00001 1 IN THE CIRCUIT COURT FOR THE FOURTH JUDICIAL CIRCUIT AND 2 FOR NASSAU COUNTY, FLORIDA 3 ROBERT HOGAN, Plaintiff, 4 vs. No. 06-CA-44 5 BAPTIST MEDICAL CENTER - 6 NASSAU, INC., a Florida corporation, Defendant and Third-Party Plaintiff, 7 vs. 8 AMERICAN CANCER SOCIETY and 9 GRAY GABLE, NASSAU VILLAGE VOLUNTEER FIRE DEPARTMENT, INC., 10 Third-Party Defendants. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 11 DISCOVERY DEPOSITION OF 12 ROBERT NORMAN HARDEN, M.D. 13 September 12, 2007 14 1:30 p.m. 15 446 East Ontario Street Suite 1011 16 Chicago, Illinois 17 Stacee L. Jackson, CSR 18 19 20 21 22 23 24 25

00002 1 APPEARANCES: 2 . 3 Appeared on Behalf of the Plaintiff; 4 COKER, SCHICKEL, SORENSON & DANIEL 5 AARON SPRAGUE, ESQUIRE 6 135 East Bay Street 7 Jacksonville, Florida 32202 8 (904) 356-6071 9 . 10 Appeared on Behalf of the Defendant 11 And Third-Party Plaintiff 12 Via Speakerphone; 13 SAALFIELD, SHAD, JAY, LUCAS & STOKES, P.A. 14 CLEMENTE J. INCLAN, ESQUIRE 15 P.O. Box 41589 16 Jacksonville, Florida 32202 17 (904) 355-4401 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 .

00003 1 APPEARANCES CONTINUED: 2 . 3 Appeared on Behalf of the Third-party 4 Defendant American Cancer Society 5 Via Speakerphone; 6 FULMER, LEROY, ALBEE, BAWMANN & GLASS 7 THOMAS TOLLEFSEN, ESQUIRE 8 4720 Salisbury Road 9 Jacksonville, Florida 32256 10 (904) 562-1020 11 . 12 Appeared on Behalf of the Third-party 13 Defendants Gray Gable and Nassau 14 Village Volunteer Fire Department, Inc. 15 QUINTAIROS, PRIETO, WOOD & BOYER, P.A. 16 TERESA A. ARNOLD-SIMMONS, ESQUIRE 17 One Independent Drive, Suite 1650 18 Jacksonville, Florida 32202 19 (904) 354-5500 20 . 21 . 22 . 23 . 24 . 25 .

00004 1 DISCOVERY DEPOSITION OF 2 ROBERT NORMAN HARDEN, M.D. 3 SEPTEMBER 12, 2007 4 THE COURT REPORTER: We're going to 5 swear in the witness, okay? 6 MR. INCLAN: Okay. 7 THE COURT REPORTER: Doctor, would 8 you please raise your right hand? 9 (WHEREUPON, the witness was duly 10 sworn.) 11 ROBERT NORMAN HARDEN, M.D., called 12 as a witness by the Plaintiff, having been 13 first duly sworn, was examined and testified 14 as follows: 15 EXAMINATION 16 BY-MR.SPRAGUE: 17 Q. Will you state your full name 18 please, Doctor? 19 A. Robert Norman Harden. 20 Q. Dr. Harden, what's your professional 21 address? 22 A. 345 East Superior Street, Chicago, 23 Illinois, 60611. 24 Q. What's located there? 25 A. The Rehabilitation Institute of

00005 1 Chicago. 2 Q. Okay. And that's not where we are 3 right now? 4 A. Correct. These are our satellite 5 offices of the same institution. 6 Q. You're an M.D.? 7 A. Yes, sir. 8 Q. What's your specialty? 9 A. Pain management. 10 Q. Okay. Are you -- do you hold 11 yourself out as a psychiatrist? 12 A. No, sir. 13 Q. Do you have a degree in psychiatry? 14 A. No, sir. 15 Q. Are you licensed to practice 16 psychiatry? 17 A. No, sir. 18 Q. Do you have a degree in psychology? 19 A. No. 20 Q. Do you hold yourself out as a 21 psychologist? 22 A. I practice psychology on a daily 23 basis at my practice. I don't -- I would 24 never say I am a psychiatrist, but I do 25 practice psychotherapy and psychology.

00006 1 Q. Okay. Are you licensed to practice 2 psychology? 3 A. Inasmuch as I'm a pain management 4 M.D., yes. I do not have a PhD, and I do 5 not have a degree in psychology, if that's 6 where you're headed. 7 Q. Okay. Does the State of Illinois 8 license psychologists? 9 A. Yes, sir. 10 Q. Do you have a license? 11 A. No, sir. 12 Q. Do you have a license to practice 13 psychology or psychiatry in any state? 14 A. No, sir. 15 Q. Now, I was looking at your CV, 16 Doctor, and it doesn't appear to me that you 17 are a member of any professional organizations 18 specifically related to psychiatry or 19 psychology. Is that right? 20 A. That's correct. Yes, sir. 21 Q. Or have you been? 22 A. No, sir. I don't think so. 23 Q. Okay. All right. Now, I want to 24 talk to you a little bit about your 25 professional practice. It looks to me like

00007 1 you're a man who wears many hats. Currently 2 you are the director for the Center of Pain 3 Studies. Is that correct? 4 A. Yes, sir. 5 Q. And an associate professor in 6 Physical Medicine and Rehabilitation. Is that 7 correct? 8 A. Yes, sir. 9 Q. And a lecturer for the Finch 10 University Health Services. Is that correct? 11 A. Yes, sir. 12 Q. You're also the clinical affairs 13 chair for the RSD -- is it the RSD 14 Association of America? 15 A. Yes, sir. Reflex Sympathetic 16 Dystrophy of America, yes, sir. 17 Q. What's your connection with the 18 International Association for the Study of 19 Pain? 20 A. I have been a member for many 21 years. I attend and lecture at their meetings 22 which are tri-annually -- I'm sorry -- every 23 third year. I guess that's not tri-annual. 24 It's every third year. I have served on 25 several different committees for them. I have

00008 1 organized and facilitated two scientific closed 2 workshops for them, one in regards to complex 3 regional pain syndrome and one in regards to 4 spinal cord injury, pain. 5 Q. Okay. And you've -- you have, in 6 fact, authored or edited a number of books and 7 articles. Is that right? 8 A. Yes, sir. 9 Q. Okay. Do you actually have a 10 medical practice where you see and treat 11 patients? 12 A. Yes, sir. 13 Q. In terms of percent how much of 14 your professional time do you spend actually 15 examining and treating your own patients? 16 A. Currently that's about 10 percent. 17 Q. Is it true, Doctor, that you only 18 see patients half a day each week? 19 A. It's actually more like a day. The 20 seeing of patients and the paperwork associated 21 with that takes me about a day every week. 22 Q. Now, the other 90 percent of your 23 time, that's spent doing all the other stuff 24 that you do; directing the pain center and 25 lecturing and teaching, all that stuff. Is

00009 1 that right? 2 A. Yes, sir, primarily research. 3 Q. Now, you were retained by an 4 attorney to act as an expert witness in this 5 case? 6 A. Yes, sir. 7 Q. How often have you done this type 8 of -- this type of expert consulting in the 9 past? 10 A. I've never been deposed as an 11 expert. I've reviewed charts in probably six 12 cases. This is the first time I've ever been 13 deposed as an expert. 14 Q. Okay. In those six cases how 15 often have you been retained by a plaintiff as 16 opposed to a defendant? 17 A. I think once by plaintiff and the 18 rest by defense. 19 Q. All right. Now, I've -- I see 20 that you brought with you your file materials? 21 A. Yes, sir. 22 Q. Is this the entirety of your file, 23 Doctor? 24 A. Yes, sir. 25 Q. Now, in reviewing these I see that

00010 1 you made notes on almost all of it, so we're 2 going to attach that whole stack as 3 Plaintiff's 1. 4 (WHEREUPON, the document was 5 marked Plaintiff's Exhibit-1 for identification 6 as of September 12, 2007.) 7 BY MR. SPRAGUE: 8 Q. Do you have -- have you generated 9 an invoice in this case? 10 A. Yes, sir, I have generated one. 11 Q. I didn't see that in the stack. Do 12 you have it with you? 13 A. No, I don't. It was actually an 14 E-invoice, so there wouldn't be a hard copy 15 record of that. 16 Q. Okay. Who -- how much have you 17 billed to this point? 18 A. Honestly I don't remember the 19 number. 20 Q. Okay. Then we're going to have to 21 get the invoice. Let's take a break and get 22 the invoice. 23 A. Okay. 24 (WHEREUPON, a recess was had, after 25 which the deposition was resumed as follows:)

00011 1 BY MR. SPRAGUE: 2 Q. I've been handed this invoice, and 3 it looks like you billed for seven hours at 4 450 an hour for a total of $3,150. Does 5 that sound right to you, Doctor? 6 (Indicating.) 7 A. Yes, sir, that's correct. That's 8 what it says. 9 Q. Now, that was as of August 8th. Is 10 that right? 11 A. Yes, sir. 12 Q. Have you put in any more time 13 since then? 14 A. Yes, sir. 15 Q. How much more time? 16 A. I don't actually know. I haven't 17 prepared an invoice for that, but I would say 18 it's -- likely it's the same amount of time. 19 Q. So another seven hours? 20 A. Yes, sir. 21 Q. So that would bring the total to 22 about $6,300? 23 A. Yes, sir. 24 Q. Okay. Are you billing for the 25 video deposition that will be taken later this

00012 1 evening for trial? 2 A. Yes, sir. 3 Q. How much are you billing for that? 4 A. I bill 650 for depositions or court 5 time or video deps or whatever. 6 Q. Okay. 7 A. 650 an hour. 8 Q. So that will be -- you know, 9 assuming we have another hour along there, 10 that will be another 650 to bring it up to 11 almost 7,000. Is that right? 12 A. Yes, sir. 13 Q. All right. Who retained you? 14 A. Ms. Arnold-Simmons. 15 Q. When were you retained? 16 A. Approximately two months ago; she 17 may have a specific date. 18 Q. Okay. What were you asked to do, 19 Doctor? 20 A. To review records and potentially 21 participate in depositions or court. 22 Q. Okay. What was the object of your 23 records review? 24 A. To look specifically as to the 25 question, does the plaintiff have complex

00013 1 regional pain syndrome? 2 Q. Okay. That was the question you 3 were asked to address? 4 A. Yes, sir. 5 Q. All right. Doctor, I want to talk 6 to you a little bit about RSD or complex 7 regional pain syndrome. And for the purpose 8 -- I realize that amongst scholars and 9 physicians there is some -- some fuzziness 10 about what this thing should be called, but 11 since everybody in the case so far is calling 12 this RSD, for purposes of what we're doing 13 today, let's just refer to it as RSD, okay, 14 Doctor? 15 A. That's -- that's performed in the 16 field as often as in legal circles. 17 Q. Okay. 18 A. The name complex regional pain 19 syndrome is preferred in the field, but 20 everybody mixes it up. So I'll be happy to 21 mix it up today, if you would like. 22 Q. Okay. So I just want to talk to 23 you about RSD in general first. Now, you 24 mentioned that you were the clinical affairs 25 chair of the Reflex Sympathetic Dystrophy

00014 1 Association of America. I was on their 2 website, and I found this in the fact section 3 of the website. And it's RSD Fact or 4 Fiction, and here we read that reflex 5 sympathetic dystrophy syndrome is a chronic 6 pain syndrome characterized by severe and 7 relentless pain. Would you agree with that 8 statement? 9 A. In a qualitative way; that's -- you 10 know, we have specific criteria for making the 11 diagnosis, but this advocacy group that you're 12 quoting now is certainly entitled to their 13 qualitative opinion. And I am in agreement 14 with that, yes. 15 Q. Okay. So you would agree that RSD 16 is characterized by severe and relentless pain? 17 A. Yes, sir. In fact, I would be 18 more attune to the specific criteria that says 19 that it is pain disproportionate to the lesion 20 that is known. 21 Q. Okay. I also find here that -- 22 there's a note -- that minor injuries can 23 cause major problems. Would you agree, 24 Doctor, that minor -- relatively minor injuries 25 can lead to RSD?

