For-Trial Video Deposition of Spine Doctor in Paralysis Case
Choo Elmers, M.D., Anna, (Pages 1:1 to 46:21)
IN THE SUPERIOR COURT FOR THE COUNTY OF FULTON
STATE OF GEORGIA
VIDEOTAPED DEPOSITION OF
ANNA CHOO ELMERS, M.D.
March 25, 2014
2020 Peachtree Road, N.W.
Carolyn J. Smith, CCR, RPR, RMR, CCR-A-1361
INDEX OF EXHIBITS
3 EXHIBITS DESCRIPTION PAGE
5 #1 Curriculum Vitae, Dr. Elmers 4, 7
6 #2 Photocopy of X-ray, [REDACTED], 14
7 SMITH 000130
8 #3 Photocopy of X-ray, [REDACTED], 14
9 SMITH 000131
10 #4 Rehabilitation and Life Care Plan 32
11 of [REDACTED], by Kathy Willard
16 INDEX TO EXAMINATION
20 By Mr. Butler 6
21 By Mr. Hiestand 35
1 (Plaintiff’s Exhibit 1 marked)
2 MR. BUTLER: Just before we started this
3 deposition, Mr. Hiestand and I conferred about some
4 medical records. It appears that the last medical
5 records that Plaintiff had from Shepherd, we — we,
6 meaning Plaintiff, acquired in late 2013 and
7 produced to Defendant then.
8 Plaintiff had requested, but had not yet
9 received, updated medical records from Shepherd.
10 Immediately before this deposition, we — Plaintiff
11 requested and received updated medical records from
12 Shepherd. And I’ve just offered them to Defense.
13 Defense and Plaintiff have just reviewed them.
14 I’ve just learned that Defense also had
15 some medical records from Shepherd that Defense
16 acquired via third-party subpoena that I had not
17 seen until today, despite previous correspondence on
18 the subject. However, I’ve now reviewed what I
19 understand to be all of the medical records from
20 Shepherd that Defendant received via third-party
22 Anything to add?
23 MR. HIESTAND: That is all accurate. The
24 only exception I would note is I understand that
25 there may have been a visit which occurred last
1 Friday, that neither one of us has yet because I
2 don’t think it’s been transcribed.
3 MR. BUTLER: Okay.
4 MR. HIESTAND: So with the exception of
5 that record, I think that’s all accurate.
6 MR. BUTLER: All right. Let’s go.
7 (Off-the-record discussion)
8 (On video)
9 THE VIDEOGRAPHER: We are on the record,
10 and the time is approximately 2:25. This is the
11 beginning of disk one for the video deposition of
12 Dr. Anna Choo Elmers. Would counsel present please
13 identify themselves and who they represent for the
15 MR. BUTLER: Jeb Butler on behalf of the
16 Plaintiff, [REDACTED].
17 MR. HIESTAND: Trevor Hiestand for the
19 THE VIDEOGRAPHER: Thank you, Counsel.
20 Would the court reporter please swear in the
22 ANNA CHOO ELMERS, M.D.,
23 having been first duly sworn, was examined and
24 testified as follows:
1 MR. BUTLER: This will be the videotaped
2 deposition of Dr. Anna Elmers, taken pursuant to
3 notice in the case of Smith against Ajuzie. The
4 deposition is taken pursuant to the Civil Practice
5 Act and for all purposes allowable under the Act,
6 including use in evidence at trial.
8 BY MR. BUTLER:
9 Q Dr. Elmers, as you know, my name is Jeb
10 Butler. I represent the Plaintiff, [REDACTED].
11 Would you state your full name for the record,
13 A My full name is Anna Choo Elmers.
14 Q And today is March 25th, 2014; is that
16 A That’s right.
17 Q Would you tell the jury where we are
19 A We’re at the Shepherd Center on
20 2020 Peachtree Road in Atlanta, Georgia.
21 Q And what do you do here at the Shepherd
23 A I’m one of the spinal cord and brain
24 injury physicians here, so I’m what you would call
25 an attending physician. I manage both spinal cord
1 and brain injury patients. I have four teams here,
2 two spinal cord teams, one brain injury team, and
3 one medical-surgical team.
4 Q Are you one of [REDACTED]’s doctors?
5 A I am.
6 Q I’ll ask you about your diagnoses and
7 treatment of [REDACTED], but first I wanted to learn a
8 little bit about your educational background. Could
9 you tell us about that, please?
10 A I can. I went to medical school at
11 St. George’s University initially, and transferred
12 to George Washington University, graduating from
13 there in 2005 in Washington, D.C. Then I moved down
14 here to Emory University, where I did my residency
15 in physical medicine and rehabilitation, the last
16 year of which I was chief resident, finishing in
18 Q Are you board certified in physical
19 medicine and rehabilitation?
20 A I am.
21 Q I’ve got here something that I’ve already
22 marked as Plaintiff’s Exhibit 1. I’ll show you that
23 and show a copy to opposing counsel. What is that?
24 A This is my CV.
25 Q Is it true and accurate insofar as it’s
1 been updated?
2 A It hasn’t been updated for a while, so I
3 haven’t put any of my talks in here but it is — the
4 meat of it is very accurate.
5 Q Dr. Elmers, do you practice spinal cord
7 A I do.
8 MR. BUTLER: At this time, we’d like to
9 tender Dr. Elmers as — as an expert in spinal cord
10 injuries, physical medicine and rehabilitation.
