·1· · · · · · · · · · · ·dr. neil julie ·2· · · in the...

·1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · IN THE CIRCUIT COURT OF THE 11TH JUDICIAL CIRCUIT

·3· · · · · ·IN AND FOR MIAMI, DADE COUNTY, FLORIDA

·4· · - - - - - - - - - - - - - - - +

·5· ·AIDA MAYOR,· · · · · · · · · · |

·6· · · · · · · · Plaintiff,· · · · |

·7· ·v.· · · · · · · · · · · · · · ·| Case No.

·8· ·LAZARO BOUZA, M.D. and· · · · ·| 13-27599 CA 01

·9· ·LAZARO BOUZA, M.D., P.A.,· · · |

10· · · · · · · · Defendants.· · · ·|

11· · - - - - - - - - - - - - - - - +

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14· · · · · · · · · Deposition DR. NEIL JULIE

15· · · · · · · · · · ·Rockville, Maryland

16· · · · · · · · · · Tuesday, May 12, 2015

17· · · · · · · · · · · · · · P.m.

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21· ·Job No. FTL-038641

22· ·Pages 1 - 160

23· ·Reported by: Cathy Jardim

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http://www.merrillcorp.com/law

·1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·Deposition of DR. NEIL JULIE, held at the offices of:

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·4· · · · · ·Merrill Deposition Services

·5· · · · · ·21 Church Street, Suite 150

·6· · · · · ·Rockville, Maryland· 20850

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13· · · · · ·Pursuant to notice, before Cathy Jardim,

14· ·Registered Professional Reporter and Notary Public of

15· ·the State of Maryland.

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Page 3·1· · · · · · · · · · · · DR. NEIL JULIE

·2· · · · · · · · A P P E A R A N C E S

·3· ·ON BEHALF OF THE PLAINTIFF:

·4· · · ·J. BRENT SMITH, ESQUIRE

·5· · · ·Bounds Law Group

·6· · · ·1751 North Park Avenue

·7· · · ·Maitland, Florida· 32751

·8· · · ·(407) 644-5151

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10· ·ON BEHALF OF THE DEFENDANT:

11· · · ·JONATHAN M. MIDWALL, ESQUIRE

12· · · ·Cole, Scott & Kissane, P.A.

13· · · ·Dadeland Centre II

14· · · ·9150 S. Dadeland Boulevard, Suite 1400

15· · · ·Miami, Florida· 33156

16· · · ·(305)350-5354

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Page 4·1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · · · · · · · ·C O N T E N T S

·3· ·EXAMINATION OF DR. NEIL JULIE· · · · · · · ·PAGE

·4· · · ·By Mr. Midwall· · · · · · · · · · · · ·5, 155

·5· · · ·By Mr. Smith· · · · · · · · · · · · · · ·150

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·8

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10· · · · · · · · · · · ·E X H I B I T S

11· · · · · · · · · (Attached to transcript)

12· ·JULIE DEPOSITION EXHIBITS· · · · · · · · · · · · · PAGE

13· ·Exhibit No. 1--Photographs· · · · · · · · · · · · ·26

14· ·Exhibit No. 2--Curriculum Vitae· · · · · · · · · · 33

15· ·Exhibit No. 3--Invoice· · · · · · · · · · · · · · ·56

16· ·Exhibit No. 4--Screen Shot· · · · · · · · · · · · ·56

17· ·Exhibit No. 5--List of testimony· · · · · · · · · ·71

18· ·Exhibit No. 6--Colonoscopy pictures· · · · · · · · 87

19· ·Exhibit No. 7--Correspondence· · · · · · · · · · · 157

20· ·Exhibit No. 8--Deposition Excerpts· · · · · · · · ·157

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Page 5·1· · · · · · · · · ·DR. NEIL JULIE

·2· · · · · · · · P R O C E E D I N G S

·3· · · · · · · · · ·DR. NEIL JULIE

·4· ·having been duly sworn, testified as follows:

·5· · · · EXAMINATION BY COUNSEL FOR DEFENDANT

·6· · · · · BY MR. MIDWALL:

·7· · · Q· ·State your name, please?

·8· · · A· ·Neil Julie.

·9· · · Q· ·And your position?

10· · · A· ·M.D.

11· · · Q· ·What kind?

12· · · A· ·Gastroenterologist.

13· · · Q· ·Is that your area of focus?

14· · · A· ·Yes.

15· · · Q· ·Are you a surgeon?

16· · · A· ·No.

17· · · Q· ·Ever been?

18· · · A· ·No.

19· · · Q· ·Radiologist?

20· · · A· ·I am not.

21· · · Q· ·Never been?

22· · · A· ·No.

23· · · Q· ·Are you a nephrologist?

24· · · A· ·No.

25· · · Q· ·Never held yourself out as such?


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · A· ·Never.

·3· · · · · Q· ·Do you hold yourself out in the community

·4· ·as a gastroenterologist?

·5· · · · · A· ·Yes, and a hepatologist.· That is part of

·6· ·gastroenterology.

·7· · · · · Q· ·You have been retained by the plaintiff's

·8· ·firm in this case; is that correct?

·9· · · · · A· ·That is correct.

10· · · · · Q· ·And they paid you to review this case and

11· ·provide opinions, correct?

12· · · · · A· ·Right.

13· · · · · Q· ·And you have been deposed before?

14· · · · · A· ·I have.

15· · · · · Q· ·You have been deposed as a defendant in

16· ·medical negligence cases before?

17· · · · · A· ·Yeah.

18· · · · · Q· ·I know you have been deposed before but

19· ·there can be a question whether "yeah" is

20· ·ambiguous --

21· · · · · A· ·I didn't realize it was.· Yes.

22· · · · · Q· ·You have been deposed as a defendant in a

23· ·medical negligence case before?

24· · · · · · · MR. SMITH:· Objection to form.

25· · · · · · · THE WITNESS:· I have.


·2· · · · · · · BY MR. MIDWALL:

·3· · · · · Q· ·How many times?

·4· · · · · A· ·I think once.

·5· · · · · Q· ·What were the allegations in that case?

·6· · · · · · · MR. SMITH:· Continuing objection.

·7· · · · · · · THE WITNESS:· Trying to remember the

·8· ·details.· One case I was deposed in was a mediation,

·9· ·in between my fellowship and residency I did emergency

10· ·medicine, and there was a fellow that had a dislocated

11· ·shoulder -- it was an ER case and it was thrown out in

12· ·mediation.

13· · · · · · · BY MR. MIDWALL:

14· · · · · Q· ·Meaning it was dismissed or settled?

15· · · · · A· ·It was dismissed with prejudice.

16· · · · · Q· ·Was there an expert in that case that

17· ·opined that you fell below the standard of care?

18· · · · · A· ·It was a California case.· Being I was the

19· ·defendant, I don't think I saw any of those documents.

20· · · · · Q· ·You were in California at the time?

21· · · · · A· ·Yes.

22· · · · · Q· ·Were there any other times you were deposed

23· ·as a defendant in a negligence case?

24· · · · · A· ·I don't know if I was deposed.

25· · · · · Q· ·You have had at least one settlement in a


·2· ·medical negligence case?

·3· · · · · A· ·Yes, one time.

·4· · · · · Q· ·Other than the one in California and the

·5· ·one that you settled?

·6· · · · · A· ·There was another case that never went

·7· ·anywhere that was in Maryland that I was named as a

·8· ·defendant in.

·9· · · · · Q· ·What were the allegations in that one?

10· · · · · A· ·In that case it was a patient with

11· ·diverticulitis and the surgeon admitted her.· The

12· ·surgeon put the patient on something like Kefzol, one

13· ·of the cephalosporins and the patient had a penicillin

14· ·allergy and she ended up with respiratory problems,

15· ·some asthma exacerbation.· She sued the surgeon, but

16· ·even though I hadn't ordered any of those medications,

17· ·I was sort of collateral damage on the lawsuit and I

18· ·was named.

19· · · · · Q· ·That was ultimately dismissed?

20· · · · · A· ·Yes.

21· · · · · Q· ·Tell me about the allegations in which you

22· ·settled?

23· · · · · A· ·That was a case of also a surgeon who did a

24· ·cholecystectomy, transected the common bowel duct, but

25· ·he thought it was an accessory duct to the Lushka, L U


·2· ·S H K A, and was sure he didn't damaged the common

·3· ·duct.· I did the ERCPs and it was unsuccessful in

·4· ·identifying the problems.· So the second time around

·5· ·the patient ended up dying of complications of bile

·6· ·leak from the duct transaction.· So I think I settled

·7· ·for about 15 percent of the total settlement.

·8· · · · · Q· ·And the allegation was that you failed to

·9· ·do an appropriate ERCP to pick up the bile leak?

10· · · · · A· ·Right.· It was a delay in diagnosis because

11· ·the ERCP had to be repeated because the patient was

12· ·agitated and unstable so the first ERCP was not fully

13· ·successful.

14· · · · · Q· ·And there was an expert who criticized your

15· ·care in that case?

16· · · · · A· ·Probably.

17· · · · · Q· ·Do you remember what type of expert it was?

18· · · · · A· ·Gastroenterologist.

19· · · · · Q· ·Did you disagree with that expert's

20· ·opinions?

21· · · · · A· ·I don't remember the opinions because this

22· ·was more than 15 years ago.· So I couldn't really tell

23· ·you.

24· · · · · Q· ·You don't recall if you agreed with that

25· ·expert's opinions who was critiquing your care?


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · A· ·Without looking at the deposition to see

·3· ·what he opined -- the patient was injured, so, you

·4· ·know, the process went through its phases, but I don't

·5· ·remember what the expert said about what I did or

·6· ·didn't do.

·7· · · · · Q· ·Has your license ever been investigated by

·8· ·any board?

·9· · · · · A· ·No.

10· · · · · Q· ·Or been denied a license to practice

11· ·medicine before?

12· · · · · A· ·No.

13· · · · · Q· ·Have you ever rotated through any

14· ·internship or residency in a Florida-based hospital?

15· · · · · A· ·No.

16· · · · · Q· ·You have never provided care and treatment

17· ·to any patient in the state of Florida?

18· · · · · A· ·Well, mother-in-law, but that was kind

19· ·of -- not in an office, sitting on a cabana chair.

20· · · · · Q· ·She asked her son-in-law to explain some

21· ·type of condition she was experiencing?

22· · · · · A· ·Right, and then her friends jumped on.

23· · · · · Q· ·Have you spoken to Ms. Mayor in this case?

24· · · · · A· ·No.

25· · · · · Q· ·Have you spoken to any of her family


·2· ·members?

·3· · · · · A· ·No, I have not.

·4· · · · · Q· ·Have you spoken to any of her treating

·5· ·doctors?

·6· · · · · A· ·No.

·7· · · · · Q· ·Have you ever been to any of the hospitals

·8· ·at which she was treated in this case?

·9· · · · · A· ·No.

10· · · · · Q· ·Have you ever been asked to defend a

11· ·gastroenterologist's standard of care who practiced in

12· ·Florida?

13· · · · · A· ·Yes.

14· · · · · Q· ·Do you remember when?

15· · · · · A· ·It was more than ten years ago.

16· · · · · Q· ·Do you know where that gastroenterologist

17· ·was located?

18· · · · · A· ·I think it was like sort of a Tampa-St.

19· ·Pete area.

20· · · · · Q· ·Do you know what the allegations were in

21· ·that case?

22· · · · · A· ·It has been so long ago -- I remember it

23· ·was in Florida, but I don't remember anything beside

24· ·that.

25· · · · · Q· ·Were you deposed?


·2· · · · · A· ·I think I was.

·3· · · · · Q· ·You don't remember the names of the patient

·4· ·or the doctor?

·5· · · · · A· ·No, long time ago.

·6· · · · · Q· ·You have been noticed for deposition and

·7· ·requested in that notice to bring documents with you.

·8· ·Do you recall that?

·9· · · · · A· ·Yes.

10· · · · · Q· ·I think you let me look at your documents

11· ·that you brought with you prior to the start of the

12· ·deposition and you have the notice?

13· · · · · A· ·I do.

14· · · · · Q· ·That was provided by the plaintiff's

15· ·counsel?

16· · · · · A· ·It was.

17· · · · · Q· ·I know you mentioned that you have a number

18· ·of documents that were on your computer?

19· · · · · A· ·Right.

20· · · · · Q· ·What were -- let's go through what

21· ·documents you received.

22· · · · · A· ·I am going to read it off of this.· It is

23· ·just as easy as reading off the computer.· Why don't

24· ·we do that.· It is not that long a list.

25· · · · · Q· ·Go ahead.


·2· · · · · A· ·On the first CD that I received I have the

·3· ·records from Baptist Health; records from Dr. Murray

·4· ·Rolnick, R O L N I C K; records from Home Health;

·5· ·records from Nagi's Pharmacy; records from Y and D,

·6· ·like David, Medical Supplies; and I just got a message

·7· ·on my phone that the mail may be coming through into

·8· ·your in boxes any second.

·9· · · · · · · On the second one --

10· · · · · Q· ·That is one CD that contained those

11· ·documents?

12· · · · · A· ·Correct.

13· · · · · Q· ·Okay.

14· · · · · A· ·Next has seven documents on the second

15· ·disk.· It is records of Baptist Hospital for October

16· ·25.

17· · · · · Q· ·What year?

18· · · · · A· ·2012.· Records of Baptist Hospital,

19· ·December 5, 2012; records for Health South, January,

20· ·2013; records for Kindred Hospital, October 2012;

21· ·records from KRMC, September 4, 2012; records from

22· ·Riviera Health, October 2012; records of St. Anne's

23· ·Nursing, November 23, 2012.· That completes CD number

24· ·two.

25· · · · · · · Then, number three, color photos from the


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·colonoscopy from August 23 and then these are all

·3· ·depositions:· Depositions of Aida Mayor, Dr. Bouza,

·4· ·Gabriel major, M A Y O R, and Haydee, H A Y D E E

·5· ·Mayor.· Now we are back to records.· Records from

·6· ·Baptist, September 17, 2012; records from Dr. Bouza, B

·7· ·O U Z A; records from Dr. Martinez; KRMC, three sets,

·8· ·8/23, for the colonoscopy; 8/24 from the admission;

·9· ·September 4, 2012, admission.

10· · · · · · · Then there are photos batched together

11· ·under 1377 but there are a total of 13 photographs

12· ·identified as badge 1377.

13· · · · · Q· ·What do those photos depict?

14· · · · · A· ·The patient's wound, scar, drains.

15· · · · · Q· ·The screen shot that says 1377, subsections

16· ·one through 13, are all depicting her wound?

17· · · · · A· ·They show the wound, the wound vac, some of

18· ·the gauze pads and peripheral gizmos.

19· · · · · Q· ·Are you an infectious disease physician?

20· · · · · A· ·No.

21· · · · · Q· ·Ever held yourself out as one?

22· · · · · A· ·No, but in gastroenterology, there is

23· ·infection in GI, there is radiology in GI, there is

24· ·pathology in GI.· Where those areas and

25· ·sub-specialties encroach on gastroenterology, I am an


·2· ·expert in that.

·3· · · · · Q· ·Have you read all of the depositions that

·4· ·you listed that you received?

·5· · · · · A· ·Did you want the photos?· This is 1377.

·6· · · · · Q· ·The actual hard copies of the photographs

·7· ·that were labeled 1377?

·8· · · · · A· ·Yes.

·9· · · · · Q· ·My question was did you read all the

10· ·depositions you received from the plaintiff's counsel?

11· · · · · A· ·I did.

12· · · · · Q· ·All of the materials you listed were

13· ·provided to you by the plaintiff's firm; is that

14· ·correct?

15· · · · · A· ·That is correct.

16· · · · · Q· ·Were any of the depositions of the family

17· ·members relevant for your opinions in this case?

18· · · · · A· ·Well, I mean, they all fill in some

19· ·important facts about what transpired.· So relevance,

20· ·I can let you get more specific about relevance.

21· · · · · Q· ·Do you believe any of the depositions of

22· ·the family members assisted in your opinions?

23· · · · · A· ·Yes.

24· · · · · Q· ·How so?

25· · · · · A· ·Well, you know, I think they filled in some


·2· ·of the details around what transpired leading up to

·3· ·the colonoscopy, the reasons for doing the colonoscopy

·4· ·and what transpired between the 23rd and the time that

·5· ·she went to Baptist Hospital.

·6· · · · · Q· ·What about the deposition of the plaintiff,

·7· ·Aida Mayor, was that deposition relevant to your

·8· ·opinions?

·9· · · · · A· ·To some extent.

10· · · · · Q· ·What extent was that?

11· · · · · A· ·I couldn't tell off the top of my head.· We

12· ·can pull it up -- I have the CDs here, but if you want

13· ·to ask me specific questions --

14· · · · · Q· ·You have final opinions?

15· · · · · A· ·I do.

16· · · · · · · MR. SMITH:· I don't mean to interrupt you.

17· ·I think he was also provided Dr. Pons' depo.

18· · · · · · · THE WITNESS:· Yes, I did get that, e-mailed

19· ·to me, P O N S.

20· · · · · · · BY MR. MIDWALL:

21· · · · · Q· ·Did you get that by e-mail?

22· · · · · A· ·I guess.

23· · · · · Q· ·Do you have final opinions?

24· · · · · A· ·Obviously I do.

25· · · · · Q· ·And you feel comfortable today testifying


·2· ·as to those final opinions?

·3· · · · · A· ·Yes.

·4· · · · · Q· ·In terms of the deposition of the

·5· ·plaintiff, Aida Mayor, how, if at all, did it assist

·6· ·in your opinions?

·7· · · · · A· ·Well, I got the firsthand description of

·8· ·what she went through and the extent of her recovery,

·9· ·her relationship with the various treaters -- just a

10· ·sense of her situation.

11· · · · · Q· ·How is that relevant to your opinions -- if

12· ·at all -- if it wasn't relevant, you can tell me and I

13· ·will move on to something else.

14· · · · · A· ·I think it didn't have as much relevance,

15· ·but her daughter-in-law gave a much more clear

16· ·narrative.

17· · · · · Q· ·Is it fair to say that Aida Mayor's

18· ·deposition testimony which you reviewed in this case

19· ·was not relevant for your opinions?

20· · · · · · · MR. SMITH:· Objection.

21· · · · · · · THE WITNESS:· I don't think I would

22· ·characterize it as that, but it is not like you are

23· ·asking me about some fact she said.· I wouldn't say it

24· ·was irrelevant.

25· · · · · · · BY MR. MIDWALL:


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·Which parts were relevant?

·3· · · · · A· ·Can I put it in your computer?· It is

·4· ·probably a guess as to which disk it is on.

·5· · · · · · · (Pause.)

·6· · · · · Q· ·While we are waiting for it to get booted

·7· ·up, when was the last time you reviewed Aida Mayor's

·8· ·deposition?

·9· · · · · A· ·Probably about a month ago.

10· · · · · Q· ·What about the other family members'

11· ·depositions, when did you last read through them?

12· · · · · A· ·I think I looked at the daughter's in the

13· ·past week and Dr. Bouza, same thing.

14· · · · · Q· ·This past week?

15· · · · · A· ·Yes.

16· · · · · Q· ·And you are looking at the plaintiff's

17· ·deposition transcript right now?

18· · · · · A· ·I am.

19· · · · · Q· ·Did you mark it or highlight any aspect?

20· · · · · A· ·I kind of wish I knew how to highlight on

21· ·this electronic media, so I didn't highlight.· I did

22· ·highlight in the daughter's transcript.

23· · · · · Q· ·Is that in the batch --

24· · · · · A· ·Yes, that is in that folder.

25· · · · · Q· ·You have the deposition in front of you?


·2· · · · · A· ·I do.

·3· · · · · Q· ·Is there any relevance to the deposition?

·4· · · · · · · MR. SMITH:· Objection to form.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·To your opinion?

·7· · · · · A· ·I think the relevance is her giving the

·8· ·best and firsthand accounting of her disability and

·9· ·limitations at the current time that have -- are

10· ·present as a result of her prolonged medical illness.

11· · · · · Q· ·Well, that deposition of the plaintiff was

12· ·taken when?

13· · · · · A· ·That was in November 2013, over a year ago.

14· · · · · Q· ·Year and a half ago?

15· · · · · A· ·I said over a year ago.

16· · · · · Q· ·You read the deposition of Dr. Pons?

17· · · · · A· ·I have.

18· · · · · Q· ·The whole thing?

19· · · · · A· ·I did.

20· · · · · Q· ·And you understand he is her treating

21· ·nephrologist?

22· · · · · A· ·Yes.

23· · · · · Q· ·And Dr. Pons felt the plaintiff, since

24· ·starting dialysis, has done remarkably well?



·2· · · · · · · THE WITNESS:· She has.· She has bounced

·3· ·back quite well from her bottom which her

·4· ·daughter-in-law described her looking like a monster.

·5· ·So Dr. Pons got hauled into the case when she was at

·6· ·her worse and she has climbed out of a deep hole.

·7· · · · · · · BY MR. MIDWALL:

·8· · · · · Q· ·What did Dr. Pons feel was the cause of her

·9· ·kidney disease?

10· · · · · A· ·Hypertension and diabetes.

11· · · · · Q· ·Conditions she had that were pre-existing

12· ·conditions?

13· · · · · A· ·Yes.

14· · · · · Q· ·Longstanding?

15· · · · · A· ·Yes.

16· · · · · Q· ·Conditions she had prior to the colonoscopy

17· ·performed by Dr. Bouza?

18· · · · · A· ·Right.

19· · · · · Q· ·Did you mark any excerpts of Dr. Bouza's

20· ·transcript?

21· · · · · A· ·A couple.

22· · · · · Q· ·That is, once again, a hard copy you

23· ·brought with you?

24· · · · · A· ·It is.

25· · · · · Q· ·You brought hard copies of excerpts of the


·2· ·transcripts of Dr. Bouza, Haydee Mayor and Dr. Pons?

·3· · · · · A· ·Right.

·4· · · · · Q· ·Those are the three transcript excerpts you

·5· ·brought?

·6· · · · · A· ·I think those are the ones.· If you want, I

·7· ·can check to see.

·8· · · · · Q· ·Please do.

·9· · · · · A· ·That is Bouza.· This is Pons.· This is

10· ·Haydee.· This is just more Haydee.· So, yes, those

11· ·three.

12· · · · · Q· ·Were there any materials that you had asked

13· ·the plaintiff's firm to provide to you that they were

14· ·not able to do?

15· · · · · A· ·No.

