00001 1 IN THE COURT OF COMMON PLEAS 2 CUYAHOGA COUNTY, OHIO 3 4 DELORES PRESCOTT, et al. : 5 Plaintiffs : 6 vs. : CASE #320644 7 RAMON T. GUIAO, M.D., : Judge Corrigan 8 et al. : 9 Defendants : 10 ---------------------- 11 Video deposition of LAURIE LEE FAJARDO, 12 M.D. taken with simultaneous tape recording on 13 Tuesday, August 10, 1999 at 7:07 p.m., at the 14 offices of Salomon Reporting Services, Suite 1700, 15 200 East Lexington Street, Baltimore, Maryland 16 21202-3517 before Sara A. Cissin, Notary Public. 17 ---------------------- 18 19 20 Reported by: 21 Sara A. Cissin 00002 1 APPEARANCES: 2 3 On behalf of Plaintiffs: 4 JOHN A. LANCIONE, Esquire 5 Lancione & Lancione 6 1300 East Ninth Street 7 1717 Bond Court Building 8 Cleveland, Ohio 44114-1503 9 216-575-1002 10 216-575-1556 (Fax) 11 12 On behalf of Defendants, Dr. George and Drs. Hill 13 & Thomas, Inc.: 14 JOSEPH H. WANTZ, Esquire 15 Mazanec, Raskin & Ryder Co., LPA 16 100 Fanklin's Row 17 34305 Solon Road 18 Cleveland, Ohio 44139 19 440-248-7906 20 440-248-8861 (Fax) 21 00003 1 APPEARANCES: (Cont'd) 2 3 On behalf of Defendant, Dr. Guiao: 4 STEPHEN D. WALTERS, Esquire 5 Weston, Hurd, Fallon, Paisley & Howley 6 25th Floor Terminal Tower 7 Cleveland, Ohio 44113-2241 8 216-241-6602 9 10 On behalf of Defendant, Dr. Morona: 11 THOMAS B. KILBANE, Esquire 12 Reminger & Reminger 13 113 Saint Clair Avenue, NE 14 Cleveland, Ohio 44114-1273 15 216-687-1311 16 216-687-1841 (Fax) 17 18 Also Present: George Sampson, Videographer 19 20 21 00004 1 STIPULATION 2 It is stipulated and agreed by and 3 between counsel for the respective parties that 4 the reading and signing of this deposition by the 5 witness is hereby waived. 6 - - - - - - - - 7 (Whereupon, Fajardo Deposition 8 Exhibit marked Defendant-George A, CV, premarked.) 9 VIDEOGRAPHER: This video deposition is 10 being taken in accordance with Ohio Rules of Civil 11 Procedure on August 10, 1999. We are located at 12 200 East Lexington Street, Baltimore, Maryland. 13 The court reporter is Sara Cissin with Salomon 14 Reporting and my name is George Sampson with 15 Aavid Video Productions. 16 The case caption is Delores Prescott 17 versus Ramon T. Guiao. The case number for the 18 Court of Common Pleas, Civil Division, Cuyahoga 19 County, Ohio is 320644. 20 The party giving notice of the 21 deposition is Joseph H. Wantz. And will the 00005 1 attorneys please identify themselves and who they 2 represent? 3 MR. WANTZ: I am Joseph Wantz. I 4 represent Dr. Walter George and Hill & Thomas 5 Radiology Group. 6 MR. KILBANE: I am Tom Kilbane. I 7 represent Dr. Morona. 8 MR. WALTERS: I am Stephen D. Walters, 9 and I represent Dr. Ramon Guiao. 10 MR. LANCIONE: I am John A. Lancione 11 and I represent the Prescott family. 12 VIDEOGRAPHER: And the witness is Dr. 13 Laurie Fajardo and will now be sworn in by the 14 court reporter. 15 - - - - - - 16 LAURIE LEE FAJARDO, M.D., 17 the witness, having been first duly sworn to tell 18 the truth, the whole truth, and nothing but the 19 truth, was examined and testified as follows: 20 EXAMINATION BY MR. WANTZ: 21 Q. Doctor, as we have just introduced 00006 1 ourselves, we were here to take your deposition 2 for purposes of replaying at trial in this matter. 3 Could you please tell the jury your name, please? 4 A. Laurie Fajardo. 5 Q. And are you -- we've referred to you as 6 doctor. Are you in fact a licensed physician? 7 A. Yes. 8 Q. Could you please tell the jury where 9 your license is held? 10 A. Maryland, Arizona, Missouri and 11 Illinois. 12 Q. And you have several licenses in 13 several states. When did you first obtain a 14 license and in which state? 15 A. 1984 in the State of Illinois. 16 Q. And have you been continuously licensed 17 in one state or another since that time? 18 A. Yes, sir. 19 Q. Tell us please a little bit about your 20 background in terms of where we are now. We are 21 here in Baltimore, Maryland. Are you employed 00007 1 here in Baltimore? 2 A. Yes, I am. 3 Q. And where are you employed? 4 A. Johns Hopkins Medical Institutions. 5 Q. And what do you do there? 6 A. I'm a radiologist. 7 Q. Do you have any specialty or any 8 certification above and beyond radiologist at 9 Johns Hopkins? 10 A. I am the director of breast imaging and 11 practice exclusively mammography and breast 12 imaging. 13 Q. You say you practice exclusively 14 mammography and breast imaging? 15 A. (Nodding head indicating yes.) 16 Q. How long have you been doing that? 17 A. For approximately ten years. 18 Q. That has been on an exclusive basis? 19 A. To one degree or another. My practice 20 has always been more than 50 percent mammography. 21 In the first years after training I did practice 00008 1 some other areas of diagnostic imaging. 2 Q. Could you tell us, doctor, a little bit 3 about your background in terms of your education 4 starting with your undergraduate degree? 5 A. My undergraduate degree is from 6 Washington University in Saint Louis in 1980. My 7 medical school degree 1984 from the University of 8 of Chicago. I did internship at the University of 9 Chicago, residency at the University of Arizona 10 and fellowship training at the University of 11 Arizona. 12 Q. And did you -- during your residency 13 did you specialize in any particular branch of 14 medicine? 15 A. Diagnostic radiology. 16 Q. And have you practiced diagnostic 17 radiology in some form or other since you have 18 completed your residency? 19 A. Yes. 20 Q. Doctor, could you explain for the jury 21 what is diagnostic radiology and what is your 00009 1 specialty of mammography? 2 A. Well, diagnostic radiology is the use 3 of x-rays, of CT scans, various types of imaging 4 to go make diagnoses in patients. And the field 5 of mammography pertains to imaging the breast and 6 looking for breast cancer. 7 Q. Doctor, have you been engaged in the 8 practice of diagnostic radiology and mammography 9 on a full-time basis? 10 A. Yes. 11 Q. Could you tell us, please, doctor, do 12 you actively engage in the practice of radiology 13 or medicine more than 50 percent of the time? 14 A. Yes. 15 Q. Doctor, could you please tell the jury 16 approximately how many patients you see for 17 mammography or breast imaging in a given week? 18 A. In a given week? Several hundred. 19 Q. Doctor, are you on any staff presently 20 other than at Johns Hopkins? 21 A. No. 00010 1 Q. In the past have you served on staff at 2 any other hospitals? 3 A. Yes. 4 Q. Could you please tell the jury some of 5 the hospitals you have served at? 6 A. Prior to my faculty position at Johns 7 Hopkins I was at the University of Virginia and 8 before that I was at the University of Arizona. 9 Q. And what positions did you hold at 10 those two universities? 11 A. At the University of Arizona I was an 12 assistant and then an associate professor of 13 radiology, and I was a director of breast imaging. 14 At the University of Virginia I was an associate 15 and then a full professor of radiology, and I was 16 the director of clinical research. 17 And at Johns Hopkins I am a professor 18 of radiology and the director of breast imaging 19 and the vice chair for clinical research. 20 Q. Now, doctor, you have indicated you are 21 a professor. Does that mean you do some teaching? 00011 1 A. Yes. 2 Q. Could you please tell the jury what 3 kind of teaching you do? 4 A. Medical student, resident and some 5 physicians in course training. 6 Q. Does that teaching include lecture-type 7 teaching? 8 A. Yes. 9 Q. Does it also include clinical-type 10 teaching where you actually have hands-on with the 11 students? 12 A. Yes. 13 Q. And how much time do you spend doing 14 that? 15 A. Well, it's difficult to say because a 16 lot of that training goes on on a daily basis when 17 you are in the clinical area. But I mean we have 18 some contact with teaching every day. 19 Q. Doctor, are you board certified? 20 A. Yes. 21 Q. Could you tell us, please, what you are 00012 1 board certified in? 2 A. Diagnostic radiology. 3 Q. And how do you become board certified 4 in diagnostic radiology? 5 A. You take both a written and an oral 6 qualifying examination. 