I think what he is

8 talking about, Judge, is in the upper right-hand

9 corner. I do not understand the technology of the

10 digitization. But I'm telling you, 11:25 a.m. to

11 11:26 a.m.

12 THE COURT: Ms. Anderson, I am not finding

13 fault with you that you do not understand that

14 because that would be a double standard. I'm

15 assuming what I am seeing here, if I look at it or

16 you look at it, is what Dr. Gambone is seeing.

17 MS. ANDERSON: Yes. All of these monitors

18 have exactly the same imagine. The court

19 technology office set this up for us. You were

20 very helpful. You have one. Did you know that?

21 THE COURT: I do know that. They have done a

22 fine job.

23 MS. ANDERSON: May we continue, Your Honor?

24 THE COURT: You certainly may.

25

95

1 BY MS. ANDERSON:

2 Q. Is that typically what you see when you go to

3 see Terry?

4 A. Yes, it is.

5 The following testimony is from the audio
portion

6 of the video.)

7 "Hi, Terry. I am Dr. Hammesfahr. How are you

8 doing?"

9 "Hi, it's mommy. "Hi, Baby. How are you?

10 Hi. Hi. Is that better? You know mommy has to fix you

11 before -- how is that? Put your head back. Is that

12 okay? How do you feel? How do you feel. What? How's

13 my girl? How is my girl, huh?"

14 BY MS. ANDERSON:

15 Q. Dr. Gambone, did Terry appear to be reacting

16 to her mother?

17 A. She appeared to be reacting. I can't say for

18 sure, but I think that was the reaction to her mother.

19 I made notice that I have had that same reaction before.

20 Q. You recognized her mother in that clip, didn't

21 you?

22 A. Yes.

23 Q. And her mother was right in front of her face,

24 right?

25 A. Yes.

96

1 Q. And Terry appeared to smile, didn't she?

2 A. Again, I'm not an expert in brain stem

3 reactions of either reaction, auditory reactions --

4 Q. No. I'm just asking your familiarity with

5 Terry Schiavo's face.

6 A. All I can tell you is that Terry did not

7 respond to me in that same fashion. And whether others

8 who cared for her, I was not aware that they were having

9 similar reactions.

10 Q. No. I understand. I'm just saying this clip

11 that we've just seen, did it appear to you, Dr. Gambone,

12 that she smiled at her mother and recognized her

13 mother's face?

14 A. Again, I can't say for sure, but there was a

15 reaction.

16 Q. There was a re- --

17 A. Reaction. Whether that was a cognitive

18 reaction or a reaction of emotion, no, I couldn't say

19 that. I think we're doing this on primitive brain stem

20 reflexes that I am not familiar with and would be best

21 evaluated by an experts in this area.

22 Q. Did it look to you as though she had a change

23 in facial expressions?

24 A. There was definitely a change in her facial

25 expressions from her resting state.

97

1 Q. Okay. Can we go to Page 02. This is from the

2 Hammesfahr examination. It's 11:30 a.m. to 11:34 a.m.

3 Would you take a look at this one, Dr. Gambone?

4 A. (Witness complies.)

5 Q. Dr. Gambone, did Terry appear to react to that

6 loud bit of piano music?

7 A. Again, there was a definite change from her

8 basic state. But was that a feeling, was that an

9 emotion, or was that a cognitive or cognizant activity?

10 I couldn't say. And I think I would have to rely on

11 other experts who have observed patients like this, on

12 their opinion.

13 Q. Now, in your experience, patients who are

14 brain injured will sometimes take a while to process a

15 command, won't they, that you give them?

16 A. That's correct.

17 Q. Simply by the nature of the injury, it takes a

18 little while to get the information processed and get it

19 back out in response, right?

20 A. That's correct.

21 Q. So the fact that she doesn't immediately

22 respond given her level of brain damage is not

23 dispositive of the issue, is it?

24 A. I'm not sure that I can answer your question.

25 Q. The fact that Terry may appear to respond in a

98

1 delayed fashion to the stimulus does not mean that she

2 does not have cognitive awareness, correct?

3 MR. FELOS: Your Honor, I object. That's a

4 very technical question. I don't think there is a

5 foundation for the question to assume that there

6 was a response, number one. Number two, I think

7 the witness has, on a number of occasions,

8 expressed what he feels is a lack of expert

9 competency.

10 THE COURT: Well, he can struggle with this

11 one, too. I think it's an appropriate question.

12 Doctor, do you remember the question?

13 THE WITNESS: Yes. Again, I am still

14 concerned that what we are observing in these films

15 are evidence of presumptive reflexes that occur to

16 anyone in this particular state given certain

17 stimuli, auditory stimuli, visual stimuli, and does

18 not necessarily mean that there is cognitive

19 awareness. Even if it's slow or not, I don't think

20 that's going to make a difference.

21 BY MS. ANDERSON:

22 Q. So if she appeared to you to laugh at that

23 music, that would be a reflex, that would be a laughing

24 reflex?

25 A. I felt there was some indication of

99

1 expressions that were different than her baseline

2 appearance, for sure. If you want to call it a laugh.

3 And a laugh, again, suggests that you gave some thought

4 to what was said, you thought you appreciated it and

5 found it funny. But I really don't want to say the word

6 "laugh." There was a response.

7 Q. And that response would be the laughing reflex

8 response to the music. Is there a name for what you are

9 talking about?

10 A. Again, you are pressuring me to give answers

11 which I don't have the expertise to give you. There is

12 no such thing that I know of of a laughing reflex, so

13 I'm not going to say to you this is a laughing reflex.

14 But there are terms for this type of reflex and I think

15 you will have to rely on your experts.

16 Q. I appreciate what you are saying, Dr. Gambone,

17 I'm just asking in your opinion.

18 A. I agree. There is definitely a change from

19 the brain baseline.

20 Q. Page 805. This is 12:24 a.m. to 12:26 a.m.

21 "Can you close your eyes and keep them closed.

22 Close your eyes. Close your eyes. I'm on this side of

23 the room here and your mother is over here. If you can

24 feel this, I want to you look at your mother. Not me

25 at, your mother."

100

1 MR. FELOS: Excuse me, Your Honor. I know

2 that playing this tape -- or as this tape is being

3 played there seems to be a continuous stream of

4 audio and then there is a pause, and I would like

5 to inquire.

6 Are we seeing a continuous stream of tape for

7 this time period or has it been edited in any way?

8 MS. ANDERSON: No. It is continuous.

9 MR. FELOS: Do you know why the audio is not

10 continuous?

11 MS. ANDERSON: The audio is how the

12 videographer did that.

13 MR. FELOS: I'm justing inquiring about that,

14 Your Honor.

15 "You want to get a little closer. Again, you

16 feel it. You want to you look at your mother.

17 Don't look at me. Can you feel that? Don't look

18 at me. Open your eyes. If you feel it, look at

19 your mother."

20 "I'm going to try something a little harder.

21 If you can feel this, I want you to look at your

22 mother. Can you look at your mother now? Say

23 something so she knows where you are."

24 "Terry, it's mommy. Over here, Honey. Mommy.

25 Can you look over here at mommy. I'm over here.

101

1 I'm over here. Can you look over here at mommy.

2 Over here. Now, look at me. Terry, look at me.

3 Good."

4 Now, Terry I'm going to tap you with a sharp

5 piece of wood. This is a hammer with a sharp piece

6 of wood. If you feel it, I want to you look at

7 your mother, not at me. Look at your mother if you

8 feel it. Good. Now, look at me. I'm going to

9 hold your eyes open for a second. Can you look at

10 me? Can you look directly at me?"

11 "Look at me. Now look at your mom. Good.

12 Excellent. Terry, look at me. Right over here.

13 Terry, open your eyes up. Open your eyes. Terry,

14 open your eyes. Very good. Good. Good job. Good

15 job young lady. Good job. Now, what I need you to

16 do is close your eyes. Close your eyes real tight.

17 Close your eyes. Close them closed tight. Keep

18 them closed. Okay. Now keep them real closed.

19 Now I want to you open your eyes real wide. Open

20 them real wide. Good job. Very good. Good job.

21 Very good."

22 "Now I want to you open your eyes real wide,

23 real wide. Open them real wide for me. Real wide.

24 Yeah, I saw that. Good job. Now open your eyes

25 real wide. Give me a real big stare. A real big

102

1 stare. Can you open them real wide for me. Terry,

2 open them real wide for me. Real wide keep them

3 moving. Okay. Give me a real wide stare. Can you

4 do that?"

5 BY MS. ANDERSON:

6 Q. Dr. Gambone, did you notice Terry at one point

7 raising her eyebrows, opening her eyes wide?

8 A. Yes. And I noticed that on my visits to her

9 she did have that mechanism to open her eyes wide.

10 There have been occasions she just bombarded someone in

11 the hall. A nurse writes that observation and I would

12 see that same response without any --

13 Q. Any prompting?

14 A. Yes, any prompting. So that is a tough call

15 for me to know whether it's the relationship.

16 Q. Did you see her also rapidly and then closed

17 her eyes after Dr. Hammesfahr's prompt on that tape?

18 A. No, because she blinked so much and her eyes

19 moved so much it was very difficult for me to see the

20 relationship. And just by my own examination of her, if

21 I were to say something, eventually -- this isn't like

22 you get that reaction, but I think it's a consistent

23 response. And, again, in my observations with her on

24 the right side she has a greater movement to the right.

25 Q. Did you know if she had a history of lazy eye?

103

1 A. No, I didn't know that.

2 Q. Mr. Schiavo didn't tell you that?

3 A. If he didn't, I don't recall that.

4 MS. ANDERSON: Let's play H-7.

5 MR. FELOS: Excuse me, Counsel. Which one is

6 that.

7 MS. ANDERSON: 312 to 314.

8 "Okay. Terry, one last time. Okay. Great.

9 We're all done."

10 BY MS. ANDERSON:

11 Q. Dr. Gambone, did you see at the very beginning

12 of that clip she raised her leg and elevated it?