16· · · · · Q· ·Is there any additional information you

17· ·would have liked to have reviewed in this case to

18· ·finalize your opinions?

19· · · · · A· ·No.

20· · · · · Q· ·Did you perform any research in order to

21· ·provide your opinions?

22· · · · · A· ·I did look up some endoscopic photography

23· ·and I brought a couple of photographs of the

24· ·particular type of polyp that Ms. Mayor turned out to

25· ·have that is called a lipoma, L I P O M A.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·When you say you researched endoscopic

·3· ·photography, what do you mean?

·4· · · · · A· ·I just wanted to bring some color

·5· ·photographs that I could bring and discuss in the

·6· ·course of this deposition.

·7· · · · · Q· ·Why?

·8· · · · · A· ·Because the polyp that Dr. Bouza excised

·9· ·with a hot polypectomy snare was in fact a lipoma

10· ·which is a harmless type of sub-mucosal polyp that

11· ·really does not need to be excised.· So I brought some

12· ·photographs to demonstrate what they look like.

13· · · · · Q· ·Have you ever encountered a lipoma before?

14· · · · · A· ·Many times.

15· · · · · Q· ·Have you ever excised a lipoma?

16· · · · · A· ·No.· I have biopsied them but not excised

17· ·them.

18· · · · · Q· ·You have taken parts of one?

19· · · · · A· ·Using forceps, yes.

20· · · · · Q· ·How much of those lipomas did you remove?

21· · · · · A· ·You don't quantify it but maybe a

22· ·twentieth, a thirtieth.

23· · · · · Q· ·Why did you biopsy those lipomas in your

24· ·own practice?

25· · · · · A· ·Just to be sure they were lipomas.


·2· · · · · Q· ·You weren't able from visualizing it at the

·3· ·time to be sure that they were lipoma as opposed to a

·4· ·cancerous lesion?

·5· · · · · A· ·I could identify them to a 99 percent

·6· ·degree of certainty from their appearance.· Just like

·7· ·a person in the zoo can say, "that is an elephant" and

·8· ·"that is an orangutan," that is pretty clear.· I could

·9· ·tell, but I did pinch biopsies to dig deeper to make

10· ·sure it wasn't some other kind of sub-mucosal lesion,

11· ·like a leiomyoma or other sub-mucosal lesion.

12· · · · · Q· ·If it had been an other sub-mucosal lesion,

13· ·it could have been cancerous; is that correct?

14· · · · · A· ·Remote possibility.

15· · · · · Q· ·It was a remote possibility enough that you

16· ·wanted to biopsy it so you didn't leave a cancerous

17· ·lesion in a patient?

18· · · · · A· ·Yes.

19· · · · · Q· ·You have taken biopsies of other masses or

20· ·polyps you have encountered within the scope?

21· · · · · A· ·Sure.

22· · · · · Q· ·That is what the colonoscopy's function is?

23· · · · · A· ·Well, the colonoscopy, like a lot of other

24· ·technology, is to be utilized with the appropriate

25· ·techniques in an appropriate situation.


·2· · · · · Q· ·Sure.· Can you answer my question?

·3· · · · · A· ·If you repeat it.

·4· · · · · · · (The reporter read the requested portion of

·5· ·the record.)

·6· · · · · · · THE WITNESS:· I have identified, and

·7· ·excised if it needs to come out.

·8· · · · · · · BY MR. MIDWALL:

·9· · · · · Q· ·You have excised before during

10· ·colonoscopies?

11· · · · · A· ·Sure.

12· · · · · Q· ·Once again, that is a function of the

13· ·colonoscopy?

14· · · · · A· ·That is one of the.

15· · · · · Q· ·Can I say scope instead of colonoscopy?

16· · · · · A· ·Yes.

17· · · · · Q· ·You are comfortable with that?

18· · · · · A· ·Yes.

19· · · · · Q· ·What are the other functions of a

20· ·colonoscopy?

21· · · · · A· ·Colonoscopy can be done as a screening, you

22· ·take people with average risk and look for any signs

23· ·of colon cancer that are asymptomatic.· It can be done

24· ·as a diagnostic test to find the source of bleeding,

25· ·chronic diarrhea, change in bowel habits.


·2· · · · · Q· ·Weight loss?

·3· · · · · A· ·Weight loss is a little broad.· You don't

·4· ·do that for everybody that has weight loss.· It can be

·5· ·done as surveillance for people that have had lesions

·6· ·in the past to make sure there are no new lesions.

·7· · · · · Q· ·What does surveillance mean?

·8· · · · · A· ·Surveillance is done for people that have

·9· ·shown an abnormality in the colon and you want to take

10· ·a look to be sure there are not any new ones.

11· · · · · Q· ·When you say an abnormality in the colon,

12· ·what are you referring to?

13· · · · · A· ·Usually polyps or colon cancer.

14· · · · · Q· ·What else?

15· · · · · A· ·Those are the main -- and then therapeutic.

16· ·If you have someone with an active bleed, then you go

17· ·in there with the colonoscope and you treat using

18· ·various devices to make the bleeding stop, and

19· ·sometimes you do that also for people who have other

20· ·problems with massive colon distension and you have to

21· ·decompress the colon, so you do a decompressing

22· ·colonoscopy.· So there is other therapeutic

23· ·colonoscopy opportunities.

24· · · · · Q· ·When you researched endoscopic photograph,

25· ·did you go to a particular website to do that?


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · A· ·I ended up ultimately going to a website

·3· ·which had good photographs that were printable.· Not

·4· ·all sites allowed for printing and so I used something

·5· ·that is sort of a library of images called Gastro Lab,

·6· ·and this is the picture and this is the reference

·7· ·material with the web address and stuff.

·8· · · · · Q· ·Let's mark that as Defendant's composite

·9· ·one for identification, please.

10· · · · · · · · · · · · ·(Julie Exhibit No. 1

11· · · · · · · · · · · · ·was marked for identification.)

12· · · · · · · BY MR. MIDWALL:

13· · · · · Q· ·The most relevant photo from the Gastro Lab

14· ·website was the first document in composite Exhibit 1?

15· · · · · A· ·That is right.

16· · · · · Q· ·You were able to download this from your

17· ·computer?

18· · · · · A· ·Well, I had to move it over to paint and

19· ·then I was able to print it.

20· · · · · Q· ·That represents what, a lipoma?

21· · · · · A· ·Yes, and then there is a little metal

22· ·device that is abutting against the lipoma which is a

23· ·cold biopsy forceps which is the device of choice in

24· ·ascertaining whether it is a lipoma.

25· · · · · Q· ·How is it to be determined if there is a


·2· ·lipoma present?

·3· · · · · A· ·In a patient who has a non-worrisome

·4· ·history, you can tell a lipoma 99 percent of the time

·5· ·just by looking at it.· If you -- you were asking how

·6· ·you would ascertain it was a lipoma?

·7· · · · · Q· ·Correct.

·8· · · · · A· ·The next step would be is you would take a

·9· ·biopsy forceps and you would biopsy the top of it see

10· ·because a lipoma is a cushion of fat and laying

11· ·underneath the mucosa and the sub-mucosa of the normal

12· ·intestine.· It is a pillow of fat lying under the

13· ·normal lining of the intestinal mucosa.· The first

14· ·biopsy will show you normal intestinal mucosa and

15· ·sub-mucosa and then sometimes we will take the same

16· ·biopsy forceps and go through the same hole where you

17· ·just pinched off a piece and do a well biopsy, W E L

18· ·L, and take a pinch that is a little bit deeper.· Then

19· ·your forceps may actually get into the lipoma so you

20· ·get some of the fatty tissue on the biopsy.

21· · · · · · · So there are two parts.· The first is if

22· ·you find the normal mucosa up above, you know this is

23· ·not an adenomatous polyp, you know it is not a

24· ·worrisome sort of common place colon polyp that needs

25· ·to be removed and then if you get your second biopsy


·2· ·you may actually get some of the fatty material and

·3· ·get 100 percent confirmation of the diagnosis.· But

·4· ·there is really two different things you find out.· If

·5· ·you biopsy and what you see is normal mucosa, you know

·6· ·this is not an adenomatous polyp and it does not need

·7· ·to be removed with a polypectomy.

·8· · · · · Q· ·Can you do the biopsy intra-operatively,

·9· ·for lack of a better word?

10· · · · · A· ·You mean at the time of the scope?

11· · · · · Q· ·Correct.

12· · · · · A· ·Yes.

13· · · · · Q· ·You said you can do this in a

14· ·non-worry -- in a patient with a non-worrisome

15· ·history.· Do you recall that?

16· · · · · A· ·Right.

17· · · · · Q· ·What is it that you mean when you say a

18· ·non-worrisome history?

19· · · · · A· ·Non-worrisome means there is an absence of

20· ·diseases that metastasized, absence of breast cancer,

21· ·an abscess of melanoma, recent history like within the

22· ·last five years of colon cancer.

23· · · · · Q· ·A history of colon cancer five years or

24· ·less is worrisome by your definition?

25· · · · · A· ·Then you have to wonder whether there could


·2· ·be a sub-mucosal mass, yes.

·3· · · · · Q· ·Can you cite to any literature in support

·4· ·of your opinion that a history of colon cancer five

·5· ·years out or more would be non-worrisome?

·6· · · · · A· ·It is common knowledge that the effective

·7· ·cure date for colon cancer is survival beyond five

·8· ·years.

·9· · · · · Q· ·Right, but survival, what, five years out,

10· ·greater than 50 percent chance but it doesn't mean

11· ·recurrence of colon cancer is ruled out, correct?


13· · · · · · · THE WITNESS:· Recurrence of colon cancer

14· ·beyond five years from the same primary is very, very

15· ·low.· We are talking less than a few percent.· When

16· ·you are talking beyond seven years, eight years, then

17· ·it is pretty much unheard of.

18· · · · · · · BY MR. MIDWALL:

19· · · · · Q· ·But colon cancer does recur?

20· · · · · A· ·Within five years it does recur.· If you

21· ·get beyond five years, you are considered a cure for

22· ·your garden variety of colon cancer.

23· · · · · Q· ·Ms. Mayor had a history of colon cancer,

24· ·correct?

25· · · · · A· ·She did.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·What kind of colon cancer was it?

·3· · · · · A· ·It was just a -- I don't have all of the

·4· ·records, but it was a standard colon cancer.· It was

·5· ·not a GI stromal tumor.· It wasn't a carcinoid.· It

·6· ·was just the general garden variety colon cancer.

·7· · · · · Q· ·What are you using to support that opinion?

·8· · · · · A· ·Just based on the commentary and quoting

·9· ·the docs who wrote notes on the patients.

10· · · · · Q· ·Which doctors?

11· · · · · A· ·You know, I didn't print out all of the

12· ·records so I have to do this from memory but Dr.

13· ·Whittwell commented on it; other doctors at Baptist

14· ·who gave a statement of a remote history of colon

15· ·cancer; and I think there was one doctor, but I don't

16· ·remember who, gave a number of ten years ago and the

17· ·family depositions implied that was about the

18· ·timeframe she had the colon cancer, but I don't have

19· ·source documents.

20· · · · · Q· ·The family is presuming the time, but you

21· ·didn't see the precise records when she was diagnosed

22· ·with the colon cancer and when it was surgically

23· ·resected?

24· · · · · A· ·Right.

25· · · · · Q· ·Anything else that would comprise a


·2· ·non-worrisome history so that you would biopsy what

·3· ·you thought was a lipoma, as opposed to excise it?

·4· · · · · A· ·In other words, if you didn't have any of

·5· ·the worrisome history features, then you are in the

·6· ·non-worrisome category which is the universe of

·7· ·everybody else.

·8· · · · · Q· ·If you thought you encountered a lipoma you

·9· ·would biopsy it, correct?

10· · · · · A· ·If you are 100 percent sure it is a lipoma,

11· ·you don't even need to biopsy it.· If you are in the

12· ·99 percent, you could go ahead and biopsy it, but you

13· ·wouldn't snare it and do a hot snare polypectomy on

14· ·it.

15· · · · · Q· ·What would be considered a worrisome

16· ·history if one encountered what they thought was a

17· ·lipoma during a scope?

18· · · · · A· ·History of breast cancer, history of

19· ·melanoma, history of GI stromal tumor I guess we could

20· ·add also, and a colon cancer within the past five

21· ·years.

22· · · · · Q· ·Once again are you referring to any

23· ·literature in support of that opinion?

24· · · · · A· ·Just my years of training as a fellow and

25· ·25 years of practice.


·2· · · · · Q· ·Did you perform any Internet research in

·3· ·order to formulate your opinions?

·4· · · · · A· ·Nothing except looking for the photographs.

·5· · · · · Q· ·Are there any materials you received in

·6· ·this case that is not depicted in that screen shot you

·7· ·sent to me.

·8· · · · · · · MR. SMITH:· I didn't get a copy of the

·9· ·screen shot.

10· · · · · · · THE WITNESS:· This?

11· · · · · · · BY MR. MIDWALL:

12· · · · · Q· ·Other than Dr. Pons' deposition?

13· · · · · A· ·Just the subpoena.

14· · · · · Q· ·You brought with you your most updated

15· ·curriculum vitae?

16· · · · · A· ·Yes.

17· · · · · Q· ·Can I see it, please?

18· · · · · A· ·Sure.

19· · · · · Q· ·You just handed me what is your most

20· ·updated CV?

21· · · · · A· ·Yes.

22· · · · · Q· ·When was it updated?

23· · · · · A· ·I think August 2013.

24· · · · · Q· ·Nothing new since that time that you felt

25· ·was pertinent enough?


·2· · · · · A· ·No, not really.

·3· · · · · Q· ·It is five pages.· We will mark it as

·4· ·Exhibit 2.

·5· · · · · · · · · · · · ·(Julie Exhibit No. 2

·6· · · · · · · · · · · · ·was marked for identification.)

·7· · · · · · · BY MR. MIDWALL:

·8· · · · · Q· ·Was there something you were looking for?

·9· · · · · A· ·There was a March 2013 briefing I gave on

10· ·Capitol Hill about colon cancer screening that I

11· ·wanted to be sure was on there.

12· · · · · Q· ·Colorectal Cancer Awareness Briefing?

13· · · · · A· ·Yes.

14· · · · · Q· ·Do you have that with you?

15· · · · · A· ·I would have that -- you know, I don't

16· ·think I have it on me.

17· · · · · Q· ·Do you consider that to be authoritative?


19· · · · · · · THE WITNESS:· It was topical.· More about

20· ·the demographics of colon cancer screening so I guess

21· ·I would not consider it authoritative.

22· · · · · · · BY MR. MIDWALL:

23· · · · · Q· ·You would not?

24· · · · · A· ·No.

25· · · · · Q· ·What was the gist of that presentation?


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · A· ·Primarily it was trying to teach

·3· ·congressional staffers and people on the hill the

·4· ·importance of screening and expanding colon cancer

·5· ·screening and the fact that doing so had actually bent

·6· ·the curve in terms of reductions death from colon

·7· ·cancer between the 1970s and 2000s.

·8· · · · · Q· ·You were advocating for the expansion of

·9· ·the use of scopes?

10· · · · · A· ·Yes -- well, expansion of colon cancer

11· ·screening, efficient colon cancer screening, scopes

12· ·being a big part of that.

13· · · · · Q· ·Scopes are a big part of screening for

14· ·colorectal cancer?

15· · · · · A· ·True.

16· · · · · Q· ·And you were advocating for screening

17· ·colorectal cancer, correct?

18· · · · · A· ·I was presenting them with statistics

19· ·showing them the benefits that have arisen from more

20· ·aggressive screening with fecal hemoccult testing and

21· ·colonoscopy and by doing so the data showed that the

22· ·mortality curves have been bent in a positive

23· ·direction through screening.

24· · · · · Q· ·And when you say screening scopes, in the

25· ·context of your presentation, what does that mean?


·2· · · · · A· ·Screening generally applies to people

·3· ·having a first-time colonoscopy, no symptoms at all

·4· ·but having it for early detection of colon neoplasms.

·5· · · · · Q· ·People that have not had colonoscopies by a

·6· ·certain age, you believe it is in their best interest

·7· ·to have one done, correct?

·8· · · · · A· ·Medicare has established a window, over a

·9· ·certain age you should have them but when you get over

10· ·75 they are saying you don't really need them any

11· ·more.· There is actually a window of time between age

12· ·50 and 75 where people should be having them to try to

13· ·detect early colon neoplasms.· Neoplasms are true

14· ·polyps and they have true cancer potential as distinct

15· ·from lipomas which are not neoplasms and don't have a

16· ·cancer potential.

17· · · · · Q· ·So in your presentation you believe that

18· ·someone between 50 and 75 years of age who has not yet

19· ·had a screening colonoscopy should have one?

20· · · · · A· ·Correct.

21· · · · · Q· ·And that is in order to try to reduce the

22· ·incidence of undiagnosed colorectal cancer?


24· · · · · Q· ·What about repeat or surveillance

25· ·colonoscopies, have you ever lectured on when those


·2· ·are indicated?

·3· · · · · A· ·I have spoken about that in the past.

·4· ·There is something that is in my bibliography, Colon

·5· ·Cancer:· An Update, which I probably but together in

·6· ·the late '90s and that touched on surveillance which

·7· ·would be follow-up colonoscopies.

·8· · · · · Q· ·Can you show me where that is, please.

·9· · · · · A· ·Sure.· Right there.

10· · · · · Q· ·You put a little dash by it.· Update on

11· ·Colonic Neoplasms?

12· · · · · A· ·Right.

13· · · · · Q· ·And you believe that was published sometime

14· ·in the late 1990s?

15· · · · · A· ·I think there is a date there.· I am not

16· ·sure.

17· · · · · Q· ·There is no date on it.

18· · · · · A· ·Yes, probably late '90s.

19· · · · · Q· ·Did you consider that to be authoritative?


21· · · · · · · THE WITNESS:· At that time I think it was,

22· ·but there is a lot that has been happened in 20 years.

23· · · · · · · BY MR. MIDWALL:

24· · · · · Q· ·Do you remember what you wrote about in

25· ·that publication about surveillance colonoscopies?


·2· · · · · A· ·We talked about what the intervals for

·3· ·follow-up colon -- if someone had a previous history

·4· ·of one polyp or multiple polyps or family history of

·5· ·colon cancers at an early age.

·6· · · · · Q· ·Do you remember what was said for people

·7· ·with a history of colon cancer?

·8· · · · · A· ·Probably after the first couple of years

·9· ·then you would go to every five years.

10· · · · · Q· ·Wait two years after some type of

11· ·intervention for the colon cancer before undertaking

12· ·surveillance colonoscopies?

13· · · · · A· ·I don't know what the current guidelines

14· ·are, but you may do a colonoscopy about a year later

15· ·and then after that probably just go to every five.

16· · · · · Q· ·Until what age?

17· · · · · A· ·That really depends on the general health

18· ·of the patient.· I think it is a judgment call as to

19· ·whether to stop at 75 or 80.

20· · · · · Q· ·You take the patient, individualized and

21· ·use your clinical judgment given what that patient's

22· ·history is and their presentation to make a decision?

23· · · · · A· ·Right.

24· · · · · Q· ·Is there anything else listed on your

25· ·curriculum vitae that makes reference to colonoscopies


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·or screening for colorectal cancer other than what you

·3· ·have told me thus far?

·4· · · · · A· ·No.

·5· · · · · Q· ·Do you belong to any societies?

·6· · · · · A· ·I do.

·7· · · · · Q· ·And they are under professional

·8· ·memberships?

·9· · · · · A· ·Right.· That is where it is listed.

10· · · · · Q· ·I am sorry?

11· · · · · A· ·You were saying listed under professional

12· ·memberships.

13· · · · · Q· ·Right.· Do any of these memberships

14· ·disseminate guidelines on when colonoscopies are to be

15· ·performed?

16· · · · · A· ·They do.

17· · · · · Q· ·Which ones?

18· · · · · A· ·Probably the AGA, and the ASGE.

19· · · · · Q· ·What do those stand for.· AGA?

20· · · · · A· ·American Gastrological Association.

21· · · · · Q· ·And do you recall what they recommend for

22· ·screening and surveillance colonoscopies?

23· · · · · A· ·Well, for surveillance, if we are talking

24· ·about patients who have had a history of prior colon

25· ·cancer or prior significant colon polyps every five


·2· ·years.

·3· · · · · Q· ·Up until what age?

·4· · · · · A· ·Again, I don't really -- I think 75 is

·5· ·pretty much the cutoff, but I think there is some

·6· ·flexibility there.

·7· · · · · Q· ·Flexibility up to age 80?

·8· · · · · A· ·Yes, looking at it on a case-by-case basis.

·9· · · · · Q· ·What about the AGA, does it disseminate

10· ·guidelines as to what type of technique to use when

11· ·removing polyps?

12· · · · · A· ·They don't really, I think, have specific

13· ·published guidelines, but there is common knowledge in

14· ·our GI training as to what devices to use in different

15· ·situations.

16· · · · · Q· ·And how do you learn what the common

17· ·knowledge is?

18· · · · · A· ·In your training, when you go through your

19· ·GI fellowship training.

20· · · · · Q· ·And what does the ASGE stand for?

21· · · · · A· ·American Society for Gastrological

22· ·Endoscopy.

23· · · · · Q· ·And you are a member of that?

24· · · · · A· ·Yes.

25· · · · · Q· ·And do they promulgate any type of


·2· ·guidelines for what technique to use when removing

·3· ·polyps while doing a scope?

·4· · · · · A· ·I think there is -- again, I don't know if

·5· ·there are formal guidelines, but I think the general

·6· ·instruction for gastroenterologists is if something is

·7· ·a neoplasm, then a neoplasm has cancerous potential

·8· ·downstream and those lesions should be removed in an

·9· ·efficient and safe manner.· On the other hand, if it

10· ·is not a neoplasm, but a purely benign lesion, that

11· ·benign lesions should be left alone if, trying to

12· ·remove them would cause unnecessary risk, like a

13· ·lipoma.

14· · · · · Q· ·One cannot always tell if what they are

15· ·seeing in a scope is a lipoma as opposed to a

16· ·neoplastic lesion, correct?

17· · · · · A· ·I would say you can tell looking at that

18· ·picture with that lesion that with a 99 percent

19· ·certainty that it is a lipoma --

20· · · · · Q· ·The picture that is just from Jane Doe or

21· ·John Doe?

22· · · · · A· ·The picture of Ms. Mayor.

23· · · · · Q· ·This is not the picture of Ms. Mayor?