7 Q. And when did you become board 8 certified? 9 A. 1989. 10 Q. Is that on a local basis, a national 11 basis, international? 12 A. It's a national basis. 13 Q. Doctor, have you -- you have indicated 14 you do some research. Could you you tell the 15 jury, please, what areas you do research in? 16 A. Basic research in development of new 17 detectors for breast imaging and clinical 18 research, some clinical trials for detection of 19 breast imaging and some other related clinical 20 trials related to breast cancer. 21 Q. So your research, would you say that it 00013 1 relates to the issues that are present in this 2 particular case in any way? 3 A. Not directly. 4 Q. Does it relate to breast cancer and 5 breast imaging though, all of your research? 6 A. Yes. 7 Q. Doctor, have you written any papers or 8 articles that have been published in medical 9 journals? 10 A. Yes, sir. 11 Q. Could you tell us, please, 12 approximately how many articles you have written 13 that have been published in medical journals? 14 A. About 80. 15 Q. About? I'm sorry? 16 A. About 80. 17 Q. Doctor, you're very soft spoken. If 18 you could speak up just a little more to make sure 19 we hear you. 20 A. Okay. 21 Q. Thank you. 00014 1 And, doctor, those articles, could you 2 tell us, please, what areas the articles you have 3 been published in cover? 4 A. Well, they cover a gamut of breast 5 imaging, some perceptual issues related to breast 6 imaging, interventional breast imaging, and the 7 development of new techniques to do 8 minimally-invasive breast biopsies and some basic 9 applied science, biomedical engineering type 10 projects, looking at new detectors for breast 11 cancer imaging. 12 Q. Doctor, have any of these articles been 13 published in what I believe are called peer 14 reviewed journals? 15 A. Yes, sir. 16 Q. And could you tell the jury, please, 17 what is a peer reviewed article? 18 A. A peer reviewed article is an article 19 that has been scrutinized by experts in the field 20 before it's qualified as acceptable to be 21 published in a journal. 00015 1 Q. And these articles that have appeared 2 in the peer reviewed journals, do they also relate 3 to breast imaging issues? 4 A. Yes, sir. 5 Q. Doctor, I am going to hand you what has 6 been marked as Defendant-George Exhibit A. Could 7 you review that and tell the jury, please, what it 8 is and identify it for them? 9 A. It's a copy of my curriculum vitae. 10 Q. And does it also have attached to it a 11 listing of the various articles that you have 12 written and had published? 13 A. Yes. 14 Q. Doctor, do any of those articles to 15 your recollection -- and I know there are some 80 16 articles -- but to your recollection, do any of 17 those articles cover the subjects that are 18 involved in this case herein? 19 A. Yes. 20 Q. And are you able as we sit here to 21 identify any of those articles? 00016 1 A. Probably one or two of them, yes. 2 Q. Doctor, now let's talk about this case. 3 Did there come a time when you were -- 4 there did come a time, I should say, when you were 5 asked to review the records and the films of 6 Delores Prescott relative to the issues involved 7 in this case; is that correct? 8 A. Yes. 9 Q. And you are requested on behalf of Dr. 10 George and Hill and Thomas to do this review; is 11 that correct? 12 A. Yes. 13 Q. Doctor, did you perform such a review 14 of the records and films? 15 A. Yes. 16 Q. And could you tell us, please, to your 17 recollection, what records and films did you 18 review? 19 A. The initial information that I was sent 20 included just radiographs, and at a later date I 21 got medical records. 00017 1 Q. Did you review -- which radiographs did 2 you review? Let's start there. 3 A. Radiographs from 1990, 1994 and 1996. 4 Q. All right. And the 1994 radiographs, 5 there are two sets of radiographs, doctor. Do you 6 recall -- did you see both the radiographs from 7 November 30th of 1994 and again from December 30th 8 of 1994? 9 A. Yes, I did. 10 Q. And, doctor, so we are clear, we are 11 here -- and I am going to back up for a minute -- 12 we are here in Baltimore taking your deposition 13 for this trial. You are not available to come to 14 Cleveland for the trial; is that correct? 15 A. That is correct. 16 Q. Doctor, could you explain to us why 17 you're not available? 18 A. Because our clinical schedule is too 19 busy. I couldn't arrange to take time off to go 20 to Cleveland. 21 Q. And we are here in the evening; is that 00018 1 correct? 2 A. Yes, sir. 3 Q. After your schedule for the day is 4 completed? 5 A. That's true. 6 Q. Now, doctor, you have reviewed those 7 radiographs as you have indicated; is that 8 correct? 9 A. Yes. 10 Q. And you also subsequently received some 11 records relating to this case; is that correct? 12 A. Yes. 13 Q. And those records, did they include the 14 radiology reports of those radiographs? 15 A. Yes, sir. 16 Q. And you reviewed those as well? 17 A. Yes. 18 A. Doctor, after reviewing those records 19 did you come to some conclusions in this case? 20 A. Yes. 21 Q. And did those conclusions -- were those 00019 1 conclusions made to a reasonable degree of medical 2 certainty? 3 A. Yes, sir. 4 Q. Now, doctor, before we get to your 5 opinions and your conclusions in this case, let me 6 ask you first if you could review for us the 7 individual films and let's start with the 1990 8 films. 9 What films did you -- were actually 10 contained in that particular packet? 11 A. In 1990 there were four films, two 12 views of each breast. 13 Q. And did you personally review those 14 films? 15 A. Yes, sir. 16 Q. Doctor, could you explain for us when 17 you reviewed these films, where did you review 18 them? 19 A. I reviewed them in my office. 20 Q. And when you say in your office, did 21 you have a room that you would go in and put the 00020 1 films on the shadow box, or could you describe 2 that for us, please? 3 A. Yes. It was a standard mammography 4 view box in a darkened room with the appropriate 5 viewing tools available to review the films. 6 Q. Now, doctor, by the time you have 7 testified the jury may have already heard about 8 this, but I want to be sure we are clear. 9 Could you describe for us in some 10 detail what a standard medical mammography viewing 11 room is and what it contains? 12 A. It's a darkened room that contains a 13 view box that is sized to fit mammographic films 14 and typically has light bulbs of a higher 15 luminescence and usually contained in the room you 16 will find things such as magnifying glasses or 17 viewers to view the films. 18 Q. And, doctor, did you -- you had that 19 available to you? 20 A. Yes, sir. 21 Q. Including a magnifying glass to help 00021 1 view the films as you deemed appropriate and 2 necessary? 3 A. Yes, sir. 4 Q. And, doctor, those four views that you 5 reviewed from 1990, could you tell us, please, 6 what your review of those films revealed, if 7 anything? 8 A. I thought the films from 1990 were 9 normal. 10 Q. Normal meaning there was no evidence of 11 any calcifications or any other suggestion of 12 breast cancer? 13 A. Yes. 14 Q. And, doctor, after reviewing those 15 films, what films did you next review, the 16 November of '94? 17 A. That's correct. 18 Q. And, doctor, could you tell the jury, 19 please, how many films there were contained in 20 that particular set? 21 A. Four. 00022 1 Q. And what area were those films taken 2 of? 3 A. They were taken of the full right 4 breast and the full left breast, two views of each 5 breast. 6 Q. And, doctor, upon your review of those 7 films, what did you find, if anything? 8 A. There are some scattered subtle 9 calcifications in the left breast. 10 Q. And, doctor, could you please describe 11 for us what you mean by scattered subtle 12 calcifications? 13 A. The two standard views of the left 14 breast that were performed showed some 15 calcifications on one of the views that were not 16 well depicted. Additional diagnostic or 17 magnification views were not done at that time. 18 So a full assessment of the calcifications cannot 19 really be made. 20 Q. Now, doctor, indicating that you did 21 see calcifications, did that tell you that there 00023 1 was cancer in this woman's breast? 