11 BY MR. BUTLER:
12 Q I’ll ask you, as I said earlier, some
13 questions about your diagnoses and treatment of
14 [REDACTED]. And I’ll ask that you respond to
15 those questions to a reasonable degree of medical
17 Can you do that, and, if you can’t do
18 that, let me know?
19 A Yes, sir.
20 Q What is [REDACTED]’s injury?
21 A [REDACTED] suffered a spinal cord injury to
22 the lower part of his spine. And that occurred in
23 the accident that was in 2011, I believe, ’10 or
25 Q Does December 2010 sound right?
1 A Yes, it does.
2 Q Is there a more specific way that you
3 classify spinal cord injuries?
4 A There is. And the best way to go about
5 this, may be — may be an explanation —
6 Q Sure.
7 A — of how spinal cord injuries are
9 Q Please.
10 A So, normally, we’ll bring a model of the
11 spine, because it’s very difficult as a layperson to
12 understand exactly what’s happened within the body
13 without actually visualizing it. So what we’ll
14 briefly chat about, if it’s okay with you guys, is
15 what I sit down and talk to my patients about. And
16 this is just so they understand their level of
18 As you’re sitting now — or as I’m sitting
19 now, this is kind of how I’m sitting. This is a
20 model of the spine. And your bottom is here, your
21 head is up here, front, and your back. The spine is
22 broken down into four different sections, as far as
23 the bones. You’ve got your cervical spine up here.
24 That’s just a fancy name for the neck bones.
25 There’s seven bones up here.
1 Then you’ve got your chest bones, your
2 thoracic spine. There’s 12 bones here. That’s the
3 area that the ribs attach to. Then you’ve got your
4 lower spine, your low back. There’s five bones here
5 called the lumbar spine. And down here, this area
6 that’s fused is called the sacrum.
7 The bones fit together like shingles on a
8 roof. And they form this tunnel in the middle that
9 houses the spinal cord, which is an extension of the
10 brain. You can think of the spinal cord like an
11 information superhighway. So messages travel up and
12 down the spinal cord from the brain to the arms to
13 the legs to the feet, your bowel, your bladder. And
14 then information travels up.
15 So if a patient were to step on a pine
16 cone, for example, before their injury, their foot
17 would send the message up to their brain, on these
18 tracks that I look at as freeways, highways, you
19 know, roads. And their brain would send a message
20 back down to your foot saying, that hurts, move.
21 And in essence, that happens
22 instantaneously. And they move. When there’s an
23 injury to the spinal cord, because the brain — the
24 bones have been broken, then those messages don’t
25 get through like they otherwise would.
1 In [REDACTED]’s case, I believe his injuries
2 were at the lower level, L — lumbar — I think 2,
3 3, and 4. And, initially, I think the worst injury,
4 if I remember correctly, was further down. The
5 spinal cord itself ends at between L1 and L2.
6 So if you look here, it says 5, 4, 3, 2,
7 1. And so the spinal cord itself ends right around
8 here. And then you’ve got a cone at the very
9 bottom, and then something that they call conus
10 medullaris, horse’s tail, that goes out. And you
11 can think of like that electrical wiring to a house.
12 So if you think about it, if the lights in your
13 house are out, that problem can be either the
14 lightbulb, the switch, or it could be the central
15 fusebox. It depends on where the issue is and that,
16 kind of, will tell you how to — you know, go about
17 managing it.
18 In — when — when we look at a spinal
19 cord injury, the issue is at the main fusebox. You
20 know, the — very central. The other thing you want
21 to look at is, you know, the horses’s tail. Think
22 of those like a bunch of roads that come out of this
23 main information highway. And all of those roads
24 travel in different directions. And so when there’s
25 an injury at that level, then certain roads are
1 going to be out, but other roads are not.
2 Hopefully, that kind of explains
3 anatomically what happened, but his injury was — is
4 classified as an L2. So current — my most recent
5 classification was L2, incomplete. Incomplete
6 referring to the fact that he has got sensation and
7 some movement below that level.
8 Q Was there ever a time when [REDACTED]’s injury
9 was classified at another level?
10 A Prior — I think when he initially left
11 Shepherd, it was a higher level, at L1.
12 Q Does that sometimes happen in the normal
13 course of treating patients, that the level changes
15 A It does. And we expect it to change in
16 the first year to 18 months, and patients may gain
17 an additional level. What I didn’t explain when I
18 talked about the spinal cord itself is, you know,
19 each of these roads, so to say, that come out of the
20 spinal cord area, they go to innervate a set of
21 muscles. And so depending on where your injury is,
22 that determines what you’re able to move, what
23 you’re able to feel.
24 So even though this doesn’t apply to
25 [REDACTED], if you think about someone that gets injured
1 at the neck level, if it’s a complete injury, it
2 would take out all motor movement and sensation
3 below that level of injury. Depending on how far up
4 it is, it determines whether they have shoulder
5 shrug, biceps, wrist extensors — you know, being
6 able to move back on your wrist — and triceps and
7 fine hand movement.
8 When we get down here at the lower back
9 lumbar level, depending on the level of injury, you
10 may have hip flexors, so you’re able to bring —
11 bring your knees up to your chest. You may be able
12 to kick out your knees — I’m sorry, your legs at
13 the knees, move your foot back and forth, and move
14 your toe up. Those are all, quote, the different
15 roads and the different wires that go to these
16 different muscles.
17 And so at [REDACTED]’s current function, he’s
18 able to move his knees to his chest, but not with
19 full strength, so not the strength that he had
20 before or the strength that you and I have. And
21 he’s able to kick out his leg at the knee a little
22 bit, more on the left than on the right. So, again,
23 very incomplete.
