1 1 IN THE COURT OF COMMON PLEAS 2 CUYAHOGA COUNTY, OHIO 3 RODNEY L. McCLENDON, 4 Plaintiff, 5 JUDGE McGINTY -vs- CASE NO. 374136 6 7 KAISER FOUNDATION HEALTH PLAN OF OHIO, et al., 8 Defendants. 9 10 - - - - 11 Deposition of ANTHONY SALUPO, taken as if upon 12 cross-examination before Laura L. Ware, a Notary 13 Public within and for the State of Ohio, at The 14 Cleveland Clinic Emergency Department, Building E, 15 Cleveland Ohio, at 8:50 a.m. on Tuesday, August 10, 16 1999, pursuant to notice and/or stipulations of 17 counsel, on behalf of the Plaintiff in this cause. 18 19 - - - - 20 WARE REPORTING SERVICE 21 3860 WOOSTER ROAD ROCKY RIVER, OH 44116 22 (216) 533-7606 FAX (440) 333-0745 23 24 25 2 1 APPEARANCES: 2 Mark W. Ruf, Esq. Hoyt Block Building, Suite 300 3 700 West St. Clair Avenue Cleveland, Ohio 44113 4 (216) 687-1999, 5 On behalf of the Plaintiff; 6 Douglas G. Leak, Esq. Mazanec, Raskin & Ryder 7 100 Franklin's Row 34305 Solon Road 8 Cleveland, Ohio 44139 (440) 248-7906, 9 On behalf of the Defendant 10 Kaiser Foundation Health Plan of Ohio; 11 Victoria L. Vance, Esq. Arter & Hadden 12 1100 Huntington Building 925 Euclid Avenue 13 Cleveland, Ohio 44115 (216) 696-1100, 14 On behalf of the Defendant 15 The Cleveland Clinic Foundation. 16 W I T N E S S I N D E X 17 PAGE 18 CROSS-EXAMINATION 3 19 BY MR. RUF 20 CROSS-EXAMINATION 49 BY MR. LEAK 21 RECROSS-EXAMINATION 64 22 BY MR. RUF 23 E X H I B I T I N D E X 24 PAGE 25 Plaintiff's Exhibit 42 3 3 1 - - - - 2 (Thereupon, Plaintiff's Exhibit 42 was 3 mark'd for purposes of identification.) 4 - - - - 5 ANTHONY SALUPO, of lawful age, called by the 6 Plaintiff for the purpose of cross-examination, as 7 provided by the Rules of Civil Procedure, being by 8 me first duly sworn, as hereinafter certified, 9 deposed and said as follows: 10 CROSS-EXAMINATION OF ANTHONY SALUPO 11 BY MR. RUF: 12 Q. Could you please state your name and spell your 13 name. 14 A. Anthony Salupo, S-A-L-U-P-O. 15 Q. Mr. Salupo, my name is Mark Ruf. I represent Rodney 16 McClendon in a lawsuit that's been brought against 17 Kaiser and the Cleveland Clinic. 18 If at any time I ask you a question and you do 19 not understand my question, please tell me. If you 20 give me an answer to a question, I'll assume that 21 you have understood the question. Okay? 22 A. Okay. 23 Q. What is your address, Mr. Salupo? 24 A. Home address? 25 Q. Yes. 4 1 A. 7015 Tobik, T-O-B-I-K, Trail, Parma Heights, 44130. 2 Q. Who is your employer? 3 A. Cleveland Clinic. 4 Q. And what is your position with the Cleveland 5 Clinic? 6 A. Clinical Manager for the emergency department and 7 surgery radiology. 8 Q. What does it mean to be Clinical Manager? 9 A. Supervisory of the day-to-day operation, budgets, 10 scheduling, ordering. 11 Q. Are you involved in training employees? 12 A. Yes. 13 Q. And what departments do you supervise? 14 A. Just the radiology department for ED and surgery. 15 Q. Could you tell me what your educational background 16 is? 17 A. High school graduate and Associate's Degree in 18 radiology. 19 Q. How long did it take you to get the Associate's 20 Degree? 21 A. Three years. 22 Q. In general, is that a two-year program or is that -- 23 A. The radiology program is two years. 24 Q. What is the name of that degree, an Associate's 25 Degree of -- 5 1 A. Of arts, sciences and radiology. 2 Q. And where did you get your degree from? 3 A. Cuyahoga Community College. 4 Q. When did you get your degree? 5 A. Let's see, that's kind of hard to remember. 1984. 6 Q. Were you employed by the Clinic immediately after 7 graduating or did you work somewhere else? 8 A. A few months after. 9 Q. And how long have you been here at the Clinic? 10 A. Fifteen years this month. 11 Q. When you first started here what was your position? 12 A. X-ray tech. 13 Q. And how long did you work as an x-ray tech before 14 being promoted? 15 A. I can't remember the exact time. 16 Q. How long have you been a supervisor? 17 A. Seven to eight years. 18 Q. How many people do you supervise? 19 A. Seventeen. 20 Q. And what types of employees do you supervise? 21 A. Radiology techs and two office assistants. 22 Q. What is a radiology tech? 23 A. An x-ray tech. 24 Q. What do they do? 25 A. Take x-rays. 6 1 Q. Do all of the techs who work here have Associate's 2 Degrees? 3 A. Some of them do and some of them are hospital based, 4 could have hospital based degrees. 5 Q. What does that mean, hospital based degrees? 6 A. Meaning that they just went -- it was a program 7 through like a two-year program based through just, 8 say, a hospital based program their courses and 9 clinical background was taken. I don't know that 10 much about them, but you could have both. 11 Q. Are there any protocols, policies or procedures that 12 an x-ray tech has to follow? 13 A. Meaning? 14 Q. Well, are there any protocols, policies or 15 procedures that are given to an x-ray tech that they 16 are required to follow? 17 A. There's attendance policies, foundation policies 18 such as that, certain departmental policies, 19 attendance. 20 Q. Are there any written policies that they're required 21 to follow in performing x-rays or deciding which 22 x-rays to perform? 23 A. No, there's no written policy. 24 Q. The x-ray techs do not take a history and physical 25 examination, correct? 7 1 A. Correct. 2 Q. And they do not assess a patient to make a 3 diagnosis, correct? 4 A. Correct. 5 Q. Do the x-ray techs make any type of independent 6 determination as to what x-ray views are going to be 7 taken? 8 A. They may, due to the information given to them, and 9 after dealing with the patient and, you know, the 10 condition the patient is in they might have to do 11 something different in order to get what they need 12 to see. 13 Q. Under what circumstances would they take views that 14 are different than the views that are ordered by 15 either a nurse or a doctor? 16 A. Due to additional information that was on the 17 ordering requisition they might have to assess, you 18 know, what was given to them, interpret that they 19 may need to see something different or more. 20 Q. So sometimes they use their discretion in taking 21 additional x-rays? 22 A. Yes, due to the information. 23 Q. Is there ever a circumstance in which they would 24 take fewer x-rays than the x-rays that were 25 ordered? 8 1 A. Yes. 2 Q. Under what circumstances would they do that? 3 A. Basically the same, with additional information they 4 have that was given to them after talking to, you 5 know, dealing with the patient, depending on the 6 patient's condition. 7 Q. What information does an x-ray tech obtain from a 8 patient? 9 A. Basically they ask them what has happened to them, 10 where they hurt, the interest of injury, point of 11 origin. 12 Q. Any other information they would obtain from a 13 patient? 14 A. No, just verbally. 15 Q. Would you agree that the exercise of ordinary care 16 by an x-ray tech requires that x-ray tech to perform 17 the x-ray views that are actually ordered by either 18 a doctor or a nurse? 19 MS. VANCE: Objection. 20 A. I really don't understand what you're saying on that 21 one. 22 Q. Well, is an x-ray tech required to perform the views 23 that are actually ordered by a doctor or nurse? 24 MS. VANCE: Objection. 25 A. No. 9 1 Q. Then what is the purpose of either a nurse's or 2 doctor's order for certain views? 3 A. A doctor may put in, or a nurse may put in an order, 4 the patient comes down here, you know, we're getting 5 a different explanation from the patient, we review 6 it with our radiologist, and then we go from there. 7 Q. So does the x-ray tech work with the radiologist to 8 determine whether or not additional views or fewer 9 views should be taken? 10 MS. VANCE: Sometimes, always, what's 11 your question? 12 A. At times. 13 Q. And at times the x-ray tech may use their own 14 independent determination? 15 A. Yes. 16 Q. Now, would you agree that an x-ray tech has less 17 medical training than either a doctor or nurse? 18 MS. VANCE: Objection. 