00015 1 A. Yes, sir. 2 Q. I also see here that treatment may 3 include medication, physical therapy, 4 psychological support, sympathetic nerve blocks, 5 and possibly sympathectomy or a dorsal column 6 stimulator. Would you agree that those are 7 all reasonable treatment options for somebody 8 who has RSD? 9 A. Yes, sir. 10 Q. A dorsal column stimulator, is that 11 another name for a spinal cord stimulator? 12 A. Yes, sir. 13 Q. Moving smartly forward, I'm going 14 to attach these two documents as Exhibit 2. 15 I will just keep them over here by me till 16 the time comes. 17 (WHEREUPON, the document was marked 18 Plaintiff's Exhibit-2 for identification as of 19 September 12, 2007.) 20 BY MR. SPRAGUE: 21 Q. I note that you edited a book 22 entitled Complex Regional Pain Syndrome 23 Treatment Guidelines. I think you have that 24 with you today, Doctor. 25 A. Yes, sir.

00016 1 Q. I want to ask you a couple 2 questions about RSD that come from -- from 3 that. First, from the preface the author 4 writes there's an awful lot we leave out how 5 a productive member of society can become too 6 disabled to work or take care of her children. 7 And a little further down it notes the 8 potential disability of RSD and the losses 9 that accompany this horrific pain. Do you see 10 that, Doctor? 11 A. Yes, sir. 12 Q. Would you agree that the pain from 13 RSD can be disabling? 14 A. Yes, sir, it can. 15 Q. Would you agree that the pain from 16 RSD can render someone unable to work? 17 A. Yes, sir, it can. 18 Q. Can it render someone unable to 19 perform tasks of daily living such as taking 20 care of children or maintaining a household, 21 that type of thing? 22 A. Yes, sir, it can. 23 Q. Thank you. Would you agree that 24 -- would you agree that the pain from RSD and 25 the associated psychological impact can attend

00017 1 personal losses and losses of -- losses in the 2 realm of family, friends, and jobs? 3 A. Yes, sir. 4 MR. INCLAN: Form. I will just 5 say form when I object to the form of the 6 question, if that's okay. 7 BY MR. SPRAGUE: 8 Q. Now, I want to switch over to the 9 section entitled Introduction Diagnostic 10 Considerations. 11 A. Yes, sir. 12 Q. And that section was actually 13 authored by you in connection with Stephen 14 Bruehl. Is that correct? 15 A. Yes, sir. 16 Q. Now, you discuss in there two or 17 three different conferences that led to -- or 18 that have the aim of defining RSD and its 19 diagnostic criteria. But I want to talk to 20 you about the Orlando conference in 1994 first 21 of all. Do I understand you correctly that 22 in 1994 a group of researchers and doctors 23 came together in Orlando and set forth a set 24 of diagnostic criteria for RSD? 25 A. Yes, sir. And, in fact, they were

00018 1 the first to name it and call it complex 2 regional pain syndrome. That was one of the 3 -- one of the reasons for that conference was 4 to rename the disease and to develop a general 5 set of diagnostic criteria or a working 6 diagnostic set. 7 Q. Okay. And those diagnostic 8 criteria were adopted by the Committee for 9 Classification of Chronic Pain of the 10 International Association for the Study of 11 Pain? 12 A. Yes, sir. 13 Q. Now, those diagnostic criteria are 14 spelled out in Table 1 of this section that 15 we've been discussing on page .8, Doctor? 16 A. Yes, sir. 17 Q. And they are also the same criteria 18 that are found in the -- what is the RSD/CRPS 19 section of the RSD Association of America 20 website. Is that right? 21 MS. ARNOLD-SIMMONS: Well, you need 22 to show it to him if you're going to ask him 23 if it's on there. 24 THE WITNESS: I'm sorry. Is this 25 what you have highlighted here?

00019 1 BY MR. SPRAGUE: 2 Q. No, Doctor. What I have 3 highlighted is not -- 4 A. Oh, this one here. I see, yes, 5 sir. Excuse me one second. Let me make 6 sure that is the same thing. Yeah, that's 7 the verbatim. You know, it's interesting, 8 though, that this writing -- this consultation 9 of what is in here is actually my writing. 10 I wrote that many years ago and now everybody 11 reproduces it, but the point is I took this 12 from the IASP Taxonomy which is not this 13 clear. They didn't have this, but I -- Dr. 14 Bruehl and I had sat down and we took all 15 the features of that, wrote this, and now that 16 has been basically promulgated many, many, many 17 times. As you see, now it's become the 18 standard. 19 Q. Okay. Now, looking at those four 20 criteria that you just said that you wrote -- 21 A. Well, I'm sorry. Let me be clear. 22 This was what the Orlando group had done. 23 Q. Okay. 24 A. They just weren't real crystal 25 about it when they talked away. They let the

00020 1 IASP publish it and they were a little bit 2 vague in terms of their terminology. So we 3 sat down in a very structured way and pulled 4 from that. So I'm saying I wrote the words, 5 but I did not author the concept. 6 Q. Okay. I understand that, Doctor. 7 Sufficent to say these are your words? 8 A. Yes, my work reflecting that the -- 9 Q. IASP consensus? 10 A. Correct, of the Orlando folks. 11 Q. And one is the presence of 12 initiating -- an initiating noxious event or a 13 cause of immobilization. Is that right, 14 Doctor? 15 A. Yes. 16 Q. And two is continuing pain, 17 allodynia, or hyperalgesia -- is that right -- 18 A. Hyperalgesia. 19 Q. -- with which the pain is 20 disproportionate to the inciting event? 21 A. Yes, sir. 22 Q. Three is evidence at some point in 23 time of edemic, changes in skin, blood flow, 24 or abnormal sudomotor activity in the region 25 of the pain?

00021 1 A. Yes, sir. 2 Q. The fourth is the diagnosis is 3 excluded by the existence of conditions that 4 would otherwise account for the degree of pain 5 and dysfunction. Is that correct? 6 A. Yes, sir. 7 Q. What is meant by evidence at some 8 time? I'm trying to focus in on the words 9 "at some time." What are you -- what is the 10 criteria trying to communicate by using that 11 term in that third criteria? 12 A. Well, the intent was that 13 historically people could have evidence or 14 present evidence that they had these things, 15 or it could be at the time of the 16 examination. So historical is acceptable as 17 well as present signs and symptoms that are 18 told to the doctor at the time of the 19 diagnosis. 20 Q. Okay. So if I understand you 21 correctly, then patient comes into the doctor. 22 He may have some signs and symptoms. Doctor 23 looks through the records, finds other signs 24 and symptoms in the past. Those signs and 25 symptoms count towards the diagnosis of RSD

00022 1 under this criteria. Is that right? 2 A. Yes, sir. 3 Q. And that's what's meant by "at some 4 time"? 5 A. Yes, sir. 6 Q. Has the IASP -- the International 7 Association for the Study of Pain adopted any 8 diagnostic criteria that supersede the criteria 9 adopted after the 1994 Orlando conference? 10 A. The IASP sponsored a symposium that 11 was held in Budapest because they knew that 12 this was a very weak criteria that needed to 13 be fixed. They published this book, for 14 instance, so I don't know at exactly -- at 15 what level you say that the IASP has 16 superseded the previous work. They clearly 17 sponsored a think tank, sponsored a closed 18 workshop, and then published a book in regards 19 -- specifically in regards to the diagnosis. 20 So that would be the most -- the most recent 21 word from the IASP, I guess, would be this 22 volume here. 23 Q. Okay. I want to -- when was that 24 published? 25 A. It would be 2001.

00023 1 Q. 2001, okay. Doctor, this Complex 2 Regional Pain Syndrome Treatment Guidelines 3 that I've been discussing with you, this was 4 published in June 2006? 5 A. Yes, sir, sounds correct. 6 Q. So that was published after the 7 book that you just referenced? 8 A. Yes, sir. 9 Q. I want you to look with me at page 10 .7. 11 A. Okay. 12 Q. Now, if I understand what you've 13 written here, the Budapest criteria are being 14 proposed to the Committee of Classification of 15 Chronic Pain for the IASP for future revisions 16 of their formal taxonomy and diagnostic 17 criteria for pain states. I guess the way I 18 understood that was that the Budapest criteria 19 had been proposed but not adopted. Is that 20 correct? 21 A. You asked me the question what is 22 the IASP saying today, but what we're 23 referring to now is specifically the Taxonomy 24 Committee. And the Taxonomy Committee is 25 charged with diagnostic criteria for all pain

00024 1 states. They simply haven't published anything 2 since 1994. 3 Q. Okay. 4 A. So -- I'm sorry -- the way you 5 asked the question is what -- IASP obviously 6 sponsored this and codified this. However, 7 the Taxonomy Committee has not met and have 8 not written a revision since 1994. 9 Q. Okay. So, again, to be specific, 10 the Taxonomy Committee adopted the 1994 Orlando 11 criteria? 12 A. Yes, sir. 13 Q. And have not yet adopted the 14 Budapest criteria? 15 A. Correct. They've not adopted any 16 criteria for any diagnosis since '94. You 17 know, I think adopted is not the proper word. 18 We should be saying codified just -- just as 19 a point of semantics. 20 Q. All right. Now, let's talk about 21 the Budapest criteria. 22 A. Okay. 23 Q. The Budapest criteria are more 24 stringent than the current criteria? 25 A. They're more specific.

00025 1 Q. Again, not to get tied up in 2 semantics, but what I'm getting at, Doctor, is 3 -- for lack of more precise language -- it's 4 more difficult for a doctor to diagnosis RSD 5 under the Budapest criteria -- you know, 6 strike that. 7 What I guess I'm trying to say is 8 fewer people would qualify for diagnosis of 9 RSD under the Budapest criteria than the 10 Orlando criteria? 11 A. That's correct. 12 Q. And that's what I mean by more 13 stringent. 14 A. Yes, sir. 15 Q. Okay. Now, going back to the 16 manual that we've been discussing the Budapest 17 criteria -- the clinical diagnostic criteria 18 are set forth in Table 3A? 19 A. Yes, sir. 20 Q. The Budapest criteria are not found 21 in the -- what is RSD section of the RSDSA 22 website. Is that right? 23 A. I don't know. I haven't reviewed 24 that website, but the paper you showed me 25 mentioned the '94 criteria or Orlando criteria,

00026 1 not the Budapest criteria. 2 Q. Okay. Now, you are one of -- for 3 lack of a better term -- one of the authors 4 of the Budapest criteria? 5 A. Yes, sir. In fact, Dr. Bruehl and 6 I had done the statistical derivation of those 7 criteria which we took to that consensus group 8 in Budapest. I would have to say yes and 9 yes to your question. 10 Q. And you're advocating that they be 11 adopted? 12 A. Yes, sir. 13 Q. Sufficent to say what is codified 14 by the Taxonomy Committee of the International 15 Association of the Study of Pain presently is 16 the 1994 -- 17 A. Yes, sir. 18 Q. -- Orlando criteria? 19 A. Yes, sir. 20 Q. Okay. In your limited medical 21 practice when a patient comes to you with 22 chronic pain and there's a suspicion that it 23 might be RSD, how do you go about diagnosing 24 them? 25 MS. ARNOLD-SIMMONS: Objection to the

00027 1 form. 2 THE WITNESS: Yeah, well, I have 3 to comment on my limited medical practice. 4 That's only been for three years and before 5 that I have 18 years of full-time clinical 6 work and director of many different types of 7 clinic in different collections including what 8 we at that time called the RSD Clinic at the 9 Medical University of South Carolina. So my 10 clinical experience is very extensive and over 11 many years. So on the basis of that 12 experience including the fact that I limit my 13 practice a bit now -- your question is, how 14 would I make a diagnosis of somebody coming 15 in? 16 BY MR. SPRAGUE: 17 Q. Yeah. When somebody comes in, what 18 would you do with them? How would you go 19 about diagnosing RSD? 20 A. Well, in general we would do a 21 very comprehensive history. 22 Q. You know what, Doctor, I don't mean 23 to interrupt you but it would be a lot easier 24 if I kind of take this step by step. 25 A. Okay.

00028 1 Q. When you say you would do an 2 in-depth or comprehensive history, how would 3 you do that? 4 A. You ask the patient what's 5 happened -- 6 Q. Okay. 7 A. -- what's going on with you since 8 the onset of this disease, any corellary of 9 things, issues that could be going on. We 10 ask a lot of questions about, you know, other 11 associated comorbidities. We would ask -- at 12 that point we would perhaps have the benefit 13 of referral information; in other words, the 14 opinion of other doctors that had seen the 15 patient including their history that they had 16 taken. So the historical part is primarily 17 from the mouth of the patient, somewhat from 18 the mouth of the record. And on the basis 19 of that we obviously form our historical 20 impression. 21 Q. Okay. There's a couple things I 22 got to ask you. First of all, I think you 23 mentioned comorbidity? 24 A. Yes, sir. 25 Q. What's that?

