Joseph Carfi, M.D. May 22, 2012 - LTC Forumltcrisklegalforum.com/wp-content/uploads/2019/10/...May...

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SUPERIOR COURT

JUDICIAL DISTRICT OF DANBURY AT DANBURY

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STEPHANIE GHANNAM, et al.,

Docket No.

-v- DBD-CV-10-6004754-S

PATRICE S. GILLOTTI, M.D.,

et al.,

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DEPOSITION OF JOSEPH CARFI, M.D., a

Witness on behalf of the Plaintiff herein,

taken by Defendants, pursuant to Notice, at

the offices of Physiatry Associates, P.C.,

2001 Marcus Avenue, Lake Success, New York, on

Tuesday, May 22, 2012, at 10:50 a.m., before

Margaret Eustace, a Shorthand Reporter and

notary public, within and for the State of New

York.

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3 IT IS HEREBY STIPULATED AND AGREED4 that all objections, except as to the form of5 the questions, shall be reserved to the time6 of the trial;7 IT IS FURTHER STIPULATED AND AGREED8 that the within examination may be subscribed9 and sworn to before any notary public with the

10 same force and effect as though subscribed and11 sworn to before this court.12

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212 A P P E A R A N C E S :3 THE BERKOWITZ LAW FIRM LLC

Attorneys for Plaintiffs4 1010 Washington Boulevard

Stamford, Connecticut 069015 (203) 324-7909

BY: RUSSELL J. BERKOWITZ, ESQ.67 DANAHER LAGNESE, P.C.

Attorneys for Defendants Patrice8 Gillotti and Physicians for Women

21 Oak Street, Suite 7009 Hartford, Connecticut 06106

(860) 247-366610 BY: LAURA E. WALTMAN, ESQ.11 O'BRIEN TANSKI & YOUNG

Attorneys for Defendant Danbury12 Hospital

CitiPlace II13 Hartford, Connecticut 06103-3402

(8600 525-270014 BY: REBECCA M. HARRIS, ESQ.15 * * *16171819202122232425

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2 (Defendants' Exhibit A, the3 Notice, was marked for4 identification.)5

6 (Defendants' Exhibit B, Cover7 Letter, was marked for8 identification.)9

10 (Defendants' Exhibit C,11 Prescription Page, was marked12 for identification.)13

14 Whereupon,15 JOSEPH CARFI,16 after having been first duly sworn, was17 examined and testified as follows:18 EXAMINATION19 BY MS. WALTMAN:20 Q. Good morning, sir. My name is Laura21 Waltman. I represent Dr. Gillotti and her22 practice group. I know you have been deposed23 before, but I would like to just review the24 ground rules to be sure that you and I are on25 the same page.

Joseph Carfi, M.D. May 22, 2012

Toll Free: 800.211.DEPOFacsimile: 212.557.5972

1384 Broadway - 19th FloorNew York, NY 10018

www.esquiresolutions.com

51 J. Carfi2 I am going to ask you a series of3 questions. Please just listen carefully,4 answer to the best of your ability. If you5 don't hear me or don't understand my question,6 please don't answer it. Stop and let me know.7 If you go ahead and answer, I will assume you8 understood the question.9 As you can see, we have a court10 reporter taking down everything said in the11 room. For that reason, please wait for me to12 finish before you start and I will wait for13 you to finish before I restart. If we speak14 at the same time, it will be hard for her to15 take down what we are saying.16 Please make sure you answer out loud17 and keep your voice up. If you point to18 something or use your hands in any way, we19 will all understand you but she can't take20 that down.21 If you need to take a break at any22 time, just let me know.23 Any questions so far?24 A. No. I understand.25 Q. What is your full name, sir?

71 J. Carfi2 services provided by this office?3 A. I have a general physiatric practice,4 just me. I have patients that come in to see5 me. I evaluate them, diagnose their6 condition, provide treatment and help them to7 get better.8 But I also have patients who have9 chronic disabilities like spinal cord

10 patients, brain injuries, amputations,11 multiple sclerosis. Clearly, they don't get12 better but they need to be managed, they have13 needs that require management, whether it's14 equipment or services, sometimes they have15 pain that has to be taken care of. So that's16 kind of a mix between acute pain types of17 situations, orthopedic issues and chronic18 disability management problems.19 Q. You may have just answered my next20 question in your last answer but what is the21 medicine of physiatry?22 A. Physiatry is a specialty in which we23 are trained to take care of people who have24 disabilities. Some of those disabilities are25 temporary, as I just said, somebody comes in

61 J. Carfi2 A. Joseph Carfi.3 Q. Ever known by any other name?4 A. No.5 Q. What is the name of the medical6 practice that we are situated in?7 A. It is called Physiatry Associates,8 PC.9 Q. Is this your business?