24· · · · · A· ·No, but we have that.· This picture is from

25· ·the website.· I was talking about the specific


·2· ·photograph of Mrs. Mayor's colonoscopy, 99 percent

·3· ·that was a lipoma.

·4· · · · · Q· ·Your opinion is 99 percent that the picture

·5· ·from the colonoscopy done by Dr. Bouza of Ms. Mayor

·6· ·depicted a lipoma?

·7· · · · · A· ·Yes, given her clinical history.

·8· · · · · Q· ·And her clinical history was what?

·9· · · · · A· ·Absence of melanoma, absence of breast

10· ·cancer, lack of recent colon cancer, so therefore 99

11· ·percent likely that it was a lipoma and by using

12· ·biopsy forceps you can make that 100 percent, with no

13· ·risk.

14· · · · · Q· ·Is there any risk associated with doing a

15· ·biopsy?

16· · · · · A· ·In the colon, no, standard cold biopsy, not

17· ·hot biopsy.

18· · · · · Q· ·Using cold forceps to perform a biopsy?

19· · · · · A· ·Correct.

20· · · · · Q· ·We got a little bit off point but the ASGE,

21· ·it is your testimony they promulgate standards or

22· ·guidelines with regard to when polyps are to be

23· ·removed and the technique they are to be removed by?

24· · · · · A· ·Well, they give guidelines and they have

25· ·journals which are one of the main journals is called


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·GI Endoscopy, that are articles written in a peer

·3· ·reviewed journal that go through new techniques or

·4· ·best practice techniques for taking out certain types

·5· ·of lesions, but in terms of the general concept that I

·6· ·outlined before, all the societies embrace the concept

·7· ·that if the polyps is a neoplasm and has malignant

·8· ·potential, you take it out.· If a lesion is 100

·9· ·percent benign, then you don't put the patient at

10· ·unnecessary risk in an effort to excise it.

11· · · · · Q· ·If the polyp is perceived to be a neoplasm,

12· ·is there a particular method that they are to be

13· ·removed that comports with the standard of care?

14· · · · · A· ·If a polyp is a neoplasm, there are

15· ·techniques that are sort of customized to the

16· ·particular size and shape and configuration of the

17· ·polyp.

18· · · · · Q· ·Okay.· Let's discuss.

19· · · · · A· ·Ask me a question.

20· · · · · Q· ·You just said there are particular

21· ·techniques you use depending on the size of the

22· ·polyps?

23· · · · · A· ·Yes.

24· · · · · Q· ·This is in the context of what is perceived

25· ·to be a neoplastic polyp?


·2· · · · · A· ·Yes.· I will get into that very quickly but

·3· ·first I will preface it by saying this patient had a

·4· ·lipoma and the appropriate procedure is to do a biopsy

·5· ·and leave it alone.

·6· · · · · · · If you have a polyp that is a true

·7· ·neoplasm, then if you have flat polyps, you can remove

·8· ·those with snares, sometimes you can use a cold snare

·9· ·or hot snare, pillow technique where you inject under

10· ·the polyp to lift it up off the wall so you can snare

11· ·it off in a more safe manner.· If it is a pedunculated

12· ·polyp, then you use snares pretty much all the time so

13· ·you take off the whole polyp and then cauterize the

14· ·trunk.

15· · · · · Q· ·A hot snare?

16· · · · · A· ·Yes.· That is kind of like a very short

17· ·run-down.

18· · · · · Q· ·In this case you were retained by the

19· ·plaintiff?

20· · · · · A· ·Correct.

21· · · · · Q· ·You knew when you were going to accept this

22· ·case it was to testify against Dr. Bouza?


24· · · · · · · THE WITNESS:· I was asked to review it and

25· ·if it was a non-meritorious case, which happens not


·2· ·infrequently, then I tell them, and that is the end of

·3· ·it.· I was asked to give an impartial evaluation and I

·4· ·did and I came to the conclusion that there was

·5· ·malpractice.

·6· · · · · · · BY MR. MIDWALL:

·7· · · · · Q· ·When you were told about the case were you

·8· ·told what the outcome was?

·9· · · · · A· ·Yes, some broad overview of the outcome.

10· · · · · Q· ·Before you had reviewed any of the

11· ·materials?

12· · · · · A· ·Probably came with this letter that was a

13· ·cover letter saying they were sending me a retainer

14· ·and asking me to remove the case.· I think I was told

15· ·there was a colonoscopy and a perforation.

16· · · · · Q· ·And that was told to you verbally?

17· · · · · A· ·I think it was.

18· · · · · Q· ·And ultimately you looked at the pathology

19· ·that was taken?

20· · · · · A· ·I looked at the pathology report.

21· · · · · Q· ·You are not a pathologist so you rely on

22· ·the path report?

23· · · · · A· ·I relied on the report.

24· · · · · Q· ·Do you hold yourself out as being able to

25· ·render a conclusion of the pathology of a substance or


·2· ·whatever it is based on looking at slides?

·3· · · · · A· ·If I had the slides in front of me I could

·4· ·tell a lipoma in front of me.

·5· · · · · Q· ·If you had the slides in front of you?

·6· · · · · A· ·Yes.

·7· · · · · Q· ·You wouldn't need to rely on the

·8· ·pathologists?

·9· · · · · A· ·I could do it on my own but the usual

10· ·scenario is there is a pathology report.

11· · · · · Q· ·And you rely on the pathologists in your

12· ·practice?

13· · · · · A· ·Right.

14· · · · · Q· ·Let's talk about your resume some more.· Do

15· ·you consider -- you are still affiliated with the two

16· ·hospitals here?

17· · · · · A· ·Yes.

18· · · · · Q· ·And what percentage of your time is spent

19· ·performing scopes?

20· · · · · A· ·Probably about 40 percent.

21· · · · · Q· ·How many scopes a week do you do?

22· · · · · A· ·Between 20 and 25.

23· · · · · Q· ·Has that been reduced?

24· · · · · A· ·It probably has come down a bit.

25· · · · · Q· ·From?


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · A· ·From 25 to 35.

·3· · · · · Q· ·Why is that?

·4· · · · · A· ·Just because I am slowing down a tad.

·5· · · · · Q· ·Slowing down, you mean in terms of your

·6· ·professional practice?

·7· · · · · A· ·Yes.· Working one less day a week.

·8· · · · · Q· ·How many days do you work now?

·9· · · · · A· ·Four days a week.

10· · · · · Q· ·Which day do you take off?

11· · · · · A· ·Tuesdays.

12· · · · · Q· ·And how long has that been the case?

13· · · · · A· ·Probably about a year.

14· · · · · Q· ·Is that the day you try to do your expert

15· ·reviews or sit for depositions?

16· · · · · A· ·That is one of the things I do.· I do a lot

17· ·of administrative stuff or family stuff or odds and

18· ·ends.

19· · · · · Q· ·And the other 60 percent of your

20· ·professional time is spent doing what?

21· · · · · A· ·Fifty percent office and about 10 percent

22· ·hospital.· That is clinical stuff.· If we include

23· ·legal, 10 percent of my time is spent on legal, case

24· ·review, and depositions, et cetera.

25· · · · · Q· ·Forty percent of your time is spent doing


·2· ·scopes, professionally?

·3· · · · · A· ·Right.

·4· · · · · Q· ·Give me the break down because I don't

·5· ·think it added up.

·6· · · · · A· ·Let's say 45 percent is office.

·7· · · · · Q· ·That consists of what?

·8· · · · · A· ·Seeing patients, reviewing records,

·9· ·dictating notes, just basically outpatient care.· Five

10· ·percent is hospital-based and 10 percent is legal.

11· · · · · Q· ·What is hospital-based?

12· · · · · A· ·Doing cases in the hospital, seeing

13· ·patients in the emergency room, doing consultations at

14· ·the hospital and doing procedures at the hospital.

15· · · · · Q· ·Has that percent of time you have spent

16· ·providing medical care in a hospital setting been

17· ·reduced in the last couple of years?

18· · · · · A· ·Yes.

19· · · · · Q· ·What has it been reduced to?

20· · · · · A· ·Probably about a third or a quarter as much

21· ·of the hospital work as I used to do.

22· · · · · Q· ·That has been the same for the past several

23· ·years?

24· · · · · A· ·Yes.

25· · · · · Q· ·In order to have more free time?


·2· · · · · A· ·Right.

·3· · · · · Q· ·And then 10 percent of your professional

·4· ·time is spent doing legal work?

·5· · · · · A· ·Yes.

·6· · · · · Q· ·That means testifying in deposition or

·7· ·trial?

·8· · · · · A· ·Right.

·9· · · · · Q· ·Preparing reports?

10· · · · · A· ·Right.

11· · · · · Q· ·Do you have any opinions reduced to writing

12· ·in this case?

13· · · · · A· ·No.

14· · · · · Q· ·Have you ever sent any e-mails or written

15· ·communications to any of the plaintiff's lawyers in

16· ·this case about your opinions or preliminary opinions?

17· · · · · A· ·No.· It has been all discussing times,

18· ·dates.

19· · · · · Q· ·When you say times and dates, you have been

20· ·doing that by e-mail?

21· · · · · A· ·Yes.

22· · · · · Q· ·Do you have those e-mails?

23· · · · · A· ·I don't.

24· · · · · Q· ·Do you have them preserved?

25· · · · · A· ·Yes.


·2· · · · · Q· ·They are on your computer?

·3· · · · · A· ·They are.

·4· · · · · Q· ·Can I get those right now?

·5· · · · · A· ·I don't think I can pull them up on my

·6· ·smart phone.· I can probably print them.· They are

·7· ·just, your deposition is May 12, it will start at 1:00

·8· ·and I will be coming in --

·9· · · · · Q· ·It is logistics as opposed to specific

10· ·dates and things like that?

11· · · · · A· ·Exactly.

12· · · · · Q· ·When were you first contacted in this case,

13· ·if you know?

14· · · · · A· ·Looks like around the first or second week

15· ·of March in 2015.

16· · · · · Q· ·Had you ever worked with the law firm

17· ·before?

18· · · · · A· ·Yes.

19· · · · · Q· ·That is the Bounds Law Group?

20· · · · · A· ·Yes.

21· · · · · Q· ·How many times had you worked with them?

22· · · · · A· ·Maybe two or three other times.

23· · · · · Q· ·This would be the third or fourth time?

24· · · · · A· ·Yes.

25· · · · · Q· ·Within how many years?


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · A· ·Within the last year.

·3· · · · · Q· ·Two to three times within the last year you

·4· ·have been working with the Bounds Group?

·5· · · · · A· ·Yes.

·6· · · · · Q· ·Somewhere you be deposed in those matters?

·7· · · · · A· ·I don't think so.· I am not sure.· I am a

·8· ·little hazy about -- I don't think I was deposed with

·9· ·the Bounds law firm but I am not sure.

10· · · · · Q· ·This is the first time in which you are

11· ·giving a deposition in which Bounds law firm was

12· ·involved?

13· · · · · A· ·Yes.

14· · · · · Q· ·All those times you have been retained by

15· ·the Bounds Law Group they paid you?

16· · · · · A· ·Yes.

17· · · · · Q· ·And you charged for your time?

18· · · · · A· ·Right.

19· · · · · Q· ·And they have all been on behalf of

20· ·plaintiffs?


22· · · · · · · THE WITNESS:· Right.

23· · · · · · · BY MR. MIDWALL:

24· · · · · Q· ·What percentage of your medical-legal work

25· ·is plaintiff as opposed to defendant currently?


·2· · · · · A· ·If you look at it in terms of times, it is

·3· ·probably about 40 percent defense, 60 percent

·4· ·plaintiff.

·5· · · · · Q· ·How long has that been the case?

·6· · · · · A· ·I would say for the last four or five

·7· ·years.

·8· · · · · Q· ·In terms of testimonial history, meaning

·9· ·times you have been deposed or provided trial

10· ·testimony in a court setting, what percent of those

11· ·have come in plaintiff cases as opposed to defense

12· ·cases?

13· · · · · A· ·Probably has been somewhere between 50-50

14· ·or 40 percent defense, 50 percent -- 60 percent

15· ·plaintiff.

16· · · · · Q· ·Have you ever been in a case against the

17· ·Bounds Law Group?

18· · · · · A· ·No.

19· · · · · Q· ·Any idea how the Bounds Law Group found you

20· ·or retained you?

21· · · · · A· ·I think it was through an attorney that I

22· ·had worked with who had been in a previous firm and

23· ·then came over to Bounds.

24· · · · · Q· ·Do you remember that person's name?

25· · · · · A· ·Maybe a guy named Mr. Carding.


·2· · · · · Q· ·In what firm did you work with --

·3· · · · · A· ·That was Morgan and Morgan.

·4· · · · · Q· ·Morgan and Morgan is a plaintiff's law

·5· ·firm?

·6· · · · · A· ·Right.

·7· · · · · Q· ·And you have worked with that law firm a

·8· ·lot of times in the past?

·9· · · · · · · MR. SMITH:· Objection.

10· · · · · · · THE WITNESS:· A fair number.

11· · · · · · · BY MR. MIDWALL:

12· · · · · Q· ·20, 30 times?

13· · · · · A· ·Yes.

14· · · · · Q· ·In the past --

15· · · · · A· ·In the past maybe ten years.

16· · · · · Q· ·Any idea how many active cases you have in

17· ·the medical-legal context?

18· · · · · A· ·You know, active is kind of a funny word

19· ·because sometimes cases go silent for a year or two

20· ·and then all of a sudden you find out they are active

21· ·again.· So I guess active right now, probably 10 or

22· ·20.

23· · · · · Q· ·And of those 10 or 20 active cases, four or

24· ·so of those are with the Bounds law firm?

25· · · · · A· ·No, not really.· At least one of those


·2· ·cases was non-meritorious.· That is over.· I think one

·3· ·of those resolved in some way --

·4· · · · · Q· ·You are talking about a case that you were

·5· ·affiliated with the Bounds Law Group?

·6· · · · · A· ·Right.· I don't consider those active.

·7· · · · · Q· ·Have you ever contributed to any research

·8· ·with regard to colonoscopies or techniques utilized

·9· ·during colonoscopies?

10· · · · · A· ·I don't think so.

11· · · · · Q· ·What about publications, have you ever

12· ·published on the techniques to use for a colonoscopy?

13· · · · · A· ·I have done things like lectured to the

14· ·endoscopy OR staff and done Power Point slide type

15· ·things for that, but I haven't published.

16· · · · · Q· ·Have you been the head of any medical

17· ·boards?

18· · · · · A· ·No.

19· · · · · Q· ·Have you been a head of any professional

20· ·memberships listed on your resume?

21· · · · · A· ·No.

22· · · · · Q· ·Have you ever been chief of staff at your

23· ·hospital?

24· · · · · A· ·I was chief of medicine and I guess chief

25· ·of gastroenterology.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·Which hospital?

·3· · · · · A· ·Shady Grove Hospital.

·4· · · · · Q· ·When was that?

·5· · · · · A· ·I need my CV.· It was sometime a while

·6· ·back.

·7· · · · · Q· ·Looks like in 1995 -- 1995 to 1996?

·8· · · · · A· ·Sounds right.

·9· · · · · Q· ·Have you ever been asked to relinquish any

10· ·of your privileges at any hospitals?

11· · · · · A· ·No.

12· · · · · Q· ·Did you bring your bills from your time

13· ·spent on this case?

14· · · · · A· ·Bill, singular.

15· · · · · Q· ·May I see that, please?

16· · · · · · · MR. SMITH:· Off the record.

17· · · · · · · (Discussion off the record.)

18· · · · · · · BY MR. MIDWALL:

19· · · · · Q· ·Looks like you received a retainer in the

20· ·amount of $1,000 in March 2015 and you billed against

21· ·that retainer?

22· · · · · A· ·Right.

23· · · · · Q· ·And the total of your charges up through,

24· ·it looks like two days ago was $5,900?

25· · · · · A· ·Right.


·2· · · · · Q· ·It just gives the days you spent time on?

·3· · · · · A· ·Right.

·4· · · · · Q· ·Does it talk about how long it took for you

·5· ·to review materials?

·6· · · · · A· ·No.

·7· · · · · Q· ·And this is your only bill?

·8· · · · · A· ·Right.

·9· · · · · Q· ·And how much time did you spend preparing

10· ·for today's deposition?

11· · · · · A· ·Well, besides what you see there, probably

12· ·another three or four hours.

13· · · · · Q· ·That would have been done in the last day?

14· · · · · A· ·That was yesterday and sometime today.

15· · · · · Q· ·Three hours yesterday up to --

16· · · · · A· ·Yesterday and today, three to four hours.

17· · · · · Q· ·Each day or total?

18· · · · · A· ·Total.

19· · · · · Q· ·What did you review?

20· · · · · A· ·That is when I got these photos.· I went

21· ·over the -- putting together all of the materials you

22· ·wanted, my list of cases, my CV, compiling and

23· ·organizing, taking the photographs of the exhibits.

24· ·Some of that was organizational and then I looked

25· ·through a few of the depositions and reports from the


·2· ·colonoscopy.· Those things.

·3· · · · · Q· ·Let's mark the invoice as the next exhibit.

·4· · · · · · · · · · · · ·(Julie Exhibit No. 3


·6· · · · · · · MR. MIDWALL:· The next exhibit is the

·7· ·screen shot of the documents that the doctor received

·8· ·from the plaintiff's firm that the doctor reviewed.

·9· · · · · · · · · · · · · (Julie Exhibit No. 4 was

10· · · · · · · · · · · · · marked for identification.)

11· · · · · · · BY MR. MIDWALL:

12· · · · · Q· ·Your charges for your deposition today are

13· ·what?

14· · · · · A· ·Minimum of $2,000, but it is $600 per hour.

15· · · · · Q· ·So you charge a minimum of $2,000 despite

16· ·how many hours the deposition goes?

17· · · · · A· ·Because I have taken the whole day.

18· · · · · Q· ·Although this is your day off

19· ·professionally?

20· · · · · A· ·Correct.

21· · · · · Q· ·And you charge $600 an hour for deposition?

22· · · · · A· ·Right, which will be offset by the 2000, so

23· ·it will be charged against that retainer or whatever

24· ·you call it.

25· · · · · Q· ·If we went four hours you would charge the


·2· ·additional, what --

·3· · · · · A· ·$400.

·4· · · · · Q· ·And then for review of materials?

·5· · · · · A· ·400 an hour.

·6· · · · · Q· ·How long has that been your rate?

·7· · · · · A· ·That has been my rate probably for the last

·8· ·three or four years.

·9· · · · · Q· ·And conferences with the plaintiff's firm,

10· ·how much do you charge for that?

11· · · · · A· ·Same, 400 an hour.

12· · · · · Q· ·How many conferences have you had with a

13· ·member of the plaintiff's law firm?

14· · · · · A· ·We haven't had any, but we just spoke

15· ·before coming here.

16· · · · · Q· ·Spoke in person, on the phone?

17· · · · · A· ·In person.

18· · · · · Q· ·Where did that take place?

19· · · · · A· ·At a restaurant right nearby.

20· · · · · Q· ·Do you and Mr. Smith have lunch together?

21· · · · · A· ·We did.

22· · · · · Q· ·He pay for it, you pay for it?

23· · · · · A· ·He paid for it.

24· · · · · Q· ·How long did the lunch take?

25· · · · · A· ·I think it was an hour.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·When did you first tell the plaintiff's law

·3· ·firm or any members in it what your opinions were?

·4· · · · · A· ·I would think it was probably in late March

·5· ·or early April.

·6· · · · · Q· ·Did you formulate final opinions before you

·7· ·read depositions in this case?

·8· · · · · A· ·No.

·9· · · · · Q· ·You waited until after the depositions in

10· ·order to formulate final opinions?

11· · · · · A· ·As far as final opinions, that is correct.

12· · · · · Q· ·How many conferences by phone have you had

13· ·with the plaintiff's law firm since you first were

14· ·contacted to see if you would take the case?

15· · · · · A· ·Two or three.

16· · · · · Q· ·Were you provided with the deposition of

17· ·Dr. David Morowitz?

18· · · · · A· ·No.

19· · · · · Q· ·Do you know who he is?

20· · · · · A· ·I know him by name, but I wouldn't

21· ·recognize him if I saw him walking down the street.

22· · · · · Q· ·Were you told that he was retained in this

23· ·case first?

24· · · · · A· ·I just found that out today.

25· · · · · Q· ·In what context?


·2· · · · · A· ·Just that it was mentioned that he had

·3· ·been, I think, retained -- I think he has been

·4· ·retained and possibly deposed.

·5· · · · · Q· ·Did the plaintiff's lawyer tell you why

·6· ·they chose to take him off the case?

·7· · · · · A· ·No.

·8· · · · · Q· ·Did you ask?

·9· · · · · A· ·No.

10· · · · · Q· ·Let's go through your opinions that you

11· ·intend to provide at trial.· Please list them and then

12· ·we can go through them.

13· · · · · A· ·My opinions are as follows:· That the

14· ·patient underwent a colonoscopy on August 23 and at

15· ·the time of the colonoscopy a lesion was excised using

16· ·hot snare polypectomy and that the polypectomy caused

17· ·a perforation of the colon at the site of the

18· ·polypectomy which is right next to the anastomosis

19· ·from a prior surgery.

20· · · · · · · My second opinion is that the use of a hot

21· ·snare to excise a lipoma was outside the standard of

22· ·care and was not the appropriate technique to be used

23· ·when faced with that lesion.

24· · · · · · · My third opinion is that the patient

25· ·subsequently never had the perforation at the


·2· ·polypectomy site definitively addressed and as a

·3· ·result she ended up with multiple intra-abdominal and

·4· ·abdominal wall complications, all arising from the

·5· ·perforation from her polypectomy.

·6· · · · · · · My fourth opinion is that based on a

·7· ·gastroenterologist's training, that Dr. Bouza failed

·8· ·and deviated from the standard of care in failing to

·9· ·recognize this lesion as a lipoma and choosing to use

10· ·the wrong technique to try and determine what type of

11· ·lesion this was.

12· · · · · Q· ·Isn't that duplicative of number two?

13· · · · · A· ·I am just doing these from memory.

14· · · · · Q· ·You looked like you were formal in how you

15· ·were listing them.

16· · · · · A· ·No.· I am an informal --

17· · · · · Q· ·Whatever.· Go ahead.