2 A. No, not necessarily. 3 Q. Could you tell us what other things the 4 calcifications could be for lack of better 5 terminology? 6 A. Well, approximately 80 to 90 percent of 7 the calcifications found in the breast are benign. 8 And there is a wide range of benign entities that 9 calcifications can represent such as calcified 10 lobules, calcified benign tumors or nodules, 11 things that have nothing to do with cancer. They 12 can be located within areas of fibrocystic change 13 which is a common finding in breasts as well. All 14 benign findings. 15 Q. Now, doctor, you have had the 16 opportunity to review the radiologist's report 17 regarding those November of 1994 films; is that 18 correct? 19 A. Yes. 20 Q. And do you see in the radiologist 21 report where he indicates that they are suspicious 00024 1 for malignancy? 2 A. Yes. 3 Q. Doctor, would you agree with that 4 opinion? 5 A. No. I don't think that you can really 6 make that determination without the appropriate 7 diagnostic images having been performed. 8 Q. And what appropriate diagnostic images 9 would you believe should be performed? 10 A. Well, there is no set standard rule for 11 you know what a radiologist should do, but in 12 general for calcifications magnification views are 13 often useful to further characterize the type of 14 calcifications that are present. 15 Q. Doctor, you'll see that the radiologist 16 in November of '94 recommended follow-up 17 procedures; is that correct? 18 A. Yes. 19 Q. Do you agree with his recommendations 20 for the follow-up procedures? 21 A. Yes. 00025 1 Q. Doctor, and, in fact, there were 2 follow-up procedures scheduled for December 30th 3 of 1994; is that correct? 4 A. Yes, sir. 5 Q. And additional films were obtained at 6 that time? 7 A. Yes, they were. 8 Q. And could you tell us, please, what 9 films were contained in the packet that you 10 reviewed from December 30th of 1994? 11 A. There are views only of the left breast 12 and there were five images. 13 Q. And, doctor, could you, please, 14 describe for us as best you can what those five 15 images were when you say five images? 16 A. Right. There were three full views of 17 the left breast, one that was the so-called 18 craniocaudal view, one which was a lateral view 19 and one which was an oblique view. These were 20 images that were obtained of the entire left 21 breast. 00026 1 And then there were two spot 2 compression images also obtained of the left 3 breast. 4 Q. Now, doctor, because I'm a layman, 5 could you explain for us a little bit more what 6 you mean by craniocaudal views, the lateral views 7 and the third view that you mentioned? 8 A. Yes. The typical mammogram when we 9 screen a patient is two views. One is the 10 craniocaudal view which is a view that's taken 11 from the top of the left breast to the bottom of 12 the left breast compressing it in a plane somewhat 13 like this (indicating). 14 The second view is call the oblique 15 mediolateral view where the breast is positioned 16 and compressed at an angle somewhat like this 17 (indicating) where the image is taken from the 18 medial side of the breast or the inside of the 19 breast to the outside or the armpit side of the 20 breast. 21 And the third view, the lateral view, 00027 1 is not a routine view; it's a view that physicians 2 often get when they're working up an abnormality 3 in the breast. It's a straight 90 degree view, 4 and it's done with the x-ray going from the inside 5 of the breast to the outside of the breast. 6 Q. And, doctor, you also talked about two 7 spot compression views. What are spot compression 8 views? 9 A. Spot compression views are x-rays of 10 the breast that are done on a small area of the 11 breast using a compression cone which is smaller 12 than what we use for the standard views which 13 compresses the whole breast. And these are done 14 to get a better look at a particular area of the 15 breast if you are trying to find an abnormality. 16 Q. Now, doctor, you used the term 17 compression views. Is the breast actually 18 compressed in a mammogram? 19 A. Yes, it is. 20 Q. Is that an uncomfortable procedure for 21 the woman? 00028 1 A. Often times it is. It's not the most 2 pleasant examination that we perform on patients. 3 Q. Now, doctor, the purpose of these views 4 in December of 1994, could you tell the jury -- I 5 didn't word that very well, but could you tell the 6 jury what the purpose of those films were in 7 December of 1994? 8 A. Yeah. Ms. Prescott was scheduled to 9 have a preoperative needle localization so that 10 the radiologist could place a wire into the 11 calcifications that were visualized on the 12 mammogram a month earlier so that the surgeon 13 could use that wire as a guide map to go in and 14 cut out pieces of tissue that might have contained 15 the calcifications. 16 So in order to do the procedure you 17 have to be sure that you can first visualize the 18 calcifications before putting the patient in a 19 special compression device that then allows you to 20 place the wire for the surgeon. 21 Q. And, doctor, again is this procedure 00029 1 uncomfortable to go through for the woman, the 2 patient? 3 A. Well, it does involve using devices 4 that will compress the breast or squeeze the 5 breast to make it thinner. It's different for 6 women. For some women it's very painful. For 7 other women it's less painful. 8 Q. And, doctor, in order to place the 9 wire, if I understood you, it is necessary that 10 the radiologist be able to localize and view these 11 calcifications? 12 A. The wire is actually passed through a 13 needle. So the radiologist has to be able to see 14 the calcifications on a picture and then put a 15 needle into the breast to the level of the 16 calcifications, and then through that needle 17 thread the wire that then anchors into the breast 18 so that the surgery can be performed. 19 Q. Now, doctor, in your review of these 20 films, could you tell the jury, please, what you 21 found upon reviewing these films? 00030 1 A. The December images did not show the 2 microcalcifications well enough that they could be 3 localized. Even when the additional spot 4 compression images were performed the 5 calcifications are just not well seen on that day. 6 Q. Could you see the calcifications at 7 all, doctor? 8 A. You can see a few faint calcifications 9 on one of the images, but you don't see them on 10 the other four. 11 Q. Well, doctor, if you have one image 12 that shows -- one view that does show the 13 calcifications, could the radiologist place the 14 wire with that one view? 15 A. It would be very difficult to place the 16 wire accurately because seeing it on one view 17 shows you where to position the needle over the 18 breast to poke into where the calcifications are. 19 However, you don't know how deep to go unless you 20 have a view in the opposite projection that shows 21 you where depth-wise in the breast the needle 00031 1 needs to be placed. 2 Q. Doctor, how many views do you need in 3 order to able to place the needle? 4 A You need at least two views performed 5 by you know various techniques, either standard 6 x-rays or stereotactic x-ray. But you cannot 7 place a wire accurately only seeing something on 8 one view. 9 Q. And, doctor, in your review of these 10 films, you found only one view that even gave you 11 a suggestion of the calcifications? 12 A That's true. 13 Q. Doctor, and again so we're clear, did 14 you view these films as well in your viewing room 15 with the appropriate mammogram viewing screen? 16 A. Yes, sir. 17 Q. All right. And, doctor, there was one 18 more set of films I believe you reviewed? 19 A. Yes. 20 Q. And that was the January of '96 films? 21 A. Yes. 00032 1 Q. And, doctor, could you please tell us 2 what those films in your review demonstrated? 3 A. The images in that review again 4 demonstrate some calcifications that are a little 5 more obvious, but are still quite subtle. And I 6 don't believe that I saw any additional 7 magnification views with that study as well, but 8 again some subtle calcifications. 