19 A. Less than a doctor. I can't speak for the nurse, I 20 don't know their job because they don't know ours. 21 Q. Is there any method of checking whether the views 22 that are ordered by a nurse or doctor are actually 23 done? 24 A. Can you say that again? 25 Q. Yeah. Is there any method of checking whether the 10 1 views ordered by a nurse or doctor are actually 2 done? 3 A. Checked by who? 4 Q. By the x-ray tech. Is there some procedure to make 5 sure that if x-rays are ordered they're actually 6 taken? 7 A. If the x-ray -- an x-ray is ordered, then it's 8 done. I mean, I really don't understand what 9 you're -- 10 Q. Well, are you telling me that if a nurse or doctor 11 orders an x-ray that x-rays should be done by the 12 x-ray tech? 13 A. That specific exact x-ray? 14 Q. Yes. 15 A. Depending on what the situation is when we see it, 16 the patient and the orders. 17 MS. VANCE: You may be, just in terms 18 of communication, getting hung up on what is an 19 order versus the study or the views. I just 20 want to make sure that we're all talking about 21 the same thing. If a request comes in for 22 x-rays a study will be done? 23 THE WITNESS: Correct. 24 MS. VANCE: Okay. 25 Q. Well, how are x-rays ordered from the Kaiser 11 1 emergency room? 2 A. Orders are put through an order entry system that 3 then is popped up onto our dec-rad system where we 4 see the order and then we take off the orders. 5 Q. What documentation is produced when somebody in the 6 Kaiser ER orders an x-ray? 7 MS. VANCE: Produced from the radiology 8 side, or do you want to know from -- 9 Q. From either Kaiser or the radiologist. 10 A. I don't know what prints out on our side. We print 11 out as we're taking off the order, a card then 12 prints out. 13 Q. When a patient comes from the Kaiser ER, is there 14 any written documentation that would come with the 15 patient? 16 A. They are sent with the requisition. 17 Q. I'm handing you what's been marked as Plaintiff's 18 Exhibit 40. Is that a requisition form for a Kaiser 19 ER patient? 20 A. Yes. 21 Q. And is that the type of form that would be sent with 22 the patient to the x-ray tech? 23 A. It's brought down by somebody from the area, given 24 to us. 25 Q. Other than Plaintiff's Exhibit 40, is there any 12 1 other written documentation that would accompany the 2 patient when they came down from Kaiser Permanente's 3 ER? 4 A. No. 5 Q. I'm handing you what's been marked as Plaintiff's 6 Exhibit 41. What is that document? 7 A. That's a dec-rad card. 8 Q. And what's the purpose of a dec-rad card? 9 A. Shows the patient's name, history, exams, has a bar 10 code on it so we can track our times, beginning, 11 ending and such. The radiologist also uses that 12 swiping bar code swiper to dictate. It has several 13 different functions. 14 Q. Who produces the dec-rad card, is it Kaiser or is it 15 the Clinic? 16 A. Radiology. 17 Q. Is the dec-rad card produced before the x-rays are 18 actually taken or after the x-rays are taken? 19 A. Before. 20 Q. Does the x-ray tech determine which views to take 21 based on Plaintiff's Exhibit 40 and Plaintiff's 22 Exhibit 41 for a Kaiser ER patient? 23 A. Combined. 24 Q. Is there any place on Plaintiff's Exhibit 41 that 25 shows the actual views that were ordered for Rodney 13 1 McClendon? 2 A. This shows the exam. This is the final card, so 3 this is the exam that was done. 4 Q. So there's an exam number? 5 A. No, it's a code that explains what it is. That's 6 for our purposes, which is those, that part of the 7 body. 8 Q. You're referring to the area at the top, it says 9 exam, it has number 3650980, then space, 10 parentheses, MC, end paren., EGFO? 11 A. 2. 12 Q. 2. And then below that it states forearm, two 13 views? 14 A. Correct. 15 Q. Is there a time put on the form for when the x-rays 16 were ordered? 17 A. Right there, yes. 18 Q. 5:05 p.m.? 19 A. That's the time it was taken off the computer. It 20 won't have the exact time that it was -- that the 21 orders were placed by Kaiser. It's the time on the 22 card that it was taken off of the computer. 23 Q. Now, would the x-ray tech have a hard copy of 24 Plaintiff's Exhibit 41 or would they just be looking 25 at the computer? 14 1 A. You have a hard copy after it's printed. 2 Q. And is a hard copy printed before the x-rays are 3 actually taken? 4 A. Yes. 5 Q. Now, down at the bottom there's some additional 6 information and under comments it states add view 7 right and left elbow to wrist; is that correct? 8 A. Yeah, that's what it says. 9 Q. Based upon your experience here in the x-ray 10 department, what does that mean, add view right and 11 left elbow to wrist? 12 A. Add view means additional view, and they just used 13 that, anyone who may order, who has access to the 14 order entry system will put any kind of comments 15 they feel they need to assist in the views that we 16 may do. 17 Q. So based on Plaintiff's Exhibit 41, initially there 18 were two forearm views ordered? 19 A. This exam was rescheduled, two forearm views to be a 20 forearm view, due to the initial information that 21 was given to us. 22 Q. Who would have rescheduled the exam? 23 A. The technologist either performing the exam or 24 observing the exam. 25 Q. And it was rescheduled due to the request for 15 1 additional views of the right and left elbow to 2 wrist? 3 A. Correct. It's not an additional view, it's just 4 stating a comment. There's a difference between the 5 two. You're combining all of that together. 6 Q. Well, it does state add view, correct? 7 A. They just put it in the wrong -- yeah, but that is 8 not a view, it's a comment. Comments, add view, 9 slash. 10 Q. Well, if it's not an additional view then what would 11 be the point of rescheduling the exam? 12 A. Because due to the information that they have given 13 us, okay, elbow to wrist is not a view. 14 Q. Well, then I don't understand what would be the 15 point of adding under comments add view right and 16 left elbow to wrist. 17 A. The reason it's rescheduled is because the exam that 18 was ordered and this did not correlate together. 19 The comment that is given to us is stating right and 20 left elbow to wrist, in return is a forearm. 21 Q. Does the x-ray of a forearm include views of the 22 wrist and elbow? 23 A. Yes. 24 Q. However, you would agree that you can have a 25 specific view of the wrist taken, correct? 16 1 A. If ordered. 2 Q. And you can have a specific view of the elbow taken? 3 A. If ordered. 4 Q. If an x-ray of the elbow is ordered, what does it 5 state on the dec-rad card? 6 A. It would have a code such as this and then would say 7 elbow. 8 Q. If x-rays were ordered of the wrist, forearm and 9 elbow, what would it state on the dec-rad card? 10 A. There would be three separate cards, each one 11 stating what that exam was. 12 Q. So there would be one card for forearm views? 13 A. Correct. 14 Q. And there would be one card for elbow views? 15 A. Correct. 16 Q. And there would be one card for wrist views? 17 A. Correct. 18 Q. What are the standard views that are taken of the 19 wrist? 20 A. PA, oblique and lateral. 21 Q. So for standard views of the wrist, how many x-rays 22 are actually taken? 23 A. Three projections, one film. 24 Q. And for the elbow, what are the standard views that 25 are taken? 17 1 A. AP and lateral. 2 Q. So how many projections and how many films are 3 produced for -- 4 A. Two projections, one view -- one film, I'm sorry. 5 Q. And for the forearm what are the standard views that 6 are taken? 7 A. AP and lateral. 8 Q. And how many projections and how many films? 9 A. Two projections, one film. 10 Q. So if x-rays were ordered of the elbow, wrist and 11 forearm, that would be seven projections and three 12 films? 13 A. Correct. 14 MS. VANCE: And three cards? 15 THE WITNESS: Correct. 