Beruflich Dokumente
Kultur Dokumente
1 APPEARANCES:
2
MR. ROBERT J. CURTIS
3 Attorney at Law
405 Tombigbee Street
4 Jackson, Mississippi 39201
5 REPRESENTING HARRIS CLAIBORNE FRAZIER
6
MR. JOHN W. CROW, JR.
7 Attorney at Law
203 Wagner Street
8 Water Valley, Mississippi 38965
9 REPRESENTING BANCORPSOUTH
10
MS. EILEEN N. SHAFFER
11 Attorney at Law
401 East Capitol Street, Suite 316
12 Jackson, Mississippi 39201
13 REPRESENTING BANCORPSOUTH
14
MR. G. TODD BURWELL
15 Latham & Burwell
618 Crescent Boulevard, Suite 200
16 Ridgeland, Mississippi 39157
17 REPRESENTING CLUB WOODLANDS, LLC, SHELBY
BRANTLEY AND STEVE DAVIDSON
18
19 MR. PAUL M. ELLIS
Butler, Snow, O'Mara, Stevens & Cannada
20 210 East Capitol Street, Suite 1700
Jackson, Mississippi 39201
21
REPRESENTING ST. PAUL TRAVELERS
22
23 MR. DEREK A. HENDERSON
Attorney at Law
24 111 East Capitol Street, Suite 455
Jackson, Mississippi 39201
25
BANKRUPTCY TRUSTEE AND ATTORNEY FOR TRUSTEE
3
1 APPEARANCES:
2
3 MR. JAMES L. MARTIN
Attorney at Law
4 388 Highland Colony Parkway
Ridgeland, Mississippi 39157
5
REPRESENTING THE HINES FAMILY AND KAY ATWOOD
6 VAN SKIVER
7
MS. ROSAMOND H. POSEY
8 Mitchell, McNutt & Sams
1216 Van Buren Avenue
9 Oxford, Mississippi 38655
10 REPRESENTING DIANE BAILEY
11
12 ALSO PRESENT: Gerald Talmadge Braddock
13
14
15
16
17
18
19
20
21
22
23
24
25
4
1 TABLE OF CONTENTS
2
3 Style........................................... 1
4 Appearances..................................... 2
5 Table of Contents............................... 3
6 Exhibit 1 (Agreed Order).................... 7
7 Examination by Mr. Crow......................... 7
8 Examination by Ms. Shaffer...................... 45
9 Exhibit 2 (Copy of Bankruptcy Schedules).... 46
10 Exhibit 3 (Order Granting Examination)...... 58
11 Exhibit 4 (Settlement Statement)............ 58
12 Exhibit 5 (Closing Disbursements Sheet)...... 58
13 Exhibit 6 (Assignment of LLC Interest)...... 58
14 Exhibit 7 (Amendment to Operating Agreement) 58
15 Exhibit 8 (Operating Agreement)............. 58
16 Exhibit 9 (Amendment to Operating Agreement) 58
17 Exhibit 10 (Legacy Bank Documents).......... 58
18 Exhibit 11 (December 15, 2005, Email)....... 58
19 Exhibit 12 (Escrow Closing Statement)....... 58
20 Exhibit 13 (Seller's Escrow Agreement)...... 58
21 Exhibit 14 (Six Shooter Operating Agreement) 58
22 Exhibit 15 (Amendment to Operating Agreement) 58
23 Exhibit 16 (April 24, 2006, Document)........ 58
24 Exhibit 17 (Assignment of Six Shooter Land).. 58
25 Exhibit 18 (Assignment of LLC Interest)...... 58
5
1 (Oath administered)
2 MR. HENDERSON: My name is Derek Henderson.
3 I'm the bankruptcy trustee and the attorney for the
4 trustee in the bankruptcy case
5 MR. MARTIN: I'm Jim Martin, attorney for the
6 Hines family and also Kay Atwood Van Skiver.
7 MS. POSEY: I'm Rosamond Posey and I'm here
8 on the behalf of Diane Bailey.
9 MR. ELLIS: Paul Ellis representing
10 Travelers.
11 MR. BURWELL: Todd Burwell representing Club
12 Woodlands, Shelby Brantley and Steve Davidson.
13 MS. SHAFFER: Eileen Shaffer representing
14 BancorpSouth.
15 MR. CROW: John Crow representing
16 BancorpSouth in connection with the civil case,
17 BancorpSouth vs. Van Buren Group and others.
18 MR. CURTIS: Bob Curtis representing
19 representing Claiborne Frazier.
20 MS. SHAFFER: Mr. Frazier, I'm Eileen Shaffer
21 representing BancorpSouth. You're here present today
22 pursuant to an agreed order regarding a motion for
23 Rule 2004 Examination of you on behalf of BancorpSouth
24 as well as others. Are you familiar with that order?
25 THE WITNESS: Yes.
7
1 civil suit?
2 A I am.
3 Q Okay. Now, you obtained a $5.4 million loan
4 from BancorpSouth. Correct?
5 A I did.
6 Q All right. Can you tell me who you dealt
7 with initially when the loan process started for the
8 bank?
9 A Right. This was back in 2001. I dealt with
10 a guy named Bobby Little.
11 Q Okay. Did you deal with anyone else from
12 that point forward in connection with your loan with
13 the bank?
14 A Yes. There was a Ron Winford that was
15 involved, and I dealt with two others -- I can't think
16 of their names right now -- that would sit in. And I
17 also had relations with BancorpSouth because they
18 bought a lot out at one of my developments in Madison
19 back in 2003, and they were somewhat involved with the
20 Van Buren loan. I'm thinking -- I can't remember
21 their names right now.
22 Q They were bank officers?
23 A They were.
24 Q All right. Did they have anything to do
25 with the Van Buren financing?
9
1 William Smith.
2 Q All right. And did you later deal with a
3 law firm by the name of Watkins & Eager?
4 A When Taylor, Covington & Smith merged, I did
5 deal with Watkins & Eager, but the best I recollect, I
6 had already sold most of the units at this point.
7 Q All right. Do you remember the name of the
8 attorney or attorneys that you dealt with at Watkins &
9 Eager?
10 A It would have been the same ones. I
11 referred at the time to the Taylor, Covington & Smith
12 group because I dealt with them, you know, since I'd
13 been in the real estate business.
14 Q Then you don't remember any other lawyers
15 that -- Taylor, Covington & Smith merged with Watkins
16 & Eager. Is that not correct?
17 A That's correct.
18 Q And you don't remember any names of the
19 Watkins & Eager firm members that you might have dealt
20 with?
21 A None others that had anything to do with the
22 Van Buren.
23 Q Looking at some of the documents that I have
24 in this case, I see the name of Ben Williams. Did you
25 deal with him --
13
1 A I did.
2 Q -- in connection with disbursing any of the
3 proceeds of these sales?
4 A I don't recall Ben handling anything on the
5 Van Buren today. I would -- there was Bobby
6 Covington's secretary who, I believe, went to Watkins
7 & Eager with the merger. Her name was Sidra and she
8 would prepare documents, and I never knew -- it was my
9 understanding -- this was back in '03/'04 -- that she
10 was wrapping up Bobby Covington's work while he was
11 slowly retiring and moving somewhere in Georgia where
12 his kids were. You know, Ben could have prepared some
13 documents and given them to Sidra for me to pick up.
14 I'm not sure.
15 Q Do you remember a Roger W. Williams?
16 A I do.
17 Q All right. What would Bobby Covington do
18 for you in this process? Or Taylor, Covington &
19 Smith, what role did they play in the sale of these
20 units?
21 A Well, let me clarify. They prepared all of
22 the condominium documents, the declaration, the rules
23 and regulations, everything down to the closing
24 documents.
25 Q Did you -- when you say "closing documents,"
14
1 A I don't recall.
2 Q What about Unit 309? That's the last one
3 that had not been sold that you lost at a municipal
4 tax sale. You didn't have any type of agreement at
5 that time that fell apart thereafter, 309?
6 A No. I recall hearing some of the owners in
7 Van Buren making lowball offers, but at this point,
8 and it's still my understanding, there is a Dana Kelly
9 involved and I've been keeping in touch with him every
10 month or so and they were doing a judicial foreclosure
11 on that unit and going to credit the judgment, and
12 that's the last conversation I had with him.
13 Q I want to talk a little bit about the
14 process of the closing of a unit. Were you provided
15 with a closing statement in connection with the sale
16 to John and Lynn Albritton?
17 A Yes.
18 Q What about Langston-Oxford Properties?
19 A Yes.
20 Q Lynn Grenfell?
21 A Yes.
22 Q John Lee?
23 A Yes.
24 Q Norma Bordeaux?
25 A Yes.
19
1 A Yes.
2 Q How long did she work for you before?
3 A She worked for -- she actually worked for
4 the construction company, which was owned by my father
5 and brother, and the best I recall, she started around
6 1995.
7 Q And so she was let go or did she quit or was
8 she terminated or what?
9 A She -- we were taken over by our bonding
10 company, St. Paul Travelers, the construction company
11 was. She worked for them for a short stint wrapping
12 up some unfinished business, and I don't know where
13 she is or what she's doing now.
14 Q When was the last time you talked to her?
15 A Back in 2007, and I don't recall what month.
16 Q And why did you talk to her? Do you
17 remember?
18 A She was at the office where I had an office,
19 and at this point, our bonding company had come in and
20 taken over control and I just saw her there in the
21 office. I remember because I was moving some of my
22 things out.
23 Q In connection with the Albritton sale, of
24 course, we weren't paid. The account, your loan, was
25 not reduced with those sales proceeds. Is that
24
1 correct?
2 A I don't recall.
3 Q Well, do you remember what you did with that
4 money? Because the bank didn't get it.
5 A Again, it's my testimony that all of the
6 money that went in the Van Buren account and was used
7 for the project.
8 Q Well, who put it in there?
9 A It would have either been someone on behalf
10 of my company or there were times I recall that Sidra
11 Allison, Bobby Covington's assistant, would make
12 arrangements to get releases signed, would send a
13 runner if the purchaser lived here in the Jackson
14 area. She was the go-between. She would have
15 documents ready for me.
16 I would run to either Taylor, Covington &
17 Smithing or Watkins & Eager's office where it is now,
18 here in downtown Jackson, and I would run by and sign
19 documents, but I don't remember the specifics of each
20 transaction.
21 Q The payments -- you remember making payments
22 on the loan, don't you?
23 A Not -- that's broad. I don't remember each
24 payment that I made on the loan, no.
25 Q Well, do you remember making a payment for
25
1 Bobby Noah?
2 A I don't.
3 Q Tim Ford?
4 A I don't.
5 Q John Lee?
6 A What I do remember about John Lee, he
7 purchased two units, and I remember him coming down
8 and purchasing the unit and dealing with -- I had
9 signed some documents and he dealt with a Ron Winford
10 and that's all I remember about John Lee.
11 Q Do you remember making any payments on
12 behalf of the sale to Langston-Oxford Properties?
13 A I don't.
14 Q And I'm referring to payments to the bank.
15 So you can't say that you did?
16 A I don't recall the specifics of each
17 transaction.
18 Q All right. Would Sammie Sartain be the one
19 that would deliver a check to BancorpSouth as far as
20 sales proceeds? Would she be the one?
21 A As I testified earlier, it could have been
22 someone on behalf of my company or it could have been
23 Taylor, Covington & Smith or Watkins & Eager.
24 Q When you say someone on behalf of your
25 company, you're referring to Sammie Sartain?
26
1 A Correct.
2 Q Would it be anyone else with your company?
3 A Could -- could have been my father if I was
4 out of pocket at times. I would narrow it down to
5 Sammie, my father, C.E. Frazier, myself or Sidra at
6 Taylor, Covington & Smith.
7 Q Did you ever tell Sidra at Taylor, Covington
8 & Smith or Bobby Covington or anyone at the firm of
9 Watkins & Eager not to send a check to BancorpSouth
10 Bank in connection with the sale?
11 A No.
12 Q Lynn Grenfell: Do you remember making a --
13 that unit was sold to her. Do you remember making a
14 payment to the bank for that sale?
15 A I don't.
16 Q Norma Bordeaux?
17 A I don't recall.
18 Q And you had one bank account that all these
19 proceeds went in, possibly another one, in the Oxford
20 area?
21 A Correct.
22 Q And those accounts would reflect all
23 disbursements made including construction costs and
24 payments on the debt?
25 A Yes.
27
1 proceeding?
2 A Yes.
3 MS. SHAFFER: If I could have those marked
4 as BancorpSouth's Exhibit No. 2, please.
5 (Exhibit 2 marked)
6 BY MS. SHAFFER:
7 Q Mr. Frazier, I'm just going to ask you a
8 couple of questions regarding those schedules because
9 I know we went into them in depth at your 341(a)
10 hearing, but did you review these schedules before you
11 signed them?
12 A Yes, I did.
13 Q Okay. I believe at the 341(a) hearing, you
14 testified that your address has changed since your
15 bankruptcy petition was filed. Is that correct?
16 A Correct.
17 Q And can you give me that address again?
18 A Yes. It's 775 Unit 36 Gulf Shore Drive,
19 Destin, Florida 32541.
20 Q And have you begun receiving mail at that
21 address?
22 A Just last week, yes.
23 Q Do you know why mail mailed to that address
24 would be returned?
25 A Only because the unit is in my stepfather
47
1 like that.
2 Q Okay. If I can call your attention to
3 Schedule A, which is a listing of real property on
4 your schedules, I just want to clarify a question that
5 was asked of you earlier. It's about four pages -- or
6 three pages over.
7 A Okay.
8 Q Do you see the second entry, Mathena
9 Wetlands?
10 A Right.
11 Q And I believe Mr. Crow asked you if there
12 was any debt on that property, and I understood you to
13 say that there was none.
14 A There is none, and let me --
15 MR. CURTIS: That's an error.
16 A Rob and I corrected this, and apparently it
17 has not been resubmitted, but it's corrected here on
18 his copy. There is no debt on Mathena Wetlands.
19 BY MS. SHAFFER:
20 Q So as I understand, the $750,000 that's
21 listed here as a debt is not correct?
22 A That's not correct.
23 MR. CURTIS: We need to amend that, Eileen,
24 to take that off because that's just an error.
25 BY MS. SHAFFER:
49
1 Country Club?
2 A I don't.
3 Q And when did you divest yourself of that
4 stock?
5 A Oh, gosh, over a year ago.
6 Q And did you sell that?
7 A There were some bills that were due. And
8 you can't sell the stock -- well, I won't say you
9 can't, but you only get like $2,000 or so, and I
10 recall them just -- there was some -- I was behind on
11 my dues there at the Country Club and they pulled that
12 money out. I recall getting a check in the mail for
13 $100 or $200 or so.
14 Q Do you own stock in any other country club?
15 A I do not.
16 Q Did you ever have an interest in Tiger
17 Enterprises, LLC?
18 A I did.
19 Q And when did you divest -- do you still have
20 an interest in that property?
21 A I don't.
22 Q And when did you divest yourself of that
23 interest?
24 A 2005 or 2006.
25 Q And what did you do with that property?
54
1 A Correct.
2 Q So do you still have an interest in the
3 company?
4 A I do not.
5 Q Do you have an interest in any other
6 companies that have not been listed previously?
7 A No.
8 Q I believe you also testified at the 341(a)
9 hearing, as well as briefly today, that you had a bank
10 account for Van Buren, LLC, at BancorpSouth. Is that
11 correct?
12 A Yes.
13 Q Did you only have one bank account at
14 BancorpSouth for Van Buren?
15 A Yes, for Van Buren.
16 Q Did you have any other business accounts at
17 BancorpSouth?
18 A Yes.
19 Q So is it my understanding that any proceeds
20 that you received as a result of the sale of the
21 various condos and units that Mr. Crow asked you
22 about, would those monies have been deposited only in
23 that BancorpSouth account?
24 A Yes.
25 Q Do you know of any reason why there would
56
1 Is that correct?
2 A Correct.
3 Q Take a look at Exhibit 4.
4 A Okay.
5 Q Is that the closing statement for the
6 purchase of that property by Flowood Developers, LLC?
7 A Yes.
8 Q Did Frazier Development, LLC, ever make any
9 capital contributions to that LLC?
10 A Yes.
11 Q What were they?
12 A When the property was not cash flowing for
13 the first year or so, we would make the bank payments
14 to satisfy the monthly note.
15 Q Okay. And how many payments did you make?
16 A Well over 12. I don't recall the amount.
17 Q Okay. Did Frazier Development, LLC, put up
18 any cash in terms of an investment at the beginning or
19 in the formation of Flowood Developers, LLC?
20 A I don't recall.
21 Q In connection with the purchase of the
22 property, that LLC got a loan for the full amount of
23 the purchase price. Correct?
24 A I don't recall the exact purchase price.
25 Q Look at the Exhibit 4 in front of you and
61
1 it reassessed?
2 Q Yes. Is that something you were supposed to
3 be doing?
4 A That is something Steve Davidson and I were
5 collectively working on.
6 Q Did you have any tenants at that property
7 out there?
8 A We did.
9 Q And who were those tenants?
10 A There was a Tandy Wansley who operated some
11 grain storage along the railroad tracks that came in
12 at some point. There was a Bekeson Glass that was the
13 original tenant that occupied about 5 percent of the
14 space. And there was some welding company, and I
15 don't recall their name.
16 Q Is it C. West (phonetic)?
17 A That's it.
18 Q Okay. Who was responsible for collecting
19 the rent from those tenants on behalf of the LLC?
20 A Again, my father, C.E. Frazier, Sammie Satin
21 or myself.
22 Q Were all rents collected from the tenants
23 who were leasing properties from that LLC deposited in
24 the Merchants & Farmers account?
25 A I don't recall.
64
1 A Yes.
2 Q Dividend payments?
3 A Yes.
4 Q Attorneys' fees?
5 A I don't recall.
6 Q Now, at any time, did Flowood Developers,
7 LLC, sell any of the property that it owned while
8 Frazier Development was still a member?
9 A There were no physical properties sold.
10 Q Were there any properties sold by Flowood
11 Developers to John Laws --
12 A Let me -- that rings a bell. Yes, there was
13 a small piece of property sold, yes.
14 Q Take a look at Exhibit 5 for me.
15 A Okay.
16 Q Is that a closing disbursement sheet from
17 the sale of that small piece of property by Flowood
18 Developers to John Laws and Janice Laws Nance?
19 A Yes.
20 Q Now, that document, Exhibit 5, is not signed
21 by you. Do you remember signing that document?
22 A I remember the document, and, yes, I recall
23 signing this when we sold the land to Laws.
24 Q Now, looking at Nos. 3 and 4 on that closing
25 disbursement statement, can you tell me -- excuse me,
70
1 Metro.
2 Q And what was Frazier Development's interest
3 in Jackson Metro Properties?
4 A I don't recall.
5 Q Was it more than 50 percent?
6 A At a point in time.
7 Q Was Frazier Development, LLC, the manager of
8 Jackson Metro Properties, LLC?
9 A Yes.
10 Q Okay. And who on behalf of Frazier
11 Development, LLC, was authorized to act on its behalf?
12 A My father and myself.
13 Q Take a look at Exhibit 8. Can you tell me
14 what that document is?
15 A It's the operating agreement of Jackson
16 Metro Properties.
17 Q Okay. I want you to take a second and look
18 through that. This is not a signed copy, but I want
19 you to review it and let me know if it's the final
20 version, what you remember of the final version of the
21 operating agreement of Jackson Metro Properties, LLC.
22 A This is the final operating agreement, but
23 it was amended as other members bought into the
24 properties.
25 Q Understood. Okay. If you would, look on
76
1 A I don't.
2 Q If I told you that Jason Young bought his
3 interest -- his 12.5 percent interest for $175,000 in
4 2003, would you be able to dispute that?
5 A As an apples-to-apples comparison, yes, I
6 would.
7 Q What do you mean by that?
8 A We did not own the amount of land in 2003
9 that the company should still own now.
10 Q Do you have any information to dispute that
11 Jason Young bought a 12.5 percent interest in that LLC
12 for $175,000?
13 A No.
14 Q Take a look at Exhibit No. 15 for me,
15 please. Is that the first amendment to the operating
16 agreement for Six Shooter Land & Timber, LLC?
17 A Yes.
18 Q And on the last page of Exhibit 15, is that
19 your signature, third up from the bottom?
20 A Yes.
21 Q And does this amendment acknowledge and
22 ratify the addition of John Davidson and Jason Young
23 as members in the LLC?
24 A Yes.
25 Q When did you first assign your interest in
90
1 A Correct.
2 Q Read Line 1 for the court reporter.
3 A "We acknowledge a debt of $390,000 to Club
4 Woodlands, LLC, and agree to repayment in six weeks."
5 Q And the "we" is talking about Claiborne
6 Frazier, Frazier Development and Frazier Construction?
7 A Right.
8 Q Okay. Did you pay Club Woodlands, LLC,
9 $390,000 within six weeks of April the 26th of '06?
10 A No.
11 Q If you'll look at Exhibit 17 for me, do you
12 recognize this document?
13 A Yes.
14 Q Is this an assignment of membership interest
15 in Six Shooter Land & Timber, LLC?
16 A Yes.
17 Q Turn to the second page of that document.
18 Is that your signature on the left-hand side under
19 "Assignor"?
20 A Yes.
21 Q And what is the date of your signature?
22 A 05/18/06.
23 Q Did you sign more than one assignment in
24 connection with your interest in Six Shooter Land &
25 Timber, LLC?
92
1 A Yes.
2 Q The date of this is September 1st of 2006?
3 A Right.
4 Q The members of Club Woodlands, LLC, are
5 Steve Davidson and Shelby Brantley. Is that correct?
6 A That's correct.
7 Q And turning to the back page of this --
8 excuse me, the next to last page of this document, is
9 that your signature on the upper left-hand side where
10 it says "Frazier"?
11 A Yes.
12 Q And then on every page at the bottom of the
13 page, are those your initials?
14 A Yes.
15 Q Did you put those initials there?
16 A Yes.
17 Q Whose initials are "A.F."?
18 A My brother, Austin Frazier.
19 Q Did he put those initials there?
20 A Yes.
21 Q Turning to the next to last page of that
22 document, is that Austin's signature next to the
23 bottom of that page?
24 A Yes.
25 Q Is that your signature at the bottom of that
94
1 page?
2 A Yes.
3 Q And this document was signed September 1st,
4 2006?
5 A Yes. Well, let me clarify. It's dated
6 September 1st of 2006. I'm not sure when I signed
7 this document.
8 Q Do you have any reason to dispute that it
9 was signed September the 1st of 2006?
10 A Yes, I do.
11 Q And why is that?
12 A It was routine for the doctors in the group
13 to fight over documents such as the operating
14 agreement, us refinancing the loan, items of that
15 nature. It was very hard to make decisions up there
16 with those guys -- being Brantley, one of the members,
17 Carroll McLeod and Steve Davidson -- by virtue of us
18 not having a Six Shooter Lodge operating agreement at
19 the time we built the lodge because people would talk
20 about the language.
21 So it was not routine for a document to be
22 dated, for example, 2004 and not be signed by
23 everybody for six or seven months later.
24 Q So you don't have any personal recollection
25 as to when this was actually signed, then, do you?
95
1 A I do not.
2 Q On the first page of Exhibit 18, Paragraph
3 2, provides that there is a right to repurchase. In
4 essence, that paragraph says that for $300,000 plus
5 interest, you could repurchase the interest you had
6 assigned in Six Shooter Land & Timber. Is that
7 correct?
8 A Correct.
9 Q If that payment was made before June the 1st
10 of 2007. Correct?
11 A Correct.
12 Q Was the $300,000 plus interest ever paid
13 back to Shelby Brantley, Steve Davidson or Club
14 Woodlands, LLC, by June the 1st of 2007?
15 A No.
16 Q If you would look at Exhibit 18 -- excuse
17 me, 19. Can you identify that document?
18 A Yes, it's another assignment of limited
19 liability company interest to Club Woodlands.
20 Q And what's the date of that assignment?
21 A October 12th, 2006.
22 Q Okay. Turn to the next to last page, Page
23 3, of Exhibit 19. Is that your signature on that
24 page?
25 A Yes.
96
1 sales that took place and pay down the loan that Van
2 Buren, LLC, owed. Correct?
3 A I don't recall.
4 Q You were the managing member of Van Buren,
5 LLC --
6 A Yes.
7 Q -- as manager of Frazier Development, LLC.
8 Correct?
9 A Correct.
10 Q Did Shelby Brantley put up any other cash in
11 connection with Van Buren, LLC, that you're aware of?
12 A No.
13 Q All right. If you'll look at the next
14 exhibit, Exhibit No. 21, can you identify that
15 document for me?
16 A Yes, it's the operating agreement of
17 Gluckstadt, Restaurant, LLC.
18 Q And on the signature page of that document,
19 is that your signature?