9 Q. Now, doctor, let me go back to the 10 December of '94 films. In reviewing those films 11 do you have an opinion to a reasonable degree of 12 medical certainty as to whether those films were 13 adequately obtained by the radiologist or the 14 radiological technician? 15 A. Yes, they were. 16 Q. And, doctor, did you find those films 17 to be adequate for your review in order to view 18 for possible calcifications? 19 A. Yes. 20 Q. Now, doctor, did you find -- or let me 21 ask this. Doctor, do you have an opinion to a 00033 1 reasonable degree of medical certainty as to 2 whether Dr. George in his performance or his 3 attempt at this procedure on December 30th of 1994 4 obtained sufficient views, sufficient number of 5 views, in order to attempt this procedure? 6 A. Yes, he did. 7 Q. He did. Okay. Doctor, could he have 8 -- would obtaining additional views have made any 9 difference in your opinion? 10 A. I think that is difficult to say. He 11 got the three standard views that we routinely get 12 of the full breast, and then he got two additional 13 spot compression views. 14 If he had only gotten a single view and 15 had given up on the procedure, I think then he 16 might have been criticized. But he did get four 17 additional views and none of those views 18 adequately showed calcifications. 19 Q. Doctor, I believe by the time you 20 testify there will be testimony from the 21 plaintiff's expert, Dr. Freedy, to the extent that 00034 1 he should have repeated the same views and 2 attempted several other techniques including I 3 believe what was called a rollover process to 4 attempt to visualize these calcifications. 5 Do you have an opinion to a reasonable 6 degree of medical certainty as to whether any 7 additional repeat views or these other techniques 8 would have assisted in completing the procedure on 9 this date? 10 A. I think it's unlikely that they would 11 have happened -- that they would have helped. The 12 three standard views are the views where if you 13 are going to find an abnormality, you'll seen them 14 a high percentage of the time. No one can say for 15 certain that doing a hundred extra views might not 16 have shown an abnormality. 17 However, I think that five views is 18 sufficient, and there is really no standard of 19 care that would say that someone should go up to 20 20 views. You need to attempt some additional 21 views and a total of five views were attempted, 00035 1 and that would seem adequate. 2 Q. Doctor, are there any effects on the 3 patient or on the ability to continue these 4 procedures by continuing to repeat additional 5 views and repeat the various mammogram -- excuse 6 me, the mammogram procedures? 7 A. Well, aside from the fact that you know 8 the imaging itself and the compression can be 9 uncomfortable and it does create some patient 10 anxiety, you do have to look at the radiation dose 11 issues, and there are people who would still argue 12 that mammography can actually induce breast cancer 13 by extra radiation. And we certainly know that 14 our patients worry very seriously about the 15 radiation doses that they get. 16 So at some point in time when you are 17 working up a patient, a radiologist has to use 18 good judgment about how many additional views you 19 are going to do with respect to radiation dose. 20 Q. Doctor, after reviewing this case and 21 reviewing the films and the records you have 00036 1 reviewed, did you reach an opinion to a reasonable 2 degree of medical certainty based on your training 3 and experience and knowledge as to whether Dr. 4 George met the standard of care for a radiologist 5 in his attempts to perform the procedure on 6 December 30th of 1994? 7 A. Yes, he did. He practiced good 8 medicine. He did everything that he possibly 9 could on that day getting five additional views to 10 perform the procedure that was scheduled for the 11 patient. 12 And when he was unable to accomplish 13 the procedure, he communicated to the surgeon and 14 recommended a reasonable follow-up for the 15 patient. 16 Q. Now, doctor, do you have an opinion to 17 a reasonable degree of medical certainty as to 18 whether Dr. George had any obligation to follow up 19 directly with the patient? 20 A. I think his primary obligation was to 21 follow-up with the surgeon who had scheduled the 00037 1 procedure and just to communicate what his 2 findings were to the surgeon and come to a next 3 best decision for the patient in conjunction with 4 the surgeon. 5 Q. And, doctor, could you explain for the 6 jury as a radiologist what is your relationship in 7 a case like this with the surgeon as a 8 radiologist? What is the radiologist's 9 relationship with the surgeon and relationship 10 with the patient? 11 A. Well, the radiologist is functioning 12 primarily as a consultant to the surgeon. 13 Typically, the patient has seen the surgeon before 14 seeing the radiologist for the localization 15 procedure and it's the surgeon that refers the 16 patient for the preoperative localization 17 procedure. 18 So under most circumstances in most 19 practices the radiologist functions as a 20 consulting physician to the surgeon rather than a 21 primary care giver to the patient. 00038 1 Q. Doctor, in your opinion to a reasonable 2 degree of medical certainty in this -- well, let 3 me back up. In this case, doctor, there will be 4 testimony at least that Dr. George communicated to 5 the surgeon, Dr. Guiao, and that Dr. Guiao then 6 recommended a four-month follow-up for the 7 patient, Laurie Prescott. However, Ms. Prescott 8 did not follow-up in four months. 9 Do you have an opinion to a degree of 10 medical certainty as to whether or not Dr. George 11 as the radiologist had any obligation to follow-up 12 four months later with this particular patient? 13 A. Yes. He did not. 14 Q. He did not? 15 A. He did not. 16 Q. Okay. Thank you, doctor. 17 And again is that based upon what you 18 have already described to us as the relationship 19 of the radiologist with the surgeon and with the 20 patient? 21 A. Yes, sir. 00039 1 MR. WANTZ: Let's go off the record for 2 a second. 3 VIDEOGRAPHER: We'll go off the record. 4 The time is 7:40. 5 (Pause.) 6 VIDEOGRAPHER: Returning to the record. 7 The time is 7:46. 8 BY MR. WANTZ: 9 Q. Doctor, just a couple more questions. 10 Before we started your trial deposition here 11 today, you had another opportunity to review these 12 films; is that correct? 13 A. Yes, sir. 14 Q. And in reviewing the films again have 15 any of your opinions or thoughts regarding what 16 you have already testified to been changed in any 17 way? 18 A. No. 19 Q. Dr. Freedy, I believe, will testify 20 that she believed that the films were adequate to 21 to be able to place the needle, the wire-guided or 00040 1 the needle-guided wire on December 30th of 1994. 2 Do you have an opinion to a reasonable degree of 3 medical certainty as to whether those films 4 adequately demonstrated the calcifications in 5 order to place the needle-guided wire? 6 A. No. The five films that were obtained 7 in December of 1994 did not adequately depict the 8 calcifications well enough to accurately place a 9 wire for surgical guidance. 10 MR. WANTZ: Thank you, doctor. I have 11 no other questions. 12 MR. WANTZ: Off the record. 13 VIDEOGRAPHER: We are off the record. 14 The time is 7:47. 15 (Pause.) 16 (Whereupon, Fajardo Deposition 17 Exhibits marked Plaintiff Exhibits 1 through 4, 18 marked.) 19 VIDEOGRAPHER: Returning to the record, 20 the time is 7:50. 21 EXAMINATION BY MR. LANCIONE: 00041 1 Q. Good evening, Dr. Fajardo. My name is 2 John Lancione, and I represent the Prescott family 3 in this case. 4 Do you recall meeting me at your 5 deposition on July 1, 1999, this summer here in 6 Baltimore? 7 A. Yes. 8 Q. Doctor, I want to ask you about some 9 medical principles concerning breast cancer. The 10 first one I want to ask you about is as follows. 