16 Q. Are you aware that a fracture of a radial head may 17 not show up on an elbow view? 18 A. I don't interpret x-rays, so. 19 Q. Do you know what view is the best for determining 20 whether or not there is a fracture of a radial 21 head? 22 A. No. 23 Q. Do you know whether there are fractures of the elbow 24 that will not show up on a forearm view? 25 A. I don't know. 18 1 Q. As an x-ray tech if a patient was complaining of 2 severe elbow pain, would you agree that an elbow 3 view would be indicated for that patient? 4 MS. VANCE: Complaining to the tech or 5 complaining to somebody else? 6 Q. Complaining to the tech. 7 A. We would review it with somebody first. 8 Q. Who would you review it with? 9 A. Either the radiologist or the ordering physician. 10 Q. Why would you review it with either the radiologist 11 or ordering physician? 12 A. Just because if they're complaining of that, if it 13 wasn't ordered and they're complaining of something 14 different, then sometimes we will, you know, if it's 15 like not in the region of what we feel that we're 16 doing or what was additionally ordered or after they 17 stated it, then we have to check -- then we check it 18 out. 19 MS. VANCE: If it's outside the 20 region? 21 THE WITNESS: Correct. 22 MS. VANCE: Okay. 23 Q. Well, as an x-ray tech if forearm views were ordered 24 and a patient was complaining of severe elbow pain, 25 would the tech have the authority to go ahead and 19 1 perform elbow views? 2 A. The elbow is included, elbow joint is included on a 3 forearm view. 4 Q. However, if elbow views are taken, you get an 5 additional two projections of the elbow, correct? 6 A. If separately ordered from a forearm? 7 Q. Yes. 8 A. Yes. It's the same view though. It's the same 9 projection, same view. 10 Q. A forearm view is the same as an elbow view? 11 A. It's included from here to here as the statement, 12 comment, requested us to do. A forearm includes the 13 wrist joint and the elbow joint. 14 Q. What about a view only of the elbow, what area is 15 x-rayed? 16 A. The elbow joint. 17 Q. Do you know if there's information that can be 18 obtained from an elbow view that cannot be obtained 19 from a forearm view? 20 A. I don't interpret the x-rays, so I'm not a 21 radiologist. 22 Q. So you don't know if additional information can be 23 obtained? 24 A. No. 25 Q. Do you know if there is an area of the elbow that 20 1 cannot be seen on a forearm view? 2 A. No, it's all included. 3 Q. Could the entire radial head be seen on a forearm 4 view? 5 A. There's different views for a radial head. 6 Q. What -- 7 A. But the whole elbow joint, which includes the ulna, 8 radius, radial head, and your humerus consisted of 9 the elbow joint, which is all on the film. 10 Q. If a doctor or nurse would order an elbow view, what 11 film would be taken by the x-ray tech? 12 A. As I stated, AP and lateral. 13 Q. AP and lateral of what? 14 A. Elbow. If ordered, strictly as that. 15 Q. So if a doctor or nurse specifically ordered an 16 elbow view, an AP and lateral of the elbow would be 17 taken? 18 A. Correct. 19 Q. Is that x-ray different than an x-ray of a radial 20 head? 21 A. Yes. 22 Q. How is it different? 23 A. It's a different projection, it's not the normal 24 routine. It's a special projection strictly of that 25 point of interest. 21 1 Q. Well, could you describe for me how the x-ray is 2 different? 3 A. Elbow view routine is shot in the AP and lateral 4 projection with the tube x-ray beam shooting 5 straight for both projections. When a radial head 6 view is requested, the tube beam is at a different 7 angle and you enter at a different -- it's not the 8 routine view for an elbow. 9 Q. And there's a different angle because that gives you 10 a better view of the radial head? 11 A. It's different positioning, different angle, tube 12 angle, to emphasize strictly for that point of 13 interest, yes. 14 Q. How would a doctor or nurse in the Kaiser ER know 15 that if they want a view of a radial head they have 16 to specifically order a radial head view? 17 A. How do they know? 18 Q. How would they know? 19 A. I don't know. I don't examine the patient. 20 Q. Well, is there any written documentation that is 21 given to the Kaiser emergency department that states 22 if you want a radial head view you specifically have 23 to order a radial head view? 24 A. I don't know. 25 Q. Have you ever called either a doctor or nurse in the 22 1 Kaiser emergency room to discuss with them that they 2 may want to take a radial head view as opposed to 3 just an elbow view? 4 A. No, because you just don't take a radial head view 5 without taking -- seeing the elbow views first. 6 Q. So if a radial head view would be ordered, you would 7 take elbow views first? 8 A. Correct. 9 Q. And then under what circumstances would you take the 10 additional radial head views? 11 A. If requested by the radiologist or an ordering 12 physician. 13 Q. In the Kaiser emergency room do you know if there is 14 a list of x-rays that can be ordered? 15 A. Every order entry system that anybody throughout the 16 foundation has access to has different screens so 17 they can go into the screens that are marked ED, 18 radiology, and it gives a list of all exams that 19 could be ordered. 20 Q. And that is called the entry order screen? 21 A. Order entry system screen. I don't know the exact. 22 Q. And there are computers in the Kaiser emergency room 23 which are part of this system? 24 A. Yes. 25 Q. On this order entry screen do you know what is 23 1 listed for the wrist, elbow or forearm? 2 A. No, I don't. 3 Q. Can the order entry screen be printed out? 4 A. I don't know. 5 MR. RUF: I would ask counsel to 6 produce a copy of the order entry screen for 7 wrist, elbow, forearm or radial head, if that's 8 possible. 9 MS. VANCE: If it's a screen that can 10 be printed, we'll print it up for you. I'll 11 check into that. 12 Q. On Plaintiff's Exhibit 40 there's a line for 13 requesting MD; is that correct? 14 A. Yes. 15 Q. There's no line on there for requesting RN, 16 correct? 17 A. Correct. 18 Q. Do you know if x-rays are ordered do those x-rays 19 have to be ordered by an MD? 20 A. For Kaiser? 21 Q. Yes. 22 A. No. 23 Q. Do you know who actually orders the x-rays from the 24 Kaiser emergency room department? 25 A. It's a wide range, doctors, nurses, PCTs. 24 1 Q. And do you agree that when any of those people order 2 an x-ray they order the x-ray based on a history, 3 physical exam and assessment of the patient? 4 MS. VANCE: Objection. 5 A. I guess, yes. 6 MS. VANCE: Well, do you know? 7 THE WITNESS: Oh, do I know for -- 8 MS. VANCE: Yeah. 9 THE WITNESS: No. 10 Q. If you decide to take additional views or fewer 11 views than the views that are ordered, do you 12 contact the ordering nurse or doctor to inform them 13 of that fact? 14 A. At times. 15 Q. Under what circumstances would you contact the nurse 16 or doctor? 17 A. If it's a difficult patient, trauma patient, you 18 know, there's different circumstances in an 19 emergency room. Everybody is different. 20 Q. If x-rays of the wrist, forearm and elbow were 21 ordered, would you contact the doctor or nurse if 22 you decided only to do forearm views? 23 MS. VANCE: You're assuming three 24 separate orders, three separate cards, and he 25 decides just to do one instead of three? 25 1 MR. RUF: Correct. 2 A. Yes, well, would I inform them? 3 Q. Yes. 4 A. No. 5 Q. Why wouldn't you contact the doctor or nurse to 6 discuss that with them? 7 A. Because of the information that was given to me I'm 8 including all points of interest, so there would be 9 no need to contact them if I included everything 10 that they did want. 11 Q. However, you've also stated that you don't know if 12 additional information can be obtained from an elbow 13 view that is not seen on a forearm view? 14 MS. VANCE: Well, objection. I think 15 he talked about that. 16 A. I can't interpret an x-ray, so I'm not a trained -- 17 I'm not a radiologist, I'm not a physician, so I 18 can't. 19 Q. Since you're not a physician, don't you think it 20 would be prudent to contact a physician if you 21 decided only to take a forearm view when x-rays of a 22 forearm and elbow are specifically ordered? 23 A. No. 24 Q. Why wouldn't that be prudent? 