1 1 IN THE COURT OF COMMON PLEAS SUMMIT COUNTY, OHIO 2 CASE NO. CV 98 05 1804 3 4 LAWRENCE PIETRO, et al., ) ) 5 Plaintiffs, ) ) 6 v. ) ) 7 GENERAL EMERGENCY MEDICAL ) SPECIALISTS, INC., et al., ) 8 ) Defendants. ) 9 - - - - - - - - - - - - - - - - - - x 10 11 DEPOSITION OF RICHARD LATCHAW 12 13 14 Taken before Brian Gary Berkowitz, 15 Shorthand Reporter and Notary Public in and for 16 the State of Florida at Large, pursuant to notice 17 of taking deposition filed in the above cause. 18 - - - 19 20 100 S.E. 2nd Street Suite 2310 21 Miami, Florida 33131 Thursday, June 10, 1999 22 10:15 a.m. - 12:20 p.m. 23 24 25 2 1 APPEARANCES: 2 On behalf of the Plaintiffs: 3 LINTON & HIRSHMAN Hoyt Block, Suite 300 4 700 West St. Clair Avenue Cleveland, Ohio 44113-1230 5 BY: TOBIAS J. HIRSHMAN, ESQ. 6 On behalf of the Defendants General Emergency Medical Specialists, S.E. Tout and Thomas Elson 7 ROETZEL & ANDRESS 8 222 South Main Street Akron, Ohio 44308 9 BY: JULIE MOORE, ESQ. (Present by Telephone) 10 On behalf of the Defendants Lynn Mason, Kevin 11 Markowski, Montrose Diagnostics and Akron General Medical Center: 12 ROETZEL & ANDRESS 13 222 South Main Street Akron, Ohio 44308 14 BY: ROCCO POTENZA, ESQ. (Present by Video Conference) 15 On behalf of the Defendants Karla Madalin and 16 Karla Madalin, M.D., Inc.: 17 BONEZZI SWITZER MURPHY & POLITO 1400 Leader Building 18 526 Superior Avenue Cleveland, Ohio 44114 19 BY: EDWARD TABER, ESQ. (Present by Video Conference) 20 On behalf of the Defendant David Cola, M.D.: 21 BUCKINGHAM DOOLITTLE & BOURROUGHS 22 4518 Fulton Drive N.W. Canton, Ohio 44735-5548 23 BY: MARK D. FRASURE, ESQ. (Present by Video Conference) 24 25 3 1 APPEARANCES (CONT'D): 2 On behalf of the Defendants Radiology and Imaging Services, Inc. and Victor Louisin: 3 REMINGER & REMINGER 4 The 113 St. Clair Building Suite 700 5 Cleveland, Ohio 44114 BY: ALAN PARKER, ESQ. 6 (Present by Video Conference) 7 8 INDEX 9 WITNESS DIRECT CROSS REDIRECT RECROSS RICHARD LATCHAW 10 By Mr. Parker 4 77 By Mr. Taber 64 11 By Mr. Frasure 75 By Ms. Moore 76 12 --------- 13 14 15 16 17 18 19 20 21 22 23 24 25 4 1 P R O C E E D I N G S 2 Thereupon, 3 RICHARD LATCHAW 4 being by the undersigned Notary Public first 5 duly sworn, was examined and testified as 6 follows: 7 DIRECT (RICHARD LATCHAW) 8 BY MR. PARKER: 9 Q. Dr. Latchaw, it really sounds like you 10 are going to have to keep your voice up for me to 11 hear you. 12 My name is Alan Parker. I represent 13 Dr. Louisin and his practice in this litigation. 14 Will you please tell us, for the 15 record, your full name? 16 A. Richard Edward Latchaw. 17 Q. And your professional address, please? 18 A. I am at the University of Miami, School 19 of Medicine, which is N. W. 12th Avenue, in 20 Miami. 21 Q. Dr. Latchaw, I take it that you 22 anticipate providing expert opinions in this 23 litigation. Is that correct? 24 A. Correct. 25 Q. Have you served as an expert witness on 5 1 previous occasions? 2 A. Yes. 3 Q. I take it you've been deposed on 4 previous occasions? 5 A. Yes. 6 Q. All right. Then you understand that 7 this is my opportunity to ask you questions. I 8 try to make my questions clear, but sometimes 9 they're not. 10 So, if you have any difficulties with 11 my questions, please let me know and I'll do what 12 I can to clarify them. 13 Is that okay with you? 14 A. That's fine. 15 Q. All right. I have not been provided 16 with a -- what you physicians call a curriculum 17 vitae, a resume. 18 Could you please give me some 19 background as to your education and your 20 professional experience? 21 A. Sure. My undergraduate work and my 22 medical school were both performed at the 23 University of Minnesota. 24 I started there in 1961, entered 25 medical school in '64, graduated in 1968 with an 6 1 M.D. 2 Went to Yale New Haven Hospital in '68 3 for a one year surgical internship. 4 Left there in '69 to go to the 5 University of Michigan in Ann Arbor, where I 6 spent four years, the first two years in 7 diagnostic radiology and the second two years in 8 neuroradiology. 9 I then went to the United States Air 10 Force in '73. Was at Travis Air Force Base in 11 California until '75. 12 Went back to Minnesota, University of 13 Minnesota, in '75. Was there until 1980. During 14 that time I moved from assistant to associate 15 professor. 16 1980 I was recruited to go to the 17 University of Pittsburgh as the chief of 18 neuroradiology. I stayed there for nine years. 19 During that time, I became a full 20 professor of radiology and neurosurgery, in 1983. 21 I became the interim chairman of the 22 department of radiology, the entire department, 23 in 1986. 24 Finally, in '89 I left; went into 25 private practice in Denver, Colorado from '89 7 1 through '91. 2 1991 I was recruited to go back to the 3 University of Minnesota, as the Peterson Chair of 4 neuroradiology. 5 I stayed there through 1995, at which 6 point I left and came here to the University of 7 Miami, where I have been for almost the last four 8 years. 9 Q. And what has your position been at the 10 University of Miami? 11 A. I am a professor of radiology and 12 neurosurgery, and chief of interventional 13 neuroradiology. 14 Q. Did I hear correctly you are chief of 15 interventional neuroradiology? 16 A. That is correct. 17 Q. When I did very briefly last night an 18 Internet search for your name, that's how I saw 19 you identified, as an interventional 20 neuroradiologist. 21 Is that currently the nature of your 22 practice? 23 A. That is correct. That is the majority 24 of what I do today, and that is my title. 25 Q. What is interventional neuroradiology? 8 1 A. Neuroradiology as a specialty is 2 divided into two portions. One is diagnostic and 3 the other is interventional. 4 The diagnostic side is characterized by 5 people who read C-Ts and MR scans. They may do 6 some angiography; they may do some myelography. 7 Those kinds of things. 8 Interventional neuroradiology are those 9 very few people within neuroradiology that 10 actually undertake therapy. We go into blood 11 vessels up in the head and neck and spine. We 12 will deposit coils, glue, plastic particles, 13 whatever it takes, to close down an aneurism or a 14 vascular malformation. 15 We will also open up blood vessels so 16 we treat acute stroke. We treat chronic 17 narrowing of arteries with stents. So, we are 18 therapy minded. 19 Q. And you actually do the interventional 20 procedures, the entry of the vessels? 21 A. Absolutely. 22 Q. Okay. I take it that neuroradiology is 23 a subspecialty of radiology. Is that correct? 24 A. That's correct. 25 Q. And I take it then that interventional 9 1 neuroradiology is a subspecialty of 2 neuroradiology? 3 A. That is correct. 4 Q. For how long have you concentrated your 5 practice in the subspecialty that we're calling 6 interventional neuroradiology? 7 A. I've done interventional as part of my 8 practice since 1975. I have been purely 9 concentrated into the interventional world since 10 '95. 11 Q. Since 1995? 12 A. Correct. 13 Q. All right. I apologize for the 14 occasions on which I'll repeat, but between the 15 lag and the possibility of the audio on this end 16 kind of reverberating and echoing, I do want to 17 make sure I understand you correctly. 18 A. I have no problem with that. 19 Q. Thank you. This may be kind of slow 20 going. I'm not fastest lawyer in the world to 21 begin with, and then I have to make sure you 22 finish your answers before I pose another one, so 23 I hope it doesn't take too long. 24 When is the last time, if ever, in your 25 professional career, that you have primarily been 10 1 a general radiologist? 2 A. 1991. Between '89 and '91 I did a lot 3 of general radiology besides the neuro that I did 4 while I was living in Denver, Colorado. 5 Q. Okay. And that was when you were in 6 private practice? 7 A. That is correct. 8 Q. And what institutions -- were you 9 affiliated with any hospitals or institutions? 10 A. I was primarily at Swedish Hospital in 11 Englewood, but we also rotated to Littleton, and 12 to Porter Hospital in South Denver. 13 Q. Describe for me, if you would, please, 14 the reasons that you left your position at the 15 University of Pittsburgh and went into private 16 practice in 1989, if I understood what you said 17 correctly. 18 A. I was the chairman of the department in 19 1989. For many political reasons they wanted 20 somebody that they would name that would be of 21 their political persuasion. 22 I mean, by "they," I mean the vice 23 president for medical affairs. 24 There were many political overtones and 25 I opted to not stay there in the co-position 11 1 which I had, which was also chief of 2 neuroradiology. 3 In fact, I opted to leave and go into 4 private practice in a town in which I could help 5 start an organization called the Colorado 6 Neurological Institute. 7 Q. What was the business of the Colorado 8 Neurological Institute? 9 A. Diagnosis and treating neurological 10 disease. 11 Q. Does it still exist? 12 A. Yes. 13 Q. All right. Tell me, if you would, 14 please, the circumstances that led you to leave 15 private practice in Denver and end up at Miami. 16 A. Well, I left Denver and I went back to 17 the University of Minnesota, and I knew the 18 school because this would be my third tour of 19 duty. 20 I had grown up there in Minnesota. I 21 had gone to medical school there. I had been on 22 staff from '75 to '80. I was recruited to go 23 back as the first one million dollar supported 24 chair of neuroradiology. It was the first such 25 chair of neuroradiology in the United States, so 12 1 it was therefore a very prestigious position to 2 assume, and that was the primary reason, plus, 3 quite frankly, I was a little bored in private 4 practice, so I went back to academia. 5 Q. Okay. And when you returned to 6 academia in 1991, did you return to the specialty 7 primarily in your practice, of neuroradiology? 8 A. Yes. Both diagnostic and 9 interventional sides. 10 Q. Okay. It's my understanding, again, 11 from my quick Internet search, that you are a 12 past president of the American Society of 13 Neuroradiology? 