11 You would agree that it is universally accepted in 12 the medical community that the earlier breast 13 cancer is diagnosed the better the prognosis will 14 be to the patient? 15 A. Yes. 16 Q. You would also agree that the key to 17 reducing death from breast cancer is through early 18 diagnosis? 19 A. True. 20 Q. Doctor, I next want to ask you about 21 mammographic findings that are suspicious for 00042 1 malignancy or cancer. You talked about some 2 earlier on direct examination. And, first of all, 3 I guess I would like to define the phrase 4 suspicious for malignancy or a mammographic 5 finding that is suspicious for cancer. 6 Would you agree that a mammographic 7 finding that is suspicious for cancer requires 8 some type of follow-up? 9 A. Yes. 10 Q. And by follow-up I mean either 11 additional mammographic views of the breast 12 through a different technique or through a 13 follow-up after a period of time has elapsed from 14 the previous mammograph. 15 A. Yes. In general that is true. 16 Q. There are some mammographic findings 17 that are so suspicious for cancer that they 18 require a biopsy; is that fair? 19 A. Yes. 20 Q. And by biopsy we mean a surgeon cutting 21 into the breast to remove the mammographic image 00043 1 that is suspicious for cancer? 2 A. In some cases, yes. 3 Q. There is a surgical biopsy and then 4 there's different types of biopsy as well; 5 correct? 6 A. Yes. 7 Q. Core needle biopsy? 8 A. Yes. 9 Q. Now, one type of a mammographic finding 10 that is suspicious for cancer are clustered 11 microcalcifications that are pleomorphic linear 12 branching and variable in size. Is that correct? 13 A. Yes. 14 Q. And another type of mammographic 15 finding that is suspicious for cancer is the 16 spiculated density? 17 A. Spiculated mass. 18 Q. Spiculated mass. 19 A. Yes. 20 Q Do you make a distinction between a 21 mass and a density on a mammogram? 00044 1 A. Absolutely, yes. 2 Q. A mass is a more defined and more 3 easily appreciated structure than just a density? 4 A. Generally seen on two views so that you 5 know it's a real finding and not a pseudofinding. 6 Q. All right. Microcalcifications and 7 spiculated masses are warning signs or red flags 8 for breast cancer when seen on a mammograph. 9 Would you agree? 10 A. Definitely spiculated masses. Some 11 microcalcifications. A majority of 12 microcalcifications are actually benign. 13 But ones having certain morphologies 14 that you mentioned earlier are the ones that are 15 the worrisome types of microcalcifications. 16 Q. And by morphology we mean -- 17 A. The shape. 18 Q. -- the shape of them? 19 A. The shape, yes. 20 Q. And I used the term pleomorphic 21 earlier. That means irregularly shaped? 00045 1 A. Yeah, pleomorphic means that they look 2 different from one calcification to the next. 3 Q. They are all not the same size and 4 characteristic shape? 5 A. That's true. 6 Q. Doctor, are you familiar with the 7 textbook of breast imaging by Daniel Kopans? 8 A Yes, sir. 9 Q. We talked about that at your 10 deposition. I believe you said that was one of 11 the most widely read books in mammography? 12 A. Yes. 13 Q. And that's a book that you refer to 14 from time to time in your practice? 15 A. Yes. 16 Q. And you have indicated that that is a 17 reliable medical textbook in mammography? 18 A. Yes. 19 Q. Have you read Dr. Freedy's deposition 20 in this case? 21 A Yes. 00046 1 Q. Did you read where she acknowledged 2 that the textbook by Dr. Kopans, Breast Imaging, 3 is a reliable authority in mammogaphy? 4 A Yes, I did. 5 Q. Would you disagree with the statement 6 in Kopans that spiculation of a mass or fine 7 linear branching calcifications are the only signs 8 that virtually always indicate cancer? 9 A. I think that the statement is true, 10 although neither of those findings are present in 11 this case. 12 Q. That is what I want to talk about next, 13 the findings in this case. And I want to first 14 talk about the November 30, 1994 mammogram. 15 You do agree based on your review of 16 the films that there was a finding of an integral 17 development of a cluster of microcalcifications? 18 A. Yes. 19 Q. And by interval we mean there was 20 nothing on the 1990 -- there were no 21 calcifications on the 1990 films, but there were 00047 1 calcifications, microcalcifications on the 2 November 30, 1994 films? 3 A. True. 4 Q. They developed in the interim or the 5 interval of time? 6 A. Yes, yes. 7 Q. Now, did you say on direct examination 8 that you did not appreciate the faint spiculated 9 density described by Dr. Ceicys in his 10 interpretation? 11 A That's true. 12 Q. You did not appreciate that? 13 A. Well, a spiculated density is actually 14 a bit of a misnomer and perhaps Dr. Ceicys will 15 explain that better to you when the time comes. 16 But a density is an amorphous area that actually 17 has shape. It's something that you could draw a 18 circle around or you could pinpoint in the breast. 19 And a spicule is a line. A spiculated mass is a 20 mass seen on two views of the mammogram that has 21 many radiating lines from it. 00048 1 What I believe Dr. Ceicys was referring 2 to was seeing a single line on the mammogram and 3 referring to that as a spicule, but that would be 4 something that he would need to clarify. 5 Q. Let's look at his radiology reports, 6 his official dictated report on his interpretation 7 of this mammogram of November 30, 1994. Do you 8 have a copy of that in front of you, doctor? 9 A. I don't believe I do unless you have 10 marked it. 11 Q. I marked exhibit -- 12 A. We do have it here. 13 Q. Okay. Plaintiff's Exhibit 3 that I 14 have marked for identification, you have a copy of 15 that in your hand which is Exhibit 1 from your 16 deposition. 17 A. Correct. 18 Q. Now, you see where Dr. Ceicys indicated 19 that there was a development of a faint spiculated 20 density? 21 A. Yes. 00049 1 Q. And his description of that is that 2 this is a suspicious lesion for neoplasm and 3 surgical consultation and excisional biopsy are 4 recommended, neoplasm being cancer; correct? 5 A. Correct. 6 Q. And Dr. Ceicys described it as 7 suspicious for cancer? 8 A. Yes, he did. 9 Q. And you testified on direct examination 10 that you do not feel that it was suspicious for 11 cancer? 12 A. That's correct. 13 Q. In fact, Dr. Ceicys said it was so 14 suspicious for cancer that he recommend surgical 15 consultation and excisional biopsy. That was his 16 impression on November 30, 1994; correct? 17 A. Yes. 18 Q. But here today to this jury your 19 testimony is that you do not feel that the 20 findings Dr. Ceicys saw were suspicious for 21 cancer? 00050 1 A. That's correct. 2 Q. Doctor, I want to turn to your previous 3 sworn testimony that you gave in this case. First 4 I want to ask you, do you recall taking the oath 5 and getting sworn testimony in this case on July 6 1, 1999 here the Baltimore? 7 A. Yes. 8 Q. I want to refer you, doctor, to page 45 9 of your deposition, if you would please turn to 10 that? 11 MR. WANTZ: 45 you said? 12 MR. LANCIONE: Page 45. 13 MR. WANTZ: Thank you. 14 Q. First, you just said you do not 15 appreciate a faint spiculated density; correct? 16 A. Excuse me? 17 Q. Your testimony here today is that you 18 do not appreciate a faint spiculated density? 19 A. No. I am saying that a faint 20 spiculated density is not a spiculated mass. A 21 faint spiculated density is not suspicious for 00051 1 carcinoma necessarily. It's something that 2 requires additional work-up. 3 Q. But nonetheless the findings that you 4 see in the films you do not consider suspicious 5 for malignancy? 6 A. I don't think that anybody can make 7 that determination on the two views that were 8 performed. The proper recommendation for that 9 patient on that day would have been to have 10 additional diagnostic workup in the form of 11 imaging. 12 Q. Doctor, I am going to read you the 13 question I asked you starting at page 16. I'd 14 like you to read your answer at line 20. 15 The question I asked you on July 1, 16 1999, was: Do you agree with the statement, this 17 is a suspicious lesion for neoplasm and surgical 18 consultation and excisional biopsy are 19 recommended? 