25 A. Because I'm including with the information that was 26 1 given to me on a daily basis -- 2 MS. VANCE: Anthony, what you may need 3 to explain is the view -- standard elbow view, 4 what that includes, and I know you've told us a 5 standard view what a forearm includes. How is 6 it that -- 7 MR. RUF: Well, I'm go to object. I'm 8 the one asking the questions. 9 MS. VANCE: Well, I think you're 10 misunderstanding. I'd like to give him an 11 opportunity to make it more clear. 12 MR. RUF: I don't have to ask the 13 questions that you want. 14 MS. VANCE: All right. We'll cover 15 that at the end if it's still an open point and 16 not clear. 17 MR. RUF: Well, I'm going to object to 18 you questioning this witness. 19 MS. VANCE: Well, I don't want you to 20 leave here with a misunderstanding of what he 21 did or not, why the department acts the way it 22 does and why he has given you the answers. 23 This is your opportunity to make sure 24 you do understand, and if I'm sensing you're 25 going to leave here with the wrong impression, 27 1 now is the time to clear it up and not tell you 2 sometime down the road. 3 So I just want to make sure that you 4 understand from the radiologist technician 5 standpoint why the forearm view, AP and 6 lateral, is not leaving out anything that the 7 elbow view, AP and lateral, would also have 8 shown to the requesting folks in Kaiser who are 9 going to examine this patient. That's all I'm 10 seeking to do, is make sure that that testimony 11 is clear. You can ask as many questions on 12 that as you want to the witness. Here's yours 13 chance. 14 Q. Do you know if an x-ray of a forearm can evaluate 15 whether or not there's a radial head fracture? 16 A. I can't. I'm not a radiologist. I can't interpret 17 an x-ray film. 18 Q. So you are -- 19 A. A diagnosis, I cannot interpret, I cannot make a 20 diagnosis on an x-ray film, I'm not an MD. 21 Q. So you are not qualified to make that 22 determination? 23 A. A diagnosis, no. 24 Q. Who would have inputted the information on 25 Plaintiff's Exhibit 41? 28 1 A. What part of 41? 2 Q. Any of it, and if there's different people explain 3 who would input the information. 4 A. The original information of the exam ordered, any 5 comments, signs, history, subjection, diagnosis, is 6 placed by Kaiser. 7 Q. Do you know what type of employee ordered the x-rays 8 for Rodney McClendon? 9 A. No, I do not. 10 Q. Is that shown on Plaintiff's Exhibit 41? 11 A. What is shown, who ordered? 12 Q. Yes. 13 A. No. 14 Q. Do you know who actually inputs the information on 15 Plaintiff's Exhibit 41 into the computer system? 16 A. Someone from Kaiser, because it will give a Kaiser 17 code. The individual, no. 18 Q. And down at the bottom under examination form 19 continued, would that information also be inputted 20 by a Kaiser employee? 21 A. Where are you looking? 22 MS. VANCE: Second half of the card. 23 A. Yeah, it's all one card. That's all placed, yeah. 24 Q. So a Kaiser employee would input all the information 25 on Plaintiff's Exhibit 41? 29 1 A. Correct. 2 Q. And that would have been done prior to the actual 3 taking of x-rays? 4 A. Correct. 5 Q. And initially two views of the forearm were ordered, 6 correct? 7 A. It says rescheduled, so I'm assuming it was 8 something beforehand. 9 Q. So the examination was rescheduled before any views 10 were actually taken? 11 A. Correct. 12 Q. And it was rescheduled because of this lower portion 13 that says comments, add view right and left elbow to 14 wrist? 15 A. Correct. 16 Q. What does it mean forearm two views if there are 17 standard three projections of the forearm? 18 MS. VANCE: There aren't. 19 A. There aren't, there's two projections. 20 Q. I'm sorry. There's three projections of the wrist? 21 A. Correct. 22 Q. So when it says forearm two views, is that talking 23 about the two projections? 24 A. Correct. 25 Q. When it says add view, does that mean add an 30 1 additional projection? 2 MS. VANCE: Objection. We've been over 3 that as to what that line means. 4 A. That's a comment. 5 Q. And my specific question is when it says add view 6 does that mean add a projection? 7 A. No. 8 Q. Well, I guess I'm confused. I don't understand the 9 point of rescheduling the exam if you get the same 10 thing with forearm two views as you get with comment 11 add view right and left elbow to wrist. 12 A. As I said, you're confusing comments add view. Why 13 they wrote add view, I don't know. I can't explain 14 it. Comments, I'm using the word comment, right and 15 left, meaning bilateral, right, left wrist to 16 elbow. We interpret that they want to include 17 everything from wrist to elbow, so that's exactly 18 what was done. 19 Q. If somebody at the Kaiser emergency department 20 wanted to actually add additional projections of the 21 wrist and elbow, what should have been inputted on 22 Plaintiff's Exhibit 41? 23 A. Depending on the point of interest, it could be any 24 kind of body part. There's routine views taken for 25 every body part or x-ray, there's a routine for 31 1 everything unless stated special views are 2 requested. Example, a knee -- 3 Q. Excuse me. Let me interrupt one second because I 4 don't think you listened to the specific question. 5 MR. RUF: Could you please go back and 6 reread the question. 7 MS. VANCE: I think he was trying to 8 answer it. Maybe we're having some difficulty 9 communicating. Go back, Laura, and read the 10 question and we'll make sure we're on the same 11 page here. 12 - - - - 13 (Thereupon, the requested portion of 14 the record was read by the Notary.) 15 - - - - 16 A. Of that specific body part? 17 Q. Yes. 18 A. Then they would state carpal tunnel view, scaphoid 19 view, radial head view, ulnar flexion. There are 20 several. If it was outside of the norm they should 21 have stated it. 22 Q. So for the x-ray tech to actually take projections 23 of the elbow, what would it have to state on 24 Plaintiff's Exhibit 41? 25 MS. VANCE: I'm sorry, repeat the 32 1 question, Laura. 2 MR. RUF: Please read the question 3 back. 4 - - - - 5 (Thereupon, the requested portion of 6 the record was read by the Notary.) 7 - - - - 8 MS. VANCE: I'm going to object because 9 projections of the elbow were taken. The 10 question makes it sound like the projections of 11 the elbow were not taken, so I'm confused. 12 A. If it was strictly with all information taken into 13 account, if it's strictly stated just elbow, then an 14 elbow would have been taken, if stated just 15 specifically that. 16 Q. Is an AP and lateral projection of an elbow 17 different than an AP and lateral projection of the 18 forearm? 19 A. It's all the same positioning. 20 Q. Do the films look identical? 21 A. No. 22 Q. What is the difference in the films? 23 A. Well, they're larger size films to cover a larger 24 size area. You're not going to use the same size 25 film as you would for an elbow over a forearm. 33 1 Q. Is the elbow area magnified on an AP and lateral 2 projection of the elbow as compared to projections 3 of the forearm? 4 A. I don't understand magnified. 5 MS. VANCE: He's got films here on this 6 patient that cover a long time period, not only 7 the ER but we know that this man has had 8 subsequent x-rays over the course of subsequent 9 months, just so you know what may be shown 10 here. Check dates if he puts up any films. 11 - - - - 12 (Thereupon, a discussion was had off 13 the record.) 14 - - - - 15 Q. Okay. I'm handing you what's been marked 16 Plaintiff's Exhibits 1, 2 and 3. Could you take a 17 look at those and tell me if those are projections 18 of the forearm? 19 MS. VANCE: Look at everything before 20 you answer the question. 21 A. These two are. 22 Q. Could you tell me which numbers they are? 23 A. I don't know the number. 2 and 3. 24 Q. What is Plaintiff's Exhibit 1 a projection of? 25 A. That's a projection of the wrist. 34 1 Q. How many projections are there on Plaintiff's 2 Exhibit 1 of the wrist? 