00029 1 A. Meaning things that may or may not 2 -- other disease, processes that may or may 3 not be associated. For instance, somebody may 4 have diabetic peripheral neuropathy and complex 5 regional pain syndrome. And although on the 6 face of it it sounds like two clearly distinct 7 syndromes or diseases. Of course, it's 8 important for us to know that because the two 9 overlap. 10 Q. Okay. 11 A. So comorbidities are simply any 12 illness, any past medical history, or any 13 other disease that the patient might have. 14 Q. Okay. Now, if you have the 15 benefit of the records of referring doctors 16 and their history, why would you want to take 17 a history from the patient? 18 A. Because it's invaluable. That has 19 to be premier in the understanding of the 20 presentation of symptoms. The patient is 21 telling us now what their symptoms are and 22 that's critical to get their subjective opinion 23 of what's going on with them and what's 24 happening. 25 Q. Why is that?

00030 1 A. That's the way we're trained. 2 That's axiomatic in my business that the 3 history is of critical importance, and it must 4 come from the patient. 5 Q. Okay. All right. So you take a 6 history. Then what would you do, Doc? 7 A. Then we do a physical examination. 8 Q. Now, why would you do a physical 9 examination? 10 A. This is an attempt to obtain more 11 data and in this case quasi-objective data 12 about what's happening with the patient. These 13 are such things as reflexes, strength 14 measurements, posture; sometimes subtle things 15 like pain behaviors, you know, whether they 16 look sad or happy or well rested or whether 17 they're -- you know, look like they've bathed 18 recently. A lot of things go into this 19 observational process. And, again, as part of 20 our training this has equal weight to the 21 history. In other words, this is where we 22 get signs. This is where we get more 23 objective data with what's going on with the 24 patient. 25 Q. Okay. So you take a history from

00031 1 the patient? 2 A. Yes, sir. 3 Q. You do a physical examination? 4 A. Yes, sir. 5 Q. What else would you do? 6 A. At that point you make a decision 7 whether or not you need any testing to 8 corroborate your impressions based on the 9 history and physical. And this is where you 10 move into a fully objective type of arena 11 where you're using machinery to test things 12 that now have no subjective component. They're 13 just simply numbers that come out of machines 14 or things like X-rays. And that is not fully 15 objective because it relies on the subjective 16 impression of the physician reading those -- 17 those type of tests. But we make an 18 estimation. Do we need any test to 19 corroborate? And that could be X-rays, MRI's, 20 electrodiagnostic testing, and then a whole 21 array of psychophysical tests and psychometric 22 tests that actually we often get with CRPS 23 patients. 24 Q. You talked about X-rays, MRI's, and 25 some other testing you would use. Is there

00032 1 anything else that you would -- testing you 2 would typically do with a patient that you 3 suspect could have or might have RSD? 4 A. Yes, sir. There would be -- 5 specifically because we have access to this 6 testing we would do thermal quantitative 7 sensory testing. 8 Q. How would you do that, Doctor? 9 A. It's a machine that heats -- has a 10 sensor -- actually, a peltier pad that heats 11 up or cools down at a specific rate. The 12 patient tells you whether, you know, when they 13 perceive it, when it becomes painful or cold 14 and when they perceive it and when it becomes 15 painful hot. And that quantitates sort of 16 exactly the temperatures that are needed to 17 elicit the perception or the first painful 18 response. So that being a quasi-objective 19 test gives you a number, a specific number. 20 The test is generated in such a way it's 21 difficult for a patient to fudge the results, 22 if you will. We would probably do infrared 23 -- quantitated infrared teletomography. 24 Q. Is that a thermogram, Doctor? 25 A. Yes.

00033 1 Q. Anything else? 2 A. Depending on the patient's 3 presentation I may get a plain X-ray to look 4 for osteopenia or bone loss. That's really 5 the only test that I would commonly use. 6 Occasionally we get oddball tests, but that 7 would be based more on comorbidity than the 8 specific diagnostic considerations of CRPS. 9 Q. Okay. Doctor, if you did a 10 thermogram that showed temperature variation -- 11 and we're talking about right to left whatever 12 extremity you're looking at, upper or lower -- 13 if you did a thermogram that showed a 14 temperature variation over one degree 15 centegrate, what would that tell but the 16 existence of RSD in a patient? 17 A. Well, that obviously would be met 18 to meet one of the criterion which speaks to 19 vasomotor disturbance or temperature or color 20 changes that you could see either historically 21 or on physical exam. If you use a 22 quantitative infrared teletomography, this will 23 allow you to quantitate a whole limb or a 24 hand or whatever versus the other. You 25 obviously have been doing your homework so one

00034 1 degree centegrate is considered diagnostic in 2 this field in this area. And it helps to, 3 if you will, take off one of the criterion in 4 terms of having a significant in average 5 temperature change one side relative to the 6 other. 7 Q. All right. Doctor, before I move 8 on -- I'm sorry -- we talked about history, 9 physical examination, testing. Is there 10 anything else you would do in your diagnosis 11 or when you're going about diagnosing a 12 patient for RSD? 13 A. No, sir. That's sufficient. 14 Q. That's it, okay. All right. 15 A. And, you know, I need to add one 16 thing to that. The diagnostic criterion both 17 of Orlando and Budapest are bedside diagnostic 18 criteria. They do not require or mention any 19 tests. The tests are corroboratory. They're 20 not -- they're not in the criterion. 21 Q. Okay. So, again, I think I 22 understand what you mean but just to be sure, 23 I think what you're telling me is that a 24 doctor can diagnose RSD without ever doing a 25 thermogram or these other tests that you

00035 1 mentioned and discussed. Is that right? 2 A. Yes, sir. 3 Q. All right. Very good. Moving on 4 then, I want to ask you some questions about 5 the treatment of RSD. And I want to take 6 you -- we've been discussing the manual. I 7 want to take you to page .29. And we're in 8 the section that is pharmacotherapy. And, 9 again, this is written by you. I didn't 10 realize that. I just looked at it right now. 11 In the section titled Pharmacotherapy there is 12 a specific section for opioids. And that is 13 on 29, correct, Doctor? 14 A. Yes, sir. 15 Q. Now, I read here the use of 16 opioids for general chronic pain management is 17 still subject to some controversy, but they 18 may have value as both a rescue and 19 maintenance treatment for CRPS. I imagine 20 since you wrote that, you would agree with 21 that statement? 22 A. Yes, sir. 23 Q. What do you mean by rescue and 24 maintenance treatment? 25 A. Rescue would be when somebody just

00036 1 occasionally took an opioid when the pain was 2 bad; a flare up or an exacerbation and they 3 would take an opioid; as we say as needed or 4 PRN. Maintenance is the opposite of that 5 meaning that it would be something that they 6 would take everyday on a schedule continuously 7 to try to keep the pain level down. 8 Q. Okay. So then if I understand 9 this sentence correctly, opioids may have value 10 for maintenance treatment of CRPS or RSD. Is 11 that right, Doctor? 12 A. Yes, sir, it may have. 13 Q. Now, this is something I'm going to 14 need you to educate me on, Doctor, because 15 obviously you know a heck of a lot more about 16 this than I do. Methadone may have a special 17 place in the treatment of CRPS because of its 18 punitive NMDA antagonism. For those of us who 19 are not versed in medical terminology what 20 does that mean? 21 A. Well, the NMDA receptor is a 22 neurochemical receptor in the nervous system 23 that responds to an excitatory nerve chemical 24 called Glutamate. Glutamate is involved in 25 pain. And Glutamate is involved in

00037 1 sensatation of the nervous system to the pain 2 response. So a drug that blocks the NMDA 3 receptor would have value in the treatment of 4 a disease that was involved with central 5 sensatation such as CPRS. In other words, it 6 goes to the -- our understanding of the 7 pathophysiology of the disease. And that's 8 why we would say it looks like Methadone may 9 have special value because in addition to 10 being an opioid, just a drug like morphine 11 that blocks the pain, it may actually act on 12 some of the pathophysiologic mechanisms of the 13 disease. 14 Q. Okay. Again, I think I understand 15 what you're saying, Doc. Then again you may 16 still be one step over my head, so let me 17 make sure that I'm clear. I think what 18 you're telling me is Methadone has special 19 value for the treatment of RSD because not 20 only does it kill pain but it also -- it 21 also treats the cause of what's, you know, 22 causing the condition. Is that what you're 23 trying to tell me? 24 A. The reason we -- yes. Simply yes. 25 Q. Okay. Now I'm sorry, Doctor, but

00038 1 you're going to have to explain one more step 2 down why that is because I still don't think 3 I follow you. 4 A. I think to put it a little bit 5 more simplistically the drug works like 6 morphine sulfate. It blocks the pain but it 7 also has a feature -- a unique feature that 8 no other opioids have which it seems to modify 9 the disease. It seems to modify one of the 10 causes or, as we say, the pathophysiology of 11 the disease. 12 Q. Okay. So are you saying that 13 Methadone might have special value in the 14 treatment of RSD? 15 A. It may have. It's a very tricky 16 drug to use, and you always have to assess 17 the risk benefit in each individual case. So 18 that's why I always couch statements like that 19 using the word "may." It may have special 20 value in some selected cases. 21 Q. All right. Now, I want to go back 22 then -- back to page .36. There's a table. 23 It's called the Pharmacotherapy Guide. 24 A. Yes, sir. 25 Q. And in one column there's reasons

00039 1 for inability to begin or progress and then 2 there's -- in the right column action. And 3 when we say inability to begin or progress, I 4 think what you're meaning is an inability to 5 begin or progress in functional restoration. 6 A. Yes, sir. 7 Q. Is that correct? 8 So if you have a problem with 9 excruciating or intractable pain one of the 10 actions is opioid treatment. Is that correct, 11 doctor? 12 A. Yes, sir. 13 Q. What is intractable pain? 14 A. It does not respond to usual or 15 simple therapy ie. the step above that. 16 Q. Okay. And so if you have 17 intractable pain opioids may be an appropriate 18 treatment? 19 A. May be an appropriate treatment, 20 yes, sir. 21 Q. Okay. Now, I want to go to -- I 22 want to talk about interventional therapies. 23 It's in the back as I'm sure you know 24 MR. INCLAN: Excuse me. Aaron, do 25 you have a lot more documents you're going to

00040 1 review with the doctor? 2 MR. SPRAGUE: Yeah. 3 MR. INCLAN: Is there a way to get 4 me a copy of these? 5 MR. SPRAGUE: Well, we've got about 6 a four-inch high stack. 7 MS. ARNOLD-SIMMONS: Well, you 8 don't have a four-inch hight stack. That's the 9 doctor's documents. The literature he's 10 brought with him is about how many pages? 11 THE WITNESS: I think this is what 12 he's referring to. He wants the copy of the 13 booklet. 14 (WHEREUPON, a discussion was had 15 off record.) 16 BY MR. SPRAGUE: 17 Q. Okay. I'm looking at page .59 now 18 under Interventional Therapies. 19 A. Yes, sir. 20 Q. And I'm in the section 21 neurostimulation. Now, is neurostimulation 22 what would be accomplished with a dorsal 23 column stimulator or otherwise known as a 24 spinal cord stimulator? 25 A. Yes, sir. That's one way to

00041 1 achieve neurostimulation. That's actually 2 central neurostimulation but you're correct. 3 Q. Now, I'm not going to go through 4 this section in verse but if I understand this 5 section on neurostimulation correctly, the 6 point is that there is evidence that suggests 7 that neurostimulation is effective in treating 8 RSD-related pain. Is that right? 9 A. No, sir. That's not proven. This 10 is considered fourth line therapy, very sort 11 of Hail Mary type stuff in the treatment of 12 CRPS. It has not been proven. There is 13 essentially no good scientific evidence 14 supporting this. There is one randomized 15 control trial out of the Netherlands that 16 would tend to support this, but it was a very 17 flawed study. So we're now in an area where 18 we've exhausted the standard of care of 19 treatment and are starting to grasp at straws, 20 if you will. 21 Q. Okay. I'm looking at the last 22 sentence of this section, Doctor. It says two 23 groups have critically reviewed these and other 24 studies in case report literature and concluded 25 that there's moderate evidence that SCS, which

00042 1 I think is neurostimulation, is effective in 2 treating CRPS-related pain. Now, my first 3 question is, what's that sentence meant to 4 communicate, Doctor? 5 A. In the opinion of Dr. Burton who 6 is an anesthesiologists and, of course, 7 involved in the implantation of these types of 8 devices he feels that the evidence is merely 9 moderate in support of this. He knows and I 10 know that the evidence is not definitive, and 11 he's quoting two articles which review this 12 and suggest that, you know, we certainly need 13 randomized control trials. So the evidence is 14 open label which is considered Class 4 15 scientific evidence. It's not very good. 16 And we all eagerly await the Class 17 1 or Class 2 evidence which would suggest that 18 this device works or does not work. But 19 that's not forthcoming after a decade of 20 having these devices put in people's backs. 21 So it's a little disappointing in terms of 22 science, but nonetheless these things are out 23 there and, of course, we wanted to include 24 this in the treatment guidelines to be fair. 25 If the standard of care treatments are not

00043 1 working, then it's appropriate to start looking 2 around for more experimental treatments. 3 Q. Then I want to take you back to 4 62, on page .62. But before we do that for 5 purposes of being clear, given everything you 6 said, I think that at a minimum there is some 7 evidence out there that suggests that spinal 8 cord stimulators are effective in treating RSD 9 pain. Is that correct? 10 A. I don't want to go semantical on 11 you about the word you use evidence. And 12 science evidence means that there are 13 randomized control trials. There is one 14 randomized control trial that is considered 15 flawed that supports this and that's it. So 16 that would not be sufficient evidence for a 17 thoughtful physician to conclude that it's 18 established and it's standard. So there is 19 some data out there, but it's as I say Class 20 4 data, Class 4 evidence that is not -- it's 21 not definitive, not sufficient to make a 22 decision about proceeding to that treatment. 23 Q. Okay. So there is some data out 24 there that suggests that spinal cord 25 stimulators are effective in treating RSD pain.