24 Q Is it important for purposes of [REDACTED]’s
25 rehabilitation that the injury is complete — or,
1 excuse me, is incomplete as distinct from complete?
2 A A complete injury refers to, you know, no
3 motor movement or sensation below that level. So,
4 prognostically, someone with an incomplete level
5 would have a better chance of walking. And I say
6 that, but — knowing that in [REDACTED]’s case, even
7 if — even though he wants to walk, the chances of
8 him walking are slim to none, walking on a regular
10 (Plaintiff’s Exhibit 2 and Plaintiff’s
11 Exhibit 3 marked)
12 BY MR. BUTLER:
13 Q I’d like to show you now what I’ve marked
14 as Exhibits 2 and 3. That’s 2, and that’s 3.
15 A Whoops.
16 Q What are those?
17 A These are films that we took when [REDACTED]
18 was here in the hospital. And so what we do — so
19 when a patient is initially injured, they may be
20 treated as a facility like Grady or Atlanta Medical
21 Center. So 911 may take them there initially, and
22 they’re stabilized.
23 And after their surgeries are done, their
24 breathing is stabilized, their hearts are
25 stabilized, and they’re ready for rehab, then they
1 come here to a place like Shepherd where someone
2 like me, quote, quarterbacks their team.
3 And so I’m kind of the person that is in
4 charge of the therapists, the nurses, I’m the go-to
5 of the team, so to say. And so what we do here is
6 just make sure that everything gets looked at. So
7 these are films from when he was here that were
8 repeated. And we do these because we want to make
9 sure that that stabilization stays intact.
10 So because of the fractures that occurred
11 to [REDACTED]’s spine — so his fractures occurred, kind
12 of in this level, in this area — the worst of which
13 was around here, the L4 area. That broken bone —
14 those broken bones rendered that segment unstable.
15 And so the instability caused compression on that
16 spinal cord, or horse’s tail, area. So all the way
17 from that horse’s tail up towards a little bit of
18 the spinal cord.
19 You can look at that like an accident on
20 the information highway, and so the messages that
21 were going back and forth before are no longer going
22 back and forth. And so I like to tell my patients
23 it’s like there was an 18-car pileup on your
24 highway, where important information was going back
25 and forth. And because of that, they can’t feel and
1 you can’t move your legs, and you can’t pee and you
2 can’t poop like you did before.
3 The doctors that saw him initially — and
4 I believe it was at Grady — that saw him initially,
5 imaged the bones and then, to stabilize that area so
6 that the injuries wouldn’t be worse, they put rods
7 and screws in like this.
8 So if you look at this, this is kind of
9 over — over-imposed on the actual diagram. You’ve
10 got two rods that come up through the back, and then
11 the screws that go in this way into this main part
12 called the vertebral body. And what that does is
13 just stabilize that segment.
14 So one way to look at it is, if you broke
15 a big piece of board in half and you needed to put
16 it back together so that there wasn’t more damage,
17 then what you would do is straighten it up again,
18 and then you would put screws above and below it to
19 hold it in place. And in essence, that’s what was
21 And so these are his films from that
22 stabilization to make sure the area remained intact.
23 And that, you know, if he was having low back pain
24 for example, it’s to look at the screws to make sure
25 nothing is coming out.
1 Q Do Plaintiff’s Exhibits 2 and 3 fairly
2 depict the hardware that’s been installed in
3 [REDACTED]’s back?
4 A Yes.
5 Q You mentioned walking just a minute ago,
6 and I wanted to return to that really quickly. Just
7 so the record is clear, although the jury will
8 probably have figured it out by this point, can
9 [REDACTED] walk on his own?
10 A No, he can’t.
11 Q Now, I know that [REDACTED] can move his legs
12 some. Why can’t he walk since he can — even though
13 he can move his legs?
14 A There’s a couple things. He was last in
15 rehab here at Shepherd several years ago. And at
16 the time that he was in rehab, he didn’t have quite
17 the strength that he has now. So he’s gotten a lot
18 back, or he’s gotten a significant amount more back
19 since he was last here in actual inpatient therapy
21 So one of the reasons is he doesn’t have
22 access to more rehabilitation. So a therapist has
23 not worked with him since he’s — he was last here.
24 The second thing is, even if you have some movement,
25 for example, you have a spinal cord injury, but you
1 can wiggle your toes, I tell my patients, you know,
2 that’s great, you know, I’m glad that you can wiggle
3 your toes. But it’s a far way from wiggling your
4 toes to walking, because there’s a lot to
6 In [REDACTED]’s case, he probably can walk a
7 little bit, maybe at home, if he had the right
8 braces, the right therapy, and the right equipment.
9 But because the energy that would be required for
10 him to walk, what we call ambulate, on a day-to-day
11 basis in the community would be so great, most
12 people simply can’t do it and, you know, don’t want
13 to do it because it’s a lot of work.
14 Q Okay.
15 A And they — they don’t move very fast from
16 place to place.
17 Q To a reasonable degree of medical
18 certainty, Dr. Elmers, will [REDACTED] ever be able to
19 walk like you can, for example?
20 A No.
21 Q When did you first examine [REDACTED]?
22 A I first examined him in 2011.
23 Q And when was the last time that you saw
25 A I last saw him on Friday.
1 Q It’s my understanding that although you
2 generally understand [REDACTED]’s treatment before you
3 saw him, and treatment that he has received outside
4 of Shepherd’s, you haven’t necessarily reviewed
5 every single medical record that’s been generated
6 about [REDACTED]; is that fair?