14 A. Correct. 15 Q. When was that? 16 A. I was the president from '97 to '98. 17 So, last year was my first year as being the 18 first past president and this year I am the 19 second past president of the ASNR. 20 Q. Would I be correct in understanding 21 that members in the American Society of 22 Neuroradiology, would be composed of individuals 23 who have as a primary focus of their practice, 24 the subspecialty of neuroradiology? 25 A. Correct. With greater and lesser 13 1 degrees of focus. Some people will practice less 2 than 50 percent of their time in neuroradiology, 3 but that is no impediment to being a member of 4 the organization. 5 Q. Do you hold board certification? 6 A. Yes. 7 Q. In what field? 8 A. Diagnostic radiology. I acquired my 9 boards in 1973. 10 I then acquired a CAQ, which is a 11 certificate of added qualifications, in 12 neuroradiology, in 1995, I believe. 13 Q. Okay. And are those your only fields 14 of board certification? 15 A. That's correct. 16 Q. In what states are you licensed? 17 A. I have a licensure in Florida that is 18 called a medical facility certificate, so-called 19 MFC, which the dean grants me, so that I can 20 practice at the University of Miami. 21 I am only now applying for my full 22 Florida licensure, because I had to take a test 23 of all of my past medical experience, general 24 medicine. So, I only just completed that test. 25 I still have my Minnesota license. My 14 1 licenses in Pennsylvania, Colorado and California 2 are currently inactive. 3 Q. So, you are only -- your only full 4 current licensure is in Minnesota. Am I 5 understanding correctly? 6 A. That is correct. 7 Q. And you have an application pending for 8 full licensure in Florida. Is that correct? 9 A. That is correct. 10 Q. And have you been practicing under the 11 medical facility certificate since you returned 12 to Florida in 1995? 13 A. That is correct. 14 Q. Is there a time limit during which you 15 can practice under a medical facility 16 certificate, or is that an unlimited time period? 17 A. No, it's a two year time period, so the 18 dean has -- in 1997, he granted me an extension, 19 and then he granted me another extension quite 20 recently, while my full licensure is pending. 21 My full licensure may come through 22 before the extension has to take effect. 23 Q. Okay. Have any licenses or privileges 24 to practice medicine ever been suspended or 25 revoked in your career? 15 1 A. No, sir. 2 Q. All right. I have then -- I want to 3 turn our attention, if I can, now, to the case at 4 hand, and ask you when you were first contacted 5 with regard to this litigation. 6 A. April? March? No, no, no, no. I'm 7 just checking my file. 8 December of '98. 9 Q. December 1998 was the first contact? 10 A. Correct. 11 Q. What was the nature of the contact? 12 A. Mr. Toby Hirshman called me from 13 Cleveland, as I recall, asked me if I would be 14 willing to look at a case, and I said yes. 15 He sent me some films. 16 That was the contact. 17 Q. Have you reviewed anything other than 18 films? 19 A. There were the radiological reports of 20 those films. I also was sent the deposition on 21 Dr. Louisin. 22 Q. Have you reviewed any depositions other 23 than the deposition of Dr. Louisin? 24 A. No. 25 Q. Have you reviewed any written medical 16 1 reports other than the radiology reports for each 2 of the films you reviewed? 3 A. No. 4 Q. I note in a report which has been 5 provided to me from you, dated December 23, 1998, 6 you list as items which have been reviewed, 7 relevant medical records. 8 Am I correct in understanding that the 9 sum total of those medical records is the 10 radiology reports for each of the films that are 11 listed in the report? 12 A. Correct. 13 Q. Nothing else. Correct? 14 A. Correct. 15 Q. All right. I have, as I just 16 indicated, the report of yours dated December 23, 17 1998. 18 Do you have that? Do you have that 19 report? 20 A. Yes, I do. 21 Q. Is that your most recent report in this 22 case? 23 A. That is the most recent and the only 24 report. 25 Q. Okay. And that was my next question, 17 1 was whether there had been any previous reports. 2 Let me ask this. Were there any drafts 3 of this December 23, 1998 report? 4 A. No. 5 Q. Have you received any written 6 correspondence from Mr. Hirshman, concerning this 7 case? 8 A. I had the initial letter of 9 introduction from him that accompanied the films, 10 giving me kind of an overall summary of the fact 11 that there were a series of films, and what the 12 overall problem was, but that is all. It was 13 just an accompanying letter. 14 Q. Okay. Do you have that with you, sir? 15 A. I don't have that. 16 Q. Do you know approximately when you 17 received that letter that had that background 18 information? 19 A. Well, it would have been with the 20 films, and so, I'm going to guess that it was 21 sometime in the month of December, given the fact 22 that I wrote the report on December 23. 23 Q. Can you tell me from your recollection, 24 sir, what the general background that you were 25 provided consisted of? 18 1 A. That this individual had, and I'm 2 referring to Mr. Pietro, had -- had the onset of 3 difficulties with swallowing, some vertigo, some 4 facial numbness. That he had seen -- he had been 5 to the emergency room. I believe I say that. He 6 had been to Akron General Medical Center as early 7 as November 30. 8 He then had the series of C-T scans 9 followed by an MR, cerebral angiogram, and that's 10 pretty much it. 11 Q. You knew that you were performing a 12 medical/legal review. Is that true? 13 A. Correct. 14 Q. Was it your understanding that 15 Mr. Hirshman was an attorney? 16 A. Sure. 17 Q. What understanding did you have 18 regarding the patient's end status after this 19 sequence of treatment? 20 A. You mean his neurological status 21 following all of these events? Is that what you 22 are asking? 23 Q. Correct. Yes. 24 A. That he -- that he apparently had some 25 residual deficits with motor weakness, some 19 1 degrees of cognitive change. The specifics of 2 those and the degrees, however, I am not aware 3 of. 4 Q. Okay. But you were aware that he had 5 residual deficits when you received this initial 6 summary and background of the case. Correct? 7 A. That is correct. 8 Q. All right. Did you receive any films 9 other than the six that are listed in your 10 December 23 report? 11 A. I also received the MR study from Case 12 Western Reserve, which I believe was a study of 13 1997. 14 Q. Okay. Anything else? 15 A. No. 16 Q. When did you receive the MR study from 17 1997? 18 A. They all came together. 19 Q. Okay. Is there a reason that that MR 20 study of 1997 is not included in your report? 21 A. It would -- I didn't think that it was 22 particularly relevant. I really focused all of 23 my attention to the C-Ts, MRs, cerebral 24 angiogram, all that in that period of time from 25 the fourth of December to the ninth of December, 20 1 1996. 2 That was really the question -- those 3 were the questions that I was being asked to 4 address. 5 Q. Fair enough. And when you received the 6 radiology films for Mr. Pietro that you've 7 indicated, the six that are on your report, a 8 seventh one that was from approximately 1997, did 9 you receive any other radiology films at all? 10 A. No, sir. 11 Q. All right. 12 How did you go about reviewing these 13 radiology films that were associated with this 14 case? 15 A. What I generally do, and what I did in 16 this case, is to take the films from their 17 initial time of being done, so I would have taken 18 the C-T scan of the head from 4 December '96, 19 looked at it, analyzed it, then continued on to 20 the seventh, the C-T of the eighth, the C-T of 21 the head of the ninth, and gone in sequence, so 22 that I could trace the sequence of the 23 radiographic findings, going on to the MR of the 24 eighth, finally the cerebral angiogram of the 25 ninth of December. 21 1 Q. Okay. So, as I understand it, what you 2 did is, you placed these films in chronological 3 order, and then you set about reviewing them 4 sequentially? 5 A. That is correct. And then only after I 6 was done with that, after I understood this case, 7 from a radiographic point of view, then would I 8 go to the actual reports themselves and see if my 9 interpretation agreed or disagreed with that 10 which had been rendered. 11 Q. Okay. At the time that you reviewed 12 the radiology films pertaining to Mr. Pietro, did 13 you review any other radiology films? 14 A. No. 15 Q. Okay. Have you ever had occasion to 16 work with Mr. Hirshman before? 17 A. Yes. 18 Q. On how many occasions? 19 MR. HIRSHMAN: Actually, he's worked 20 against me, I think, not with me. 21 THE WITNESS: Is that right? 22 MR. HIRSHMAN: I had a case some years 23 ago, where I was defending it, and he was the 24 attorney who was -- he was the doctor who was 25 retained by the plaintiff's attorney. 22 1 BY MR. PARKER: 2 Q. To your knowledge, have you ever been 3 previously retained by Mr. Hirshman? 4 A. He has corrected me, and I am assuming 5 that his recollection is far more correct than 6 mine. So, my answer would be no, he's not 7 retained me. 8 Q. Okay. Do you have recollection, 9 though, of being a witness that was adverse to 10 Mr. Hirshman? 11 A. Well, now that he reminds me, I think 12 he's correct. I'd have to look back in the 13 history to know which case it was, but I -- I 14 trust his memory. 15 Q. Do you know how Mr. Hirshman came to 16 contact you in this case? 17 A. I would like to assume that he 18 remembered me as being a good adversary, and 19 someone that would be truthful and, therefore, 20 someone that could be helpful to him on this 21 occasion. 22 Q. Do you know how he came to contact you, 23 however? 24 A. The specifics, no, I do not. 25 Q. All right. On how many occasions have 23 1 you reviewed radiology films in medical 2 malpractice cases? 3 A. I see about nine or ten cases a year. 4 Q. How long have you done so? 5 A. Since 1981. 