00044 1 A. Yes, sir. 2 Q. Is that right? 3 A. Yes, sir. 4 Q. Now going back to page .62 -- 5 A. Yes, sir. 6 Q. -- Figure 1, interventional pain 7 treatment algorithm for CRPS. 8 A. Yes, sir. 9 Q. What is this, Doctor? 10 A. This is an algorithm that was 11 written by Dr. Burton to try to sort out the 12 massive information or lack of information, if 13 you will, about interventional treatments for 14 CRPS. And it is simply his recommendation 15 about how to proceed. 16 Q. Okay. So I guess what I'm asking 17 is, is this kind of the -- his suggestions 18 about treatments that you might want to try 19 like you try minimally evasive treatments and 20 if those don't work, you proceed to more 21 evasive treatments. And if those don't work, 22 you proceed to surgical and experimental 23 therapies. Is that kind of -- am I correct 24 in reading it that way? 25 A. Yes.

00045 1 MS. ARNOLD-SIMMONS: Objection to the 2 form. Go ahead. 3 BY MR. SPRAGUE: 4 Q. The answer was yes? 5 A. Yes, sir. 6 Q. So under minimal evasive you have 7 sympathetic nerve block. Is that right? 8 A. Yes, sir. 9 Q. And under more evasive therapies we 10 have neurostimulation, right? 11 A. Yes, sir. 12 Q. Now -- and I think I asked this 13 question before in the context of talking 14 about some of the treatments that were set 15 forth on the RSDSA website, but I think you 16 just testified that you would agree that both 17 of those are reasonable treatment options for 18 somebody who might have RSD? 19 A. I'm sorry. What treatment options? 20 Q. Sympathetic nerve blocks and 21 neurostimulation. 22 A. They're certainly in the treatment 23 recommendations, but they are meant to be 24 second line. Primary first line treatments 25 are physical therapy and occupational therapy

00046 1 and functional restoration. It's only if the 2 patient fails to progress that the treating 3 team makes a decision as to whether to add 4 drugs or stronger drugs to add psychotherapies 5 or more intensive psychotherapies or to proceed 6 to some sort of interventional treatment 7 starting with minimally evasive and then going 8 to the more evasive or experimental treatments. 9 Q. Okay. But sufficent to say these 10 are reasonable treatment options. 11 MR. INCLAN: Form. 12 THE WITNESS: You know, these -- 13 as I say when you get to the bottom of this 14 list, you're into things that are not proven. 15 They do not reach the level of Class 1 or 2 16 evidence. Therefore, they can't be considered 17 standard of care. Insurance companies often 18 don't pay for these, for instance, on the 19 basis of that. And until somebody bothers to 20 go out and actually do the randomized control 21 trials or a surrogate of the randomized 22 control trials which may be necessary with 23 these type of devices it's all experimental. 24 It's just simply not proven yet in the 25 scientific literature. Now, there's an

00047 1 interesting subpoint here. Sympathetic nerve 2 blocks which are minimally evasive are also 3 not proven. 4 BY MR. SPRAGUE: 5 Q. Okay. Now, I want to talk to you 6 about your opinions, Doctor -- 7 A. Yes, sir. 8 Q. -- in this case. First thing I 9 want to do is just to provide -- just to 10 provide a framework for discussion. And so 11 details left out just again to provide a 12 framework for discussion. Can you give me the 13 laundry list of the opinions that you've 14 reached in this case. Just list them out for 15 me. 16 A. Okay. It is my opinion that Dr. 17 Hogan had something happen to him when he cut 18 his hand. The sequella to that are a little 19 bit perplexing to me. However, of course, I 20 have the records of many professionals that 21 have seen him. And I can see a trail of 22 signs and symptoms developing throughout that. 23 It is my opinion that there is no doctor in 24 the entire record who has either documented or 25 observed sufficient signs and symptoms to make

00048 1 a Budapest-based criteria, the more specific 2 criteria set that we have now. 3 There's only one doctor who has 4 documented sufficient signs and symptoms to 5 even comment on the IASP criteria. That 6 doctor is Dr. George. And he does give 7 enough signs and symptoms to make an 8 IASP-based criteria with the exception of 9 Criterion 4 which is a better explanation or 10 some other reason that Dr. Hogan would be 11 portraying the pain and pain behaviors and the 12 signs and symptoms. 13 There is also another doctor in the 14 record, a Dr. Halprin, who did document 15 sufficient signs and symptoms to potentially 16 make a diagnosis both on the basis of IASP 17 and Budapest, but he on the basis of his 18 signs and symptoms would say he does not have 19 CRPS either on the basis of the IASP criteria 20 or the Budapest criteria. So, in other words, 21 he does document enough signs and symptoms 22 that we would say he does not have it. So 23 it is my opinion after reviewing these records 24 that I could state to a reasonable degree of 25 medical certainty that Hogan has CRPS.

00049 1 Q. Okay. A little behind you; let me 2 just finish writing here. Okay. Now, Doctor, 3 if I boil down what you just told me, I 4 think the punchline is your main opinion is 5 that you can't document or can't say within a 6 reasonable degree of medical certainty that Dr. 7 Hogan has RSD? 8 A. Yes, sir. 9 Q. That's the punchline? 10 A. Yes, sir. 11 Q. Any other opinions? 12 MR. INCLAN: Form objection. 13 MS. ARNOLD-SIMMONS: Same objection. 14 THE WITNESS: I certainly would 15 have opinions about, you know, the voracity of 16 presentation, the thoroughness of documentation, 17 the doctors' opinions about technologies that 18 they've used, and the value of those 19 technologies. In other words, I have many 20 opinions, but I think my salient opinion 21 should be as to my -- you know, my area of 22 expertise which is the diagnosis of this 23 disease. 24 BY MR. SPRAGUE: 25 Q. Okay. Fine. And all those things

00050 1 you just talked about, those are wrapped up in 2 the punchline you can't determine whether this 3 man has RSD? 4 A. Yes, sir. 5 MS. ARNOLD-SIMMONS: Objection, form. 6 BY MR. SPRAGUE: 7 Q. Do you have any opinions about what 8 Dr. Hogan does have? 9 A. I know possibilities. I have not 10 seen the gentleman obviously to get it out. 11 You know, I haven't gotten a history. I 12 haven't taken a physical exam. I do not have 13 the benefit of tests. So I'm going by the 14 record. There are a number of possibilities 15 in terms of what could be explaining his 16 signs, symptoms, and pain behaviors so... 17 Q. Okay. Understand what I'm asking, 18 do you have an opinion within a reasonable 19 degree of medical probability as to what is 20 going on with Dr. Hogan? 21 A. No, sir. 22 Q. Do you have any opinions within a 23 reasonable degree of medical probability as to 24 Dr. Hogan's employability? 25 MR. INCLAN: Form objection.

00051 1 THE WITNESS: Yes, sir, on the 2 basis of the record I do. 3 BY MR. SPRAGUE: 4 Q. Okay. What are those? 5 A. It is my opinion that he can work. 6 It is my opinion that he can work in the 7 field of medicine. I am unclear as to 8 whether or not he will specifically be able to 9 be a general surgeon. I understand that there 10 are signs and symptoms that he presents in the 11 one case that he does not present in the next 12 case. And apparently there's some information 13 about him being able to do considerably more 14 outside of clinical appointments that he can 15 do in the clinical appointment. 16 Q. Are those your only opinions as far 17 as his ability to be employed? 18 A. Yes, sir. 19 Q. Now, leaving out again subpoints 20 and details and things that may fit in with 21 these two main punchlines that we discussed, 22 do you have any other major, you know, 23 punchline-type opinions in this case? 24 MR. INCLAN: Form objection. 25 THE WITNESS: That's a real

00052 1 difficult question to answer. I mean it may 2 prove that some of my opinions on this case 3 are salient or punchline items to someone, 4 perhaps not to you, but you're absolutely 5 right. The overarching opinions that I have 6 are that he in my opinion does not meet 7 criteria for CRPS and in my opinion certainly 8 can work in the medical field. 9 BY MR. SPRAGUE: 10 Q. Okay. I think we now have our 11 list. So I now know what to talk to you 12 about. We'll talk about the Budapest criteria 13 and not being able to say within a reasonable 14 degree of medical certainty that Dr. Hogan has 15 RSD, and then we'll move on and talk about 16 employment and employability, all right. 17 MS. ARNOLD-SIMMONS: Objection, form. 18 THE WITNESS: Yes. 19 BY MR. SPRAGUE: 20 Q. Let's talk with the Budapest 21 criteria in a little bit more detail, Doctor, 22 okay. 23 A. Okay. 24 Q. How would a doctor, clinician use 25 the Budapest criteria in his diagnosis and

00053 1 treatment of somebody with RSD? 2 A. Well, as I say, a patient would 3 come in. The first and foremost 4 responsibility of the physician is to diagnose, 5 and they would use these criteria to decide 6 whether a patient had complex regional pain 7 syndrome or not. And then, of course, they 8 have to make a decision about the "or not" 9 and what the other possibilities might be and 10 then use criteria hopefully to make those 11 diagnoses if they felt like the patient -- if 12 the patient did not have CRPS. 13 So the Budapest criteria are 14 considerably more specific, in other words, a 15 better shot of actually diagnosing the disease 16 than the IASP criteria. So specifically 17 appropro to your question they can use 18 criteria to much more specifically make that 19 diagnosis; does the patient have CRPS or not. 20 Q. Okay. I actually asked you the 21 wrong question. 22 A. Okay. 23 Q. That wasn't actually what I was 24 getting at. 25 A. Okay.

00054 1 Q. What I'm trying to understand is, 2 how do the criteria work? 3 A. So criteria are pretty simple. 4 They're meant to be statements and they're yes 5 or no answers to the statements. The first 6 statement of the Budapest criteria are 7 continuing pain that is disproportionate to any 8 inciting event. So this -- the physician 9 says, well, in my experience a person that has 10 laceration of a finger of a hand, this is the 11 amount of time it would take them to heal. 12 This is how long they would have pain, then 13 healing would occur, and that should stop. So 14 if they felt like this was disproportionate to 15 that, they would say yes to that criteria. 16 That's Criterion 1. 17 Q. Okay. 18 A. Criterion 2 must report at least 19 one symptom in each of the following four 20 categories. 21 Q. Is it in each of the following 22 four or three of the four? 23 A. Must report at least one symptom in 24 each of the four following categories. 25 Q. Are we talking about clinical

00055 1 diagnostic criteria or the research? 2 A. You're correct. This is the 3 research. For the clinical criteria which is 4 the less specific of the two you require one 5 symptom in each of three following categories. 6 Q. Okay. So three of the four 7 following categories. 8 A. This book that doesn't have that 9 but this book does. Do you want me to go by 10 this book? 11 Q. Go by that book so we're reading 12 the same thing. 13 A. Okay, same page. Critical 14 diagnostic criteria; must report at least one 15 symptom in three of the four following 16 categories. You're absolutely correct. Sensory 17 reports of hyperesthesia and/or allodynia. 18 That means they are very sensitive to a 19 specific testing. 20 Q. I'm sorry. Hyperesthesia, is that 21 the same thing as -- I can pronounce it if 22 I'm looking at it. 23 A. Hyperpathia? 24 Q. Or hyperalgesia. 25 A. It's not exactly the same thing.