7 A That’s fair.
8 Q Is it important for you or do you feel
9 like you need to review every single medical record
10 that’s ever been generated about [REDACTED]?
11 A No, I get a good sense of what he’s doing
12 and where he’s at by seeing him.
13 Q We’ve talked a lot about [REDACTED]’s injuries
14 to his, sort of, lower half and how they affect his
15 legs. Do you expect over the long term for [REDACTED]’s
16 spinal injury to affect his upper body?
17 A Well, definitely. The legs, as made by
18 God, were going to be what you use to walk around.
19 And, you know, walking is kind of what we were
20 designed to do. And so people who don’t walk, their
21 arms become their legs. And so all of the tension
22 from rolling and whatnot will develop into overuse
23 injuries in their upper extremities.
24 Q What kind of changes would you expect over
25 time to [REDACTED]’s upper extremities?
1 A Long term, you know, you expect overuse
2 because shoulders just were not meant to be used
3 like that. So just like baseball players that
4 are — pitchers, for example, that are constantly
5 pitching, and they don’t get that break in between,
6 their shoulders wear down. And so as a result, they
7 need surgery, you know, whether it’s rotator cuff or
8 whatever it might be.
9 But it’s the same for a spinal cord
10 patient. They are now using their arms and legs as
11 their primary mode of transport. And because of
12 that, the wear and tear is a lot greater. And so
13 long term, likely some pain in his shoulders and
14 possibly surgery to, you know, repair injuries like
15 rotator cuff injuries.
16 Q Would injuries like rotator cuff injuries
17 and other problems we’ve talked about affect the
18 type of equipment that [REDACTED] will need to remain
19 independent as he grows older?
20 A Yes, it does. So the time for recovery in
21 between surgery and getting back into independence,
22 during that time, he would most likely need a power
23 chair, and so he — so he could still get around.
24 I’ve had several patients who, during the time that
25 they have undergone surgery, they’re not able to be
1 as active as they were before.
2 And so a lot more needs to be monitored in
3 that time, namely mood, because, you know, you’ve
4 taken someone who possibly is very active to someone
5 that is not able to do anything at all because of
6 the — being laid up by their shoulders.
7 Q What about skin care, Dr. Elmers? Is that
8 something that’s important for [REDACTED]?
9 A Skin care is probably one of the most
10 important things that I emphasize with my spinal
11 cord patients. And so as we are all sitting here,
12 you know, we do shifting. You know, you’ll notice
13 that you’ll sit in one spot for a long time, and
14 then you’ll want to shift around because that spot
15 is not getting the oxygen that it needs.
16 And so in a spinal cord injured patient,
17 that feedback is not there. And so [REDACTED] has to do
18 weight shifts. Currently, it’s every 15 to
19 30 minutes. But normally, it’s every 30 minutes.
20 And it may look something like this, where he comes
21 up and then — or it may look like this, where
22 you’re just wondering what he is doing, why is he
23 just leaning to one side or the other side. And
24 that’s to offload pressure to that area of his skin.
25 If that’s not done, then you get skin
1 breakdown. And [REDACTED] actually has some skin
2 breakdown on his sitting bones, where — you know,
3 where he sits up on his chair.
4 Q If skin breakdown occurred and went
5 untreated, could that be a serious problem, or is
6 that just a minor discomfort?
7 A It actually can be a very serious issue.
8 And one of the examples that I use with my patients
9 is, you know, skin is something you have to be
10 hypervigilant about. If you remember Christopher
11 Reeves, Superman, suffered a spinal cord injury.
12 And when he passed away, some speculated that it was
13 because of a pressure wound, which was unheard of,
14 because he had all this money and 24/7 care. But he
15 was a much higher level, so he couldn’t do anything
16 on his own.
17 But skin problems, you know, if it’s the
18 one thing I want my patients to take away, it’s that
19 you need to monitor that skin very closely. Because
20 once it breaks down, you know, when it heals or even
21 after surgery, it’s not as strong as it was the
22 first time. And, unfortunately, even in the best
23 cases, best-case scenarios, there may be breakdown.
24 And I — you know, we just had some
25 someone here, who after 20 or 30 years, did not —
1 of not having any issues actually had skin breakdown
2 because his cushion ruptured and he didn’t know it.
3 And so even in the best-case scenario, you can have
4 cushions that rupture, you could have, you know,
5 over-inflated cushions that can impair healing and
6 whatnot. So long answer to your very short question
7 is, yes, skin is very important.
8 Q Thank you, Doctor. I wanted to ask you
9 about some things that we don’t normally discuss
10 in — in polite company that I might feel a little
11 uncomfortable asking about, actually, but it
12 involves what I think you-all call [REDACTED]’s bladder
14 A Right.
15 Q How does [REDACTED] urinate?
16 A So after someone suffers a spinal cord
17 injury, the bowel and bladder are normally affected
18 as well, depending on the, you know, severity of the
19 spinal cord injury. The name of the bladder is
20 neurogenic bladder after it’s been affected from a
21 spinal cord injury. Neurogenic, just meaning coming
22 from the nerves, neurogenic.
23 In man, there are four different ways that
24 that bladder can be managed after a spinal cord
25 injury. What we take for granted every day, being
1 able to get up, go to the bathroom in very little
2 time, is something that spinal cord injured patients
3 have to deal with for the rest of their lives
4 because they can’t urinate like they did before.