6 Q. Can you give me an estimate as to the 7 percentage of time that you review cases on 8 behalf of attorneys representing patients versus 9 reviewing them on behalf of attorneys 10 representing health care providers? 11 A. I would say that about 70 percent of 12 the time I am on the defending side, that is, on 13 the side of the doctors or the institution, and 14 about 30 percent of the time I am on the 15 plaintiff's side. 16 Q. Have you had occasion to testify in 17 court? 18 A. Yes. 19 Q. On approximately how many occasions? 20 A. Actual court appearances, I think 21 I -- I looked at it a number of months ago, and I 22 think there were five or six court appearances. 23 Q. And in addition to that, I take it you 24 had occasion to testify in deposition? 25 A. Correct. 24 1 Q. Approximately how many times have you 2 done so? 3 A. When I checked my logs a few months 4 ago, I think I had 18 depositions. 5 Q. I take it that you retain a log or some 6 sort of record of your -- of your testimonial 7 appearances? 8 A. Yes. Pretty loose log. 9 Q. But it's a written document? 10 A. It's really kind of a small notebook, 11 actually, listing the date that I submit a bill 12 and to whom I submit it, and the name of the 13 patient. 14 So, it's pretty minimal. It's just a 15 way of insuring that in fact I get remunerated. 16 It's really no attempt to make a data base out of 17 it with any more data than what I've indicated. 18 Q. Do you have that log with you? 19 A. No, no. 20 Q. You maintain it, I take it, in a place 21 where it can be located and you could provide it? 22 A. Oh, sure. Yes. 23 Q. Do you have a current curriculum vitae? 24 A. Yes, I do. 25 Q. Do you have that with you? 25 1 A. No. 2 MR. HIRSHMAN: I have a copy of it, 3 however. 4 MR. PARKER: Okay. All right. 5 BY MR. PARKER: 6 Q. Similarly, Dr. Latchaw, I take it that 7 you maintain that at a place where you can 8 produce it, if requested. Correct? 9 A. That is correct. 10 Q. All right. 11 MR. HIRSHMAN: I would note that Julie 12 Moore has one, as well, and she received it 13 by requesting it. 14 MR. PARKER: All right. 15 BY MR. PARKER: 16 Q. Dr. Latchaw, do you have an 17 understanding of Dr. Louisin's role in this case, 18 when if ever he had contact with the patient, the 19 nature of the patient? 20 Just tell me your understanding in that 21 regard, please. 22 A. He was the interpreter, in particular, 23 of the C-T scan of 4 December '96. 24 Q. What was that date again? 25 A. December 4 of 1996. 26 1 Q. Okay. And to your knowledge, did he 2 have any other contact with this patient or 3 interpretative role with respect to this 4 patient's radiology films? 5 A. No. 6 Q. Okay. And that's my understanding, as 7 well, and for that reason, as I continuing my 8 questioning this morning, I'm going to really be 9 focusing primarily on that December 4, 1996 film. 10 It's going to be my focus. 11 I guess before I get into that, I am 12 curious about what you have in that file of 13 materials before you. 14 Can you please run through the stack 15 that you have brought with you, if do you have 16 anything else with you pertaining to this case 17 that perhaps isn't on the table? 18 A. I can tell you what's in my folder. 19 Q. Okay. Is there anything else that you 20 brought with you, that isn't on the table? 21 A. No. 22 Q. Okay. Then if you would please run 23 through and tell me what's in your folder, I 24 would appreciate it. 25 A. I will start from the most recent to 27 1 the most past. 2 The first is an E-mail from 3 Mr. Hirshman's secretary, telling me of the date 4 and location of this deposition. 5 Next is a few small pieces of paper 6 listing some names and addresses of places in 7 Miami where this deposition could be conducted 8 with videotaping. 9 A couple of notes of Mr. Hirshman's 10 phone number. 11 A bill to Mr. Hirshman on 23 December. 12 A copy of that bill. 13 And then the copies of the original 14 dictations regarding the C-T, MR and angiographic 15 studies. 16 And also the -- a copy of a report from 17 Case Western regarding the MR of the head from 18 1997. That's it. And also -- 19 Q. The report -- 20 A. I should mention my report, also, from 21 December 23. 22 Q. You mentioned a report from Steve 23 Foster regarding what? 24 A. I'm sorry? 25 Q. It sounded like you said you had a 28 1 report from Steve Foster regarding an MR, and I 2 couldn't hear the rest of that item. 3 A. I'm not sure to which you are 4 referring. I said that there was a report from 5 Case Western of Cleveland regarding an MR of the 6 head, from 1997, and after that, I said that I 7 have a copy of my report from December 23 of 8 1998. 9 Q. That cleared it up. I just completely 10 misunderstood a few of the words in your answer, 11 I guess. 12 MR. HIRSHMAN: Of course he has -- he 13 also has films, and I don't know if you 14 wanted him to go through those, as well, or 15 not, but he has them right in front of him. 16 MR. PARKER: That's exactly what I was 17 about to raise. I can see that there are 18 envelopes with films. 19 BY MR. PARKER: 20 Q. Tell me the films that you have. 21 A. I have C-T scans of the head from 22 December 4, December 7, December 8, December 9; 23 an MR of the head from December 8. These are all 24 1996. 25 I have a cerebral angiogram performed 29 1 on December 9, and I have the MR of the head from 2 Case Western in 1997. That's it. 3 Q. Have you done anything else -- have you 4 done anything else in preparation for giving 5 opinions in this case, other than to review these 6 films? 7 A. No. 8 Q. You haven't conducted any research? 9 You haven't performed any interviews? Anything 10 else? 11 A. No. 12 Q. Okay. I want to direct your attention, 13 if I can, to the C-T of December 4, 1996. And do 14 you have a copy of Dr. Louisin's report of that 15 C-T? 16 A. Yes, I do. 17 Q. Okay. I want to see if in as far as 18 that report is written, if you are in agreement 19 or disagreement with its findings. 20 When you have that report before you, 21 let me pose a question. 22 A. Okay. I have the report and the films. 23 Q. Okay. And this is the report of the 24 exam of December 4, 1996, I believe dictated or 25 dated on December 5, 1996 by Dr. Louisin. 30 1 Correct? 2 A. I'm not sure if, in fact, it was 3 dictated on the fourth and typed on the fifth, or 4 if it was dictated on the fifth. I don't have 5 any way of being sure. 6 There's a little denotation above 12/5 7 that says "DAP." So, I guess that must mean date 8 of report. 9 Q. Okay. I think we're looking at the 10 same piece of paper. That's what I'm mostly 11 concerned about. 12 Typically, when I see a radiology 13 report, the findings are expressed as an 14 impression. Is that the normal nomenclature? 15 A. There is most commonly a body of the 16 report and then people come down with impression, 17 or conclusion. 18 Q. Okay. All right. And the second 19 paragraph of the body of this report has some 20 findings. It's the paragraph that begins with, 21 "There's no mass lesion." 22 Do you see that? 23 A. Correct. 24 Q. Do you agree from your review of the 25 C-T film of December 4, that there is no mass 31 1 lesion? 2 A. Correct. 3 Q. You also agree that there is no midline 4 shift? 5 A. Correct. 6 Q. You also agree that there is no 7 hemorrhage? 8 A. Correct. 9 Q. Do you agree or disagree with the 10 statement that there is no focal parenchymal 11 lesion? 12 A. That is incorrect. 13 Q. That's incorrect. 14 The next finding. Do you agree that 15 there is no extraaxial mass or hematoma? 16 A. Correct. 17 Q. Do you agree that the ventricles are 18 normal? 19 A. Correct. 20 Q. Do you agree that the bone window 21 images of the skull base are unremarkable? 22 A. Correct. 23 Q. And in the next paragraph is 24 impression. I take it from your report that you 25 disagree with the impression that this is a 32 1 normal exam? 2 A. Correct. 3 Q. All right. Now, what is meant by a 4 parenchymal lesion? 5 A. The parenchyma is the brain substance. 6 Q. Tell me, please, your impression 7 regarding any parenchymal lesions in this 8 patient. 9 A. There are abnormalities involving the 10 right cerebellar hemisphere. 11 Q. How would you describe those 12 abnormalities? 13 A. There are small areas of low density 14 abnormality located within the right cerebellar 15 hemisphere, on at least three of the slices on 16 each of the unenhanced and enhanced scans. So 17 that that would make this multi-focal areas of 18 low density abnormality of the right cerebellar 19 hemisphere. 20 Q. Which images on the C-T scan show these 21 abnormalities? 22 A. If we go to the unenhanced scan, which 23 is labeled as exam 5071, it is image 8, which has 24 a subtle area of abnormality. Image 9, image 10 25 and image 11. 33 1 If we go to the contrast enhanced 2 portion of this study, which is denoted by the 3 plus C in the upper left-hand corner, there are 4 images 31, 32 and 33, which are abnormal. 5 Q. From that film and that film alone, can 6 you tell me what the cause of the low density 7 abnormalities are? 8 A. These are most consistent with areas of 9 cerebral or, in this case, cerebellar ischemia. 10 Q. And what is the -- the C-T is reporting 11 a low density area, I take it. Am I 12 understanding that correct? 13 A. I'm sorry? 14 Q. The C-T is not -- does not tell us 15 directly -- I'm sorry. I'm having a hard time 16 phrasing my question here. 17 What the C-T shows us, if I understand 18 correctly, and maybe I don't understand 19 correctly, is, it shows us the relative density 20 of the various tissues that appear on the image. 21 Is that correct? 22 A. Correct. 23 Q. It's based upon the pattern and 24 appearance of those relative densities compared 25 to the radiologist's knowledge and experience of 34 1 what normal looks like, that a radiologist infers 2 and determines a diagnosis or impression. Is 3 that basically fair? 4 A. That's in part correct. 5 Q. Do you need to -- to correct it for me 6 or make it a little -- make my understanding a 7 little fuller so that I'm accurate? 8 A. Yes. 9 Q. Go ahead. 10 A. Okay. The -- an additional piece of 11 information would be whether or not the lesions 12 enhance or do not enhance. 