18· · · · · A· ·I guess fifth would be had the patient been

19· ·evaluated with biopsy forceps which is the standard of

20· ·care, the diagnosis of the nature of the polyp -- or

21· ·the nature of the lesion would have been successfully

22· ·made and the perforation and all the downstream

23· ·consequences of the perforation would not have

24· ·occurred and I think that pretty much covers it.

25· · · · · Q· ·I just want to make sure since you have


·2· ·been deposed before many times you understand that

·3· ·this is my only chance to question you and ask about

·4· ·your opinions before trial.

·5· · · · · A· ·Right.

·6· · · · · Q· ·And I just want to be thorough and make

·7· ·sure you are letting me know about any other

·8· ·anticipated opinions you may have at trial?

·9· · · · · · · MR. SMITH:· I will ask him about the

10· ·pathology specimen size and I am going to ask him

11· ·about -- he kind of alluded to it, but I want it to be

12· ·clear, that the subsequent care and treatment was

13· ·caused and necessary and reasonable.

14· · · · · · · MR. MIDWALL:· Say that again?

15· · · · · · · MR. SMITH:· I am going to ask him about the

16· ·pathology report and I am also planning to ask him

17· ·about the medical care and treatment -- subsequent

18· ·medical care and treatment.· So if you want to explore

19· ·that -- that it was necessary and reasonable.

20· · · · · · · MR. MIDWALL:· You are going to elicit an

21· ·opinion from him at trial that subsequent care and

22· ·treatment that the plaintiff underwent after the scope

23· ·was reasonable and appropriate?

24· · · · · · · MR. SMITH:· Was caused by and necessary and

25· ·reasonable.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · · · MR. MIDWALL:· Was caused by the scope and

·3· ·was necessary and reasonable?

·4· · · · · · · MR. SMITH:· Caused by the polypectomy and

·5· ·was necessary and reasonable care and treatment as it

·6· ·relates to the negligence and I am going to ask him

·7· ·about the pathology, size of the pathology specimen.

·8· · · · · · · THE WITNESS:· That is under the umbrella of

·9· ·improper technique.· The doctor identified the polyp

10· ·as a 7 millimeter polyp and proceeded to hack off or

11· ·excise a 15 millimeter piece of tissue, which

12· ·according to his reckoning, was only half polyp.· So

13· ·he took off a much larger piece of the colon wall than

14· ·was appropriate give the size of the lesion that he

15· ·described.

16· · · · · · · BY MR. MIDWALL:

17· · · · · Q· ·Any other opinions?

18· · · · · A· ·That is it.

19· · · · · Q· ·Have you ever had a perforation occur when

20· ·you performed a colonoscopy?


22· · · · · · · THE WITNESS:· I have.

23· · · · · · · BY MR. MIDWALL:

24· · · · · Q· ·How many times?

25· · · · · A· ·Once.


·2· · · · · Q· ·How many colonoscopies have you performed

·3· ·since you have entered private practice?

·4· · · · · A· ·Let me see.· I would say between 10 and

·5· ·15,000.

·6· · · · · Q· ·And how long ago did that perforation

·7· ·occur?


·9· · · · · · · THE WITNESS:· About ten years ago.

10· · · · · · · BY MR. MIDWALL:

11· · · · · Q· ·Did you commit negligence when that

12· ·perforation took place?


14· · · · · · · THE WITNESS:· No.

15· · · · · · · BY MR. MIDWALL:

16· · · · · Q· ·So perforations can occur place in the

17· ·absence of medical negligence; is that correct?

18· · · · · A· ·Correct.

19· · · · · Q· ·Perforations in the context of a scope are

20· ·a known complication of a scope?


22· · · · · · · THE WITNESS:· They are known but sometimes

23· ·they are avoidable so in that case, the fact that they

24· ·are known is not an excuse.

25· · · · · · · BY MR. MIDWALL:


·2· · · · · Q· ·Was the perforation you caused avoidable?


·4· · · · · · · THE WITNESS:· I think not.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·So it is your testimony there are certain

·7· ·unavoidable perforations that can occur in the context

·8· ·of a scope?

·9· · · · · A· ·Yes.

10· · · · · Q· ·Are you relying on any type of literature

11· ·to support that opinion?

12· · · · · A· ·Well, the question is are there certain

13· ·unavoidable perforations that can occur in the course

14· ·of a scope?· What we are saying is there is a

15· ·technical limitation to the procedure whereby using

16· ·statistics, if you are doing five or 10,000

17· ·colonoscopies, there is going to be a perforation that

18· ·occurs.

19· · · · · Q· ·Just out of sheer statistics?

20· · · · · A· ·Right.

21· · · · · Q· ·So a GI who performs 10 to 15,000 scopes

22· ·will statistically have at least one perforation take

23· ·place in his or her practice?


25· · · · · · · THE WITNESS:· At some point.


·2· · · · · · · BY MR. MIDWALL:

·3· · · · · Q· ·Regardless of whether there is medical

·4· ·negligence associated with that perforation, correct?

·5· · · · · A· ·Well, I think you have to look at the

·6· ·particulars to see if it was an avoidable perforation

·7· ·or unavoidable roll of the dice.

·8· · · · · Q· ·Is it your testimony that there are

·9· ·unavoidable perforations that can occur in a scope?

10· · · · · A· ·I think in the course of taking out polyps

11· ·over a certain period of time, if you do enough of

12· ·them, there will be -- a perforation will occur.

13· · · · · Q· ·Despite there being the absence of medical

14· ·negligence in that perforation taking place?

15· · · · · A· ·Right.

16· · · · · Q· ·Why is that?

17· · · · · A· ·Well, let me give you an analogy.· If there

18· ·are thunderstorms, there may be a million people in a

19· ·given location but a lightning bolt will strike and it

20· ·will hit one person and that person will get struck by

21· ·lightning.· That is just a statistical event.· If the

22· ·lightning strikes the ground repeated times, something

23· ·like that will happen.· You will have people that are

24· ·very cautious, if there is a lightning storm, they

25· ·will go inside the house.· They will never get struck.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·You may have a bunch of guys that decide to go out

·3· ·golfing and their chances are much, much higher.

·4· ·Still there is statistical inevitability that people

·5· ·get struck by lightning every once in a while, but

·6· ·there are things you can do to make that less likely,

·7· ·there are things you can do to make it more likely.

·8· · · · · Q· ·In the perforation you caused, what did you

·9· ·do to make it more likely a perforation?


11· · · · · · · THE WITNESS:· Well, it was a fairly big

12· ·polyp that was fairly flat and the patient also had

13· ·medical conditions that pre-disposed her to not

14· ·healing well, she was diabetic, on steroids, those

15· ·were risk factors on the patient's side that I

16· ·couldn't control.

17· · · · · Q· ·What technique did you use in the one you

18· ·caused perforation?


20· · · · · · · THE WITNESS:· It was a hot snare

21· ·polypectomy.

22· · · · · · · BY MR. MIDWALL:

23· · · · · Q· ·So knowing the risks that that person

24· ·brought, you nonetheless used a hot snare?

25· · · · · A· ·Correct.


·2· · · · · Q· ·How big was the polyp?

·3· · · · · A· ·I think about two centimeters.

·4· · · · · Q· ·Why didn't you try to biopsy it first?

·5· · · · · A· ·Because it was a clearly a neoplasm and not

·6· ·a lipoma.

·7· · · · · Q· ·And the pathologist confirmed that?

·8· · · · · A· ·Yes.

·9· · · · · Q· ·Why didn't you use cold forceps?

10· · · · · A· ·Because the excision would have been

11· ·incomplete.

12· · · · · Q· ·And that would have left potentially

13· ·cancerous lesion in the body?

14· · · · · A· ·Well, it would have left residual

15· ·neoplastic tissue, as opposed to residual, harmless

16· ·lipoma tissue so I needed to take out the whole

17· ·neoplasm.

18· · · · · Q· ·Because you didn't want there to be

19· ·cancerous tissues left in the body?

20· · · · · A· ·Yes.

21· · · · · Q· ·That was a clinical decision you made?

22· · · · · A· ·Yes, based on extensive training and

23· ·knowledge of what polyps look like and what lipomas

24· ·look like.

25· · · · · Q· ·How many colonoscopies has Dr. Bouza


·2· ·performed?

·3· · · · · A· ·I don't know.

·4· · · · · Q· ·He discussed that.

·5· · · · · A· ·I do think so, but I don't remember how

·6· ·many he has done.

·7· · · · · Q· ·I think he said he had done at least

·8· ·30,000.


10· · · · · · · THE WITNESS:· That is about it.

11· · · · · · · BY MR. MIDWALL:

12· · · · · Q· ·That is twice as many as you have done.

13· · · · · A· ·Yes.

14· · · · · Q· ·Do you know how many perforations he has

15· ·had?

16· · · · · A· ·I think he said five to 10.

17· · · · · Q· ·Are you just guessing?

18· · · · · A· ·That is kind of what I remember.

19· · · · · Q· ·Are you going to provide an opinion about

20· ·life expectancy for Ms. Mayor?

21· · · · · A· ·No.

22· · · · · Q· ·As we sit here today do you know what

23· ·Ms. Mayor's current medical status is?

24· · · · · A· ·She is kind of weak.· She has gotten some

25· ·of her strength back compared to her condition back in


·2· ·2013, but she is in an independent living situation

·3· ·and she is under the frequent care and attention of

·4· ·her daughter-in-law.

·5· · · · · Q· ·This is all information you learned from

·6· ·the plaintiff's counsel during our break?

·7· · · · · A· ·No.· Actually I think we talked about it

·8· ·before we started the deposition.

·9· · · · · Q· ·At the restaurant?

10· · · · · A· ·Yes.

11· · · · · Q· ·Have you looked at any medical records that

12· ·clinically describe what Ms. Mayor's situation is?

13· · · · · A· ·Only what I was able to glean from

14· ·Dr. Pons' deposition.

15· · · · · Q· ·And we already talked about Dr. Pons

16· ·believes she has done extremely well?


18· · · · · · · THE WITNESS:· That is a relative term.

19· · · · · · · BY MR. MIDWALL:

20· · · · · Q· ·That was his testimony, was it not?

21· · · · · A· ·Well, yes, but at one point she looked like

22· ·death warmed over.

23· · · · · Q· ·My question is what her current medical

24· ·status is.· Do you know what her current medical

25· ·status is?


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · A· ·Just what I told you.

·3· · · · · Q· ·Have you asked to see any medical records

·4· ·to see what Ms. Mayor's current medical condition is?

·5· · · · · A· ·I have not.· I have seen pictures of her

·6· ·skin condition where her wound has finally healed.

·7· · · · · Q· ·Do you know the date of that?

·8· · · · · A· ·Of the photograph?· I don't think I have a

·9· ·date, but I did look at the picture, which I guess

10· ·would be number 13 on that 1377 series, number 12 and

11· ·number 13.

12· · · · · Q· ·Have you asked to review any current

13· ·medical records for Ms. Mayor, the plaintiff?

14· · · · · A· ·No.

15· · · · · Q· ·Do you know if they are available for you

16· ·to review had you desired to do so?

17· · · · · A· ·I would assume they are available, but I

18· ·don't know that they are available.

19· · · · · Q· ·Do you intend to provide any testimony at

20· ·the trial as to what the current medical status of

21· ·Ms. Mayor is?

22· · · · · A· ·As of this point I would think not.

23· · · · · Q· ·Then I will not ask you any more questions

24· ·about her current medical status in terms of

25· ·limitations or lack there of because you are not going


·2· ·to provide such testimony.· Is that fair?

·3· · · · · A· ·That seems fair.

·4· · · · · Q· ·You do understand though that from a

·5· ·nephrological point of view according to Dr. Pons'

·6· ·medical records you have reviewed and his sworn

·7· ·testimony, from a nephrological point of view he feels

·8· ·she is doing well?

·9· · · · · A· ·Right.

10· · · · · Q· ·Are you going to provide standard of care

11· ·criticisms as to any other medical provider other than

12· ·Dr. Bouza?

13· · · · · A· ·No.

14· · · · · Q· ·You did bring a testimonial case list and I

15· ·would like to mark that as an exhibit, please.

16· · · · · A· ·Sure.

17· · · · · Q· ·We will mark that as the next exhibit.· One

18· ·page and this is a copy to be marked?

19· · · · · A· ·Right.· You can take it.

20· · · · · · · · · · · · ·(Julie Exhibit No. 5

21· · · · · · · · · · · · ·was marked for identification.)

22· · · · · · · BY MR. MIDWALL:

23· · · · · Q· ·This is testimonial history at either trial

24· ·or depositions from 2012 to the present?

25· · · · · A· ·No, actually that is probably until August


·2· ·of 2014.· I haven't had a chance to update that.

·3· · · · · Q· ·So since August of 2014 have you given

·4· ·depositions or trial testimony?

·5· · · · · A· ·I think I did one or two depositions and I

·6· ·just did a trial a couple of weeks ago.

·7· · · · · Q· ·Did you obtain any medical records of the

·8· ·plaintiff before she underwent -- strike that.

·9· · · · · · · Did you obtain any medical records from the

10· ·plaintiff before she went to Dr. Bouza in July of

11· ·2012?

12· · · · · A· ·I think I had seen -- I know I saw

13· ·Dr. Bouza's records and another doctors' records. I

14· ·don't know how far back those went.· Dr. Martinez's

15· ·records didn't go back as far as even July.· So, no.

16· · · · · Q· ·So at least the first medical record that

17· ·you have in this case is from the July 23, 2012 office

18· ·visit that the plaintiff had with Dr. Bouza?

19· · · · · A· ·Right.

20· · · · · Q· ·You agree that the colonoscopy in this case

21· ·was indicated, correct?

22· · · · · A· ·Well, I think it was a judgment call. I

23· ·wouldn't say that doing it was a deviation of the

24· ·standard of care.

25· · · · · Q· ·Just so we are clear, you agree that


·2· ·Dr. Bouza's decision to take Ms. Mayor to have a scope

·3· ·in this case was within the standard of care, correct?

·4· · · · · A· ·Yes.

·5· · · · · Q· ·What were the concerns Dr. Bouza noted when

·6· ·determining whether or not he should take Ms. Mayor to

·7· ·have a scope?

·8· · · · · A· ·I think it was primarily some abdominal

·9· ·pain, 18 pound weight loss, according to what he

10· ·verbally reports, although that wasn't well-documented

11· ·and her history of colon cancer.

12· · · · · Q· ·She had not had a scope in how many years?

13· · · · · A· ·I don't know.

14· · · · · Q· ·He testified about that, did he not?

15· · · · · A· ·In his deposition.· I didn't see it in the

16· ·primary record.

17· · · · · Q· ·Do you know how many years at least from

18· ·your review of the records in this case she had last

19· ·had a scope?

20· · · · · A· ·I don't recall.

21· · · · · Q· ·Do you agree that she should have had at

22· ·least one surveillance scope done within the time

23· ·period of five years or less after her surgery for her

24· ·prior history of colon cancer?

25· · · · · A· ·Yes.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·And she had not had one done?


·4· · · · · · · THE WITNESS:· I would have to look.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·Did you review any materials, including

·7· ·depositions of the family members in which they said

·8· ·that Ms. Mayor had undergone a scope from the time she

·9· ·had surgery to remove the cancer in her colon up until

10· ·the date of her August 23, 2012 scope?

11· · · · · A· ·I am not sure the daughter knew.· I don't

12· ·think the patient -- that her memory was really that

13· ·excellent so it was hard to fill in the gaps.

14· · · · · Q· ·Was the finding of abdominal pain in the

15· ·left lower quadrant of Ms. Mayor, given her history,

16· ·given your training, what could that have represented?

17· · · · · A· ·Well, for pain, that differential includes

18· ·painful diverticular disease, diverticulitis,

19· ·something having to do with a GYN problem, it could be

20· ·kidney-type pain, it could be a neoplasm.

21· · · · · Q· ·Those are all within the realm of a

22· ·differential diagnosis?

23· · · · · A· ·Right.

24· · · · · Q· ·In the context of Ms. Mayor when she

25· ·presented to Dr. Bouza's office on July 23, 2012?


·2· · · · · A· ·Right.

·3· · · · · Q· ·Her history of an 18 pound weight loss in

·4· ·the context of Ms. Mayor once again could have been

·5· ·within the realm of a differential diagnosis of what?

·6· · · · · A· ·There are a lot of things that can cause

·7· ·weight loss.· That is a pretty large differential but

·8· ·if you are putting it together with left lower

·9· ·quadrant pain, then that would raise the possibility

10· ·of some type of gastroenterological process.

11· · · · · Q· ·Could it be indicative of a potential

12· ·neoplastic lesion?

13· · · · · A· ·Theoretically, yes.

14· · · · · Q· ·More likely than not it is within the realm

15· ·of a differential diagnosis?

16· · · · · A· ·It is within a differential diagnosis, yes.

17· · · · · Q· ·Of course, the personal history of colon

18· ·cancer that Ms. Mayor had raises the indicia that

19· ·there could be recurrence of a neoplastic condition?

20· · · · · A· ·I wouldn't use the word recurrence because

21· ·that implies coming back of the original lesion, but

22· ·there could be a new colon cancer arising.

23· · · · · Q· ·The history that the plaintiff provided of

24· ·having a history of colon cancer was concerning enough

25· ·to Dr. Bouza that there might be a new colon cancer


·2· ·presenting?


·4· · · · · · · THE WITNESS:· It was a reasonable concern.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·It was reasonable for Dr. Bouza to be

·7· ·concerned about that at the time he decided to have

·8· ·the patient undergo a colonoscopy, correct?

·9· · · · · A· ·Yes.

10· · · · · Q· ·And at the time he was performing the scope

11· ·it was reasonable for him to be concerned about that

12· ·possibility?


14· · · · · · · THE WITNESS:· That only implies whether

15· ·there should be a procedure or not.· That shouldn't

16· ·cloud his judgment in terms of what he sees at the

17· ·time of the exam.

18· · · · · · · BY MR. MIDWALL:

19· · · · · Q· ·Fair enough.· But it is important enough

20· ·for him to decide to take her for a scope.

21· · · · · A· ·Right.

22· · · · · Q· ·In terms of the prep for the scope, are you

23· ·critical of Ms. Mayor for the prep?

24· · · · · A· ·Well, it is hard to know, you know, whether

25· ·it is a bad prep or bad compliance or she has bad


·2· ·transit or what, but it was a poor prep.

·3· · · · · Q· ·Have you performed scopes on patients who

·4· ·have had poor preps before?

·5· · · · · A· ·Yes.

·6· · · · · Q· ·And why did you decide to do scopes in your

·7· ·cases in which patients of yours had admittedly poor

·8· ·preps -- preparations?

·9· · · · · A· ·Well, it depended on the context of the

10· ·patient, whether I thought they would come back again

11· ·to have it done again, what my index of suspicion was

12· ·that there was something I didn't want to miss, all

13· ·those things factor in.· Optimally what you try to do

14· ·is bring them back the next day or have them come back

15· ·again for another study after a better prep and it is

16· ·something I do more often than just -- then just tough

17· ·it through.

18· · · · · Q· ·Are you critical of Dr. Bouza in this case

19· ·for proceeding with the colonoscopy in spite of the

20· ·plaintiff's poor prep?

21· · · · · A· ·I am critical of his choice to go ahead and

22· ·do a large excision of a colon polyp in someone with a

23· ·poor prep in a lesion that looks like a classic

24· ·lipoma.· The reason I am saying that is if he saw this

25· ·lesion and he thought it looked strange, the


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·appropriate thing would be to do the biopsies I

·3· ·discussed, and with the knowledge that if it turned

·4· ·out to be significant adenoma, which is a one in a 100

·5· ·possibility, he could have been brought her back a

·6· ·month or two later to take it off in a cleaner colon

·7· ·that was better prepped.

·8· · · · · Q· ·But if there was concern this was

·9· ·neoplastic lesion, you would want to remove that?

10· · · · · A· ·Yes, but looking at it that is a one in 100

11· ·lesion.

12· · · · · Q· ·But God forbid that is the one in the 100,

13· ·then you have left cancer in the patient?

14· · · · · A· ·No.· You are saying neoplasm is a cancer.

15· ·A neoplasm is not a cancer.

16· · · · · Q· ·So you are saying a patient that has a

17· ·potentially neoplastic lesion in their body whom is

18· ·elderly, had a history of colon cancer, complains of

19· ·lower quadrant pain and allowing that neoplasm to stay

20· ·in the body?

21· · · · · A· ·You are taking a lesion that has a one in

22· ·100 chance of being a neoplasm, a one in maybe 10,000

23· ·chance of being a colon cancer -- no, probably less

24· ·than that, a one in 50,000 chance of it being a colon

25· ·cancer, and you are putting them at a major risk by


·2· ·doing a hot snare polypectomy and an excessively large

·3· ·hot snare polypectomy, in a dirty colon which will do

·4· ·significantly worse if it perforates.

·5· · · · · Q· ·In this case you saw the color photographs

·6· ·from the scope done?

·7· · · · · A· ·Yes.

·8· · · · · Q· ·Do you see the presence of any stool?

·9· · · · · A· ·I see some liquid -- kind of golden residue

10· ·of liquid stool, but that is it.

11· · · · · Q· ·You understand that Dr. Bouza was able to

12· ·use lavage during the scope?

13· · · · · A· ·Yes, I was aware of that.

14· · · · · Q· ·And that was an appropriate thing to do?

15· · · · · A· ·Well, right, it is the appropriate thing to

16· ·do if you are going to go ahead with the colonoscopy.

17· · · · · Q· ·And the purpose of the lavage in the

18· ·context of this patient was to do what?

19· · · · · A· ·To clean as much of the stool away as you

20· ·could possible.

21· · · · · Q· ·Which is the original purpose of an

22· ·appropriate prep?

23· · · · · A· ·Yes.

24· · · · · Q· ·Let's assume the original prep was done

25· ·initially by Ms. Mayor properly, then Dr. Bouza would


·2· ·not have needed to use lavage, correct?


·4· · · · · · · THE WITNESS:· That is true.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·Although there are sometimes when there has

·7· ·been an appropriate prep but you still use lavage?

·8· · · · · A· ·Yes.

·9· · · · · Q· ·Why is that?

10· · · · · A· ·Because preps are not always 100 percent

11· ·effective so there may be some stuff still hanging

12· ·around.

13· · · · · Q· ·Even when a patient has been compliant and

14· ·done a good prep, there is no such thing as a perfect

15· ·prep?

16· · · · · A· ·Right.

17· · · · · Q· ·That is why a physician uses lavage to

18· ·ensure as much a visualization as possible?