20 A Yes.
21 Q Okay. Who were the members of Gluckstadt
22 Restaurant, LLC?
23 A Shelby Brantley and Frazier Development.
24 Q Who was the manager of that LLC?
25 A Let's see. Frazier Development.
102
1 Q As individuals?
2 A There was really -- it was a homemade
3 trailer. It was never titled.
4 Q Okay. And you said it was "homemade." Did
5 y'all pay for the trailer or did you make it
6 yourselves?
7 A We hired out welders and they made it for
8 us.
9 Q Where is that trailer now?
10 A It's at my stepfather's office.
11 Q Is it still for sale?
12 A No.
13 Q Where is your stepfather's office?
14 A I-55 in Jackson.
15 Q Do you know the address?
16 A 4705 I-55 Frontage Road.
17 Q What is the business located in that office?
18 A Josten's Class Rings and National Awards.
19 Q And do you, your father and brother own that
20 trailer equally?
21 A Yes.
22 Q There is no LLC agreement or operating
23 agreement for Six Shooter Lodge. Is that correct?
24 A There is one that four of the six members
25 signed.
111
1 Metro debt.
2 Q Okay. Well, if you look at Paragraphs 2 and
3 3, I think it says that it's related to those.
4 A It does. It does.
5 Q All right. But you don't dispute that you
6 signed this back in April of '06?
7 A I don't.
8 Q All right. So at a point in time, who
9 actually owes Club Woodlands? Do you personally owe
10 this debt or does Frazier Development owe the debt or
11 is it Frazier Construction that owes the debt or a
12 combination?
13 MR. BURWELL: Object to form.
14 A I would say it's a combination.
15 BY MR. HENDERSON:
16 Q Okay. And why do you say that?
17 A I was a member of Frazier Development. I
18 was the manager. I would say it would be more myself
19 and Frazier Development than Frazier Construction.
20 Q Did you personally owe Club Woodlands, LLC,
21 any money?
22 A No.
23 Q Okay. If you owe them 390- and then you
24 give them -- Club Woodlands, this Frazier Development
25 gives them an LLC, this agreement, but you don't know
118
1 how much credit you got, but you in your mind were
2 thinking 250- for the Flowood Developers?
3 A That's discussions that I had with Davidson.
4 Q Okay. So if you owed 390- and you got a
5 $250,000 credit after you gave them Flowood
6 Developers, did you just owe them the balance at that
7 point?
8 MR. BURWELL: Object to form.
9 A Yes, I owed them the balance. And as I
10 testified earlier, the only property that I had that
11 was unencumbered was the land at Six Shooter.
12 BY MR. HENDERSON:
13 Q Okay. Now, let's talk about that.
14 Exhibits 18 and 19 are two more assignments. Correct?
15 A Correct.
16 Q Do you remember these ones dated September
17 of '06, No. 18, and then No. 19 is dated October of
18 '06?
19 A I remember those from the meeting today. I
20 did not remember those prior to coming here today.
21 Q Okay. Let's talk about No. 18. I'll give
22 that back to you. It's dated first. This is dated
23 September of '06. Now, it's styled "Assignment." Is
24 that correct?
25 A It is.
119
1 A Correct.
2 Q And did you -- tell me why you gave this
3 assignment to Shelby Brantley. If you didn't owe him
4 any money and you didn't get any credit from him, why
5 would you sign this and give it to him?
6 A Because I was trying to repay them the debt
7 that was owed by Jackson Metro/Frazier Development.
8 And they approached me, being Davidson and Brantley,
9 at different times when they saw that the Colony
10 Crossing first sale had not gone through. It was my
11 intent to collateralize what was owed by Frazier
12 Development/Jackson Metro to Club Woodlands.
13 Q Okay. At the bottom of that first page,
14 Mr. Burwell pointed this paragraph out, Paragraph
15 No. 2, talking about the right of repurchase.
16 A Correct.
17 Q Okay. So it was clearly a purchase of
18 Mr. Brantley?
19 A Correct.
20 Q But you're telling me you still don't know
21 what the price was?
22 A That's --
23 Q I mean, isn't that what you're saying?
24 A That's what I'm saying, correct.
25 Q Okay. It also says at the top of that same
122
1 A Correct.
2 Q And that's between you individually and Club
3 Woodlands, LLC?
4 A Correct.
5 Q Okay. So this assignment is roughly a month
6 after the one you've already given Shelby Brantley
7 individually. Is that correct?
8 A Correct.
9 Q Okay. And you, again, personally are
10 assigning what in this agreement? What are you
11 transferring?
12 A My interest in Six Shooter Land & Timber.
13 Q Okay. And hadn't you just assigned that
14 same interest to Shelby Brantley on September 1st, the
15 agreement we just looked at?
16 A That's correct.
17 Q Okay. So you did it on September 1st, '06,
18 and then you turned around and did it again in
19 October of '06, but this time it didn't go to Shelby
20 individually, did it?
21 A Correct.
22 Q It went to Club Woodlands, LLC?
23 A Correct.
24 Q Okay. Was this considered to be a sale or
25 an assignment?
124
1 A In my opinion, an assignment.
2 Q Okay. And did you -- what did you receive
3 personally for signing this agreement?
4 A The Six Shooter land agreement, it was my
5 intention for it to collateralize and make up the
6 balance of the debt over and above the $250,000 that I
7 pegged for the Flowood assignment. And there were
8 several discussions that I had at different times with
9 Brantley and Davidson of when Colony Crossing sold, I
10 would pay them some $150,000, a hundred to a hundred
11 and fifty, and I would get the Six Shooter land back,
12 but that never happened. I never got the cash and I
13 was never able to make a sale from 2005 on that I got
14 any sizable amount of cash, you know, $10,000.
15 Q Well, there's no repurchase agreement in
16 this second assignment, is there?
17 A There is not.
18 Q Okay. The first agreement, you sold it to
19 Shelby, and the second agreement you gave Club
20 Woodlands an assignment?
21 A Correct.
22 Q Is that fair?
23 A That's fair.
24 MR. BURWELL: Object to the form.
25 BY MR. HENDERSON:
125
1 A Yes.
2 BY MR. BURWELL:
3 Q The 2,500 acres that Mr. Henderson asked you
4 about, you don't personally own any part of that 2,500
5 acres, do you?
6 A That's correct.
7 Q Do you know if John Davidson has signed any
8 consent or ratification to the assignment of your LLC
9 interest in Six Shooter Land & Timber?
10 A I don't know that.
11 MR. BURWELL: That's all I have.
12 MR. ELLIS: Let's go off record for a
13 minute.
14 (Off record)
15 EXAMINATION
16 BY MR. ELLIS:
17 Q Mr. Frazier, my name is Paul Ellis. I
18 represent Travelers. In my motion for the Rule 2004
19 Examination, we requested some documents. Have you
20 brought -- which was granted by the Court. Have you
21 brought those documents to the examination today?
22 A No. I just saw it last night when I met
23 with my attorney.
24 Q Okay.
25 A And I'll be glad to get to you I'd say
135
1 within 30 days --
2 Q Okay.
3 A -- what I have.
4 MR. CURTIS: We don't have most of what was
5 on the list. We don't have most of what was on the
6 list.
7 MR. ELLIS: Okay.
8 MR. CURTIS: There were a good many
9 documents there. Most of that is not available to us.
10 BY MR. ELLIS:
11 Q All right. When did you enter into the
12 charging order with the Hines with respect to I think
13 it was the Tupelo Development, LLC?
14 A I'd have to look. I don't recall. I don't
15 recall the exact date.
16 Q What year?
17 A 2006.
18 Q Do you recall about which month?
19 A I don't.
20 MR. CURTIS: May I interrupt for just a
21 moment to interject something? We did bring you some
22 of the documents, very limited, but we do have a few
23 things for you.
24 MR. ELLIS: Okay. I would appreciate
25 whatever documents you have.
136
1 A 2002.
2 Q Okay. And what was the purpose of the
3 formation of that limited liability company?
4 A To develop a shopping center in Madison.
5 Q Okay. And if you can, look on Page 20 and
6 just tell me the members and their membership
7 interest?
8 A Frazier Development and LEG Properties.
9 Q Okay. And both had a 50 membership
10 interest. Correct?
11 A Correct.
12 Q And you were the manager of Madison Market.
13 Correct?
14 A Yes.
15 Q And you were in charge of the day-to-day
16 operations?
17 A Yes.
18 Q And you were authorized by the operating
19 agreement to purchase, hold and sell property on
20 behalf of Madison Market. Correct?
21 A Yes.
22 Q Okay. The third exhibit, I believe it's 26,
23 is the HUD settlement statement from the sale of
24 Madison Market?
25 A Yes.
141
1 A I don't.
2 Q Okay. Did you give notice of the sale to
3 the members?
4 A No.
5 MS. POSEY: Okay. I think that's all the
6 questions I have.
7 EXAMINATION
8 BY MR. MARTIN:
9 Q Mr. Frazier, I'm here on behalf of the Hines
10 family and also Kay Atwood Van Skiver. Looking at
11 Exhibit 26, which appears to be the closing statement
12 for the sale of the Madison Market Shopping Center, it
13 reflects a payment to Watkins & Eager for either
14 25,000 and change or 35,000 and change; I can't
15 discern the exact amount. Do you know what those
16 funds were paid to Watkins & Eager for?
17 A Not exactly.
18 Q Do you know whether or not that represents
19 the legal fee for handling this one transaction?
20 A I assume so.
21 Q Or was it other work that you or any of your
22 companies may have engaged Watkins & Eager on?
23 A It could have been, but I'm not sure.
24 Q Okay. And you were asked about the bank
25 that had the mortgage on this property. Line 610
145
1 Plantation?
2 A My wife has dealt with several brokers, and
3 I don't recall -- I don't recall the companies, but
4 these are houses that are in foreclose and/or short
5 sales.
6 Q And so your testimony is that you personally
7 have no interest in any property at Kelly Plantation
8 at this time?
9 A I do not.
10 Q Nor have any under contract?
11 A I do not.
12 Q Where is your wife employed or does she
13 work?
14 A Presently she's employed for Fox-Everett.
15 Q In Jackson?
16 A Correct.
17 Q Where did you -- did you hunt this past
18 hunting season?
19 A I did.
20 Q Where did you hunt?
21 A In Belzoni, Mississippi.
22 Q At what club?
23 A Both my stepfather's club and Mathena
24 Wetlands.
25 Q Your stepfather's club is named what?
149
1 Development, LLC?
2 A I did.
3 Q When was that?
4 A I want to say it was 2004.
5 Q And how did you -- what exchange -- what did
6 you pay for it?
7 A It was assigned to me at the request of the
8 bonding company at the time and there was nothing
9 paid.
10 Q Did you assign or convey your interest in
11 the construction company --
12 A I did not.
13 Q -- to Austin?
14 A I never owned any of the construction
15 company. Now, let me take -- the Jackson construction
16 company. We did have a company at the time in Tupelo,
17 and I think I assigned that to him back then.
18 Q You assigned your interest in the Jackson
19 construction company or the Tupelo construction
20 company?
21 A Tupelo. I never owned any of the Jackson
22 construction company.
23 Q What is or was the name of the Tupelo
24 company?
25 A It started as Pryor & Frazier Construction,
151
1 A Yes.
2 Q On your statement of intention, you have
3 indicated that you assigned the proceeds of the sale
4 of Duck & Rice Farms, LLC, to Billy Atwood. Do you
5 recall that?
6 A I do recall that.
7 Q Okay. Have you executed a document that
8 assigns your interest in Duck & Rice Farms, LLC?
9 A I remember executing a document, among some
10 other things, in an effort to pay Billy Atwood back,
11 and I can't recall what all -- without looking at the
12 document what all was up there, but Duck & Rice Farms
13 sold, I don't know, about two or three years ago.
14 Q Did Mr. Atwood receive any of the proceeds
15 from the sale of Duck & Rice Farms?
16 A No.
17 Q Who are or were the members of the Duck &
18 Rice Farms, LLC?
19 A Frazier Development or Claiborne Frazier
20 owned 50 percent; I can't remember which one. The
21 other partner is a guy named Steve Grisham who is a
22 local farmer in Belzoni.
23 Q Okay. Do you remember executing a
24 promissory note to Kay Atwood Van Skiver --
25 A I do.
154
1 Q -- of $75,000?
2 A I do.
3 Q Is that a copy of the note?
4 A Yes.
5 MR. MARTIN: Let's have this marked.
6 (Exhibit 27 marked)
7 BY MR. MARTIN:
8 Q Did Mrs. Van Skiver loan you $75,000?
9 A She did.
10 Q That was September 15 of '06?
11 A Correct.
12 Q So you would have received her check or her
13 cash sometime around September 15th of '06?
14 A Correct.
15 Q How did you -- what did you represent to her
16 as to how you would repay that note?
17 A This document.
18 Q Okay. Among other things, it says that it
19 would be paid out of the proceeds of the sale of Duck
20 & Rice Farms, LLC.
21 A That's correct.
22 Q Okay. And you indicated that Duck & Rice
23 Farms, LLC, did sell its land?
24 A It did.
25 Q How much acreage did Duck & Rice Farms own
155
1 at that time?
2 A About 850 acres.
3 Q Okay. Do you remember who you sold it to?
4 A I don't specifically.
5 Q Okay. Would you agree with me that the sale
6 of that property occurred in October of '06?
7 A That sounds right, yes.
8 Q Okay. Let me hand you another document.
9 Does that appear to be a distribution check out of
10 that sale made payable to you as manager of Frazier
11 Development?
12 A Yes, it does.
13 Q Okay.
14 MR. MARTIN: Let's have that marked.
15 (Exhibit 28 marked)
16 BY MR. MARTIN:
17 Q Would you agree that out of the sale of Duck
18 & Rice Farms, you or Frazier Development received
19 $209,217.25?
20 A Yes.
21 Q And do you also agree on the back of --
22 well, the document that you have in front of you,
23 Exhibit 28, is a photocopy of the front and back of
24 that check?
25 A That's correct.
156
1 A Everything.
2 Q And how long has Mr. Parker been performing
3 accounting work for you and your family companies?
4 A 2004.
5 Q Since 2004?
6 A Correct.
7 Q On Page 3 of your means test calculation, on
8 Part 3 you indicate that your family income is $56,000
9 -- actually, $56,168. Is that any part of income that
10 you would have received or earned?
11 A We're still flipping.
12 MR. CURTIS: On Page 3? Oh, okay. Okay.
13 That's the -- that's the median family income for a
14 household, but he did not complete the means test
15 because his debts are primarily nonconsumer debts.
16 Apparently, that's a default figure that was
17 just put in there based on the government standards
18 for household of five people. It calculated his three
19 children in there, but actually he didn't complete
20 that. That's not really his income figure.
21 BY MR. MARTIN:
22 Q Mr. Frazier, how many people live in your
23 household?
24 A It depends on which household right now.
25 When I'm in Destin, my two kids. When I'm here at
160
1 A Robin Word.
2 Q And when did Robin Word quit being your CPA?
3 A '03.
4 Q And why did he quit being your CPA?
5 A I don't know that he quit. We, through our
6 office manager, found Bob Parker. So I don't view him
7 as quitting.
8 Q You've been asked a lot of questions about
9 the sale of property owned by Jackson Metro
10 Properties. Was there a prepayment penalty associated
11 with the sale of that property?
12 A There was.
13 Q And do you know how much that was?
14 A I don't.
15 Q Did any of the money from the sale of
16 property owned by Jackson Metro Properties go to
17 Frazier Construction?
18 A Yes.
19 Q Do you know how much?
20 A I don't.
21 Q Do you know what for?
22 A Yes. There were two large anterior
23 build-outs there were done within the Jackson Metro
24 Properties. One was for Icon Office Solutions and
25 there was monies that went to the construction company
166
1 CERTIFICATE OF REPORTER
2
3 I, MOLLY A. BENOIST, Registered Professional
4 Reporter and Notary Public in and for the State of
5 Mississippi, do hereby certify that the above and
6 foregoing pages contain a full, true and correct
7 transcript of the Rule 2004 Examination of
8 CLAIBORNE FRAZIER, taken in the aforenamed case at the
9 time and place indicated, which proceedings were
10 recorded by me to the best of my skill and ability.
11 I also certify that I placed the witness
12 under oath to tell the truth and that all answers
13 were given under that oath.
14 I certify that I have no interest, monetary
15 or otherwise, in the outcome of this case.
16
17 This the 1st day of April, 2009.
18
19 ________________________
20 MOLLY A. BENOIST, RPR
Mississippi CSR #1722
21
22 My Commissions Expires:
23 May 26, 2012
24
25
1 2
1 IN THE UNITED STATES DISTRICT COURT 1 APPEARANCES:
FOR THE SOUTHERN DISTRICT OF MISSISSIPPI
2 JACKSON DIVISION 2
MR. CRYMES M. PITTMAN
3 3 Pittman, Germany, Roberts & Welsh
410 South President Street
4 VICTOR AGUILAR PLAINTIFF 4 Jackson, Mississippi 39201
5 VERSUS NO. 3:07cv740 TSL-JCS 5 REPRESENTING PLAINTIFF
6 LOWE'S HOME CENTERS, INC. DEFENDANT 6 MR. KEN R. ADCOCK
Adcock & Morrison
7 7 199 Charmant Drive, Suite 1
Ridgeland, Mississippi 39157
8 8
REPRESENTING DEFENDANT
9 9
10 10 ALSO PRESENT: Jeff Conner, videographer
11 11
12 DEPOSITION OF JOHN MORIARITY, JR., M.D. 12
13 13
14 14
15 15
16 16
17 17
Deposition Taken at the Instance of Plaintiff
18 In the Offices of NewSouth NeuroSpine 18
Flowood, Mississippi
19 On March 6th, 2009 19
Commencing at 9:58 a.m.
20 20
21 21
REPORTED BY: MOLLY A. BENOIST, RPR
22 Mississippi CSR #1722 22
23 BOND & BENOIST, LLC 23
Post Office Box 1576
24 Madison, Mississippi 39130 24
(601) 936-4466
25 25
3 4
1 TABLE OF CONTENTS 1 THE VIDEOGRAPHER: This is the video
2 2 deposition of Dr. John Moriarity taken in the suit
3 Style.......................................... 1 3 styled Victor Aguilar vs. Lowe's Home Centers, Inc.,
4 Appearances.................................... 2 4 being No. 3:07-cv-740 TSL-JCS in the United States
5 Table of Contents.............................. 3 5 District Court for the Southern District of
6 Exhibit 1 (Re-Notice of Deposition)........ 4 6 Mississippi, Jackson Division.
7 Examination by Mr. Pittman..................... 5 7 We are at NewSouth NeuroSpine in Flowood,
8 Exhibit 2 (Curriculum Vitae)............... 10 8 Mississippi. Today's date is Friday, March 6th, 2009.
9 Exhibit 3 (Lumbar Spine Drawing)........... 52 9 The time is 5:26 p.m. The court reporter is Molly
10 Exhibit 4 (09/20/07 Surgery Charge Info)... 58 10 Benoist with Bond & Benoist. I am Jeff Conner, the
11 Exhibit 5 (03/25/08 Aguilar Statement)..... 66 11 legal video specialist, with Conner Reporting.
12 Exhibit 6 (Copy of Medical Records)........ 67 12 Will the attorneys please introduce themselves on
13 Examination by Mr. Adcock...................... 67 13 audio?
14 Exhibit 7 (Physical Therapy Records)....... 103 14 MR. PITTMAN: Crimes M. Pittman for Victor
15 Exhibit 8 (Dr. Vohra Clinic Note).......... 105 15 Aguilar, the plaintiff.
16 Exhibit 9 (Imaging Study Results).......... 125 16 MR. ADCOCK: Ken Adcock for the defendant,
17 Exhibit 10 (04/17/07 Letter to Dr. Aden)... 126 17 Lowe's Home Centers.
18 Exhibit 11 (07/24/07 Letter to Dr. Aden)... 130 18 THE VIDEOGRAPHER: Thank you. Swear the
19 Exhibit 12 (E-mails from Dr. Aden)......... 132 19 witness, please.
20 Further Examination by Mr. Pittman............. 146 20 (Oath administered)
21 Certificate of Reporter........................ 156 21 MR. PITTMAN: All right. This deposition is
22 22 being taken pursuant to renotice. Even though the
23 23 address is incorrect on the renotice, we're all here,
24 24 and I've made the renotice Exhibit No. 1.
25 25 (Exhibit 1 marked)
5 6
1 MR. PITTMAN: This deposition is also being 1 treatment of problems involving the central nervous
2 taken pursuant to the Federal Rules of Civil Procedure 2 system, which is the brain and spinal cord, and
3 and will be used for all purposes thereunder. 3 peripheral nervous system, which are the nerves that
4 JOHN L. MORIARITY, JR., M.D., 4 radiate out into the upper and lower extremities and
5 having first been duly sworn, testified as follows: 5 into the trunk.
6 EXAMINATION 6 Q Okay. And is your practice limited to
7 BY MR. PITTMAN: 7 neurosurgery?
8 Q Dr. Moriarity, my name is Crymes Pittman. 8 A Yes.
9 We have met. I represent Victor Aguilar. I'm here to 9 Q All right. Do you practice with a group?
10 ask you a few questions about your treatment of 10 A I do.
11 Mr. Aguilar. First, though, would you please state 11 Q All right. And what's that -- the name of
12 your full name for the record? 12 your group?
13 A My full name is John Leroy Moriarity, Jr., 13 A The group is NewSouth NeuroSpine.
14 but I'm often called Jack, and you'll see that on 14 Q Okay. And that's a relatively new group, I
15 different documents. 15 believe?
16 Q Okay. And where do you call home, Doctor? 16 A It is. We were formed almost one year ago.
17 A I live now in Jackson, Mississippi. 17 Q Okay. And what was the name of your group
18 Q And how long have you lived in Jackson? 18 that you practiced with at the time you -- well, I
19 A It will be seven years this June. 19 guess back in 2006?
20 Q Okay. And what is your profession? 20 A Back in 2006, it was Mississippi
21 A I'm a neurosurgeon. 21 Neurosurgery & Spine Center, which was a smaller
22 Q Okay. If you would, please explain to the 22 group, all of which has been absorbed into NewSouth
23 jury what a neurosurgeon does. 23 NeuroSpine.
24 A Neurosurgery is that surgical subspecialty 24 Q Okay. And where do you practice? What is
25 that involves -- that deals with the surgical 25 the physical location of your --
7 8
1 A Where we are now, which is in Flowood at 1 is the final step in certification of a subspecialist
2 2470 Flowood Drive. 2 position. So you have to first go to college, then go
3 Q Okay. And, Doctor, please give me the 3 to medical school and then participate in a recognized
4 benefit of your educational background. 4 residency program, and once you successfully complete
5 A I attended college and medical school at 5 that and are in practice for a specified amount of
6 Stanford University in Stanford, California. After 6 time and complete a number of cases, you then submit
7 finishing medical school in 1995, I went to Johns 7 an application to the American Board of Neurological
8 Hopkins to the Johns Hopkins Hospital for my surgery 8 Surgery. They look -- they review the application,
9 internship and my neurosurgery residency, and then I 9 review all the cases you've submitted, both from
10 remained at Johns Hopkins from 2001 to 2002 as a 10 training and after training, and then they have you
11 faculty member as an instructor in neurosurgery, and 11 sit for an oral examination.