13 An additional piece of information 14 would be whether there are previous studies which 15 might add significant information, such as 16 previous C-Ts or previous MR, previous 17 angiography, et cetera. 18 And then lastly, very important is the 19 clinical history, so that we can correlate both 20 the radiographic findings and the historical 21 presentation. 22 Q. Okay. I guess, though, what I am 23 trying to understand is sort of the limitations 24 of a C-T image. I mean, I mean, you've told me 25 that the findings on these images are most 35 1 consistent with an area of cerebellar ischemia. 2 If I understand C-T imagery correctly, 3 though, the C-T image isn't telling us whether or 4 not there is ischemia or loss of blood flow. 5 Rather, it's showing us that there's a change of 6 density and the physician has to infer the cause 7 of that. Am I incorrect? 8 A. That's -- that's correct. One wouldn't 9 expect the C-T images to speak or in any other 10 way indicate what the cause is. 11 The tissue is seen to be of abnormal 12 constituents and, therefore, one must use that 13 knowledge and plus the radiologist's experience, 14 to make a particular diagnosis. 15 Q. Sure. But the C-T image is not a 16 direct measure of ischemia; is it? 17 A. Correct. 18 Q. All right. How long does ischemia need 19 to be present before its evidence reveals itself 20 on C-T images? 21 A. It depends upon the degree of the 22 abnormality. If we are talking about cerebral 23 ischemia, one may not see a -- an abnormality 24 where blood flows are, for example, in the teens, 25 and when I say in the teens, I mean blood flow 36 1 that would be, for example, 16 cc.s per one 2 hundred grams of the tissue per minute. One 3 might not see that area of ischemia for six to 4 eight hours. 5 However, if the flows were down at five 6 or six cc.s per one hundred grams of tissue per 7 minute, then one might see that abnormality 8 within an hour or two. 9 So, the degree of ischemia of the 10 disease process will determine how quickly an 11 abnormality is seen. 12 Q. Okay. Now, in this case, do you have 13 an understanding of what the flow rate or flow 14 impairment was? 15 A. No, I don't have a measure of cerebral 16 blood flow. 17 Q. All right. Can you tell us from a 18 review of these images, then, with any degree of 19 reasonable probability, the age of the ischemic 20 changes that you interpret? 21 A. Well, first of all, I can tell you that 22 the blood flow certainly is below 20 cc.s per one 23 hundred grams per minute, because that's about 24 the only way we would have gotten any degree of 25 abnormality at all. 37 1 Second of all, that we are probably 2 dealing with abnormalities that are at least 24 3 hours, given their small size and the fact that I 4 see them this well. They're probably at least 24 5 hours, but it may be as much as five, six, eight 6 days old. 7 Q. How can you rule out that it's even 8 older than that? 9 A. I cannot absolutely do that, because I 10 do not see absolute evidence of enhancement on 11 this study, and therefore, your question is 12 correct. They may be a year old, for all I know. 13 Now, against that is the fact that one 14 of them is -- is somewhat grayer than the other. 15 The one that is relatively well circumscribed may 16 be old. The one that is less circumscribed may 17 be newer. 18 I don't have enhancement to tell me 19 that in fact the lesions are within a two week 20 period and, therefore, I am not absolutely 21 certain as to the date that these would have 22 occurred. 23 Q. Specifically, how many focal areas of 24 abnormality are you seeing? 25 A. I think there are two in the cerebellar 38 1 hemisphere. 2 Q. Both in the right cerebellar 3 hemisphere. Correct? 4 A. Correct. 5 Q. All right. What, if any, significance 6 is there that even with contrast enhancement you 7 don't see a definite enhancement of the 8 abnormality? 9 A. I personally wouldn't put too much 10 credence with that particular finding or lack 11 thereof, because the lesions are pretty small, 12 and therefore, if there is any degree of subtle 13 enhancement, it might be hard to see it. 14 So, that's why I say just because I 15 don't see them absolutely enhancing, I would not 16 be willing to say that these are, therefore, old, 17 for example, months old. It may be that just 18 because of their small size, I won't see the 19 enhancement. 20 Q. Okay. I'm going to make an inference 21 from your answer and it might be incorrect, so 22 let's see if it's correct. 23 I'm inferring from your answer that one 24 of the things that contrast enhancement sometimes 25 does, is lets experts like yourself age the 39 1 abnormality. Is that correct? 2 A. Correct. 3 Q. All right. And am I understanding that 4 in this case, because of the small size of these 5 focal abnormalities, the contrast isn't really 6 helping you age these lesions? 7 A. That's correct. 8 Q. Is that correct? 9 A. That's correct. 10 Q. All right. Now, is contrast also used 11 in C-T studies simply to assist the radiologist 12 in finding abnormalities? 13 A. Yes. 14 Q. Am I correct that in this case, the use 15 of a contrast agent did not make the 16 abnormalities significantly more apparent? Is 17 that true? 18 A. That is correct. 19 Q. All right. Do you know whether or not 20 contrast enhancement was used in this case for 21 the purpose of aging a possible lesion if one was 22 to be found, or whether it was used simply to 23 help identify a possible lesion if indeed one was 24 present? 25 A. Not specifically, but it is very rare 40 1 in my occasion that -- in my experience, that in 2 fact we make that distinction. 3 In other words, we'll use contrast 4 material for a variety of reasons, all at the 5 same time. 6 Q. I got you. Okay. 7 I've often heard the following kind of 8 discussion with regard to plain x-rays and I want 9 to see if you agree. 10 I know that it's been a few years since 11 you've been in general radiology. But 12 obviously -- let's discuss plain x-rays for a 13 minute. 14 I have heard that, of course, on many 15 occasions, a fracture, for instance, is quite 16 clear and any competent radiologist is going to 17 see it. I assume we can agree with that. But I 18 also -- it's also my understanding that sometimes 19 a fracture, an abnormality, can be of a nature 20 that different competent radiologists can look at 21 the same film and not interpret it the same way. 22 Am I correct in my understanding, or is 23 this a fallacy I'm talking about? 24 A. It depends on the fracture. As a -- 25 Q. Okay. 41 1 A. As a generality, you're correct 2 that -- that interpretations are that, and there 3 can be on occasion, room for interpretation 4 differences. 5 Q. Now, would the same hold true for 6 neuroradiology images, C-Ts and MRs, that is that 7 competent radiologists can look at the same films 8 and have legitimate disagreements with regard to 9 their interpretation? 10 A. Again, it depends on the abnormality 11 that one is looking at. 12 Q. Okay. I don't know how to ask this 13 question other than just to ask it. How obvious 14 or how subtle are the abnormalities you see in 15 the December 4, 1996 films, to you? 16 A. They're quite obvious. 17 Q. All right. And why is that? 18 What is it about them that's obvious? 19 A. That's a difficult thing to answer, 20 because it's kind of like saying, how do I know 21 my mother? 22 Because they are what they are. They 23 aren't symmetric relative to the opposite 24 cerebellar hemisphere, and those little black 25 areas don't belong in the cerebellum in a normal 42 1 person. They're just -- they're just abnormal. 2 I would be very irritated with one of my 3 residents if they didn't see these. 4 Q. Okay. Now, you've repeatedly indicated 5 that these abnormalities were small. 6 What do you mean by that? Can you give 7 me a dimension? 8 A. Oh, they're probably a centimeter and a 9 half, two centimeters. 10 Q. Each of them? 11 A. Correct. 12 Q. And when you say that they're a 13 centimeter to a centimeter and a half in size, 14 you are talking about an actual size. Correct? 15 The lesion itself, the real lesion, the 16 real area of abnormality in the brain, has that 17 size and dimension. Am I understanding 18 correctly? 19 A. I would doubt that. I would suspect if 20 you did a post-mortem examination, that the areas 21 of abnormality would be significantly larger. 22 It's just that we see the iceberg, the tip of the 23 iceberg here. We see those areas that are most 24 affected, therefore, the most ischemic, but there 25 will be areas on the periphery that will be also 43 1 abnormal pathologically. 2 Q. I hear what you are saying. I 3 understand it. I guess I'm trying to understand 4 the different points or make a different point, 5 and I want to see if it's correct. 6 When you say the lesion is one 7 centimeter to one-and-a-half centimeters in size, 8 it's not appearing on that film in front of you 9 as a -- as a one centimeter size lip, because the 10 image in front of you is much smaller than actual 11 size. Do you follow me? 12 A. I follow you, but I don't agree with 13 you. 14 Q. Okay. Well, explain to me. Because 15 each image on the films you are looking at, each 16 image is what, maybe 6 centimeters by 6 17 centimeters? 18 A. Yes. If I see a lesion for example, 19 that is, you know, 4 millimeters in size on the 20 film, I assume that it's about a centimeter in 21 size normally, because of the degree of 22 modification that has gone on to print these 23 films. 24 So, what I said is that the true 25 lesion, the true low density, if we blew this 44 1 image up to normal size of the head, we would 2 probably see that the lesion that we see is 3 probably a centimeter and a half to two 4 centimeters. 5 If we did a pathological examination, 6 we might find that the actual lesion is three to 7 five centimeters in size. 8 Q. Okay. But I think actually -- I 9 think -- believe it or not, we're saying the same 10 thing. 11 A. Okay. 12 Q. If we're to make those images life 13 size, the abnormality we would see in the image 14 would be one to one-and-a-half centimeters; 15 correct? 