13 A. Yes.

14 Q. Have you ever observed that?

15 A. No, I have not observed that.

16 Q. Do you know how that would come about?

17 A. Yes. It may very well be a spinal or low back

18 reflex.

19 Q. That would cause her, while she is lying on

20 her back, to raise her leg?

21 A. I didn't see her do that before.

22 Q. Okay. Fair enough.

23 MS. ANDERSON: I need one minute, Your Honor.

24 THE COURT: Yes.

25 MS. ANDERSON: May have one?

104

1 THE COURT: Yes.

2 MS. ANDERSON: This is part of Dr. Crawford's

3 examination of Terry. In you turn to the last time

4 on the tape, George, it's 1:8 to 6:45.

5 MR. FELOS: 1:48 to 6:45?

6 MS. ANDERSON: Right, the count.

7 MR. FELOS: Okay.

8 THE COURT: Ms. Anderson, is that the time?

9 MS. ANDERSON: No. It's the counter.

10 "Terry, all right. Hi. Hi, Baby. Hi. Hi.

11 How are you? How is your cold? How is your cold,

12 Sweetheart? Rubber. Rubber. Did you have coffee?

13 Did you have coffee? Huh? You feel better? Huh?

14 You want to go home? You still have a cold? You

15 still have a cold?"

16 "Can you say coffee? You want coffee? Is

17 your cold any better? Are you still sleepy? Are

18 you still sleepy? I bet you are. You feel better?

19 Is your cold any better? Huh. You have the air

20 conditioning turned down a little bit. Yeah. Are

21 you okay today? Are you tired?"

22 "Dad is here. Yeah. He came to see you

23 today. You feel better? Huh. You feel better?

24 What? What? What? Now you have a hiccup. Yeah.

25 Okay. You've got the hiccups. It's just the

105

1 hiccups, sweetheart. It's okay. It's just the

2 hiccups. It's just the hiccups. Okay. All right.

3 Yeah. It's okay. Do you need your coffee? Huh?

4 You sound better. Yeah, you do. You sound better.

5 You look a little tired. Are you okay? Huh?

6 BY MS. ANDERSON:

7 Q. Dr. Gambone, were you present when

8 Dr. Crawford examined Terry?

9 A. No, I was not.

10 Q. Do you know if Terry had a cold on the day he

11 examined her?

12 A. No, I have no -- I don't know what day it was.

13 Q. It was July 9.

14 A. July 9, if she had a cold? I'm not -- I

15 wasn't aware of it.

16 Q. Were you present on July 9 when Dr. Bambakidis

17 examined her?

18 A. No, I was not.

19 Q. Were you present during any of the

20 examinations?

21 A. No, I wasn't.

22 Q. All right. Now, on this video I showed you,

23 that piece of Dr. Crawford's examination, did you

24 observe a change in Terry's face again when she saw her

25 mother?

106

1 A. Yes.

2 MR. FELOS: Objection to the form of the

3 question. There is no foundation that she saw her

4 mother.

5 THE COURT: Overruled.

6 MS. ANDERSON: Thank you, Your Honor.

7 BY MS. ANDERSON:

8 Q. Go ahead.

9 A. There was a change in her face. And there are

10 changes in her face, at least changes that I have

11 observed myself.

12 Q. Does her face change when she perceives you

13 are in the room? Does she do that to you?

14 A. No, she does not. She has done that when I am

15 observing her and there is no reason for her to make

16 those expressions. I have observed those expressions.

17 Q. I thought you said that her expression was

18 unchanging. That you've never have seen --

19 A. At first, there was, not dramatically so.

20 When I first saw her, there was a lot more fleshy

21 muscle. That is the movement of the head and opening of

22 the eyes very wide, the movement of the mouth. I had

23 not heard her moan, but the other nurses have reported

24 that.

25 Q. You have never heard that?

107

1 A. No, but it's very similar to snoring.

2 Q. Similar to snoring?

3 A. Right.

4 Q. You didn't perceive any changes in modulations

5 in the vocalizing?

6 A. It was some change in modulation, but I

7 wouldn't consider it a speech.

8 MS. ANDERSON: To H-09. This clip runs in

9 Dr. Hammesfahr's exam from 2:50 p.m. to 2:52, so

10 this is a short clip.

11 BY MS. ANDERSON:

12 Q. Dr. Gambone, what was Dr. Hammesfahr doing?

13 A. I believe that he was auscultating the muscles

14 of the neck.

15 Q. He was listening to her carotid arteries?

16 A. That's correct.

17 Q. Auscultation is a fancy medical term for

18 listening?

19 A. Yes.

20 Q. Did you do that when you examined her?

21 A. Yes, I did.

22 Q. Do you always do it when you physically

23 examine her?

24 A. No. But when I examined her, there was an

25 examination that was done.

108

1 Q. Now, he also had a stethoscope up on her

2 temples. What was he doing there; could you tell?

3 A. He was also, possibly, listening to her signs.

4 Q. Thanks.

5 MS. ANDERSON: This is the same clip.

6 "Very good. Good. Are you Terry Schiavo?

7 Now, it's easier to sit, so we will sit her from

8 here to here. Look back here. Can you close your

9 eyes tightly? Keep them closed. Keep them closed.

10 Good."

11 BY MS. ANDERSON:

12 Q. Dr. Gambone, did you see that part of the tape

13 where Dr. Hammesfahr asked her to keep her eyes closed

14 and he tried to pull them apart? Did you see that?

15 A. Yes.

16 Q. Did you ever attempt that particular little

17 procedure with her?

18 A. Yes, I have, and I have gotten similar

19 responses.

20 Q. You have gotten a similar response?

21 A. Yes.

22 Q. You told her on command to keep her eyes

23 closed?

24 A. No. I'm saying I told her to open her eyes

25 and she keeps them closed.

109

1 Q. In this particular instance when he told her

2 to close them and tried to open them. That was my

3 question. Did you ever try to do that?

4 A. No.

5 Q. Would you agree if she was squeezing her eyes

6 shut and keeping them shut in response to his command,

7 that would be evidence of cognitive awareness?

8 A. Again, I am very doubtful about the

9 relationship of his voice to the response.

10 Q. So you are doubting the procedure?

11 A. Yes, because she has these repetitive

12 movements over and over and over again. Her eyes are

13 open, they are shut. And that command may or may not be

14 the reason for that. If you are there long enough and

15 you say things over and over again, one of these times

16 they're going to happen.

17 Q. But you have never given the command to her to

18 keep her eyes shut and keep them shut?

19 A. No, I have not.

20 Q. Now, what efforts have you made as her

21 treating physician to improve her medical condition?

22 A. I'm not sure what you're getting at.

23 Q. Help her get better, to help her recover

24 neurological function.

25 A. Her condition is one that there is no

110

1 recovery.

2 Q. And so -- go ahead.

3 A. The damage that is in the brain is not

4 repairable.

5 Q. So the answer to my question is nothing?

6 A. The answer is not nothing. The answer is to

7 us providing the medical care for the treatment and

8 medical problems that might occur to cause her the

9 problems. Adjusting the tube feeding, the problems that

10 arise on tube feeding, handling those.

11 Q. Of course, I'm not speaking about medical

12 bumps along the road. I'm asking you as her treating

13 physician. What steps you have taken to help her

14 recover neurological function?

15 A. I have obtained consultations with other

16 physicians, consultations with therapists. And there

17 was nothing that anyone suggested that I could do to

18 improve her condition.

19 MS. ANDERSON: Thank you, very much. May I

20 have just a moment, Your Honor?

21 THE COURT: Yes.

22 MS. ANDERSON: Your Honor, I'm through except

23 this last little inquiry.

24 BY MS. ANDERSON:

25 Q. What is Trivco Enterprises?

111

1 A. Trivco Enterprises?

2 Q. Yes.

3 A. It is a liability company that I own.

4 Q. And its business is buying out the estate of

5 deceased people?

6 A. No.

7 Q. What is the business?

8 A. The business is investments.

9 MS. ANDERSON: Okay. I have no further

10 questions at this time, Your Honor.

11 THE COURT: Thank.

12 Mr. Felos, do you have anymore questions of

13 this witness?

14 MR. FELOS: Yes, I do, Your Honor.

15 THE COURT: How long do you expect?

16 MR. FELOS: I expect at least an hour.

17 THE COURT: Okay. Maybe we should take a

18 break.

19 Dr. Gambone, I will instruct you not to

20 discuss this case or your testimony with anyone.

21 You are instructed not to associate with anyone

22 during this and not discuss the case.

23 Okay. Let's take a luncheon recess.

24 (Whereupon, a luncheon recess was taken after

25 which the following proceedings transpired.)

112

1 THE COURT: Okay, Mr. Felos.

2 Dr. Gambone you are still under oath.

3 CROSS-EXAMINATION

4 BY MR. FELOS:

5 Q. You were asked on cross-examination,

6 Dr. Gambone, about taking vital signs, whether you take

7 vital signs of Terry and also blood pressure readings.

8 The blood pressure readings that you took -- that were

9 taken before you by the nursing staff of Terry Schiavo,

10 they were within the normal range?

11 A. Yes, they were.

12 Q. For a patient like Terry, with a blood

13 pressure reading of 96 over 65, 107 over 78, and 101

14 over 71, would you consider those normal readings?

15 A. They would be within the normal range of

16 someone in Terry's condition.

17 Q. Now, has Terry had a bed sore in 12 years, to

18 your knowledge?

19 A. Not that I'm aware of.

20 Q. Would you consider Terry a total-care patient?

21 A. Yes, she is total-care.

22 Q. What has to be done on a total-care patient to

23 prevent the skin surface from breaking down?

24 A. Continual turning at a minimum of every two

25 hours. The areas of pressure needs to be relieved.

113

1 Q. And the areas where Terry has contractures in

2 her arms, what is needed to be done there to prevent

3 breakdown of the skin?

4 A. They would use a positioning device or some

5 soft material to prevent the bones from causing pressure

6 areas and the breakdown of skin.