12 then in 2002, I came to Mississippi to start my 12 During your residency, you take a written
13 practice. 13 examination, that's the first part, and then after
14 Q And I believe you just said it, but where 14 residency, the final thing is to have an oral
15 was it again that you did your residency? 15 examination, which I went to Houston to take in
16 A At Johns Hopkins. 16 November of '06. And then after the oral examination,
17 Q And are you currently board certified? 17 they certify you as board certified. So it's really
18 A I am, yes. 18 the final step for a subspecialist.
19 Q And what are you board certified in? 19 Q You have more testing. Right?
20 A In neurological surgery. 20 A Uh-huh, but it was the last one. Although,
21 Q Okay. And please explain to the jury what 21 now there's maintenance of certification. So every
22 being board certified means. 22 three years, we have to complete another test online
23 A Board -- board -- 23 and submit continuing medical education units. So
24 Q Go ahead. 24 it's now -- for my generation of surgeons, it's
25 A I'm sorry to interrupt. Board certification 25 an ongoing process.
9 10
1 Q All right. Now, are you currently licensed 1 A Yes. Yes.
2 to practice medicine? 2 Q And are you currently a member of any
3 A Yes. 3 medical associations?
4 Q And were you so licensed in 2006? 4 A I'm a member of the American Association of
5 A Yes. 5 Neurological Surgeons and the Neurosurgical Society of
6 Q Were you licensed in Mississippi? 6 America, and those are the two professional
7 A Yes. 7 memberships.
8 Q How long have you been licensed in 8 Q Okay.
9 Mississippi? 9 A And I'm not sure that's updated. That may
10 A This July will be seven years. 10 not have the Neurosurgical Society of America on
11 Q Okay. Are you licensed in any other states? 11 there, but it should have my board certification dates
12 A No, I'm not. 12 on there.
13 Q Have you ever been licensed in any other 13 Q Okay. I tell you what we'll do is we'll
14 states? 14 make a CV, which we believe has your old address on it
15 A I was licensed in Maryland when I was in 15 and may not have one of your associations on it, we'll
16 residency there, but I am no longer licensed there. 16 go on and make that Exhibit 2, and if we need to
17 Q Did you just let that license lapse? 17 supplement later for any reason, we can. So --
18 A I did. 18 (Exhibit 2 marked)
19 Q All right. Are you currently on staff at 19 MR. PITTMAN: All right. At this time,
20 any hospitals? 20 Plaintiff tenders Dr. John Moriarity as an expert
21 A I am. I am on staff after River Oaks where 21 witness in the field of neurosurgery.
22 I do the vast majority of my surgeries and I'm also on 22 MR. ADCOCK: No objection.
23 staff at Baptist, CMMC and Rankin Medical Center. 23 BY MR. PITTMAN:
24 Q And when you say "River Oaks," you mean 24 Q All right. Doctor, have you ever had
25 River Oaks Hospital in Flowood. Correct? 25 occasion to treat a patient named Victor Aguilar?
11 12
1 A Yes, I have. 1 device broke and a significant amount of wood fell on
2 Q Okay. And do you remember the first time 2 the patient and he had to briefly hold it up and then
3 you saw Mr. Aguilar? 3 was knocked down. Then I go on further to say that he
4 A With the aid of my chart, I am able to -- 4 told me at that time that he was doing well before the
5 Q You're perfectly -- you can refer to your 5 accident but since the accident had multiple
6 chart at any time; that's part of it. 6 complaints.
7 A I did. I saw Mr. Aguilar, according to my 7 Q Okay. Was he having any pain at that time?
8 chart, first in February of 2006. 8 A When he saw me, he was complaining of low
9 Q Okay. And do you recall how Mr. Aguilar 9 back pain but was not having -- he had previously had
10 came to see you? 10 some pain in his lower extremities but was only having
11 A He was referred to me in consultation by 11 numbness in his lower extremities at that point.
12 Dr. Brannon Aden. And I'm -- his primary doctor at 12 Q Okay. And "at that point," what you mean
13 the time was Dr. Allen Sheely, and I'm not sure if 13 is -- is --
14 Allen also referred him as well. 14 A When I saw him on February 16th.
15 Q Okay. And, let's see, that visit is the 15 Q Two months after the accident?
16 February 16 of 2006 visit. Correct? 16 A Yes.
17 A Yes. According to my notes, that's correct. 17 Q Now, on that day in February of 2006, did
18 Q All right. And when Mr. Aguilar came to see 18 you obtain any imaging studies or did you have any to
19 you, did you obtain a history? 19 review?
20 A Yes, I did. 20 A I believe he had already had a lumbar MRI.
21 Q And what did that history reveal to you? 21 It looks like he had had it the same day and was sent
22 A In February of 2006, Mr. Aguilar and his 22 to my office with it and I was able to review that.
23 wife related to me that on December 17th, 2005, he was 23 Q And what did those -- what did that MRI
24 involved in an accident while shopping at Lowe's. 24 reveal? First of all, what's an MRI?
25 They told me that a cable broke or a similar retention 25 A So an MRI is a -- is really the central type
13 14
1 of imaging study we use in spine surgery. It's a 1 I'm talking about, and for the purposes of this, I
2 non-X-ray based imaging study that allows us to see 2 don't think those details are critical, but he does
3 soft tissue structures well such as nerves and discs 3 appear to have what I'd call a partially lumbarized
4 and spinal cord. So we use it often in spine 4 S1, which is just a normal variant.
5 surgeries so that we can see the structure that we're 5 I describe that, and then I describe the
6 most trying to protect or decompress. 6 degree of disc degeneration, or wear and tear that the
7 Q And to paraphrase, that's your preferred 7 patient has, and I rated that as moderate to severe
8 study to use? 8 and said that it was true on multiple levels. I
9 A That is really the best study to get an 9 thought it looked worse in the lowest level of the
10 overall look at the lumbar spine. There are more 10 lumbar spine, which is not uncommon, and then I noted
11 detailed studies such as a myelogram that you can get, 11 that he had what I call a Grade I slip at L4-5.
12 but in terms of a first glance to get in a noninvasive 12 The medical name for that that I would
13 way, MRI is really the best study. 13 probably use somewhere in the chart as well is called
14 Q Okay. And what did Mr. Aguilar's MRI reveal 14 the spondylolisthesis and what that means is that two
15 to you on February 16 of 2006? 15 of the vertebral bodies are not lined up normally.
16 A In my note, I begin in the discussion of the 16 The spine, when you look at it from the side, has a
17 study done that day describing a little bit about a 17 normal smooth curve to it and the vertebral bodies
18 small anatomic variant that he has that affects how 18 adjacent to each other should be relatively lined up
19 you count his lumbar levels. There are normally five 19 across that curve, and Mr. Aguilar's spine shows that
20 lumbar segments between the lowest rib, which is the 20 L4 and L5 are not aligned. They have slipped relative
21 twelfth thoracic segment, and the top of the sacrum. 21 to each other.
22 He has a little bit of an abnormality there that could 22 And the combination of that slip and the
23 confuse the counting, and I usually begin my reading 23 bone spurs and the disc disease cause significant
24 of films explaining clearly what I'm seeing so that at 24 nerve root compression at that level, and that's at
25 any point I can go back and know exactly what level 25 L4-L5, so that's between the fourth and fifth lumbar
15 16
1 vertebrae in his spine. The other levels I felt 1 back of the patient. When you're looking at it from
2 showed much less significant findings. 2 the side, his L4 and L5 vertebral bodies, these two,
3 Q All right. And just so the jury can 3 don't line up. So L4 is slipped forward relative to
4 understand, you've brought a model with you today. 4 L5. And you can imagine that slip worsens any nerve
5 A Yes. 5 compression that's back here because you're pulling
6 Q If you would, just show -- 6 this bone forward and kinking, effectively, the nerves
7 A This is actually a model -- if you can get 7 back here. And so that's -- that's the primary
8 this in the picture, this is a model of the whole 8 problem I saw on his films was what I call an L4-5
9 human spine and almost roughly to the appropriate 9 spondylolisthesis or an L4-5 slip.
10 size. But this is divided into three segments, or 10 Q All right. You can -- if you want to put
11 four segments really: This is the cervical region; 11 that down, we may refer back to it later.
12 the thoracic region, which the ribs come from; and 12 A Sure.
13 then the lumbar region, or more commonly called the 13 Q And in addition to reviewing the -- taking a
14 low back. The lumbar region then joins with a larger 14 history and reviewing some imaging films, did you also
15 block of bone here called the sacrum, and it's the 15 perform a physical exam?
16 sacrum that joins with the bones that make up the 16 A I did, and I can review that here in my
17 pelvis and hips. 17 note.
18 So this is the lumbar spine here and it's 18 Q Well, if there's anything pertinent to this
19 numbered one to five, and here is L5, which is the 19 discussion that that exam revealed, please discuss it.
20 lowest lumbar vertebrae, and this is L4. 20 A I don't see any abnormality in the exam on
21 And Mr. Aguilar's problem is -- is a multitude of 21 February 16th.
22 things, but the central problem for him is that his L4 22 Q Okay. Well, based on the tests you had
23 and L5 vertebral bodies don't line up, and by "don't 23 performed, the presentation of Mr. Aguilar and the
24 line up," we mean when you're looking at it from the 24 studies you reviewed and the history you reviewed, did
25 side -- this is the front of the patient; this is the 25 you -- did you form an impression as to Mr. Aguilar's
17 18
1 condition? 1 the patient x-rayed with them standing and have them
2 A I did. I note in my assessment and plan 2 bend forward and bend back and see if they have any
3 that he has a lumbar spondylolisthesis, which is this 3 dramatic abnormal motion at the level that's slipped
4 slip between L4 and L5. I then go on to detail the -- 4 or other levels just to see if there's something that
5 my thinking in regards to the causation of this, and I 5 may require more urgent surgical treatment.
6 specify here that I thought it is likely that some of 6 And as long as that's not there, then I
7 these underlying imaging -- imaging findings in terms 7 usually recommend that they see a physical medicine
8 of the slip and disc degeneration were there prior to 8 and rehabilitation doctor like Dr. Vohra, as I did in
9 his accident, but based on his history, I would say 9 Mr. Aguilar's case, to try to get him some relief
10 that the accident caused the symptoms that brought him 10 without -- without surgical treatment.
11 to my office, and -- and I also thought those symptoms 11 Q Okay. And you mentioned -- and we'll go
12 were, to a reasonable degree of medical probability, 12 into more detail later, but your note says that any
13 related to that structural problem. 13 problems he may have had before the accident were
14 But based on the fact that the patient was 14 asymptomatic, if I'm reading that correctly. Explain
15 at that point neurologically intact, I favored not 15 to the jury what you mean --
16 operating on him. I tend to have a relatively high 16 A Yeah.
17 threshold among surgeons for performing something like 17 Q -- by asymptomatic versus symptomatic.
18 a lumbar fusion because it's not a small procedure and 18 A Well --
19 it's not one I would want to have done on me lightly. 19 MR. ADCOCK: We -- we object to leading. I
20 So given the fact that he was neurologically intact on 20 don't think -- I don't think the doctor had gone into
21 his exam, I thought that it would be reasonable and in 21 what was symptomatic or not symptomatic previously.
22 his best interest to try to pursue aggressive 22 MR. PITTMAN: He read his note earlier. I
23 nonsurgical treatment prior to doing, so I wanted to 23 disagree, but your -- your objection is noted.
24 have him undergo some what we call dynamic films, 24 BY MR. PITTMAN:
25 which is lumbar flexion-extension films where we have 25 Q Doctor, explain to the jury what the
19 20
1 difference between asymptomatic and symptomatic is. 1 Q Okay. And it's to -- well, to ask you the
2 A Well, symptoms are the things patients 2 question: You believe that the symptoms that you
3 complain of to physicians. Signs are the things that 3 refer to in your note were -- were caused by the
4 physicians find in examining patients. So there's 4 accident. Is that what you're saying?
5 symptoms and signs, and symptoms are the things that 5 A I do.
6 patients come to the doctor complaining of and -- or 6 MR. ADCOCK: Object to leading.
7 sit at home complaining of. 7 A I do believe that the symptoms were caused
8 And so for Mr. Aguilar, in my note, I say 8 by his accident, and I also believe -- and this is
9 that based on the patient's history it sounded like 9 where we get into some confusion -- that the
10 the structural problem in his spine was entirely 10 structural problem is related to his symptoms. At the
11 asymptomatic or "totally asymptomatic" I think is the 11 same time, I think that structural problem was
12 phrase I use in my note, meaning that he may have had 12 probably to some degree was an underlying thing that
13 that underlying structural problem, and I think very 13 was there prior to the injury, but it was laying -- it
14 likely had it to some degree, but we don't, to my 14 was sitting there basically quietly until it was
15 knowledge, have imaging prior to his accident. 15 bothered.
16 But I think to some degree he must have had 16 And so I think the accident served to take
17 some of those signs of wear and tear, but prior to the 17 an underlying structural problem and either -- it
18 accident, based on his history, those were not 18 certainly worsened it in terms of his complaints and
19 bothering him, and then he suffered the accident and 19 making him symptomatic and possibly worsened it
20 he had symptoms at that point. So before the accident 20 structurally, and that I don't think we know well.
21 without symptoms, we would call him asymptomatic, 21 But I would say based on his history, he
22 meaning "asymptomatic" is without symptoms. And after 22 related to me that he was feeling well, then had
23 the accident, I would say he became symptomatic, 23 something fall on him at Lowe's, and then wasn't
24 meaning he was complaining of things and had things 24 feeling well. And so I don't think it's a huge
25 that bothered him. 25 conceptual leap to say that the symptoms were caused
21 22
1 by that accident. 1 I -- but I really thought based on his symptoms and
2 BY MR. PITTMAN: 2 the structural issues in his spine, I really thought
3 Q Okay. 3 that he would in the relatively near future need
4 A And so I would say -- I would say that to a 4 surgery including a decompression and fusion; I even
5 reasonable degree of medical certainty that the 5 mention it in my first note, which is relatively
6 symptoms that he visited me for were related causally 6 uncommon for me to mention something like that in my
7 to that accident. 7 first note.
8 Q Okay. And you've explained it very well, 8 But I finish my first note by saying that if
9 but since he objected, let me just ask a non-leading 9 the flexion-extension films show significant
10 question. What caused Mr. Aguilar's symptoms? 10 instability, which is not just the slip but his change
11 A Based on the history he related to me, I 11 in it as he moves -- because the MRI is done with him
12 would say to a reasonable degree of medical 12 lying on his back, so I want to do the film standing
13 probability that his symptoms were caused by the 13 to see if he moves significantly. So I said in my
14 accident at Lowe's. 14 note that if he moves significantly or if Dr. Vohra is
15 Q Thank you. Sorry for that technicality. 15 not able to provide him durable relief, then I would
16 Counsel forced me to do it. 16 recommend he return to the office and discuss what's
17 All right. And I believe you mentioned that 17 called a lumbar decompression and fusion, which is
18 you sent Mr. Aguilar to -- for some flexion films. 18 where we decompress the nerves by taking all the
19 A Yes, for flexion-extension films. 19 pressure off them removing the bone and the ligament
20 Q And after those films, you were going to 20 and the bone spurs on the nerve and disc material, and
21 decide whether or not to refer him to Dr. Vohra. 21 then once we've done that, we fuse them or fixate them
22 What, in fact, did you -- what was your plan for 22 by locking them together with screws and rods.
23 Mr. Aguilar? 23 So at that point, I wanted to check to see
24 A The plan even at the first visit was that we 24 if the lumbar flexion-extension films showed
25 would make some effort at nonsurgical treatment, but 25 significant instability. If they didn't, I felt that
23 24
1 it would be worthwhile for him to try some nonsurgical 1 him, but I didn't read them until probably about 12
2 therapy, see if we could get him further bettered. I 2 days later and then dictated them, and then it gets
3 know that he throughout when we've seen him has been 3 tight. So, yeah, I'm now -- I'm now reading a note
4 incredibly motivated to work and be active, and so I 4 from March 1st, 2006, which is a reading of the films
5 wanted to give him a chance to do that and see if we 5 done from the visit on February 16th, 2006. Sorry
6 could do that and avoid surgery. 6 about that.
7 Q Okay. And so did the films reveal any 7 MR. ADCOCK: Is that the --
8 significant instability? 8 THE WITNESS: Let me see. February 17th?
9 A They didn't. They -- they show some 9 Yes, those -- those should be the same films if those
10 suggestion of abnormal motion at L4 and L5, but I 10 are lumbar films, yeah, but I'm not reading that note.
11 didn't feel it was significant enough that he was at 11 MR. ADCOCK: Okay.
12 any increased risk relative to what I thought when I 12 THE WITNESS: That -- I think that's
13 first saw his MRI. So I don't think they added any 13 probably just the radiologist's impression, which I'm
14 new information that changed my plan. 14 just reading my -- I'm reading my note of my reading
15 MR. ADCOCK: Do you -- I want to object. I 15 of that film, I believe. I probably have that report
16 don't see the -- the -- has that been produced? 16 somewhere in here, too. Well, I don't reference it.
17 MR. PITTMAN: It's right there. You're 17 BY MR. PITTMAN:
18 looking at it. Shows slight L4-L5 slip. 18 Q In any event, Doctor, did you refer -- refer
19 MR. ADCOCK: That's a different date. 19 Mr. Aguilar to Dr. Vohra?
20 That's March the 1st. 20 A Yes. I say in the note when I -- after the
21 MR. PITTMAN: He -- 21 visit with me, I said I would like to see
22 THE WITNESS: Yeah. I ordered the films on 22 flexion-extension films, or dynamic films. I read
23 the 16th, and then what I usually do is review them 23 those, felt that they didn't basically corner us into
24 and then I'll send a letter. So they were done -- it 24 having to recommend surgery. I didn't think there was
25 looks like they were done the day after I visited with 25 anything immediately dangerous on those films and so I
25 26
1 recommended that he see Dr. Vohra for a trial of what 1 that surprise you if that were the case?
2 I call non-surgical therapy, which is more formally 2 A No. I think he was improving a little bit
3 called physical medicine and rehabilitation therapy. 3 when he saw me. I think he was even -- even without
4 Q Okay. 4 Dr. Vohra or -- or me, I think he had improved a
5 A And then I say again that if this fails -- 5 little bit already. So that wouldn't necessarily
6 in my March 1st note, I say, "Again, if this fails, we 6 surprise me. I think once these symptoms are started,
7 will consider a lumbar decompression and fusion as the 7 I think it's common for them to wax and wane over
8 patient has a significant structural lesion in his 8 time.
9 lumbar spine and I think there's a significant chance 9 Q And when the symptoms get better, does that
10 that he will require surgery." I think still at this 10 mean that his condition has resolved?
11 time I was thinking we were looking at four to eight 11 A I think it just means that the symptoms
12 weeks and he would need surgery. 12 have -- have gotten better. I don't think it -- it
13 Q Okay. Do you know if -- if Dr. Vohra's 13 certainly doesn't mean that the structural problem has
14 treatment improved Mr. Aguilar's symptoms at all? 14 gone away or the -- or the likelihood that he's going
15 A As I recall, I think it did initially, but I 15 to continue to be bothered has gone away. I think --
16 don't know that I have that in my notes. I often will 16 in my experience, this is the kind of problem that
17 discuss that with Dr. Vohra but then not transcribe it 17 once this cascade of events has started, it's very
18 in my notes or I'll look at his notes that he sends me 18 hard to get the patient to where they are completely
19 but not dictate them into my notes. So I don't have 19 well in a durable way for a long period of time. I
20 any primary recollection of whether the initial visit 20 think that's -- that's hard to do, and I think for
21 was successful or subsequent visits or what type of 21 Mr. Aguilar most of that was due simply to his
22 modalities he went through. 22 incredible ability to tolerate his symptoms. He
23 Q The -- well, let's -- let's presume that 23 continued to work -- to my knowledge, I think he
24 Mr. Aguilar was feeling better after a round of 24 continued to work through almost this entire time to
25 physical therapy and two visits to Dr. Vohra. Would 25 some degree, or at least for the latter part of it.
27 28
1 Q You sound surprised by that. 1 socioeconomic part in which the patient has been
2 A I am. I still am. He vividly stands out in 2 injured by a large -- by something falling on him at a
3 my mind because of that. 3 large company that he could go home, not work and seek
4 Q Okay. And why him over some other patients? 4 compensation for that because he's been injured. I
5 A I don't think most people in his situation 5 think, unfortunately, in a lot of patients that plays
6 -- the vast majority of people in his situation I 6 into their clinical history, and I think in
7 don't think would have been -- would have been willing 7 Mr. Aguilar that really has not at all. He's -- he's
8 or able to continue to work. 8 just continued to work to my amazement.
9 Q And I don't want to put words in your mouth, 9 Q Okay. You mentioned a waxing and waning of
10 so I'm not. So when you say unwilling, is that 10 the symptoms, and I think certainly you can explain
11 because of the pain level? 11 what you mean by that to the jury, but what would --
12 A Well, I think there's multiple issues -- 12 what are some of the things in your experience and in
13 Q Okay. 13 your opinion that might cause symptoms to wax or wane
14 A -- in patients in these situations where 14 or get better or get worse?
15 there's a -- a pending legal battle and possible -- 15 A Well, I think -- there's two issues. I
16 the possibility of compensation, and there's issues of 16 think there's the pathophysiology, the real mechanism
17 blame and there's an accident where he was clearly a 17 of the pain, may change in the sense that some days
18 victim of something falling on him. 18 he's more inflamed than others. Some days he may
19 I think there -- just on the medical side, 19 sleep in the wrong position, work a little harder, do
20 he has a significant structural lesion that most 20 something else that makes it a little more inflamed.
21 people are unable to do active work with that 21 Other days where things are a little calmer, it gets a
22 structural problem. Most patients I have with far 22 little less inflamed.
23 smaller structural problems are much more 23 So I think there's some real underlying
24 incapacitated than him. That's just the medical part. 24 change going on there, and then I think there's also
25 And then there is the whole psychosocial 25 the fact that what a patient complains of doesn't
29 30
1 always make it into our chart and I think it does with 1 that I think it's still there.
2 varying accuracy and reliability. 2 BY MR. PITTMAN:
3 So I find with Mr. Aguilar, if I ask him how 3 Q Okay. Now, back to your -- back to your
4 he's doing, I usually get very short answers and they 4 notes, you referred -- referred him to Dr. Vohra in
5 usually center around "Okay. I can work. I'd rather 5 March, and yet he returned to see you in July,
6 just keep working," you know, things like that. And 6 specifically July 27th of 2006. Is that correct? Is
7 if you ask him more detailed questions and probe more 7 that your next note?
8 deeply, you find that, well, he actually spends each 8 A I see a note from July 6th, 2006, yes.
9 night hurting. He gets home at night and his back and 9 Q Oh, I'm sorry. I skipped a note. Thank
10 leg hurt. His wife says he complains, you know, 10 you.
11 frequently to her about it. 11 A Did you say the 26th?
12 But -- so I think part of the variation in 12 Q I did. That's the next visit.
13 the chart is actually not a real variation in him; 13 A I have one from --
14 it's more a variation in our ability to accurately 14 MR. ADCOCK: Can I borrow this, Crymes?
15 assess what's bothering him. So I think it's two 15 MR. PITTMAN: Sure.
16 things that make -- it's not uncommon, I think, for 16 A I actually have one from July 27th and
17 the symptoms to wax and wane. I don't think it means 17 July 6th --
18 that something dramatic is happening in his back 18 BY MR. PITTMAN:
19 that's different. 19 Q Okay.
20 Q The -- what you're saying is the underlying 20 A -- are the two notes I have.
21 condition remains the same? 21 Q The one I'll refer you to is the
22 A I think it still sits -- 22 July 6th note. How was he doing after being treated
23 MR. ADCOCK: Object to leading. 23 by Dr. Vohra?
24 A I think it does. I mean, I just think it's 24 A It sounds like it says he was -- it sounds
25 not -- you know, we've certainly imaged him enough 25 like he was doing well. It says, "Overall he's
31 32
1 feeling much better today than he did shortly after 1 my history on that note that he is still actively
2 the accident and when he saw me last in the office." 2 working, and I think that always gave me pause about
3 And then I said, "But he does report some left greater 3 pushing him, you know, towards surgical treatment of
4 than right lower extremity pain and numbness," which 4 his problem.
5 are similar to the pattern, as I recall, that he had 5 MR. ADCOCK: We -- we object to the doctor's
6 when he saw me except he had more numbness than pain6 response as nonresponsive to the question. There's
7 when he saw me initially and now he had some pain with 7 nothing about surgery in the notes of July 6th, 2006,
8 the numbness. And then he says, "This is worse with 8 or a -- or a consideration of surgery.
9 exertion." 9 THE WITNESS: Okay. I'm sorry, let me
10 Q So at that point, had Mr. Aguilar's 10 explain. The word "intervention" from a surgeon means
11 condition changed? 11 surgery in general. So my interventions are surgery.
12 A I thought he looked like he was a little bit 12 But other than that, that's fine.
13 -- symptomatically a little bit better and still 13 MR. ADCOCK: I don't -- I just don't see
14 working, which has been a huge issue for me that has 14 surgery in the -- in the notes of July the 6th.
15 left me on the fence in terms of pushing him to -- to 15 MR. PITTMAN: Okay. Well, I think he's
16 surgical treatment in this problem. It's not a 16 allowed to explain his treatment of Mr. Aguilar
17 problem I really want to -- it's a large enough 17 however he wants.
18 surgery and a hard enough one to get over that it's 18 MR. ADCOCK: Well, I just think it was
19 not something I encourage people to pursue because my 19 nonresponsive to the question and I objected to it.
20 fear is when they wake up, they'll think: Why was he 20 MR. PITTMAN: Well, it's not your objection
21 trying to talk me into this? This doesn't feel like 21 so I don't think that's your objection to make.
22 it was as fun as he said it was. 22 MR. ADCOCK: I can make an objection as
23 So I try to -- I try to keep a very sober 23 nonresponsive and move to strike, and that's what I
24 attitude about what a large surgery it is and how hard 24 did.