16 A. I said one-and-a-half to two in my 17 original comment. 18 Q. Okay. Okay. Reading ahead in your 19 report, you report that C-T scan of December 7, 20 December 8 and December 9, and I believe that you 21 indicate that they are all unchanged from the 22 report of December 4. From the film of December 23 4. Is that correct? 24 A. That is correct. 25 Q. And does that tell us whether or not 45 1 there's a -- a change in the tissues, or is that 2 a limitation of C-T scanning, or what is the 3 significance, if any, of that finding to you? 4 A. Oh, it can be taken in a variety of 5 ways. It depends on the pathophysiology of what 6 we think might be going on. 7 For example, in this case, the fact 8 that they haven't changed may simply be a 9 reflection of the fact that this individual has 10 had kind of an up and down course of his ischemic 11 symptomatology, so we -- we tend to see tissue 12 that is either sick or dead, and that's what 13 accounts for the gray to gray-black appearance. 14 That's what we mean by ischemia. It's 15 either ischemic but alive or it's ischemic and 16 dead. So, this up and down course may be 17 reflected in the fact that further tissue hasn't 18 necessarily died, but the -- but the tissues are 19 still at risk. Other areas may be -- 20 Q. What is it -- 21 A. Other areas may be already dead. For 22 example, the very black area that I mentioned, 23 because one is blacker than the other, is 24 probably dead. The gray area, that may be 25 ischemic and sick, but recoverable. 46 1 Q. What is it that accounts, if you know, 2 and if this is something for the neurologist to 3 answer, then just let me know that, but what is 4 it that's accounting for this patient's up and 5 down course, presence of symptoms and the 6 disappearance of symptoms? 7 A. Whenever you have an arterial 8 narrowing, the survival or not of the particular 9 tissue at hand is, to a very large degree, 10 dependent upon the collateral flow that occurs, 11 and so, in this case, for example, if we have a 12 disease process involving the right posterior 13 inferior cerebellar artery, the sources of 14 potential collateral flow are from the right 15 anterior inferior and the right superior 16 cerebellar arteries. 17 Now, it -- the life or death of the 18 tissue at hand, therefore, depends upon the state 19 of the collateral, and the state of the narrowing 20 of the right posterior inferior cerebellar 21 artery. So, it's a balancing act, and that's why 22 symptoms may go up or down. 23 If one narrows down the posterior 24 inferior cerebellar artery totally, then the 25 collateral flow may not be sufficient to keep the 47 1 tissues alive. So, it's a balancing act. And 2 each case is different. 3 Q. Okay. And do you know whether or not 4 it's that presence of collateral flow that was 5 accounting for Mr. Pietro's up and down course? 6 A. I make mention later on in my report, 7 particularly vis-a-vis the angiography, that 8 there is collateral circulation to the PICA, 9 P-I-C-A, that's the posterior inferior cerebellar 10 artery, distribution from the right anterior 11 inferior cerebellar artery, which is called the 12 AICA, A-I-C-A. So, I make mention of the 13 collateral in my report. 14 Q. I understand you made mention. My 15 question was whether or not you can tell us 16 whether that accounts for his up and down course, 17 or whether it's something we don't really know? 18 A. All of the pathophysiology that I've 19 just described is most consistent with his up and 20 down course. 21 Q. Okay. And so, I take it that it's your 22 opinion then that that's what explains his up and 23 down course? 24 A. Correct. 25 Q. All right. I'm -- you had talked about 48 1 the principle of arterial narrowing as causing 2 ischemia. What are the causes for arterial 3 narrowing? 4 MR. HIRSHMAN: Let me just interject 5 here. You're talking about in this case or 6 in general? 7 MR. PARKER: In general, at this point. 8 THE WITNESS: The most common in our 9 society is atherosclerotic disease, so-called 10 hardening of the arteries. In the younger 11 patient population, it may be dissection, 12 which is a tearing of the intima away from 13 the media of the vessel wall from a variety 14 of mechanisms. 15 There may be an embolic occlusion or 16 partial occlusion of a vessel. The embolus, 17 which is either clot or hard atherosclerotic 18 material, may come from the heart or the next 19 vessels below the area of the occlusion. 20 There are also other causes, such as 21 arteritis. We could keep going, but those 22 are the main ones. 23 BY MR. PARKER: 24 Q. Vasoconstriction? 25 A. Vasoconstriction is usually temporary, 49 1 producing temporary symptoms, and the 2 constriction goes away most of the time. 3 Q. And I presume you could have any of 4 this in combination with, for instance, 5 hypotension and end up with an ischemic area? 6 A. That is correct. 7 Q. All right. Now, let's take it to this 8 patient. What's the cause of the arterial 9 narrowing in this patient? 10 A. I think he has a dissection, which 11 involves the distal right vertebral artery and 12 extends into the origin of the right PICA. 13 Q. Okay. And is there radiographic, 14 direct radiographic evidence of that dissection? 15 A. Yes. 16 Q. And where did you find that? I, 17 frankly, found your discussion of the 18 angiography -- I'm a layman and I got a little 19 lost in it, and I apologize for that. 20 I assume that -- where is the evidence 21 of dissection? Is it in the angiography? 22 A. Correct. 23 Q. Because I saw that you couldn't exclude 24 the possibility of a more proximal dissection. 25 A. Yes. 50 1 Q. Where is the dissection? 2 A. Distal right vertebral artery. 3 Q. Where is the dissection you saw? 4 A. You mean where in the blood vessel or 5 on which study? 6 Q. Where in the blood vessel? 7 A. I will quote from page 2, top 8 paragraph. "The right vertebral artery near the 9 origin of the right occipital branch is narrow; 10 unfortunately, the rest of the more proximal 11 right vertebral artery has not been included in 12 the imaging, so that the possibility of a more 13 proximal dissection cannot be ascertained." 14 Q. Okay. So, when you say the right 15 vertebral artery near the origin of the right 16 occipital branch is narrow, you mean there's a 17 dissection there? 18 A. Correct. 19 Q. All right. That narrowness isn't 20 explained by congenital narrowness or 21 vasoconstriction, or is that a possibility? 22 A. None of the above. It is all 23 dissection. 24 Q. Okay. Were there false lumen observed? 25 A. I've never seen a false lumen in the 51 1 many, many dissections I've seen over the years, 2 when the dissection involves the vertebral, 3 carotid, or intercranial vessels. The false 4 lumen sign is seen in the aorta when one does 5 either angiography or cross-sectional imaging. 6 Q. Okay. So it may very well be that my 7 ignorance is showing. 8 Are you telling me that a dissection in 9 the cerebral artery simply doesn't resolve in a 10 false lumina? It's not the same kind of 11 dissection we see in the aortic vessels? 12 A. We -- we don't see it as a second lumen 13 unless you do something like an MR or C-T scan 14 through the blood vessel. 15 When we do an angiogram, and I was 16 describing the angiographic studies, one sees a 17 narrowing of the blood vessel. One doesn't see a 18 second lumen such as one might see in the aorta. 19 You just don't see that. You can see 20 occasionally -- 21 Q. Okay. 22 A. Let me just finish. You can 23 occasionally see a so-called tram track 24 appearance, which is a double lumen, but that is 25 quite unusual. 52 1 Q. Okay. And you didn't see it in this 2 case? 3 A. That is correct. 4 Q. How does a person such as yourself rule 5 out that this narrowing is due to atherosclerotic 6 disease, or embolic occlusion or localized 7 vasoconstriction? 8 A. The patient does not have 9 atherosclerotic disease elsewhere. The distal 10 vertebral artery is an excessively unusual 11 location for having atherosclerotic narrowing 12 unless there is atherosclerotic disease somewhere 13 else. 14 The business of -- I believe the term 15 you want is vasospasm, rather than 16 vasoconstriction. 17 Vasospasm occurs generally because 18 there is something happening, such as 19 subarachnoid hemorrhage in the head, which then 20 leads to a narrowing of the blood vessel. 21 This is an extracranial portion of the 22 blood vessel which then extends to the PICA, 23 which is intracranial. So, the combination of 24 extra and intracranial means that this process 25 has to straddle the dura. Therefore, could not 53 1 be accounted for by subarachnoid hemorrhage. 2 One would have to then consider that 3 this would be a vasospasm of unknown etiology, 4 totally out of the blue. I cannot deal in that 5 kind of subjective conjecture. It is most 6 consistent with dissection. 7 Q. Okay. From the materials that were 8 provided to you, do you have an understanding as 9 to whether there were specific repetitive 10 circumstances in which Mr. Pietro's 11 symptomatology flared? For instance, upon 12 awakening or upon presentation to physicians or 13 anything like that? Do you have an understanding 14 one way or the other? 15 A. I -- I do not have that degree of 16 specificity of knowledge. The only -- 17 Q. Okay. 18 A. The only piece that I do understand is 19 that there was a waxing and waning of his 20 symptomatology. 21 Q. Okay. Now, if Doctor -- I take it that 22 you will opine that Dr. Louisin fell below the 23 standard of care for a general radiologist in his 24 interpretation of these films. Correct? 25 A. Correct. 54 1 Q. Now, tell me what a general radiologist 2 would have to do to be within standard of care, 3 having seen these films. 4 A. He would do exactly the same as a 5 neuroradiologist, because there is only one 6 standard of care, and that is that he would see 7 them, and comment upon them. 8 Q. Does he have to reach exactly the same 9 conclusion as you do, Dr. Latchaw? 10 A. No. He has to see them and identify 11 that they are, in fact, abnormal. 