7 Q. Does that involve movement of her arms?

8 A. Yes. The staff would have to move her arms,

9 yes.

10 Q. Uh-huh.

11 MS. ANDERSON: Judge, I'm having a little

12 trouble hearing the very end of Dr. Gambone's

13 answer.

14 THE COURT: Did you wear it out?

15 MS. ANDERSON: I think I wore it out. But I

16 am having trouble hearing the very end of

17 Dr. Gambone's answers.

18 THE COURT: Don't hesitate to ask and we will

19 have him repeat it. We will have the court admin'

20 look at these.

21 BY MR. FELOS:

22 Q. Dr. Gambone, make sure you keep your voice up.

23 A. Yes, I will.

24 Q. Okay. Thank you.

25 If you believe that Teresa Schiavo would

114

1 benefit from physical therapy provided by the physical

2 therapist, would you recommend that?

3 A. Yes, I would.

4 Q. Have you recommended that?

5 A. I have not received a report from the physical

6 therapist suggesting therapy.

7 Q. Now, you picked up her care in 1998 from

8 Dr. Mulroy?

9 A. That's correct.

10 Q. In the two or three -- upon picking up her

11 care, you reviewed her medical records?

12 A. Yes, I did.

13 Q. And those medical records that you reviewed,

14 were those from the inception of her care after this

15 trauma in 1990?

16 A. The information was not complete, but it was

17 sufficient information to obtain a history of what had

18 happened prior. There was some evaluation.

19 Q. Do you know whether Dr. Mulroy had her in

20 physical therapy?

21 A. I don't recall.

22 Q. In fact, the recommendations or the evaluation

23 of a physical therapist -- I believe you testified no

24 physical therapy was needed; is that correct?

25 A. That's correct.

115

1 Q. You were asked some questions about

2 swallowing. Would you agree that the ability to handle

3 saliva is common among vegetative patients?

4 A. Handle it in what way?

5 Q. Being able to swallow your own saliva.

6 A. Are you talking about original saliva or some

7 type of reflex movement or just saliva by gravity going

8 down the esophagus?

9 Q. I'm talking about the involuntary swallowing

10 reflex.

11 A. Yes.

12 Q. Do you know whether vegetative patients

13 usually maintain involuntary swallowing reflexes?

14 A. There is a reflex, yes, in which saliva would

15 be removed.

16 Q. In your review of Terry Schiavo's medical

17 records, were you aware that swallowing studies were

18 performed on her?

19 A. Yes.

20 Q. What do you recall the results of those

21 studies were?

22 A. The results of those studies revealed that she

23 could not swallow.

24 Q. Now, when you said they revealed she could not

25 swallow, they actually place not a liquid, but a

116

1 substance in the throat, don't they?

2 A. Yes, they do.

3 Q. Has Terry Schiavo ever had pneumonia?

4 A. I believe she has, but she did not have

5 pneumonia while she was under my care, that I knew of.

6 Q. You were asked some questions, I believe,

7 about Hospice, referring to Hospice and a six-month

8 standard. Would you disagree that the rule of thumb

9 that you talked about before for Hospice eligibility is

10 a six month life expectancy if the disease follows its

11 normal course?

12 A. That's correct.

13 Q. If Terry Schiavo's disease followed its normal

14 course, in other words, without intervention of her

15 artificial life support, would she die within six

16 months?

17 A. Yes, she would.

18 Q. Now, I want to ask you about the last

19 urinalysis. I believe you testified, and correct me if

20 I am wrong, on your cross-examination that the last

21 urinalysis performed on Terry was pursuant to court

22 order. I would like you to look at the -- I think it's

23 Petitioner's Exhibit 2, which are the studies that you

24 wrote about a week or so ago pursuant to court order.

25 A. Yes.

117

1 Q. Now, correct me if I am wrong, but were you

2 asked to do blood work on those studies or to do a blood

3 workup?

4 A. Yes.

5 Q. Was there any urinalysis done pursuant to --

6 is there any urinalysis reflected on those records?

7 A. No, there's not.

8 Q. Why did you request a urinalysis be performed?

9 A. The nurses had complained that Terry was

10 moaning from time to time, and their thought was the

11 moaning was related to problems with the feeding tube.

12 But there could be other causes. She was checked for

13 constipation, and that was not the problem. So a urine

14 was done to check for infection.

15 Q. That's what revealed the urinary tract

16 infection that she had just a couple weeks ago?

17 A. Yes. These tests came coincidental with what

18 was court ordered to what I ordered. It happened pretty

19 much in the same day or just a few days.

20 Q. Just to clarify your prior testimony. The

21 urinalysis that you ordered a couple weeks ago in which

22 the urinary tract infection was discovered, it was not

23 done pursuant to court order, was it?

24 A. I don't believe so. It was just coincidence

25 they were ordered at the same time.

118

1 Q. You weren't asked about Terry's CAT scan that

2 was recently performed on your cross-examination. I

3 would like you to take a look at Petitioner's Exhibit 3,

4 which are the results of the CAT scan study performed on

5 July 2, 2002.

6 MS. ANDERSON: Excuse me, Your Honor. Is

7 Mr. Felos going to offer these into evidence?

8 THE COURT: No, he is not. He is just asking

9 him if he recognizes them.

10 Let me ask a question, if I might.

11 I believe on cross-examination we talked about

12 CT scan. You are talking about a CAT scan. They

13 are one in the same; is that correct?

14 MS. ANDERSON: I understand.

15 MR. FELOS: Yes.

16 MS. ANDERSON: It's cumulative tomography.

17 BY MR. FELOS:

18 Q. Dr. Gambone, are you familiar with

19 Petitioner's Exhibit 3 that I'm having you review?

20 A. Yes. I did see that report.

21 Q. And how did you receive that report?

22 A. How I did receive that report?

23 Q. Yes.

24 A. Meaning what?

25 Q. Well, I mean, who sent it to you; do you

119

1 recall?

2 A. If I could look at the report again. This

3 report was sent to my office in Tampa.

4 Q. Do you recognize this as part of

5 Terry Schiavo's medical records?

6 A. Yes.

7 MR. FELOS: Your Honor, I would like to

8 introduce this into evidence as Petitioner's

9 Exhibit Number 3.

10 THE COURT: Is there an objection?

11 MS. ANDERSON: No objection, Your Honor.

12 THE COURT: It will be so received.

13 BY MR. FELOS:

14 Q. Now, in talking about on cross-examination you

15 had, I believe, testified that you believed the CT scan

16 showed most of Terry's brain was gone. I want to read

17 to you a portion of Petitioner's Exhibit 3 in evidence

18 and ask you if you remember that.

19 MS. ANDERSON: Your Honor, this is very

20 improper for what Mr. Felos is doing. If he is

21 attempting to refresh Dr. Gambone's recollection,

22 he needs to let Dr. Gambone look at that CT report

23 and refresh his own recollection and let him

24 question, then, about it. What he is doing now

25 should be on redirect, not cross. He is going

120

1 about it backwards. He is, in effect, testifying;

2 Mr. Felos is. So I object to this manner of

3 dealing with this document.

4 MR. FELOS: Your Honor, this has been accepted

5 into evidence. This CT scan was a matter brought

6 up on cross-examination. I certainly have a right

7 to read from the exhibit and ask the witness a

8 question.

9 THE COURT: But it's in evidence. If you are

10 going to introduce it into evidence, I will read

11 it. If you want to hand it to the witness and ask

12 him if he agrees with it, that's fine. But I'm not

13 going to let you stand up there and read it into

14 the record and ask him if it's okay.

15 MR. FELOS: Well, Your Honor, we have had

16 earlier today, in essence, part of the Respondents'

17 case be read into the record; what was appearing on

18 the videotape and questions asked of the witness.

19 THE COURT: Well, it's pretty hard to ask a

20 witness a question about a piece of video and not

21 ask him to look at it. But that's exactly what

22 they did. They played the video, he looked at it,

23 and they asked him questions.

24 So hand him the document, let him look at it,

25 and you as him questions. We will treat you just

121

1 like we treated Ms. Anderson.

2 BY MR. FELOS:

3 Q. Dr. Gambone, in reviewing the CAT scan report,

4 is there anything that would support your previous

5 testimony that there was little or no brain in

6 Terry Schiavo's cerebral hemispheres?

7 A. Yes.

8 Q. Would you read that portion, please?

9 A. The impression from the radiologist was

10 "Defuse encephaloneuralgia and infarction consistent

11 with anoxia. Number two, hydrocephalus ex vascular.

12 And, three, neuro simulator present."

13 Q. If you can, read the sentence starting with

14 there.

15 A. In the discussion the radiologist reports --

16 MS. ANDERSON: Wait, Your Honor. Mr. Felos

17 has not asked the witness a question. He is asking

18 him now to read the document into evidence.

19 MR. FELOS: Well, I can't ask the question

20 until I have him read that.

21 MS. ANDERSON: He is not asking a question.

22 THE COURT: Him reading the document is no

23 different than you reading the document in the

24 record. Ask him a question based upon the

25 document. I am going to read the document before I

122

1 rule. So the fact that he reads it into the record

2 didn't pertain to anything except that it takes us

3 longer to conclude his testimony.

4 BY MR. FELOS:

5 Q. Do you see any notation in that report

6 specifically regarding the amounts of brain matter in

7 Teresa Schiavo's cerebral hemisphere?

8 A. Yes.

9 Q. What is that in the discussion provided by the

10 radiologist?

11 A. He reports there is a small amount of brain

12 substance remaining in the cerebral hemisphere, mainly

13 in the anterior temporal lobes.

14 Q. Thank you, Dr. Gambone.

15 Now, would you call yourself a general

16 practitioner, Dr. Gambone?

17 A. I would call myself a specialist in internal

18 medicine and geriatric medicine.

19 Q. Do you consider yourself a specialist in

20 neurology?

21 A. No, I do not.

22 Q. And is it common for an internist to rely on

23 the opinions of expert doctors in the course of their

24 treatment of a patient?

25 A. That is correct, extremely in unusual

123

1 conditions.