25 it is to get over. And so for me, I put at the end of 25 MR. PITTMAN: On what basis would you move
33 34
1 to strike that answer? 1 problem, we would assume it's a lumbar nerve root and
2 MR. ADCOCK: I just said it, nonresponsive 2 not a central nervous system problem or a peripheral
3 to your question and on the grounds that what he 3 nerve problem in his lower extremities. So for him,
4 testified to was not in his notes anywhere. 4 that would be consistent with nerve roots in his low
5 THE WITNESS: Wait. I'm sorry, what was -- 5 back being compressed and not functioning well.
6 I'm still confused as to what was not in my notes. 6 Q You say in your note that he -- "clinically
7 MR. PITTMAN: He just -- it doesn't matter. 7 he looks relatively good." What does that mean?
8 THE WITNESS: Okay. 8 A I think it means that -- I try to separate
9 MR. PITTMAN: Let's move on. 9 the assessment of a patient in sort of a clinical
10 THE WITNESS: I'm confused. I'll try -- I'm 10 picture and a radiographic picture. And he has never
11 not sure. 11 radiographically looked very good, meaning his X-rays
12 MR. PITTMAN: He's -- overruled. 12 have always shown the significant structural lesion,
13 A So, basically, I thought he looked good and 13 but his clinical picture is more: How is he doing day
14 felt that I wouldn't recommend surgery at that point. 14 in and day out? Does he come into the office in a
15 BY MR. PITTMAN: 15 wheelchair or does he walk in? Does he tell me he's
16 Q Okay. 16 working or is he sitting at home in bed on pain
17 A Or -- or to put it in the words of the note, 17 medications?
18 recommend any intervention, which as a surgeon my 18 So for him, I thought at this visit he
19 interventions are surgery. 19 looked clinically well. He walked into the office and
20 Q All right. Thank you for clearing that up. 20 was telling me he's still working. So that's what I
21 I note that -- I see that in your note you 21 mean by "clinically," and I try to separate that out
22 -- he has some numbness. What is the significance of 22 from radiographically, which is how his X-rays look.
23 numbness at that point? 23 Q So at that point, you thought -- you thought
24 A Well, it implies some form of nerve 24 that he was able to go about his day. Is that
25 dysfunction in general. We -- for Mr. Aguilar's 25 correct?
35 36
1 A I did. I said -- I recommended that he 1 an L5 radiculopathy," which what that means is that,
2 continue with regular activity and I will see him 2 like the bones in the low back, the nerve roots are
3 again in my office in six weeks' time. 3 numbered L1 to L5, and so the L5 nerve root is the
4 Q But nonetheless, was it your -- is it your 4 nerve that in Mr. Aguilar is most likely to be
5 opinion that he was experiencing pain at that time? 5 compressed because of his problem at L4-5.
6 A In my initial part of my note, I say that he 6 And an L5 radiculopathy, the word -- or
7 was -- he had lower extremity pain and numbness. 7 prefix "radic," or R-A-D-I-C, is I believe from the
8 Q Okay. Now, that was on July 6th. I believe 8 Latin for root, and then "pathi" is disease. So it
9 he came back to see you a few weeks later. How was he 9 basically means he has a disease of his L5 nerve root.
10 doing at that time? 10 And to be even more formal, I could have said he has
11 A I have a note from the 27th of July, and it 11 an L5 compressive radiculopathy, meaning I think it's
12 says, "Mr. Aguilar returns today and reports worse 12 a problem with that L5 nerve root because it's being
13 left lower extremity pain. It is in the similar 13 pinched, and the easiest way to say this is that I
14 pattern as his pain before in his left buttock and 14 thought he had a pinched nerve. That's the sort of
15 posterior lateral thigh and leg." And then I say that 15 medical version of pinched nerve.
16 he denies any symptoms in his foot. And then I say 16 Q And I'm going to show you some pictures, and
17 that he visited with the physical therapist two weeks 17 it may be easier -- I'm going to hand you a pen. If
18 ago, which must have been shortly after his visit or 18 you would, just sort of draw for the jury where that
19 maybe even before the visit with me previously. 19 nerve root would be and where it was being pinched, if
20 Q And what was -- what is the condition -- 20 you can. You may not be able to.
21 what is your diagnosis at that point? What does he 21 A Well, do you have a picture of just -- here,
22 have? 22 this might be better.
23 A At this point, I said, "Assessment and plan: 23 Q Okay. All right.
24 Mr. Aguilar has worsening left lower extremity pain." 24 A So here, this is a picture looking down on
25 And then I say that, "I think this likely represents 25 the spine with this being the back of the patient and
37 38
1 this being the front of the patient. Here's is the 1 things, and you can have any variety of those. You
2 disc, and then these are the surrounding bony 2 can also have a nerve that's pinched and it be
3 structures. 3 asymptomatic or not bothering a patient. So for him,
4 And for Mr. Aguilar, his nerves were pinched 4 the effect of pinching of that L5 nerve root at
5 mostly not here as they exit the spine, but mostly in 5 different times would manifest itself as weakness or
6 this area here, an area that we call the lateral 6 pain or numbness or sometimes two or three of those
7 recess. I divide nerve root compression in the spine 7 all at once.
8 into three areas: There's the foramen, which is the 8 Q And just to be clear for the jury, do you
9 area where the nerve exits the spine, there's the 9 have an opinion as to what caused that pinching, that
10 lateral recess, and there's the central canal. 10 nerve pinching?
11 And really Mr. Aguilar has compression of 11 A I -- I still thought, and throughout the
12 nerves at all three spots, but for his L5 nerve root 12 time of caring for Mr. Aguilar, that these symptoms
13 to be compressed at L4-5, just because of the anatomy 13 were started by his accident at Lowe's.
14 of the spine, that would be in the lateral recess. So 14 Q Okay. Now, on that date, it looks like your
15 an L5 radiculopathy would be caused by pinching of the 15 plan changed. You wanted to try something else. What
16 nerve in this location (indicating), and that's 16 was it you tried on that date, on July 27th of 2006?
17 important to us as surgeons just because where the 17 A I say that I thought he had this L5
18 nerve is pinched can change how we go about taking the 18 radiculopathy or pinched L5 nerve and then I
19 pressure off of the nerve. 19 recommended a trial of a Medrol dose pack, which is an
20 Q And -- and what is the result of the nerve 20 oral form of steroids that you can take over five days
21 being pinched? 21 with a decreasing dose of steroids with the hopes of
22 A Most often the result of a nerve being 22 just reducing the inflammation around the nerve.
23 pinched is dysfunction of that nerve for the muscles 23 Q Okay.
24 and sensory activities it does. So you would have -- 24 A And then I say that I'll follow up with him
25 pain, numbness and weakness are the most common 25 at four weeks and then we will consider a new lumbar
39 40
1 MRI or possibly a trial of epidural steroid 1 Q Okay. So is it fair to say that at that
2 injections. 2 point he was doing better?
3 Q Okay. And the purpose of steroids is what, 3 A Yes. In fact, my assessment and plan
4 again, just to be clear? 4 begins, "Mr. Aguilar is doing better."
5 A Just to reduce inflammation around the 5 Q Okay. But the fact that he was doing
6 nerve. 6 better, had his condition resolved?
7 Q Okay. 7 MR. ADCOCK: Object to leading.
8 A It doesn't really change the compression of 8 A The -- the condition from the immediately
9 the nerve; it just reduces irritation around the 9 previous visit I thought had improved. Again, I think
10 nerve. It's sort of a potent form of taking an 10 clinically he looked better, but structurally I think
11 Ibuprofen. 11 he still had the same nerve root compression. I don't
12 Q All right. I believe he came back to see 12 -- I don't think the Medrol -- I know that the Medrol
13 you in August. And had his -- had his condition 13 dose pack didn't change that structural picture, if
14 changed significantly? 14 that's what you're asking.
15 A I have a note from August 24th that says, 15 BY MR. PITTMAN:
16 "Mr. Aguilar returns today and says that he is having 16 Q Yeah. Let's go on to the next -- the next
17 daily left lower extremity pain but he felt like it 17 visit on September 26th of 2006. Based on your note,
18 was better than his last visit." Again, I say that he 18 do you see any significant change in Mr. Aguilar's
19 is still working, and then I describe the distribution 19 condition?
20 of the pain, which is still consistent with his L5 20 A It looks similar, but it looks more like
21 nerve root. 21 he's back to the note from July 27th, 2006, than
22 And at this -- at this point, he was denying 22 necessarily the immediate note before that. It looks
23 significant right lower extremity symptoms, and I 23 like he has the weakness back in his left foot in a
24 mention that, and then I examined him and said his -- 24 muscle that's consistent with the L5 nerve root and
25 his strength appeared to be normal. 25 he's still having pain in that leg.
41 42
1 And I -- in my assessment and plan, I say, 1 you in October of 2006. Had he had any change in his
2 "He still has a left L5 radiculopathy." So I -- I 2 condition at that time?
3 would say this is one of the probably more symptomatic 3 A Let me see. I said, "He feels that he is
4 visits than the previous visit but consistent with the 4 slightly better but still having some left lower
5 visit, too, earlier. So it seems like he's about -- I 5 extremity pain." And I think in my handwritten note I
6 don't see a dramatic change in this note. 6 said the intensity of his symptoms vary -- varies.
7 Q Okay. Was -- was surgery a consideration at 7 I'm sorry, that's from the -- that's from the
8 that time? 8 September 26th note. I said that he says his symptoms
9 A Let me see my assessment and plan. I do -- 9 vary in intensity. But on this note, I say that, "He
10 I do mention more details here about surgery. I say, 10 feels slightly better but still has the same exam with
11 "He clearly has severe stenosis at L4-5." And then I 11 a little bit of weakness in his left foot."
12 say, "If his symptoms increase, then we will consider 12 Q Okay.
13 an L4-5 decompression," and then I go on to explain 13 A And then in the assessment and plan, I say
14 the details of that of trying to do it through a 14 the same, similar thing to the previous notes, which
15 minimally invasive approach instead of a larger more 15 is, "I wouldn't recommend any aggressive intervention
16 open procedure that would take more time to heal. 16 at this time," meaning that I wouldn't -- at this
17 Q Okay. But at that point on 17 point wouldn't say he -- wouldn't recommend surgery.
18 September 26th of 2006, were you -- were you 18 Q Okay. Well, if you wouldn't recommend
19 recommending surgery? 19 surgery at that time, when would you consider surgery?
20 A Let's see. I'm not sure how I phrased it. 20 A He's been a very difficult case because it's
21 I think I said at that point "if his symptoms 21 -- it's hard for me to think of times I've recommended
22 increase," so I think I was still holding out hope 22 a lumbar fusion for someone who is doing relatively
23 that he would do what he's done before, which is get 23 manual labor working full-time. It's just a hard
24 better from this episode. 24 thing for me to do because it's a larger surgery.
25 Q Now, I believe Mr. Aguilar returned to see 25 So for him at this point, I think I was
43 44
1 waiting for him to come in even more symptomatic, 1 impairment or difficulty working, and I thought: If
2 expecting him to because of how his imaging studies 2 we have someone who is working already, I'd hate to do
3 looked. I think -- I think at this point, I still was 3 the surgery and have him less able to work.
4 not there. I still had not seen enough of his course 4 So at this point, I was, again, kind of
5 to realize, Gee, we just need to -- you know, we need 5 trapped by the fact that he was continuing to work and
6 to try to get him better to get him out of this cycle 6 had gotten a little bit better and we were kind of I
7 of, you know, varying symptoms. 7 think with BandAids here and there nursing him along.
8 Q Well, you say it's a difficult case and you 8 So at this point, I didn't recommend any surgery but
9 say you're reluctant on the manual labor. Explain 9 said that if he gets worse, maybe we'll try epidural
10 that a little further. Why is that difficult to you? 10 steroid injections and then consider possible lumbar
11 A It's just difficult because I know it's not 11 decompression.
12 -- some of the surgeries or the main surgery that is 12 Q Okay. Now, when Mr. Aguilar returned to see
13 probably the best overall structural option for 13 you on January 4th of 2007, I see in your note that it
14 Mr. Aguilar is not a small surgery. There are some 14 says he has 20 percent axial and spara-pinus --
15 ways we can do it to make it a little less invasive, 15 paraspinous low back pain at the iliac crest and
16 but it's still a lumbar decompression and fusion, and 16 80 percent of the problem is left lower extremity
17 those are surgeries that generally I'm used to doing 17 pain, that is, buttock pain and the lateral thigh and
18 on patients who are totally unable to work. 18 leg pain. What does that mean?
19 And, again, it gets back to unable or unable 19 A Just -- it's basically me asking him and his
20 and unwilling to work. 20 wife where his pain is on his body. So I'm trying to
21 And in his case, I think the willing part is 21 find out if he has more back pain or more leg pain
22 where he's overcoming the problem more is he just 22 because our treatment is -- it can be a little bit
23 continued to work and so that always gave me pause 23 different depending on whether someone has more back
24 because I thought -- you know, a lumbar fusion is 24 pain or more leg pain. We're generally better at
25 associated with a significant risk of disability or 25 treating lower extremity pain and can do so with
45 46
1 smaller operations. So I try to sort that out, and 1 steroid injections and we referred him for that.
2 with Mr. Aguilar the problem has been that he -- he 2 Q And what did you hope to accomplish with
3 often had both and that makes -- that makes his -- 3 the epidural injections?
4 that makes the treatment a little more difficult. 4 A I think more -- that's a slightly more
5 Q All right. At this time, where was the 5 aggressive form of treatment than a Medrol dose pack,
6 majority of his pain? 6 basically. It's another form of delivering steroids
7 A The majority at this time was in his left 7 to the nerve. With the Medrol dose pack, you take the
8 lower extremity, based on this note. It says 80 8 steroids by mouth and they go to your entire body and
9 percent of the problem is in his left lower extremity. 9 also to the nerve, and with a steroid injection,
10 Q And what do you mean by "left lower 10 they're delivered more directly under X-ray guidance
11 extremity" exactly? 11 to the nerve, and so that was just a hope to address
12 A The left lower extremity would be -- lower 12 that 80 percent of his problem that was left lower
13 extremity comprises basically hip, buttock, thigh and 13 extremity pain.
14 leg. "Leg" is not a term I'll use except to specify 14 Q Well, you mentioned directly by an X-ray.
15 that part between your knee and your ankle, which is 15 Explain to the jury what -- what an epidural injection
16 technically your leg. Above that is your thigh, and 16 consists of.
17 then there's your hip and buttock. So I count all of 17 A So an epidural -- let me first define
18 that as lower extremity. So anything that is not 18 "epidural." The nerves are lined -- the nervous
19 back, basically, below your waist is counted as lower 19 system is really lined by multiple membranes. In the
20 extremity. 20 spine, there's really only two that we concern
21 Q What was your plan at that point on 21 ourselves with, and the outer one that is the thickest
22 January 4th of 2007? 22 is called the dura or dura mater, which I think
23 A Let me see. It says that, "Mr. Aguilar, his 23 translates as tough mother. "Mater" is mother and
24 wife and I have had another long discussion." And I 24 "dura" is tough, like endurable. And so dura is this
25 did at this point recommend a trial of epidural 25 dark outer lining here.
47 48
1 Below that is called subdural and outside of 1 A I have done a few in the past, but I don't
2 that is called epidural. So an epidural steroid 2 regularly do them.
3 injection is one that is delivered to just outside the 3 Q Right. Now, did the epidural injections
4 lining of the nerve and is a steroid injection 4 seem to help him at all, "him" being Mr. Aguilar?
5 delivered usually under X-ray guidance so that they 5 A I don't see -- I will have to look in the
6 can pick exactly what nerve they're going to put the 6 next note. Let me see. Here's a note from
7 injection on. 7 April 17th, 2007. It says he -- it says, "He is
8 And then a pain management specialist will 8 feeling better. He has undergone epidural steroid
9 deliver that steroid injection to the compressed nerve 9 injections three times." And then I say, "These have
10 and there is usually some spread to an adjacent nerve, 10 definitely helped." And then I say, "He's also been
11 but they usually can focally deliver it to one area so 11 put on Lyrica," which is a medication to help with
12 that there's not significant spread. 12 pain from nerve compression or nerve problems. And
13 Q How do they -- how do they focally deliver 13 then I say that, "He is still working and remains very
14 it? 14 active."
15 A Just with a needle. It's basically an 15 Q All right. So -- so Mr. Aguilar was still
16 injection done under X-ray guidance. So they sedate 16 working and remaining active. Was he experiencing any
17 the patient -- and, again, I'm not -- these are not 17 pain at that time?
18 things I do, but they sedate the patient and while 18 A I say that, "He still reports some axial and
19 they're sedated they under X-ray guide a needle down 19 paraspinous low back pain at the level of his iliac
20 to where they want to put it and then they inject the 20 crest," which is basically the hipbone or belt line.
21 medication. 21 And then I say, "He has pain in his bilateral buttock
22 Q Okay. But while you don't -- you may not do 22 and left posterior lateral thigh and leg into the left
23 that, you're familiar with the process? 23 foot."
24 A Yes. Yes. 24 Q Were you considering the results of the
25 Q Okay. 25 epidural injections and whatever level of pain he was
49 50
1 experiencing at that time? Were you considering 1 think it's still very likely that the patient will
2 surgery on that visit on July 24th of 2007? 2 eventually develop bad enough low back and lower
3 A I think -- I really think for Mr. Aguilar 3 extremity pain that he will require a decompression."
4 there's never -- well, first, there's almost -- most 4 Then I say, "I think it's very likely to
5 people visit me expressly for the consideration of 5 involve a lumbar decompression and fusion, but we will
6 surgery, so I think there's some background 6 certainly entertain the possibility of doing a less
7 consideration of that. For him, because of his 7 invasive procedure if I think that's reasonable." And
8 initial imaging studies, surgery has always been a 8 then I say again I think it's reasonable for him to
9 potential consideration, but I think this -- from what 9 continue working and try some physical therapy.
10 I can tell, this assessment and plan reads similar to 10 Q So back in 2007, did you believe surgery
11 the others in the sense that he has this very 11 would ultimately come to fruition?
12 significant structural problem in his lumbar spine 12 A I think at this I still did, that he
13 with clear nerve root compression and lack of -- and 13 eventually would need it, same as -- same -- I think
14 lack of normal alignment in his spine, or a slip. And 14 this tone sounds similar to my very first note where I
15 then I say, "However, the patient is doing remarkably 15 thought: He just can't keep doing this and tolerating
16 well." 16 it.
17 So there's always been -- in most of the 17 Q All right.
18 notes for Mr. Aguilar, as I can recall, there's that 18 A But since it's not a -- you know, this is
19 disconnect with the fact that he has this significant 19 technically not a malignant disease. It's not like
20 structural problem but he continues to work through 20 cancer or something where we have to operate on a
21 it, and I think that's the thing that's always given 21 patient to prevent some awful thing. This is
22 me pause. 22 technically a benign disease, meaning that it doesn't
23 Then I say here again, "Given the fact that 23 kill him. So as long as he's tolerating it, I was
24 he's working and feeling better, I would not be 24 happy to let him continue to try to tolerate it. As
25 willing to recommend surgery at this time. However, I 25 amazed as I was, I was happy to let him keep trying to
51 52
1 do it. 1 I say it's "axial and paraspinous," which means that
2 Q When was the last time you saw Mr. Aguilar? 2 it's in the center of the spine and also out in the
3 A I will have to look at my chart. Let me 3 muscle on the sides. And then, "He continues to have
4 see. This last note was from April 17th, '07, and 4 left greater than right lower extremity symptoms."
5 then there's a note from July of '07. 5 MR. PITTMAN: Let's -- let's go off the
6 Q Uh-huh. 6 record for just a second.
7 A That one says he's feeling about the same at 7 THE VIDEOGRAPHER: Off record at 6:22 p.m.
8 the start. And then I saw him October of '07, and I 8 (Off record)
9 think -- 9 (Exhibit 3 marked)
10 Q Well, how was he doing in October? Any 10 THE VIDEOGRAPHER: On record at 6:43 p.m.
11 different? 11 MR. PITTMAN: All right. Back on the
12 A It starts, it says, "Mr. Aguilar continues 12 record.
13 to complain of low back and lower extremity pain." 13 BY MR. PITTMAN:
14 And then it says, "He's still working." It says, 14 Q Dr. Moriarity, I believe when we last --
15 "With significant work, he notices axial low back 15 when went off the record, we were talking about the
16 pain, but usually this is relatively mild. His chief 16 December 5 of 2008 visit. Is that correct?
17 complaint is bilateral buttock pain that can be severe 17 A Yes, I believe so.
18 and worse on the left than on the right." 18 Q Okay. And --
19 And then I say, "He's still working but has 19 A You asked when I had last seen him.
20 modified his work activity so he's not lifting as much 20 Q Okay. And was the December 5th, 2008, visit
21 and he does wear a brace during his work." And then 21 the last time you've seen him?
22 my last note -- if my chart is complete, my last note 22 A I believe, according to my chart, and I
23 is from December 5th, 2008. And then this says, "He 23 don't recall seeing him since then.
24 continues to complain of low back pain again at the 24 Q Okay. And what were his complaints at that
25 iliac crest," or really kind of at the belt line. And 25 time?
53 54
1 A It says that, "He continues to complain of 1 have a difficult problem. He has clear low back pain
2 low back pain at the iliac crest that is axial and 2 and lower extremity pain." Then I say, "To a
3 paraspinous," again, in the middle and off to the 3 reasonable degree of medical certainly, I think both
4 sides. And then I said, "He has pain in the left 4 of these symptoms are the result of his injury at
5 greater than right buttock and posterior lateral thigh 5 Lowe's." And then I say -- then we get into the
6 and leg." And then I say, "He occasionally feels 6 issues we've touched upon. "I think the structural
7 weakness in dorsiflexion of his left foot," which is a 7 lesion in his lumbar spine likely existed to some
8 related muscle to the one that I had tested earlier -- 8 degree prior to the injury. I still think his
9 in earlier notes and was weak. 9 symptoms were caused by the injury and I think the
10 Q Okay. I see in your notes you discuss the 10 injury served to make his underlying lumbar spine
11 treatment provided by Dr. McLeod and Dr. Vohra. What 11 problem a symptomatic problem that will likely require
12 is the significance of including that in your note? 12 surgery."
13 A That's just a note for me. In a person 13 And then I say, "For the patient's benefit,
14 who's been back to the office so many times, I just 14 I'm going to call his attorney," I guess meaning you.
15 want to make sure that I -- I always go back and look 15 And then I say, "I'm also going to call Dr. Aden to
16 to make sure that we've tried those things. 16 explain things." I think his wife had asked that I do
17 Those are two very common things that I'll 17 that just mainly to get -- make sure she's getting all
18 try for people before finally saying, "Okay, they've 18 the information so that she could hear it again. And
19 sort of done all the things I would do if it were me 19 then I say, "After that, we will likely repeat a
20 before considering surgery." So I'll almost always 20 lumbar MRI and lumbar flexion-extension films and have
21 try to put something in about that. 21 the patient return to clinic."
22 Q Okay. And in this last visit, did you have 22 So I think at this point I had said we're
23 an opinion with regard to surgery? 23 going to get an updated view of his back and have him
24 A Let me look at how I phrased it in the 24 come back, but I think my opinion is probably the same
25 assessment and plan. I say, "Mr. Aguilar continues to 25 that I'm -- at whatever point he says he's not
55 56
1 tolerating his symptoms to his satisfaction, I would 1 Q Well, at this point in December of 2008, did
2 recommend surgery -- 2 you feel like any of those other conservative measures
3 Q Okay. 3 would be beneficial considering the length of time and
4 A -- which I think is about the same as the 4 the actual treatment that had been rendered?
5 note from February of 2006 except now he's gone 5 A No, I don't -- Mr. Aguilar is not someone I
6 through some of the other nonsurgical things that I 6 would recommend a different type of nonsurgical
7 would recommend. 7 treatment for. I think he has tried the things that I
8 Q All right. So -- and did -- what other 8 would recommend and that I would go through if it were
9 conservative measures could you take other than what 9 me with his imaging studies.
10 you've already undertaken? 10 Q So as we sit here today, do you have an
11 A Well, there are a number of things that you 11 opinion as to whether Mr. Aguilar will require
12 can do for -- for back and leg pain. In terms of 12 surgery?
13 well-recognized things, I think rest, 13 A I still think it's -- that he's virtually
14 anti-inflammatories, time; those three may actually be 14 certain to require a lumbar decompression and fusion.
15 the best three with no -- no -- not being hard on my 15 Q Okay.
16 colleagues, Dr. Vohra and Dr. McLeod, but those three 16 A I just think with the symptoms he has --
17 may be our best nonsurgical ones and then physical 17 symptoms he has and the structural problem he has, I
18 therapy or some form of exercise therapy and then 18 think it's something that he is slowly marching
19 epidural steroid injections. I think those are the 19 towards. Just the only difference, unique thing for
20 main things. 20 him is that he's marching to it much more slowly than
21 Part of what Dr. Vohra does is he'll often 21 any other patient I can recall because of his ability
22 refer a patient for chiropractic treatment, and that's 22 to tolerate the symptoms and his willingness to
23 another modality. And then another thing that is more 23 continue to work.