5 And so the four ways of managing that are,
6 first, there’s the Foley catheter, which is the tube
7 that goes through the urethra in the penis and goes
8 into the bladder. You can think of the bladder like
9 a balloon. And so here’s your balloon, and then
10 there’s a little hole here, and it comes out through
11 the penis.
12 You put a tube in through the penis. It
13 seems like it’s through the penis, but it’s through
14 the urethra. And that tube comes up, and it’s like
15 a straw, and it sits kind of up here, and it drains
16 the bladder all the time.
17 That tube called the Foley stays in there
18 all the time. And it’s not something I recommend
19 because it can cause skin breakdown in patients. So
20 initially a spinal cord patient, say, at the acute
21 hospital like Grady or Atlanta Medical, may have
22 that. But that gets removed pretty quickly. And
23 they may need it again if they’re hospitalized or
24 something comes up.
25 But the ideal way for someone like [REDACTED]
1 is something called intermittent catheterization,
2 or, abbreviated, IC. In that case, every four to
3 six hours, a catheter is inserted through the penis,
4 drains the bladder and then discarded. And that
5 happens every four to six hours. In [REDACTED]’s case,
6 he does it every four hours.
7 It’s still introduction of a foreign body
8 four to six times a day. So if you do it every four
9 hours, it’s six times a day. Every six hours, it’s
10 four times a day. So four times a day, he’s
11 introducing a foreign object into his bladder to
12 drain that area and keep his bladder from
14 Before catheters were developed in spinal
15 cord injured patients, kidney failure was actually
16 the most common cause of death. And so we have to
17 make sure that his bladder is well managed and that
18 his bladder doesn’t overfill. Because when it
19 overfills, you can have backing up, so to say, if
20 you look at it like a plumbing system, backing up
21 into the — into the kidneys.
22 And so he has to watch what he’s drinking.
23 He has to watch to make sure that he’s cathing,
24 maybe getting up in the middle of the night to cath.
25 And we have our patients here set alarms so that
1 they get up in the middle of the night and do this
3 The other two ways of managing it are
4 condom catheters. And so that’s where you have a
5 condom that you put over the penis and it — with
6 reflex voiding. So that’s just a fancy word for the
7 bladder will actually go on its own, when it
8 contracts and will go into the — the catheter, the
9 condom catheter. And then the last way is something
10 called a suprapubic tube.
11 And so if [REDACTED] were not able to
12 catheterize on his own, then I would recommend one
13 of these other methods, most likely a suprapubic
15 Q Does [REDACTED] insert his own catheter —
16 A He does.
17 Q — multiple times a day?
18 A He does.
19 Q What about urinary tract infections? Is
20 [REDACTED] at an increased risk of those?
21 A He is. And anyone that would introduce a
22 foreign object to their sterile — the sterile parts
23 of their body are at risk for urinary tract
24 infections. And that’s something that spinal cord
25 injured patients have to be very aware of. He
1 actually has gotten a handful of them.
2 When I saw him on Friday, he had just
3 gotten treatment for a urinary tract infection.
4 It’s something that manifests a little bit
5 differently in spinal cord patients because they can
6 get so sick from a urinary tract infection. And so
7 I always tell my patients, you know, if you feel
8 like you’re starting to get one, then we need to be
9 aware so we can treat you for it.
10 Q How would [REDACTED] know if he had a urinary
11 tract infection?
12 A He’ll start to feel badly, or he’ll get a
13 fever. But he will feel it. It’s just like if you
14 were coming down with a cold or the flu, he — you
15 know, that’s kind of how he would feel.
16 Q When —
17 A But different people feel different
19 Q When — when [REDACTED] gets a urinary tract
20 infection, is it just sort of a moderate
21 unpleasantness, or does he actually feel bad while
22 he has it?
23 A He — he actually feels bad. So in — in
24 the spinal cord patient, urinary tract infections
25 are always considered complex or complicated,
1 because of the bladder and the complexity, you know,
2 of the injury itself. So spinal cord injured
3 patients do not respond to — you know, if you had a
4 urinary tract infection, you would probably take a
5 couple antibiotics over — or take antibiotics over
6 a couple of days, and you’d be better.
7 But it probably wouldn’t keep you out of
8 work. It probably wouldn’t really make any —
9 wouldn’t slow down your life, so to say. In spinal
10 cord patients, it definitely could make a huge
11 difference. So in my inpatients, the patients that
12 I see in the hospital, when someone has a urinary
13 tract infection, it could take them out of therapy
14 because they just don’t feel good.
15 Q Are — are urinary tract infections common
16 among spinal patients?
17 A They are.
18 Q The next two subjects I’ll just — I’ll
19 just address very briefly. Does [REDACTED] defecate
20 or — or poop in the same way that someone who
21 doesn’t have a spinal cord injury does?
22 A He doesn’t. He actually has voluntary
23 bowel movement. So he can sense when he needs to
24 poop, and he can poop on his own. But, you know,
25 there has been injury to those roots. And so when
1 he was first injured, he definitely could not. And
2 my sense is, even what he’s doing now, is not normal
3 compared to what he was doing before.
4 Q What about — just briefly, what about
5 [REDACTED]’s sexual abilities? Have they been affected
6 by his injury?
7 A They have. So most of my spinal cord
8 patients will need something like Viagra or Cialis,
9 or sometimes even a penile pump or injections to get
10 an erection and then to, you know, have intercourse.