00056 1 Hyperesthesia is sort of the umbrella under 2 which hyperpathia and hyperalgesia fall. So 3 that means they're just sensitive to sensation. 4 Q. Okay. Can one have both 5 hyperesthesia and allodynia? 6 A. Yes. 7 Q. Keep going then, Doc. 8 A. Okay. So they have hyperesthesia 9 and/or allodynia. They have vasomotor changes 10 meaning changes in the blood flow to the skin, 11 blood flow to the affected part. So this 12 would be characterized in terms of the 13 clinical exam in terms of temperature asymmetry 14 and/or skin color changes and/or skip color 15 asymmetry. 16 Q. Okay. Now, before we move on, Doc 17 -- so when you say temperature asymmetry, 18 you're saying one limb is hotter or cooler 19 than the other? 20 A. Yes, sir. 21 Q. And skin color changes -- can you 22 give us some examples of that, Doctor? 23 A. It could be if the limb was 24 cooler, you would expect it would be blue or 25 cold.

00057 1 Q. Okay. 2 A. I'm sorry. Blue or pale. 3 Q. Okay. 4 A. Sometimes even to white; if it was 5 hotter, it would be redder. 6 Q. Okay. 7 A. Is that enough or do you want 8 more? 9 Q. How about modeling, Doctor? 10 A. Modeling is interesting. It is 11 probably more a reflection of sympathetic 12 distribution to the skin. It doesn't 13 necessarily go in line with vasomotor increase 14 or vasomotor disease. In other words, I guess 15 skin modeling is kind of a vague sign or 16 symptom to mention. It doesn't really help in 17 terms of understanding vasomotor change. 18 Q. One last question before we move on 19 to the next area, but skin color asymmetry -- 20 pretty self-explanatory but that means one limb 21 is a different color than the other? 22 A. Yes, sir. 23 Q. All right. Go on then. Is that 24 sudomotor edema? 25 A. Sudomotor and edema.

00058 1 Q. Sudomotor? 2 A. Sudomotor means sweat. 3 Q. Okay. 4 A. So there's sweating abnormalities 5 meaning that they're either sweating more or 6 less on one side relative to the other and 7 edema of course is swelling. This means that 8 they're simply swollen up on one side relative 9 to the other. 10 Q. Okay. 11 A. And then the last factor is motor 12 and/or trophic. Motor means power -- means 13 muscles. It can refer to a decreased range 14 of motion and/or motor dysfunction such as 15 weakness; tremor which is a shaking of the 16 affected part; dystonia means abnormal 17 posturing of the affected part. And then the 18 trophic part are changes in the hair, nails, 19 or skin. 20 Q. Okay. Let me talk about trophic 21 changes. 22 A. Okay. 23 Q. From past experience I think I 24 understand that one of these trophic changes 25 is you actually -- hair loss, exfoliation.

00059 1 Someone with RSD might lose the hair on the 2 affected limb. Is that right, Doctor? 3 A. That's possible, yes, sir. 4 Q. What about the skin appearing thin 5 or shiny? 6 A. Thin, shiny appearance or thick 7 callous appearance, these both can occur 8 actually. You were referring to heir. It's 9 more common that you will have increase hair 10 growth on the affected part. The skin changes 11 actually go through usually a progression from 12 sort of thin shiny looking to a more course 13 thick callous looking appearance. 14 Q. Okay. So I don't mean to 15 interrupt you but -- so skin that appears thin 16 is one of the trophic changes that's 17 consistent with the criteria? 18 A. Yes. 19 Q. Go on. 20 A. And then it says sweaty asymmetry 21 and this means they're sweating more or less 22 on one side versus the other. 23 Q. Okay. All right. Now -- 24 A. We were talking about -- 25 Q. I understand, Doctor. Don't worry

00060 1 about it. We're fine. 2 A. -- hair, nails, and skin. Actually 3 you can have nail changes too, if you want to 4 discuss that. 5 Q. What would those nail changes be? 6 Can you give me some examples? 7 A. Thickening, ridging, or cracking of 8 the nails. 9 Q. Okay. Now, the criteria says you 10 have to have three of the four. So -- and 11 these are symptoms. I'm sorry. I'm going to 12 have to break this up into one -- two 13 questions. 14 A. Yes, sir. 15 Q. Symptoms, I think I'm understanding, 16 is what the patient reports? 17 A. Yes, sir. 18 Q. So a patient comes in, and he's 19 got a report of symptoms in three of the four 20 categories. So if he comes in and says my 21 hand is cold, I think it's swollen and 22 weak -- 23 A. Yes, sir. 24 Q. -- that qualifies? 25 A. Yes, sir, for the criteria.

00061 1 Q. For the criteria; so he doesn't 2 have to also have allodynia, for instance, or 3 if he comes in and reports allodynia but not 4 like motor or trophic changes, you would still 5 qualify. Any of the three out of the four 6 categories would meet the criteria? 7 A. I'm not sure I understand, but I 8 can explain that. He needs to have sensory 9 and/or vasomotor and/or sudomotor and/or motor, 10 three of the four symptoms. 11 Q. Okay. 12 A. So, in other words, he could not 13 have any changes motor and still meet the 14 three of four. 15 Q. Okay. But you must have sensory? 16 A. No, no, he can have vasomotor, 17 sudomotor, and motor and still meet the 18 criteria without the sensory. 19 Q. Okay. 20 A. So he just has to have three of 21 those four. 22 Q. In any mix? 23 A. In any mix, yes, sir. 24 Q. Very good. Now I understand you. 25 Okay. Now, 3 is must display at least one

00062 1 sign. Now sign I'm taking to mean something 2 that the doctor himself observes; this is a 3 finding? 4 A. Yes, sir. 5 Q. And there's an asterisk there that 6 says a sign is counted only if its observed 7 at the time of the diagnosis. What do you 8 mean by that? 9 A. When a doctor is doing the 10 evaluation to assess the criteria, they have 11 to see it. 12 Q. Okay. 13 A. And they have to document it. 14 Q. So you got to have one sign in two 15 or more of the categories -- 16 A. Yes, sir. 17 Q. -- at the same time? 18 A. Yes, sir. 19 Q. Do the signs have to be observed 20 at the same time the symptoms are reported? 21 A. Well, in the same examination 22 period; it all would occur over the course of 23 an hour or so. They can say that, you know, 24 these are my symptoms. These have occurred 25 historically or they're occurring now, and at

00063 1 that time in the same ballpark being -- give 2 or take an hour the doctor has to observe the 3 signs. 4 Q. Okay. And then the categories are 5 the same. I don't think we have to go back 6 over them. 7 A. Correct. 8 Q. Is that right? 9 A. Correct. 10 Q. What is acceptable evidence of 11 temperature asymmetry? 12 A. In my opinion this is meant to be 13 a physical diagnosis so that needs to be -- 14 it certainly needs to be observed by the 15 doctor and documented by the doctor. We -- 16 in our clinics, of course, use quantitative 17 infrared teletomography I because that is 18 subjective. 19 Q. But is it sufficient, for instance, 20 for the doctor to put the -- his hand on the 21 affected limb and say, yep, it's cold? 22 A. Well, he has to do it versus the 23 other side. 24 Q. Okay. But it's cold? 25 A. Has to document asymmetry; that's a

00064 1 critical part of this. It's not sufficient to 2 put their hands on the affected part and say 3 it appears cold to me because that's relative. 4 They have to simultaneously say the right side 5 versus the left side is cooler or the right 6 side versus the left side is warmer. 7 Q. But you can do that with your 8 hands? 9 MR. INCLAN: Form objection. 10 BY MR. SPRAGUE: 11 Q. Again, evidence of edema; what is 12 acceptable evidence of edema? 13 A. At the bedside it needs to be 14 measured with a tape measure or something and 15 documented, of course, again side to side. 16 Preferentially there's a process called volume 17 immetry which is basically where the patient 18 takes the unaffected part and puts it in a 19 bucket of water that's graduated to measure 20 how much water is displaced to a certain level 21 and then go to the affected side and they put 22 their hand at the same point and see how much 23 water is displaced. You'll see now in an 24 objective way -- it's quasi-objective because 25 it's recorded by the doctor. But in a

00065 1 quasi-objective way you'll be able to 2 quantitate edema or swelling. 3 Q. Is edema something that can be 4 eyeballed? 5 A. If it's gross it can be eyeballed. 6 I think my point about the volume immetry and 7 the measuring is that subtle edema cannot 8 really be eyeballed. It has to be measured. 9 Q. Finally, trophic changes; what's 10 acceptable evidence of trophic changes? 11 A. These are all things that are 12 observed by the physician and documented by 13 the physician. 14 Q. Okay. 15 A. And, again, you know, I think 16 prudently any doctor that would presume to 17 make these diagnoses this is all well 18 documented by a picture. So, you know, we 19 take pictures of people when they come into 20 the clinic of their hands and feet and all 21 that kind of stuff. So then it's beyond the 22 observation and documentation of the doctor, 23 but they have some way to corroborate that, if 24 anybody ever asks. 25 Q. All right. Tell me, Doctor, why

00066 1 you say that you can't conclude within a 2 reasonable degree of medical probability that 3 Dr. Hogan has RSD? 4 A. Well, again, because I'm reading 5 through the records and the doctors -- I mean 6 I won't assume I know why it is that they 7 did not document sufficient signs and symptoms 8 to make the diagnosis, but they simply did not 9 with the exception of two doctors; Dr. George 10 -- as I say, he almost made the clinical 11 diagnostic criteria, but he didn't -- he 12 didn't -- he wasn't quite there -- wasn't 13 quite enough to make the Budapest, but he does 14 have enough to make the IASP. 15 Q. Okay. 16 A. And Dr. Halprin who actually has a 17 wealth of signs and symptoms; I mean he 18 mentioned these but, of course, in his 19 examination they are not present. In other 20 words, he has enough data to say Dr. Hogan 21 does not have CRPS. So the only two doctors 22 that have actually documented enough in their 23 record at any one time, on any given occasion 24 are George and Halprin. 25 Q. Okay.

00067 1 A. The other docs say -- you know, 2 they may mention something in one part of the 3 record and then, you know, may say something 4 about it later but that's not the spirit of 5 the thing. They got to do it all at once. 6 Q. Before I go on you're aware, aren't 7 you, Doctor that Dr. Halprin was retained and 8 paid for by the defendants? 9 A. Yes, sir. It was an IME, 10 independent medical examiner. I don't know if 11 it was by defense or the payers. I'm not 12 real sure. I know he was an IME. 13 Q. Okay. Now, I want to make sure I 14 understand you. You looked at each doctor and 15 I think what you're telling me is that no 16 doctor on any given visit observed enough 17 signs and symptoms to make the diagnosis that 18 Dr. Hogan had RSD. Is that what you're 19 telling me? 20 MR. INCLAN: Form. 21 THE WITNESS: That's correct with 22 the exception of Halprin and George. 23 BY MR. SPRAGUE: 24 Q. Now, I want to talk to you about 25 Dr. George. You mentioned that he doesn't

00068 1 have enough signs and symptoms to meet the 2 Budapest criteria. Where does he fall down 3 there? 4 A. I didn't mention that specifically 5 in my little notes here, but I simply stated 6 that he -- he did have sufficient to make the 7 IASP. He did not have sufficient to make the 8 Budapest research or clinical criteria. 9 Q. Okay. So you sitting here right 10 now you can't tell me what it is about Dr. 11 Halprin's records or findings that fails to 12 meet the Budapest criteria? 13 A. You meant to say George. 14 Q. I'm sorry. Dr. George. Yes, I 15 did. 16 A. I could. If you would like me to 17 go to the records I could. 18 Q. Yeah, go to the records. 19 A. (Indicating.) 20 Q. Now while you're going through the 21 records I think you referred to Dr. George as 22 a relatively clueless block jock. 23 MS. ARNOLD-SIMMONS: Objection to the 24 form. Would you like him to answer your 25 other question or this question?