24 on the edge of things is things like acupuncture, more 24 Q And should he have that surgery, do you have
25 holistic-type treatment. 25 an opinion as to whether that surgery is the end
57 58
1 result of -- or what do you believe caused that 1 charges, or I guess estimates of charges, for surgery,
2 surgery to occur? 2 anesthesiology and the hospital.
3 A Well, I think the cause for his surgery 3 Q And are you familiar with those charges?
4 would be his symptoms. 4 A Yes.
5 Q Okay. 5 Q Okay.
6 A And then I've said in the notes that I think 6 A These appear to be consistent with charges
7 his symptoms are related to the original injury or 7 for this procedure.
8 accident. 8 Q Are the charges the normal and customary
9 Q And by "accident," you mean the accident at 9 charges for a surgery of this type?
10 Lowe's? 10 A Yes, these would be the normal and customary
11 A Yes, the accident at Lowe's where something 11 charges for this.
12 fell on him. 12 Q Okay. And I believe the total is $67,500,
13 Q Okay. I had previously sent you a letter 13 if my math is right. Is that correct?
14 requesting some of these opinions that you've 14 A That's -- that's what I see, yes.
15 discussed today, and I believe at some point I had 15 MR. PITTMAN: Okay. I would like to mark
16 asked you for some figures regarding surgery. You may 16 that as the next exhibit.
17 have it in your file. I'm going to give you -- 17 (Exhibit 4 marked)
18 A Okay. 18 THE WITNESS: Where did this go?
19 Q I tell you what, if you could, just identify 19 MR. PITTMAN: You can just give it back.
20 that document for me, please. 20 Thank you.
21 A This appears to be a letter dated September 21 BY MR. PITTMAN:
22 20th, 2007, from my previous practice -- same partners 22 Q And we talked about the $67,500 for the
23 but previous practice -- called Mississippi 23 surgery. What -- what surgery is it that you're
24 Neurosurgery & Spine Center, and it appears to 24 recommending at this time?
25 reference to Mr. Aguilar. It appears to list the 25 A Well, it's --
59 60
1 MR. ADCOCK: We -- we object to the leading. 1 -- you know, basically the same procedure for the
2 MR. PITTMAN: That's not leading. I'm 2 purposes of this, but subtly different to him so that
3 asking what surgery are you recommending at this time. 3 when he wakes up he doesn't hurt as much. That's --
4 He just said -- 4 for me that's really the debate now is whether he
5 MR. ADCOCK: I don't think he's recommending 5 needs -- whether we can find some way to get around
6 surgery. 6 doing a larger procedure, but it's going to be --
7 BY MR. PITTMAN: 7 whatever we do is going to be a lumbar decompression
8 Q Okay. Well, let me ask you that question. 8 and some form of fusion for him.
9 Are you recommending surgery at this time? 9 Q Okay. And when you say "fusion," what do
10 A Based on my last note, I said I would look 10 you mean?
11 at MRI and flexion-extension films and have him return 11 A Well, it's really actually a misnomer. It's
12 to the office to discuss that. So I don't have -- my 12 really a fixation in reality. What we're doing is the
13 last note doesn't say that I've made a final decision, 13 decompression part is taking the pressure off the
14 but imaging what his films are like and if he 14 nerves and then we fixate the patient, meaning lock
15 continues to feel the way he felt on December 5th, I 15 them down in that position with some sort of internal
16 think we're at the point where he's done everything I 16 instrumentation or hardware, basically screws and
17 can think to have him do. So he's at -- he's at that 17 rods.
18 point where I think I would say he needs a 18 And so the fusion part is that screws and
19 decompression and fusion, which is the same -- the 19 rods part, and the decompression part is taking
20 same procedure I mentioned in February of '06, which 20 pressure off the nerve. And the way we divide it for
21 is basically take the pressure off the nerves at L4-5 21 someone like Mr. Aguilar is we would say, Well, the
22 and then stabilize that segment. 22 decompression part is really helping for the leg pain
23 And part of the reason I want to reimage him 23 and the fusion part is more trying to address the
24 and bring him back is to see if there is some way we 24 instability and back pain that he's having, even
25 can get through that in a less invasive way or try to 25 though it's not that simple to separate them because
61 62
1 they relate. 1 A More likely --
2 But that's why he -- because of his 2 MR. ADCOCK: We -- we -- we object. I think
3 structural problem, that's why he would require that, 3 the doctor has outlined the conditions that he
4 and I think that's -- I think that's where he is. We 4 would -- he would recommend surgery and he doesn't
5 have sat so many times in the office and I have 5 know at this point, so --
6 recommended that surgery and then he and his wife say, 6 MR. PITTMAN: Well, I -- quit testifying,
7 "Well, but he's working. Is it dangerous to wait? Is 7 Ken. I'm going to ask my question again.
8 it dangerous for him to continue to work?" And I 8 BY MR. PITTMAN:
9 don't think that it's dangerous for him to continue to 9 Q Is it more likely than not that you would
10 work, but that's -- that's the surgery all along for 10 recommend surgery for Mr. Aguilar?
11 Mr. Aguilar that I think, you know, eventually he's 11 MR. ADCOCK: Same objection.
12 going to need. 12 A By "more likely," do you mean more than
13 Q Okay. So just to be clear for the record, 13 50 percent?
14 based on all that you've discussed and the treatment 14 BY MR. PITTMAN:
15 that's been provided so far, do you recommend surgery 15 Q Yes.
16 for Mr. Aguilar? 16 A I think it would be well more than 50
17 A I would if he comes back and has these same 17 percent.
18 complaints, barring some bizarre or dramatic change in 18 Q If you were to assign a percentage to it,
19 his clinical condition, then that's what I would 19 what percentage would you assign?
20 recommend at our next visit and recommend an L4-5 20 A I'm going to put it somewhere in the
21 decompression and fusion. 21 ballpark of 90 probably.
22 Q Is it more likely than not -- 22 Q Okay.
23 A Oh, I -- meaning? 23 A Somewhere up there.
24 Q -- that you would recommend -- that you 24 Q And that surgery that is 90 percent likely,
25 would recommend surgery? 25 is that the decompression you described a few minutes
63 64
1 ago? 1 A In the short term, he would --
2 A The decompression and fusion. 2 Q All right.
3 Q Okay. And that's the surgery that is 3 A -- for sure, and that would probably last
4 estimated at $67,500. Correct? 4 out until 12 to 16 weeks after surgery.
5 A Yes, based on -- based on those charges. 5 Q What would those restrictions be?
6 That's the surgery that those charges are based on. 6 A It would be really strict limitation on any
7 Q Okay. And I understand these were done in 7 lifting; I usually don't let people lift over
8 September of 2007. 8 20 pounds. I try to limit their amount of twisting
9 A That's true, and I don't -- I don't know if 9 and bending. They will be -- he'll be in a brace when
10 they've changed in a material way since then, but 10 he's up and around for probably at least the first 12
11 those appear to be consistent with what I remember. 11 to 16 weeks after surgery. So it's a pretty limiting
12 Q If they've changed, how would they have 12 -- and this is one of the reasons that I've been
13 changed? Would they have gone up or down? 13 hesitant to launch into it. It's a pretty limiting
14 A Well, I don't know for that particular 14 surgery. Eventually, once he gets out to 12 or 16
15 procedure because we've changed into a different 15 weeks, if it looks like he's fusing well, then I would
16 practice. So I don't know if our billing changed for 16 release those restrictions gradually and let him start
17 those particular codes, but I don't imagine it's 17 returning to more normal activity.
18 changed by an appreciable amount. 18 Q And by "more normal activity," would you
19 Q Okay. 19 expect for him to ultimately be able to work?
20 A But that's an easy thing for us to answer. 20 A I would, because -- because -- mainly
21 We could have someone in my office answer that to 21 because of Mr. Aguilar. I think there are few things
22 the -- to the dollar amount. 22 I could do to keep him from working, but -- and I
23 Q All right. Following surgery, should you 23 think in general, structurally this type of operation
24 perform the surgery that we just discussed, would 24 does not carry with it permanent long-term
25 Mr. Aguilar have any restrictions? 25 restrictions because -- at least once they've fused,
65 66
1 because once he fuses at L4-5 where the bone grows 1 I know you may have said this in one form or another,
2 in -- because I do a fixation; a fusion is something 2 but to be clear, do you have an opinion as to the
3 that will take time after surgery as the bone has to 3 cause of Mr. Aguilar's injuries?
4 heal. 4 MR. ADCOCK: Object to repetition.
5 Once he fuses at that level, that L4-5 level 5 Did you make this an exhibit, Crymes?
6 is no longer a joint. It's no longer -- it no longer 6 MR. PITTMAN: I can, yeah. We'll make it an
7 can move. So the only thing we're worried about then 7 exhibit.
8 is disease at the adjacent levels, and that's 8 (Exhibit 5 marked)
9 something that he could develop with time in the 9 A I think it's still the same opinion I've
10 future, but I wouldn't -- I wouldn't significantly 10 said in the notes, is that I think that the symptoms
11 restrict his activity because of that risk because I 11 he presented to me with initially and the symptoms he
12 think he could -- I think he could return to work and 12 had in each of the visits and in December are the
13 be relatively active again. 13 result of his injury as Lowe's, just reading from my
14 Q Now, we had requested -- and I don't know 14 note.
15 that we have all of your visits. We had requested an 15 And then I say here, "I still think his
16 itemization of expenses for his office visits, and do 16 symptoms were caused by the injury and I think the
17 those appear to be the normal charges for office 17 injury served to make his underlying lumbar spine
18 visits? 18 problem a symptomatic problem" -- meaning make it
19 A Yes, these do. 19 something that bothers him -- "that will likely
20 Q Okay. 20 require surgery." By "likely," I think that's what we
21 A I haven't looked at the back pages, but this 21 assigned the 90 percent to.
22 first page seems to be the entire list. Yeah, so 22 BY MR. PITTMAN:
23 these -- these appear to be the normal evaluation and 23 Q Okay. Now, Doctor, you've given several
24 management charges. 24 opinions today. Were all of the opinions you've
25 Q Okay. Doctor, do you have an opinion -- and 25 given, were all of those given to a reasonable degree
67 68
1 of medical probability? 1 subjective thing that the patient's relating to you?
2 A Yes, they were. 2 A Yes.
3 MR. PITTMAN: And I have -- the medical 3 Q You don't -- you don't see the back pain on
4 records we've gone through -- 4 an X-ray or --
5 MR. ADCOCK: Exhibit 5. 5 A No. I think in some cases, you can look at
6 MR. PITTMAN: -- that I've referred to, I 6 a structural lesion and say, "Gee, that has to -- that
7 have a copy of those. I'm going to get them out and 7 has to hurt." I think Mr. Aguilar's imaging studies
8 make them an exhibit, but otherwise I'm done for now, 8 are impressive enough that they probably approach
9 Doctor. Thank you for your time. 9 that, but they're not -- they're not as dramatic as,
10 MR. ADCOCK: Is that going to be six? 10 say, a dramatic fracture or a large tumor or something
11 THE REPORTER: It's six. 11 where it makes it easy. I would agree that the
12 MR. PITTMAN: It is? 12 majority of patients we have we struggle with properly
13 THE REPORTER: Uh-huh. That was five. 13 assigning a structural source for their low back pain.
14 (Exhibit 6 marked) 14 Q All right. And so you take the history
15 EXAMINATION 15 given to you by the -- by the patient --
16 BY MR. ADCOCK: 16 A Yes.
17 Q Dr. Moriarity, again, my name is Ken Adcock 17 Q -- and the pain description given to you by
18 and I represent Lowe's in this case. 18 the patient, where -- you know, where does it hurt,
19 When you have a patient that comes in and 19 how does it hurt --
20 describes back pain to you, how do you go about 20 A Right.
21 diagnosing what's causing the back pain? 21 Q -- that sort of thing. And those are
22 A Well, we do it basically the way we diagnose 22 subjective factors and findings that you have?
23 anything, which is history, physical exam and imaging 23 A Yes.
24 studies. 24 Q Not that you've found, but related to you by
25 Q Okay. And the back -- the pain is a 25 the patient?
69 70
1 A Right, it's just his history, what he tells 1 such as --
2 me. 2 A And by "trauma," I mean different than what
3 Q And then you do what we can say are 3 he went through. I mean, you know, a significant
4 objective tests: X-rays, MRIs, physical exam? 4 motor vehicle collision and a fracture.
5 A Yeah, I would say X-ray and MRI are 5 Q Okay. And one of the things would be pain
6 objective. Physical exam probably falls in between 6 medication, right, that you would -- that you could
7 just because it requires participation. 7 prescribe for back pain?
8 Q Sure. 8 A Sure, to go along with their rest or
9 A So you can -- it can be clouded. I don't 9 exercises or something.
10 think -- in Mr. Aguilar's case, that's not an issue 10 Q Okay. And you could prescribe rest, stay
11 because he's such a straightforward person. But, 11 off work, right, and lay down, you know, and let it
12 yeah, so physical exam to me kind of is in between 12 give your back a chance to rest?
13 those two. 13 A Yeah, we -- we don't usually do that
14 Q Okay. And once you get all the information 14 long-term, but we will often do that in the first few
15 back, whatever it is, the course of treatment and 15 weeks following an injury.
16 standards of treatment required in your profession is 16 Q For a week, two weeks, whatever. And that
17 to first try conservative treatment. Is that correct? 17 helps?
18 A Are you talking about just for the treatment 18 A Yeah. I don't think it's well defined, but,
19 of back pain? 19 yeah, I think it helps.
20 Q Yeah. 20 Q That helps sometimes.
21 A Yes. 21 A Yeah.
22 Q Okay. 22 Q So we've got rest, pain medication.
23 A I would think with rare exception, probably 23 Physical therapy is another thing that you could
24 excluding trauma and tumors, that that would be true. 24 recommend?
25 Q Well, there would be other -- other things 25 A For back pain, yes, in particular.
71 72
1 Q And what -- what is physical therapy and why 1 pain or lower extremity pain.
2 does that help sometimes? 2 Q The key words here, I think, are stretching
3 A Well, that's a -- that's a deep question, 3 the muscles for flexibility and strengthening the
4 and both of which probably Dr. Vohra would be better 4 muscles around the problem area to --
5 able to answer. In general, I think for patients with 5 A Right.
6 complaint -- I sort of divide the world into two 6 Q And both of those work together to relieve
7 parts, which is, I'm sure an oversimplification. But 7 pain. Right?
8 those who have pain around their spine instead of 8 MR. PITTMAN: Objection. Are you
9 people who have pain principally in the lower 9 testifying? Is that a question?
10 extremity -- Mr. Aguilar has both -- but for just the 10 MR. ADCOCK: That's cross-examination,
11 back pain component of his problem, we -- and I 11 Counselor.
12 presume that's due to some problem in the joint 12 A I would think. I think that's what it would
13 complex of the spine in the vertebral column, so some 13 be. Again, Rahul Vohra would be much better able to
14 problem with the muscles, the joints, the ligaments 14 answer, but that's what I think is generally how I
15 the discs and their sort of structural soundness. 15 conceive of it is sort of increased range of motion
16 And so for me, physical therapy is an 16 and strengthening. Just sort of -- I think of it sort
17 attempt to increase the flexibility of that, to 17 of how you would rehabilitate a knee or a shoulder,
18 strengthen the muscles around a joint complex. So 18 but the problem is it's a ton of joints packed
19 that's how I think physical therapy helps. Dr. Vohra 19 together in a much more complex array.
20 may say that's all been disproven and there's another 20 BY MR. ADCOCK:
21 reason, but for me it's really a sense of just trying 21 Q Then the other thing that you mentioned was
22 to strengthen that joint the way you would do therapy 22 steroid injections --
23 for a shoulder -- 23 A Yes.
24 Q Right. And you -- 24 Q -- or acupuncture?
25 A -- different than how we would treat leg 25 A Right, which --
73 74
1 Q And those are two different things, but -- 1 joint to do its job kind of, for whatever reason, from
2 A Yes. Yeah, very different. 2 an injury or whatever, and then there's the people who
3 Q But those are -- you mentioned steroid 3 have a compressed or irritated nerve with pain in
4 injections; you get an injection directly by the nerve 4 their lower extremity.
5 or on the outer edges of the nerve. 5 And so the joint complex folks are the ones
6 A Right. Well, there's two -- there's sort of 6 I put in sort of the physical therapy bin, and the
7 two types of steroid injections. There's the systemic 7 lower extremity symptoms are the ones I put in the --
8 steroid injection that -- and I don't know if 8 in the bin of trying to provide some anti-inflammatory
9 Mr. Aguilar received one of those at some point, but 9 signal to the nerve.
10 that's the kind you would get at your regular medical 10 Q Yes, sir. But if you -- if you have a
11 doctor, which is a steroid injection, but it's really 11 successful conservative treatment by any of these
12 a systemic -- it goes to your whole body -- 12 methods and procedures, the pain medication, physical
13 Q Uh-huh. 13 therapy, injections, if those are successful in
14 A -- and by design goes to your whole body. 14 relieving pain, then your treatment has been
15 It's the kind you'd get for sinus problems or back 15 successful, hasn't it?
16 problems or anything. 16 A I think that's a tautology, isn't it? If
17 Then there's the epidural steroid injections 17 it's successful, it's been successful.
18 that Dr. -- that Mr. Aguilar got that are epidural 18 Q Yeah.
19 steroid injections, which are focal injections into 19 A I think that's -- I would agree with that.
20 the spine, and those are more, in my opinion, to 20 Q So that's good.
21 treat -- those are really not designed for back pain. 21 A I think that's inarguable.
22 Those are really for lower extremity symptoms. 22 Q If those things -- if the conservative
23 And that's how I sort of divide the group 23 treatment worked --
24 up. For me, there's the people who have the spinal 24 A Right.
25 column joint complex pain from -- from failure of that 25 Q -- there's no need to consider the next
75 76
1 step, which is aggressive, radical end to this thing. 1 A Yeah. The same as profound weakness in your
2 Only if conservative treatment doesn't work do you 2 lower extremities, though. Any --
3 even consider surgery. Is that correct? 3 Q Which is --
4 A Yeah, I think surgery is reserved for 4 A -- any important dysfunction of an important
5 patients who fail to have durable symptomatic relief 5 nerve.
6 with nonsurgical treatment or who have a problem that 6 Q And profound decreased functioning of a
7 leaving them without surgical treatment puts them at 7 nerve results in a decrease in strength, doesn't it,
8 increased risk or danger of neurologic injury. 8 usually?
9 Q Like if their bowels or bladder -- if the 9 A It depends if that nerve is a motor nerve.
10 back problem like herniated disc or other things makes 10 Q Okay. Well, if it's --
11 them have incontinence, bowel or bladder problems? 11 A So if it's a -- so, I mean, there are nerves
12 A I wouldn't -- that's not really what I 12 that don't do any motor -- that don't have significant
13 meant. I meant someone who is -- they're at risk if 13 motor function. So -- so I wouldn't say that as a
14 you leave them because they've got a tumor growing in 14 general rule a profoundly nonfunctioning nerve
15 their spine or they're unstable. So they may be doing 15 manifests as weakness. For a spinal nerve root --
16 fine when they're sitting with you, but you know that 16 that's true for the lumbar nerve roots in general.
17 if they stand up or fall or get hit, they will have 17 It's not true for all spinal nerve roots, though.
18 injury. The bowel or bladder I would put more in 18 Q Typically the people you perform the type of
19 someone with just ongoing symptoms. That's sort of -- 19 surgery that you're talking about performing on --
20 that's sort of the same thing as lower extremity pain 20 considering performing on Mr. Aguilar are people that
21 or numbness. 21 complain of pain all the time, their level of
22 Q But that's -- wouldn't that be a situation 22 functioning is very low, they're not working, they're,
23 that you would consider recommending surgery -- 23 you know, sitting down or laying down a lot of the
24 A Yeah. 24 time, aren't they?
25 Q -- immediately? 25 A For a lumbar fusion, I think that's
77 78
1 definitely true. 1 Q The spondylolisthesis is usually a
2 Q And this is a -- this is a last resort of 2 congenital sort of defect, isn't it?
3 treatment is to these type of people when they reach 3 A No. "Congenital" means present at birth.
4 that point -- 4 So I wouldn't say a spondylolisthesis is present at
5 A Yeah. 5 birth. Right?
6 Q -- they can't work in general? 6 Q Well, it usually develops without any kind
7 A I think that's true. That's how I -- that's 7 of trauma, doesn't it? It's a -- it's a --
8 how I would view it. 8 A No, I think there's a wide classification of
9 Q Okay. 9 spondylolistheses, and I don't think that -- I don't
10 A And that's why I put them through all these 10 think you can make that statement that a
11 other things to see if we can get them durably better. 11 spondylolisthesis is necessarily congenital or a
12 Q Right. Okay. Can a slip and fall accident 12 traumatic problem. I'm not aware that the symptoms --
13 make an old structural problem like you described 13 Q Well, it can develop -- it can develop
14 Mr. Aguilar had that preexisted the Lowe's accident 14 without any --
15 become symptomatic? 15 MR. PITTMAN: Let him finish his answer,
16 A I would back up and just say that are 16 Ken.
17 presuming it preexisted. I don't know that he had a 17 A I'm just saying, you're saying things that
18 slip. I don't know that he had a spondylolisthesis 18 aren't -- just aren't accurate. So I'm trying to get
19 necessarily before his accident. I've never seen any 19 us -- get this to --
20 pre-accident imaging on him. 20 BY MR. ADCOCK:
21 Q Well, that's -- that's Mr. -- I mean, 21 Q Well --
22 Dr. Vohra, that was his testimony that it was -- 22 A First of all, it's not a congenital problem.
23 degenerative disc disease was old, spondylolisthesis 23 I would say it's a spondylolisthesis.
24 was -- 24 Q I could pull -- I could pull the medical
25 A Yeah, the degenerative disc disease was old. 25 dictionary out here and go into it, but it's a --
79 80
1 A That would be -- I may benefit from it. 1 Q I thought his -- I thought you said that
2 Q It's a forward displacement of the vertebrae 2 according to the --
3 over the -- of the upper -- upper vertebrae over a 3 A Is it a pars defect?
4 lower vertebrae segment -- 4 Q In the -- in the --
5 A That's a spondylolisthesis. 5 A I don't remember seeing that.
6 Q -- usually the fourth and fifth -- 6 Q Isn't it L4-L5?
7 A Uh-huh. 7 A It is L4-5, yes.
8 Q -- due to a developmental defect. 8 Q And that's -- that's what I just described.
9 A Yeah, it's a developmental defect, yes. 9 A See, you're -- you're sort of mixing terms
10 It's not a congenital slip. Right? So at birth, they 10 here. We've got to be real careful because you've
11 don't have a spondylolisthesis. That's what I'm -- 11 required it, and so we should keep you to the same
12 Q But as the spine develops -- 12 standard you've held everyone else.
13 A I'm trying to be real careful with the 13 You said that which involved a pars defect,
14 language here as you have required us to do this whole 14 and I just want to go look and refresh my memory as to
15 time. 15 whether or not Mr. Aguilar had a pars defect, because
16 Q Okay. But it's a thing that dev- -- as the 16 I don't remember -- I don't remember him having a pars
17 spine develops over the years -- 17 defect. I don't see that.
18 A Right, right. 18 Q Well, what is it? What is a -- what is a
19 Q -- it develops this defect which causes the 19 pars defect?
20 spondylitic defect. 20 A Well, you just read it to me and said you
21 A What they're probably talking about is one 21 knew what it was.
22 due to a pars defect or a spondylolysis. 22 Q That's the definition. I used the medical
23 Q In the pars interarticularis. 23 dictionary for spondylolisthesis.
24 A Right, which is Mr. Aguilar doesn't have 24 A Well, let me explain what the words mean.
25 that I'm aware of. 25 Let me explain what the words that you read mean.
81 82
1 Q Okay. 1 he must have -- I think it's very likely he had some
2 A A pars defect is a defect in this part of 2 slip.
3 the bone called the pars interarticularis, which is -- 3 I would probably say he has, at least to
4 these are the joints in the lumbar spine here. Right? 4 some degree, a degenerative spondylolisthesis, not a
5 So this is a facet joint here formed between, in this 5 congenital one and not a pars defect one. So there's
6 case, three and four, and here between four and five, 6 different -- there are different -- they're different
7 and here between five and one. 7 beasts.
8 So between these joints, you have is this 8 BY MR. ADCOCK:
9 little neck of bone. I don't know if we a better 9 Q Would you agree with me that this developed
10 drawing of it, but I think one of your pictures had it 10 over a period of time before the Lowe's accident?