12 Q. And am I correct then that that's what 13 standard of care in your opinion requires that he 14 do, simply identify that they are abnormal? 15 Correct? 16 A. Correct. 17 Q. I take it from the way you worded your 18 report, that standard of care doesn't demand that 19 the general radiologist be able to identify the 20 cause of the abnormality. Am I correct in that 21 inference? 22 A. I would -- I would expect that a 23 standard of care level here would be that once 24 they are identified as abnormal, that a 25 differential diagnosis of that abnormality would 55 1 be given. 2 I would not expect that the 3 radiologist, be it a general radiologist or 4 neuroradiologist, would necessarily say this 5 could only be ischemia and give only one 6 diagnosis. 7 Most of the time, most of us, when we 8 see abnormalities, try to give a bit of a 9 differential diagnosis. 10 Q. Okay. Is there anything else that the 11 standard of care required Dr. Louisin to do under 12 the circumstances as you understand them? 13 A. Yes. I think that if one reads the 14 report, in the second line, it says that an 15 urgent C-T study is performed. 16 My understanding of standard of care 17 would be that urgent or emergent studies be 18 communicated directly with the ordering 19 physician, so that appropriate management can be 20 undertaken. 21 Therefore, I would say that if the 22 abnormalities had been identified, that these 23 abnormalities would then have been directly 24 communicated to the physician. 25 Q. Okay. Anything else required of 56 1 Dr. Louisin as a general radiologist, to comply 2 with standard of care? 3 A. No, sir. 4 Q. Okay. So, let's make sure I understand 5 what your criticisms are with regard to 6 Dr. Louisin. 7 Number one, he should have observed and 8 interpreted abnormalities and reported them. 9 Number two, having made that 10 observation, the reporting, he should have 11 communicated directly with the ordering 12 physician. 13 Am I understanding your opinions 14 correctly? 15 A. That is correct. 16 MR. HIRSHMAN: I think he also made 17 reference to the providing of a differential 18 diagnosis. So let's not forget that. 19 THE WITNESS: That's -- that should 20 really have been number two, and the way that 21 I would order these, therefore, would be 22 number one, identification, number two, 23 differential diagnosis, and number three, 24 communication. 25 BY MR. PARKER: 57 1 Q. All right. Now, the providing of a 2 differential diagnosis is obviously dependent 3 upon finding an abnormality; correct? 4 In other words, if he reports it as 5 normal, he's not providing a diagnosis other than 6 normal scan. 7 A. That's correct. 8 Q. All right. Anything else in criticism 9 of Dr. Louisin? 10 A. No, sir. 11 Q. I take it that the general radiologist 12 would typically not be making determinations as 13 to what, if any, treatment is indicated for the 14 neurological abnormalities you've seen? 15 A. The general radiologist may be aware of 16 potential treatments. He may -- most likely, 17 would not undertake those treatments, but he is 18 more than likely aware of them. 19 Q. All right. Will you be testifying at 20 trial as to the therapeutic treatment that was 21 indicated in this case, or is that a field that 22 to your understanding, is best left to the 23 neurologists? 24 A. It depends upon what I am asked. I am 25 a treating physician. I am an interventionalist. 58 1 I treat people with heparin. When I cause a 2 dissection, I treat people with anti-platelet 3 drugs. I am fully competent to do so. I am 4 familiar with the literature. If asked, I can 5 comment. So, it depends on what I'm asked to 6 discuss. 7 Q. Okay. Was this patient a candidate for 8 TPA therapy? 9 A. TPA? 10 Q. Yes. 11 A. No. I wouldn't have given him TPA. 12 What I would have done would have been to either 13 treat him with anti-platelet drugs or treat him 14 with anticoagulation. I prefer the latter. 15 Q. And why is that? 16 A. Well, that's just been my experience, 17 that when I see a dissection, or if I cause one, 18 that I treat the patient immediately with 19 heparin, leave them on heparin for a number of 20 days and wait until I see evidence that the 21 intimal flap has gone back to approximate the 22 media. 23 One is attempting to avoid the kinds of 24 final complications that Mr. Pietro endured. 25 Q. My ignorance is really going to show 59 1 with this next question, but it's been bugging me 2 and I'm going to ask it to you, and maybe you can 3 explain it to me. 4 A. Okay. 5 Q. Why would anticoagulation or 6 anti-platelet therapy be appropriate? And I 7 understand it is. I've seen the literature. But 8 why is it appropriate in the face of a 9 dissection? My layman's instinct says a 10 dissection increases the risk of these problems. 11 Why anticoagulation or anti-platelet? 12 A. I'm going to ask you to just repeat the 13 very last part of that. There was a plane flying 14 overhead and I couldn't hear very well. I 15 understand -- 16 Q. My confusion is simply that it seems to 17 me, again, my ignorance is showing, that 18 anti-platelet or anticoagulation would run the 19 risk of exacerbating a dissection. 20 A. And I understand -- 21 Q. I must be wrong. 22 A. I understand your question. And if I 23 could just paraphrase your question, it would be 24 this. That if you have bleeding within the 25 layers of the arterial wall, in this case between 60 1 the intima and the media, wouldn't 2 anticoagulation or anything that interferes with 3 the normal ability to clot, wouldn't that simply 4 increase the bleeding within the wall of the 5 artery? Am I correct? Is that your question? 6 Q. Yes. 7 A. Okay. And I think -- 8 Q. Yes, very much so. 9 A. It's a very good question. And I would 10 respond by saying that what we all fear is the 11 progressive bleeding within the arterial wall and 12 the progressive narrowing of the lumen, such that 13 there is stagnation of blood. 14 It is the stagnation of the blood that 15 potentially causes the most catastrophic final 16 events. So that for example, as the arterial 17 lumen narrows, the blood stagnates. The blood 18 begins to coagulate within the lumen. You may 19 therefore get propagation of clot into normal 20 vessels or release of a portion of the 21 intraluminal clots to become an embolus. 22 I've seen it many times, and so, for 23 example, it's the post-chiropractic patient who 24 four days later pops a clot from the vertebral 25 tear up to the top of the basilar artery and the 61 1 patient becomes quadriplegic immediately. And 2 so, therefore, what you are trying to do is 3 prevent the intraluminal clot formation. That's 4 the disaster, potential disaster. But I do 5 understand your question, and it's a good one. 6 Q. Okay. Has heparin been proven to be 7 efficacious in preventing acute stroke? 8 A. I will answer that by saying that it 9 depends upon what one means by "proven." There 10 has been no double blinded controlled study of 11 the use of heparin for acute stroke, ever, which 12 is an amazing comment for all of the use of 13 heparin throughout the world, it has never been 14 subjected to a pure double blinded controlled 15 study. 16 If that's what one means by "proven," 17 then my answer to you would be, no. 18 Is it used by a huge number of 19 clinicians? And the answer is, yes. 20 Q. Okay. It's interesting that our 21 conversation has now turned to study design, 22 because I want to ask you a little bit of 23 questions about studies that are performed when 24 we want to study the ability of radiologists to 25 interpret findings on films. 62 1 Am I correct that when one wants to do 2 such a study and determine whether or not 3 radiologists see an item on a radiologic film, 4 usually you set the study up so that the 5 physician is given the image in a sequence of 6 other images that may be normal and may be 7 abnormal, but it's hidden randomly within a 8 series of films for them to study? 9 A. It depends upon the study. Obviously, 10 what you are describing is a perception study 11 that, for example, if one studies perception of 12 chest film abnormalities, the way you've 13 described it is a very common way to set the 14 study up. 15 So the question is, for example, can 16 you see the nodule in the lung parenchyma, and 17 they'll mix a bunch of normal and abnormal cases 18 up and see how often the observer is able to 19 detect the abnormality. 20 Or, over all the abnormality, some 21 false positive, false negatives. So that what 22 you've described, is a study design of 23 perception. 24 Q. Okay. Why is it set up that way, 25 specifically? 63 1 A. The -- one is simply in that kind of a 2 study, trying to see whether or not simply pure 3 observation is sufficient and, if so, how often, 4 to see a particular kind of an abnormality. 5 Now, that differs from the kinds of 6 studies that could be set up somewhat 7 differently, in which you would have history plus 8 the radiographic findings. 9 When I was at the University of 10 Pittsburgh, we undertook with NIH money a series 11 of these kinds of tests, some of them with 12 history, some of them without, and tried to 13 determine what is the role of history, for 14 example, in the perception of the radiologist. 15 So, there's a variety of ways to do the studies. 16 Q. Okay. Sure. One of the things, if I'm 17 correct, that you are trying to prevent, is bias 18 being introduced into the radiologist's 19 interpretation, a bias due to knowing what the 20 question is, what the issue is. Right? 21 A. That's correct. In the kind of study 22 without the history, that is correct. 23 MR. PARKER: Okay. Let me look at my 24 notes and there's probably much more to 25 explore, but I think as far as it relates to 64 1 Dr. Louisin, I may be done. 2 I think that's all I have at this 3 point. I -- are there other people here who 4 have questions? 5 Why don't we swap places so the Doctor 6 can see the questioner? 7 Thank you, Doctor. 8 THE WITNESS: Thank you. 9 CROSS EXAMINATION 10 BY MR. TABER: 11 Q. Dr. Latchaw, I represent Dr. Madalin, 12 who is a neurologist. 