2 Q. I believe you were -- I believe you testified

3 on cross-examination that you partially relied on

4 Dr. Barnhill's opinion as to Terry Schiavo being in a

5 vegetative state. In your review of your medical

6 records, prior to your and Dr. Barnhill seeing the

7 patient, had you ever seen any other reference to that

8 event?

9 A. Yes, I believe I did. And if you asked me

10 where I saw that, I'd probably have difficulty without

11 having the record.

12 Q. I would like to show you Petitioner's Exhibit

13 4 marked for identification, which is a discharge

14 summary from Mediplex Rehab in Bradenton.

15 MS. ANDERSON: Judge, I move to strike that

16 last bit of testimony from Mr. Felos. He needs to

17 approach the witness with the document and ask him

18 if he recognizes the document and ask him how he

19 recognizes it. He doesn't need to make a speech

20 about what they are ahead of time.

21 MR. FELOS: Your Honor, I'm not giving a

22 speech. I'm just identifying the title of the

23 document I am showing him.

24 THE COURT: A normal question is, do you

25 recognize this? What is it? Then, it's

124

1 identified. You have already identified it in your

2 question. Say what it is.

3 I am going to grant the Motion to Strike and

4 allow to you rephrase the question.

5 BY MR. FELOS:

6 Q. Do you recognize the document I just handed

7 you which is marked Petitioner's Exhibit 4?

8 A. Vaguely. This happens to be part of the

9 documents that I reviewed when I took over her care in

10 1998.

11 Q. Do you recognize that as part of

12 Terry Schiavo's medical chart and records?

13 A. Yes, I do.

14 Q. Thank you.

15 MS. ANDERSON: Mr. Felos, I would like to have

16 a copy of that exhibit.

17 MR. FELOS: Your Honor, I'd move to introduce

18 Petitioner's Exhibit 4 into evidence.

19 THE COURT: Is there an objection?

20 MS. ANDERSON: If I may take a moment, Your

21 Honor, to look at this.

22 THE COURT: Yes, ma'am.

23 MS. ANDERSON: These are -- part of this

24 exhibit that I have been handed is a duplicate.

25 There are two copies of the discharge summary.

125

1 It's also jumbled up there, actually.

2 No objection, Your Honor.

3 THE COURT: Thank you. It would be so

4 received.

5 (Whereupon, the document referred to was

6 received in evidence as Petitioner's Exhibit Numbers 3

7 and 4.)

8 BY MR. FELOS:

9 Q. Now, I believe you mentioned that -- we

10 discussed on your cross-examination that you discussed

11 Terry's additional care with the staff at the Hospice;

12 is that correct?

13 A. That's correct.

14 Q. Do you recall -- you were asked a question, I

15 believe, "Do you ever see Terry's mother with Terry",

16 and you said no.

17 A. That's correct.

18 Q. Do you recall seeing any record in the -- any

19 record in the Hospice medical notes regarding Terry's

20 mother visiting her?

21 A. I do not recall offhand.

22 Q. Let me show you part of Respondents' exhibit

23 introduced into evidence, Hospice medical records, and

24 ask you if that refreshes your recollection?

25 MS. ANDERSON: Judge, that's a problem. This

126

1 is not the way you refresh somebody's recollection.

2 If he has a question about a specific page in

3 Respondents' Exhibit 12, he needs to draw

4 Dr. Gambone's attention to it and ask the question.

5 But he is asking -- he's, in effect, suggesting to

6 refresh of his recollection, and that's improper

7 because Dr. Gambone hasn't indicated that looking

8 at that would refresh any recollection he might

9 have that he no longer has. It's a different

10 animal, is what he is doing.

11 THE COURT: He is asking him to look at this

12 and see if he can refresh his recollection.

13 MS. ANDERSON: He hasn't indicated that his

14 recollection needs refreshing, which is a necessary

15 predicate.

16 THE COURT: He said, "I don't remember."

17 That's the standard predicate answer to may I

18 refresh your recollection.

19 MS. ANDERSON: And, then, there is the

20 intermediate step, "if you look at this record,

21 would it refresh your recollection." I haven't

22 heard him say that it would.

23 THE COURT: Okay. Why don't you say that,

24 Mr. Felos?

25 BY MR. FELOS:

127

1 Q. Regarding Page 58 of Respondents' Exhibit, I

2 would like you to take a look at this and ask you if it

3 would refresh your recollection?

4 A. This is -- I don't recall this particular

5 passage.

6 Q. Okay. Would you be surprised, Dr. Gambone,

7 that there are many entries in the hospital's medical

8 records regarding visits of Mrs. Schindler to her

9 daughter?

10 A. It would not surprise me.

11 Q. Would it surprise you there are many entries

12 in the Hospice medical notes regarding Mrs. Schindler's

13 visits with her daughter?

14 A. I would think, yes.

15 Q. Would it surprise you that those records

16 reflect that Terry is not responsive to the mom?

17 A. On the video, it's not what I would expect.

18 Q. Regarding Terry's teeth, you testified that a

19 dentist saw Terry; is that correct?

20 A. Yes.

21 Q. And you received a report of his findings?

22 A. Yes.

23 Q. Did the report evidence any problems with her

24 teeth?

25 A. No.

128

1 Q. Now, I believe you testified on

2 cross-examination that you didn't believe that a

3 hygienist, dental hygienist, came out afterwards and

4 cleaned her teeth. Are you aware that a dentist -- do

5 you know whether or not the dentist came out afterwards

6 and cleaned her teeth?

7 A. If the dentist did, I wasn't aware of it.

8 Q. Now, you were asked about the will to live.

9 This is this part of the survival instinct?

10 A. I would think so.

11 Q. Now, you were asked questions about

12 responsiveness and whether responsiveness in a patient

13 indicated or contraindicated a vegetative condition.

14 Would it make a difference in that answer as to whether

15 the response was involuntary as opposed to meaningful?

16 A. Yes, it would make a difference.

17 Q. Would an involuntary response to a stimulus,

18 which is the environment, contraindicate a vegetative

19 condition?

20 A. No.

21 Q. Now, I believe you were asked "would you be

22 surprised if Terry lifted her leg on demand if I pressed

23 her leg," and I believe you stated you would. Would you

24 be surprised that -- would you be surprised if that --

25 let me rephrase that.

129

1 Could a press of her leg coincide with an

2 involuntary action or movement on the part of Terry?

3 A. That's correct.

4 Q. Would that be particularly surprising?

5 A. No.

6 Q. You mentioned that there is a DNR order in

7 Terry's chart.

8 A. That's correct.

9 Q. Do you know whether there was a DNR order in

10 her chart before you took over her care?

11 A. I believe that there was a DNR order before I

12 took over her care. I am not positive.

13 Q. Do you know a presumptive audio oriented

14 process?

15 A. No.

16 Q. Now, you were shown various portions of the

17 videotape examinations on Terry. Do you recall when the

18 video starts that music is playing?

19 A. Yes.

20 Q. Did you see any reaction of Terry initially

21 when the music was playing?

22 A. Movements of her head and eyes are movements

23 which I have observed her make without any music or

24 interaction.

25 Q. To your knowledge, does Terry have a -- to

130

1 your knowledge does Terry have a startle reflex?

2 A. Yes.

3 Q. What is a startle reflex, Dr. Gambone?

4 A. To respond to stimuli, to loud sounds or a

5 painful reaction is a startle response.

6 Q. There is a portion of the tape where Terry was

7 moaning while her mother was by the bedside. Do you

8 recall that?

9 A. Yes, there was a noise. On one video, there

10 was nasal sounds. I wasn't clear if -- I called it

11 snoring. I wasn't sure if it was related to her cold,

12 if it was a moan, or snore or nasal congestion.

13 Q. Do you know for a fact whether Terry had a

14 cold in 2002?

15 A. No, I don't know that for a fact.

16 Q. During the time that -- and correct me if I am

17 wrong, but was Terry's -- was Terry's mom making

18 physical contact with Terry during the time that you saw

19 her moan?

20 A. I believe so. She was off to the left of the

21 screen. I failed to see where her hands were at times.

22 Q. Would it surprise you that these tapes review

23 numerous occasions where Terry's mother kisses her and

24 asks her questions when there is no moaning?

25 A. Yes. According to the nurses, she does moan

131

1 all the time.

2 Q. Now, you were asked to listen to her carotid

3 arteries?

4 A. Yes.

5 Q. And what was the result of listening to her

6 carotid arteries? Did you find anything wrong?

7 A. No, I did not.

8 MR. FELOS: I have no further questions, Your

9 Honor.

10 THE COURT: Thank you.

11 Anything further, Ms. Anderson.

12 MS. ANDERSON: Just a few, Judge.

13 RECROSS-EXAMINATION

14 BY MS. ANDERSON:

15 Q. Would it be unusual if the dentist cleaned a

16 Hospice patient's teeth?

17 A. I couldn't answer that.

18 Q. Has that ever happened, in your experience?

19 A. Has the dentist come in and cleaned the person

20 in Hospice's teeth?

21 Q. Yes.

22 A. I haven't had that much experience with

23 Hospice. I couldn't comment on what their policy is to

24 clean the teeth.

25 Q. I can't hear you.

132

1 A. I don't know what their policy is, procedure

2 on teeth cleaning, the dentist.

3 Q. At nursing homes, would it be unusual for a

4 dentist to clean the patient's teeth?

5 A. No. Again, not unusual, because some of the

6 patients are very difficult and would require the

7 dentist's expertise.

8 Q. As the attending physician, would you be

9 informed if the patient's teeth were cleaned?

10 A. Only if medication were required for sedation.

11 Q. Have you ever --

12 A. Or antibiotics, or something that involved an

13 order. But just routine cleanings that are done on a

14 routine basis, I'm not sure.

15 Q. I think you said earlier that you are not sure

16 if the State's regulation are not the same for nursing

17 home?

18 A. They are not. As far as the dental, I'm not

19 sure what their policy and procedure is. I know they

20 are not regulated by the State, so they are different.