00069 1 BY MR. SPRAGUE: 2 Q. Answer this question first. 3 A. Okay. This question, so we're 4 going to George's record here. 5 Q. Yeah, it's right here. That's what 6 I'm looking at. That is actually -- I see 7 you have written relatively clueless block 8 jock. 9 A. Yes, sir. 10 Q. And so the other question was, what 11 does Dr. George fail to -- 12 A. Okay. 13 Q. -- find? 14 A. Let me see. So I'm going through 15 the notes here and one thing he mentions -- 16 dystrophic changes, color and temperature 17 changes, and weakness in terms of symptoms. 18 And in terms of the physical examination he 19 mentions noticeably cooler. So he did mention 20 three symptoms and one sign. 21 Q. Okay. And that is -- when is 22 that, Doctor? 23 A. 5/02/06. 24 Q. So let's see. We have -- again, 25 Doctor -- I'm sorry. But I think you said

00070 1 -- what were the three complaints again? 2 A. In terms of the three symptoms that 3 he portrayed at that time that are documented; 4 he has dystrophic which is thinning of skin. 5 Then he says discoloration. So although I 6 would not consider that sufficient 7 documentation -- I mean what does he mean by 8 that by discoloration, and was it asymmetric 9 and was it relative to -- but I will spot 10 him that symptom as a color change as a 11 vasomotor change. 12 And then he says weakness. Again, 13 it's very poorly characterized, very vague, but 14 to be generous to this record I would say, 15 okay, we'll go ahead and say that he's 16 documenting a history of weakness. But then 17 he goes to physical examination and he says 18 one thing, noticeably cooler to touch. 19 Q. Okay. So that would be one. That 20 would be vasomotor, right? 21 A. Yeah. 22 Q. I want to direct your attention to 23 the findings right above that. Patient has 24 visual evidence of RSD consistent with thinning 25 of skin.

00071 1 A. Uh-huh. 2 Q. Okay. Is that a trophic change? 3 A. Yes. 4 Q. So Dr. George also observed a 5 trophic change? 6 A. Yeah. That's -- yes. 7 Q. So now we have a sign of vasomotor 8 and trophic? 9 A. Let me see. Visual evidence, 10 general examination, yes. 11 Q. So correct me if I'm wrong, Doctor, 12 but that gives us our two signs, doesn't it? 13 A. If you're willing to -- to allow 14 his lack of documentation that these are 15 asymmetric changes; when he states that he's 16 got thinning of skin, discoloration and 17 weakness but he doesn't mention whether this 18 is bilateral or not. 19 Q. Okay. But he does note those 20 things? 21 A. He does note those things. 22 Q. And if we're talking about left 23 versus right and they're asymmetrical, that 24 would give us our signs and symptoms? 25 A. It's important to note that in the

00072 1 diagnostic criteria that the -- it is required 2 that it is asymmetrical, all of these things 3 to be asymmetrical. 4 Q. Doctor, I'm asking you to assume 5 that they're asymmetrical. 6 A. Assume that they're asymmetrical 7 although it's not stated in the record. 8 Q. Assume that they're asymmetrical -- 9 A. Yes, sir. 10 Q. -- that would give us our two 11 signs, correct? 12 MS. ARNOLD-SIMMONS: Objection to the 13 form of the question. 14 MR. INCLAN: Join. 15 BY MR. SPRAGUE: 16 Q. Correct? 17 A. Correct. 18 Q. So then on this visit Dr. Hogan 19 would have met the Budapest criteria? 20 MS. ARNOLD-SIMMONS: Objection. 21 THE WITNESS: Not if you read the 22 criteria and require documentation as to 23 asymmetry. 24 BY MR. SPRAGUE: 25 Q. Okay.

00073 1 A. I mean my point is simply this, to 2 record that he's weak as he does -- he just 3 says weakness. I mean is he weak in his 4 toes or in his jaw muscles or his arm or 5 fingers or hand? And this, of course, is 6 relevant to the diagnosis. So the fact that 7 he's recorded these things without mentioning 8 asymmetry is problematic in terms of the 9 criteria and, of course, he hasn't addressed 10 the fourth criteria but we can talk about 11 that. 12 Q. Well, hold on for a second, Doctor. 13 Dr. Hogan began has a problem with his left 14 upper extremity, right? 15 A. Yes. 16 Q. And he comes to Dr. George and 17 he's seeing him about the left upper 18 extremity, right? 19 A. Yes. 20 Q. And not the jaw or his legs or his 21 feet. 22 A. Uh-huh. 23 Q. So isn't it reasonable to assume, 24 Doctor, that when we're talking about visual 25 evidence of RSD, thinning of the skin, we're

00074 1 talking about the left upper extremity? 2 MS. ARNOLD-SIMMONS: Objection to the 3 form of the question. 4 MR. INCLAN: Join. 5 MR. TOLLEFSEN: Join. 6 THE WITNESS: I can't assume what 7 Dr. George was examining or commenting on. He 8 is very vague. I mean you have to admit 9 that his objective section is very sparse, 10 very limited. And for better or worse he's 11 not documented the necessary elements to, in 12 my opinion, make the diagnosis by the Budapest 13 criteria. 14 BY MR. SPRAGUE: 15 Q. All right. So I just want to go 16 back to this one more time, Doctor, because I 17 don't think we've gotten a clear answer on it. 18 Again, assume that there is asymmetry, if Dr. 19 George has observed thinning of the skin, 20 discoloration and weakness that's asymmetrical, 21 that would give us two signs -- 22 MS. ARNOLD-SIMMONS: Objection. 23 BY MR. SPRAGUE: 24 Q. -- or more than two signs? 25 MS. ARNOLD-SIMMONS: Objection, form

00075 1 of the question. 2 MR. INCLAN: Join. 3 THE WITNESS: If we make those 4 assumptions, then I would say that, yes, he 5 meets Criteria 3. That does not make the 6 diagnosis. But given those assumptions that 7 it is asymmetrical and that he had documented 8 that, that would be correct. He meets 9 Criterion 3. 10 BY MR. SPRAGUE: 11 Q. Okay. Let's go on then to 12 5/31/06. 13 A. 5/31/06, okay, got it. 14 Q. Do we meet the criteria on 5/31/06? 15 A. We're talking about, again, the 16 signs? 17 Q. Uh-huh. 18 A. Criterion 3 specifically? 19 Q. Criterion 3. 20 A. He says left upper extremity is 21 very pale and cool to the touch. We might 22 make the assumption that he's talking about 23 the other side. But, again, I mean, you 24 know, it would be necessary to know that his 25 right upper extremity was not also cool.

00076 1 Patient has hyperalgesia and allodynia. There 2 is atrophy of the skin evidenced. 3 Q. So, again, assuming asymmetry, we 4 have a sign of sensory and a sign of 5 vasomotor or vaso -- yeah, vasomotor? 6 A. Correct. 7 Q. So those are signs in two or more 8 areas, right? 9 A. Two or more factors, if you make 10 the assumption of asymmetry. 11 Q. Okay. Now, let's go to 3/01/2007. 12 A. Wait a minute. I'm sorry. I'm 13 skipping over some of my records here. I'm 14 sorry. I don't have any records from '07 15 from Dr. George. 16 Q. Okay. 17 A. I will be happy to take a look at 18 what you have. 19 Q. Yeah, I have -- I only have one 20 copy, so we're going to have to look on 21 together, Doctor. 22 A. Okay. 23 Q. But left upper extremity is very 24 pale and cool to the touch. Do you see that 25 general examination?

00077 1 A. Yes. 2 Q. So that would be -- again, that 3 would be a sign in -- 4 A. Vasomotor. 5 Q. -- vasomotor? 6 Hyperalgesia, and allodynia -- 7 A. Yes, sir. 8 Q. -- that's a sign in sensory? 9 A. Yes, sir. 10 Q. And then if we go down, physical 11 examination, neurologic, diminished strength, 12 left upper forearm, that would be a sign 13 in -- 14 A. Motor. 15 Q. -- motor? 16 And then hypersensitivity of the 17 right hand and arm. Let's see. Motor 18 diminished, strength, left upper extremity due 19 to pain and weakness. And he also lists 20 patient's hand shows exfoliative features, and 21 that would be trophic. Is that correct? 22 A. That's not correct. I don't know 23 what he means by exfoliative features. That 24 usually means his skin is flaking off. I'm not 25 exactly sure how that fits.

00078 1 Q. But sufficent to say going on, 2 patient has hyperalgesia and pale and cool to 3 the touch. That's a sign in vasomotor and 4 sensory, correct? 5 A. Yes. He records changes that would 6 be -- I'm sorry. Pain, vasomotor, and motor 7 and -- again, if he had documented asymmetry, 8 then he would have met Criterion 3. Of 9 course, in all these records that you're 10 asking me to review that doesn't mean that 11 he's meeting Criterion 2 or 4. But 12 nonetheless -- and I really -- and I want to 13 go back to my point. In no record does he 14 meet Criterion 2 and 4. So we're talking 15 about -- I'm sorry -- 3. I'm sorry, 2 and 16 3. So we're talking about 3 -- Criterion 3 17 now. It's important to realize he has to 18 meet both. He must meet Criterion 2 as well 19 as Criterion 4 as well as Criterion 3 in 20 making the diagnosis. 21 Q. All right. So then let's go back 22 to the 5/2/06 record, Doctor. 23 A. Okay. 24 Q. Now, you've already testified, I 25 think, that on that occasion we -- giving him

00079 1 the benefit of the doubt we meet Criterion 2? 2 MR. INCLAN: Form. 3 THE WITNESS: I'm sorry. Give him 4 the benefit of the doubt; we would say that 5 if he had document asymmetry, we would give 6 him Criterion 3. 7 BY MR. SPRAGUE: 8 Q. Yeah. 9 A. Criterion 2 is another matter with 10 Dr. George's notes, if you will. 11 Q. But I think you testified earlier 12 that he -- that on this occasion he did have 13 his three symptoms? 14 A. Yeah, I'm sorry because I was 15 actually reading under what he has as general 16 examination and symptoms. That is not 17 correct, my error. 18 Q. Okay. 19 A. These are still under Criterion 3, 20 in other words, signs. You have to go back 21 up to the part that he has listed HPI. And 22 that's where we would pull out the symptoms. 23 So you are correct. I misspoke on that but 24 I was just simply looking at that, and it 25 looked like symptoms to me. It doesn't look

00080 1 like signs to me. 2 Q. So does Dr. Hogan present symptoms 3 sufficient to meet Criterion 2 on 5/2/2006? 4 A. Okay. He has pain. That is 5 Criterion 1. 6 Q. So we got 1. We need 3. 7 A. Then we need to document three of 8 the four. Okay. I'm sorry. One is 9 Criterion 1. That doesn't count for Criterion 10 2. For Criterion 2 we have to have 3 of 4. 11 Q. Okay. 12 A. Okay. So we have extremes in 13 temperature variations. Again, that's -- I 14 don't know what he's documenting here. He's 15 got temperature variations. Is that from day 16 to day or from moment to moment and is it -- 17 more importantly from side to side? So I 18 couldn't conclude that that would be a 19 vasomotor symptom. Associated signs and 20 symptoms, numbness; now numbness is not usually 21 associated with complex regional pain syndrome. 22 We're looking for allodynia meaning light touch 23 is now painful, not numbness. 24 So numbness would actually go 25 against the diagnosis of CRPS. He has

00081 1 weakness. So that is a symptom. Poor sleep, 2 fatigue, anger, anxiety; of course, these are 3 psychological. And that's it. So, in other 4 words, he doesn't get the three of four 5 factors for symptoms on that day. 6 Q. Okay. 7 A. We conclude that if he had 8 diagnosed -- I mean if he had documented 9 asymmetry and used less vague terminology that 10 he may meet two or in this case three signs. 11 But he didn't document enough in terms of 12 symptoms on that day. 13 Q. Okay. Tell me about Criterion No. 14 4. What would you need to see in the 15 records in order for Criterion 4 to be 16 satisfied? 17 A. He needs to discuss a differential 18 diagnosis. Any doctor -- especially in 19 evaluation -- needs to discuss the other 20 possibilities and begin a process of ruling 21 those in or ruling those out. It is not 22 considered the best practice to, you know, 23 make a single conclusion unless it's a 24 diagnosis like renal disease and you can 25 document an objective change in laboratories or