11 Most of my spinal cord patients don’t actually
12 ejaculate. And so when it comes to fertility, they
13 would need to go to a fertility specialist and have
14 their sperm harvested.
15 Q I wanted to ask you something about
16 special consequences for ordinary events. And what
17 I mean is, given [REDACTED]’s injury, are there things
18 that might be common for someone who doesn’t have a
19 spinal cord injury that have special consequences
20 for [REDACTED], given that he does have a spinal cord
22 A So, you know, spinal cord injury will
23 affect your bones. And so in someone with a spinal
24 cord injury, they become what we call osteopenic.
25 That’s just a fancy name for loss of bone. And
1 so — you know, the brittle bones or the very
2 fragile bones. And so he’s at higher risk for
3 breaking his bones than you and I are because of all
4 the calcium that seeps out and whatnot.
5 He’s — so if during a transfer, for
6 example, he —
7 Q What do you mean by transfer?
8 A Oh, I’m sorry. So, you know, [REDACTED] can’t
9 walk, and he can’t stand — stand up and move from
10 place to place. So he’s confined to his chair. So
11 when he needs to get from his chair to his bed, he
12 has to lift up and kind of, you know, transfer
13 himself over a surface to the next surface that he
14 wants to be on.
15 Because of the quality of his bones —
16 and, you know, I have not checked an X-ray on him
17 lately because there’s been no reason to — but long
18 term, his bones would be more brittle. And so he
19 could break bones a lot easier, whether they be his
20 long bone in his femur, or his ankles, anything like
22 And he wouldn’t necessarily know it
23 immediately if he were to break it because of his
24 incomplete sensation.
25 Q Okay. So if [REDACTED], say, were to fall
1 during a transfer from his chair to his bed, would
2 he have to take special action that someone like me
3 might not have to take if I were to fall out of my
5 A Well, if [REDACTED] were to fall out of his
6 chair or bed — and he has more sensation than
7 someone, say, with an — a complete injury, he may
8 actually feel pain. But what he would need to do is
9 just get checked out. And so — one example I could
10 think of is one of my patients in the hospital now,
11 he went home this weekend to see how the
12 modifications were going on in his house, and he
13 rammed into a door, the side of a door.
14 He can’t feel it. So, you know, he didn’t
15 think anything of it. But by the time he came back
16 to us, it was all bruised up. And, you know, we
17 took X-rays. We needed to make sure that it wasn’t
18 a broken bone or anything. The same is true for
19 [REDACTED]. He’ll need to make sure that he is a little
20 more vigilant about things like his skin, his bones,
21 his — you know, caring for his bladder, his bowels.
22 Everything is a little more effort.
23 Q I wanted to ask you now about [REDACTED]’s
24 life care plan. Tell the jury in the abstract, what
25 is a life care plan?
1 A A life care plan is a way to kind of
2 estimate what the cost of someone’s injury is going
3 to be, so lifelong needs.
4 Q Did you work with Kathy Willard in this
5 case to develop a life care plan?
6 A I did.
7 Q Tell the jury how that goes, how you and
8 Ms. Willard worked together on that.
9 A So I — I know [REDACTED] from clinic, and so
10 I have an understanding of what his injury level is.
11 She knows [REDACTED] from, you know, interviews with
12 him, visiting him. And so she has an idea of what
13 his injury and his needs are. And so, together, we
14 come up with what we foresee him needing for the
15 rest of his life.
16 Q Did you and Ms. Willard meet to discuss
17 this kind of thing?
18 A We did.
19 (Plaintiff’s Exhibit 4 marked )
20 BY MR. BUTLER:
21 Q I want to show you now what’s been marked
22 as Plaintiff’s Exhibit Number 4. Tell the jury what
23 that is, please.
24 A This is [REDACTED]’s life care plan.
25 Q Is that the life care plan that you and
1 Ms. Willard developed and that you approved?
2 A It is.
3 Q Do you approve Plaintiff’s Exhibit 4 as
4 medically necessary to provide [REDACTED] with the
5 future medical care that he needs?
6 A Yes, I do.
7 Q Will that life care plan, Dr. Elmers,
8 improve [REDACTED]’s quality of life?
9 A Absolutely.
10 Q I wanted to ask you some about future
11 complications which I think are mentioned, but not
12 gone into in great detail in the life care plan. Is
13 there a possibility that you could think of now that
14 [REDACTED] might need future treatment or future
15 surgeries related to his injury?
16 A We talked about this a little bit. He may
17 need, you know, shoulder surgery in the future. He
18 may need skin surgery. You know, there are so many
19 things that can come up with a spinal cord injured
20 patient in the future that is — you know, that you
21 may see in another patient farther along down the
22 line. So, meaning years out, you know, these are
23 the things that we worry about that our patients
24 will need.
25 Q What about if [REDACTED] were to get sick in
1 the same way that — that I might get sick? If he
2 got the flu or something, would his care needs
3 escalate, or go up, as a result of that illness?
4 A If he were to get the flu or something,
5 given his level of injury, he would respond similar
6 to you and I would. You know, his lungs are not as
7 affected by the injury as someone with, say, for
8 example, a higher level of injury.
9 But if he were to get a urinary tract
10 infection, his urinary tract infection could
11 progress to what we call sepsis, which is an
12 overwhelming infection of the body, more likely than
13 yours and mine may.
14 Q I wanted to ask you this — and we’re
15 almost finished — but how is [REDACTED] doing? How is
16 he adjusting to his injury?