19· · · · · A· ·Yes.

20· · · · · Q· ·And also why else?

21· · · · · A· ·Why else?

22· · · · · Q· ·Sure.

23· · · · · A· ·If there is an area you want to see and

24· ·there is mucus or whatever that is in the way, you can

25· ·use it to push that stuff away.


·2· · · · · Q· ·Looking at the color photographs of the

·3· ·scope done in this case that you have in front of you,

·4· ·do you believe that that field is able to be

·5· ·visualized?

·6· · · · · A· ·Reasonably well, yes.

·7· · · · · Q· ·So if you were visualizing that field that

·8· ·Dr. Bouza was looking at in the scope, you would

·9· ·consider that to be reasonably well-visualized field

10· ·so you can proceed with the scope, correct?

11· · · · · A· ·Yes.

12· · · · · Q· ·Do you agree there was diverticulitis in

13· ·the sigmoid colon?

14· · · · · A· ·That was in the report.· I didn't see

15· ·pictures, but I assume Dr. Bouza recognizes

16· ·diverticulitis better than he recognizes lipoma.

17· · · · · Q· ·We can strike that last part.· That was not

18· ·really necessary.

19· · · · · · · Has any regulatory agency ever examined any

20· ·of the depositions you provided?


22· · · · · · · THE WITNESS:· Never.

23· · · · · · · BY MR. MIDWALL:

24· · · · · Q· ·Have you ever had any inquiry about the

25· ·testimony you have provided in medical-legal cases?


1· · · · · · · · · · · ·DR. NEIL JULIE


·3· · · · · · · THE WITNESS:· Not to my knowledge.

·4· · · · · · · BY MR. MIDWALL:

·5· · · · · Q· ·Do you agree with Dr. Bouza's

·6· ·recommendation for a repeat colonoscopy to be done in

·7· ·two years?

·8· · · · · A· ·No -- well, again, that is a judgment call.

·9· ·Since this was a poor prep case, sometimes you do

10· ·bring those patients back earlier so I need to know

11· ·his thinking as to why he wants her to come back after

12· ·two years.· He said preparation of the colon was poor.

13· ·That is kind of like if you were to grade that that is

14· ·like a D or an F in terms of the prep.· So maybe that

15· ·is why he wanted her to come back.

16· · · · · Q· ·So that would have been reasonable and

17· ·appropriate?

18· · · · · A· ·I guess, yes, because of the prep problems,

19· ·but then again, you get into the question of how old

20· ·is she, how disabled is she, there is a very good

21· ·argument to make for not repeating the colonoscopy in

22· ·a patient that would then be 81 years old and has

23· ·significant other medical problems.

24· · · · · Q· ·That is once again a judgment call

25· ·individualized to the patient?


·2· · · · · A· ·Right.

·3· · · · · Q· ·But a patient like Ms. Mayor that is

·4· ·complaining of pain?

·5· · · · · A· ·Right.

·6· · · · · Q· ·Do you agree that the -- well, can lipomas

·7· ·appear sessile?

·8· · · · · A· ·They are sub-mucosal lesions so they are

·9· ·sessile but we don't usually use that particular

10· ·language, sessile, in terms of lipomas as we do with

11· ·neoplasms.

12· · · · · Q· ·Is there a particular technique in order to

13· ·adhere to the standard of care to remove sessile

14· ·polyps?

15· · · · · A· ·A sessile neoplasm is removed generally

16· ·with snare, either cold or hot.· Sometimes you lift it

17· ·up with a pillow of saline, and nowadays there is even

18· ·a technique of sub-mucosal dissection, but that is not

19· ·at tertiary centers.

20· · · · · Q· ·Typically how do grossly lipomas appear?

21· · · · · A· ·Grossly how do they appear?

22· · · · · Q· ·Correct.

23· · · · · A· ·They are sub-mucosal.

24· · · · · · · (Pause.)

25· · · · · A· ·A lipoma, it is a pillow of fat, a pocket


·2· ·of fat and it is sitting underneath a normal lining of

·3· ·the intestine.· So it appears just like a pillow would

·4· ·appear under a thin blanket.· It has that appearance

·5· ·of something under something else, just like in the

·6· ·picture that I printed out and just like the picture

·7· ·from Ms. Mayor.· Because of the fact that there is

·8· ·fat, a lot of fat in it, it is like a whole packet of

·9· ·fat and it tends to have a yellowish-orange color to

10· ·it that you can sometimes see.· And another thing that

11· ·is characteristic of it, when you look at the colon

12· ·lining of the lipoma it is smooth and looks like

13· ·normal lining cells, just like the rest of the colon

14· ·or like the tissue on the inside of your cheek.

15· · · · · · · So you have normal-appearing tissue on top

16· ·of this mound.· So it looks like a mound or a pillow

17· ·under a blanket.

18· · · · · Q· ·And you have heard that there has been

19· ·studies in the literature that lipomas grossly can be

20· ·confused as being neoplastic?

21· · · · · A· ·I haven't seen the literature.· I would be

22· ·interested if you wanted to provide it to me.· But I

23· ·don't really recall.

24· · · · · · · There is one other thing I forgot to

25· ·mention.· Not so much as appearance but behavior.


·2· ·Another thing we will do with a lipoma, we will take a

·3· ·biceps forceps, without opening it, we will poke it.

·4· ·Because fat is soft and decompressible, it will

·5· ·deform.· You can actually push on it and it will give

·6· ·way as opposed to a muscular tumor.

·7· · · · · Q· ·Typically grossly lipomas appear in the way

·8· ·you just described it, correct?

·9· · · · · A· ·Right.

10· · · · · Q· ·Does that mean all lipomas appear grossly

11· ·in that manner?

12· · · · · A· ·If we say those are four different

13· ·attributes, some lipomas have one or two attributes

14· ·that are more obvious, like some will be super yellow.

15· ·Others of them will be so big that they

16· ·almost -- depending on which wall they are lying on,

17· ·the weight of the lipoma itself will start to have it

18· ·pull off the wall.· This is my copy.· So if it gets to

19· ·be big enough, it will actually hang off the wall

20· ·because of gravity.· They can have that appearance.

21· ·Some will be less yellow.· They will all be soft.

22· ·They will have different attributes and depending on

23· ·the particular lipoma, some will have attributes that

24· ·are more dominant than others.

25· · · · · Q· ·What do neoplastic lesions look like?


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · A· ·When you look at the actual cells -- the

·3· ·tissue that overlies -- that makes up a neoplasm,

·4· ·first of all, it is not normal cells lying on top of

·5· ·an abnormal sub-mucosal thing.· What you have is the

·6· ·cellular patterns and growth patterns look a little

·7· ·different in a neoplasm.· It will be lumpy, nodular,

·8· ·granular-looking and it will disrupt the normal pink,

·9· ·kind of glistening clear look of the normal mucosa.

10· · · · · Q· ·In the color photographs you have from the

11· ·scope done in this case, can you show me where the

12· ·lipoma is?

13· · · · · A· ·Sure.· Do you want me to mark this?

14· · · · · Q· ·If you want.· This is your copy.

15· · · · · A· ·Yes.· I printed this out -- I think I

16· ·printed it off of the disk.· I am not sure if I

17· ·xeroxed this or not.· Anyway, it is like -- that kind

18· ·of bulge look.· It is kind of like the childhood

19· ·picture of the boa constrictor that eats a pig, you

20· ·have a lump.

21· · · · · Q· ·You just put black ink around the three

22· ·photographs where you depicted the lipoma; is that

23· ·correct?

24· · · · · A· ·Correct.

25· · · · · Q· ·We will mark this as the next exhibit, 6.


·2· · · · · · · · · · · · ·(Julie Exhibit No. 6


·4· · · · · · · BY MR. MIDWALL:

·5· · · · · Q· ·Can you describe grossly what the lipoma

·6· ·looks like for Ms. Mayor?

·7· · · · · A· ·Could I -- sorry?

·8· · · · · Q· ·Describe what the lipoma in Ms. Mayor looks

·9· ·like?

10· · · · · A· ·That is the one I marked.· The one in

11· ·Ms. Mayor's case, it looks like a pillow.· It looks

12· ·like normal mucosa lying over it.· Which is best seen

13· ·on photo two, that is the bottom one.· You can see at

14· ·the bottom of that mound, sort of in the 6:00 position

15· ·there is pink glistening mucosa.· Some of the other

16· ·parts of the polyp have orange, gold-ish liquid, but

17· ·you can see the nice pink color and you can see it has

18· ·a nice smooth appearance, sort of like a coated

19· ·enteric Asprin.· It is smooth, natural curve, no

20· ·lobulations, no irregularity, no strange looking

21· ·mucosa.

22· · · · · Q· ·Do you believe in this case that Dr. Bouza

23· ·obtained appropriate consent from Mrs. Mayor as

24· ·pertains to the scope?



·2· · · · · · · THE WITNESS:· I don't really -- I didn't

·3· ·really look at the informed consent as an issue.

·4· · · · · · · BY MR. MIDWALL:

·5· · · · · Q· ·So you are not going to criticize the

·6· ·informed consent that Dr. Bouza obtained from the

·7· ·plaintiff in this case, correct?

·8· · · · · A· ·Well, correct.

·9· · · · · Q· ·You understand that -- well, you seek

10· ·informed consent of all of your patients that undergo

11· ·colonoscopies?

12· · · · · A· ·Yes.

13· · · · · Q· ·Why do you do that?

14· · · · · A· ·Well, I think you get informed consent so

15· ·people know what the risks are, and what the potential

16· ·risks of the procedure are, but I don't consider the

17· ·informed consent as a permit to do things that are

18· ·inappropriate as part of the procedure.

19· · · · · Q· ·That wasn't my question.· My question was

20· ·do you obtain informed consent from your patients to

21· ·do scopes?


23· · · · · · · THE WITNESS:· I do.

24· · · · · · · BY MR. MIDWALL:

25· · · · · Q· ·And that is to ensure that patients are


·2· ·aware of the potential risks of undergoing the scope?


·4· · · · · · · THE WITNESS:· Right.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·As well as what the procedure entails?

·7· · · · · A· ·Yes.

·8· · · · · Q· ·One of the risks of colonoscopy is

·9· ·perforation?

10· · · · · A· ·True.

11· · · · · Q· ·And any informed consent that adheres to

12· ·the standard of care must include perforation as one

13· ·of the risks, correct?

14· · · · · A· ·Correct.

15· · · · · Q· ·Why?

16· · · · · A· ·Well, because it is one of the major known

17· ·complications, but, as I said before, there are

18· ·avoidable complications.· That is one of the known

19· ·avoidable complications.

20· · · · · Q· ·That is a known complication as well?


22· · · · · · · THE WITNESS:· Yes, but in this case

23· ·avoidable.

24· · · · · · · BY MR. MIDWALL:

25· · · · · Q· ·My question was aren't perforations a known


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·complication associated with colonoscopy?


·4· · · · · · · THE WITNESS:· They are.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·You tell patients that you could

·7· ·potentially cause a perforation?

·8· · · · · A· ·Right.

·9· · · · · Q· ·And you tell them that is a risk they have

10· ·to be willing to take?


12· · · · · · · THE WITNESS:· Yes, they have to, but,

13· ·again, it is implied there wouldn't be any unnecessary

14· ·risks that the patient will be put through which could

15· ·be avoided by better practice.

16· · · · · · · BY MR. MIDWALL:

17· · · · · Q· ·You can answer all of the questions you

18· ·want when counsel asks you, but I want you to just

19· ·answer my questions.

20· · · · · A· ·I thought I did.

21· · · · · Q· ·Do you tell your patients that you could

22· ·potentially cause a perforation?

23· · · · · A· ·Correct.

24· · · · · · · MR. SMITH:· Objection.· Asked and answered.

25· · · · · · · BY MR. MIDWALL:


·2· · · · · Q· ·If I understand correctly from your

·3· ·opinions, your criticism of Dr. Bouza is that he

·4· ·removed what you thought was clearly visually a

·5· ·lipoma, correct?

·6· · · · · A· ·Which was an unnecessary act.

·7· · · · · Q· ·And is it your testimony that all lipomas

·8· ·should not be removed?

·9· · · · · A· ·Well, I think in the rare circumstance

10· ·where a lipoma is so huge it is causing symptoms, that

11· ·might be a horse of a different color.

12· · · · · Q· ·What types of symptoms can huge lipomas

13· ·cause?

14· · · · · A· ·It would have to be more than seven or

15· ·eight centimeters causing obstructive symptoms.· That

16· ·is very rare.· Not in this case where the lipoma was

17· ·in the one centimeter range.

18· · · · · Q· ·Pathologically, what were the dimensions of

19· ·the lipoma that was removed?


21· · · · · · · THE WITNESS:· They don't specify how much

22· ·of the tissue was the lipoma itself.· Fifteen by 11

23· ·millimeters of tissue was removed on a 7 millimeter

24· ·polyp, according to Dr. Bouza, which means he took out

25· ·7 millimeters of polyp and an additional eight


·2· ·millimeters of something else which was probably colon

·3· ·wall.· So they didn't specify how much of the polyp

·4· ·was lipoma.

·5· · · · · Q· ·Is there any evidence that you can cite to

·6· ·that tells us how big the lipoma was?

·7· · · · · A· ·I would have to look at the path report

·8· ·which I didn't print out.· So I would have to refer to

·9· ·that.

10· · · · · Q· ·Do you have a copy of the path report?

11· · · · · A· ·I am looking at it right now.· The

12· ·description that the pathologist uses is, quote,

13· ·colonic polyp with sub-mucosal lipoma, close quote.

14· ·Then they say under the gross, the specimen consists

15· ·of nodular, pale tan, tissue measuring 1.5 by one by

16· ·one centimeters, but they don't say in the description

17· ·how much of that is lipoma itself and how much of that

18· ·is the attached normal colon wall that overlies or is

19· ·adjacent to the lipoma.

20· · · · · Q· ·What does nodular mean in the context of

21· ·this patient?

22· · · · · A· ·They are talking about the gross and that

23· ·is kind of a non-specific term.· They are just

24· ·describing it and I don't know if it is because it

25· ·gets cinched up and burns that it contracts a little


·2· ·bit or whether it is the effects of the fixative. I

·3· ·don't know what to make of that.

·4· · · · · Q· ·The pathologist is describing the specimen

·5· ·as having a pale tan appearance; is that right?

·6· · · · · A· ·Right.· Lipoma is usually the color of

·7· ·yellow more than tan.

·8· · · · · Q· ·In this case the pathologist, who is

·9· ·trained to diagnose lipomas, correct, by pathology?

10· · · · · A· ·Right.

11· · · · · Q· ·It is describing the lipoma as having a

12· ·pale tan color?

13· · · · · A· ·No, they are describing the specimen.· We

14· ·know only part of the specimen is lipoma and part of

15· ·it is normal colon wall.· We don't know when he or she

16· ·is saying pale tan tissue, we don't know if they are

17· ·referring to the normal intestinal wall or the actual

18· ·pocket of fat lying under the wall.

19· · · · · Q· ·Well, the normal intestinal wall was

20· ·grossly described as having a pale tan appearance.

21· · · · · A· ·It could be.· I have a nice tan.

22· · · · · Q· ·What about nodular?

23· · · · · A· ·Nodular, I am not particular what they

24· ·meant by that adjective.

25· · · · · Q· ·So it is your testimony that Dr. Bouza


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·should have grossly determined from the appearance of

·3· ·the polyp that it was a lipoma, especially in the

·4· ·context of the history of the patient, correct?


·6· · · · · · · THE WITNESS:· I wouldn't say especially by

·7· ·the history, but in appearance he should have

·8· ·recognized it as a lipoma.

·9· · · · · · · BY MR. MIDWALL:

10· · · · · Q· ·And you described for us already what in

11· ·the appearance in this case led you to believe it was

12· ·obvious prospectively that this was a lipoma?

13· · · · · A· ·Right.

14· · · · · Q· ·And it is your testimony that had you been

15· ·standing in Dr. Bouza's shoes doing the colonoscopy in

16· ·real time, you would have been able to visualize the

17· ·polyp and determine from its appearance that it was a

18· ·lipoma?

19· · · · · A· ·I would call it a lesion.· But I would have

20· ·been able to look at the lesion and determine that it

21· ·was a lipoma, in real time.

22· · · · · Q· ·And therefore, he should have biopsied a

23· ·part of it, determined what the pathology was, and

24· ·then assuming it was confirmed it was a lipoma, he

25· ·should have left it, the lesion, by itself.


·2· · · · · A· ·Correct.

·3· · · · · Q· ·And proceeded with the rest of the scope

·4· ·and then completed the procedure?

·5· · · · · A· ·Right.

·6· · · · · Q· ·Had this indeed been a polyp, would the use

·7· ·of a hot snare have been an appropriate technique?

·8· · · · · A· ·If it was a true neoplastic polyp, than a

·9· ·snare polypectomy would have been appropriate,

10· ·although the margin of excision he used was still

11· ·excessive.· He has in his report seven millimeters,

12· ·and the pathologist's specimen was ten by fifteen

13· ·millimeters.

14· · · · · Q· ·Well, did the CT scan done after Ms. Mayor

15· ·returns to the emergency room later that day confirm

16· ·any perforation in the abdominal wall?

17· · · · · A· ·In the colon wall there is a perforation.

18· · · · · Q· ·Do you know what area of the colon wall it

19· ·is?

20· · · · · A· ·On the CT scan you can't really tell.· They

21· ·see free air and some inflammation.

22· · · · · Q· ·So we are not able to determine if there

23· ·was a perforation in the area that Dr. Bouza removed

24· ·part of that abdominal wall per your testimony?



·2· · · · · · · THE WITNESS:· Well, it is based on a

·3· ·temporal element and the location of the free air, and

·4· ·the timing of her symptoms, there is strong grounds to

·5· ·infer that the hole was where the polypectomy was

·6· ·performed.

·7· · · · · · · BY MR. MIDWALL:

·8· · · · · Q· ·But you have no evidence from review of

·9· ·this file to support that opinion?

10· · · · · A· ·Well, we do based on what was later seen by

11· ·Dr. Whittwell when he did his operation on September

12· ·18 when he actually found the hole.

13· · · · · Q· ·That was two and a half weeks later?

14· · · · · A· ·Right.

15· · · · · Q· ·Can you tell us precisely where that lipoma

16· ·was in the context of the colon?

17· · · · · A· ·It was right up at the anastomosis because

18· ·you can see in the pictures there is a little ridge of

19· ·light pink tissue where the anastomosis is.· So it is

20· ·right at the rim of the ileocolic anastomosis.

21· · · · · Q· ·And you have removed polyps before that

22· ·were right near the ileocolonic anastomosis?

23· · · · · A· ·A few.

24· · · · · Q· ·And it is within the standard of care if

25· ·indicated to remove polyps near the ileocolonic


·2· ·anastomosis, right?

·3· · · · · A· ·There is, but that is an interesting point

·4· ·because when you actually look at lesions at the

·5· ·ileocolonic anastomosis, you have to have an even

·6· ·higher index of suspicion that it is not a true

·7· ·neoplasm.· You can have suture granulomas from the

·8· ·stitching or you can have things like lipomas, so that

·9· ·makes it even less likely that it is a true neoplasm

10· ·because of the location, but, to answer your question,

11· ·I have removed polyps that were close to the

12· ·anastomosis.

13· · · · · Q· ·There was colon cancer in the area where

14· ·the anastomosis was done, correct?

15· · · · · A· ·Ten years before.

16· · · · · Q· ·And you are aware of the literature that if

17· ·there is a recurrence of colon cancer, it can occur in

18· ·the area of the anastomosis.

19· · · · · A· ·Well, again, you are using the word

20· ·recurrence.· Recurrence implies that the same original

21· ·disease has come back and that doesn't occur after ten

22· ·years.· So could there be an occurrence of a new

23· ·cancer in that location?· That is possible.

24· · · · · Q· ·That is one thing that Dr. Bouza -- it was

25· ·appropriate for him to be aware of that possibility at


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·the time he performed the scope, correct?

·3· · · · · A· ·But after ten years without -- having had

·4· ·successful surgery for colon cancer, there is no

·5· ·reason to be any more suspicious of a lesion there

·6· ·than anywhere else in the colon.

·7· · · · · Q· ·Do you know how many years prior to the

·8· ·scope done in this case Ms. Mayor had colon cancer?

·9· · · · · A· ·Well, just looking at one report which is

10· ·from Dr. Geada, G E A D A, dated August 25, he wrote,

11· ·quote, status post surgery around ten years ago, close

12· ·quote.· So that is one of a few areas where people

13· ·give us that timeframe.

14· · · · · Q· ·Are ileocolonic anastomoses more

15· ·susceptible to perforation?

16· · · · · A· ·Depends on the kind of procedure you do.

17· ·For something like this, polypectomy, I don't know.

18· · · · · Q· ·Sorry, you don't what --

19· · · · · A· ·I don't know.

20· · · · · Q· ·You are not of the opinion in that this

21· ·case the ileocolonic anastomosis was more predisposed

22· ·to perforation, correct?

23· · · · · A· ·No, I don't.

24· · · · · Q· ·From the pictures you see in this case the

25· ·colon appeared clean?



·3· · · · · · · THE WITNESS:· It appeared to be a little

·4· ·dirty, but not super bad at this one location.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·So the color photographs you saw various

·7· ·aspects of the colon, it appeared the majority of the

·8· ·time to be clean?

·9· · · · · A· ·It is not various aspects, but he is

10· ·looking at one particular region and in that one

11· ·particular region it didn't look too bad, but he says,

12· ·right below that he says preparation of the colon was

13· ·poor so there were probably other areas that were much

14· ·dirtier.

15· · · · · Q· ·The areas we have photographic evidence of

16· ·that you can see in front of you appear to be a proper

17· ·visualization of the field?

18· · · · · A· ·Yes.

19· · · · · Q· ·And whether or not Dr. Bouza encountered

20· ·stool in other areas of the colon, can you state he

21· ·did or did not?

22· · · · · A· ·You can only infer from his statement that

23· ·the colon prep was poor.

24· · · · · Q· ·But you understand that he performed lavage

25· ·to address the poor preparation, correct?


·2· · · · · A· ·That is true.

·3· · · · · Q· ·Which is designed to deal with a poor prep,

·4· ·correct?

·5· · · · · A· ·Right.· But, I mean, he didn't have

·6· ·pictures from various areas.· He could have actually

·7· ·washed this lipoma off a little better which would

·8· ·have been made it even clearer that this was a lipoma

·9· ·and he could have taken some pictures of what the

10· ·colon wall looked like after he did the polypectomy,

11· ·which would have been useful given the outcome we are

12· ·looking at now.