3 A. Two. 4 Q. I'm handing you what's been marked as Plaintiff's 5 Exhibit 6. It's a Kaiser film of 6-28-98. Could 6 you please take a look at that film. 7 MS. VANCE: That was done at a Kaiser 8 facility, that's not a Cleveland Clinic film, 9 and also not done in an ED setting, for what 10 that's worth. 11 Q. Does Plaintiff's Exhibit 6 show projections that 12 would be done if projections were ordered from the 13 Cleveland Clinic Radiology Department for the 14 elbow? 15 A. Yes. 16 Q. And does Plaintiff's Exhibit 6 contain any 17 projections that are not shown on Plaintiff's 18 Exhibits 2 or 3? 19 A. No, they're the same. 20 MR. LEAK: Excuse me. Which ones are 21 the same? I'm sorry, I just want to make sure 22 I'm clear on the numbers. 23 A. A projection, if I can explain, AP, lateral, that's 24 an AP, lateral, different parts of the body, but the 25 projections and the parts of the anatomy somewhat 35 1 are included on both. 2 MR. LEAK: Thank you. 3 Q. Okay. I'm handing you what's been marked as 4 Plaintiff's Exhibit 7, it's a Kaiser film of 5 4-28-98. Are there any projections on Plaintiff's 6 Exhibit 7 that are not shown on Plaintiff's Exhibits 7 2 and 3? 8 MS. VANCE: What's the date there, 9 Mark? 10 MR. RUF: 4-28. 11 MS. VANCE: 4-28. 12 A. No. 13 MS. VANCE: 7 is also AP, lateral of 14 the elbow. 15 A. Correct. 16 Q. I want you to assume that on February 6th 17 Plaintiff's Exhibit 40 under exams requested stated 18 elbow, slash, wrist, slash, forearm. Would the 19 exams requested be different than the exams shown on 20 Plaintiff's Exhibit 41? 21 A. Would they be different? 22 Q. Yes. 23 A. Yes, because there's one card here versus if I'm 24 assuming that's what was written. I don't have the 25 actual -- I have the actual here, I don't have the 36 1 actual there. 2 Q. So if the triage nurse actually intended to order 3 elbows -- strike that. 4 If the triage nurse actually intended to order 5 x-rays of the elbow and x-rays of the forearm and 6 x-rays of the wrist, that is not done on Plaintiff's 7 Exhibit 41? 8 MS. VANCE: Objection. There's no 9 testimony that's what the triage nurse did or 10 expected to do or intended. 11 Q. Go ahead, you can answer the question. 12 A. I'm confused. Could you just restate it again? 13 Q. Yes. If the triage nurse actually intended to order 14 x-rays of the wrist and x-rays of the forearm and 15 x-rays of the elbow, is that done on Plaintiff's 16 Exhibit 41? 17 MS. VANCE: Objection. 18 A. It would be three separate orders. 19 Q. So then -- 20 A. Three separate cards, if it was put into the 21 computer that way. 22 Q. So if only one card was produced then the order was 23 not as intended, correct? 24 MS. VANCE: Objection. 25 A. Yes, but if there was one card there was one order. 37 1 Q. So Plaintiff's Exhibit 41 is not an order for 2 separate projections of the elbow, wrist and 3 forearm? 4 A. Correct. 5 Q. So if the employee in the Kaiser emergency room 6 wanted to order separate projections of the elbow, 7 wrist and forearm, three cards should have been 8 produced? 9 MS. VANCE: Objection. 10 A. Yes. 11 Q. And when I referred to card, I was referring to 12 dec-rad card. 13 A. Yes. 14 Q. Now, after the x-rays are taken by the tech, what 15 documentation is kept with the films? 16 A. The requisition that is sent by Kaiser. 17 Q. So Plaintiff's Exhibit 40? 18 A. Yeah. Yes. 19 Q. Would Plaintiff's Exhibit 41 be sent with the 20 films? 21 A. No. 22 MS. VANCE: Sent where? Let's be sure 23 about that. 24 Q. What happens to Plaintiff's Exhibit 41 after the 25 films are actually taken? 38 1 A. This goes with the films to the radiologist, the 2 radiologist uses this information and this bar code 3 to dictate through the dictating system. When he's 4 done reading the exam the card is thrown away, this 5 is put with the films and the films are sent back to 6 Kaiser. 7 Q. For a Kaiser ER patient, are the films put into some 8 type of jacket? 9 A. Yes. 10 Q. I'm handing you what's been marked as Plaintiff's 11 Exhibit 42, which is the Kaiser jacket for Rodney 12 McClendon. Would you please take a look at that 13 document. 14 MS. VANCE: That's a minimized reduced 15 version of a larger size, full size x-ray 16 jacket. 17 A. That's the jacket that we use. 18 Q. So for a Kaiser patient would the jacket look like 19 Plaintiff's Exhibit 42? 20 A. No. 21 Q. What would the jacket look like? 22 A. I can get one to show you. 23 Q. Please do that. 24 25 - - - - 39 1 (Thereupon, a discussion was had off 2 the record.) 3 - - - - 4 MS. VANCE: We're not going to mark 5 that. We need those, but you can look at it. 6 MR. RUF: Let's go off the record one 7 second. 8 - - - - 9 (Thereupon, a discussion was had off 10 the record.) 11 - - - - 12 MR. RUF: Let's go back on the record. 13 Q. You've handed me the jacket that would be used for a 14 Kaiser Permanente ER patient, correct? 15 A. Yes. 16 Q. And that jacket on the top it says Kaiser Permanente 17 Medical Care Program, Ohio Region, Department of 18 Radiology? 19 A. Yes. 20 Q. Correct? 21 A. Yes. 22 Q. And on the bottom it says unread films, correct? 23 A. Yes. 24 Q. And there's also a plastic material where paper can 25 be inserted, correct? 40 1 A. Yes. 2 Q. What would be inserted in this plastic area? 3 A. The requisition provided by them. 4 Q. So that would be Plaintiff's Exhibit 40? 5 A. Yes. 6 Q. Plaintiff's Exhibit 41 would not be put in the 7 plastic area, correct? 8 A. Correct. 9 Q. Because Plaintiff's Exhibit 41 would be discarded? 10 A. After dictation, correct. 11 Q. However, the information on Plaintiff's Exhibit 41 12 would still remain in the computer system, correct? 13 A. The dec-rad system? 14 Q. Yes. 15 A. Yes. Can I make a comment -- 16 Q. Yes. 17 A. -- just to clarify something. One of your last -- 18 one of your questions you were stating if the nurse 19 had written a certain something on the -- Exhibit 20 40. 21 Q. Yes. 22 A. And what comes across on 41 is that a lot of times 23 what is ordered is rescheduled due to the fact that 24 the same information is included on that with a less 25 expense and less radiation to a patient. So that's 41 1 why if we look at the comment section I think there 2 was a misunderstanding I think between layman's 3 terms, you know, no offense, but of why it's done. 4 Q. I don't understand what you're telling me. 5 A. Okay. If on Exhibit 40 is written wrist, elbow, 6 forearm and they only placed one order, be it elbow, 7 be it a forearm, be it a wrist, only one card, and 8 with the additional information that they provided 9 us this is telling us to include, yes, these three, 10 so it's combined on a large film, as this patient 11 was it looks like a large man, to make sure all 12 three points of interest were included. 13 So that's why an ordering physician would not 14 be notified, because there was only three and one 15 card they had put the wrong point of interest. We 16 included all three points of interest and used the 17 exam, one code, to include all three. 18 I think you were kind of misunderstanding why, 19 because there was not three cards, regardless of 20 what was written. I wasn't there that day, but this 21 is just protocol, I mean, normal practice, so I just 22 wanted to clarify that with you. 23 MS. VANCE: So the view that was taken 24 reconciles what would have been written on 25 Exhibit 40 and 41, based on his assumption. 42 1 MR. RUF: Objection. Move to strike. 2 THE WITNESS: I didn't understand 3 that. 4 MS. VANCE: Okay. 5 THE WITNESS: I didn't understand 6 that. 7 Q. What information or documentation is produced by the 8 Clinic Radiology Department to let the Kaiser ER 9 physicians or nurses know what views were actually 10 taken? 11 A. They have the actual film. 12 Q. However, a radiology report does not accompany the 13 films, correct? 14 A. Correct. 15 Q. The radiologist dictates the report into the 16 system? 17 A. Correct. 18 Q. And -- 19 A. And also written up here, a little something up 20 there. 21 Q. So you're referring to Plaintiff's Exhibit 40 under 22 emergency physician's interpretation? 