10 A. Yes.11 Q. Are you the sole owner?12 A. Yes.13 Q. Do you have employees?14 A. Yes.15 Q. How many?16 A. I have one full-time and one, two,17 three part-time.18 Q. The full-time, what position is that?19 A. Office manager.20 Q. And the three part-times?21 A. I have a billing person, I have a22 front office person, and I have a nurse who23 helps organize the files that I have to review24 and such.25 Q. What is the nature of the clinical

81 J. Carfi2 with acute shoulder pain or neck pain, maybe3 they are, quote, temporarily disabled,4 unquote, but we diagnose, treat, get people5 better.6 The other big aspect of what we do is7 taking care of people with permanent8 disabilities, as I mentioned, spinal cord9 injuries and things such as that. But we are

10 actually trained to take care of the human11 being that has a disabling condition, so12 somebody who is paralyzed from the waist dawn,13 that is their condition, but that human being14 is going to have vocational issues, they're15 going to have emotional issues, as well as16 functional issues, equipment and therapy17 needs. So we take care of basically the18 person that's got that disabling condition.19 Q. Does a physiatrist provide those20 vocational, functional, therapeutic therapies21 or do you work in combination with other22 specialists?23 A. It depends on the specific situation.24 Obviously, it is a team approach, so very25 frequently I will refer patients to a physical





91 J. Carfi2 therapist or an occupational therapist or a3 speech therapist.4 There are things which I may be able5 to teach somebody or a brace that I can6 prescribe, I don't make the brace, I have to7 refer to somebody that actually makes the8 custom molded brace. So many of the services9 are referred out.10 I just do primarily the medicine, the11 medical part of it.12 Q. Does your office provide PT or any13 other kind of therapy in this office?14 A. I do not, no.15 Q. What percentage of your patients are16 pediatric versus adult?17 A. Very small percent. My practice by18 far and away is an adult practice in terms of19 my actually treating patients. In my clinical20 practice generally the youngest patient is 1021 or so. Typically it is going to be some kind22 of issue, whether it is an orthopedic issue or23 might be a spina bifida or CP. But a very24 small percent. We are talking a couple of25 percent in my universe of patients really is

111 J. Carfi2 specialist?3 A. Based upon the clear need for ongoing4 management. Things that will change over time5 as the child will grow and develop and things6 of that nature. I just knew that this7 particular individual needed somebody hands-on8 going forward through their childhood.9 Q. So is it fair to day that today, if

10 that type of patient presented to you, you11 would likewise probably refer to a pediatric12 specialist?13 MR. BERKOWITZ: Objection to the14 form of the question.15 A. Yes, I would. I would want what's16 best for the patient, yes.17 Q. Just to be clear, the pediatric18 patients you have today are not long-term,19 continuous type care, they are more short20 term?21 A. I would say that's accurate. I have22 seen them intermittently but not -- I can't23 say anybody has been coming back on a regular24 basis for years and years, that is correct.25 Q. Is it fair to say that a patient's

101 J. Carfi2 going to be pediatrics.3 Most of the kids that I see are in4 the context of the medical-legal work that I5 do, having evaluated many, many such children.6 Q. Is pediatric physiatry a recognized7 subspecialty?8 A. It is currently a recognized9 subspecialty.

10 When I was in training it was not,11 but it is now a fellowship and boarded12 specialty within the field of physical13 medicine and rehabilitation.14 Q. Are there any instances where you15 would refer a patient to a pediatric16 physiatrist for their specialized training?17 A. I have done so a handful of times in18 the past. Typically, it is a telephone19 referral, somebody will call and I will listen20 to the situation and say, "You should see a21 pediatric physiatrist," but that's happened a22 handful of times since I have been in practice23 20, 25 years.24 Q. What, based on your memory, prompted25 you to decide the patient needed a pediatric

121 J. Carfi2 medical history is an important component of3 physiatry?4 A. Sure, yes.5 Q. Do you have any expertise in6 obstetrics or gynecology?7 A. No, ma'am, I do not.8 Q. Neonatology?9 A. No.