13 Doctor, having gone through your report 14 today, and also the questioning for the last hour 15 and a half, two hours now, do you believe that we 16 have covered all the criticisms that you have in 17 this case? 18 A. I believe that's correct. I would 19 always hold open that other questions may be 20 forthcoming, but I believe that is correct. 21 Q. Doctor, do you have hospital privileges 22 anywhere? 23 A. Yes. I have hospital privileges at 24 Jackson Memorial Hospital and the University of 25 Miami Hospital and Clinic. Those are the 65 1 two -- two of the University Hospitals, and then 2 I also have privileges over at the V.A. Medical 3 Center, which is across the street from the 4 university. 5 Q. Doctor, in your current practice, 6 approximately how many patients are admitted 7 under your service, say in an average month? 8 A. I don't -- I don't admit patients. I 9 don't -- a radiologist tends not to admit 10 patients. 11 Q. Okay. You would be involved with a 12 patient as a consult to someone already admitted 13 to a hospital, then? 14 A. Almost everything that I do. Now, I do 15 get patients who come in and are referred 16 directly to me for whatever the abnormality is, 17 but because I'm a radiologist, I tend to then 18 have the patients admitted through another 19 service. For example, I usually use the 20 neurosurgery service because I work so closely 21 with that department. 22 Q. Doctor, you were asked before about the 23 items that you had reviewed in this case, and you 24 were very specific that you had reviewed films, 25 radiology reports, the depo of Dr. Louisin, and 66 1 then the 1997 MR. 2 Could you tell me the date of the '97 3 MR that you reviewed? It's not mentioned in your 4 report. 5 A. 4 -- no, I'm sorry. June 18, '97. 6 Q. Thank you. Now, Doctor, I was a bit 7 curious, having read your report, you have drawn 8 some conclusions that in my reading would not be 9 contained in those four sets of materials that I 10 just mentioned, and I want to follow up on that 11 statement. 12 For example, in the last paragraph of 13 your report, you mention three more days elapsed, 14 et cetera, et cetera, about three lines from the 15 end. 16 The question to you is, what other 17 information or sources of information do you 18 have, other than those four enumerated things I 19 just mentioned? For example, was something 20 contained in the chronology from Mr. Hirshman, 21 useful to you in rendering your opinion? 22 A. I had an overview from Mr. Hirshman of 23 the series of events when the patient went to see 24 his physician, and then was admitted to or was 25 seen in Akron General, et cetera. They were a 67 1 relatively brief overview, however. 2 Q. Okay. And it's fair to say, though, 3 that those overviews did provide you at least 4 some minimal assistance in formulating your 5 opinions? 6 A. That's correct. 7 Q. Thank you. 8 Doctor, you have no opinions as to the 9 patient's current deficits, if any. Is that 10 correct? 11 A. I am only aware in a very general and 12 vague way, that he does have neurological 13 deficits, but that's the extent of my knowledge. 14 Q. And it would be fair to say that you 15 have not reviewed enough material in order to 16 render any opinions to a probability in that 17 regard? 18 A. That is correct. 19 MR. HIRSHMAN: In regard to what his 20 present condition is, I take it you are 21 talking about? 22 MR. TABER: I'm sorry, Toby. I 23 couldn't hear you. 24 MR. HIRSHMAN: In that regard, meaning 25 rendering an opinion as to what his present 68 1 condition is. Is that a fair -- 2 MR. TABER: Correct. 3 BY MR. TABER: 4 Q. Doctor, you've taken us through how you 5 would interpret the December 4 C-T of the head, 6 and my question to you in follow-up is, did you 7 see any abnormal findings other than those that 8 you have communicated to us today? 9 A. Do you mean on the December 4 C-T? 10 Q. I do. 11 A. No. I have discussed all of the 12 pertinent findings. 13 Q. Doctor, your charges for your depo 14 today, please? 15 A. $750 per hour. 16 Q. And is there a minimum number of hours? 17 A. No. No. 18 Q. And what is your charge for -- thank 19 you. What is your charge for trial testimony, 20 please? 21 A. It's -- it's a little bit variable. It 22 depends upon how long I'm gone. If I go away for 23 a whole day, I'll have a particular charge. If 24 it's here in Miami, I'll have a different charge. 25 It depends upon how long I have to be away from 69 1 my practice. 2 Q. Hypothetically, if you fly from Miami 3 to Cleveland for trial testimony, how will you 4 bill that? 5 A. Let's say that I'm gone from -- let's 6 say I give testimony on a Friday morning. I have 7 to go in Thursday night. By the time I get back 8 it's Friday night. So, I've missed a complete 9 day. 10 Q. Right. 11 A. Normally speaking that would be 12 something like anywhere from eight to ten 13 thousand dollars. 14 Q. And can you tell me how much you 15 charged Mr. Hirshman for the reporting you've 16 done prior to today? 17 A. Whenever I review films or go to the 18 library to review literature, whatever else I'm 19 doing, I charge $500 an hour. 20 If I -- therefore, if I were to be gone 21 for 24 hours, I might end up with a $12,000 bill. 22 However, I tend not to charge that, because I do 23 have to spend some time sleeping. 24 Q. Okay. Doctor, the question exactly, I 25 want to know, at this point, is how much you have 70 1 charged Mr. Hirshman so far, in reviewing this 2 case prior to today's deposition? 3 A. In my file, I have a bill that I sent 4 to him on December 23, for $1500. 5 Q. Thank you. 6 Doctor, your report is on a letterhead 7 stating Radiology Research, Incorporated. 8 Can you describe for me the nature of 9 that corporation? 10 A. Yes. That is a corporation that I 11 formed when I was in Pennsylvania. I use it to 12 flow through any royalties on the two books that 13 I have published, or any of the outside 14 consultations, for example, medical malpractice 15 that I do. 16 It's simply a way to keep out of my 17 usual salary structure this other kind of income. 18 Q. Okay. So, essentially, then, your work 19 as an expert witness is separate from your work 20 for the University of Miami? 21 A. That is correct. 22 Q. Okay. So, your work on this case 23 really has nothing to do with your teaching 24 position. Correct? 25 A. Other than the fact -- 71 1 Q. In a business sense. 2 A. Other than the fact that I am a 3 teacher, but you are correct. It is separate 4 from. 5 Q. Doctor, how would you rate the quality 6 of the December 4 C-T scan? I presume what you 7 have is a copy of the original? 8 A. Yes. I have seen the original, 9 Mr. Hirshman brought the original today, and it's 10 a good original. 11 Q. Doctor, I want to follow up just 12 briefly on your comments about how you would have 13 treated this patient, and you mentioned both in 14 your report and today, that you may have treated 15 the patient with some anticoagulants. 16 My question to you is, would you agree 17 that another physician treating this patient may 18 opine within the standard of care not to use 19 anticoagulants for this patient, given what you 20 know about this patient? 21 MS. MOORE: Objection. 22 MR. HIRSHMAN: I'm not sure he said he 23 would have treated this patient. I think he 24 indicated he treats patients. I don't think 25 he indicated that he would be treating this 72 1 patient. 2 THE WITNESS: Should I answer? 3 MR. HIRSHMAN: You can answer the 4 question. I'm not -- go ahead. Answer the 5 question. 6 THE WITNESS: Generally speaking, when 7 I am aware of a dissection that I have 8 caused, then I immediately start heparin on 9 the patient. That is my behavior pattern. 10 When I cause it, it's usually from a 11 wire or a catheter, something that I am 12 actually doing to the patient, and I start 13 the patient on heparin. 14 However, I am aware that there are 15 other ways of treating patients, that it is 16 controversial, that not everybody agrees with 17 either anticoagulation or anti-platelet 18 drugs, and it is not my position in this case 19 or in my normal life to get involved in a 20 dispute on those matters. 21 I was simply indicating previously, 22 that is how I treat a patient. 23 BY MR. TABER: 24 Q. Fair enough. I appreciate that. 25 Doctor, in the third paragraph of your 73 1 December 23 report, the last sentence, 2 you -- well, end of the last sentence, you say, 3 "There is a suggestion of subtle enhancement." 4 What do you mean by that? 5 A. Are you referring to page 1 or page 2? 6 Q. Page 1. 7 A. Page 1, yes. Under point -- 8 Q. The paragraph numbered 3? 9 A. Under point number three, and it's a 10 description of the MRI of 12/8, but I do say that 11 there is a suggestion of subtle enhancement of 12 these lesions. 13 Q. Right. What do you mean? 14 A. Well, exactly that, that they do 15 enhance, and that would tend to help date them, 16 because enhancement is generally anywhere from 17 approximately the second or third day through 18 the -- approximately a two week period of time, 19 sometimes longer. 20 Obviously, if it's a very marked degree 21 of enhancement, a large area of abnormality, but 22 if enhancement is present, it would indicate -- 23 it would help to date the timing of these 24 lesions. 25 Q. Okay. And what is the significance of 74 1 that in this case? 2 A. Well, in this case, it means that 3 they're not a year old or two months old, that 4 they all are quite consistent with the episode 5 that this patient has undergone since late 6 November. 7 Q. Could they also indicate merely changes 8 between the quality of those two types of films 9 or differences in the imaging itself? 10 You refer to them as subtle, and that's 11 why I presume that they may be of no significance 12 whatsoever. 13 A. Oh, no. It's abnormal. No, no, no. 14 It's absolutely abnormal. It's just that it is 15 subtle enough that it might not be perceived on a 16 C-T scan, which is a type of exam which requires 17 a greater degree of enhancement to be 18 perceptible. 19 Q. What, then, do you mean in paragraph 1, 20 second to last sentence, where you say, "The 21 enhancement would be subtle"? What do you mean 22 by "subtle" there? 