23 A. Yes. The radiologist will write a little comment, 24 plus also dictates into the dictating system since 25 40 accompanies the patient back. We do not house 43 1 the films here at the Cleveland Clinic, that's why 2 this req. is provided and a little brief, or 3 whatever the case may be, what they interpret or 4 see, is written down there. 5 Q. So the radiologist would actually write the views 6 that were taken -- 7 A. No. 8 Q. -- on Plaintiff's Exhibit 40? 9 A. That's not what I said. Interpretation, what 10 they've seen off the film. 11 Q. So if the request was rule out fracture, they may 12 say normal -- 13 A. Negative. 14 Q. Or negative forearm? 15 A. Whatever they may be looking at, the point of 16 interest. If they did see, however, they diagnosed 17 it, you know, they just write something. 18 Q. However, the actual views taken would not be listed 19 on Plaintiff's Exhibit 40? 20 A. By the radiologist, no. 21 Q. Would they be listed by any Cleveland Clinic 22 employee? 23 A. No. 24 Q. So a Kaiser emergency room employee would have to 25 actually either look at the films or go into the 44 1 dec-rad card system to see what views were actually 2 taken? 3 A. Kaiser employees don't have access to the dec-rad 4 system. 5 Q. So the only way a Kaiser employee could determine 6 what views were actually taken is to actually look 7 at the films? 8 MS. VANCE: Objection. 9 A. Or call us. 10 MS. VANCE: He also talked about the 11 dictation system. 12 Q. So there's three options, they could actually look 13 at the films, they could call you, or they could 14 listen to the dictation? 15 A. Correct. 16 Q. Other than the order entry screen, is there any 17 other information that is on a computer in the 18 Kaiser ER that relates to radiology? 19 A. For exams to be ordered? 20 MS. VANCE: Do you know? 21 A. No, I don't. 22 Q. Is any other information put into the computer by 23 the Clinic, other than the dec-rad card 24 information? 25 A. Yes. 45 1 Q. What? 2 A. Well, when they complete an exam they have -- you 3 know, they change it, you know, put their names, who 4 completed it, ended, times, stuff like that. They 5 put that into the system when they're done with the 6 exam. 7 Q. Are the views that are actually taken put into the 8 system? 9 A. No, because they're already listed. It just tells 10 you the exam. No. 11 Q. Is there any other information that's put into the 12 computer? 13 A. Just film sizes, film count, times, ending, 14 departure and who did the exam. 15 Q. When you refer to film count, are you referring to 16 number of films or projections? 17 A. Number of films. 18 Q. Were you involved in any way in the actual taking of 19 films for Rodney McClendon? 20 A. No. 21 Q. Do you know the name of the x-ray tech that actually 22 took the projections for Rodney McClendon? 23 A. No. 24 Q. Have we gone through the complete process of what 25 happens when somebody in the Kaiser emergency room 46 1 orders films and the films are actually taken? 2 A. I think so, pretty much. 3 Q. Is there any part of that process that we have not 4 covered? 5 A. Well, I think it's kind of hard to answer yes or no 6 questions without, you know, getting the concept of 7 exactly what really happens. It looks too choppy. 8 Q. Why don't you take me through the whole process 9 then, just so we're clear. 10 A. They order an x-ray, wherever it may be, they put it 11 through the system, it comes up to us on our screen, 12 we print out the exam, the patient comes to us with 13 the requisition, we read over the requisition, we 14 bring the patient in the room, you know, we ask the 15 patient, you know, where do you hurt, this and that, 16 we compare all the information we have, and then we 17 do what we have to do to get that exam done in a 18 timely fashion with a limited amount of exposures, 19 take the films, develop them, complete the exam, 20 give everything to the radiologist, take the patient 21 back. 22 Q. Based upon your experience here at the Clinic, if 23 you were actually involved in the taking of Rodney 24 McClendon's films, if he complained of severe elbow 25 pain to you, are there any views that you would have 47 1 taken or would you have contacted anybody to ask 2 them about additional views that would be different 3 from the views that were actually taken? 4 MS. VANCE: And you're assuming -- are 5 you assuming anything written down on Exhibit 6 40 that he would take into consideration, and 7 anything being written on Exhibit 41 that you 8 would also want to take into consideration, if 9 you're putting him into that hypothetical 10 position? 11 Q. That's fine, if you need to -- 12 A. If the patient came to me, assessing this patient, 13 doing this as long as I have, if I see, regardless 14 what was written here, after I looked at this, read 15 this -- 16 MS. VANCE: Referring to the -- 17 Q. Please refer to the document numbers. 18 A. Sorry. After reading 40 and reading 41, I would 19 compare them both after talking to the patient. If 20 I included all the areas of interest between both of 21 these documents and they were included both on the 22 film, then I know I covered where the patient was 23 complaining, I took the routine views for those 24 points of interest. 25 Q. If he had complained of severe elbow pain would you 48 1 have considered taking a radial head view? 2 A. No. 3 Q. And why not? 4 A. Because a radial head view is usually obtained only 5 after somebody maybe reads the film, be it a 6 nonradiologist like the ordering physician or a 7 radiologist or a resident, that might suspect 8 something different, which only they can see due to 9 the fact of their training of being a radiologist. 10 It is not a normal routine view. 11 I may hit my elbow and, you know, as long as I 12 know that I got these views I'm not going to assume 13 that something is broken or fractured on a radial 14 head or that I would obtain that view. Make sense? 15 Q. Could you tell me all the views or projections that 16 can be taken of the bones in the area of the elbow? 17 A. Well, not without my book. 18 Q. We've talked about a forearm view, we've talked 19 about a radial head view. 20 A. You mean what includes the elbow joint? 21 Q. Yes. Are there any other types of views that can be 22 taken of the elbow area? 23 A. Are you talking about views of the elbow or what 24 other parts of the body include the elbow? Because 25 you threw forearm in there too. 49 1 Q. Well, first, somebody that's suspected of having a 2 fracture of the elbow, what are all of the 3 projections that could be ordered? 4 A. There's -- 5 MS. VANCE: Objection. 6 A. -- several different views. I don't know the names 7 of all of them offhand. I mean -- 8 Q. Well, why don't you tell me the names that you do 9 know. 10 A. Well, there's AP, lateral, condyloid process, radial 11 head view, several more, but I don't know them off 12 the top of my head. 13 Q. Would all those be listed on the order entry 14 screen? 15 A. No. 16 MR. RUF: That's all I have for now. I 17 believe Mr. Leak will have some questions for 18 you. 19 MR. LEAK: Mr. Salupo, my name is Doug 20 Leak. I represent Kaiser. My question is 21 going to be more specific about the procedure. 22 - - - - 23 CROSS-EXAMINATION OF ANTHONY SALUPO 24 BY MR. LEAK: 25 Q. When you said a radiology tech uses Exhibits 40 and 50 1 Exhibit 41, do they use them in conjunction with 2 each other when they're performing the views? 3 A. 40 is provided to us. 4 Q. By Kaiser? 5 A. By Kaiser. 6 Q. Can I clarify one thing then. When you say is 7 provided by Kaiser, you mean it's coming from the 8 Kaiser emergency room department, correct? 9 A. Correct. 10 Q. That means it can come from a PA? 11 A. (Indicating.) 12 Q. Is that a yes? 13 A. Anybody, yes. 14 Q. A doctor? 15 A. Yes. 16 Q. Or a nurse? 17 A. Yes. 18 Q. Do you know whether or not there's nurses in the 19 emergency room department employed by the Cleveland 20 Clinic? 21 A. I don't know -- 22 Q. Okay. 23 A. -- how that works. 24 Q. But it could come from anyone? 25 A. Correct. 51 1 Q. And so what you mean is it's the Kaiser emergency 2 room? 3 A. Correct. 