10 Q. Pediatric neurology?11 A. No.12 Q. Any medical expertise outside of the13 field of physiatry?14 A. No.15 Q. We are going to get to your file in a16 minute, but I understand you prepared two17 written reports. In the written reports where18 you address Athan's medical history, is it19 fair to say that you were summarizing the20 records that you were given?21 A. That's exactly what I was doing. The22 medical records were reviewed and they were23 summarized. Yes, that's what is in my24 reports.25 Q. But where you comment, for example,





131 J. Carfi2 on his events at birth or his treatment in the3 NICU, you are not professing expertise in4 those fields of medicine, are you?5 A. I am not; that's correct.6 Q. Your opinions are based upon what's7 in the medical records and in your field of8 physiatry?9 A. That and my physical examination of10 the patient and the history taken from the11 primary caregivers, my knowledge and12 experience, yes, all of that.13 Q. When you are dealing with your own14 patients, do you typically diagnose a specific15 disorder or does the patient come to you with16 a diagnosis?17 A. That's a good question. Generally I18 am making my own diagnosis with my own19 clinical patients. Sometimes people come to20 me and say, "Well, the doctor says I have a21 bulging disk," but I am going to examine,22 evaluate and make my own conclusion as to what23 I think the problem is in a particular person.24 Q. Do you presently have any cerebral25 palsy patients?

151 J. Carfi2 psychologist's report from school or a3 neuropsychological evaluation. Because they4 are much more detailed.5 Q. Do you conduct standardized testing6 in this office?7 A. With respect to what?8 Q. Cognitive impairment.9 A. The only thing I would do is with an

10 adult patient, a Mini-Mental Status,11 Standardized Mini-Mental status exam, it's not12 appropriate for kids. That's the only13 standardized thing I would do, just to get a14 sense of the situation in an adult person.15 Q. Would you agree that a patient's16 treating physician is better suited to assess17 the patient's clinical status or clinical18 needs?19 A. Again, it depends upon the specific20 needs that you are referring to and I guess21 the intelligence and training and experience22 of the doctor you are talking about. I can't23 agree to that in a global sense.24 Q. How about all things being equal?25 MR. BERKOWITZ: Objection to the

141 J. Carfi2 A. I have a few adult patients, yes. I3 see them intermittently, though, it's not a4 regular -- like everybody else, sometimes they5 will have a problem they need some help with6 but it's not a regular monthly type of7 situation.8 Q. So you will see them for an acute9 situation?

10 A. Yes, something that's changed.11 Q. Are you managing any continuous12 treatment that they are receiving with other13 providers, for example, physical therapy or14 occupational therapy?15 A. Not at this time.16 Q. Would you agree that a pediatric17 neurologist is better suited to quantify a18 child's degree of cognitive impairment than a19 physiatrist?20 A. Depends on the training. So I can't21 say that's universally the case, no.22 Q. Do you assess cognitive functioning23 with your pediatric patients?24 A. Just in a general sense. I typically25 rely upon other experts, let's say, the

161 J. Carfi2 form of the question.3 Q. If you understand it, you can answer.4 A. Well, I believe I understand the5 question. Clearly, if the patient's treating6 pediatrician or internist is better, perhaps,7 able to handle the medical aspects, but if you8 have somebody who is disabled, that general9 internist or pediatrician may not be able to

10 handle the disability-related aspects of that11 person's care. That's where someone like me12 comes in.13 Q. Let me qualify the question. I think14 I was unclear and that was my mistake. As15 between a physiatrist performing an IME or an16 exam for litigation versus a patient's17 treating physician, would you agree the18 treating physician is better able to assess19 the patient's clinical needs?20 A. Not always, frankly. I can't agree21 with that on a universal basis.22 Q. Can you explain your disagreement?23 A. Sure. First of all, we all have24 different areas of experience and expertise.25 So a child's treating pediatrician or even





171 J. Carfi2 pediatric neurologist may not have the same3 broad knowledge as someone like myself with4 respect to how to deal with somebody who has a5 physically or cognitively disabling condition6 in terms of therapies that are necessary,7 equipment, braces, things of that nature.8 Q. Okay. Have you personally ever9 treated a patient -- a pediatric patient with10 cognitive deficits?11 A. In the distant past, as part of my12 training, I have had six months of pediatric13 rehabilitation experience. Intermittently,14 through various clinics, but nothing that I15 can recently point to and ongoing in my16 practice currently.17 Q. Can you just give me a time frame of18 how far in the back we are talking?19 A. Sure. I would say we are going back20 probably 25 years or so, in terms of21 specifically what you said, a child with22 cognitive deficits.23 Q. A moment ago I asked you about24 summaries in your two reports. Did you25 prepare those summaries yourself or did you