21 Q. Has anyone at Hospice ever informed you that

22 Terry's teeth were cleaned?

23 A. No.

24 Q. Did you ever see a chart notation that Terry's

25 teeth were cleaned as a result of this examination in

133

1 2002?

2 A. No.

3 Q. Okay. You said here that they received a

4 report from the physical therapist suggesting the

5 viability of therapy for her?

6 A. That's correct.

7 Q. Has the physical therapist ever seen Terry?

8 A. Yes, the physical therapist has seen Terry.

9 Q. No. I'm talking about -- forgive me. I

10 confused you.

11 While she has been at Hospice, has a physical

12 therapist ever seen Terry?

13 MR. FELOS: Your Honor, I have got -- this may

14 be within the scope of cross-examination, but not

15 recross. The scope of recross are just new matters

16 that are brought up on redirect. I didn't bring up

17 any new matters on redirect.

18 MS. ANDERSON: He certainly did. That

19 particular item right there was on his item of

20 redirect.

21 MR. FELOS: That was not on the subject that

22 was redirect from cross-examination. Recross is

23 limited to new matters that I brought up.

24 THE COURT: Well, new matters aren't supposed

25 to be brought up in redirect. I'm giving both

134

1 sides fair latitude in this proceeding. I examine

2 that you certainly brought up physical therapy.

3 BY MS. ANDERSON:

4 Q. Let me make sure that we are communicating.

5 I'm speaking about Terry's time at Hospice.

6 A. Correct.

7 Q. Since she has been at Hospice, has she been

8 seen, and by seen, I mean evaluated by a physical

9 therapist?

10 A. I believe that she was seen for an evaluation

11 for therapy.

12 Q. Now, was she has not received any physical

13 therapy?

14 A. No.

15 Q. Okay. And the chart that I directed your

16 attention to earlier where you signed it and said that

17 the husband declined the evaluation, is that the second

18 evaluation?

19 MR. FELOS: Your Honor, if I can object. I

20 asked him a question on redirect about the husband

21 and physical therapy. That was a matter on

22 cross-examination. I didn't bring it up on

23 redirect. She is just cross-examining the witness

24 again.

25 MS. ANDERSON: He has opened the door about

135

1 this physical therapy by asking this question.

2 MR. FELOS: That does not open the door for

3 her repeating cross-examination.

4 THE COURT: Well, it's -- I'm going to give

5 her a little latitude, Mr. Felos. I am not going

6 to allow her to go right back through her

7 cross-examination, of course.

8 BY MS. ANDERSON:

9 Q. You are saying you think Terry was evaluated

10 by physical therapist when she came into the hospital?

11 A. Yes.

12 Q. And sometime after that you have this

13 conference in which the husband declined the evaluation

14 for physical therapy?

15 A. The note that you referred to were date

16 April 20, 1998, okay.

17 Q. Right.

18 A. And that's when I had indicated that after

19 speaking with Michael, he declined another evaluation.

20 That was not Hospice.

21 Q. Now, you said that she did have some

22 swallowing tests.

23 A. Yes.

24 Q. What year?

25 A. I don't recall the exact year.

136

1 Q. More than ten years ago?

2 A. Again, I don't recall the exact dates or times

3 so I'm not going to guess.

4 Q. You haven't ordered any swallowing tests,

5 though, in the last four, four-and-a-half years?

6 A. No. Now, she has been evaluated by a speech

7 therapist who did not recommend a swallowing test

8 because the bedside examination suggested she was high

9 risk for aspiration. That's why the tests were not

10 ordered.

11 Q. And there is a charted entry on that?

12 A. Yes.

13 Q. What's the date of that chart entry?

14 A. I would have to go back in the record and pull

15 it out.

16 Q. That was since she has been at Hospice?

17 A. The -- I definitely -- this was when she was

18 at the Gardens, and I don't believe it was revisited at

19 Hospice.

20 Q. Basically, she hasn't seen any therapists

21 since she has been at Hospice, right?

22 A. I can't answer that question.

23 Q. To your knowledge?

24 A. It's not -- it's not a matter of not seeing,

25 but did she receive therapy because evaluations are done

137

1 and screenings are done to see if someone will benefit

2 from therapy.

3 Q. Has she been evaluated?

4 A. Yes, she received evaluations.

5 Q. When she got to Hospice?

6 A. Yes.

7 Q. But she received no therapy since then?

8 A. Yes, that's correct.

9 Q. My last question, Doctor. The second

10 urinalysis that was just done, you know, was done

11 because Terry made complaints of pain. The nurses

12 called you or --

13 MR. FELOS: There was no testimony, Your

14 Honor, that Terry made complaints of pain.

15 THE COURT: Well, she can ask the question and

16 the witness may say yes or no depending upon the

17 question that she is entitled to frame.

18 BY MS. ANDERSON:

19 Q. And by complaints of pain, I'm talking about

20 her moaning.

21 A. What I can tell you is, first of all, it was

22 the nurse practitioner who was involved. So I wasn't

23 involved in some of this transmittal of information.

24 But beyond that, the complaint was of moaning. And the

25 nurse who reported the increase moaning felt there was a

138

1 change in condition that should be reported for a

2 medical evaluation. And after discussions with the

3 nurses, I found they were concerned about the feeding

4 tube, problems with the feeding tube. They had it

5 checked for connection problems. That was noted. And

6 then, after some adjustments in the tube, it did seem to

7 change the situation. And urine was collected and

8 infection was found.

9 Q. Well, somewhere along the line, some medically

10 trained person interpreted that change in her condition

11 as evidencing pain or discomfort, correct?

12 A. As a response to irritation in the bladder.

13 This moaning could be, you know, ideal with bringing

14 treatment for many causes. And in long-term care, the

15 various individuals may have different responses in her

16 care. Moaning suggested there was a change of

17 condition.

18 Q. That somebody interpreted as a pain response?

19 A. Yes, that was her interpretation.

20 MS. ANDERSON: That was my question. Thank

21 you.

22 No further questions, Your Honor.

23 THE COURT: Anything further of this witness?

24 MR. FELOS: No, Your Honor.

25 THE COURT: Thank you. Dr. Gambone, you may

139

1 stand down.

2 Okay. Anything further for us to pick up this

3 afternoon?

4 MS. ANDERSON: Not this afternoon, Your Honor.

5 THE COURT: Who would be your witness on

6 Monday.

7 MS. ANDERSON: Dr. Hammesfahr.

8 THE COURT: Due to the fact that we would

9 probably be playing the entire video of his

10 examination, would it be prudent to start it at

11 9:00.

12 MS. ANDERSON: It's entirely up to you, Judge.

13 Immaterial to me.

14 THE COURT: Well, I'm trying to be

15 accommodating to the lawyers.

16 MS. ANDERSON: Are we having the time change

17 this weekend?

18 THE COURT: No. I don't think so.

19 MS. ANDERSON: It's next weekend then.

20 THE COURT: Mr. Felos, what are your thoughts

21 about Monday?

22 MR. FELOS: Your Honor, if we are to see two

23 hours and 50 minutes of the videotape, it might be

24 a good idea to start a little bit earlier. If

25 Ms. Anderson has no objection, why don't we stand

140

1 in recess until 9:00 a.m. Monday morning.

2 I would like to enter Petitioner's Exhibits 3

3 and 4 that were accepted into evidence and also

4 introduce into evidence Petitioner's Exhibits 1 and

5 2 which were Dr. Gambone's Comprehensive Medical

6 Examination and the report.

7 MS. ANDERSON: Wait a minute. What are we

8 doing?

9 THE COURT: He is wishing to place Exhibits 3

10 and 4, which I have already received into evidence;

11 although, I don't have physical possession of them.

12 I was going to ask you about your Exhibit 12,

13 although I don't have physical possession of it.

14 MS. ANDERSON: It's in the book and copy that

15 Dr. Gambone testified from right there.

16 THE COURT: Do you wish me to have this copy?

17 MS. ANDERSON: Judge, the duplicates are in

18 the book. And for your convenience - so I can take

19 this copy back - if you wish, we could take the

20 ones in the notebooks as the official ones.

21 THE COURT: So let me have your Exhibits 3 and

22 4, which I have already received.

23 MR. FELOS: That's Exhibit 3, and I have to

24 locate 4, Your Honor.

25 MS. ANDERSON: Judge, you have admitted

141

1 Petitioner's 3 and 4.

2 THE COURT: Yes, ma'am, and your 12. Now

3 Mr. Felos wishes also, at this time, to introduce

4 Petitioner's Exhibits 1 and 2, which I believe he

5 said Dr. Gambone had identified.

6 MR. FELOS: Yes, his Comprehensive Medical

7 Evaluation of the results of the recent health

8 screening.

9 THE COURT: Is there an objection?

10 MS. ANDERSON: I have no objection to their

11 coming in.

12 THE COURT: Thank you.

13 (Whereupon, the document referred to was

14 received in evidence as Petitioner's Exhibit Numbers 1

15 and 2.)

16 THE COURT: Okay. Anything further?

17 MR. FELOS: No, Your Honor.

18 THE COURT: All right.

19 MS. ANDERSON: Will this room be secured over

20 the weekend or no?

21 THE COURT: My guess is nobody is going to

22 leave anything anyway. Are you? I'm talking about

23 your files.

24 MS. ANDERSON: No. I will take the files out

25 of the courtroom.

142

1 THE COURT: You are going to take yours?

2 MR. FELOS: Yes.

3 THE COURT: I will take mine, also. Until

4 9:00 a.m. on Monday.

5 THEREUPON, the hearing terminated until
9:00

6 a.m. Monday morning.

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143

1 CERTIFICATE OF REPORTER

2 STATE OF FLORIDA )

3 COUNTY OF PINELLAS)

4 I, TONYA H. MAGEE, RPR, Registered Professional
Reporter, Notary Public, State of Florida at Large:
5
DO HEREBY CERTIFY that the foregoing proceedings
6 were taken before me at the time and place set forth
in the caption thereof; the proceedings were
7 stenographically reported by me in shorthand, and the
foregoing pages, numbered 1 through 142 inclusive,
8 constitute a true and correct transcript of my said
stenographic notes.
9
I further certify that I am not a relative,
10 employee, attorney, or counsel of any of the parties,
nor relative or employee of such attorney or counsel,
11 nor financially interested in the outcome of the
foregoing action.
12

13 IN WITNESS WHEREOF, I have hereunto affixed my
official signature this 23rd day of January, 2003,
14 at Clearwater, Pinellas County, Florida.