4 Q. Okay. Is that information handwritten? 5 A. Yes. 6 Q. You had also mentioned that Kaiser gets it going in 7 the system, I think, when you were going through the 8 process. And when you say that, do you mean do they 9 put other information into the computer in addition 10 to the requisition form? 11 A. Yes. 12 Q. What is that? 13 A. They use their computer system for all different -- 14 what the specifics are I don't know, but they're 15 used for all different aspects. 16 Q. Do you have access to that to get that information? 17 A. No. 18 Q. Do you know what's contained on that when they get 19 it going through the system, what information they 20 put into that? 21 A. No. 22 Q. So what is coming to you in the radiology department 23 is a handwritten requisition form, correct? 24 A. Correct. 25 Q. Then we have the rad card? 52 1 A. Correct. 2 Q. Who physically generates the rad form? 3 A. Whoever takes it off the screen, our screen. It 4 could be an office assistant or rad tech. 5 Q. So within your department? 6 A. Correct. 7 Q. But what are they working off of when you say off 8 the screen? 9 A. There's different phases of it. Just there's like 10 the first just shows the history number, name, exam 11 order, and then as you continue through it there's 12 another screen that gives -- like shows like their 13 location and street, address and age and birth date, 14 and then the next screen will actually show like the 15 ordering physician. 16 It's the same kind of information, suspect, you 17 know, diagnosis, part of interest, history, but it 18 just shows up differently on this than it does on 19 this. Then you go to a different screen, and it 20 actually shows you what the exam is and then it 21 prints out like room number. 22 Q. I guess what I'm trying to figure out is who's 23 putting the information on the screen that your 24 office person or whoever -- 25 A. Oh, that's all put in by them. 53 1 Q. Is that what you mean by it goes through the system? 2 A. Yeah, they place the orders. They have to place the 3 orders before we know like even anybody is going to 4 be coming down. 5 Q. What is the difference between that information and 6 what's on the requisition form then? 7 A. It's basically the same kind of information. It's 8 just it comes -- the final copy comes out 9 different. 10 Q. Okay. 11 A. It's called schedule. The dec-rad system is you 12 have to schedule it, so we're actually scheduling 13 what they're putting in, even though all the 14 information is already preplaced we're just 15 scheduling. 16 Q. Do you know who on the Kaiser end puts that 17 information into the computer? 18 A. No, I don't. 19 Q. Now, so the information on the rad card does not 20 come from the requisition form? 21 A. From 40? 22 Q. Yeah. 23 A. No. 24 Q. It does not come -- on 41, that information on 41 25 does not come from the requisition form? 54 1 A. No. I mean, like some of the information, like this 2 will say clinical for rule out fracture, rule out 3 fracture, but a lot of times this will be different 4 than what the exams requested are. 5 Q. But you have access to -- 6 A. To both, right, to do, to compare. 7 Q. Do we have any way of finding out before this was 8 rescheduled what was in the place under exam number 9 and forearm two views? 10 A. Well, the exam number, if you look, is the same 11 number as this down here. 12 Q. Got you. 13 A. So that will remain the same. There is a screen 14 that you could look at to see what was originally 15 ordered. 16 Q. Before the forearm two views? 17 A. Correct. 18 MR. LEAK: I'm going to ask if you can 19 produce that if that's available. 20 MS. VANCE: We'll find out if it's 21 printable. I don't know. 22 Q. Now, it's your interpretation when you see this, 23 comments, you don't know what add view means, that's 24 not something normally there, those two words, add 25 view? 55 1 A. No. I mean, it might be something that pops up like 2 automatically, along with which I was trying to 3 explain before. I think it's a combination of 4 comments or additional view. 5 Q. And right and left elbow to wrist, you interpret 6 that to mean forearm views? 7 A. Yeah. Well, I mean, I think technically, yes, but I 8 mean they're just saying that's saying to us for 9 doing x-rays that you want to see everything from 10 the wrist to the elbow. 11 Q. I want you to assume that on the requisition form it 12 said bilateral x-rays of wrist, slash, forearm, 13 slash, elbows. Just so we're clear, how would you 14 interpret that in terms of what views must be 15 taken? 16 MS. VANCE: Taken together with Exhibit 17 41? 18 MR. LEAK: No. This is in general, not 19 specific. 20 A. If I seen that was written there, three different 21 exams? 22 Q. Yes. 23 A. And with this comment here -- 24 Q. I just want you to focus on the requisition form. 25 If you saw that, how would you interpret that? 56 1 MS. VANCE: But -- I'm objecting. 2 A. I would interpret they wanted to see everything from 3 here to here. I mean, that's why they're ordering 4 these things. 5 Q. Even if it said bilateral wrist, slash, forearm, 6 slash, elbow? 7 A. Correct. 8 Q. If someone wanted separate views of the wrist, 9 forearm and elbow, how would you expect to see that 10 written, whether it's in the comment or whether it's 11 on the requisition form? 12 A. They would specify it under exams. 13 Q. Have you ever in your experience had separate views 14 taken at the same time of the wrist, forearm and 15 elbow? 16 A. Yes. 17 Q. I see on this rad sheet there is no mention of where 18 the pain is; am I correct? 19 A. Correct. 20 Q. If it's not on the rad sheet, how do you as a -- is 21 that information you would want to know, where the 22 pain is? 23 A. Correct. 24 Q. How would you determine where that is? 25 A. You ask the patient. 57 1 Q. And if the patient said in the elbow, would you as a 2 radiology tech question whether or not you need 3 separate AP and lateral views of the elbow? 4 A. No. If I looked at something like, I mean, as 5 looking at this, the size of this patient, and he 6 told me that his pain was more distally, I mean, 7 proximal, and I took it and I noticed that I had 8 this and this all looks the way it's supposed to 9 look, then I would know that I gave him what he 10 needed. 11 Q. Do you know in this case then why if there was 12 supposed to be two views of the forearm why there 13 are views of the forearm and then separate views of 14 the wrist? 15 A. To my experience, because this is left here, okay, 16 this is the right here, okay. So what they did was 17 she didn't get, or he did not get, the view. If you 18 notice, this is like kind of dark here, so they just 19 did it to include it because this didn't come out 20 exactly flat, so it's just really a combination. 21 There's no extra charge. 22 Q. So what you're saying is actually the wrist views 23 are an extension of the forearm view? 24 A. Yes, because this may have come out darker. I don't 25 know. I wasn't there. But it does happen on a 58 1 daily practice. 2 Q. You've already answered a lot, so I'm probably 3 checking off a lot. 4 A. That's fine. 5 Q. What is the purpose of having both a requisition 6 form and the rad card? 7 A. Well, these were provided in the beginning when 8 everything opened, 40, because the films aren't 9 housed here, so they won't get a hard paper 10 dictation like the CCF patients do, so that was just 11 provided so they would have a little something up 12 there, whereas -- and this is for dictation purposes 13 and for completing and things like that. 14 Q. I know you weren't involved in this case, but the 15 fact that this was rescheduled, when there's a 16 rescheduling is that because there's some kind of 17 question as to what is supposed to be taken or 18 you're trying to reconcile; under what circumstances 19 is it rescheduled? 20 A. It's rescheduled due to the fact things are always 21 ordered wrong. You know, something different might 22 have been obtained or additional. There could be 23 several different reasons why you would reschedule 24 something. 