20 A. I'm sorry. That's not on my page 45. 21 Which page 45 are you on? 00052 1 Q. On my page 45, question at line 16. 2 That is Dr. George's deposition. That is why. 3 Here I'll hand you -- first maybe 4 please confirm for the jury that I am handing you 5 a copy of your deposition? 6 A. Okay. 7 Q. And the question at page 45 was: Do 8 you agree with the statement that this neo -- that 9 this is a suspicious lesion for neoplasm and 10 surgical consultation and excisional biopsy are 11 recommended? What was your answer? 12 A. Yes, I don't argue with that. I don't 13 argue with Dr. Ceicys' opinion, but that would not 14 have been my opinion had I looked at those images. 15 Q. Nonetheless, his opinion was what and 16 his recommendation was what a careful and prudent 17 radiologist would recommend? 18 A. I don't argue with his recommendation 19 or his opinion on the case. 20 Q. Doctor, would you agree that it is a 21 general truth in radiology that the standard of 00053 1 care in radiology is that all suspicious 2 mammographic findings are to be considered cancer 3 until proven otherwise by histologic 4 classification? 5 A. I would say in general that's true. 6 Q. And that's because breast cancer is a 7 progressive disease? 8 A. Yes. 9 Q. And if it's not removed from the breast 10 it will continue to grow? 11 A. Under most circumstances, yes. 12 Q. And it will eventually spread? 13 A. Some cancers will and some cancers 14 won't, but there are certainly some cancers that 15 do metastasize. 16 Q. And those that do metastasize if not 17 removed will ultimately kill the patient? 18 A. Yes, they can. 19 Q. Doctor, I next want to talk about the 20 December 30, 1994 cancelled localization of 21 biopsy. 00054 1 A. Uh-huh. 2 Q. Dr. George's function on December 30, 3 1994 was to place a wire in the lesion that Dr. 4 Ceicys described to guide Dr. Guiao to remove it 5 surgically. Is that fair? 6 A. Yes. 7 Q. And when Laurie Prescott came to 8 Southwest General Hospital on December 30, 1994 9 she had mammograms taken of her left breast only? 10 A. Yes. 11 Q. And that was so Dr. George could look 12 at the films, presumably find the lesion, and wire 13 guide a wire into it or needle guide a wire into 14 it? 15 A. Yes. 16 Q. Now, Dr. George was only able to see 17 microcalcification on one view of all of the 18 images that were taken of Laurie Prescott's breast 19 on December 30, '94; is that right? 20 A. Yes. 21 Q. And that was the craniocaudal view? 00055 1 A. I don't recall exactly which view it 2 was, but it was on a single view only. 3 Q. When you looked at the December 30, 4 1994 films on numerous occasions, you also saw the 5 microcalcifications on the craniocaudal view? 6 A. Okay. 7 Q. Correct? 8 A. Correct. Would you like me to review 9 them again for you? 10 Q. Well, no, you have testified that you 11 have reviewed them several times, and your 12 opinions haven't changed. And you did appreciate, 13 I believe you said, subtle calcifications on the 14 craniocaudal view? 15 A. Okay. 16 Q. Now, Dr. George claims he did not 17 appreciate the calcifications on any other views 18 of the breast from the December 30, 1994 films. 19 Is that consistent with your recollection of his 20 testimony? 21 A. Yes. 00056 1 Q. Now, there were calcifications on both 2 the craniocaudal view and the mediolateral oblique 3 view taken a month earlier, November 30, 1994; 4 correct? 5 A. I think they are there, but they are 6 really sort of a restrospective finding. They are 7 very subtle, very subtle. 8 Q. But you will agree that looking at the 9 November 30, 1994 films there are 10 microcalcifications on two views of the left 11 breast, craniocaudad and MLO? 12 A. They are, but they're not well depicted 13 on both views. 14 Q. Doctor, you would agree that 15 microcalcifications from malignancies do not 16 disappear in 30 days' time? 17 A. No, they shouldn't, no; that is 18 correct. 19 Q. So because there were 20 microcalcifications on two views on November 30, 21 1994, they should have been there on December 30, 00057 1 1994 on two views; would you agree? 2 A. In theory, yes. 3 Q. And is it your opinion that there was a 4 mammographic abnormality demonstrated on the 5 December 30, 1994 films because of the presence of 6 microcalcifications on the one view? 7 A. Yes. 8 Q. Now, because Dr. George was only able 9 to see the calcifications on the one view, based 10 on what he said in his report, he assumed that 11 they weren't real which is why he cancelled the 12 procedure. Is that fair? 13 MR. WANTZ: Objection. 14 A. I am not sure I read that I assumed 15 they're not real. Can I just review the report 16 there? 17 Q. Let me hand you what I have marked as 18 Exhibit 1 which is the Southwest General Hospital 19 chart, and Dr. George's interpretation of that 20 procedure is the last page. I am referring to 21 what he stated here in the second last sentence 00058 1 that he does not identify any findings that 2 weren't localization or biopsy. 3 A. Oh, I see. It says, but I cannot with 4 certainty reproduce the nodule and do not identify 5 any findings that warrant localization or biopsy. 6 Is that the statement? 7 Q. Yes. 8 A. Yes, I see that. 9 Q. Do you believe he made an assumption 10 that the calcifications he saw on this 11 craniocaudad view were not real? 12 MR. WANTZ: Objection. 13 A. No, I think that he concluded that he 14 could not with certainty reproduce the findings so 15 that he could safely place the localization wire. 16 I don't think that he's assuming that they 17 disappeared or that they weren't real, but for any 18 number of circumstances his ability to perform the 19 procedure safely on that patient that morning was 20 limited. And there are a number of reasons why 21 some lesions may not be manifested a month later 00059 1 on a mammogram, and we are fairly familiar with 2 most of those, I would say. 3 Q. You also testified on direct that Dr. 4 George made a recommendation for a reasonable 5 follow-up? 6 A. Uh-huh. 7 Q. Can you tell me where in his dictated 8 report there is any recommendation stated for 9 follow-up for Laurie Prescott? 10 A. I don't see any recommendation for 11 follow-up in this report. Only that he discussed 12 it with Dr. Guiao, the surgeon, and after Dr. 13 Guiao reviewed the films with Dr. George, they 14 decided to cancel the patient's procedure on that 15 day. 16 Q. Is there anyplace in Exhibit 1, the 17 hospital chart from Southwest General Hospital, 18 for the December 30, 1994 cancelled biopsy where 19 Dr. George -- it's indicated that Dr. George made 20 a recommendation for follow-up after the cancelled 21 localization? 00060 1 A. I don't believe I remember seeing that 2 in here, although it has been a little while since 3 I reviewed it. 4 Q. What evidence do you have to give you 5 the ability to say Dr. George made a 6 recommendation for reasonable follow-up? 7 A. Maybe it wasn't Dr. George. Maybe it 8 was his surgeon. At some point in time in 9 discussing the facts of this case a form on 10 follow-up was brought up as having been 11 recommended for the patient. I don't recall 12 exactly which of her physicians did that, but I 13 believe at least someone discussed that either in 14 their deposition or in their records. 15 And then you asked me many times on my 16 deposition whether that was reasonable, and that 17 is probably where I remember it from. 18 Q. Okay. Do you recall any testimony in 19 this case that you have read of all the 20 depositions of all the witnesses where anybody 21 states that Dr. George communicated directly to 00061 1 the patient, to Laurie Prescott, a recommendation 2 for follow-up? 3 A. No. 4 Q. I want to tell you that Dr. George 5 testified in his deposition that he made a 6 face-to-face communication with Laurie Prescott. 7 Do you recall that from his testimony, doctor? 8 A. Yes, I believe I do. 9 Q. Other than his testimony that he gave 10 after suit was filed and he was a defendant in 11 this case, is there anywhere that indicates in the 12 hospital chart or any medical records that Dr. 13 George himself made a recommendation to Laurie 14 Prescott for a follow-up mammogram after the 15 December 30, '94 procedure? 