13· · · · · Q· ·But you were not there during the

14· ·colonoscopy; Dr. Bouza was, correct?

15· · · · · A· ·Right.

16· · · · · Q· ·And you would agree that the photographs we

17· ·have of the colonoscopy, regardless of whether they

18· ·are in color or not, are not the same quality as

19· ·visualizing it with his own eyes as Dr. Bouza was,

20· ·correct?


22· · · · · · · THE WITNESS:· That is true.

23· · · · · Q· ·And that is what someone who does

24· ·colonoscopies day in and day out is trained to do, to

25· ·visualize these things in real time, correct?


·2· · · · · A· ·Right, but it should have been even clearer

·3· ·for him who had an even bigger screen and a better

·4· ·visualization to recognize this as a lipoma.

·5· · · · · Q· ·Going back to the perforation you had about

·6· ·ten years ago, what technique did you use that caused

·7· ·the perforation?


·9· · · · · · · THE WITNESS:· I used a hot snare and it was

10· ·a fairly big polyp and she had poor wound healing and

11· ·it was -- that was pretty much it in a nutshell.

12· · · · · · · BY MR. MIDWALL:

13· · · · · Q· ·When you were using the hot snare to remove

14· ·that polyp, were you resigned to the fact that you

15· ·were going to cause a perforation?

16· · · · · A· ·Not really.· I knew that it was a potential

17· ·possibility, but I didn't think it was an

18· ·inevitability.

19· · · · · Q· ·Do you think there was some technique you

20· ·used during the hot snare that caused the perforation

21· ·or was it just bad luck because of her poor wound

22· ·healing?


24· · · · · · · THE WITNESS:· Like a lot of things it is a

25· ·combination of the two.· One of the known effects of


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·hot snare polypectomy, you get a mechanical injury to

·3· ·the surrounding tissue by closing the wire loop but

·4· ·then you get a much more extensive thermal injury

·5· ·which is as a result of the high intensity current

·6· ·that you are putting through the wall which destroys a

·7· ·lot more tissue than the mechanical operation of the

·8· ·snare itself.· So you know those are the effects.· To

·9· ·some extent, technique is important, but I thought my

10· ·technique was good.· The patient's underlying health

11· ·and physical fitness and wound healing is also a

12· ·factor.

13· · · · · Q· ·You have certainly seen other physicians

14· ·cause perforations in patients whom were not

15· ·pre-disposed to poor wound healing?

16· · · · · A· ·Right.

17· · · · · Q· ·Using a hot snare?

18· · · · · A· ·True.

19· · · · · Q· ·And from your review of either of those

20· ·case studies and attending lecture, why did those take

21· ·place?

22· · · · · A· ·Well, you know --


24· · · · · · · THE WITNESS:· Well, I think it has to do

25· ·with -- I think if it is done with a bad device, there


·2· ·is a hot bio-feed forceps, that is not a good way to

·3· ·remove a polyp because there is very unpredictable

·4· ·extent of tissue destruction.· So doctors don't use

·5· ·that any more.· But if you have a large polyp that is

·6· ·very sessile, that is neoplastic, if you take off a

·7· ·polyp like that you will cause an extensive burn to

·8· ·the wall and that increases the risk of perforation.

·9· · · · · Q· ·Based upon your review of the scope report

10· ·and Dr. Bouza's deposition, what things during the

11· ·scope do you believe Dr. Bouza did appropriately and

12· ·within the standard of care?


14· · · · · · · THE WITNESS:· He had the patient sedated

15· ·appropriately.· He inserted the scope appropriately.

16· ·He navigated through the twists and turns of the colon

17· ·to reach the anastomosis appropriately.· Those are the

18· ·things he did appropriately.

19· · · · · · · Unfortunately, he did one thing very

20· ·inappropriately, but you asked me what he did

21· ·appropriately.

22· · · · · Q· ·Right.· I am asking you what he did

23· ·appropriately.

24· · · · · · · The findings he put on his report, do you

25· ·agree with them?


·2· · · · · A· ·I disagree with his description of the

·3· ·polyp.· He wrote a sessile polyp, under findings, a

·4· ·sessile polyp, 7 millimeters in size.· Polyp was

·5· ·removed with a hot snare.· Resection and retrieval

·6· ·were complete.· I think the correct description was

·7· ·sub-mucosal lesion probably lipoma was found.· The

·8· ·correct report would have read the polyp was 7

·9· ·millimeters in size.· Cold forceps biopsies were

10· ·obtained from the sub-mucosal lesion.

11· · · · · Q· ·Why was it inappropriate in your opinion

12· ·for Dr. Bouza to have described this polyp as sessile?

13· · · · · A· ·Because it is a sub-mucosal lipoma.

14· · · · · Q· ·When would it be appropriate to say a polyp

15· ·was sessile in its appearance?

16· · · · · A· ·Well, first, it would have to be a true

17· ·polyp which is either hyper-plastic or neoplastic.

18· ·This is neither.· Sessile is used in conjunction with

19· ·polyp and this was not a true polyp, this was a

20· ·sub-mucosal lesion.

21· · · · · Q· ·When someone says a polyp is sessile, what

22· ·do they mean in the context of a neoplasm?

23· · · · · A· ·Well, when a neoplasm is sessile, that

24· ·means it is flat, it does not protrude up away from

25· ·the wall.


·2· · · · · Q· ·In this case do you know how much the

·3· ·lipoma was protruding?

·4· · · · · A· ·You can see it here.· It is just a

·5· ·sub-mucosal elevation of a few millimeters.

·6· · · · · Q· ·Can you tell us with any precision how much

·7· ·this lipoma is protruding?

·8· · · · · A· ·It is just kind of lifting -- it is raising

·9· ·the wall from below.· So it is an elevation of maybe 3

10· ·millimeters in height.

11· · · · · Q· ·You are obviously looking at the 2-D image

12· ·of this, correct?

13· · · · · A· ·Well, there is no 3-D image that I have

14· ·available.

15· · · · · Q· ·Right.· Dr. Bouza had 3-D image?

16· · · · · A· ·No, he did not have a 3-D image.

17· · · · · Q· ·He wasn't using a 3-D on --

18· · · · · A· ·If you look at TV screen, is that 2-D or

19· ·3-D?

20· · · · · Q· ·2-D.

21· · · · · A· ·He was looking at the TV screen.

22· · · · · Q· ·He wasn't able to get angles --

23· · · · · A· ·He can look at it from different angles.

24· ·We are getting still photos of that.· We are all

25· ·looking in 2-D.· He was able to look at it in real


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·time.

·3· · · · · Q· ·He was also able to look at it from varying

·4· ·angles?

·5· · · · · A· ·Correct.

·6· · · · · Q· ·You are not able to do that from the

·7· ·photographs you have seen in this case?

·8· · · · · A· ·Only from two or three angles.

·9· · · · · Q· ·You are clearly not able to visualize what

10· ·the lipoma looked like in real time like Dr. Bouza

11· ·was, correct?


13· · · · · · · THE WITNESS:· Well, you know, I think that

14· ·makes it even more apparent that he was very

15· ·mistaken --

16· · · · · Q· ·Just answer the question.· I just want to

17· ·you answer the question.· Do you remember what the

18· ·question was?

19· · · · · A· ·Yes, I do.

20· · · · · Q· ·Please answer.

21· · · · · A· ·I am able to tell looking at these pictures

22· ·that it was a lipoma.· He had an even better vantage

23· ·point so he should have been even clear on the fact.

24· · · · · · · MR. MIDWALL:· Read back the question,

25· ·please?





·5· · · · · · · THE WITNESS:· Can you read it again?



·8· · · · · · · THE WITNESS:· I am able to recognize this

·9· ·just like if you saw three photographs of President

10· ·Obama, you could say, hey, that is President Obama

11· ·without walking around him.· I can recognize it was a

12· ·lipoma.

13· · · · · Q· ·That wasn't the question.· Do you remember

14· ·what the question was?· We had it read back two times.

15· · · · · A· ·I do remember.· You are asking me about

16· ·visualization.· I am visualizing it in a different way

17· ·than he visualized it.· A less complete way than he

18· ·visualized it.· Nonetheless, I am still recognizing it

19· ·for what it is based on the photographs.

20· · · · · Q· ·Do you agree with the finding in

21· ·Dr. Bouza's report that a small mouth diverticula were

22· ·found in the sigmoid colon?

23· · · · · A· ·I can't agree or disagree because I am just

24· ·taking that at verbatim.

25· · · · · Q· ·You were not able to independently verify


·2· ·whether that was true?

·3· · · · · A· ·No.· I could probably look at the CAT scan

·4· ·and maybe look for the diverticula there, but I did

·5· ·not do that.

·6· · · · · Q· ·In terms of the recommendations about using

·7· ·the Metamucil, at least one teaspoon in eight ounces

·8· ·of any beverage twice a day indefinitely, is that

·9· ·appropriate?

10· · · · · A· ·Yes.

11· · · · · Q· ·Discharging the patient home that day was

12· ·appropriate?

13· · · · · A· ·Yes.

14· · · · · Q· ·Wanting her, meaning Ms. Mayor, to return

15· ·to the endoscopist in three weeks time was

16· ·appropriate?

17· · · · · A· ·It was at the time of discharge, yes.

18· · · · · Q· ·One of the things that a patient like

19· ·Ms. Mayor is told to do after a colonoscopy is to be

20· ·cognizant of any feelings of fever or chills; is that

21· ·correct?

22· · · · · A· ·Yes.

23· · · · · Q· ·Why is that?

24· · · · · A· ·Because that could be a warning sign of a

25· ·complication.


·2· · · · · Q· ·Such as what?

·3· · · · · A· ·Such as perforation or aspiration during

·4· ·the procedure.

·5· · · · · Q· ·You tell your patients that as well,

·6· ·correct?

·7· · · · · A· ·It is on their discharge instruction

·8· ·sheets.

·9· · · · · Q· ·Patients of yours are to be mindful if they

10· ·develop symptoms of fever or chills, correct?

11· · · · · A· ·Yes.

12· · · · · Q· ·Do you perform the scopes you do presently

13· ·at hospitals or in your office?

14· · · · · A· ·About 95 percent at our endoscopy center

15· ·which is a dedicated procedure center and about 5

16· ·percent at the hospital.

17· · · · · Q· ·What is a hemicolectomy?

18· · · · · A· ·Removal of half of the colon.

19· · · · · Q· ·Was that done for Ms. Mayor prior to her

20· ·interactions with Dr. Bouza in this case?

21· · · · · A· ·Yes, it is kind of give or take.· She had a

22· ·little less than a hemicolectomy, if we want to talk

23· ·about it accurately in terms of the amount they took.

24· ·They took out her cecum, ascending colon, all the way

25· ·up to her hepatic flexure.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·Just based upon your experience, why was

·3· ·that done for Ms. Mayor?

·4· · · · · A· ·For colon cancer, generally because of the

·5· ·way the cancer go to lymph nodes and then spread, the

·6· ·idea is not to just remove the obvious mass but the

·7· ·whole collecting system of lymphs.

·8· · · · · Q· ·So there was a concern by the surgeons who

·9· ·surgically removed her colon cancer that there could

10· ·be metastasis?


12· · · · · · · THE WITNESS:· There was that concern.· The

13· ·ten year interval proved that concern to be

14· ·ill-founded or turned out she did not have metastasis,

15· ·but that was their concern at the time of the

16· ·operation.

17· · · · · · · BY MR. MIDWALL:

18· · · · · Q· ·Can unexplained weight loss be a sign and

19· ·symptom of colon cancer?

20· · · · · A· ·Of many things including colon cancer, yes.

21· · · · · Q· ·Do you agree that vital signs were

22· ·monitored appropriately during the scope, correct?

23· · · · · A· ·Yes.

24· · · · · Q· ·Pre-operative work-up was done

25· ·appropriately?


·2· · · · · A· ·It was.

·3· · · · · Q· ·You agree that, in this case, that

·4· ·Ms. Mayor had a thermal perforation?

·5· · · · · A· ·Well, it was a combination.· You have the

·6· ·mechanical component and the thermal component. I

·7· ·think the early part of the perforation was primarily

·8· ·mechanical and then was followed by the thermal

·9· ·injury, which means the wall where the thermal event

10· ·has occurred is -- has a transmural injury and will

11· ·have necrosis but that occurs -- it takes time, 24,

12· ·48, 72 hours, for that portion of the wall to really

13· ·break down and deteriorate.· So the fact that she had

14· ·symptoms according to her daughter-in-law 45 minutes

15· ·after the colonoscopy means she had a perforation

16· ·early.· The thermal injury is what evolved over the

17· ·24th, 25th, 26th.· That took more time.

18· · · · · Q· ·When you say Ms. Mayor had a mechanical

19· ·perforation, what do you mean?

20· · · · · A· ·Well, we know from the way the description

21· ·is made of the size of the tissue removed and the

22· ·polyp seen, that tissue in excess of the polyp itself

23· ·was snared and burnt, cut off.· That would have

24· ·created a hole, maybe not that big a hole, but a hole

25· ·in the wall of the colon so when she started to get


·2· ·symptomatic 45 minutes afterwards, that was the

·3· ·earliest sign of the perforation, but then as I

·4· ·mentioned before, the damage due to the burn extends

·5· ·outwards from that ring which means the perimeter of

·6· ·that mechanical hole will get bigger and bigger as the

·7· ·tissue dies away from the thermal injury.

·8· · · · · Q· ·So when you say there is a mechanical

·9· ·injury, what are you referring to, what was the

10· ·mechanism?

11· · · · · A· ·You cut a little too deep, you cut a little

12· ·too much as was the case in Dr. Bouza's polypectomy,

13· ·he took out a larger chunk than what the polyp

14· ·measured out as.· So in addition to taking out the

15· ·polyp, he took a piece of the wall.· The wall is only,

16· ·say, four millimeters or so thick.· So he cut too

17· ·deep, and that means he cut not just the polyp but

18· ·what was underneath the polyp, which was the wall.

19· ·That is another reason you leave these polyps alone.

20· ·They are sub-mucosal.· They are deep.· If you cut

21· ·underneath the lipoma, there is not much wall left.

22· ·That was actually cut with the wire and with the

23· ·current, but then the damaging effects of the

24· ·electrical current caused the tissue destruction to

25· ·spread out from that initial, mechanical hole, kind of


·2· ·like a depth radius kind of effect.

·3· · · · · Q· ·Is a hot snare technique better used for

·4· ·larger polyps?

·5· · · · · A· ·Well, again, talking in the general sense,

·6· ·not in this particular case, for larger polyps a hot

·7· ·snare is generally what we use.

·8· · · · · Q· ·Why is that?

·9· · · · · A· ·Because you need -- I had a polyp last week

10· ·which was big, like the size of a walnut, but it was

11· ·on a stalk, so you need the cautery effect of the

12· ·cutting device to prevent a lot of bleeding.

13· · · · · Q· ·Because in your case the size and the depth

14· ·of it because of the stalk?

15· · · · · A· ·Yes, because there are usually blood

16· ·vessels in the stalk and the bigger the polyp, the

17· ·bigger the vessels, so you want to use the actual

18· ·thermal effect of the wire to cauterize the vessels.

19· · · · · Q· ·And remove the entirety of it?

20· · · · · A· ·Yes.

21· · · · · Q· ·And that is best done by utilizing the hot

22· ·snare technique, correct?

23· · · · · A· ·Right.

24· · · · · Q· ·Would you agree that a polyp one and a half

25· ·centimeters should be removed using hot snare


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·technique?


·4· · · · · · · THE WITNESS:· Well, I would like to

·5· ·distinguish between the facts of this case.· This was

·6· ·not a one and a half centimeter polyp.· This was a

·7· ·lipoma.· But in a neoplastic polyp that is one and a

·8· ·half centimeters, you would want to use a hot snare.

·9· · · · · · · BY MR. MIDWALL:

10· · · · · Q· ·For the reasons you just stated?

11· · · · · A· ·Yes.

12· · · · · Q· ·Using cold snare technique, cold forceps, a

13· ·one and a half centimeter neoplastic polyp, because

14· ·why not?

15· · · · · A· ·Because it can cause bleeding.· We

16· ·sometimes do that with really flat neoplasms in the

17· ·right colon, we shave them off the wall cold.· That is

18· ·used sometimes.· There is some risk of bleeding.· If

19· ·they are sessile neoplasms, they are not usually that

20· ·vascular so they don't bleed that much.

21· · · · · Q· ·In this case do you believe the perforation

22· ·became walled off?

23· · · · · A· ·I think the perforation, before the thermal

24· ·injury had its full impact, was not a large

25· ·perforation, and I think because she had scar tissue


·2· ·from her previous hemicolectomy, that portion of the

·3· ·intestine was probably tacked on pretty closely to the

·4· ·posterior abdominal wall, so I don't think it was

·5· ·walled off, but it was probably contained for a while.

·6· · · · · Q· ·What do you mean by that?

·7· · · · · A· ·There wasn't like full

·8· ·peritoneal contamination of the entire peritoneum,

·9· ·there were just some pockets and regions where the air

10· ·collected, where the liquid feces could start to build

11· ·up which actually broke through her abdominal wall at

12· ·the time of the operation at Baptist and so --

13· · · · · Q· ·When was that operation done?

14· · · · · A· ·That was the 17th or the 18th.

15· · · · · Q· ·Of September.· I am just talking about

16· ·during the time she was at Kendall Regional Medical

17· ·Center --

18· · · · · A· ·26th was the first time.

19· · · · · Q· ·Right.· She was discharged on September 1.

20· ·During that timeframe, do you agree that the

21· ·perforation was sealed off?


23· · · · · · · THE WITNESS:· I don't think it was sealed

24· ·off.· I think there was a CAT scan on the 24th that I

25· ·viewed.


·2· · · · · Q· ·When was that, August 24?

·3· · · · · A· ·August 24, like 1 a.m.· There was another

·4· ·CAT scan on September 4.· There was free air seen in

·5· ·both and I think the September 4 one had a drain in

·6· ·place which would allow some of the air actually to

·7· ·blow through the hole.

·8· · · · · Q· ·Go back to the first admission.· That is my

·9· ·question.· Stick to that.· Answer that.

10· · · · · A· ·I think the perforation was not huge at

11· ·that point, when the surgeon went in on the 24th, but

12· ·I don't think it had really walled off.· I think it

13· ·was locally semi-contained because of scar tissue but

14· ·it hadn't really walled off.

15· · · · · Q· ·And there was no feces that was draining

16· ·through that perforation, correct?

17· · · · · A· ·She wasn't really eating much.· She had the

18· ·colonoscopy.· Within an hour of leaving she felt

19· ·horrible.· She came back to the hospital.· She was

20· ·NPO.· So no, there wasn't a lot of feces in the

21· ·abdomen, but there wasn't a lot of food in her GI

22· ·tract either.

23· · · · · Q· ·There was no feces depicted on the CT scan

24· ·done on the 24th, correct?

25· · · · · A· ·No.


·2· · · · · Q· ·And CT scans can pick up feces if it is

·3· ·present, can it not?

·4· · · · · A· ·Solid, yes, but, like I said, she hadn't

·5· ·really had much to eat from the 23rd to the time of

·6· ·the operation --

·7· · · · · Q· ·A CT scan can pick up semi-liquid feces as

·8· ·well, correct?

·9· · · · · A· ·I think if you look at that CT scan, it

10· ·would have been possible that there could have been a

11· ·small amount of feces and the CT wouldn't have shown

12· ·it, if it was liquid feces, it wouldn't necessarily

13· ·show up on CT.

14· · · · · Q· ·Are you a radiologist?

15· · · · · A· ·I look at a huge amount of abdominal films,

16· ·but I am not a radiologist.

17· · · · · Q· ·Are you disagreeing with the radiologist

18· ·that interpreted the August 24, 2012 CT scan?

19· · · · · A· ·I don't think there is any argument between

20· ·us about solid feces, but I am saying she hadn't had

21· ·any solids since the 22nd.

22· · · · · Q· ·I am asking if there was the presence of

23· ·any feces.· I think we already agreed the CT scan does

24· ·not recognize solid feces.· Now I am asking if there

25· ·was presence of any feces and Brent just provided you


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·with the CT scan report, correct?

·3· · · · · A· ·He did.

·4· · · · · Q· ·You are looking at it and you will respond

·5· ·to the question.

·6· · · · · A· ·Right.

·7· · · · · · · He doesn't comment on feces being present,

·8· ·but again, I do quality improvement at our centers so

·9· ·when we see patients with perforations after

10· ·colonoscopy, it is more common than not that there is

11· ·no feces at the time of the surgery because the bowel

12· ·has been prepped.· They don't have feces in their GI

13· ·track.· That is the whole point of a colonoscopy prep.

14· ·So there was no feces.

15· · · · · Q· ·There was no feces seen by the radiologist

16· ·that interpreted the August 24, 2012 CT scan, correct?

17· · · · · A· ·Right.

18· · · · · Q· ·And as you sit here today, you cannot

19· ·testify within a reasonable degree of medical

20· ·certainty that any feces went through the perforation

21· ·that was -- that existed on August 23, correct?


23· · · · · · · THE WITNESS:· I would say more likely than

24· ·not there was some liquid material that went through

25· ·that hole.· I won't call it feces, but it was liquid


·2· ·material coming from the inside of her intestines that

·3· ·went through her hole, some small amount.

·4· · · · · · · BY MR. MIDWALL:

·5· · · · · Q· ·Can you quantify that small amount?

·6· · · · · A· ·No.

·7· · · · · Q· ·And you agree that liquids can be depicted

·8· ·on a CT scan, correct?

·9· · · · · A· ·When they are in excess of a certain

10· ·threshold amount.

11· · · · · Q· ·And what is that threshold amount?

12· · · · · A· ·It is hard to say.· There was inflammatory

13· ·stranding and changes which --

14· · · · · Q· ·Just answer the question, is there a

15· ·threshold amount of liquid that can be detected on a

16· ·CT scan?

17· · · · · A· ·I can't give you a number.

18· · · · · Q· ·Because you don't know?

19· · · · · A· ·I don't.

20· · · · · Q· ·So as we sit here today you agree that if

21· ·there was a perforation that you agree was from

22· ·mechanical and thermal done by the scope by Dr. Bouza

23· ·you cannot quantify how big a perforation it was as of

24· ·August 23, 2012, correct?