15 _________________________
TONYA H. MAGEE, RPR
16 Court Reporter and
Notary Public, State of
Florida
17

18 Acknowledged before the undersigned
this day of January, 2003,
19 by Tonya H. Magee, who is personally
known to me.
20
_______________________________
21 Notary Public, State of Florida

22

23

24

25

144

1

2 IN THE CIRCUIT COURT OF THE
SIXTH JUDICIAL CIRCUIT IN AND FOR
3 PINELLAS COUNTY, FLORIDA
PROBATE DIVISION
4

5 IN RE: THE GUARDIANSHIP OF File No.90-2908-
GD-003
THERESA MARIE SCHIAVO,
6 Incapacitated. APPEAL
___________________________________// VOLUME II
7
MICHAEL SCHIAVO, as Guardian of the
8 person of THERESA MARIE SCHIAVO,

9 Petitioner/Appellee,

10 vs.

11 ROBERT SCHINDLER and MARY SCHINDLER,

12 Respondents/Appellants.
________________________________________________//
13

14 BEFORE: The Honorable GEORGE W. GREER

15 PLACE: Pinellas County Courthouse
315 Court Street North
16 Clearwater, Florida

17 DATE: October 14, 2002

18 TIME: Morning Session

19 REPORTED BY: TONYA H. MAGEE, RPR
Court Reporter and Notary
Public
20 Sixth Judicial Circuit
___________________________________________
21
HEARING
22 ___________________________________________

23 Pages 144 - 273

24 ROBERT A. DEMPSTER & ASSOCIATES
P.O. BOX 35
25 CLEARWATER, FLORIDA 34618-0035
(727) 443-0992

145

1 A P P E A R A N C E S:

2

3 GEORGE J. FELOS, ESQUIRE
595 Main Street
4 Dunedin, Florida 34698

5 Attorney for the Petitioner/Appellee.

6

7

8 PATRICIA FIELDS ANDERSON, ESQUIRE
447 Third Avenue North, Suite 405
9 St. Petersburg, Florida 33701

10 Attorney for the Respondents/Appellants.

11

12

13

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15

16

17

18

19

20

21

22

23

24

25

146

1

2 P R O C E E D I N G S

3 THE COURT: Yes, ma'am?

4 MS. ANDERSON: Are you ready?

5 THE COURT: Yes, sir.

6 MS. ANDERSON: The Respondents call Dr.

7 William Hammesfahr.

8 MR. FELOS: Your Honor, before we take

9 testimony, I want to address something.

10 THE COURT: Very well, Mr. Felos.

11 MR. FELOS: Your Honor, before we embark on

12 today's adventure, I'm a little concerned about the

13 timing, and I think it would be wise and helpful to

14 have a little blueprint.

15 As the Court knows, under the unique situation

16 of this proceeding, we have one day allocated for

17 each physician. It's my understanding that we're

18 going to be seeing the entirety of Dr. Hammesfahr's

19 examination, which was two hours 50 minutes, on the

20 second day. I believe Dr. Maxfield was there on

21 the next day and so was Dr. Hammesfahr. That was

22 an extra 40 minutes. That's part of his

23 examination. We may be seeing three-and-a-half

24 hours of tape.

25 Of course, I'm sure we will not be seeing it

147

1 continuous; the tape is going to break, questions

2 are going to be asked. I think it would be

3 extremely unfair to the Petitioner to turn over

4 cross-examination at seven or eight o'clock tonight

5 when you have had eight or nine hours taken on

6 direct examination.

7 I think before we start, perhaps we can hear

8 how long the expected direct examination will be

9 and get a little idea of how we're going to proceed

10 time-wise today. I just don't think it's fair to

11 have nine or ten hours of direct and redirect

12 examination, which leaves me only a couple hours of

13 cross-examination sometime in the wee hours.

14 THE COURT: I thought we had this discussion a

15 few days ago.

16 MS. ANDERSON: Now, if it helps the Court --

17 we did, Your Honor. We did discuss this. If it

18 helps, Dr. Maxfield will be testifying tomorrow and

19 I do not expect his testimony to be as lengthy.

20 But I do predict turning Dr. Hammesfahr over to

21 Mr. Felos for cross-examination sometime probably

22 mid afternoon. He'll have time for cross.

23 MR. FELOS: Mid afternoon would be -- that's

24 fine. I just didn't want to find myself here at

25 eight o'clock at night starting my

148

1 cross-examination.

2 THE COURT: All right. Dr. Hammesfahr.

3 THE BAILIFF: Stand here, if you would, sir,

4 face the judge and take your oath.

5 THE COURT: Do you solemnly swear the

6 testimony you will give in this cause will be the

7 truth, the whole truth, and nothing but the truth

8 so help you God?

9 THE WITNESS: I do.

10 THE COURT: Thank you, sir.

11 THE BAILIFF: Thank you. Have a seat, please.

12 Please, speak in a loud clear voice for the court.

13 MS. ANDERSON: Your Honor, may I approach the

14 witness and give him a bottle of water?

15 THE COURT: Sure.

16 DIRECT EXAMINATION

17 BY MS. ANDERSON:

18 Q. Dr. Hammesfahr, would you state your name and

19 spell your last name for the benefit of the court

20 reporter, please.

21 A. William Hammesfahr, H-A-M-M-E-S-F-A-H-R.

22 Q. Would you tell the court briefly about your

23 education.

24 A. Was accepted to medical school directly from

25 high school as part of the Northwestern Honors Program

149

1 of Medical Education, six-year medical program in which

2 we did two years of undergraduate medical work followed

3 by four years of medical school.

4 Q. When did you enter Northwestern Medical

5 School?

6 A. I entered in 1976. I graduated in 1982. From

7 there I went into training for neurosurgery and

8 neurology at Medical College of Virginia. I trained in

9 neurosurgery and neurology until approximately 1988.

10 The position including C-level positions in neurosurgery

11 as well as neurology.

12 I underwent fellowship training in EEGs at the

13 same time and also Transcranial Doppler examinations at

14 the same time.

15 Q. Is that part of your post-residency training

16 in EEG and Transcranial Doppler?

17 A. No. It was done as part of my residency

18 training because I was in both departments and we worked

19 together for much of the time. In neurosurgery we would

20 work close with neurology and vice versa. When I went

21 into neurology, I had the freedom to do post-residency

22 training work in addition to my residency duties in

23 neurology.

24 Q. And so you left the medical college in

25 Virginia in 1988 when you completed that training?

150

1 A. Correct.

2 Q. Is that associated with the any university?

3 A. It is the Medical College of Virginia, which

4 is associated with Virginia Commonwealth University in

5 Richmond, Virginia.

6 Q. Are you board certified in any area of

7 medicine?

8 A. I'm board certified in pain management as well

9 as in neurology.

10 Q. Are you licensed to practice in your area of

11 specialty?

12 A. I am licensed to practice medicine in Virginia

13 and California and Florida.

14 Q. Are you presently in practice?

15 A. Yes, I am.

16 Q. Where are you in practice?

17 A. In Clearwater, Florida.

18 Q. Now, have you lectured in any field of

19 neurology?

20 A. Yes, I have.

21 Q. On what topics have you lectured?

22 A. I have lectured on spinal injuries, brain

23 injuries, stroke and mistreatment, vascular injuries of

24 the brain and mistreatment, the use of Transcranial

25 Doppler to guide therapy, and the use of computerized

151

1 EEGs to guide therapy. That's the bulk of the

2 treatments, with certain minor variations. Some dealing

3 with case studies and some dealing with stroke

4 prevention crisis.

5 Q. Now, have you ever given any lectures for

6 which the attendees were awarded continuing medical

7 education credits?

8 A. Yes, I have.

9 Q. How many times?

10 A. I'm not sure. I have done it many times.

11 Q. Do you recall where?

12 A. Well, I have given it at the National Practice

13 Update Convention in Orlando. I believe that was two

14 years ago. I have given it at Family College

15 Osteopathic Practices Convention, state of Florida,

16 several times. Each of those were generally two to four

17 hours lectures. I have given it at the University of

18 Florida. I have given it at a series of other major

19 universities.

20 I have done several national conventions

21 including applied autonomic disorders, reflex sympathy

22 disorders and also International Hyperbaric Conference

23 that deals with cerebral palsy and treating cerebral

24 palsy.

25 Q. In the course of your practice, have you ever

152

1 been invited to be a research grantee for the United

2 States Department of Education?

3 A. Yes, I have.

4 Q. Do you recall -- how long did you do that?

5 A. Well, I believe I'm still on the list;

6 although, I think they have dissolved that committee

7 over the last couple years. I was first on the list, I

8 think, around -- I'm not sure. In the early or mid 90s.

9 Q. Did you actually conduct random studies?

10 A. Yes, I did.

11 Q. Do you have any specialized knowledge in some

12 particular aspect of neurology?

13 A. My area of specialty is brain injury and

14 vascular diseases. Historically, it's also involved

15 pain management and also the use of ultrasound and

16 electronic monitoring of the nervous system.

17 Q. During the course of your practice, have you

18 ever had occasion to treat patients diagnosed with

19 anoxic encephalopathy?

20 A. Yes, I have.

21 Q. Can you estimate how many?

22 A. Probably about 100 that were treated for

23 technique. Before that, I have treated many over the

24 course of the years prior to using vasodilators with

25 these types of patients, but I'm not really exactly

153

1 sure, you know, how many that is. It may be more.