16 A. Yeah. I don't recall anything specific 17 in the medical records. 18 Q. Is there any indication in the dictated 19 report by Dr. George of the word abnormal 20 mammogram? Is there any statement that this is an 21 abnormal mammogram in that report? 00062 1 A. I don't see the word abnormal or the 2 word mammogram in here at all. I think that-- 3 Q. Or abnormal findings or suspicious 4 findings? 5 A. I see the words small focal nodule. I 6 guess you could look at that as a finding on the 7 mammogram. 8 I am not quite sure I understand your 9 question. 10 Q. You can keep that document. 11 A. Okay. 12 Q. The reference of small focal nodule 13 refers to the November 30, 1994 study -- 14 A. Yes. 15 Q. -- if you read that entire sentence. 16 But as far as Dr. George's interpretation of the 17 December 30, 1994 films, there is no indication in 18 there that he has found a suspicious abnormality 19 in the breast? 20 A. I think that is true. I think that is 21 why he couldn't do the procedure on that day. 00063 1 Q. Doctor, I want to ask you about the 2 issue of whether Laurie Prescott's breast cancer 3 likely would have been diagnosed earlier had this 4 follow-up mammogram occurred. 5 You stated in your report to the 6 attorneys in this case that had the mammogram that 7 allegedly was recommended to her to happen within 8 four months after the cancelled attempted biopsy, 9 had that happened it is highly likely that her 10 breast cancer would have been diagnosed at that 11 time. Do you stand by that statement today? 12 A. Well, I think there is a good 13 likelihood that a mammogram four months later 14 might have shown findings similar to the mammogram 15 in November. No one can say with one hundred 16 percent certainty, but it certainly would be 17 prudent to attempt to get some additional imaging 18 on this patient just to confirm what might have 19 been suspected on the November mammogram. 20 Q. And you state in your report that it is 21 very likely that an early diagnosis of her disease 00064 1 would still have been made. You stand by that 2 statement? 3 A. Well, I was assuming that a proper 4 diagnostic mammogram would have been done with 5 magnification views. 6 Q. And magnification views would have been 7 prudent because magnification allows for better 8 visualization of calcifications? 9 A. True. 10 Q. So it's your testimony to this jury 11 that had an appropriate diagnostic mammogram been 12 performed within four months after the cancelled 13 biopsy of December 30, 1994, it is very likely -- 14 or I am going to use your language -- it is very 15 likely that early diagnosis of Laurie's disease 16 would still have been made? 17 A. I think there's a greater than 50 18 percent chance that it would have. Again, no one 19 can say you know one hundred percent with 20 certainty, but it doesn't create an argument for 21 not recommending a short term interval follow-up 00065 1 on the patient. 2 Q. Short-term interval follow-up would 3 have been the careful and prudent and safest thing 4 for Laurie at that time; would you agree? 5 A. Well, there are a number of things that 6 could have been done. Her needle localization 7 could have been rescheduled for another month. I 8 mean I think those are decisions that the surgeon 9 and the patient's primary care physician and 10 radiologist have to make together because somehow 11 someone has to safely go in there and localize the 12 finding. 13 So I think rather than say don't have a 14 mammogram for another year, that everything is 15 fine, doing something in a short-term interval is 16 a good thing to have done. 17 Q. You mentioned another attempt at biopsy 18 within a month. That would have been a reasonable 19 and prudent recommendation? 20 A. Yes, that is one recommendation that 21 could have been made. 00066 1 Q. That would have been within the 2 standard of care? 3 A. Yes. Again, I mean we wouldn't have a 4 hundred percent certainty that the procedure could 5 have been performed, but you know you could have 6 attempted to do it again. 7 Q. Doctor, I want to now talk about the 8 January 23, 1996 mammogram. There have been 9 statements in this case by some other experts that 10 the January 23, 1996 mammogram was normal. 11 Doctor, you would agree that the 12 January 23, 1996 mammogram was not a normal 13 mammogram? 14 A. The January 1996 mammogram shows the 15 calcifications. They are obscured by some breast 16 tissue. They are very faint and they are very 17 subtle. I would say that even in 1996 this cancer 18 falls into the category of the more subtle cancers 19 that we face in mammography for diagnosis. This 20 is not a large mass. It's not spiculated. There 21 are no linear calcifications. There are no 00067 1 branching calcifications. The calcifications are 2 not of differing size. They are all very small, 3 about the same morphology, and over an area that 4 is probably well under a centimeter in that breast 5 on the mammogram. 6 Q. The January 23rd mammogram? 7 A. Yes. 8 Q. Those subtle findings make that an 9 abnormal mammogram? 10 A. Yes. But I would say that there is a 11 percentage of radiologists who wouldn't detect it. 12 Q. Doctor, is there a different standard 13 for general diagnostic radiologists compared to a 14 specialist like yourself who specializes in 15 mammography, or is the standard of care the same 16 for the general diagnostic radiologist and the 17 specialist like yourself or Dr. Freedy? 18 A. Well, I would hope that somehow the 19 standard of care would be equalized, but certainly 20 people with more experience and who practice 21 mammography exclusively are going to be better at 00068 1 at it than people who practice community medicine. 2 Q. But as far as the standard of care that 3 you're testifying about today, it applies across 4 the board? 5 A. Yes. 6 Q. The mammogram of January 23, 1996 does 7 show an increase in the density in the upper outer 8 quadrant of the left breast compared to the 9 December 30, 1994 mammogram? 10 A. Yes. 11 Q. And the January 23, 1996 mammogram 12 shows an increase in the calcifications compared 13 to the December -- or compared to the November 30, 14 1994 mammogram? 15 A. It shows a small increase. It's not a 16 gross increase though. 17 Q. And if you were interpreting the 18 mammogram for this patient, Laurie Prescott, the 19 January 23, '96 mammogram, you would have 20 mentioned in your report the microcalcifications? 21 A. Yes. 00069 1 Q. Dr. Grossman did not mention the 2 microcalcifications in his report? 3 A. Yes. 4 Q. If you were interpreting this January 5 23, 1996 mammogram for Laurie Prescott, you would 6 have recommended further workup because of these 7 abnormalities? 8 A. Yes, I probably would have. 9 Q. Dr. Grossman did not recommend further 10 workup; correct? 11 A. Correct. 12 Q. In fact, he said there was no evidence 13 of underlying pathology? 14 A. Yes, he did. 15 Q. That was wrong? 16 A. It was an error in judgment on his 17 side. But again you know I really would like to 18 point out that it's not a gross egregious area. 19 This is a very subtle breast cancer. 20 Q. And if you were interpreting these 21 films, you would have mentioned the 00070 1 microcalcifications as well? 2 A. Yes. 3 Q. And Dr. Grossman did not? 4 A. Correct. 5 Q. Dr. Fajardo, the findings on the 6 November 30, 1994 films show the cancer that was 7 ultimately diagnosed in Laurie Prescott in April 8 of 1996; isn't that true? 9 A. I believe so, yes. 10 Q. And, Dr. Fajardo, you would agree that 11 under the circumstances that existed on December 12 30, 1994 that further diagnostic evaluation was 13 required for Laurie Prescott's left breast? 14 A. Yes. 15 Q. And one of the doctors caring for 16 Laurie -- Dr. Morona, Dr. Guiao, or Dr. George -- 17 had a duty to follow-up with her after the 18 December 30, 1994 cancelled localization? 19 MR. KILBANE: Objection. 20 MR. WALTERS: Objection. 21 MR. WANTZ: Objection. 00071 1 A. Yes. 2 Q. Dr. Morona did not follow-up with 3 Laurie Prescott; did she? 4 MR. WANTZ: Objection. 