00082 1 something. Since we're dealing with a 2 syndrome we need to make sure that there's no 3 other possibilities. So I don't see that. I 4 don't see any discussion of other possibilities 5 unless, of course -- I'm sorry. Unless, of 6 course -- well, not that day. Oh, I'm sorry. 7 He does say depression and anxiety. That 8 certainly is a possibility for explaining the 9 signs and symptoms that Dr. Hogan portrays on 10 this day. So maybe he is trying to give us 11 a differential diagnosis when he says 12 depression and anxiety is one of his ICD-9 -- 13 I'm sorry. Actually, it's '06 so it would be 14 ICD-9. 15 Q. Now, you say that Dr. George has 16 sufficient documentation to meet the current 17 IASP criteria? 18 A. Yes. 19 Q. Tell us about that, Doctor. 20 A. Well, again, you want me to just 21 go over the records until we conclude. 22 Q. No, just basically. 23 A. So in general presence of an 24 initiating noxious event and he does at least 25 at first document the initiating event -- or

00083 1 cause of immobilization. Dr. George is really 2 actually not documenting the onset and the 3 circumstances of the initial injury. So it's 4 questionable whether he really meets Criterion 5 1. But Criterion 1 -- well, it's questionable 6 whether he meets that. 7 Q. Sufficent to say there was an 8 initiating noxious event in this case? 9 A. Yes. We have that historically 10 from many other sources but not this source. 11 No. 2, continuing pain, yes, allodynia. In 12 terms of the note -- I'm looking at that now. 13 He does not document allodynia. Hyperalgesia, 14 he does not document hyperalgesia. In fact, 15 he documents numbness which is sort of the 16 opposite which is disproportionate to any 17 inciting event. So he didn't get that one. 18 Q. Let me stop you there, Doctor. 19 A. Yes, sir. 20 Q. On 5/31/06 doesn't Dr. George 21 document hyperalgesia and allodynia? 22 A. Of course, I'm talking about 23 5/2/06. You said which one? 24 Q. 5/31/06. 25 A. Yes, sir. He specifically mentions

00084 1 patient has hyperalgesia and allodynia. 2 Q. And he also documents that on 3 3/1/2007, Doctor? 4 A. Well, these are signs. We are 5 talking what he has documented under signs 6 here. We are not talking symptoms, and we 7 are not talking about Budapest. So we don't 8 have to worry too much about signs and 9 symptoms. We're back to IASP criteria. 10 Q. Yeah, I know. 11 A. Yes, in some of his records he 12 does document. 13 MS. ARNOLD-SIMMONS: Can you all 14 hold on? 15 (WHEREUPON, a recess was had, after 16 which the deposition was resumed as follows:) 17 MR. SPRAGUE: Let's go back on the 18 record. 19 BY MR. SPRAGUE: 20 Q. Doctor, just in the interest of 21 time just to short circuit this whole line of 22 questioning, sufficent to say I believe it's 23 your opinion based on your prior testimony 24 that Dr. George does have sufficient 25 documentation to satisfy the current 1994 IASP

00085 1 criteria? 2 MS. ARNOLD-SIMMONS: Objection to the 3 form. 4 THE WITNESS: There's actually one 5 of his notes that does. Some of his notes 6 do not but one of his notes does. 7 BY MR. SPRAGUE: 8 Q. Okay. So based on that note Dr. 9 George could have concluded that Dr. Hogan has 10 RSD under those 1994 criteria? 11 A. I'm sorry. But there is one 12 exception to that. I cannot state that for 13 sure because he has not addressed Criterion 4 14 to my satisfaction. He's not developed or 15 investigated or discussed a differential 16 diagnosis with the exception of making a 17 diagnosis of depression and anxiety. 18 Q. Okay. A person can both have RSD 19 and be depressed. Is that right? 20 A. That's correct. 21 Q. And they can both have RSD and 22 have anxiety. Is that correct? 23 A. Yes, sir. 24 Q. Now, with reference to Dr. Hogan's 25 other treating physicians; Dr. Twigg, Dr.

00086 1 Jerinati, Dr. Steinberg, Dr. Kirkpatrick 2 (phonetic) and the doctor that examined him 3 from the Social Security Administration, Dr. 4 Ullah, is it your opinion that none of these 5 doctors have sufficient documentation in any 6 one of their visits to make a diagnosis of 7 RSD under any of the criteria. Is that what 8 you're opinion is? 9 A. That's correct, yes, sir. 10 Q. Now, you would agree with me, 11 though, Doctor, that Dr. Twigg has observed at 12 one time or another hyperesthesia? 13 A. You know, I have to say that I 14 don't believe I have any notes from Dr. Twigg, 15 so I can't really comment on that. 16 Q. You didn't receive notes from Dr. 17 Twigg? 18 A. I don't have any records from Dr. 19 Twigg. 20 Q. Okay. So you don't know whether 21 Dr. Twigg observed hyperesthesia or not? 22 A. No. 23 Q. Or -- then you also wouldn't know 24 if she observed that left handgrip strength 25 was decreased?

00087 1 A. No. If you want me to look at 2 the record that you've got in your hand, I'll 3 be happy to. 4 Q. These are just my notes. You 5 would also agree with me that Dr. Steinberg 6 noted that his left hand was cool? 7 A. Yes, sir. Steinberg mentioned very 8 few signs and very few symptoms in his note 9 but yes. 10 Q. And Dr. Ullah had noted edema in 11 the left upper extremity? 12 A. Here it is. Yes, sir. 13 Q. And he noted weakness in left upper 14 extremity? 15 A. Actually, I don't have that in my 16 notes. Can you show me where he said that? 17 Q. I'm looking where it says 18 extremity, upper. 19 A. Yes, I see. 20 Q. Right upper extremity is completely 21 normal. Left upper extremity showed early 22 dystrophic changes. Do you see that? 23 A. Yes. 24 Q. Now, are dystrophic changes 25 consistent with a finding of RSD?

00088 1 A. Yes, under Criterion 3, yes, sir. 2 Q. He's beginning to lose muscle mass 3 compared to the right. Do you see that? 4 A. Yes, I see that. 5 Q. There was local edema. Do you see 6 that? 7 A. Yes, I do. 8 Q. Grip strength was at best four out 9 of five compared to five out of five on the 10 right. Do you see that? 11 A. Yes, sir. 12 Q. So that's what I was referring to 13 with -- 14 A. When you say said weakness. 15 Q. -- weakness. So that's asymmetric? 16 A. Yeah. He's properly referring to 17 left versus right, upper extremity. So the 18 muscle mass, range of motion, and the grip 19 strength all fall under motor. 20 Q. That's one. 21 A. The edema is two. 22 Q. Okay. 23 A. And then dystrophic changes -- 24 unfortunately, he doesn't mention what 25 dystrophic changes. But he says something in

00089 1 the left hand. So that could potentially be 2 three. 3 Q. Three signs of RSD? 4 A. Yes. 5 Q. That's all I'm getting at. And he 6 also noticed purplish discoloration? 7 A. Yes, he says purple in color. 8 Q. Compared to the right hand? 9 A. I'm sorry. He does not make the 10 asymmetry thing, but he says left hand becomes 11 purple in color from time to time. 12 Q. No, no. I'm talking about -- 13 again, extremities, upper, left hand was warm 14 today but had a purple discoloration as 15 compared to the right hand. 16 A. I'm sorry. Yes, yes, I see it. 17 Thank you. Yes, he says purplish 18 discoloration. 19 Q. Okay. And those are all signs 20 consistent with RSD, correct? 21 A. Correct. 22 Q. And, Dr. Kirkpatrick at various 23 times noted swelling? 24 A. Yes. 25 Q. Decreased strength?

00090 1 A. Could you kindly show me that, sir? 2 The problem with Kirkpatrick's records is they 3 dribbled in over time, but I'm sure I could 4 find it. But it might save some time if you 5 could show me. 6 Q. Okay. 7 A. Or I'll look too. 8 Q. I'm looking at January 18, 2006, 9 objective, extremities, left hand clearly has 10 increased swelling compared to the right. In 11 addition, left hand demonstrates an increased 12 number of white spots associated with modeling 13 of the skin. The patient demonstrated 14 decreased strength and range of motion 15 throughout the left upper extremity. And that's 16 what I'm talking about, decreased strength and 17 range of motion. 18 A. Yes. He said that in that note. 19 Q. And that would be consistent with 20 RSD? 21 A. Now, is he mentioning that as a 22 symptom or is he mentioning that as a sign? 23 Q. He's mentioning that in his section 24 entitled objective, so I'm assuming that's a 25 sign.

00091 1 A. Physical examination, okay, yes. So 2 that would be a sign, correct. 3 Q. He also noted in January 10, '07, 4 and August 28, '07, bluish discoloration? 5 A. Yes, I recall that. 6 Q. And that is consistent with RSD? 7 A. Yes. 8 Q. Now, again, your problem with these 9 doctors isn't that they didn't note signs or 10 symptoms of RSD. It's just that the signs 11 and symptoms don't happen to coincide at the 12 same time such that they can make a diagnosis 13 at any one visit? 14 A. So what you're asking me to do is 15 to make an aggregate -- 16 Q. No, no, I'm not asking you to make 17 any sort of aggregate. I'm just making sure 18 I'm clear on your opinions. You're not saying 19 that they haven't observed anything consistent 20 with RSD. 21 A. Yeah. 22 Q. Your saying they haven't observed 23 them at the same time such that they can meet 24 the Budapest criteria? 25 MR. INCLAN: Form objection.

00092 1 THE WITNESS: In terms of 2 Kirkpatrick he never makes sufficient signs and 3 symptoms to make the Budapest criteria even in 4 aggregate. 5 BY MR. SPRAGUE: 6 Q. Okay. 7 A. George does make the IASP criteria 8 on one note with the exception of the first 9 criterion. So I means that's what I'm saying. 10 Q. But let me ask you this question, 11 Dr. Ullah, Dr. Kirkpatrick, Dr. Twigg, and 12 Dr. Steinberg have all at some time observed 13 signs that are consistent with the diagnosis 14 of RSD? 15 A. Yes, sir. 16 Q. All right. Now, you mentioned that 17 you have some ideas about other different 18 possible things that might be going on with 19 Dr. Kirkpatrick other than RSD. Why don't you 20 tell us about those, Doctor? 21 MS. ARNOLD-SIMMONS: Objection to the 22 form. You said Dr. Kirkpatrick. 23 MR. SPRAGUE: Can I go off the 24 record for just a second? 25 (WHEREUPON, a discussion was had

00093 1 off record.) 2 BY MR. SPRAGUE: 3 Q. You mentioned earlier in your 4 deposition that you had some ideas of things 5 that might possibly be going on with Dr. Hogan 6 other than RSD. Why don't you tell us about 7 those. 8 A. Well, the lack of sufficient signs 9 and symptoms to meet all criterion for this 10 specific criteria for RSP makes one need to 11 apply Criterion 4 and start to look for other 12 possibilities. And other possibilities are 13 some type of neuropathy as yet uncharacterized. 14 He's not had really the type of work-up -- 15 the type of testing that would be necessary to 16 document that. 17 He could have a psychological 18 diagnosis that would cause him to portray 19 signs and symptoms of CRPS, and those 20 psychological diagnoses -- some of which are 21 diagnosed such as depression and anxiety -- 22 are often associated with the production at 23 least of symptoms that could be read as 24 consistent with CRPS. Other psychiatric 25 diagnoses that are possible would be factitious

00094 1 disorder which is the psychological production 2 of signs and symptoms such as applying a 3 tourniquet to the affected part so that it 4 would be swollen and would have color and 5 temperature changes. 6 And then, of course, there is 7 secondary gain which is a possibility that he 8 would have some sort of personal gain that 9 would cause him to produce or continue to 10 produce symptoms, perhaps to manufacturer or 11 produce signs. And then the last thing is 12 opioid induced hyperalgesia. He's taking quite 13 high doses of opioids. And these drugs are 14 well known to make or create a situation of 15 hyperalgesia and allodynia in a subset of 16 patients particularly in high doses. And I 17 would characterize Dr. Hogan's dose of opioids 18 to be quite high. 19 Q. Okay. Now, these are the 20 possibilities. Now, you haven't seen Dr. 21 Hogan? 22 A. That's correct. 23 Q. You haven't examined him? 24 A. No, I have not. 25 Q. Haven't taken a history from him?