2 Q. What does anoxic mean?

3 A. Anoxic means without oxygen.

4 Q. And how does that differ from hypoxic?

5 A. Well, it really doesn't differ from hypoxic.

6 Anoxia and hypoxic encephalopathy both deal with the

7 difficulty of getting oxygen to the brain, so there is

8 really no major difference with respect to the pathology

9 that occurs with the brain itself.

10 Q. Encephalopathy means what?

11 A. Encephalopathy means disorder or disease of

12 the brain.

13 Q. So anoxic encephalopathy does not tell you

14 what structures in the brain have been affected or

15 damaged, correct?

16 A. It's a general term. So anoxic suggests there

17 has been a lack of oxygenation of the brain for whatever

18 reason. That can be due to carbon monoxide poisoning,

19 where a person inhales a gas other than oxygen. Or, it

20 could be something like a cardiac arrest or lack of

21 blood flow to the brain.

22 Hypoxic encephalopathy is really essentially

23 the same thing. Hypoxic encephalopathy generally means

24 that diffusely in the brain, the brain has been injured.

25 So it tends not to be localized to one specific point,

154

1 although, injuries can be very severe, affect the entire

2 brain, or a very minor and swollen areas.

3 Q. And would those both be called encephalopathy?

4 A. Yes, they would. Encephalopathy correlates to

5 a diffuse injury. You could have widespread diffuse

6 injury or more localized areas, but patterned throughout

7 the brain diffusely.

8 Q. Now, have you also had occasion through the

9 course of your practice to treat patients who have

10 suffered stroke?

11 A. Yes, I have.

12 Q. How many?

13 A. Well, again, that's tough to answer. Most of

14 my work from about 1995 has been dealing with the use of

15 vasodilators and stroke patients. So from that time, I

16 would estimate two to 3,000 patients. Slightly more, if

17 possible.

18 Before that we treated a lot of stroke

19 patients through the emergency room or through general

20 referrals or in hospitals where stroke is a common

21 disorder.

22 Q. Is stroke linked in any way to a heart attack?

23 A. Stroke can be linked to heart attacks, yes.

24 Q. How could it been linked?

25 A. There are two main mechanisms that a stroke is

155

1 linked to heart attacks. The first is that after a

2 heart attack, the heart is damaged. Small blood clots

3 forming can break off and cause injuries to one or many

4 different blood vessels in damage the brain tissues from

5 those blood vessels.

6 Q. Would that be called an embolic stroke?

7 A. That's usually called an embolic stroke, yes.

8 Q. Caused by a brain embolism?

9 A. Right. An embolism, being a small clot that

10 has gone off to the brain.

11 The second type of a stroke that tends to

12 occur is when you have a drop of blood pressure that is

13 sudden and beyond the ability of the body to compensate.

14 That causes a lack of blood flow to the brain, and that

15 lack of blood flow results in anoxia or hypoxia to the

16 brain or lack of oxygen delivered to the brain, which

17 causes brain injury.

18 Q. When you say "lack of oxygen" or a reduced

19 amount of oxygen to the brain causes injury, what does

20 the brain do? How does that injury manifest itself?

21 A. Well, in all strokes from any cause, whether

22 it's from cardiac arrest or it's from anoxia or hypoxia

23 or a drowning, in all strokes common things happen. The

24 first thing that happens is you have a lack of oxygen

25 delivered to the tissue. That itself causes damage to

156

1 the tissue.

2 Q. What happens? Does it shrivel up?

3 A. Different areas of the brain, different things

4 happen in it. Certain areas of the brain are more

5 sensitive to lack of blood flow than other areas of the

6 brain, or lack of oxygen. So those would be injured

7 first. There is going to be areas to the brain that are

8 injured more and areas to the brain that are injured

9 less in these types of episodes.

10 Q. What are the more sensitive structures in the

11 brain with regard to blood flow?

12 A. The more sensitive areas are areas that deal

13 with memory and concentration. And then the cortex of

14 the brain in the cerebral hemispheres are less

15 sensitive. Areas that deal with communication are more

16 sensitive than areas that deal with strength. But they

17 have -- they are various different scenarios in these

18 different areas. Then what happens is that that tissue

19 itself may die. Other areas of the tissue become

20 injured and may be able to survive. And then other

21 areas will sort of go into hibernating state and other

22 areas will continue to function.

23 Then, the second thing that happens is the

24 blood vessels. The blood vessels leading to that area

25 can be damaged just like the nerves can be damaged.

157

1 When the blood vessels become injured, they narrow or

2 constrict and they try to stay narrow and constricted.

3 There's a loss of normal blood flow, normal vascular

4 function, which means that the blood vessels starve the

5 brain of oxygen.

6 In the normal person, there's something called

7 autoregulation, where the blood vessels will try to open

8 up again or open up at certain times.

9 Q. Is that autoregulation the body's attempt to

10 overcome this infection?

11 A. Yes, it is. But in the injured brain, you

12 lose autoregulation. So these blood vessels don't tend

13 to open back up, nor do they tend to compensate properly

14 for poor blood flow to the area. And once the blood

15 vessels become injured, then tend to say narrow.

16 Q. The blood vessels themselves?

17 A. The bloods vessels themselves.

18 Q. Now, have you devised a therapy to expand

19 those blood vessels?

20 A. Yes, I have.

21 Q. And can you tell the court, in brief, what

22 that therapy consists of.

23 A. Well, the therapy really consists of standard,

24 time-tested, and long-term understandings of the blood

25 vessels and how they respond and how to treat them.

158

1 It's well understood these blood vessel disorders that

2 arise after an injury exit. They have been identified

3 in cardio disease. They have been identified in stroke

4 and brain injury. They have been identified in skin

5 injuries, kidney injuries, everywhere in the body.

6 The principles of what I talked about, as far

7 as injury, are well identified and well observed over

8 the last 50 to 100 years.

9 Q. And is there anything special about blood

10 vessels in the brain as opposed to other parts of the

11 body?

12 A. Well, the blood vessels in the brain are

13 slightly different than -- the blood vessels themselves

14 are not different from elsewhere in the body, but there

15 are some unique characteristics to the brain that has

16 made this standard application of vasodilators to the

17 brain more difficult.

18 Q. What are those differences?

19 A. There are really several differences. The

20 first one is that there is something called the blood

21 brain barrier, which is a chemical sheeting or coating

22 around blood vessels that tends to prevent medications

23 from going into the tissue and then affecting the blood

24 vessels from the outside of the tissue.

25 Q. So if you would administer the patient

159

1 medication with a shot, the blood brain barrier would

2 prevent the medication from reaching the brain tissue?

3 A. That has been the thought over the last 30 or

4 40 years that that's what's happening.

5 Q. And how did you get around this problem, if

6 you were able to get around it?

7 A. Well, we actually made a very unusual and odd

8 observation about 1994, and that was that we had an

9 large number of patients with brain injuries that were

10 part of my practice. We also had what was then and

11 still is very new technology in the office. Several

12 types of new technology. But for these purposes, what

13 turned out to be most important was a special type of

14 ultrasound that looks at the blood vessel diameter

15 inside of the brain.

16 Up until 1994, it was thought there weren't

17 many medications that could actually affect the blood

18 vessels inside of the brain other than medication that

19 narrowed blood vessels due to the oxygenation after

20 stroke patients.

21 Q. Did you determine that your patients were

22 victims of cerebral vasospasm?

23 A. It was thought that these patients -- that

24 many of these patients had a brain injury but that they

25 also had vasospasm on their examination, yes. And the

160

1 reason for that was that they had severe migraines.

2 Q. How did a migraine related to vasospasm?

3 A. Patients with chronic migraines after an

4 accident with brain injury, what happens in a migraine

5 is blood vessels constrict. When it constricts to a

6 very high rate, other blood vessels may actually dilate

7 and it could cause the pain of a headache.

8 Q. Why would another area dilate?

9 A. Back in 1994, the understanding of a migraine

10 was that a blood vessel would constrict, pinning off

11 some of the blood flow to the brain, then the brain

12 would release carbon monoxide around the area of the

13 blood vessel and that would cause the blood vessel to

14 dilate.

15 When the blood vessel would dilate more than

16 it was necessary to compensate for the lack of blood

17 flow to the area and that overdilation causes headache.

18 So what would happened was medications that were

19 designed to treat migraine were designed to make the

20 blood vessel narrow and cut down the pain.

21 Q. So the conventional treatment therapy for

22 migraine back in 1994 was to use vaso-constricting

23 drugs?

24 A. Correct.

25 Q. And you noticed in your patients this unusual

161

1 phenomenon of migraines plus brain injury; is that what

2 happened?

3 A. Correct. What happened was we had a series of

4 patients. I did a lot of work for Social Security and I

5 also did a lot of work for people involved in severe

6 auto accidents. So there was long before treatment, an

7 evaluation stage they had gone on for many years.

8 Patient with Social Security were disabled for over one

9 year and were expected to be permanently disabled for me

10 to treat them.

11 What we found is that a lot of these patients

12 had migraines or partial paralysis or weaknesses and

13 balance problems and memory problems. We tried to find

14 a new technique to control their headache. Not new to

15 me, but, rather, there were a series of anti-migraine

16 medications, like Imitrex, that had just come to

17 market.

18 Q. Now, were those vasodilators?

19 A. These are vasoconstrictors. Now, these

20 patients who are on Social Security for chronic

21 migraines or brain injuries for up to 17 years, and they

22 have tried a lot of different medications. So at that

23 time I didn't think any of the new medications coming

24 out would treat their headaches. Rather, what I thought

25 we would do is monitor a series of these patients with

162

1 different testing techniques, try out different

2 medications on them while being monitored. And we would

3 identify the proof that might be seen on one set of

4 tests and the proof that might be seen in some patients

5 in other tests, we would then generate a cocktail.

6 Q. What do you mean by "cocktail?"

7 A. In medicine, it's common when you deal with

8 patients who are having very severe problems to use two

9 or three or four medications in that patient to treat

10 the medical problem. No single medication will do the

11 trick, so you have to try to use several different

12 medications.

13 Q. In conjunction, you mean?

14 A. In conjunction, correct. We actually see that

15 in a lot of blood pressure medicines and cardiology

16 medicines where there will be two or three medicines

17 combined in a single pill.