17 A So the appointment that I had with him on
18 Friday was actually a great appointment. The last
19 time I had seen him before that was the fall — last
20 fall. And I kind of felt like there were things
21 that he just had not accepted yet with his injury.
22 His overall just mood and affect were different back
23 in the fall.
24 And in fact, Friday’s appointment happened
25 on Friday because — I don’t know if it was a
1 transportation issue or what happened. He was
2 actually scheduled for earlier. As a 3-4 month
3 followup to the fall appointment. I am thrilled to
4 report that his mood — I mean, he was a different
5 person when I saw him on Friday, and just so much
6 more optimistic, very glass half-full, and really
7 starting to adjust and take life back.
8 And so one of the things I say to my
9 patients like [REDACTED] or any paraplegic patient is
10 that, you know, this injury has changed your life.
11 It’s kind of made everything like your bowel and
12 bladder, sexual function different. It’s made it so
13 much more of an effort. But I anticipate and expect
14 that my spinal cord patients at the paraplegic level
15 or lower, where they have full function of their
16 arms, will lead full, complete, independent lives,
17 provided they have good resources and are able to
18 get to — you know, get the things that they need.
19 Q Is [REDACTED] trying to get better?
20 A Yes, he is.
21 MR. BUTLER: Thank you. That’s all I
24 BY MR. HIESTAND:
25 Q Doctor, thank you so much. I’d just like
1 to ask you a few additional questions about your
2 treatment. First of all, do you know how many times
3 you’ve seen [REDACTED], Mr. [REDACTED]?
4 A I think it’s four or five times.
5 Q Okay. And I’m showing the first time that
6 you saw him would have been on March 16th of 2011.
7 A That’s right.
8 Q All right. And at that time, he indicated
9 that he had returned to school, and he was living on
10 campus at Clark Atlanta University?
11 A Right.
12 Q Okay.
13 A I think so.
14 Q You —
15 A I’m trying to remember if —
16 Q You do know that he is a college student?
17 A Yes.
18 Q Okay.
19 A I knew at the time of the accident, he was
20 a college student.
21 Q And as — after the accident, he had
22 actually returned to school as a computer arts
24 A Okay.
25 Q Did you know that?
1 A I didn’t — I didn’t know that.
2 Q When you spoke to him on Friday, did you
3 speak with him about how he’s doing in college right
5 A When I spoke to him on Friday, I asked if
6 he was in school, and I don’t think he is in school
7 right now.
8 Q Okay. Was he taking the quarter off?
9 A I don’t recall. But I think he was
10 pursuing — and, actually, I know he was pursuing
11 more auditions, Open Mic opportunities. And he’s
12 actually performed at the Apollo since I last saw
13 him, which I thought was great.
14 Q I think that was a notation dated
15 February 5th of 2014. He had come in, and he had
16 reported that, at that time, he was sitting out a
17 quarter, but he was returning to college.
18 A Okay.
19 Q Do you remember that?
20 A I don’t think I saw him in —
21 Q Okay.
22 A — February, but —
23 Q Did you review his notes before today’s
24 deposition from maybe some of the other folks at
25 Shepherd that had seen him?
1 A I did, but I don’t think I reviewed all of
3 Q Okay. But it appears as though he’s
4 trying to pursue a career; is that fair to say?
5 A Yes, it is.
6 Q And certainly there’s nothing about his
7 injury that would prevent him from getting a college
8 education. Would you agree with that?
9 A I agree.
10 Q And there is nothing about his injury that
11 would prevent him from seeking a career that he
12 would love and could make a living from after he
13 finishes school. Would you agree?
14 A I’m —
15 MR. BUTLER: I object —
16 A — sorry, repeat that one more time.
17 BY MR. HIESTAND:
18 Q Is there anything about his injury that
19 would prevent [REDACTED] from pursuing a career
20 after graduating from college?
21 A Depends on what that career is.
22 Q Sure.
23 A And that’s another thing I tell my
24 patients. If your career was to be a star baseball
25 player, then it’s probably not going to happen. If
1 it was — and I think in his case he wanted to be a
2 dancer. And so that is probably not going to
4 Q There are certainly other ways to make
5 money, though, other than as a dancer. Would you
7 MR. BUTLER: I object, beyond the scope.
8 A Absolutely.
9 BY MR. HIESTAND:
10 Q I’m sorry, Doctor, what was that?
11 A Yes, he can.
12 Q Okay.
13 A Yes.
14 Q Let me ask you this, do you encourage all
15 of your spinal injury patients, especially
16 paraplegics, that they should pursue a career that
17 would be adapted to their individual disability?
18 A Yes.
19 Q And is there anything about [REDACTED]
20 that you think would prevent him from pursuing a
22 A No.
23 Q Is there anything about [REDACTED]’s
24 injury that would prevent him from pursuing a
1 A No. He — you know, we are going to refer
2 him to the fertility specialist, so — family as in
3 have children?
4 Q Sure.
5 A Yes, we are going to refer him to a
6 fertility specialist and see if that’s doable.
7 Q There’s nothing to prevent him from
8 getting married, certainly?
9 A No.
10 Q Nothing to prevent him from having
11 children, either adopting children or having
12 children of his own, is there?
13 A No — no.
14 Q There is really — and — and I think you
15 did a good job of summarizing what it means to be a
16 spinal injury patient and somebody who adapts to a
17 new life. And would you agree with me that your
18 life is always going to be different after that
19 injury, but there is really nothing that’s
20 preventing you from having a fulfilling life? Is
21 that fair to say?
22 A Absolutely.
23 Q And a lot of that is also going to depend
24 on [REDACTED]’s motivation?