11 that you handed. The bone picture you handed me 11 A I would agree that it's very likely that
12 initially would be a better way to show this. And I 12 some significant portion of his imaging studies
13 can show you what a pars defect -- but I don't -- see, 13 developed over time, same as I've said in his notes
14 I don't think Mr. Aguilar has a pars defect. 14 multiple times.
15 Q Well, let's -- let's -- let's move on from 15 Q And how --
16 there. I don't want to -- 16 A But I think the slip, the degree of slip --
17 MR. PITTMAN: Well, I think he gets to 17 to say with certainty that the degree of slip was the
18 answer your question. I mean -- 18 same the day before his accident as the day after I
19 A If you don't want me to, that's fine. 19 think is probably unreasonable just because of the
20 But for the record, I don't think he has a 20 force with which he -- it sounds like he fell on his
21 pars defect, so that definition I don't think applies 21 buttocks which could exacerbate a lumbar
22 to his particular problem. And I don't mean to say 22 spondylolisthesis. So it could be --
23 that I think with any degree of certainty that the 23 Q But we -- but we don't know?
24 lumber -- that whatever the big stack of stuff that 24 A That's what we started with. That was my
25 fell on him necessarily caused him the slip. I think 25 first --
83 84
1 Q We don't know? 1 question is no. Technically he has disc -- "hernia"
2 A -- point, yeah. 2 means material moving to a place where it doesn't
3 Q Okay. And there are different grades of 3 belong. So technically he has disc material that is
4 spondylolistheses, aren't there? 4 in the place it doesn't belong. So it is technically
5 A There are. There are. 5 in the wrong spot. But in common neurosurgical talk,
6 Q How many? 6 when we say "herniated disc," we usually mean they
7 A Graded one to five. 7 have a focal soft disc herniation that has come out
8 Q Okay. And he's got a Grade I, which is the 8 and has pinched a nerve.
9 least -- the least -- 9 Q Okay.
10 A Yeah. 10 A For him --
11 Q -- the least of the five grades? 11 Q The discs between the spinal --
12 A Yes. Yeah, they're graded based on -- it's 12 A Right.
13 easy to think of. They're graded by the -- if you 13 Q -- has been -- has been squished and pushed
14 think of -- divide the vertebral body into 25 percent 14 out --
15 pieces, Grade I is the first 25 percent, Grade II is 15 A Right.
16 the second, third. Grade V is I think also called 16 Q -- into the nerve. Right?
17 spondyloptosis, which is the vertebral body completely 17 A Right, and we usually mean that's a soft
18 falls off the body below it, so that's not one you 18 thing. In Mr. Aguilar, we would say his is a
19 hear much of. 19 spondylotic or like you were saying degenerative disc
20 Q Okay. And he didn't -- Mr. Aguilar doesn't 20 where it's a broad disc bulge. Sometimes we'll call
21 have a herniated -- what you refer to as a herniated 21 it a disc osteophyte complex to say that it's disc and
22 disc, does he? 22 bone that are going where they don't belong from sort
23 A He has what we would call a spondylotic disc 23 of repeated wear and tear. So I would agree, but
24 bulge, so -- and the language here is just not great. 24 it's -- it's a long answer, but I would agree that he
25 It's not well defined. So the short answer to your 25 doesn't have just a simple soft herniated disc.
85 86
1 Q And you -- Mr. Aguilar is 60 years old. And 1 A Yes, he has multilevel -- yeah, multilevel
2 over -- 2 degenerative disc disease.
3 A I would have to look at my chart, but I 3 Q From his genetics or age or whatever, he's
4 that's right. 4 got it?
5 Q I mean, we can -- 5 A Yes.
6 A Yeah, yeah. 6 Q And that's happened -- that's happened over
7 Q I think -- I think that's right. 7 a period of years?
8 But you would expect a man such as 8 A That's slowly progressive over time, yeah.
9 Mr. Aguilar that does carpentry work, manual type 9 Q Okay. And he's got it --
10 labor to have degenerated disc in his back. That 10 A I would say that could not have happened
11 happens to just about everybody in the aging process, 11 suddenly.
12 doesn't it? 12 Q That didn't happen at Lowe's?
13 A I would agree to that. I don't know that 13 A Unh-unh. Unh-unh, no.
14 it -- I don't know that it necessarily is 14 Q Okay.
15 occupational. I think -- like I have it and I have 15 A The only thing I was saying that I think I
16 not done a lot of heavy lifting in my life. So I 16 just would be cautious about is the degree of his
17 think it happens virtually in everyone. And there are 17 slip. I think it -- it would be hard for me to pound
18 some people that in spite of their smoking and obesity 18 my fist on the table and say, "It was exactly that
19 just don't have it, and other people in spite of being 19 many millimeters slipped the day before his accident
20 thin and not smoking and not lifting have it. So I 20 as the day after." I think it is possible that the
21 think it just happens. There is a genetic component 21 accident could cause the slip to be a few more
22 and an environmental component to it, like -- like 22 millimeters, but I don't think it's possible the disc
23 virtually everything else. 23 -- the accident could have caused healthy discs to
24 Q And Mr. Aguilar has degenerative disc 24 suddenly look dark and worn out. I don't think that
25 disease, doesn't he? 25 happens.
87 88
1 Q Okay. And in addition to the 1 field cuts.
2 spondylolisthesis that we've discussed, he's got 2 Q And what type of -- what type of doctor is
3 degenerative disc disease at level L4-L5, doesn't he? 3 she?
4 A Yes, and at 3-4 and at 5-1. 4 A She's an ophthalmologist. I think I was
5 Q Okay. 5 originally referring patients to her because she was
6 A In fact, I think from my note, "Disc looks 6 friends with my former nurse. My former nurse had
7 worse at 5-1." 7 worked with her. So when I asked, "Who's
8 Q But that didn't -- that didn't -- that 8 ophthalmologist to see," my former nurse recommended
9 wasn't caused at Lowe's? 9 her.
10 A The degenerative disc disease? 10 Q Okay. And do you know her personally?
11 Q Right. Right. 11 A Just through work really.
12 A No, no, no. It wasn't. 12 Q Okay. And did you know that Mr. Aguilar's
13 Q Okay. All right. And that's the area that 13 wife works --
14 you wanted to -- if you have to do surgery, that's the 14 A Yes.
15 area you want to -- that's the area you want to do 15 Q -- as a housekeeper for Ms. -- for
16 surgery on? 16 Dr. Aden?
17 A At L4-5, yes. 17 A Yes. Yes.
18 Q Okay. All right. And you didn't look at 18 Q Okay. And has for 15 --
19 the treatment of Mr. Aguilar at -- at Baptist Medical 19 A I don't know for how long.
20 Clinic, did you? 20 Q A long time.
21 A I don't -- I didn't mention it in my notes, 21 A Yeah, I know they knew each other through
22 so I imagine no. 22 that relationship.
23 Q And how do you know Dr. Aden? 23 Q All right. And how do you know -- or do you
24 A I refer patients to her for preoperative 24 know Dr. Sheely?
25 evaluation for pituitary tumors or if they have visual 25 A Allen Sheely?
89 90
1 Q Yeah. 1 A I think it was Brannon Aden initially.
2 A I know Allen because I operated on his 2 That's what my note says, I think, and then Allen
3 father probably five or six years ago. Allen called 3 Sheely is mentioned as his medical doctor. Let me
4 me. I was on call one Friday night and I went down to 4 check just to make sure. But, yes, he was sent to me
5 River Oaks to meet his father who had a spine problem. 5 in consultation by Brannon Aden is what it says.
6 Q Okay. 6 Q Okay. All right. And you had -- or your
7 A That's how I met Allen. 7 office had Mr. Aguilar -- and Mr. Aguilar does not
8 Q And do you know him on a personal basis? 8 speak English, does he?
9 A I think similar to Dr. Aden. If I saw them, 9 A He speaks some.
10 I would be conversational with them, but we've not 10 Q Okay. Did you have to have an interpreter
11 done things together. 11 or did you have to have somebody with him?
12 Q He's your -- has he referred patients to 12 A I think -- I speak Spanish, so I think I
13 you? 13 could get through it with him, but we do effectively
14 A Yes. Yes, he has. 14 have an interpreter every time because his wife speaks
15 Q Okay. And Dr. Aden, is she in the -- it's 15 English and Spanish well together. So I don't
16 the same area out here where we are at River Oaks? 16 think -- my Spanish alone and his English alone I
17 A Yes. She's in the ophthalmology building 17 don't think would be a very fruitful interaction. I
18 just across the street from River Oaks, or down the 18 think his wife helps a lot.
19 way across from Marty's Pharmacy. 19 That's part of the issue with his symptoms
20 Q And I think you first -- I'm going to go 20 is it's hard to get -- you know, I'm getting them --
21 through these. I have some specific questions on the 21 I'm getting some of it from her and some from him and
22 different days that you saw -- that you examined 22 it takes a subjective problem and makes it even more
23 Mr. Aguilar. 23 subjective I think.
24 And who referred Mr. Aguilar to you? Was it 24 Q All right.
25 Dr. Sheely or Dr. Aden? 25 A But, no, so we've always done it not with a
91 92
1 formal interpreter, but I don't think he's ever been 1 Q All right. Going down to your assessment
2 here without her and that's been a big help. 2 and plan --
3 Q All right. I want to show you this 3 A For which -- for my first note?
4 questionnaire I think that your office had Mr. Aguilar 4 Q Yeah.
5 complete. 5 A Okay. Hang on. Let me get back there. I
6 A Do you have the back? Is this one I just 6 don't want to get these -- these were in order for the
7 copied for you? 7 first run-through, so I want to get them back there.
8 Q No. This is -- I think that's in -- I don't 8 Okay. Good.
9 know if it's -- it may be in the record. 9 Q I'm on February 16th.
10 A Here, I can show you -- 10 A February 16th, 2006. Okay. Now I'm there.
11 MR. PITTMAN: I don't have it either. 11 Q Okay. Did he have a normal neurologic exam?
12 A Okay, I can see this. This is a 12 A I reviewed it just a bit ago, and I don't
13 double-sided sheet. Here, I'll show you. I have the 13 recall seeing an abnormality, so I'm going to say yes,
14 original. 14 and I think I even mention that in the assessment and
15 This is their initial intake sheet that they 15 plan. Yes, I say the fact that he has an intact
16 fill out independent of me, and then I kind of go over 16 neurologic -- or "intact neurologic strength." So,
17 it with them briefly. Here's the back. 17 yes, his exam looked intact.
18 BY MR. ADCOCK: 18 Q So he didn't have any weaknesses of the
19 Q Okay. And that's just -- okay. 19 extremities or limbs that you found --
20 A This is just an intake form or basically a 20 A No, not that I found.
21 review of systems form. 21 Q -- on your physical exam?
22 Q Okay. 22 A Not according to this note.
23 A And I can photocopy the back of that. Yeah, 23 Q All right. And you knew -- Mr. Aguilar or
24 you didn't get the back either. That's primarily a 24 his wife described what type of work he did --
25 review of systems form that we use. 25 A Yes.
93 94
1 Q -- and you were aware that he was working? 1 A Okay.
2 A I believe I was. I know in subsequent 2 Q And you say, "I would be reluctant to
3 visits I mention it pretty frequently. I don't know 3 recommend surgery for the patient given the fact that
4 if I knew at this visit that he was still working. 4 he has intact neurologic strength and does not have
5 Let me see just to be -- I don't know. I don't know 5 significant lower extremity pain."
6 that I knew he was still working at this point. I 6 A Right.
7 just can't find it right now. 7 Q So at this point, he wasn't a candidate for
8 Q All right. At any rate, I don't see in here 8 surgery?
9 where you recommended or told him -- 9 A No. I thought he -- it's the same as a lot
10 A I didn't change anything, it doesn't look 10 of -- similar to his other notes in the sense that
11 like. 11 based on the imaging -- I mean, the picture, he's got
12 Q You didn't tell him don't -- "Rest for the 12 every reason in the world for surgery, but he's
13 next week"? 13 clinically looked like he was doing too well for me to
14 A No. 14 recommend a big surgery.
15 Q You didn't tell him to not go to work, did 15 Q Well, I just want to briefly go through this
16 you? 16 because I'm trying to speed up.
17 A No, it doesn't look like I did. 17 A Yeah, yeah.
18 Q You didn't tell him not to lift anything, 18 Q Out of five grades of spondylolisthesis that
19 not to -- not to walk, not to squat, not to -- 19 we've talked about -- Grade I being the lowest, the
20 A No, not -- no. 20 minimum, and Grade V being the worst -- he's only got
21 Q You didn't restrict his activities in any 21 Grade I, right, in L-4 --
22 way? 22 A Right, yeah.
23 A No. No. 23 Q -- L-5?
24 Q All right. And you -- and I'm about halfway 24 And then he's got degenerative disc disease
25 down here of your assessment and plan. 25 that we've --
95 96
1 A Right. 1 generally don't operate on disc degeneration --
2 Q -- described as being, you know, what age 2 Q Okay.
3 and genetics -- 3 A -- so it doesn't really matter what it was
4 A Sure. 4 caused by.
5 Q -- over the ages that didn't have anything 5 His spondylolisthesis is a Grade I, which
6 to do with Lowe's; he's got that at three levels. 6 the vast majority of patients we operate on for a
7 But everybody -- a lot of people have that 7 spondylolisthesis are a Grade I or a Grade II. So the
8 at his age, don't they? 8 fact that he's a 1 is of no -- it doesn't mean that:
9 A Just the disc disease, sure. 9 Gee, he's only one-fourth of the way to a surgical
10 Q Okay. So, you know, he's got the less -- 10 candidate.
11 the least severe spondylolisthesis and he's got, you 11 We don't -- we don't operate on 3's and 4's
12 know, degenerative disc disease that a lot of people 12 hardly ever because they're so, so, so rare. So
13 have, he doesn't have any herniated discs, and so I'm 13 basically the whole world of spondylolistheses are
14 having difficulty, you know, seeing where you're 14 almost all Grade I and II, basically.
15 coming from. 15 The main thing he has is moderate to
16 He doesn't have any nerve damage. He's got 16 severe -- just like I say in my notes, moderate to
17 normal strength, normal neurologic exam here. I'm 17 severe lateral recess stenosis, and I just about never
18 having difficulty seeing where you're coming from, 18 use the word "severe" alone because I feel like it
19 Dr. Moriarity, on he's a candidate for surgery. I 19 leaves me no room -- should the picture get worse, I
20 mean, you state in here in your own notes that -- 20 feel like there's no other word I can use like "super
21 A I'm just saying based on his imaging 21 severe" or "really severe." So pretty much moderate
22 studies, he has moderate to severe stenosis. See, 22 to severe for me is about as bad a nerve root
23 you've missed -- you've kind of missed the point of 23 compression as you can have on an MRI.
24 what we would be operating on. So he's got disc 24 So the idea that his MRI is somehow mild
25 degeneration, sure. Everyone has that and we 25 because he's got disc degeneration and a Grade I
97 98
1 spondylolisthesis sort of grossly misses the point of 1 Q -- concerning those X-rays.
2 his MRI. So that's what I mean when I say 2 A Uh-huh.
3 radiographically he has a very dramatic MRI that I 3 Q And I'm asking you if you agree with me that
4 think anyone who looks at it who reads MRIs would 4 these two MRIs, the lateral and extension, did not
5 agree. Clinically, however, he's doing well, so 5 show instability in his lumbar spine?
6 that's why I didn't recommend surgery. 6 A Well, it's not -- first, it's not an MRI.
7 So maybe I didn't -- you know, this spinal 7 It just an X-ray.
8 canal in him is dramatically reduced in its diameter; 8 Q Okay.
9 that's a problem. That's one of the main things I 9 A And so, no, it did not show -- what my note
10 treat. So he has moderate to severe stenosis. 10 says is "did not show significant instability in his
11 So that -- you mentioned the disc 11 lumbar spine." What that means is that he has this
12 degeneration and the slip, but you missed the main 12 slip. Significant instability: Now, I think most
13 structural problem that could be causing him symptoms. 13 surgeons would say just the presence of the slip means
14 And, in fact, that's why I mentioned that he doesn't 14 he has instability. That's generally not how I use
15 have leg weakness or leg pain, which is surprising 15 the term.
16 given the severity of his stenosis. So does that make 16 For me, "instability" means that when he
17 more sense now why I say his MRI is impressive? 17 stands and moves that those two bodies abnormally
18 Because it is -- it is an impressive MRI. 18 translate relative to each other, meaning they slip,
19 Q Okay. Well, you had the lateral and 19 activity slip.
20 extension MRIs done on the next day. 20 And in him, I thought he slipped a little,
21 A You mean the X-rays? 21 but it was not dramatic, meaning he didn't go -- some
22 Q Yeah, the X-rays. 22 people when they stand -- will have a Grade I slip
23 A Okay. 23 when they're lying down or no slip, and when they
24 Q And you made a note March 1, 2006 -- 24 stand, they'll go to a Grade II or III, and what I was
25 A I think I've got that, yeah. 25 staying in this note was he's not in that small group
99 100
1 of people who have where it looks like the top half of 1 Hang on. Here we go.
2 their spine is going to fall off the bottom half, 2 Now, what date, March 10th?
3 which is an uncommon thing, but I still do 3 Q Yep.
4 flexion-extension films to check for it to make sure 4 A I have it, yeah.
5 that -- because it would change my threshold because 5 Q Okay.
6 then I think you are getting into a problem where it 6 A It was in the very front.
7 could get dangerously worse, which I don't think -- I 7 Q And he goes through his examination, history
8 don't think he had. 8 given, and he -- down here at the bottom,
9 Q And you have this in your -- in your notes, 9 "Impression," he says Mr. Aguilar is complaining of
10 in your file. This is Dr. Vohra's initial -- you 10 thoracolumbar --
11 recommended that he go see Dr. Vohra? 11 A Thoracolumbar, just mid-back, sort of here
12 A Right. 12 (indicating). Thoraco and lumbar, basically, is what
13 Q Okay. 13 Dr. Vohra's saying.
14 A Right. 14 Q Okay. And he refers him to physical
15 Q This is Dr. Vohra's March 10 -- and I think 15 therapy, doesn't he?
16 that's over in this section, March 10, 2006. 16 A Yeah. He says, "Thoracolumbar pain as well
17 A Let me see if I can find it. I've kind of 17 as tingling in both lower extremities," and then
18 mixed these up. Was it a big stack of notes from 18 says -- somewhere it says that he's been having this
19 Rahul or smaller? Hang on. Hang on. I might be -- 19 and leg pain since his accident.
20 no. 20 Q And have you reviewed the physical therapy
21 Okay, I'm going to have to look at yours. 21 from Southern Physical Medicine & Rehabilitation?
22 Well, hang on. Let me just see. It bothers me when 22 A No, I haven't. I almost never review those
23 they're not in order. There it is. No, no, no. 23 notes just because they're not always available to me
24 Q I saw it in there somewhere. 24 when I'm seeing the patient. But, no, I've not --
25 A Yeah, I know. Near the front? Here we go. 25 I've not reviewed them.
101 102
1 Q I think Dr. -- Dr. Vohra, we've taken his 1 A And I think they do. There's one, it looks
2 deposition, and he testified that he prescribed 2 like an initial evaluation, almost in April, basically
3 physical therapy for March, April and May, and I want 3 the end of March. It says, "The patient complains of
4 to show you those records -- 4 weakness in his left lower extremity," and it mentions
5 A Okay. 5 his stenosis. And then from there, it progresses with
6 Q -- real quick and just ask you if you would 6 some notes that don't seem to indicate his condition,
7 agree with me that Mr. Aguilar progressed well and 7 but then other notes that say that his symptoms are
8 goals were achieved in his physical therapy. 8 improving. I forget where I saw that, but I think I
9 THE VIDEOGRAPHER: Mr. Adcock, we've got 9 saw something that said better with stretching and
10 another two minutes. Do you mind if I change tapes 10 strength, and then it says something "better less" --
11 real quick? 11 and I think it's a "P" indicating pain.
12 MR. ADCOCK: Yeah. 12 Q Well, let me just sum it -- sum it up. Was
13 THE WITNESS: Is my phone bothering you at 13 the goal -- the goal was met?
14 all? 14 A Yeah, and I think there's an end note here
15 THE VIDEOGRAPHER: Yeah, it just went off. 15 that says that. There's an end note that is legible
16 THE WITNESS: Okay. 16 that says, "Patient seen for five visits. Goals met.
17 THE VIDEOGRAPHER: Off record at 7:36 p.m. 17 DC'd from physical therapy." So, yeah, that -- I
18 (Off record) 18 think that's fair. And I'm guessing Dr. Vohra would
19 THE VIDEOGRAPHER: On record at 7:40 p.m. 19 agree with that. If he didn't, then I would defer to
20 THE WITNESS: Okay. I've been asked to look 20 him about that. He would know more about that.
21 at some PT -- some physical therapy forms and see if 21 Q Okay. Let me show you -- that's Dr. Vohra's
22 they indicate that Mr. Aguilar progressed well through 22 note of May of 2006.
23 physical therapy. Is that -- is that correct? 23 MR. ADCOCK: I would like to mark these --
24 BY MR. ADCOCK: 24 these physical therapy records as the next exhibit.
25 Q Yeah. 25 THE REPORTER: That's No. 7.
103 104
1 (Exhibit 7 marked) 1 Q But he reported that, you know, mission
2 A So this is a note, May 18th of '06, from 2 accomplished here, you know.
3 Dr. Vohra. It says, "He is doing well. His 3 A But what you asked was, "Dr. Vohra didn't
4 symptomatology" -- and I'm just reading from it. "His 4 recommend surgery, did he?" And my answer to that is
5 symptomatology has resolved. He's not having any pain 5 I don't think I've ever seen him recommend surgery.
6 complaints." And then it recommends that he continue 6 Q But your answer would be, no, he didn't
7 with a home exercise program and then see him on an 7 recommend surgery?
8 as-needed basis. 8 A No, I would say in this and every other case
9 BY MR. ADCOCK: 9 we've cared for together he has not recommended
10 Q Okay. 10 surgery.
11 A Or "is independent with his home exercises." 11 Q You sent -- you sent the patient to
12 I think that means he's doing something at home. And 12 Dr. Vohra for rehab treatment, physical therapy under
13 that was May -- May of '06. 13 his --
14 Q May 18, '06. 14 A Right, physical medicine and rehabilitation.
15 A Okay. So that was early. 15 Q Physical medicine and --
16 Q So Dr. Vohra did not recommend surgery, did 16 A Right.
17 he? 17 Q For back pain. Right?
18 A No. He generally wouldn't, but -- but he 18 A Back is mainly the thing that I sent him
19 would just refer back to me for that. 19 for. It sounds like they also were treating his lower
20 Q He saw -- excuse me. Were you finished? 20 extremity symptoms as well, but I think back was the
21 A I was just saying he's -- he's not a 21 main goal.
22 surgeon. 22 Q And in three months of treatment, he came
23 Q Right. Right. But he -- 23 back to Dr. -- Dr. Vohra in May and he was pain-free?
24 A I don't think I've ever seen a note where he 24 A Right. You're just reading from that note,
25 recommends surgery. 25 right, that I just read, yes. It sounds like he had
105 106
1 no pain. 1 Q And you said that, "He looks relatively
2 Q All right. And Dr. Vohra released him at 2 good, has an intact neurological exam." What did you
3 that point for home exercise program? 3 mean by "intact neurological exam"?
4 A Yeah. Based on that note, it says he just 4 A Meaning the things I tested on his exam were
5 -- he says, "He is independent with his home exercise 5 normal. So that would, usually in this note, involve
6 program," which I think he's free to do it alone. 6 just testing the major muscle groups in each lower
7 Q Okay. And, apparently, Dr. Vohra didn't 7 extremity, and then his reflexes while decreased were
8 tell him, "Don't go to work"? Dr. Vohra didn't 8 not -- did not appear to be asymmetric or
9 restrict his activities in any way? 9 pathologically so.
10 A It doesn't sound like it. 10 Q So was his neurologic exam normal?
11 Q Okay. 11 A Yes, that's what "intact" -- yeah, "intact"
12 MR. ADCOCK: I want to mark this as the next 12 is synonymous with normal.
13 exhibit. 13 Q And you state in there that you "don't think
14 (Exhibit 8 marked) 14 his symptoms are significant enough that I would
15 A And I don't know if he did in his first 15 recommend any intervention." And "intervention," you
16 visit. I don't know what he recommended there. 16 meant surgery?
17 BY MR. ADCOCK: 17 A Yeah. For me that means surgery, yes.
18 Q I think he recommended physical therapy, and 18 Q So at this point, Dr. Moriarity, you are of
19 we went through it. 19 the opinion that surgery was not going to be
20 A Yeah, and just follow up with his family 20 necessary?
21 doctor for other things, and then I think he ordered 21 A No, I don't know that I mean that I'm saying
22 extra X-rays. 22 he's never going to need it. I'm saying at this time
23 Q All right. July 6th, 2006: You saw him a 23 I don't think his present symptoms are significant
24 couple of months after Dr. Vohra released him? 24 enough that I would recommend surgery. I think what I
25 A Yes. 25 meant was exactly what that said.
107 108
1 Q "His symptoms aren't significant enough that 1 weakness in his EHL," which is an abbreviation for
2 I would recommend intervention." And you're talking 2 extensor hallucis longus, which is the muscle in his
3 about surgical intervention? 3 left leg that was weak in July.