00095 1 A. No, I have not. 2 Q. Haven't done any testing on him? 3 A. No, sir. 4 Q. And I think your prior testimony is 5 that although these are possibilities, you do 6 not have an opinion within a reasonable degree 7 of medical probability that any of this is 8 going on? 9 A. No, sir. 10 MR. INCLAN: Form. 11 THE WITNESS: You're asking me to 12 discuss the possibilities or the differential 13 diagnosis and that's what I'm doing now. 14 BY MR. SPRAGUE: 15 Q. But it's not your -- it's not your 16 opinion within a medical degree -- reasonable 17 degree of medical probability that any of this 18 is actually happening with Dr. Hogan? 19 A. That's right. 20 MR. INCLAN: Objection, form. 21 THE WITNESS: No, sir, I don't 22 have sufficient information from this record to 23 comment one way or the other to a reasonable 24 degree of medical certainty. 25 ///

00096 1 BY MR. SPRAGUE: 2 Q. Do you have any opinion as to the 3 cause of Dr. Hogan's present physical and/or 4 psychological state? 5 A. I don't have an opinion to a 6 reasonable degree of medical certainty as to 7 cause, but I could speculate, if you'd like. 8 Q. Let me ask you this question. In 9 response to questions about cause would 10 anything you have to say be speculation? 11 A. It's simply based on the records 12 that I have in front of me and, as you say, 13 I have not met him, not examined him. 14 Q. Okay. And I understand that. All 15 I'm asking is would your answers to the 16 questions about causation be speculation? 17 A. Informed speculation, yes. 18 Q. Do you have any opinions as to 19 what the appropriate treatment for Dr. Hogan 20 would be at this point in time? 21 A. Yes, sir. 22 Q. What are those opinions? 23 A. I feel that he could benefit from 24 intensive psychotherapy. I feel that he could 25 benefit from a radical change in his

00097 1 pharmacotherapy. I think it's inappropriate in 2 the sense of opioid-induced hyperalgesia -- and 3 probably ill advised in this case. I feel 4 that he could probably benefit from some 5 intensive physical and occupational therapy; 6 physical to deal with some of the subjective 7 weakness that he's portraying in some of the 8 examinations; and occupational therapy to start 9 the process of teaching him how he might begin 10 to learn how to operate again, to do surgery, 11 or if he chooses to participate in a different 12 type of medical practice. 13 He could in that same context 14 benefit from some vocational rehabilitation. He 15 may benefit from some processes like 16 biofeedback, sort of -- this is more like 17 psychotherapy; certainly falls under the 18 cognitive behavioral psychotherapy realm, but I 19 think he could specifically benefit from such 20 items -- such issues as thermo biofeedback, 21 muscle biofeedback, stress management, 22 relaxation, coping skills, imagery, 23 self-hypnosis. These are certainly some of 24 the prominent features of cognitive behavioral 25 psychotherapy that could be very helpful in a

00098 1 case like this, if I saw him and agreed with 2 the findings and the conclusions that these 3 doctors have arrived at. 4 Q. This opinion that you just set 5 forth regarding Dr. Hogan's treatment -- 6 A. Yes, sir. 7 Q. -- is this a thing that is merely 8 possible or is this an opinion within a 9 reasonable degree of medical probability? 10 A. Well, I have to answer that in two 11 parts. The first is I'm going on the record 12 in what I see, and I'm making punitive 13 possible diagnoses. And you asked me to say 14 what treatments should he get on the basis of 15 either those punitive possible diagnoses or the 16 diagnosis of CRPS. I assume that that's what 17 you're asking me. But if we assume that I 18 agree with that and I think that he has any 19 or all of those potential diagnoses that I had 20 mentioned and the signs and symptoms that I 21 see in the record scattered around, I would 22 say that to a reasonable degree of medical 23 certainty these things could help him. 24 Q. Okay. 25 A. I mean this goes to a very

00099 1 important point. You know, it would be bad 2 practice for me to presume to treat somebody 3 that I have not examined. 4 Q. Okay. 5 A. You know, what I'm saying is I'm 6 making assumptions that I sort of somehow from 7 this record get an idea of what's wrong with 8 him and then state to a reasonable degree of 9 medical certainty that these treatments would 10 help. 11 Q. Would you be more confident in your 12 opinions regarding his treatment if you had 13 the opportunity to examine him first? 14 A. Yes. That would be necessary for 15 me to -- in terms of proper practice and 16 standard of care to make a recommendation as 17 to treatment. 18 Q. All right so. 19 A. I guess your question is not really 20 fair in the sense that I have not had an 21 opportunity to do the proper thing which is to 22 examine the patient. 23 Q. So is it fair to say, Doctor, that 24 in the absence of -- having not been able to 25 examine Dr. Hogan that you aren't really able

00100 1 to set forth a treatment plan for him? 2 A. Correct. 3 Q. Let's talk about your opinions as 4 to Dr. Hogan's future employability. I 5 believe you testified earlier that you feel he 6 can work and he can work in medicine again. 7 Can you elaborate on that? 8 A. Okay. I said he can work. I 9 said he can work in medicine. And I said I 10 think with proper treatment he probably can 11 work as a surgeon again. So your question 12 goes to the middle one of those to work in 13 the medical field. Is that correct? 14 Q. Well, okay, actually let's break it 15 up into three then. 16 A. Okay. 17 Q. You say he can work again. And 18 what I want -- I mean that's kind of a 19 skeletal blanket statement. I'm just asking 20 you to elaborate on he can work again. What 21 do you mean by that? Why do you say that? 22 A. Well, my experience in treating 23 people, for instance, with CRPS -- if we were 24 to assume that he does have CRPS, essentially 25 all of the patients that come through our

00101 1 program end up working again, if they have a 2 desire to do so. But also in rehab I treat 3 people with amputations. 4 So if we can assume worse case 5 scenario that he has absolutely no use 6 whatsoever of his left hand, then there are 7 literally tens of thousands of jobs in our 8 society that he can do; just as when I see a 9 patient with an upper extremity amputation. You 10 know, I can find work for them to do. This 11 is the process of vocational rehabilitation and 12 occupational therapy, of course, and a little 13 creativity in developing and sometimes 14 retraining. But I have no doubt. It's not 15 a medical certainty but I am a hundred percent 16 certain that there is work that he can do. 17 Q. Okay. Now, Doctor, you don't hold 18 yourself out as an expert in vocational 19 rehabilitation, do you? 20 A. I'm as much an expert as any 21 doctor could be. I've involved myself in 22 vocational rehabilitation as a practice for 20 23 years. 24 Q. Okay. Are you aware that there 25 have been specific vocational rehabilitation

00102 1 experts that have been retained in this case? 2 A. No, I'm not. 3 Q. And so you're unaware of their 4 opinions? 5 A. No, not aware. 6 Q. Okay. 7 A. Unless they're one of the doctors 8 that are in this list. I mean is that any 9 of these guys that we mentioned before in your 10 list of doctors that are in my records? I 11 mean I don't know if any of those are 12 occupational medicine specialists. I don't 13 think any of them are. 14 Q. Okay. Assuming Dr. Hogan has RSD, 15 is it your opinion that he can go back to 16 work as a surgeon? 17 A. The third, that depends. It 18 depends on his prognosis, his progress, and 19 his willingness to incorporate modifications, 20 restrictions, and to participate in an 21 occupational therapy and vocational 22 rehabilitation process. But it is my opinion 23 that if he has CRPS that he could be made 24 safe as a general surgeon again. 25 Q. Okay.

00103 1 A. And, in fact, I've had patients 2 that were in exactly that same situation; 3 general surgeons with CRPS that have gone on 4 to return to work. 5 Q. And I think you mentioned that he 6 could go back to work in some other medical 7 field. Is that correct? 8 A. Yes, sir. 9 Q. Can you tell us about that opinion, 10 why you say that and the basis for that? 11 A. For instance, radiology is a field 12 where he doesn't even have to use his hand. 13 He just simply has to sit in a quiet room, 14 use his eyes and his mind, and participate in 15 decisions about what the X-ray shows or what 16 the MRI shows or that sort of thing. 17 Q. All right. Doctor -- 18 A. He can -- you know, to add to 19 that, he could do almost anything that did not 20 involve the specific digital skill of a 21 surgeon. I mean he could be an internal 22 medicine doctor or psychiatrist or, since you 23 raised the issue, an occu-med doctor. He 24 could function as these types of doctors as a 25 one-armed man if, as I say, worst case

00104 1 scenario. 2 (Indicating.) 3 Q. Doctor, we've talked about your 4 review of the records, the fact that you can't 5 state within a reasonable degree of medical 6 certainty that Dr. Hogan has RSD based on what 7 you've read. We've talked about your opinions 8 as to employability. We've talked about future 9 treatment. We've talked about possible 10 differential diagnoses. Do you have any other 11 opinions in this case? 12 A. I don't have any other salient 13 opinions in this case. I certainly don't have 14 any other opinions to a reasonable degree of 15 medical certainty which is what you're most 16 interested in. 17 Q. I'm concerned about the qualifier 18 "salient." Are there other things that stand 19 out in your mind in this case, details that 20 we haven't filled in, and some of these other 21 salient opinions that you feel are important 22 and need to come out on the table? 23 MR. INCLAN: Form, objection. 24 THE WITNESS: When I say salient, 25 what I mean by that is I don't think they're

00105 1 relevant to the case. I mean -- you know, I 2 could, for instance, express my discomfort and 3 embarrassment that some of my colleagues are 4 not documenting better. But that's not really 5 specifically salient to this case. So I do 6 have opinions. It's just that they're not 7 specifically relevant or specifically germane 8 to this particular process that we're involved 9 in. 10 BY MR. SPRAGUE: 11 Q. So can we assume by that answer 12 that we have discussed all of the relevant 13 germane -- anything that you feel is relative 14 and germane in this case we've discussed? 15 A. Well, I believe so. I mean there 16 may be some things that come up on cross but 17 clearly I think we've covered the big points. 18 Q. Have you discussed this case with 19 any other retained experts by the defendants? 20 A. No, sir. 21 Q. Have you discussed this case with 22 any of the attorneys involved? 23 A. Yes, sir. I have discussed it 24 with Teresa Arnold-Simmons. 25 Q. Okay. Can you tell me about how

00106 1 -- first of all, how many times have you 2 spoken with Ms. Arnold-Simmons? 3 A. Probably five occasions. 4 Q. Okay. Can you tell me what 5 you guys have discussed on those five 6 occasions? 7 A. Well, as my role in this she's 8 asked me what I thought about the case. She's 9 asked me what I thought about the diagnosis, 10 plus and minus, pro and con. She's asked me 11 about specific doctors and their opinions about 12 specific elements. She's asked me for a little 13 explanation about some of the technical 14 details. We've discussed how to make a 15 Budapest criteria diagnosis, how to make the 16 IASP diagnosis, what is the distinction between 17 those; talked about some of the tests, how 18 they work. 19 Q. Okay. 20 A. I think that's it. 21 Q. Anything that hasn't come out on 22 the table today? 23 A. I don't think so. 24 MR. SPRAGUE: I don't have any 25 other questions then.

00107 1 MS. ARNOLD-SIMMONS: Clemente, do you 2 have any questions? 3 MR. INCLAN: No questions here. 4 MR. TOLLEFSEN: None for me. 5 MS. ARNOLD-SIMMONS: Okay. I've got 6 -- then it's -- this doesn't need to be on 7 the record. 8 THE COURT REPORTER: I do need to 9 put on the record whether you're ordering this 10 and what you have to say about that. 11 MR. SPRAGUE: Oh, yeah, we're going 12 to order. 13 MS. ARNOLD-SIMMONS: Yeah, we'll 14 order it. Off the record. 15 (WHEREUPON, a discussion was had 16 off record.) 17 THE COURT REPORTER: Mr. Tollefsen, 18 I need to put on the record whether you're 19 ordering this. 20 MR. TOLLEFSEN: I'd like a copy, 21 please. 22 THE COURT REPORTER: Is that 23 Mr... 24 MR. TOLLEFSEN: Tollefsen. 25 THE COURT REPORTER: Oh, okay.

00108 1 And, Clemente? 2 MR. INCLAN: Yes, Clemente. I would 3 like a copy as well. 4 THE COURT REPORTER: Thank you. 5 . 6 . 7 . 8 . 9 . 10 . 11 . 12 . 13 . 14 . 15 . 16 . 17 . 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 .

00109 1 CERTIFICATE OF REPORTER 2 . 3 I, Stacee L. Jackson, Certified Shorthand 4 Reporter for the State of Illinois, do hereby 5 certify that the foregoing was reported by 6 stenographic and mechanical means, which matter 7 was held on the date, and at the time and 8 place set out on the title page hereof and 9 that the foregoing constitutes a true and 10 accurate transcript of same. 11 I further certify that I am not related 12 to any of the parties, not am I an employee 13 of or related to any of the attorneys 14 representing the parties, and I have no 15 financial interest in the outcome of this 16 matter. 17 I have hereunder subscribed my hand on the 18 14th day of September, 2007. 19 20 __________________________ 21 Stacee L. Jackson, CSR 22 . 23 . 24 . 25 .

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