25· · · · · A· ·We can only quantify it in terms of the


·2· ·large amount of free air that was in the abdominal

·3· ·cavity which means it was a decent size hole.

·4· · · · · Q· ·How much free area was described?

·5· · · · · A· ·I think it was described as moderate to

·6· ·large amount.

·7· · · · · Q· ·Look at the CT report.

·8· · · · · A· ·Okay.· They say, extensive pneumoperitoneum

·9· ·most pronounced in the right abdomen, which is where

10· ·the polyp was, and there is mild stranding at the

11· ·level of the distal small bowel loops.

12· · · · · Q· ·Is there any mention made of free air?

13· · · · · A· ·Pneumoperitoneum is free air.· So they say

14· ·it is extensive pneumo, which is air, in the

15· ·peritoneum.

16· · · · · Q· ·What is pneumoperitoneum?

17· · · · · A· ·Pneumo is air, from the Latin word, in the

18· ·peritoneum.· So pneumoperitoneum is free air.

19· · · · · Q· ·But we don't know how big that perforation

20· ·is?

21· · · · · A· ·There was extensive pneumoperitoneum in

22· ·that area within a little over 12 -- about 14 hours of

23· ·time from the colonoscopy.

24· · · · · Q· ·But nonetheless, that perforation was not

25· ·able to be picked up on the CT scan?


·2· · · · · A· ·Perforation is clearly present because of

·3· ·the pneumoperitoneum.

·4· · · · · Q· ·That wasn't my question.

·5· · · · · A· ·A hole is not something that you generally

·6· ·see on a CT scan.

·7· · · · · Q· ·A perforation absolutely can be depicted on

·8· ·a CT scan, isn't that correct?


10· · · · · · · THE WITNESS:· A hole --

11· · · · · · · BY MR. MIDWALL:

12· · · · · Q· ·Perforation is a hole.

13· · · · · A· ·Follow me.· Let me finish.· A hole is an

14· ·absence of wall.· If you have a hole in a wall, that

15· ·is the absence of wall.· A CT scan detects things that

16· ·are there.

17· · · · · Q· ·Is it your testimony that a CT scan cannot

18· ·depict a perforation in the abdominal wall?

19· · · · · A· ·What it depicts is the integrity of the

20· ·wall is gone and there is air in the peritoneum.· It

21· ·is basically an inferential statement that there is a

22· ·hole there.

23· · · · · Q· ·A CT scan can pick up the integrity of a

24· ·wall, correct, abdominal wall?

25· · · · · A· ·A CT scan is good at picking up things that


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·are there.· It is not very good at finding small

·3· ·holes.

·4· · · · · Q· ·Did the radiologist who is trained to

·5· ·interpret CT scans note the lack of abdominal wall?


·7· · · · · · · THE WITNESS:· The lack of abdominal what?

·8· · · · · · · BY MR. MIDWALL:

·9· · · · · Q· ·Wall.

10· · · · · · · Let the record reflect that you are looking

11· ·at the CT scan.

12· · · · · A· ·Like I say, it is an inference.· Let me

13· ·read the exact language.· Then you can question me on

14· ·it.· Extensive pneumoperitoneum identified, most

15· ·pronounced in the right abdomen.· Provided history of

16· ·colonoscopy today.· This may represent perforated

17· ·viscus.· That is an inference.· But what I am saying

18· ·is you just don't see -- on a CT scan you don't see a

19· ·hole.· That is simply my point.

20· · · · · Q· ·Well, if the radiologist had felt more

21· ·likely than not there was a perforation, he or she

22· ·would have said that, correct?


24· · · · · · · THE WITNESS:· They did say that.

25· · · · · · · BY MR. MIDWALL:


·2· · · · · Q· ·Where did they say there was a perforation

·3· ·more likely than not?

·4· · · · · A· ·In a temporal context, provided the history

·5· ·of colonoscopy today.· This may represent perforated

·6· ·viscus.

·7· · · · · Q· ·What is infectious peritonitis?

·8· · · · · A· ·When you get abdominal contents or

·9· ·infectious material that leaks out into the abdominal

10· ·cavity, it causes a huge inflammatory reaction and

11· ·that is infectious peritonitis.

12· · · · · Q· ·What are the signs and symptoms of it?

13· · · · · A· ·Abdominal pain, abdominal tenderness,

14· ·sometimes rigidity in the wall when you push on it.

15· ·You can have fever, other symptoms.

16· · · · · Q· ·Did Ms. Mayor have fever during her

17· ·admission to Kendall Regional Medical Center from

18· ·August 21, 2012 to September 1, 2012?

19· · · · · A· ·No.

20· · · · · Q· ·Did she evidence any signs of infectious

21· ·peritonitis during that admission?

22· · · · · A· ·I think she had abdominal pain, but I don't

23· ·think she had laboratory abnormalities.

24· · · · · Q· ·She had been complaining of abdominal pain

25· ·prior to the scope?


·2· · · · · A· ·That is true.

·3· · · · · Q· ·You agree that Dr. Bouza's response to the

·4· ·plaintiff's complaints a few hours after the

·5· ·colonoscopy were appropriate, correct, in terms of

·6· ·having her go to the emergency room?

·7· · · · · A· ·Well, there is some kind of disagreement in

·8· ·terms of the conversation that took place between the

·9· ·daughter-in-law and Dr. Bouza.· Ultimately the patient

10· ·did end up in the emergency room which was the right

11· ·place to be.

12· · · · · Q· ·There was a note in the chart, was directed

13· ·to go to the emergency room?

14· · · · · A· ·Right, but there were statements by

15· ·Dr. Bouza where he said, give her an enema and she

16· ·said, no, we are going to the ER.

17· · · · · Q· ·Let's just go by the documentation done at

18· ·that time.· You agree, first of all, that

19· ·documentation in the chart was appropriate, correct?

20· · · · · A· ·Yes.

21· · · · · Q· ·So it looks like the complaints of pain,

22· ·first of all, per the documentation, occurred three to

23· ·four hours later?

24· · · · · A· ·Again, there is controversy to that but the

25· ·chart says three to four hours.


·2· · · · · Q· ·Does that affect your opinion that there

·3· ·was a mechanical and thermal injury?

·4· · · · · A· ·It is mixed because thermal doesn't tear a

·5· ·hole in the wall, it just causes cell death which

·6· ·leads to a hole in the wall after the necrosis breaks

·7· ·the wall down.· So I think there was a combination of

·8· ·both.

·9· · · · · Q· ·You agree that Dr. Bouza was appropriate to

10· ·want the patient, Ms. Mayor, to be seen by a surgeon?

11· · · · · A· ·Yes.

12· · · · · Q· ·And to undergo imaging studies that she

13· ·did?

14· · · · · A· ·Yes.

15· · · · · Q· ·Why was that appropriate?

16· · · · · A· ·Because suspicion was perforation and CAT

17· ·scan is the best way to look for it.

18· · · · · Q· ·I think opinion number three -- opinion one

19· ·is that the plaintiff underwent a scope and that

20· ·the -- she had a lesion excised through hot snare that

21· ·caused a perforation?

22· · · · · A· ·Yes.

23· · · · · Q· ·There is no doubt that there was a

24· ·perforation from the hot snare, correct?

25· · · · · A· ·Right.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·And the decision by Dr. Bouza to use the

·3· ·hot snare on what you identify as the lipoma was

·4· ·inappropriate.· That was another one of your opinions.

·5· · · · · A· ·Right.

·6· · · · · Q· ·The third opinion was that the plaintiff

·7· ·subsequently never had her perforation definitively

·8· ·addressed.· Do you recall saying that?

·9· · · · · A· ·Yes.

10· · · · · Q· ·What do you mean by that?

11· · · · · A· ·What I mean is that the patient underwent

12· ·an exploration by laparotomy by Dr. Martinez.

13· · · · · Q· ·The surgeon?

14· · · · · A· ·Correct.

15· · · · · Q· ·At that point Dr. Bouza's involvement is

16· ·relegated to the back?

17· · · · · A· ·He is peripheral.

18· · · · · Q· ·This is now a surgical issue?

19· · · · · A· ·Yes.

20· · · · · Q· ·Why is that?

21· · · · · A· ·Because the remedy that is required is a

22· ·surgical remedy.

23· · · · · Q· ·Remedy of a perforation?

24· · · · · A· ·Right.

25· · · · · Q· ·When there is a perforation -- which do


·2· ·occur from time to time in colonoscopies, the way to

·3· ·address it is through surgery, correct?

·4· · · · · A· ·Yes.

·5· · · · · Q· ·Typically what type of surgery?

·6· · · · · A· ·Again, I am not a surgeon so I will not

·7· ·tell you the best surgical procedure.

·8· · · · · Q· ·As long as you are not going to provide

·9· ·what the appropriate surgical response should be I

10· ·will not ask you a bunch of questions about that?

11· · · · · A· ·Okay.

12· · · · · Q· ·But we do agree that it is a surgical case

13· ·at the time Dr. Martinez is consulted, correct?

14· · · · · A· ·Yes.

15· · · · · Q· ·So the decision by Dr. Bouza to consult the

16· ·surgeon was appropriate?

17· · · · · A· ·It was.

18· · · · · Q· ·And then it is Dr. Bouza's role to go to

19· ·the periphery and let the surgeon do his or her job?

20· · · · · A· ·It becomes a primary surgical job but they

21· ·both share the job of getting the patient better but

22· ·now it is Martinez's task to step in and fix the

23· ·perforation.

24· · · · · Q· ·It is the surgeon's job to identify what

25· ·the problem is and what surgically may be done to


·2· ·rectify the problem, correct?


·4· · · · · · · THE WITNESS:· Right.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·These are things that Dr. Bouza is not

·7· ·trained nor expected to do, correct?

·8· · · · · A· ·He is not expected to come up with the

·9· ·actual surgical plan.

10· · · · · Q· ·Sure, or to determine the appropriate

11· ·surgical procedure to be done?

12· · · · · A· ·I think there needs to be consultation done

13· ·between the surgeon and the doctor so each knows what

14· ·the other is doing.

15· · · · · Q· ·And you agree that in this case Dr. Bouza

16· ·and Dr. Martinez did speak in conference before

17· ·Dr. Martinez performed the laparotomy, correct?

18· · · · · A· ·Right.

19· · · · · Q· ·Which was appropriate?

20· · · · · A· ·Yes.

21· · · · · Q· ·At that point a discussion occurs and

22· ·Dr. Martinez decides to be a laparotomy, that is no

23· ·longer Dr. Bouza's responsibility?


25· · · · · · · THE WITNESS:· I think that is true.


·2· · · · · · · BY MR. MIDWALL:

·3· · · · · Q· ·You said you would agree you are not a

·4· ·surgeon and would not be able to comment on what

·5· ·technique to use?

·6· · · · · A· ·Right, I wouldn't tell them what to do in

·7· ·the OR.

·8· · · · · Q· ·And neither should Dr. Bouza, correct?

·9· · · · · A· ·Correct.

10· · · · · Q· ·So going back to your opinion that "never

11· ·definitively addressed what was causing the

12· ·intraabdominal wall perforation," what do you mean by

13· ·that?

14· · · · · A· ·I mean, one, there is plenty of evidence in

15· ·what happened after the 24th that there was a

16· ·perforation.

17· · · · · Q· ·What evidence is that?

18· · · · · A· ·Well, the patient subsequently went on to

19· ·have recurring problems with pain, with constipation,

20· ·with eventual break down of the region of the wound

21· ·where the drain was put, and eventually ended up with

22· ·inter-cutaneous fistula, all of which are evidence of

23· ·a perforation that was festering and it was never

24· ·successfully resolved.

25· · · · · Q· ·When you say successfully resolved, you


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·mean there needs to be a surgical solution to those

·3· ·clinical manifestations, correct?

·4· · · · · A· ·Right.

·5· · · · · Q· ·Once again, that is within the realm and

·6· ·expertise of the surgeon?

·7· · · · · A· ·True.

·8· · · · · Q· ·So what do you think should have been done,

·9· ·if anything differently in this case, that you feel

10· ·qualified to testify about?


12· · · · · · · THE WITNESS:· Now you are asking me what to

13· ·venture into what should have been done --

14· · · · · · · BY MR. MIDWALL:

15· · · · · Q· ·Let me ask you this way, because you do

16· ·provide an opinion, that "subsequently never had it

17· ·definitively addressed."· It sounds like you are

18· ·saying this was a surgical response that was

19· ·necessary?

20· · · · · A· ·Right.

21· · · · · Q· ·So you are not blaming Dr. Bouza for that,

22· ·correct?


24· · · · · · · THE WITNESS:· Well, if not for the

25· ·perforation, there would not have been a need to


·2· ·address anything.

·3· · · · · · · BY MR. MIDWALL:

·4· · · · · Q· ·Right, but you are not blaming Dr. Bouza

·5· ·for the surgical decisions made by Dr. Martinez in

·6· ·this case, correct?


·8· · · · · · · THE WITNESS:· Let me just say, the

·9· ·definitive remedy, whether surgical or not surgical,

10· ·was to find the hole and remove the hole and to

11· ·re-hook things up so they were in normal continuity

12· ·without any holes.· That is what needed to be done.

13· ·Now this ended up being something that needed to be

14· ·done surgically, but both of the doctors are

15· ·physicians who are tasked with the care of this lady

16· ·and they need to see her through a very stormy course

17· ·to a successful outcome and I think there is some

18· ·co-participation even if it is done by the surgeon to

19· ·find the hole and fix the hole.

20· · · · · Q· ·You understand clinically from August 24,

21· ·2012, to September 1, 2012, the day the plaintiff went

22· ·home from Kendall Regional Medical Center, she was

23· ·improving, correct?

24· · · · · A· ·Correct, and I think Dr. Bouza did write a

25· ·note saying something like that and I think both he


·2· ·and Dr. Martinez kind of missed the boat and the facts

·3· ·of what transpired after that showed they both called

·4· ·it wrong.

·5· · · · · Q· ·What do you mean the "facts of what

·6· ·transpired later"?

·7· · · · · A· ·She ended up getting sicker again in the

·8· ·first week of September and ended up going to Baptist

·9· ·on the 17th of September shows that they were

10· ·incorrect in their assumption she was getting better.

11· · · · · Q· ·Well, clearly Dr. Martinez, at least from

12· ·his operative note, was performing procedures to deal

13· ·with a suspected perforated viscus, correct?


15· · · · · · · THE WITNESS:· But he never identified and

16· ·fixed the perforation.

17· · · · · · · BY MR. MIDWALL:

18· · · · · Q· ·Once again that is not Dr. Bouza's job or

19· ·responsibility, correct?


21· · · · · · · THE WITNESS:· It was not his job but --

22· · · · · · · BY MR. MIDWALL:

23· · · · · Q· ·Dr. Bouza was not in the operating room

24· ·telling him what to fix, correct?

25· · · · · A· ·That might not have been a bad idea


·2· ·actually.

·3· · · · · Q· ·Is it your testimony that the standard of

·4· ·care required Dr. Bouza to have been in the operating

·5· ·room with Dr. Martinez when he performed the

·6· ·laparotomy?

·7· · · · · A· ·All I said was it might not have been a bad

·8· ·idea in retrospect.· It is not the standard of care,

·9· ·but there was a perforation.· It was not successfully

10· ·identified.· It was not successfully fixed.· The

11· ·outcome is in these records we have before us.

12· · · · · Q· ·But to Dr. Bouza, when he spoke with

13· ·Dr. Martinez after the surgery, that an

14· ·intra-abdominal drain was placed?

15· · · · · A· ·Yes.

16· · · · · Q· ·Although he is not a surgeon, it was

17· ·reasonable for Dr. Bouza to have seen that, been done,

18· ·and say, okay, that was a reasonable step to be taken

19· ·by the surgeon, correct?


21· · · · · · · THE WITNESS:· I wouldn't agree with that.

22· · · · · · · BY MR. MIDWALL:

23· · · · · Q· ·It was inappropriate for an intra-abdominal

24· ·drain to be placed?

25· · · · · A· ·As the only treatment, that would have


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·gotten me very worried.

·3· · · · · Q· ·What is an enterotomy?

·4· · · · · A· ·An enterotomy is a hole in the intestine.

·5· · · · · Q· ·That is what Dr. Martinez was going to do,

·6· ·he was going to repair the enterotomy?

·7· · · · · A· ·No, there was an incidental enterotomy,

·8· ·which, when he was going into the abdomen with its

·9· ·previous adhesions, that means that he accidentally

10· ·cut into some small bowel and he did repair that.· But

11· ·that is a good point.· If he had made that enterotomy

12· ·and decided not to fix it, and left a drain where the

13· ·enterotomy was that he created, that would not have

14· ·been smart.· He fixed his own enterotomy.· There was

15· ·another one where the perforation was.· He never

16· ·really found that.· He never repaired it.· He just put

17· ·a drain in.

18· · · · · · · To me as a gastroenterologist, even though

19· ·I didn't do the cutting, I know that is not a good

20· ·idea.· Dr. Bouza should have recognized that wasn't a

21· ·good idea.

22· · · · · Q· ·Dr. Martinez, one of the things he was to

23· ·do when he performed the laparotomy was to look for

24· ·any perforations, correct?

25· · · · · A· ·Right.


·2· · · · · Q· ·And Dr. Martinez describes in his operative

·3· ·note what he saw?

·4· · · · · A· ·Right.

·5· · · · · Q· ·Did he see the presence of a perforation?


·7· · · · · · · THE WITNESS:· He did not see a perforation.

·8· · · · · · · BY MR. MIDWALL:

·9· · · · · Q· ·Did he see the presence of feces?

10· · · · · A· ·He did not see feces.

11· · · · · Q· ·Did he see the presence of stool

12· ·contamination?

13· · · · · A· ·Apparently he did not.

14· · · · · Q· ·Obviously Dr. Martinez, part of his job was

15· ·to wash out stool contamination to the extent there

16· ·was any and lavage the area so there could be

17· ·decreased possibility of infection, correct?


19· · · · · · · THE WITNESS:· Right.

20· · · · · · · BY MR. MIDWALL:

21· · · · · Q· ·And it looks like in the days following the

22· ·operation performed by Dr. Martinez, that at least per

23· ·Dr. Bouza's rounding on the patient each day, he felt

24· ·from a gastroenterology perspective that the patient,

25· ·Ms. Mayor, was doing better, correct?


·2· · · · · A· ·That is what he wrote.

·3· · · · · Q· ·He found her to have decreased bowel

·4· ·sounds?

·5· · · · · A· ·Yes.

·6· · · · · Q· ·What does that mean, in the context of this

·7· ·patient?

·8· · · · · A· ·Decreased bowel sounds?

·9· · · · · Q· ·Yes.

10· · · · · A· ·That is a relative term.· Decreased bowel

11· ·sounds would sometimes mean that the intestines are

12· ·not really contracting in a normal peristaltic manner.

13· ·So that is not such a good thing.

14· · · · · Q· ·There was bowel sounds, correct?

15· · · · · A· ·There were some, yes.

16· · · · · Q· ·If there is a perforation do you hear bowel

17· ·sounds?

18· · · · · A· ·You may hear diminished bowel sounds or you

19· ·may hear no bowels sounds and diminished or decreased

20· ·are very similar.

21· · · · · Q· ·What about bowel movements, do patients

22· ·typically have bowel movements?

23· · · · · A· ·Many days they won't, and in her case, six

24· ·or seven.

25· · · · · Q· ·She had a bowel movement on the 3rd of


·2· ·August?

·3· · · · · A· ·If we count from the colonoscopy, that

·4· ·would be seven days out a bowel movement.· That is

·5· ·also worrisome.

·6· · · · · Q· ·On the 29th of August she had good bowel

·7· ·sounds per Dr. Bouza's note?

·8· · · · · A· ·Right.

·9· · · · · Q· ·That is clinically a sign or symptom that

10· ·can indicate there is no perforation, right?


12· · · · · · · THE WITNESS:· That is a lot of conclusion

13· ·to hang on one physical finding.

14· · · · · · · BY MR. MIDWALL:

15· · · · · Q· ·We have a patient markedly improving in

16· ·terms of her abdominal exam, correct?

17· · · · · A· ·Yes.

18· · · · · Q· ·It is a patient who as of August 29 is in

19· ·no distress or abdominal discomfort, correct?

20· · · · · A· ·Right.

21· · · · · Q· ·There were bowel signs present per the

22· ·nurses' notes and per Dr. Bouza's findings on August

23· ·30, correct?

24· · · · · A· ·Yes.

25· · · · · Q· ·We have as of August 30 the patient having


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·a small bowel movement, correct?

·3· · · · · A· ·Right.

·4· · · · · Q· ·This is a trend that once again the patient

·5· ·is improving?

·6· · · · · A· ·She is improving in terms of not having

·7· ·generalized peritoneum, yes, but she was on strong IV

·8· ·antibiotics.· She was getting a lot of supportive

·9· ·care.· Because of the fact that this was a localized

10· ·perforation, it didn't cause manifestations in her

11· ·whole bowel, she eventually had a bowel movement, but

12· ·look at what played out.· This area broke down further

13· ·because there was a hole that was never fixed and it

14· ·bore out through the abdominal wall and caused

15· ·necrotizing fascitis.

16· · · · · Q· ·As of August 30, 2012, we have a patient

17· ·that has been trending in a positive direction,

18· ·correct?

19· · · · · A· ·It is just a false sense of security but,

20· ·yes -- okay, they did have a false sense of security.

21· · · · · Q· ·Retrospectively?

22· · · · · A· ·Well, prospectively too.· The problem is

23· ·they never really remedied the hole.

24· · · · · Q· ·Prospectively, what sign or symptom can you

25· ·cite to as of August 30, 2012 that showed that there


·2· ·was a concern that this patient may be having

·3· ·peritonitis?

·4· · · · · A· ·Well, I think that she had a drainage tract

·5· ·and I don't know whether they did extensive cultures

·6· ·of the drainage tract or whether they did a fistula

·7· ·gram through the drainage tract, which would have been

·8· ·a good idea.· They didn't really keep looking to see

·9· ·if there was a problem.· They did get a false sense of

10· ·security that there didn't seem to be a problem, but

11· ·we know from what happened afterwards, that that was a

12· ·false sense of security, so they could have done more

13· ·aggressive studies to look at what was going on right

14· ·here, before the time it started to necrose and break

15· ·down and rot.

16· · · · · Q· ·Is it your opinion that Dr. Bouza was

17· ·responsible for that?


