For-Trial Video Deposition of Spine Doctor in Paralysis Case

Choo Elmers, M.D., Anna, (Pages 1:1 to 46:21)

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IN THE SUPERIOR COURT FOR THE COUNTY OF FULTON

STATE OF GEORGIA

 

 

 

VIDEOTAPED DEPOSITION OF

 

ANNA CHOO ELMERS, M.D.

 

March 25, 2014

 

2:24 p.m.

 

Shepherd Center

 

2020 Peachtree Road, N.W.

 

Atlanta, Georgia

 

Carolyn J. Smith, CCR, RPR, RMR, CCR-A-1361

.

2

 

 

INDEX OF EXHIBITS

 

2

 

3   EXHIBITS       DESCRIPTION                   PAGE

 

4

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

12

13

14

15

16                   INDEX TO EXAMINATION

17

18                                                Page

19

20   By Mr. Butler                                   6

21   By Mr. Hiestand                                35

22

23

24

25

 

4

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

21   subpoena.

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

5

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

14   record.

15             MR. BUTLER:  Jeb Butler on behalf of the

16   Plaintiff, [REDACTED].

17             MR. HIESTAND:  Trevor Hiestand for the

18   Defendant.

19             THE VIDEOGRAPHER:  Thank you, Counsel.

20   Would the court reporter please swear in the

21   witness?

22                 ANNA CHOO ELMERS, M.D.,

23   having been first duly sworn, was examined and

24   testified as follows:

25

6

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.

7                       EXAMINATION

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,

12   please?

13        A    My full name is Anna Choo Elmers.

14        Q    And today is March 25th, 2014; is that

15   right?

16        A    That’s right.

17        Q    Would you tell the jury where we are

18   today?

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

22   Center?

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

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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

17   2009.

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

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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

6   medicine?

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

16   certainty.

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

24   ’11.

25        Q    Does December 2010 sound right?

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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

8   classified.

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

17   injury.

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.

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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.

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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

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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

14   somewhat?

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

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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,

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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

9   basis.

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

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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

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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

20   done.

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.

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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

20   rehab.

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

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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

5   coordinate.

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

24   him?

25        A    I last saw him on Friday.

19

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?

20

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

21

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

22

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 —

23

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

13   program.

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

24

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]

25

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

13   overfilling.

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

26

1   they get up in the middle of the night and do this

2   procedure.

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

14   tube.

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

27

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

18   things.

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,

28

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

29

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

21   injury?

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

30

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

21   that.

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

31

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

4   bed?

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?

32

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

33

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

34

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

35

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

22   have.

23                       EXAMINATION

24   BY MR. HIESTAND:

25        Q    Doctor, thank you so much.  I’d just like

36

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

23   major?

24        A    Okay.

25        Q    Did you know that?

37

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

4   now?

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?

38

1        A    I did, but I don’t think I reviewed all of

2   them.

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

39

1   it was — and I think in his case he wanted to be a

2   dancer.  And so that is probably not going to

3   happen.

4        Q    There are certainly other ways to make

5   money, though, other than as a dancer.  Would you

6   agree?

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

21   career?

22        A    No.

23        Q    Is there anything about [REDACTED]’s

24   injury that would prevent him from pursuing a

25   family?

40

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

41

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

42

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

16   there?

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

43

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

6   witness.

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

17   surgery?

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

44

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

6   agree?

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

23   prescription.

24             So I always tell my patients, if you have

25   a urinary tract infection, we need to culture it,

45

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

4   culturing.

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

24   situation?

25        A    I do.

46

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,

4   self-medication.

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.)

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