25 A Yes. And, actually, what I will say there
1 is — so [REDACTED] suffered an injury kind of at the
2 worst time of his life.
3 Q Age 18?
4 A Yes.
5 Q Uh-huh (affirmative.)
6 A It’s a really tough time to suffer an
7 injury because he has not gotten into a career yet.
8 And so, you know, if I look at my patients, my
9 patients who get into accidents or suffer injuries
10 after they’ve established their careers actually are
11 a little bit better off because they’ve already
12 established themselves.
13 And so, for example, I have a patient
14 that’s a C4 quad, meaning all he can do is shrug his
15 shoulders. But he’s dependent on everyone else for
16 everything, draining his bladder, changing his
17 colostomy bag, getting around. But he was an
18 electrical engineer. So his career path was already
19 established before his injury. And he was able to
20 go back to work, as far — as long as he was able to
21 bring an attendant with him so that they could
22 change out his catheter bag and they could turn
23 pages, you know, the little things that he couldn’t
24 do — or the big things he couldn’t do on his own.
25 We actually have an adolescent team here
1 at Shepherd. And so that team of patients are kind
2 of in that age group, you know, as young as 12 and
3 up to 18, 19, 20, sometimes up to 20. That’s a
4 special team here because we recognize that it’s a
5 very difficult time to suffer an injury. You’re
6 kind of at a time in your life where you’re trying
7 to find yourself still and figure out what you want
8 to do.
9 And so those, I would say, are my patients
10 that have the most difficult time adjusting because
11 if they don’t have direction already before, then
12 this is not going to help them have direction.
13 Q There’s nothing about [REDACTED]’s situation,
14 though, that would tell you that he would not be
15 able to self-direct himself in this respect, is
17 A No. But once we are — and that’s why I
18 was so — actually, I was so happy to see that his
19 mood was better on Friday, because he’s finally,
20 after all these years, accepting that this is
21 probably going to be permanent.
22 Q Which would —
23 A And —
24 Q Which would, in theory, allow [REDACTED] to
25 make appropriate decisions and to make appropriate
1 goals for the changes that have occurred in his life
2 so he can build a career, so he can build a family,
3 and he can build a fulfilling life?
4 A Absolutely.
5 MR. BUTLER: I object to cutting off the
7 BY MR. HIESTAND:
8 Q Were you able to finish your responses?
9 A Yes.
10 Q Thank you. You have discussed some
11 potential complications that [REDACTED] may have. For
12 example, because he is more dependent on the use of
13 his upper extremities, that there is a possibility
14 that he could, for example, need surgery. But
15 certainly you’re aware of spinal cord injury
16 patients, paraplegics, who don’t require shoulder
18 A Yes.
19 Q And so when you talked about future
20 complications, those are things that may happen or
21 may not happen?
22 A Right.
23 Q And you had also talked about the
24 increased occasions of urinary tract infections.
25 You’re certainly aware that persons can treat
1 urinary tract infections themselves, they can get
2 medications, and they can treat it. It’s not going
3 to be something that’s going to require
4 hospitalization or a visit to a doctor every time
5 you have a urinary tract infection. Would you
7 A I actually disagree with you there,
8 respectfully, because —
9 Q Before you answer — just let me make sure
10 that you answer, are you saying that patients will
11 need hospitalization —
12 A No.
13 Q — every time? Okay.
14 A I’m not.
15 Q Okay.
16 A But I will disagree with you because when
17 patients start to treat their own urinary tract
18 infections, i.e., bum antibiotics off of friends or
19 whatever, that’s where we end up with — because you
20 had mentioned that they could self-treat. They
21 can’t self-treat unless they were in Mexico, because
22 they can’t get the antibiotics without a
24 So I always tell my patients, if you have
25 a urinary tract infection, we need to culture it,
1 because if you’re going to continue having these, we
2 need to find out what’s causing them. I don’t want
3 you to just blindly treat it every time without
5 Q I guess what I meant is not so much
6 self-medicate where you would get illegal drugs
7 or —
8 A Thank you.
9 Q — or medications, but, for example,
10 somebody may have an ongoing prescription or
11 relationship with their doctor, where their doctor
12 may give them a prescription for say, Bactrim.
13 A Yes.
14 Q A broad — you know what Bactrim is?
15 A I do.
16 Q A broad spectrum medication. And their
17 doctor may say, listen, if you’re beginning to
18 experience some symptoms, go ahead and take some of
19 your Bactrim, take a ten-day program of it. And if
20 it clears up, you’re going to know, and you don’t
21 need to come in to see me?
22 A Yes.
23 Q Would you agree that that may be the
25 A I do.
1 Q Okay. So maybe my use of the term
2 self-medicate was probably not accurate.
3 A We’re very sensitive about that here,
5 Q And I understand that, and that’s very
6 important. But I guess what I’m saying is persons
7 who have spinal cord injuries, in time, they’re
8 going to adjust to their condition, and they’re
9 going to understand their condition. And it may be
10 a situation where it’s not going to — for example,
11 every fall is not going to require a trip to the
12 doctor. Every —
13 A Absolutely.
14 MR. HIESTAND: Okay. All right. Doctor,
15 thank you.
16 MR. BUTLER: Nothing further.
17 THE VIDEOGRAPHER: This concludes the
18 videotape deposition of Dr. Anna Elmers. The time
19 is 3:13 p.m., and we are off the record.
20 (Signature reserved)
21 (Deposition concluded at 3:13 p.m.)