191 J. Carfi2 like.3 Q. Maybe when we take a break, or at the4 end?5 MR. BERKOWITZ: You should have it;6 we gave it to you. But we will make7 another copy if you can't find it right8 now.9 MS. HARRIS: That is the one he sent

10 us.11 MS. WALTMAN: Thank you.12 Mark this, please.13 (Defendants' Exhibit D,14 CV, was marked for15 identification.)16 Q. I would just like to run through your17 education and training background.18 MS. HARRIS: What number is that,19 Laura?20 MS. WALTMAN: D.21 Q. Where did you attend undergraduate?22 A. My first year was at Carnegie Mellon23 University. As a freshman I transferred to24 SUNY Albany, where I actually earned my25 undergraduate degree, Bachelor of Science in

181 J. Carfi2 have any assistance?3 A. No, I prepared the summaries.4 Q. Were you provided with any summaries5 or digests of Athan's medical records, either6 from plaintiff's attorney or anybody else?7 A. Not that I recall. I was provided8 with the records that I list in the first9 paragraph of each narrative.

10 Q. What is your role in the case today?11 Are you going to be providing any standard of12 care opinions in this matter?13 A. I will not.14 Q. Any causation opinions in this15 matter?16 A. I will not.17 Q. So just so you and I understand each18 other, your role is limited to Athan's future19 treatment and management of his conditions?20 A. Current and future treatment and21 management, yes.22 Q. Current and future treatment, okay.23 Do you have a current CV?24 A. I can get one. I don't have it on my25 person, but I can get that for you, if you

201 J. Carfi2 Biology.3 Q. What year?4 A. 1974.5 Q. And after that?6 A. Then I went to graduate school at7 Rensselaer Polytechnic Institute.8 Q. Did you graduate?9 A. Yes, I did. Master's in Chemistry.

10 Q. What year?11 A. 1977.12 Q. Medical school?13 A. Medical School, Mount Sinai School of14 Medicine, Class of '81.15 Q. Residency?16 A. The Physical Medicine and17 Rehabilitation at the Rusk Institute for18 Rehabilitation Medicine, NYU. Graduated 1984.19 Q. Any fellowship training?20 A. No.21 Q. Board certifications?22 A. Board certified in physical medicine23 and rehabilitation.24 Q. What year?25 A. 1985.





211 J. Carfi2 Q. And are you required to be3 recertified?4 A. No.5 Q. Have you?6 A. I have not, no.7 Q. Beginning with your residency at the8 Rusk Institute, can you walk me through your9 clinical and academic positions, your10 employment?11 A. Sure. Well, I was a resident at the12 Rusk Institute, this is both training and13 employment, obviously. When I finished that14 program, I joined an older doctor in15 Westchester County. He was the senior doctor,16 I was the junior associate in his practice.17 Q. What was the name of the practice?18 A. His name was Jerome Gristina,19 G.R.I.S.T.I.N.A., M.D. I don't recall the20 practice having a name per se.21 Q. Okay.22 A. I then returned to academic medicine,23 became full time at the Mount Sinai Medical24 Center.25 Q. Can I just stop you there to put some

231 J. Carfi2 A. No, I was in Great Neck. They had an3 outpatient facility here in Great Neck.4 Q. And your -- you did that from '90 to5 '92?6 A. Correct.7 Q. Do you hold any academic positions8 presently?9 A. Yes.