5 A. I'm sorry. I don't know. I am not 6 familiar with those records. 7 Q. Dr. Guiao did not follow-up with 8 Laurie Prescott; did he? 9 MR. WALTERS: Objection. 10 MR. WANTZ: Objection. 11 MR. KILBANE: Objection. 12 A. I don't recall. I didn't look at the 13 surgeon's records. I only looked at the images 14 and the radiology records. 15 Q. Dr. George did not follow-up with 16 Laurie; did he? 17 A. No. 18 MR. LANCIONE: Those are all the 19 questions I have at this time. Thank you. 20 MR. KILBANE: No questions. 21 EXAMINATION BY MR. WALTERS: 00072 1 Q. Doctor, Steve Walters. I represent Dr. 2 Guiao. Just a couple of questions. 3 When Dr. George was unable to localize 4 the masses or densities for purposes of inserting 5 a needle and then guiding a wire through the 6 needle, it was a reasonable thing, was it not, to 7 cancel then further procedures that day? 8 A. I don't think that Dr. George had any 9 other recourse but to cancel the procedure. If 10 you cannot see an abnormality, you cannot put a 11 needle into it. 12 Q. And if the radiologist cannot see an 13 abnormality and put a needle into it, the surgeon 14 does not know where to cut and cannot just be 15 going in there blindly cutting? 16 A. Dr. Guiao would not have been able to 17 perform surgery on her unless there was a wire in 18 that area for him to excise unless he wanted to 19 take off one-quarter of Ms. Prescott's breast 20 which in all likelihood the patient would not have 21 enjoyed the cosmesis afterwards. So the point -- 00073 1 what most surgeons try to achieve is minimal 2 excisional breast biopsy, taking out as little 3 tissue as possible because we don't know ahead of 4 time that something is going to be cancer. So you 5 don't want to cut out a significant portion of the 6 patient's breast. That's why we do needle wire 7 localizations, so that they've got the wire in the 8 area exactly in the abnormality so they can take 9 out as little tissue as possible. 10 Q. So if the pathologist which, of course, 11 is a different type of physician, comes back and 12 says, no, this is not malignant; it's a benign 13 piece of tissue, then at least the patient has not 14 been scarred or maimed by the process of getting 15 this sample, this tissue sample? 16 A. That is the whole idea behind putting 17 the wires in the breast before surgical excision. 18 Q. Dr. Fajardo, if I understand your 19 testimony the recommendation to Mrs. Prescott and 20 then communicated to her family physician of a 21 follow-up diagnostic imaging of the breast within 00074 1 a four-month period is a reasonable 2 recommendation; is that correct? 3 A. Yes, it is. 4 MR. WALTERS: That's all I have. 5 MR. KILBANE: No questions. 6 EXAMINATION BY MR. WANTZ: 7 Q. Doctor, I have just a couple follow-up 8 questions for you to cover a couple of things. I 9 would like to go back to the report of Dr. George 10 from the December 30th attempt. And Mr. Lancione 11 asked you several questions about this in 12 reference to the fact that there was no indication 13 in there that Dr. George communicated with Dr. 14 Guiao regarding the four-month follow-up. 15 Do you see where Dr. George writes in 16 his report: I discussed this with Dr. Guiao? 17 A. Yes, sir. 18 Q. And he -- 19 MR. LANCIONE: I just want to object 20 because I said the patient, not Dr. Guiao. I 21 object that it's a mischaracterization of my 00075 1 question. Go ahead and answer. 2 BY MR. WANTZ: 3 Q. Is it your understanding that Dr. 4 George communicated with Dr. Guiao regarding his 5 recommendations for follow-up procedure? 6 A. He wrote in his report that he 7 discussed his procedure on December 30th with Dr. 8 Guiao and that Dr. Guiao reviewed the films with 9 him. 10 Q. And you are aware that a -- there is 11 some evidence that a four-month follow-up was 12 recommended; is that correct? 13 A. Yes. 14 Q. There is a letter from Dr. Guiao to Dr. 15 Morona indicating that he had talked to the 16 patient and recommended a four-month follow-up; is 17 that correct? 18 A. Yes. 19 Q. All right. And it's your opinion that 20 that a four-month follow-up would have been 21 appropriate in this case? 00076 1 A. Yes, it would have. 2 Q. Doctor, is there anything in Dr. 3 George's written report that suggests that he 4 didn't believe there were calcifications or 5 microcalcifications in Ms. Prescott's breast? 6 A. No. 7 Q. In fact, doesn't he suggest in there 8 only that he could not reproduce them and, in 9 fact, based on everything else they were 10 recommending that she have follow-up? 11 A. Yes. 12 Q. And, doctor, you indicated that another 13 alternative would have been to perform and a 14 repeated attempt at biopsy approximately a month 15 later, and that that would be within the standard 16 of care. Is it a breach of the standard of care, 17 doctor, to not have attempted that route rather 18 than the route Dr. George and Dr. Guiao decided to 19 pursue? 20 A. No. 21 MR. WANTZ: Thank you, doctor. I have 00077 1 no other questions. 2 EXAMINATION BY MR. LANCIONE: 3 Q. Dr. Fajardo, I don't want to beat a 4 dead horse, but is the word follow-up contained in 5 Dr. George's dictation of December 30, 1994? 6 A. No. 7 Q. Or repeat mammogram, are those words 8 contained in his dictation? 9 A. No. 10 Q. Doctor, have you read the deposition of 11 Laurie Prescott in this case? 12 A. It has been a few months, yes. 13 Q. Do you recall her testimony that 14 neither Dr. George nor Dr. Guiao made a 15 recommendation for follow-up? 16 A. I don't recall that explicitly. 17 Q. You would agree that the failure to 18 recommend follow-up to Laurie Prescott after the 19 cancelled localization would be a breach of the 20 standard of care? 21 A. Yes. 00078 1 MR. LANCIONE: No further questions. 2 EXAMINATION BY MR. WANTZ: 3 Q. Doctor, just briefly again to be clear, 4 is it your opinion that it was Dr. George's 5 responsibility to follow-up and ensure that the 6 patient had a repeat mammogram in four months? 7 A. No. 8 MR. WANTZ: Thank you, doctor. I have 9 no further questions. 10 MR. WALTERS: That is it. 11 MR. WANTZ: That is it. 12 VIDEOGRAPHER: This concludes the 13 deposition. The time is 8:26 p.m. 14 MR. WANTZ: Doctor, for the record I 15 guess we should -- we don't have to put this on 16 video, but we have trial starting this coming 17 Monday. The transcript is going to be typed up. 18 Do you want to review it or do you 19 waive your right to review the transcript? 20 THE WITNESS: You can review it for me. 21 That is all right. 00079 1 MR. WANTZ: And to the attorneys, are 2 we going to have -- I assume we all waive the 3 filing of it prior to the trial? 4 MR. WALTERS: Yeah. 5 MR. LANCIONE: Yes. 6 MR. KILBANE: Yeah. 7 MR. WANTZ: Thank you. 8 (Examination concluded 8:26 p.m.) 9 10 11 12 13 14 15 16 17 18 19 20 21 00080 1 STATE OF MARYLAND SS: 2 I, Sara A. Cissin, a Notary Public of the 3 State of Maryland, do hereby certify that the 4 within named, LAURIE LEE FAJARDO, M.D., personally 5 appeared before me at the time and place herein 6 set out, and after having been duly sworn by me, 7 was interrogated by counsel. 8 I further certify that the examination was 9 recorded by me and this transcript is a true 10 record of the proceedings. 11 I further certify that the stipulation 12 contained herein was entered into by counsel in my 13 presence. 14 I further certify that I am not of counsel 15 to any of the parties, nor an employee of counsel, 16 nor related to any of the parties, nor interested 17 in the outcome of this action. 18 As witness my hand and notarial seal this 19 12th day of August, 1999. 20 My commission expires _______________________ 21 March 1, 2000 Notary Public 00081 1 C O N T E N T S 2 WITNESS: LAURIE LEE FAJARDO, M.D. PAGE 3 EXAMINATION BY: 4 Mr. Wantz 5, 74, 78 5 Mr. Lancione 40, 77 6 Mr. Walters 72 7 8 9 10 EXHIBITS (Defendant-George) PAGE 11 A CV 4 12 13 EXHIBITS (Plaintiffs) 14 1 Southwest General Hospital records 40 15 2 Fajardo 12/11/97 letter to Crisafi 40 16 3 Radiology Report, Dr. Morona 40 17 4 Radiology Report, Dr. Guiao 40 18 19 20 21