18 Q. And your reason for devising this cocktail was

19 what?

20 A. To stop pain.

21 Q. By dilating the vessels?

22 A. No. It was to stop pain by trying to find

23 medications that would stop these people's pains. It

24 was not to dilate the blood vessel, because the standard

25 thinking at that time was that the blood vessel

163

1 constricted and it later expanded and caused the

2 headache. So what we were seeing, in theory, was that

3 the blood vessels were already dilated at the time of

4 the migraine and causing the headache. So, we were

5 looking for only pain relief.

6 Q. So by the time the pain manifests itself, the

7 thinking at the time was the blood vessels were already

8 compensated and dilated?

9 A. Correct.

10 Q. So when you try these cocktails, what did you

11 discover?

12 A. Well, we never got to a cocktail. What

13 happened was we had six patients in our office at one

14 time, gave them Imitrex. Another six get a new medicine

15 called Toradol.

16 Q. Toradol?

17 A. Yes. It's T-O-R-D-A-L.

18 We use medicine that have very short onset of

19 action and they use patients who are very severely

20 disabled from the brain injuries and need help walking

21 to get to the exam table or testing table or they would

22 need to be brought in in a wheelchair.

23 Q. Was there speech discernible?

24 A. Many of them had severe difficulty speaking.

25 Many had severe weakness in one arm or leg. They had

164

1 balance problems where they couldn't walk unassisted;

2 they would fall into walls when they were walking.

3 Something of that nature.

4 Most of them are had neuropsychology tests

5 done on them before us for many years documenting severe

6 brain injuries. If you spoke to them and gave them

7 instructions, sometimes they wouldn't understand these

8 instructions when it came to caregivers.

9 Q. What happened when you began -- well, first of

10 all, how did you decide to treat these patients?

11 A. Well, what we did was put them on a monitor,

12 electronic monitor with evoked potential, or EEGs,

13 computerized EEGs, or Transcranial Doppler, and gave

14 them the medicine, the Imitrex or Toradol.

15 Q. When you say you had them on a monitor, you

16 had them hooked up on the machine and gave them the

17 drugs?

18 A. Correct.

19 Q. What was the purpose of that?

20 A. Well, this is typically a standard technique.

21 Again, my background was extensively surgery in the

22 intensive care unit and medicine. In this fields, it's

23 common to monitoring ongoing monitoring of the patient

24 or serial monitoring the patient with technology to help

25 to give you an indication early on whether or not having

165

1 proven that from a technique that you are applying to

2 that patient.

3 Q. And you would be able to tell that from the

4 monitor and device that you're using?

5 A. Sure. This is just like using an EKG monitor

6 in the emergency room or in an ICU. You might have a

7 blood oxygen monitor as well as an EKG monitor as well

8 as a blood pressure monitor. The idea of monitoring the

9 medication's effect is the standard part of the medicine

10 when you have to deal with customizing doses and also

11 trying to look what you're trying to deal with, the

12 effect of.

13 Q. So what happened?

14 A. Well, the patients who had Imitrex, we gave

15 them the medicine, we watched them, and their blood

16 vessels constricted just like which thought and

17 understood Imitrex should work. The patients with head

18 injuries, they became very confused. And

19 neurologically, they worsened.

20 Q. And what did you do for them?

21 A. That's what we expected from Imitrex.

22 Imitrex, in fact, has had a lot of research since then

23 that talks about -- that wasn't around at the time, that

24 talks about the narrowing of the blood vessels and

25 patients with heart disease, Imitrex can actually put

166

1 them into a heart attack.

2 So we got what we expected. We saw the

3 ultrasound that showed further narrowing. The headache

4 did go away quite dramatically, so that was a very

5 effective tool. But they frequently got worse in

6 minutes. They had trouble to where they couldn't get

7 onto the table and couldn't get off the table without

8 having help. They returned from normal to not normal.

9 Q. And, then, what did you decide to do?

10 A. Well, we also gave Toradol on the same day to

11 other patients. Again, this is the using the same kind

12 of monitoring. Toradol, at that time, was a shot, so it

13 had very rapid action. Toradol did something very

14 unexpected.

15 Q. What was that?

16 A. What it did was it relieved the headache

17 entirely, but it did it through a different mechanism

18 than Imitrex, which had never been reported before. The

19 mechanism was that it made the blood vessels dilate

20 inside of the brain.

21 Q. So this initial set of patients, you used a

22 vasoconstrictor among one group of patients. And on the

23 same day gave the other group of patients a vasodilator.

24 A. Correct. But that's not what we meant to do.

25 Toradol wasn't known to be a vasodilator at the time we

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1 gave it. It was known to be a medicine like Motrin, a

2 anti-headache medicine. It was not thought to be a

3 vasodilator.

4 Q. So you had this unexpected result. And how

5 did you proceed?

6 A. Well, it was unexpected. It meant that if

7 this -- it meant that even if Toradol worked by

8 vasodilating or Toradol had a different mechanism of

9 acting, we then went to a second set of categories of

10 medicine, which were vasoconstrictors on one side, like

11 Imitrex, and were standard anti-migraine medicines,

12 Ergotamines, E-R-G-O-T-A-M-I-N-E-S, caffein. It is a

13 series of very strong, very short-acting medications

14 that are used to constrict blood vessels and relieve

15 migraines, commonly.

16 On the other hand, we used some very

17 short-acting vasodilators that were known to be

18 vasodilators for patients. We got the same exact same

19 results all over again.

20 Q. The what results?

21 A. We got the same results that we got with the

22 first one. Within ten or 15 minutes, those given the

23 vasoconstrictor, the headaches would leave. The

24 Transcranial Doppler would show worsening, meaning more

25 narrowing of the constriction, which is the understood

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1 mechanism of how these medicines worked. The headache

2 went away, but the patient, in front of us,

3 deteriorated. They would develop abnormal reflexes,

4 balance problems, thinking problems. They were quite

5 dramatic.

6 Q. And what happened with the vasodilation

7 patients?

8 A. With the other group, we had an equally

9 dramatic effect. The ultrasound, again, showed

10 dilation of the blood vessels. The patients themselves

11 had a dramatic improvement. They would eventually clear

12 up in front of you. They could understand and follow

13 commands, which they had troubling doing before. They

14 could get up and down from chairs.

15 We do a test, which is standard in neurology,

16 called a Romberg and Tandem Gait. A Romberg examination

17 is where a person stands at attention with their heels

18 and toes together and closes their eyes. You

19 essentially see how their balance is. It's a sign of

20 neurological injury for those who sway and have balance

21 problems.

22 The other test that goes with that is a tandem

23 gait. A tandem gait is what the police officers use for

24 drunk driving tests where you have a person walking a

25 straight line. These persons, prior to getting the

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1 vasodilator, could not do that. When they got the

2 vasodilator, 15 to 20 minutes later, were able to do

3 those tests, for the most part, without difficulty,

4 being able to walk around unassisted. Then, when they

5 eventually wore off, the ultrasound, again, worsened.

6 They couldn't do those tests again.

7 The same thing happened with the Imitrex group

8 and vasoconstrictors. They couldn't do it. When they

9 started, it got worse and then returned to their

10 baseline as the medication wore off.

11 Q. Over the years -- this happened in '94?

12 A. Yes. So this meant that you have migraine, in

13 at least these patients, was not correct. What was

14 really happening was that the migraine was more like a

15 heart attack.

16 In a heart attack, the beginning of a heart

17 attack, the patient has a narrowing in the blood

18 vessels. And the blood vessels downstream dilate to try

19 to make a vacuum to pull blood through that narrow area.

20 Q. As the bottom overcoming the narrowing?

21 A. Correct. In that heart attack, the dilation

22 causes pain, chest pain. What you do with those

23 patients is give them a vasodilator, nitroglycerin, and

24 the pain goes away. As the blockage opens up, the

25 downstream areas dilate to compensate to return to

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1 normal size. As they return to normal size, the pain

2 goes away.

3 When we use nitroglycerin on these brain

4 injured patients, we saw the same phenomenon happen. As

5 in Toradol or other vasodilators, we saw proof: The

6 heart attack patient started feeling brief better; we

7 saw the pain go away; we saw the neurological exam

8 improve.

9 Q. How, over the years, have you refined this

10 technique?

11 A. Well, mainly by very close observation of

12 patients, serial observations of patient.

13 Q. Serial observation of patients?

14 A. Observing patients for long periods of time

15 both in the office as well as months and years down the

16 road.

17 Eventually, there have been new medications

18 that have also come out. This technique has allowed us

19 to identify these medicines easily and to use them with

20 patient --

21 Q. Now, what is the -- what does the term

22 Kenombra mean with regard to blood flow to the brain?

23 A. Kenombra is an old concept, a scientific

24 concept that was first seen in wound healing, but it's

25 been seen -- as technology's gotten more sophisticated,

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1 it's been seen in every organ. It's the body's common

2 response to injury of any form. That response is that

3 you get different areas of brain tissue or heart tissue

4 or skin tissue, have different degrees of injury. The

5 areas farthest away from the site of the injury are the

6 least damaged. Sometimes they are not even damaged at

7 all, but they are thrown into a hibernating stage.

8 Areas closest to the site of the injury or at

9 the site of the area may be dead. And seeing everything

10 from hibernating tissues or even normal tissue -- you

11 know, normal tissue by definition is normal tissue

12 outside of the area damage. Everything from hibernating

13 tissue to undamaged tissue, a tissue which, for some

14 reason, cannot carry out its normal functions; either

15 there is not enough blood flow into the area for it to

16 have the energy to carry out its normal function or

17 there's been some other injured area of problem, lack of

18 glucose or sugar or protein, whatever. So its

19 undamaged cells, not active cells, not functioning

20 active cells carrying out what they are designed to do

21 all the way into the deeper areas where you actually

22 have deadened areas.

23 Q. Now, has your technique or method of treating

24 patients resulted in any insight on your part in any

25 number?