25 Q. And you believe based upon your experience that the 59 1 reason this was rescheduled was based upon the 2 comment you want to reconcile the exam with what was 3 in the comments section? 4 A. Correct. 5 Q. Do the radiology techs go to the ordering person to 6 clarify whether something like this comes up, a 7 rescheduling question? 8 A. It depends on the -- every situation is different. 9 This particular case, even though, I mean, since 10 there was an individual exam ordered after looking 11 at the screen that I seen what was originally 12 ordered and why it was changed. 13 It was changed because the first thing that was 14 entered, scheduled as, would not have coincided with 15 this comment. So this exam, in return, the reason 16 this is used is because it's including all of these 17 points of interest here. 18 Q. But you don't know without going back and either 19 doing research or looking at the computer system 20 what was there previous to the forearm two views? 21 You know what I'm saying? 22 A. What was that again? 23 Q. You don't know what was in that area of forearm two 24 views? 25 A. Before? 60 1 Q. Before. 2 A. Not until I looked in the computer. 3 Q. Thanks. The commentary, does that mean that what 4 was entered by Kaiser when a person in your 5 department was working off of that to come up with 6 the rad sheet had a separate section called comment 7 also, do you know? 8 A. How their screen looks I know is different than when 9 it comes across on our orders, so I'm assuming this 10 is a separate section, as it shows up on our card. 11 Q. So that could have been a comment section by your 12 department interpreting what was on the information 13 on the screen while they were working up there? 14 MS. VANCE: Objection. 15 Q. Do you know what I mean? 16 A. No, I'm confused. 17 Q. Is that a standard -- 18 A. That shows up if there's something in there or not. 19 The word comments would show up there if there's 20 something in there or not. 21 MS. VANCE: Even if it's blank? 22 THE WITNESS: Correct. 23 Q. So basically the person in your department, whether 24 it's the office personnel, I don't know, whoever is 25 generating the rad sheet, is entering that 61 1 information based upon their review of what's on the 2 Kaiser information? 3 A. No. That was placed in there by Kaiser, not by my 4 employees. 5 Q. On the rad sheet it was placed by a Kaiser -- 6 A. It was placed in their order entry system. It came 7 across on our dec-rad system preprinted. That was 8 not put in by any of my personnel, that was put in 9 by Kaiser. 10 Q. How does it automatically get in on the rad sheet? 11 A. Just as the rest of it, bilateral, fell, they fill 12 it out on the order entry system. None of this is 13 put in by my people. I'm hitting return, return, 14 return until this prints off. This is all placed by 15 them or whoever may place an order. 16 Q. So what you're saying then the original, going back 17 to the forearm two views, what was on there before 18 should also be in their system too, correct? 19 A. Correct. Their original should be in their system. 20 The only thing I can change on this here is the 21 exam. I cannot change any of the other stuff that 22 was placed by them. 23 Q. Then is it fair to say that the change to the 24 forearm two views was made within your department? 25 A. Correct. 62 1 MR. LEAK: And so when I asked the 2 question of producing what was on there before, 3 that information could very well be in the 4 Kaiser system. 5 MS. VANCE: Correct. 6 Q. Would it show up in your system though? 7 A. What they placed? 8 Q. Because the change was made? 9 A. No, no. 10 Q. Okay. 11 A. Wait. The original, what they originally placed? 12 Q. Yes. 13 A. Shows up on our system, yes. So it could be in 14 two. If I could see what they originally placed, 15 no, I couldn't see theirs, I could see mine. 16 Q. Almost done. Do you know in your experience whether 17 it's unusual to have a suspected diagnosis of rule 18 out fracture in an exam of the forearm? 19 A. I mean, rule out fracture could be used for any body 20 part. 21 Q. I mean, have you had circumstances before where 22 you've had rule out fractures and you've just taken 23 views of the forearm? 24 A. Oh, yeah. I mean, fractures, it doesn't have to do 25 with a specific exam, it could be used for 63 1 anything. 2 MR. LEAK: That's all I have. Thank 3 you. 4 MR. RUF: Let's go off the record one 5 second. 6 - - - - 7 (Thereupon, a discussion was had off 8 the record.) 9 - - - - 10 MR. LEAK: Why don't we go on the 11 record because Vicki has already established 12 that we have looked, not we, Vicki and Mr. 13 Salupo have, already looked. 14 Q. I just want to clarify that. EGFO2, is that the 15 code for forearm views? 16 A. Correct. 17 Q. And Vicki and, I guess this is all inclusive, 18 apparently you have gone back and looked at the 19 inquiry thing you called it, I guess? 20 A. Yes. 21 Q. And there was a different code in place at the 22 EGFO2? 23 A. Correct. 24 Q. And my understanding is that that code was 25 consistent with bilateral elbow views? 64 1 A. Correct. 2 Q. And so just to finish up my question before, what 3 happened here, I know you weren't the person there, 4 but what you believe happened is you had the order 5 bilateral elbows show up and you had the comment 6 down below that said right and left elbow to wrist, 7 which you interpret to mean forearms? 8 A. To include the wrist and elbow. 9 Q. And so to make it consistent, it was changed from 10 bilateral elbows to forearm two views? 11 A. That included all the areas of interest. 12 MR. LEAK: Thank you. Now you can do 13 whatever you want in terms of talking with 14 Vicki. Off the record. 15 - - - - 16 (Thereupon, a discussion was had off 17 the record.) 18 - - - - 19 MR. RUF: I don't think I'm going to 20 need to go back to the computer. I just want 21 to clarify. 22 - - - - 23 RECROSS-EXAMINATION OF ANTHONY SALUPO 24 BY MR. RUF: 25 Q. For Rodney McClendon originally it said elbow two 65 1 views; is that correct? 2 A. According to the original screen. 3 Q. And a Cleveland Clinic employee, based on the 4 comments section, went back in and changed that to 5 forearm two views, correct? 6 A. To include all the areas of interest, yes. 7 Q. And that's because there was a request for the 8 wrist, forearm and elbows? 9 A. Yes. 10 MS. VANCE: Well, there was a request 11 for right and left elbow to wrist. 12 A. Correct. I don't have the original number 40 to 13 vouch for what was originally written. I have what 14 was on -- first scheduled on the card, what was 15 rescheduled and what their comments were. This 16 would help a lot, but that's all I have. 17 Q. And the forearm view was taken because it shows the 18 wrist, elbow and forearm? 19 A. Correct. 20 MR. RUF: Thank you. That's all I 21 have. 22 MS. VANCE: Okay. 23 MR. LEAK: Thank you. 24 25 ANTHONY SALUPO 66 1 2 C E R T I F I C A T E 3 4 The State of Ohio, ) SS: County of Cuyahoga.) 5 6 7 I, Laura L. Ware, a Notary Public within and for the State of Ohio, do hereby certify that the 8 within named witness, ANTHONY SALUPO, was by me first duly sworn to testify the truth, the whole 9 truth, and nothing but the truth in the cause aforesaid; that the testimony then given was reduced 10 by me to stenotypy in the presence of said witness, subsequently transcribed into typewriting under my 11 direction, and that the foregoing is a true and correct transcript of the testimony so given as 12 aforesaid. 13 I do further certify that this deposition was taken at the time and place as specified in the 14 foregoing caption, and that I am not a relative, counsel or attorney of either party or otherwise 15 interested in the outcome of this action. 16 IN WITNESS WHEREOF, I have hereunto set my hand and affixed my seal of office at Cleveland, 17 Ohio, this day of , 1999. 18 19 Laura L. Ware, Ware Reporting Service 20 3860 Wooster Road, Rocky River, Ohio 44116 My commission expires May 17, 2003. 21 22 23 24 25