19· · · · · · · THE WITNESS:· I think Dr. Bouza was

20· ·responsible for the perforation and the perforation

21· ·was the result of a procedure that never should have

22· ·been done and then all of the downstream consequences

23· ·are the result of the subsequent care.

24· · · · · Q· ·I didn't quite understand that answer.· Can

25· ·you answer my question?· Do you blame Dr. Bouza for


·2· ·what you thought was a false sense of security?

·3· · · · · A· ·In part, yes.

·4· · · · · Q· ·Why?

·5· · · · · A· ·Because he knew that there was a

·6· ·perforation, he knew that the only thing that had been

·7· ·done about the perforation was to put in the drain,

·8· ·and he did not -- he did not take the steps to make

·9· ·sure that the problem had been completely rectified.

10· · · · · Q· ·And what steps would those have been?

11· · · · · A· ·Well, I think when they did the CAT scan on

12· ·the 4th of September there was still a substantial

13· ·amount of air, although less, in the right upper

14· ·quadrant.· They probably could have done something a

15· ·little bit more definitive.· They could have done a

16· ·virtual colonoscopy.· They could have done a fistula

17· ·gram through the drainage tract.· There was a drain

18· ·coming out of a stab wound in her abdomen.· They could

19· ·have gone in with gastrografin and dye to see if that

20· ·drain communicated with the bowel.· Those would have

21· ·been two useful tests that were not done.

22· · · · · Q· ·Can you cite to any literature in support

23· ·of that opinion?

24· · · · · A· ·You are asking me for clinical

25· ·recommendations of the things that could be doable to


·2· ·make sure everything was okay.· That is just my

·3· ·clinical training and all so I can't give you specific

·4· ·studies but those are studies that are useful to look

·5· ·at anatomy in a situation like that.

·6· · · · · Q· ·Did the lipoma in this case resemble any

·7· ·characteristics of a neoplastic polyp?

·8· · · · · A· ·Pretty much it is like -- pretty much all

·9· ·of the attributes, the smooth glistening surface, the

10· ·mound effect, the slightly yellowish color, all look

11· ·like lipoma.· There is nothing that would push me

12· ·toward neoplasm at all.

13· · · · · Q· ·Is it your testimony there is nothing that

14· ·you can visualize from the scope that in any way

15· ·resembles a neoplastic polyp?


17· · · · · · · THE WITNESS:· It is just a bump sticking

18· ·out from a wall.· That is it.

19· · · · · · · BY MR. MIDWALL:

20· · · · · Q· ·And everything else that you visualize from

21· ·the lipoma, in your mind -- any GI physician

22· ·performing scopes could determine this was absolutely

23· ·a lipoma?

24· · · · · A· ·I would think any GI that was worth his

25· ·salt would recognize this as a lipoma.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·You agree that from August 24, 2012 until

·3· ·her discharge September 1, 2012, the plaintiff did not

·4· ·have any signs of an infection?

·5· · · · · A· ·Well, I know she had a normal white count

·6· ·and no fever, but she was on big time antibiotics.

·7· ·Those caveats being said, she didn't have any clear

·8· ·signs of infection.

·9· · · · · Q· ·You see patients who have had significant

10· ·IV antibiotics and still have an elevated white blood

11· ·cell count, correct?

12· · · · · A· ·Yes.

13· · · · · Q· ·Why is it that perceived neoplastic polyps

14· ·need to be removed right away?

15· · · · · A· ·That is like two questions.· I think

16· ·neoplastic polyps need to be removed because they have

17· ·cancerous potential.· The second part is perception

18· ·versus misperception.· It is important that a doctor

19· ·be able to tell what is neoplastic and what is not

20· ·neoplastic.· This was misperception by Dr. Bouza.· But

21· ·neoplastic polyps should be removed.

22· · · · · Q· ·Have you ever had a patient whom has had a

23· ·perforation for two weeks without any fever, stool

24· ·leakage, elevated white blood cell count?

25· · · · · A· ·In my personal experience, no, but I have


·2· ·seen patients who are post-surgical who have a drain

·3· ·in place which then allows for whatever infection

·4· ·there is to kind of like not be retained in the

·5· ·abdominal cavity and kind of like wick out and in a

·6· ·lot of those patients they have an infection but it is

·7· ·a drain infection and we used to have patients with

·8· ·abdominal abscesses and radiologists would put a thick

·9· ·catheter in the abscess and drain it externally and

10· ·the patients would look fine, but they still had a

11· ·fistula or abscess or hole in their gut but it was

12· ·being trained externally so they were fine.

13· · · · · Q· ·There is fatty growth associated with

14· ·neoplastic polyps, correct?

15· · · · · A· ·Fatty growth associated with neoplastic

16· ·polyps?· Not in the colon, you won't see a neoplastic

17· ·that has a fatty tumor with it.

18· · · · · Q· ·There can be a layer of mucosa over a

19· ·neoplastic, correct?

20· · · · · A· ·Very unusual.· The neoplasm arises from the

21· ·mucosa layer and then grows out and down or down and

22· ·out but it is right at the top layer that the disease

23· ·is.

24· · · · · Q· ·In your experience, when a perforation

25· ·occurs you will have peritonitis occur almost right


·2· ·away, correct?

·3· · · · · A· ·You know, with these injuries that are

·4· ·largely thermal in addition to mechanical, it can come

·5· ·up within a couple of days.

·6· · · · · Q· ·Typically within 48 hours?

·7· · · · · A· ·72 at the outside.

·8· · · · · Q· ·Outside of 72 hours is very, very atypical?

·9· · · · · A· ·You had a person here in antibiotics and

10· ·the drain in the right upper quadrant so all of the

11· ·bad stuff was being drawn out through the drain.· You

12· ·can see the ultimate outcome.· The patient never

13· ·really had global peritonitis.· What she ended up with

14· ·was a fistulous tract, where her intestines formed the

15· ·fistula to her skin so all of the fecal material went

16· ·into the abdominal wall and then burned a hole in her

17· ·abdominal wall and came out through the skin.· So all

18· ·of the bad stuff was being drawn out through a tract,

19· ·but it was still bad stuff.

20· · · · · Q· ·Ultimately why did she develop peritonitis?

21· · · · · A· ·Because of the perforation.

22· · · · · Q· ·Why did it take for over two weeks for the

23· ·peritonitis to develop?


25· · · · · · · THE WITNESS:· She was getting broad


·2· ·spectrum antibiotics.· The drain was steering all of

·3· ·the liquid feces and bacteria and all of the bad

·4· ·things from the hole in her intestines out through the

·5· ·abdominal wall.· Eventually that part that got stuck

·6· ·to the abdominal wall caused the necrotizing fascitis,

·7· ·but that is all a localized process.· The reason it

·8· ·was not generalized peritonitis for a few weeks, was

·9· ·all the infection was being period steered and

10· ·detoured into her right abdominal wall.

11· · · · · Q· ·Were there any irregularities on the

12· ·lipoma?


14· · · · · · · THE WITNESS:· If you look at the picture,

15· ·which is all we have besides the path report, it was

16· ·pretty much smooth and fairly regular.

17· · · · · · · BY MR. MIDWALL:

18· · · · · Q· ·Were there any irregularities, though?


20· · · · · · · THE WITNESS:· No, it looks pretty smooth

21· ·and well rounded to me.

22· · · · · · · BY MR. MIDWALL:

23· · · · · Q· ·What is a benign polyp?


25· · · · · · · THE WITNESS:· Benign means not cancerous.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · · · BY MR. MIDWALL:

·3· · · · · Q· ·That is how you would characterize it?

·4· · · · · A· ·What, benign?

·5· · · · · Q· ·Yes.

·6· · · · · A· ·Benign means something is not cancerous and

·7· ·polyp is a descriptive term that has to do with the

·8· ·shape of something on the wall of the intestine,

·9· ·something that is protruding from the wall or an

10· ·irregularity on the wall.· Those are the words.

11· · · · · Q· ·Should benign polyps ever be removed using

12· ·the hot snare?


14· · · · · · · THE WITNESS:· Benign neoplastic polyps

15· ·should be removed using a hot snare sometimes, yes.

16· · · · · · · BY MR. MIDWALL:

17· · · · · Q· ·If the plaintiff had had her colon cancer

18· ·resected six years prior to seeing Dr. Bouza, would

19· ·that change your opinion in any way?

20· · · · · A· ·If it was six years then there would have

21· ·been an extremely small, maybe one in 50,000 chance

22· ·that this -- that a lesion like this could be related

23· ·to recurring colon cancer, but six years would be

24· ·pretty much the limit.

25· · · · · Q· ·Do you still advertise your willingness to


·2· ·do medical-legal reviews?


·4· · · · · · · THE WITNESS:· I never have.

·5· · · · · · · BY MR. MIDWALL:

·6· · · · · Q· ·I thought you list yourself with MedQuest?

·7· · · · · A· ·I think I ceased doing any work with them

·8· ·maybe ten years ago and I don't think I ever knew if

·9· ·they advertised -- I think I told them not to use my

10· ·name in any advertisements.· Unless you have seen

11· ·something, I have never advertised.

12· · · · · Q· ·Do you still refuse to take any cases

13· ·against Maryland area gastroenterologist's?


15· · · · · · · THE WITNESS:· I think I had done one about

16· ·20 years ago.· I think that was the last one.· I would

17· ·rather not do that, but I have taken some cases

18· ·against doctors in Virginia which is right across the

19· ·river.

20· · · · · · · BY MR. MIDWALL:

21· · · · · Q· ·You don't practice in any Virginia-based

22· ·hospital?

23· · · · · A· ·No.

24· · · · · Q· ·Can you cite to any literature or

25· ·guidelines that state that you are not to remove a


·2· ·lipoma?

·3· · · · · A· ·It is just kind of gastroenterology 101.

·4· ·Going back to the Hippocratic oath, we had it

·5· ·summarized as "first do no harm."· This is a good

·6· ·example of this "first do no harm" dictum which is

·7· ·over a thousand years old.· A lipoma being a lesion

·8· ·without any malignant potential, to put somebody at

·9· ·risk, as happened here, we know that is something you

10· ·would never do.· Or only the rare, rare case where it

11· ·is symptomatic.

12· · · · · Q· ·You talk about your opinions as it pertains

13· ·to the pathology report?

14· · · · · A· ·We did.

15· · · · · Q· ·You understand that the plaintiff has

16· ·recovered from the perforation, correct?

17· · · · · A· ·I do understand that, yes.

18· · · · · Q· ·As we sit here today can you cite to any

19· ·permanent injuries that the plaintiff has sustained

20· ·because of the perforation?

21· · · · · A· ·Well, you know, I think that is something I

22· ·can't answer in detail, but I know that her family and

23· ·her own performance status is probably not completely

24· ·back to where it was back in 2011 when she was a very

25· ·independent and viable person.


·2· · · · · Q· ·Based upon your review of the materials in

·3· ·this case can you provide an opinion within a

·4· ·reasonable degree of medical probability that the

·5· ·plaintiff has sustained an injury because of the

·6· ·perforation?

·7· · · · · A· ·I can only refer to the daughter-in-law and

·8· ·her talking, granted it was a while ago, about the

·9· ·mother-in-law's constant pain and inability to drive

10· ·herself around and she has an activity level that is

11· ·not what it used to be.· That is all I can say.

12· · · · · Q· ·Do you know what the current activity level

13· ·of the plaintiff is?

14· · · · · A· ·I think she is living on her own, she is

15· ·pretty much house-bound, she doesn't drive herself,

16· ·she has frequent pain.

17· · · · · Q· ·What is the source of that?

18· · · · · A· ·What is the source of that comment --

19· · · · · Q· ·That the plaintiff is house-bound, can't

20· ·drive and has frequent pain?

21· · · · · A· ·I think that is from the daughter-in-law's

22· ·deposition, but that was a while back.

23· · · · · Q· ·Maybe a year or so back.· That was

24· ·pre-dialysis?

25· · · · · A· ·True.


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · Q· ·Do you know as we sit here to a reasonable

·3· ·degree of medical certainty under oath if the

·4· ·plaintiff has any permanent injuries because of the

·5· ·perforation, yes or no?

·6· · · · · A· ·I don't know.


·8· · · · · · · BY MR. MIDWALL:

·9· · · · · Q· ·We have gone over all of your opinions?

10· · · · · A· ·We have.

11· · · · · Q· ·I think that is all my questions.

12· · · · · · · MR. SMITH:· I have a few.

13· · · · · · · EXAMINATION BY COUNSEL FOR PLAINTIFF

14· · · · · · · BY MR. SMITH:

15· · · · · Q· ·Mr. Midwall just asked you if Ms. Mayor

16· ·suffered any permanent injuries as a result of the

17· ·colonoscopy perforation -- do you remember that?

18· · · · · A· ·I do.

19· · · · · Q· ·I want you to take a look at that picture

20· ·and tell me what you see in that picture?

21· · · · · A· ·She has a very long vertical scar extending

22· ·from about the end of her breast bone to just above

23· ·the pubis.· She has a lateral scar.· She has a big

24· ·sort of closed-in defect in the right abdominal wall

25· ·that is probably where she had her big abdominal wound


·2· ·but that closed in through secondary healing.· So she

·3· ·has like a big pucker where the ostomy may have been

·4· ·or the wound may have been.· She also has another one

·5· ·lateral, kind of a tilted scar from her right flank

·6· ·down heading towards that ostomy site.

·7· · · · · Q· ·Are those injuries that you see in that

·8· ·picture, are those permanent?

·9· · · · · A· ·Those are permanent.

10· · · · · Q· ·Are those related to the colon perforation?

11· · · · · A· ·Absolutely.

12· · · · · Q· ·So when you testified earlier that you

13· ·couldn't say whether she had a permanent injury, can

14· ·you now say at least looking at those pictures, that

15· ·she has at least as to those pictures and her scars

16· ·has suffered a permanent injury as a result of the

17· ·colon perforation?

18· · · · · A· ·Based on these pictures she has suffered

19· ·permanent injuries, yes.

20· · · · · Q· ·Is that opinion likewise to a reasonable

21· ·degree of medical certainty?

22· · · · · A· ·Yes, it is.

23· · · · · Q· ·And you have read Dr. Whittwell's, W H I T

24· ·T W E L L, deposition about the surgery he did?

25· · · · · A· ·I have.


·2· · · · · Q· ·Can you tell us what type of procedure he

·3· ·performed?

·4· · · · · A· ·He had to take out a big block of tissue

·5· ·which was probably about 13 by 18 centimeters to

·6· ·remove a bunch of necrotized abdominal wall.· She had

·7· ·drainage of fecal material up into the abdominal wall

·8· ·causing necrotizing fascitis and abdominal wall

·9· ·abscess, so there was a large subcutaneous abscess

10· ·because of where the infection had tunnelled out and

11· ·he removed an area of necrotic muscle and fascia

12· ·measuring 25 by 13 centimeters and then also he said

13· ·there was an obvious perforation of the colon exposed

14· ·here where the stool was coming out.

15· · · · · Q· ·Did he perform any type of ileostomy on

16· ·her?

17· · · · · A· ·He did.· In addition to the debridement and

18· ·removal of muscle and facia, he did an ileostomy.

19· · · · · Q· ·Now, in performing the procedures you read

20· ·in his op note there, did that alter her anatomy in

21· ·any way?

22· · · · · · · MR. MIDWALL:· Form.

23· · · · · · · THE WITNESS:· The ileostomy would bring all

24· ·of the intestinal contents out of through the skin and

25· ·they remove the remaining colon as a blind loop for a


·2· ·while, until December when he hooked her back up

·3· ·again, three months later.

·4· · · · · · · BY MR. SMITH:

·5· · · · · Q· ·So the anatomy after the procedure would

·6· ·not have been the anatomy she was born with, correct?

·7· · · · · A· ·Right.

·8· · · · · Q· ·So any changes or alterations to that type

·9· ·of anatomy that she was born with would be a permanent

10· ·change, correct?

11· · · · · A· ·Exactly, yes.

12· · · · · Q· ·So at least as of Dr. Whittwell's operative

13· ·report she also had some permanent injuries that you

14· ·would relate to the colon perforation Dr. Bouza

15· ·caused?

16· · · · · A· ·Right, she lost a substantial portion of

17· ·her right abdominal wall and some additional

18· ·intestines.

19· · · · · · · MR. MIDWALL:· Objection.

20· · · · · · · BY MR. SMITH:

21· · · · · Q· ·And that opinion is to a reasonable degree

22· ·of medical probability?

23· · · · · A· ·It is.

24· · · · · Q· ·I also wanted to ask you real quick, we

25· ·alluded to it earlier, and I don't know that opposing


1· · · · · · · · · · · ·DR. NEIL JULIE

·2· ·counsel asked you, but you have had an opportunity to

·3· ·review Ms. Mayor's post colonoscopy medical and

·4· ·hospital records that you identified for us earlier?

·5· · · · · A· ·There was a Riviera Center and Health South

·6· ·and one other M and somebody -- M and L.

·7· · · · · Q· ·And you also reviewed the multiple Baptist

·8· ·Hospital admissions?

·9· · · · · A· ·I did.

10· · · · · Q· ·From September through January of 2013?

11· · · · · A· ·Right.· There were several.

12· · · · · Q· ·And you provided and reviewed the Health

13· ·South Rehab Hospital records?

14· · · · · A· ·Yes.

15· · · · · Q· ·And the Kindred Hospital records?

16· · · · · A· ·Yes.

17· · · · · Q· ·And you provided and reviewed the Riviera

18· ·Health Resort and St. Anne's Nursing Center records?


20· · · · · Q· ·And you were provided some type of health

21· ·health care, M and K Home Health Care records?

22· · · · · A· ·Yes.

23· · · · · Q· ·That is in addition to the Kendall Regional

24· ·Medical Center records for the two admissions we

25· ·discussed earlier?


·2· · · · · A· ·That is correct.

·3· · · · · Q· ·Was that medical care and treatment, the

·4· ·records you were provided and reviewed, was that

·5· ·necessitated or caused, needed, by Dr. Bouza's colon

·6· ·perforation and negligence in this case?

·7· · · · · · · MR. MIDWALL:· Objection.

·8· · · · · · · THE WITNESS:· All of that was negligence

·9· ·and it arose from the difficult course she had after

10· ·the perforation of the colon.

11· · · · · · · BY MR. SMITH:

12· · · · · Q· ·Was the post colonoscopy medical and

13· ·hospital care and treatment necessary and reasonable

14· ·that she received?

15· · · · · · · MR. MIDWALL:· Objection.

16· · · · · · · THE WITNESS:· Yes, it was necessary and

17· ·reasonable and her injuries were grave as the

18· ·photographs demonstrated and it is wonderful she has

19· ·recovered as much as she has.

20· · · · · · · BY MR. SMITH:

21· · · · · Q· ·And are those opinions held to a reasonable

22· ·degree of medical probability?

23· · · · · A· ·They all are.

24· · · · · Q· ·I don't have any further questions.

25· · · · FURTHER EXAMINATION BY COUNSEL FOR DEFENDANT


·2· · · · · · · BY MR. MIDWALL:

·3· · · · · Q· ·By your own testimony she has recovered

·4· ·wonderfully, correct?

·5· · · · · A· ·I think it is wonderful she has done this

·6· ·well.· Considering what she went through, it is quite

·7· ·remarkable, but I would imagine she still have some

·8· ·residual issues that she would not have had had she

·9· ·not had this sequence of events.

10· · · · · Q· ·You have no idea what residual issues she

11· ·has or does not have; isn't that correct?

12· · · · · A· ·I think the records can speak for

13· ·themselves.

14· · · · · Q· ·Those records are from two years ago in

15· ·some cases.· Can you provide any documentation,

16· ·records or anything to support the opinion you just

17· ·provided?

18· · · · · A· ·No, I cannot.

19· · · · · Q· ·Thank you.

20· · · · · · · THE COURT REPORTER:· Mr. Smith, do you want

21· ·a copy of the transcript?

22· · · · · · · MR. MIDWALL:· Read or waive?

23· · · · · · · MR. SMITH:· Read.

24· · · · · · · MR. MIDWALL:· I will order along with the

25· ·exhibits.


·2· · · · · · · MR. SMITH:· Yes, he will read and I would

·3· ·like a copy.

·4· · · · · · · MR. MIDWALL:· Hold on, while you are still

·5· ·here, let's make another composite exhibit of the

·6· ·correspondence that the doctor has received from the

·7· ·plaintiff's firm, and we will mark the deposition

·8· ·excerpts that you brought with you here today as the

·9· ·next composite exhibit.

10· · · · · · · · · · · · ·(Julie Exhibit Nos. 7-8

11· · · · · · · · · · · · ·were marked for identification.)

12· · · · · · · (Signature having not been waived, the

13· ·deposition of DR. NEIL JULIE was concluded at 4:42

14· ·p.m.)

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1· · · · · · · · · · · ·DR. NEIL JULIE

·2· · · · · · · · ·ACKNOWLEDGEMENT OF DEPONENT

·3· · · · · ·I, DR. NEIL JULIE, do hereby acknowledge that

·4· ·I have read and examined the foregoing testimony, and

·5· ·the same is a true, correct and complete transcription

·6· ·of the testimony given by me and any corrections

·7· ·appear on the attached Errata Sheet signed by me.

·8

·9

10· ·____________________· · · · ·_____________________

11· · · · (Date)· · · · · · · · · · · (Signature)

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·2· · · CERTIFICATE OF SHORTHAND REPORTER - NOTARY PUBLIC

·3· · · · · ·I, Cathy Jardim, Professional Reporter, the

·4· ·officer before whom the foregoing proceedings were

·5· ·taken, do hereby certify that the foregoing transcript

·6· ·is a true and correct record of the proceedings; that

·7· ·said proceedings were taken by me stenographically and

·8· ·thereafter reduced to typewriting under my

·9· ·supervision; and that I am neither counsel for,

10· ·related to, nor employed by any of the parties to this

11· ·case and have no interest, financial or otherwise, in

12· ·its outcome.

13· · · · · ·IN WITNESS WHEREOF, I have hereunto set my

14· ·hand and affixed my notarial seal this 12th day of May

15· ·2015.

16· ·My commission expires:

17· ·July 31, 2017

18· ·________________________

19· ·NOTARY PUBLIC IN AND FOR THE

20· ·State of Maryland

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·2· · · · · · · · · ·E R R A T A· S H E E T

·3· · · ·IN RE:· Mayor v. Bouza

·4· ·RETURN BY:

·5· ·PAGE· · ·LINE· · · · · · · ·CORRECTION AND REASON

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