4 A Yeah, "His present symptoms aren't 4 Q So normal physical exam, normal -- normal
5 significant enough." Yeah, so I think what this says 5 neurologic exam?
6 is that on July 6th, 2006, I thought he was doing too 6 A Right. Yeah, his neurologic exam on
7 well for me to recommend surgery. 7 August 24th was normal, according to this note.
8 Q Right. 8 Q So if he's got a normal physical exam and
9 A And then I just recommend that he follow up 9 normal neurologic exam, you didn't need -- you weren't
10 with me in six weeks. 10 considering surgery at that point, were you?
11 Q All right. Let's go to August 24th, 2006. 11 A I didn't recommend it. No, I wouldn't
12 A Skip July 27th? 12 recommend it based on that note.
13 Q Yeah. 13 Q Okay. And he's -- he's doing pretty well in
14 A Okay. 14 this visit, isn't he?
15 Q All right. His physical exam was normal, 15 A Uh-huh. Uh-huh.
16 wasn't it? 16 Q Okay. All right.
17 A Which -- we're going in order or just -- 17 A The note before, he was weak and had pain,
18 Q August 24th. 18 but he had improved by this visit.
19 A August 24th, okay. 19 Q All right. Let's go up to October 31st,
20 Q Middle paragraph there. 20 2006, when you examined him.
21 A Right. He had had weakness in his previous 21 A Uh-huh.
22 visit on his physical exam, and at this visit, I 22 Q He's still having some -- some pain but he
23 thought he had no longer had any weakness. 23 was -- he had a negative straight leg raising test.
24 Q Strength was normal? 24 And what is that?
25 A Yes. Yeah, it says, "I don't detect any 25 A Which -- which date are you on?
109 110
1 Q October 31st, 2006, according to my note. 1 A Well, we usually talk about it, but I don't
2 A So he has a positive straight leg raising 2 -- I won't give it to them unless they ask for them or
3 test on October 31st. 3 want them --
4 Q Oh, okay. Okay. I'm sorry. 4 Q And that's --
5 He has some pain, but you said, 5 A -- because it's not an antibiotic. It's not
6 "Symptomatically he's stable to slightly improved." 6 -- it's really just if they feel they can tolerate it
7 Is that correct? 7 without pain medication, then they get a big clap on
8 A Yeah, I believe so. That's what the note 8 the back from me and I'm happy for them.
9 says, and that's compared to -- yeah, that's not 9 So, no, I won't -- you know, it's different
10 compared to the August note. That's compared to 10 than other medications like blood pressure medication,
11 September 26th, '06. 11 diabetes medication, antibiotics where you tell the
12 Q Okay. And you've been treating him from 12 patient, "You have to take this regardless of how you
13 February of 2006 to October now of 2006. You hadn't 13 feel." Pain medications are something the patient --
14 recommended that he quit working and rest, had you? 14 you know, they have to subjectively want to take them.
15 A No. 15 You can't -- I can't make them take them.
16 Q You hadn't recommended that he limit or 16 Q Okay. And you knew he was continuing to
17 restrict his activities in any way, had you? 17 work and had a good functional activity level, didn't
18 A No, no. 18 you?
19 Q Okay. You hadn't recommended any pain -- 19 A I don't know that I go into that much
20 hadn't given him a prescription for pain pills, had 20 detail. I say, "He is able to work but he does so
21 you? 21 with some difficulty."
22 A No, he never -- never asked for them. 22 Q Okay.
23 Q But, you know, if -- if you think the 23 A That's October 31st. So I don't -- I don't
24 patient is in enough pain, you're going to offer them 24 go into much detail there.
25 and prescribe them, aren't you? 25 Q All right. Well, at any rate, and I'm
111 112
1 quoting you in this, in your office notes, "Given 1 A Sure.
2 this, I would not recommend any aggressive 2 Q You work with him --
3 intervention at this time." And you're talking about 3 A Uh-huh.
4 "aggressive intervention" -- 4 Q -- all the time --
5 A Surgery. 5 A Uh-huh.
6 Q -- is surgery. Right? 6 Q -- with patients?
7 A Yes. 7 A Yes.
8 Q You're not recommending surgery at this 8 Q And he thought the patient was pain-free and
9 point -- 9 released him --
10 A No. 10 A Right.
11 Q -- October 31st, 2006? 11 Q -- from his care back in May of '06.
12 A No. 12 A Right. We looked at that note, yes.
13 Q All right. January 4th, 2007, you decide to 13 Q So why didn't you send Mr. Aguilar back to
14 try other conservative treatment of epidural 14 Dr. Vohra for the same plan that had worked earlier?
15 injections, don't you? 15 A Because now he has -- now my concern is that
16 A In the assessment and plan, it says, "I 16 he has more lower extremity pain than back pain. You
17 think it would be worthwhile for him to undergo a 17 know, it seemed to be -- on January 4th, 2007, he told
18 trial of epidural steroid injections." 18 me 80 percent of his problem was left lower extremity
19 Q Okay. Now, physical therapy had worked and 19 pain. And like we agreed initially, Dr. Vohra's
20 you'd met your goals with Dr. Vohra. Right? 20 initial treatment was geared towards back pain.
21 A Right. Well, the therapists had met their 21 So to send him back when 80 percent of his
22 goals. I didn't have -- those are specific goals they 22 problem was not in the area that I would recommend
23 set out that I don't describe. 23 treatment for with Dr. Vohra didn't at the time and
24 Q And you trust Dr. Vohra's judgment, don't 24 doesn't now seem to make sense. But that's really
25 you? 25 why, because of the 80 percent back -- 80 percent leg
113 114
1 pain. 1 concentrated in the lower extremity at this --
2 Even though he had leg pain when he saw 2 A Based on the note, that's what he told me.
3 Dr. Vohra initially, he had lower extremity pain in 3 Q All right.
4 March, but his primary complaint listed in Dr. Vohra's 4 A But I would agree he's had back and leg pain
5 note and in my note at that time was back pain. And 5 since the injury.
6 like I said earlier, I sort of divide the world into 6 Q And if Mr. Aguilar testified that he -- the
7 two groups. And at this point in January of '07, he 7 pain got much better for several months after these
8 seemed more -- he's always been a little bit in both 8 epidural injections, would you disagree with that?
9 groups, but at this point he seemed more in the lower 9 A If I -- if he told me his pain got better,
10 extremity pain group than in the back pain group. 10 no. I mean, I think the pain is a subjective
11 Q Well, I'm reading from Dr. Vohra's March 10, 11 complaint. I would base that on him and I can't
12 2006, notes here that he complained of pain going down 12 imagine disagreeing with him other than -- other than
13 his left leg. 13 if I saw in my notes that he had told me something
14 A Uh-huh. Yeah, I think he's always had back 14 entirely differently, and then I would just say, "Hey,
15 and leg pain. 15 you told me something differently on this day."
16 Q And so -- 16 Q All right. Well --
17 A But I think we also agreed earlier that 17 A But, you know, I think if he says his pain
18 Dr. Vohra's goal was treatment of back pain. In fact, 18 is better, then I would trust that his pain is better.
19 I think you said that. 19 Q Let's go to your notes from 04/17/2007.
20 Q Well, he had leg pain then, too? 20 A Uh-huh.
21 A I agree. He's had back and leg pain since 21 Q He returns and says he's feeling better,
22 the stuff fell on him at Lowe's. 22 doesn't he?
23 Q All right. So -- 23 A Yes. That's the first line. It says,
24 A I would agree. 24 "Mr. Aguilar returns today and says that he is feeling
25 Q So that's why you thought the pain was more 25 better."
115 116
1 Q You had more MRIs and lumbar flexion films 1 treatment that you tried on Mr. Aguilar, and both the
2 done, didn't you? 2 physical therapy and the epidural steroid injections
3 A Yes. 3 both worked in relieving his pain, didn't it?
4 Q And they showed the same things that the 4 A I would say both gave him partial
5 first ones did, didn't they, basically? 5 intermittent relief.
6 A Yeah, I notice here I use -- I don't say 6 Q Okay.
7 "moderate to severe," I say "severe." But that's 7 A Or, I'm sorry, "intermittent" is not the
8 probably such a small change in language that -- 8 word I meant. I meant partial transient relief is
9 Q So would you agree with me, Dr. Moriarity, 9 what I would say. Partial transient relief.
10 that the pain -- that the epidural steroid injections 10 Q Both of them worked, were successful,
11 accomplished what you recommended them or what you 11 weren't they, in what you set out to do?
12 prescribed them for? 12 A I would say both gave him partial transient
13 A I think they provided him partial relief of 13 relief.
14 his symptoms, yes. 14 Q And that's what you prescribed both of them
15 Q Okay. In fact, you state that he's enjoyed 15 for?
16 relief with Mr. McLeod's epidural steroid injections 16 A Partial transient relief is not really the
17 and -- and Lyrica. 17 goal of our treatment. I don't know if you were a
18 A Right. Yeah, I say, "He has certainly 18 patient and I told you, "I'm going to do something for
19 enjoyed some relief with Dr. McLeod's epidural steroid 19 you but it's only going to help for a little while and
20 injections and the Lyrica." 20 take part of your pain away," I would think by
21 Q So the second type -- excuse me, did I -- 21 "success" you would mean, "I want all my pain gone for
22 A No, no. I'm missing -- I'm missing a -- I'm 22 good," at least that's how most patients come to me
23 correcting my notes as I go. I'm missing an 23 expecting that.
24 "apostrophe s." 24 And so I wouldn't call partial transient
25 Q So this is the second type of conservative 25 relief a glowing success. So, no, I would not -- I
117 118
1 would not agree with the term "success." The problem 1 A Right, what we're calling the "medical
2 is "success" is such a vague term, so I'm trying to be 2 record" is what he's told me.
3 very specific. I think it gave him partial transient 3 Q Yeah.
4 relief based on the medical record and I think -- 4 A That's all I have. So if you have other
5 Q Well, a sixty -- 5 records you'd like me to review, fine. But we're
6 A -- it's adequate enough because it's the 6 talking about a guy who was feeling well, a ton of
7 truth. 7 stuff fell on him while shopping at Lowe's, and now he
8 Q A 60-year-old with degenerative disc disease 8 doesn't feel well.
9 at several levels is going to have some good days and 9 Q Did Mr. --
10 bad days, aren't they? They're going to have pain 10 A This is not that complicated.
11 sometimes and they're not going to have pain 11 Q Did Mr. Aguilar tell you that he studies
12 sometimes. Wouldn't you agree with that? 12 Judo and Hapkido, different types of martial arts?
13 A Back or leg? I mean, it's a very broad -- I 13 A I don't recall him discussing martial arts
14 mean, are you asking do 60-year-old's backs hurt 14 with me, no.
15 intermittently? Sure. 15 Q Okay.
16 Q Yeah. 16 A He may have and I may have it in here, but I
17 A Yes, they do. 17 just don't recall that.
18 Q Okay. 18 Q Did he tell you in -- I don't have the
19 A Now, according to the medical record, his 19 record here -- either June of '06 or June of '07 that
20 wasn't hurting prior to a bunch of stuff falling on 20 he slipped and fell on a metal pipe at work?
21 him at Lowe's. 21 A June? Let me go back and see. I don't
22 Q Well, you didn't look at any medical 22 recall that, but let me look. June of '06.
23 records; that's what Mr. Aguilar told you. Right? 23 MR. PITTMAN: Just so the record is clear,
24 A And that's what -- 24 Ken, you don't remember if that was or June of '06 or
25 Q So that's a subjective -- 25 June of '07 and you don't have that --
119 120
1 MR. ADCOCK: I could look it up. It's in 1 was hitting on every note.
2 Mr. Aguilar's deposition. Oh, 06/14 -- June 14, 2007. 2 Q I think we missed maybe two visits.
3 A So June 14, '07. So I'm looking for a note 3 A Which happen to be the ones where he was
4 somewhere in July of '07. 4 complaining of things.
5 BY MR. ADCOCK: 5 Q Well, it was just short --
6 Q Yeah. And let's -- we're chronologically 6 A Which is just coincidental.
7 going. Let me go back and let me finish up. 7 Q It was just short --
8 A Well, we're skipping notes, though, is the 8 A Okay. I just want to make sure that --
9 thing that's confusing me. 9 Q If you want to read them back, you know, but
10 Q Well, we've gotten up to April 17, 2007. 10 our court reporter -- we're going to have to come
11 A Okay. But do you want to go -- okay. 11 back.
12 Q Well, this is June and we're going 12 A I understand. I'm happy to stay here til
13 chronologically. 13 midnight --
14 A Yeah, but you're skipping notes. That's 14 Q Okay.
15 what's confusing me. You're picking out the notes 15 A -- five days from now.
16 where he feels better and missing the notes where he 16 Q All right.
17 says he's not feeling well. 17 A But let's not be loose with our language
18 Q Well, because I'm trying not to be here -- 18 here and say we've gone through things chronologically
19 I'm trying to -- 19 when we have skipped notes, and those happen to be the
20 A If we're going to be here, let's get it 20 notes where he reports weakness or pain. Okay? Let's
21 right. 21 just --
22 Q He's already gone -- he's already gone over 22 Q Take as much -- take as much time as you
23 -- 23 need to.
24 A I just don't want the record to reflect that 24 A Let's just go through it, and if you want to
25 the chronological timeline you just brought us through 25 go through it, I'm happy to, but let's get it right.
121 122
1 This is about uncovering the truth. It's not about 1 the time of June 14th, '07.
2 painting the picture we want. Okay? 2 Q All right. Let's go back to April 17, 2007,
3 BY MR. ADCOCK: 3 and finish up on that date.
4 Q That's what I'm here to get -- get at, 4 A Okay.
5 Dr. Moriarity -- 5 Q Your opinion at that time is that you would
6 A Okay. 6 not be willing to recommend surgery. Do you agree
7 Q -- is -- you know, that's what we're seeking 7 with that?
8 here. 8 A Yeah. It says, "Given this, because of his
9 A Good. Good. 9 sub-partial relief with Dr. McLeod's steroid
10 So, now, what was your question? 10 injections and Lyrica, I would not be willing to
11 Q Do you have any records or reports of the 11 recommend surgery at this time." Yes, I would agree.
12 slip and fall injury that Mr. Aguilar sustained on the 12 Q In fact, you thought it was reasonable for
13 job on June -- 13 him to continue working, doing whatever activities,
14 A June of '07. 14 and maybe try some physical therapy if he needs it?
15 Q -- June 14, '07? 15 A Yes. Yeah, that's down at the bottom, "For
16 A Let me see. I have a note from July 24th of 16 now I think it's reasonable for him to continue
17 '07, a note from April 17th. There's only one note I 17 working and try some physical therapy," and that may
18 have that would be most -- the nearest to that and I 18 be those additional notes you mentioned, therapy
19 don't see -- I don't see any mention of it in my 19 notes.
20 notes. So the answer would be no, I don't. 20 Q And the -- and the reason that you would
21 Q Okay. 21 perform surgery because of the spondylolisthesis would
22 A I say -- in that note, I say, "He's feeling 22 be because of potential instability of the spine,
23 about the same," and that means that between 23 right, to correct the instability?
24 July 24th, 2007, and April 17th, 2007, he said he was 24 A That's one of the reasons. In him, that's
25 unchanged. So that would be -- that would be across 25 probably not the main reason.
123 124
1 Q Okay. 1 flexion-extension film that I had on my first reading
2 A But that's one of the reasons. 2 of the earlier flexion-extension films. It's only on
3 Q All right. And your -- the MRI that was 3 this reading that I felt like his slip increased when
4 done on April 17, 2007, when you -- when you saw 4 he flexed, and I don't -- I'd have to sit down with
5 him -- and we just went over the notes -- came back 5 those two together to explain why I think that's
6 with the opinion of the radiologist that Grade I 6 different.
7 spondylolisthesis with no evidence of instability 7 Q But you -- you disagreed. The radiologist
8 identified at L4-L5 disc level. Is that correct? 8 called it one way --
9 A That probably can't be, because that can't 9 A Yeah.
10 be an MRI because it wouldn't come -- I mean, it's 10 Q -- no instability?
11 surely not an MRI, so it must be an X-ray. 11 A But I don't think that's a huge difference.
12 Yeah, so this -- this is an X-ray and it 12 For him, his decompression -- I mean, his surgery, the
13 says -- it's correlated with an MRI, but it's an 13 fusion would not be done in Mr. Aguilar to protect him
14 X-ray. And it shows Grade I spondylolisthesis of L4 14 from a dangerous degree of instability.
15 with respect to L5. And it says, "This does not 15 While I say he has a clear slip that clearly
16 significantly change with flexion or extension." 16 increases in flexion, remember back at the beginning
17 The only part I would disagree with is my 17 the reason I did those flexion-extension films was to
18 note says he has an L4-5 slip that clearly increases 18 try to rule out a dangerous degree of instability, and
19 in flexion. So I disagreed with Dr. Ellison on that. 19 I don't think that he has that. The fusion in him
20 But it sounds -- other than that, it sounds roughly 20 would be because the surgery is being done to
21 the same. 21 decompress him to take the -- because he's got severe
22 Q Well, he says -- he says, "No evidence of 22 compression of his nerves at L4-5, which is made worse
23 instability identified at L4-L5." 23 by the slip.
24 A Right. He's saying it doesn't -- he's 24 Well, the problem is when you decompress
25 saying -- that's the same reading of the 25 someone who already has a slip, which is evidence that
125 126
1 that joint's not doing well, when you decompress them, 1 in your file and ask you if you can identify that.
2 you're not making that joint stronger. And so we 2 A Yes. This is a -- not really a form letter
3 worry -- when we decompress somebody who already has a
3 because I dictate them individually, but it's a letter
4 slip, we will often instrument that person, fuse them, 4 back to Brannon just as the referring doctor. And I
5 to hold them together. 5 just say that, "I've had the pleasure of visiting with
6 So the fusion is not being done -- it's 6 him. I've included a copy of my note. He continues
7 almost being done to prevent us from making him 7 to have a dramatic structural lesion on his lumbar
8 unstable after his decompression. Does that make 8 imaging studies but is clinically doing remarkably
9 sense? 9 well," which is the same sort of disconnect he's had
10 So it's not -- I'm not saying -- even though 10 for most of his visits. And then it says, "Given
11 I think he does have a slip that increases when he 11 this, I'm going to follow up with him in three
12 flexes, the primary issue in him is just the -- the 12 months."
13 main issue is the fact that there's stenosis at that 13 Q Okay. You don't mention anything about
14 level. 14 surgery?
15 Q All right. 15 A No. I'm just recommending followup. And
16 A So I don't think it's a huge difference, but 16 that's -- that's related to this note, so that should
17 I do in this note -- and I don't think I sat down and 17 match the assessment and plan of April 17th, which is,
18 compared this flexion-extension to the previous ones, 18 "I would not be willing to recommend surgery at this
19 but in this note, I did feel he slipped a little more. 19 time."
20 MR. ADCOCK: All right. I want to mark that 20 MR. ADCOCK: All right. Let's mark that as
21 as the next exhibit. 21 the next exhibit.
22 (Exhibit 9 marked) 22 (Exhibit 10 marked)
23 BY MR. ADCOCK: 23 A So, yeah, that's basically a summary --
24 Q I want to show you a letter from you to 24 THE REPORTER: Wait, wait. Sorry.
25 Dr. Brannon Aden dated April 17, 2007, that we copied 25 A That's a summary of my assessment and plan
127 128
1 from April 17th. 1 A Yes, that he is.
2 Yeah, gotta give her time to type. 2 Q And you state in here, and I'm asking if you
3 BY MR. ADCOCK: 3 agree with me, you do not recommend surgical
4 Q All right. Let's go to your notes of July 4 intervention because it would be difficult for you in
5 24th, 2007. 5 the surgery to improve his current level of
6 A Okay. So about three months later. 6 functioning after surgery. Is that right?
7 Q Yeah. 7 A That's -- that's almost verbatim from my
8 A Is that right? 8 note, yes.
9 Q All right. And I want to go down to the 9 Q And you've told Mr. Aguilar that, too,
10 assessment and plan, but if you need to review the -- 10 haven't you?
11 A I'm okay. You can just ask the question and 11 A Yes.
12 I'll find it. 12 Q And you've told him you don't know if he'll
13 Q Okay. He's continued to work this whole 13 have the same amount of pain or not after surgery,
14 time. And at this point, the accident happened at 14 haven't you?
15 Lowe's December 17, 2007. You first started treating 15 A Right. I would say -- I don't see that
16 him in February of 2006. I mean, I'm sorry, the 16 here, but I would say in general I tell people that.
17 accident happened December 17, 2005. 17 So, yes, I would agree with you.
18 A Yes. 18 Q So you've told Mr. Aguilar and it's your
19 Q You began treating him in February of '06. 19 opinion that this complicated, really aggressive
20 A '06. Now we're in July of '07. 20 surgery that, you know, you've considered, you don't
21 Q Yeah, we're -- we're a year and five months 21 know if you can improve his functioning which would
22 from when you first started treating him. He's worked 22 allow him to continue to work, do you? You don't
23 the whole time -- 23 know if you can make it --
24 A A year and eight months, yeah. Yeah. 24 A No.
25 Q He's highly motivated to work. 25 Q You don't even know if you could keep it the
129 130
1 same, do you? 1 that you're not going to recommend surgery until his
2 A You mean know for certain? 2 functioning goes down to the level and pain goes up to
3 Q Right. 3 the level that he comes to you and --
4 A Yeah, I think in general we don't know that. 4 A Yeah, I say here that he may -- he may reach
5 Q And you don't know if you can decrease the 5 a level -- "At some point, he may reach a level that
6 pain that he's having or not, do you? 6 will inhibit his daily activities enough that he
7 A No. For his -- for his type of problem, I 7 wishes to proceed with surgical intervention."
8 usually tell people that there's no chance of complete 8 Q Okay.
9 pain relief. I tell them there's about a 75 percent 9 A But, yeah, this is basically just for her
10 chance of meaningful pain relief that would leave them 10 convenience. I try for the referring doctors to
11 six to 12 months after surgery glad they had surgery 11 summarize my assessment and plan.
12 and about a 20 percent chance of no pain relief and 12 MR. ADCOCK: Let's mark this the next
13 about a 5 percent chance that they could be worse 13 exhibit.
14 after surgery. That's sort of the general outline I 14 (Exhibit 11 marked)
15 give them. 15 BY MR. ADCOCK:
16 Q You told him to keep working, and you didn't 16 Q All right. This is -- this is something I
17 restrict activities at all, right, in July of 2007? 17 don't understand that I found in your file. It's
18 A I don't see -- I said, "I think it's fine 18 apparently copies of e-mails dated September 13, 2007,
19 for him to continue to work and exercise and take 19 between Brannon Aden and your office, and I think this
20 Lyrica." So, yeah, I don't think I recommended any 20 is the second page, maybe, of it.
21 restriction. 21 A Yeah, it does look like e-mails. It looks
22 Q You also wrote Dr. Aden a letter the same 22 like -- it looks like it's to Amy. It's a list -- I'm
23 date, and I'll hand you that. 23 trying to figure out why Amy would get it, but I guess
24 A Yeah, this is just to summarize for her. 24 maybe Shawn's e-mail was not working. It's from
25 Q Okay. And basically say the same thing, 25 Brannon to Shawn with a list of questions basically
131 132
1 related to surgery, "What is the prognosis? How will 1 exhibit.
2 he do? Percent" -- I imagine that's the word "chance" 2 (Exhibit 12 marked)
3 probably, instead of change. "A percentage chance 3 A But I don't -- somewhere there should be a
4 that surgery will completely fix the problem?" 4 note dated September 18th, 2007, was it?
5 But, yeah, that -- so that looks like an 5 BY MR. ADCOCK:
6 e-mail I think between -- I don't think Amy was 6 Q Uh-huh.
7 necessarily the intended recipient of that. I think 7 A Because my note on there seems to indicate I
8 it was supposed to be between Shawn and Dr. Aden. 8 dictated a response. So somewhere in here is probably
9 Q But this is communication about your 9 my answer to --
10 treatment of Dr. Aguilar (sic)? 10 MR. PITTMAN: He's got a response dated that
11 A Yeah, it looks like a list of questions 11 day.
12 about what would -- what would I recommend was the 12 THE WITNESS: Oh, okay. Oh, okay. Oh, I
13 prognosis, what type of surgery. That's as best I can 13 see. Yeah, here's my answer to all those questions.
14 tell. I don't remember seeing it prior to today, but 14 MR. PITTMAN: And it's been produced.