23 A. I state on the line before, that the 24 abnormalities are relatively small in size, and 25 their enhancement would be subtle. 75 1 In other words, particularly with 2 ischemia and particularly with relatively recent 3 onset ischemia, the enhancement tends to start 4 slowly and progress. 5 Now, if the lesion is small, and if we 6 were early in the process, the degree of 7 whiteness of the enhancement pattern may be 8 relatively hard to see. 9 Therefore, the fact that I don't 10 definitely see such whiteness on the C-T of 12/4, 11 does not mean in my opinion that the lesions are 12 not acute to subacute. 13 MR. TABER: Doctor, I believe that's 14 all the questions I have for you at this 15 time. I just would like to reserve my right 16 to recall this witness in case the need would 17 arise in the future, which I don't anticipate 18 at this time. 19 Thanks a lot, Doctor. 20 THE WITNESS: Thank you. 21 MR. FRASURE: Doctor, my name is Mark 22 Frasure. I represent Dr. Cola. I have some 23 questions for you. 24 MR. HIRSHMAN: Mark, I'm going to 25 interrupt you for a minute because you kind 76 1 of faded out. 2 I would ask you to simply tell him 3 again who it is that you represent. We 4 didn't hear that. 5 MR. FRASURE: Yes. I represent the 6 family physician, Dr. Cola. 7 My name is Mark Frasure, and I do not 8 have any questions of you. Thank you. 9 THE WITNESS: Thank you. 10 MR. POTENZA: Doctor, Rocco Potenza. I 11 represent Akron General Medical Center and I 12 don't have any questions. 13 THE WITNESS: Thank you. 14 MS. MOORE: Doctor, this is Julie 15 Moore. I represent Drs. Tout, Elson and 16 their professional corporation. Just so I'm 17 clear, I do have one question for you. 18 CROSS EXAMINATION 19 BY MS. MOORE: 20 Q. Based upon your earlier testimony, I 21 take it that you are not going to be rendering 22 any opinions concerning the standard of care 23 other than those which would apply to Dr. Louisin 24 as a radiologist. Correct? 25 A. That is correct. 77 1 Q. And you will not be testifying at trial 2 concerning any other standards of care other than 3 those applying to radiology or Dr. Louisin in 4 this case? Is that correct? 5 A. I think that as a generality, you're 6 correct. I'm not sure. Things get asked at 7 trial. But I would say that as of today, you are 8 correct. 9 Q. And I believe your earlier testimony 10 also indicated, that you just stated earlier, 11 that you weren't in a position to get involved 12 with opinions outside of the field of radiology. 13 Is that right? 14 A. That's -- that's not quite correct. 15 Because I am a treating physician, I can be asked 16 about neurological processes, pathophysiology and 17 treatment as it pertains to things that I do and 18 that I work with. 19 Q. Doctor, you hold no board 20 certifications in emergency medicine; do you? 21 A. That is correct. 22 MS. MOORE: Thank you, Doctor. I have 23 nothing further. 24 REDIRECT (RICHARD LATCHAW) 25 BY MR. PARKER: 78 1 Q. Dr. Latchaw, this is Alan Parker. I 2 have just a couple of some housekeeping questions 3 I need to ask. 4 You told us several times that you are 5 currently engaged in -- in the clinical practice 6 of medicine. 7 Do you also have administrative 8 responsibilities? 9 A. Yes. I am the chief of the section of 10 interventional neuroradiology. I am also on a 11 number of committees in my department of 12 radiology. So, in that sense, the answer is, 13 yes. 14 Q. Okay. Are you still engaged in any 15 ventures of writing or contributing to the 16 professional literature? 17 A. Yes. I -- in my CV, I have -- I have 18 written about 350 articles or chapters of various 19 types. I continue to do that. And I also 20 lecture. I've given about 450 lectures, 21 internationally and nationally. So, I do all of 22 that. 23 Q. What percentage of your professional 24 time is spent in administrative duties, as 25 chairman of your department, or chief of your 79 1 department, in committee work, et cetera? 2 A. Probably about five to seven percent. 3 Q. Okay. And in publishing and in 4 contributing to the literature, what percentage 5 of your professional time? 6 A. Probably fifteen to twenty, in terms of 7 the so-called academic pursuits. 8 Q. Okay. And are there other demands upon 9 your time other than patient care and teaching? 10 I'm talking about your professional time. 11 A. Yes. I've been very involved in 12 societal activities, as you may note. I've 13 previously -- now that I've retired as the 14 president, those kinds of activities have dropped 15 rather dramatically, to probably 5 percent or 16 less. 17 Q. Okay. All right. And what percentage 18 of your time is spent in patient care or the 19 teaching of medicine in an accredited 20 institution? 21 A. I would say about 70 to 75 percent of 22 my time. 23 Q. Okay. You have films in front of you. 24 Typically, does a radiologist make 25 interpretations off of photographic films like 80 1 you have, or do they typically make them off a 2 monitor or what? 3 A. Oh, it varies quite a bit now. The 4 traditional way, of course, was to make them off 5 of film, but we have the -- the more electronic 6 we go, the more we use monitors, but, you know, 7 the tradition has been film. 8 Q. Okay. Do you know which was done in 9 this case? 10 A. No, I don't. Not for sure. 11 Q. Does it matter? I mean, is the view 12 different utilizing the monitor? 13 A. No. As we go electronic, there's 14 been -- everybody has been pushing to be sure 15 that there is no decrease in the quality of the 16 image that one sees. That's -- that's a very big 17 issue in our profession. 18 Q. Okay. I guess the last thing that I 19 want to ask about has to do with your currently 20 pending application and pending test results for 21 the Florida license. 22 Were you eligible to apply for your 23 full Florida license before the present time? 24 A. Sure. 25 Q. Okay. And why have you not done so 81 1 until recently? 2 A. Well, for example, in order for me to 3 take the test three weeks ago, which I passed, by 4 the way, I had to go back and review all of my 5 pediatrics, OB/GYN, general surgery, general 6 medicine, and that took me about five months of 7 study, and frankly, I just didn't have those five 8 months when I first got here, and just by hook 9 and crook I've finally done it and finally passed 10 it. 11 MR. PARKER: Okay. I think that's all 12 I have. 13 THE WITNESS: Thank you. 14 MR. HIRSHMAN: That's it, then. 15 THE REPORTER: Signature? 16 MR. HIRSHMAN: Do you want to 17 talk -- we've got a videotape here, so I'm 18 going to ask for a copy of it, as well. 19 You're taping it at your end there. Is that 20 what's going on, Alan? 21 MR. PARKER: That's my understanding. 22 It's being done at a remote location. We're 23 in a big conference room and they've got a 24 technical control room somewhere that I 25 haven't even seen. It's my understanding 82 1 that they were going to pop a videotape in. 2 In my previous experience, my previous 3 experience, sometimes that videotape runs 4 out. 5 Did we get a videotape of this? Okay. 6 The recorder was running and, of course, I 7 have no problem with you getting a copy of 8 it. 9 MR. HIRSHMAN: I would request at this 10 time -- who is the person running the tape? 11 MR. PARKER: What's your name? 12 MR. GOODMAN: Craig Goodman. 13 MR. HIRSHMAN: What's the phone number 14 there? 15 MR. PARKER: (216) 368-6562. 16 MS. MOORE: I'm sorry. What was that, 17 65? 18 MR. HIRSHMAN: I would ask that 19 Mr. Goodman provide me with a copy of that 20 videotape at this point. Is that adequate 21 for you, Mr. Goodman? 22 MR. PARKER: He's just indicated that 23 if the recorders were working, he actually 24 has two copies. So you have his name and 25 number, and he's instructed to provide it to 83 1 you. 2 MS. MOORE: Can I get the last digits 3 of that phone number, please? I have 65 and 4 I didn't hear the last two. 5 MR. PARKER: 62. 6 MS. MOORE: Thank you. 7 MR. HIRSHMAN: Thank you. 8 THE REPORTER: Signature from the 9 witness? 10 MR. HIRSHMAN: Do you wish to read this 11 or are you willing to waive signature? 12 THE WITNESS: I think I'll waive this 13 one. 14 MR. HIRSHMAN: The doctor has indicated 15 his willingness to waive signature. 16 MR. PARKER: Okay. 17 MR. HIRSHMAN: Thank you. 18 MR. PARKER: Thank you. 19 THE WITNESS: Thank you. 20 (Witness excused.) 21 (Thereupon, at 12:20 p.m., the 22 deposition was concluded.) 23 --------- 24 25 84 1 CERTIFICATE OF OATH 2 3 STATE OF FLORIDA ) 4 COUNTY OF DADE ) 5 6 I, the undersigned authority, certify 7 that RICHARD LATCHAW personally appeared before 8 me and was duly sworn. 9 10 WITNESS my hand and official seal this 11 21st day of June 1999. 12 13 14 15 16 _________________________________ Brian Gary Berkowitz 17 Notary Public - State of Florida 18 19 20 21 22 23 24 25 85 1 CERTIFICATE 2 3 STATE OF FLORIDA ) COUNTY OF DADE ) 4 5 I, Brian Gary Berkowitz, Shorthand 6 Reporter, do hereby certify that RICHARD LATCHAW was by me first duly sworn to testify the whole 7 truth; that I was authorized to and did stenographically report the foregoing deposition 8 in stenotype; and that the foregoing pages, numbered from 1 to 83, inclusive, are a true and 9 correct transcription of my shorthand notes of said deposition. 10 I further certify that said deposition 11 was taken at the time and place hereinabove set forth and that the taking of said deposition was 12 commenced and completed as hereinabove set out. 13 I further certify that I am not a relative, employee attorney or counsel of any of 14 the parties, nor am I a relative or employee of any of the parties' attorney or counsel connected 15 with the action, nor am I financially interested in the action. 16 The foregoing certification of this 17 transcript does not apply to any reproduction of the same by any means unless under the direct 18 control and/or direction of the certifying reporter. 19 IN WITNESS WHEREOF, I have hereunto set my 20 hand this 21st day of June, 1999. 21 ________________________________ 22 Brian Gary Berkowitz Notary Public - State of Florida 23 24 25