15 it -- and I'm not sure if I -- let me see. Does it 15 BY MR. ADCOCK:
16 say "dictated"? Yeah, so I must have dictated an 16 Q I think that's -- I think that's what you --
17 answer to this somewhere. 17 A Yeah, so this is that. That's that
18 Q Okay. 18 (indicating). No, that's not it.
19 A Do you have that note? 19 Q There's actually one July 17th.
20 Q And it says -- this is Dr. Brannon Aden's 20 A That's this. It's this thing, because
21 e-mail to Shawn in your office. She says, "This is a 21 that's dated September 18th.
22 list of stuff which we will need to determine an 22 Q Okay. Are these the same?
23 appropriate settlement with Lowe's." 23 A No. They just don't look the same. I don't
24 A Yeah, that's what it says. 24 think they are, are they? No. They're different.
25 MR. ADCOCK: Let's mark that as the next 25 Aren't they dated differently, too?
133 134
1 Q Yeah. Why are there two? One of them, 1 Q July --
2 July 17, 2007, is to Mr. Pittman, and September 18, 2 A I see. My note's here, but this is before
3 2007, is to -- 3 this note.
4 A This is in response to that e-mail you just 4 Q Right.
5 showed me and this is probably in response to a letter 5 A Okay.
6 from Mr. Pittman is what I would guess, given that 6 Q In your letter that you've signed -- you
7 that's addressed to him. So -- and I don't know why 7 signed this letter to Mr. Pittman -- of July 17, '07,
8 there are two. But, yeah, September 18th one is 8 you recommend, you said, "It's likely that we will
9 directly related to this e-mail. That has to be true. 9 have to do surgery on Mr. Aguilar at some point."
10 MR. ADCOCK: Okay. I'm just going to mark 10 A Uh-huh.
11 these collectively. I think, Crymes, you've already 11 Q All right. Yet your notes, your office
12 marked that one, haven't you, or have you? 12 notes, from the February '06 up through this date,
13 MR. PITTMAN: I don't think I've marked 13 July 17, '07 --
14 either one of them. They've been produced, but, no. 14 A Uh-huh.
15 I figured you would object that they were cumulative 15 Q -- never say that, that it's likely that he
16 in light of the fact that he's sitting here 16 will need surgery in the future. Why --
17 testifying. But that's fine. Go ahead. I would love 17 MR. PITTMAN: I object to that -- hang on.
18 to have them entered into evidence. 18 Let me just -- one at a time.
19 BY MR. ADCOCK: 19 THE WITNESS: You guys go.
20 Q Well, my question to you, Mr. -- I'm sorry, 20 MR. PITTMAN: A, I object to that
21 Dr. Moriarity -- I'm trying to hurry up here -- is up 21 characterization. I disagree. I think you are
22 through July 17, 2007, in your notes, you have never 22 misquoting and mis-paraphrasing, if that's a word,
23 recommended surgery for Dr. Aguilar (sic), yet in this 23 what his notes say. I think he can certainly take
24 letter to Mr. Pittman -- 24 care of himself after that.
25 A You mean July 24th, '07, but, yes. 25 BY MR. ADCOCK:
135 136
1 Q You can answer. 1 July 17th?
2 A So what date range did you give? 2 A I'm saying exactly what this says written in
3 Q From the first day -- from the first time 3 black and white in plain English, that it is very
4 you treated him up to July 17, 2007, you don't state 4 likely at some point in the future that he will need
5 that -- that Mr. Aguilar will likely need surgery. 5 surgery, the same thing I said in March two weeks --
6 You state it for the first time in this letter -- and 6 of '06, two weeks after first meeting the man.
7 I'm asking you if you agree with this. You state it 7 Q Is that may or -- he may or may not ever --
8 for the first time July 17, 2007. 8 it's his choice. It's not your choice. Right?
9 A That's just false. We went through that 9 A Right. That's 100 percent true.
10 note already. 10 Q He may or may not have surgery?
11 MR. PITTMAN: The first note says he's 11 A Right.
12 likely to have surgery. You are mis- -- 12 Q You haven't recommended it up to this point?
13 A I said from the beginning that I think 13 A At this point, I have not -- I have not sat
14 surgery is likely, and then on March 1st I say that 14 across from him and told him, "I think you need it."
15 there is a significant chance that he will require 15 Q As we sit here today?
16 surgery for this in the future. It's consistent with 16 A As -- no, we've already gone through that.
17 my notes, so... 17 In my notes, I think there is a significant chance
18 BY MR. ADCOCK: 18 that I think we said was somewhere in the range of
19 Q Are you not recommending surgery in this 19 90 percent. But we have not -- I have not had that
20 letter? 20 discussion with him as of this day, but that letter is
21 A See, now you've changed your question. 21 consistent with my chart.
22 Q Yeah. 22 Q Okay. Just to -- just to clear it up,
23 A So we agree that that is consistent with my 23 because I'm a little confused, for the record, you
24 notes. So now the next -- now the next point is? 24 have not sat across the table from Mr. Aguilar and
25 Q Are you recommending surgery at that -- on 25 told him that you recommend that he have surgery?
137 138
1 A I've told him every time he's come except 1 A Yes, I would agree.
2 the first visit probably, but probably every visit 2 Q -- that he have surgery --
3 since then, I've told him that, "If these symptoms are 3 A Yes, based on --
4 bothering you enough, here's what the surgery is like, 4 Q -- as we sit here today?
5 and you have to tell me if you think your symptoms are 5 A Based on his -- his comparison of his
6 bothering you enough that you wish to pursue this 6 symptoms to the potential risk of surgery, I would
7 surgery at this time." That's the same thing I've 7 agree, yes.
8 told him every time. 8 Q Okay.
9 Q I'm asking if you recommended that he -- 9 A But it's just not -- I just don't want --
10 that it's your opinion that he undergo surgery. 10 his problem is not the kind that I can -- it's not a
11 A And I'm telling you that every time he's 11 brain tumor, it's not cancer, it's not a dangerous
12 come to the office, I have said, "Here's the surgery, 12 problem. So those problems are ones where I will take
13 here are the risks, here are the benefits, here's the 13 a patient and say, "You're really making a mistake.
14 likelihood of success. Do you think you're hurting 14 You've got to have surgery. You've got to understand
15 enough to undergo that?" And so far the answer from 15 this problem." His is not that type of problem.
16 him has been, "No." 16 Q All right. October '07 is the last time you
17 Q You haven't answered my question. 17 treated him, right, up until December of '08?
18 Dr. Moriarity, have you recommended to Mr. Aguilar 18 A Yes. My notes go from October 23rd, '07,
19 that -- 19 and then to December 5, '08, yes.
20 A His answer to this point has been, "No, I 20 Q So he went 14 months -- you went 14 months
21 don't think my symptoms are significant enough that I 21 here without seeing him?
22 want to go through that surgery," and so based on 22 A Yes.
23 that, we don't recommend surgery or plan surgery. 23 Q And did you -- did you discharge him in
24 Q So you would agree with me that you have not 24 October of '07?
25 recommended -- 25 A Let me look. I don't believe so. No, I
139 140
1 just said the same thing. I said, you know, "We'll 1 epidural steroid injections is not an indication for
2 wait to hear from him as to whether or not he wishes 2 me to continue to send someone. In fact, the people I
3 to consider surgical intervention. If he does, then I 3 work with most often won't continue to give epidural
4 would recommend a new lumbar MRI, new 4 steroid injections if you're only getting transient
5 flexion-extension films and a return visit to the 5 partial relief. They feel it's outside the standard
6 office." So I think we left it open and said, you 6 of care to continue to do it.
7 know, "You holler at me if you think your symptoms are 7 So my answer would be no, I wouldn't -- I
8 bad enough that you wish to consider surgery." 8 wouldn't send him for more of those if we're sitting
9 Q Well, you would -- you would have -- if he 9 here in October and he continues to have back and
10 came back with complaints of pain, you would have 10 lower extremity pain and he's already been through
11 recommended -- you would have given him pain 11 them.
12 medication, physical therapy or some more epidural 12 Q Dr. Moriarity, are you aware that the only
13 injections, wouldn't you, short of -- short of 13 work that Mr. Aguilar has missed is coming to see --
14 surgery, because they worked before, didn't they? 14 taking off work to come and see you, taking off work
15 A Probably not. I probably wouldn't go 15 to come and see Dr. Vohra, taking off work to go to
16 through another round of those. 16 physical therapy and to get epidural injections?
17 Q Well, they worked before in decreasing the 17 A I'm not aware of that, but I have no trouble
18 pain, didn't they? 18 believing it. The man -- the man is outstanding.
19 A We continue to go round and round. 19 Q Since December 2005.
20 Transient partial relief is not our goal of therapy, 20 A I would agree; he is an incredible man.
21 like we talked about before. Remember when you said, 21 Q We're over three years after -- after this
22 "Well, you would agree they were successful" and I 22 incident and --
23 tried to more accurately define what is success? 23 A You have no trouble convincing me. He is an
24 Q Uh-huh. 24 amazing, hard-working, decent guy. You're right.
25 A So transient partial relief of a round of 25 Q That's a guy that's functioning pretty good
141 142
1 if he's able to work -- 1 is close, within $100 or so.
2 A I agree. 2 MR. PITTMAN: Just ask your question.
3 Q -- forty hours and plus over time, some 3 BY MR. ADCOCK:
4 60-hour weeks? 4 Q Would you agree that is relatively your fee
5 A I agree. 5 so far, $555?
6 Q So he's functioning at a pretty good level, 6 A Where am I on here? Oh, I'm under
7 isn't he? 7 Mississippi Neurosurgery & Spine Clinic.
8 A Yeah. Yes, sir, that's what all my notes 8 Q There's -- there's your statement.
9 say pretty much. 9 A I think that looks like a ballpark figure.
10 Q All right. From my calculation, and I'm 10 Q Okay.
11 trying to wrap up here, Dr. Moriarity, for all the 11 A And those are just for office visits
12 office visits that -- that -- in all your treatment of 12 basically.
13 Mr. Aguilar, your statement, I've added it up, and 13 Q All right. And you've given an opinion --
14 it's five hundred -- and this is what Mr. Pittman and 14 Mr. Pittman has marked this -- that if Mr. Aguilar has
15 his itemization of the medicals -- 15 to -- if he -- if comes back and says, you know, "I
16 MR. ADCOCK: You say, Crymes, it's $555. 16 can't tolerate this pain and I'm going to have to have
17 MR. PITTMAN: I don't think that's up to 17 surgery," your fee would be $20,000?
18 date, but -- I have a different amount. 18 A That would be -- that's a list of charges.
19 THE WITNESS: I've not seen it. 19 I think that's an estimate of the charge for the
20 MR. PITTMAN: Yeah, you -- whatever. 20 surgery, yes.
21 MR. ADCOCK: If you want to add it up, it's 21 Q And how long would the operation be that you
22 in the -- you've marked it as an exhibit. 22 would be treating Mr. Aguilar for?
23 MR. PITTMAN: I know, but they change. When 23 A The surgery would be four hours.
24 he goes back to the doctor -- 24 Q Okay. And how did you arrive at $20,000?
25 MR. ADCOCK: Well, I mean, this is -- this 25 A I didn't. Someone in our billing office
143 144
1 did. That's what everyone in our office charges. 1 nights?
2 Q Okay. And, then, so that would be a 2 A I don't know.
3 tremendous jump in what you've charged him for 3 Q Well, shouldn't we find -- shouldn't we find
4 treating him for since February 2006, wouldn't it? 4 that out?
5 A Yeah. In general, surgical charges are much 5 A It's probably based on an average. They
6 higher than evaluation and management charges. 6 probably just took an average number of PLFs, you
7 Q Okay. 7 know, PLF and pedicle screw fixations that I do, and
8 A So office visits don't bill as much as 8 did that. That looks about like a reasonable number.
9 surgery visits -- 9 Q And if it's -- if it's for two nights,
10 Q All right. 10 that's around 21,000-something a night or a day?
11 A -- and surgical cases. 11 A Right. Right, 43,000 divided by two, you're
12 Q And anesthesiology, you had somebody in your 12 right.
13 office figure that up, too? 13 Q The last time you saw Mr. Aguilar, it was --
14 A Probably someone in their office. 14 and I'm -- I'm close to being through. I'm about
15 Q All right. 15 finished.
16 A Probably someone in the anesthesia office. 16 December 5, 2008, you state that you're
17 Q How many days would Mr. Aguilar have to stay 17 going to have to call Mr. Pittman, or Mr. Aguilar's
18 in the hospital? 18 attorney, to discuss the status of his case and call
19 A Probably three nights. Two to four nights I 19 Dr. Aden. Why did you have to call the attorney and
20 think would be the average. You know, they may 20 Dr. Aden?
21 have -- they may have said, "Well, it should probably 21 A As I recall, his wife asked that I do that.
22 be Monday to Friday," but with his attitude and 22 She -- I think parts of it is she's always concerned
23 fitness going in, he could probably get out sooner. 23 that I'm not getting her -- you know, because you've
24 Q Is this charge of 43,000 for River Oaks 24 got one person who speaks Spanish and English, another
25 Hospital, is that calculated on two nights or four 25 person who speaks English and some Spanish, and then a
145 146
1 person who speaks mostly Spanish and a little bit of 1 Q But nothing scheduled as we sit here -- as
2 English, and I think she's always -- it's not uncommon 2 we sit here today?
3 for her to finish a visit and say, "Can you call 3 A Not that I -- not that I know of. My
4 Mr. Pittman and can you call Dr. Aden and tell them 4 secretary would know a few weeks in advance, but I
5 what you told me so that they hear it, too, and I can 5 wouldn't. I'll know on the day I come in and he's
6 ask them questions?" So that's probably just her 6 scheduled.
7 request, and that's why I say, "For the patient's 7 Q Okay. You've never restricted Mr. Aguilar's
8 benefit." 8 activities. Right?
9 Q Did you release Dr. -- I mean, Mr. Aguilar 9 A No. I would send him to Dr. Vohra to do
10 in December '08? 10 that initially. But, no, after that, I never did.
11 A No. I hardly ever release a patient. 11 Q You never told him he couldn't work?
12 Q Did you schedule another -- did you schedule 12 A No.
13 another -- 13 Q Never told him to rest?
14 THE REPORTER: I'm sorry, what did you say? 14 A No, not that I recall from the notes.
15 A I said I hardly ever release a patient. My 15 Q And you've never prescribed pain medication?
16 patients are pretty much my patients for the rest of 16 A He never asked for them once.
17 my career, for the rest of their life. 17 MR. ADCOCK: Okay. That's all I have.
18 BY MR. ADCOCK: 18 FURTHER EXAMINATION
19 Q Does he have -- you finished? 19 BY MR. PITTMAN:
20 A Yes. 20 Q Just a few follow-up questions. Doctor, are
21 Q Does he have another scheduled appointment? 21 you mindful of -- during this time of treating
22 A No. I just -- I say -- I don't say a 22 Mr. Aguilar of a need to work for him?
23 specific date. I say, "After that, we will likely 23 A I just got the sense that it was incredibly
24 repeat a lumbar MRI and lumbar flexion-extension films 24 important for him to be at work, and my guess would be
25 and have the patient return to the clinic." 25 it was a mixture of financial need and just his
147 148
1 personal approach to things. I got the sense that he 1 and changed his work activity, but I -- that wasn't
2 was someone who sort of reminded me of my father in 2 for me.
3 the sense that he just -- he feels like he is supposed 3 Q So, as Mr. Adcock pointed out, he hadn't --
4 to be working every day of his life. 4 he hasn't missed a day of work except for doctors'
5 Q And while you didn't place any formal 5 visits --
6 restrictions on Mr. Aguilar, based on your 6 A Yeah.
7 observations, were there potentially other 7 Q -- physical therapy visits, but he's changed
8 restrictions that he may encounter? 8 the way he works, correct, according to your notes?
9 A Well, I think in some of my notes I mention 9 A I remember one of my notes said he -- he
10 he limited himself at work and changed his work 10 changes how he carries things or tries not to climb a
11 activities on his own to limit his amount of lifting 11 ladder as much or something. I can't remember the
12 and carrying. Normally, if I'm -- if I've not 12 details. I'd have to look back.
13 operated on someone and they don't have a dangerous 13 Q What about things like wearing a brace to
14 degree of instability -- which we've discussed in 14 work?
15 detail, but I don't think he has a dangerous degree of 15 A I mention that, too, in that same note, I
16 instability in his back -- normally I won't restrict 16 think.
17 them because it's really based on their symptoms. 17 Q Now, you initially tried conservative
18 And then if there's formal restrictions 18 therapy. Correct?
19 based on their nonsurgical treatment, that's something 19 A I would say we have tried conservative
20 I would rely on Dr. Vohra to do during his treatment, 20 therapy, yes.
21 but since that had come and passed, I wouldn't -- it's 21 Q Tried and tried it?
22 not normal that I would say, "Well, we're not going to 22 A He has had a long course of it, yes.
23 do surgery, but I don't want you to do X, Y and Z." 23 Q Okay. And as you sit here today, do you
24 So I wouldn't normally restrict him. But he -- I know 24 feel like the conservative options that you've offered
25 he did -- in one of the notes, he restricted himself 25 Mr. Aguilar are sufficient?
149 150
1 A I do. I think the only thing that comes out 1 better and then he would come back -- and I'd say I'll
2 of this is, you know, I certainly cannot be called 2 see him in six weeks and then he comes back in a few
3 overly aggressive in terms of recommending surgery for 3 weeks with complaints. So I don't think there was any
4 him, but I think he has been through a relatively 4 time where he was all better.
5 exhaustive length of time of trying different things 5 Q And by -- you mentioned he never had durable
6 including his own modifications of his activity, his 6 relief.
7 home exercises, his physical therapy, his epidural 7 A I think he had days that were pain-free. I
8 steroid injections, his trial of Lyrica. I think he's 8 think he had maybe even a week or two or a month where
9 been through a significant amount of nonsurgical 9 he felt good, but I think he's had intermittent bouts
10 treatment and I really wouldn't put him through more 10 of back and lower extremity pain and numbness since
11 of that. 11 his accident at Lowe's.
12 Now, if he came back to me and said, "I'm 12 Q Okay.
13 really dying to try one more injection and I think I'd 13 A And that's what my chart would reflect, and
14 make it if I could just have one more of those," I 14 I think even Dr. Vohra's notes is consistent with
15 would have trouble talking him out of it because I 15 that, that he feels better, but I don't think it meant
16 don't think it's a dangerous thing and I don't think 16 that we have solved his lumbar stenosis and nerve root
17 his primary problem is dangerous to him on a 17 compression.
18 day-to-day basis, but I wouldn't recommend that as a 18 Q And the -- when that pain comes back, it is
19 plan at this point is more of that. 19 related -- or is it related to that initial problem
20 Q But even with this exhaustive therapy, did 20 for which you first treated him?
21 -- was there any time that exhaustive therapy solved 21 A I still think his symptoms from this
22 all his problems, as Mr. Adcock suggests? 22 December of '08 note are related to the initial
23 A No, I don't think in my notes that there's 23 problem of the accident.
24 any point where he was all better for any meaningful 24 Q Now, Mr. Adcock talks about degenerative
25 length of time. I mean, he saw me and was feeling 25 disc disease. He's really missing the boat as far as
151 152
1 Mr. Aguilar, isn't he? 1 know, the potential requirement for fusion or
2 MR. ADCOCK: Object to -- object to leading. 2 replacing of screws is simply because of the
3 A Well, I think that's part of it. It's only 3 decompression we would need to treat the stenosis and
4 one facet of the problem, and it's the facet that we 4 the fact that he already has a slip. So we're more
5 would be the least likely to recommend surgery for, 5 concerned about that progressing if we just take the
6 for a variety of reasons, and many of which he stated 6 bone away and don't fixate him.
7 perfectly, that it's a degenerative process that 7 Q Okay. Well -- and I guess back to my
8 occurs for genetic environmental reasons and things we 8 original question, and I think maybe you said that,
9 have not yet identified, and it is in the vast 9 but just to be clear, degenerative disc disease in and
10 majority of people a painless process. Degenerative 10 of itself doesn't cause pain?
11 disc disease in general doesn't hurt, otherwise 11 A Well, that's unfortunately a billion dollar
12 everyone would have unrelenting back pain from about 12 question.
13 20 until we die because we all have discs that are 13 MR. ADCOCK: Object to leading.
14 degenerating during that period of time. 14 A That's -- we struggle with --
15 So he has degenerative disc disease, he has 15 BY MR. PITTMAN:
16 a spondylolisthesis, or a slip, and he has severe 16 Q Let me rephrase it, then. How about that?
17 stenosis. It's the stenosis that is to me the most 17 Do people walk around with degenerative disc
18 impressive in the sense that he's able to get up and 18 disease and they don't know they have it?
19 walk and go to work and lift and carry things and go 19 A I would say the vast majority of people with
20 up a ladder with that degree of stenosis. I think 20 degenerative disc disease don't know that they have
21 that's the remarkable part. 21 any significant problem in their back, and you can
22 The other problems -- if he just had a small 22 have worse -- worsening almost invariably -- or I
23 slip that wasn't unstable and he didn't have nerve 23 would say invariably degenerative disc disease worsens
24 compression, it wouldn't -- surgery wouldn't really be 24 with time, but back pain does not necessarily.
25 an issue. It's the stenosis, the requirement -- you 25 There are people who can say, "Boy, in my
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1 30's my back really hurt and now I'm 45 and my back 1 above 50 percent. I don't have any mathematical way
2 doesn't hurt as bad," but their MRI has to look worse 2 to come to it, but I think from the day I met him, I
3 because they're older. So, yeah, I would say 3 think a lumbar decompression and fusion has been
4 degenerative disc disease is sort of -- sort of just a 4 circling his boat and gradually closing in on him.
5 sidelight to this problem. You know, it's not -- it's 5 The only unique thing about his case is how gradually
6 not the central issue. 6 it has done that, and I think that's more a testament
7 Q We talked about his conditions and whatever 7 to just what an incredible person he is.
8 may have been preexisting or not. What was caused by 8 BY MR. PITTMAN:
9 Lowe's, I think you certainly addressed that. Do you 9 Q And this surgery you're rec- -- or you would
10 believe it's time for Mr. Aguilar to have surgery? 10 recommend that more than likely he's headed for, as
11 A I -- 11 you just described, it costs money, doesn't it?
12 MR. ADCOCK: Object to leading. 12 MR. ADCOCK: Object to leading.
13 A I think it's time for him to come back to 13 A It does. We passed around how much the
14 the office with a new lumbar MRI and new lumbar 14 charges are for me, anesthesia and the hospital stay.
15 flexion-extension films and for me to sit down and 15 BY MR. PITTMAN:
16 say, "We have nothing else to offer you. If you're 16 Q Okay. And just to conclude, Doctor, you
17 hurting daily and it's interfering with, you know, you 17 believe -- what do you believe caused the condition
18 enjoying your life and working and doing things, then 18 which Mr. Aguilar will ultimately require surgery for?
19 I would recommend surgery." 19 A The same as my last note. "To a reasonable
20 BY MR. PITTMAN: 20 degree of medical certainty, I think both of the
21 Q And to be clear, I think you said there's a 21 symptoms of low back and lower extremity pain are the
22 90 percent chance that -- 22 result of his injury at Lowe's."
23 A Yeah, that's a ballpark figure. 23 Q And in order to resolve those conditions,
24 MR. ADCOCK: Object to leading. 24 you will need to do what?
25 A I said it was 90. I would say it's well 25 A For those symptoms, I would -- I very
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1 likely -- and we've put a number on it before, but I 1 CERTIFICATE OF REPORTER
2 would very -- I will very likely recommend an L4-5 2
3 decompression and fusion. 3 I, MOLLY A. BENOIST, Registered Professional
4 MR. PITTMAN: Thank you, Doctor. Appreciate 4 Reporter and Notary Public in and for the State of
5 your time. 5 Mississippi, do hereby certify that the above and
6 THE WITNESS: No problem. 6 foregoing pages contain a full, true and correct
7 MR. ADCOCK: Did y'all get everything out of 7 transcript of the deposition of JOHN L. MORIARITY, JR,
8 this? 8 M.D., taken in the aforenamed case at the time and
9 THE VIDEOGRAPHER: End of deposition. Time 9 place indicated, which proceedings were recorded by me
10 is 8:39 p.m. 10 to the best of my skill and ability.
11 (Deposition concluded at 8:39 p.m.) 11 I also certify that I placed the witness
12 12 under oath to tell the truth and that all answers
13 13 were given under that oath.
14 14 I certify that I have no interest, monetary
15 15 or otherwise, in the outcome of this case.
16 16
17 17 This the 17th day of February, 2009.
18 18
19 19 ________________________
20 20 MOLLY A. BENOIST, RPR
Mississippi CSR #1722
21 21
22 22 My Commissions Expires:
23 23 May 26, 2012
24 24
25 25
$ 20 pounds [1] 64/8 32/14 35/8 105/23 107/6