10 Q. Can you explain?11 A. Yes, I still have a teaching position12 at the Mount Sinai Medical Center, assistant13 professor -- clinical assistant professor of14 rehabilitation medicine at Mount Sinai.15 Q. What does that entail?16 A. That entails -- I supervise a brain17 injury clinic there. I sometimes am asked by18 the residents for a lecture, I assist in19 interviewing prospective residents for the20 residency program, and anything else that the21 department asks me to do.22 Q. Do you teach any courses on a regular23 basis?24 A. No, just the clinic.25 Q. During a given school year, about how

221 J. Carfi2 years -- I'm sorry, I just want to put some3 years.4 How long were you with Dr. Gristina?5 A. Two years.6 Q. And then you returned to academics?7 A. Yes.8 Q. At where?9 A. Mount Sinai Medical Center. I was an

10 assistant professor of rehabilitation11 medicine. After a year I became the associate12 clinical director of the department, did that13 from '86 to 1990. In 1990 I became a medical14 director of an outpatient brain injury15 facility. New Medico Associates, N.E.W,16 M.E.D.I.C.O., based in Boston.17 Simultaneously with that position I18 was developing a small private practice. Then19 in 1992, I stepped out into solo private20 practice and have been in private practice21 since.22 Q. 1992 was the start of this business?23 A. Yes.24 Q. Going back to your medical25 directorship, were you located in Boston?

241 J. Carfi2 many hours a week or month -- how you would3 estimate your time in the academic field?4 A. How much time do I spend at Mount5 Sinai; is that what you are asking?6 Q. Yes. I don't know if it's7 specifically at Mount Sinai, but about how8 many hours do you devote to your academic9 position?

10 A. I would say on a monthly basis, two11 to three hours on a monthly basis I am there.12 Q. And that's year round, two to three13 hours a month year round?14 A. Well, that's on average. Certain15 months I'm there more, other months I'm there16 less, I am just trying to paint the big17 picture for you.18 Q. Can you walk me through a typical19 workweek for you then?20 A. Typical workweek?21 Q. Yes.22 A. Sure. Mondays I have patients all23 day. Tuesdays I may have occasional patients24 but I spend most of my time doing this kind of25 work, you know, reviewing files and records,





251 J. Carfi2 preparing my reports, things of that nature.3 Wednesday is similar to Tuesday, again, I may4 have scattered patients. Thursday, patients5 all day. Friday, again, I do this type of6 work primarily on Fridays. And that's my7 workweek. I take work home, I work on the8 weekends, as we all do.9 Q. So Tuesday, Wednesday and Friday are10 similar schedules?11 A. Yes.12 Q. Could you break down a percentage of13 your time seeing patients versus the legal14 work?15 A. Sure. About 40 percent of my time is16 clinical, 60 percent is forensic,17 approximately.18 Q. In that forensic, you are including19 examinations, review of documents,20 depositions, trial testimony?21 A. All that stuff, yes.22 Q. Do you have hospital privileges?23 A. I do not have admitting privileges.24 I am on staff at Winthrop University Hospital25 but I do not admit, I don't have admitting

271 J. Carfi2 Q. Have your admitting privileges ever3 been suspended or revoked?4 A. No.5 Q. Have any of your prior employers ever6 been investigated for any wrongdoing?7 A. I believe New Medico Associates was8 investigated.9 Q. And that was -- your status with New

10 Medico, that was around 1990, you said?11 A. Yes.12 Q. What was the situation just briefly?13 A. I believe they were under14 congressional investigation for billing15 issues, aggressive marketing practices and16 some patient care issues at some facilities,17 somewhere. They own about 45 facilities18 around the country.19 Q. Anything impact your facility in20 Great Neck?21 A. Not that I was ever informed.22 Q. Do you know what the outcome of that23 was?24 A. The outcome, as I understand it, is25 New Medico Associates corporate entity

261 J. Carfi2 privileges there.3 Q. When did you last have admitting4 privileges at any institution?5 A. I last had admitting privileges to6 Winthrop about three years ago. And then the7 affiliation was changed.8 Q. The hospital affiliation?9 A. Yes, it has to do with New York State

10 regulations and such, but I'm what we call an11 affiliated attending, at Winthrop, which means12 I don't admit but I am still on staff there.13 I can take advantage of the CME opportunities,14 the library, things of that nature.15 Q. Have you had occasion in the last16 three years to need to admit a patient?17 A. No. I haven't admitted anybody in a18 number of years.19 Q. Do you recall the year you last20 admitted a patient?21 A. That would be 1989 or 1990, the last22 time I actually admitted somebody.23 Q. That was Winthrop?24 A. No, that would have been Mount Sinai,25 when I was full time at Mount Sinai.

281 J. Carfi2 divested itself of their assets and3 disappeared essentially.4 Q. Is that why you left or had you5 already left?6 A. I think I had already left, so I7 wasn't aware of that situation. I was8 planning on going into private practice, so I9 had already left at the point of the

10 investigation, I believe.11 Q. Do you give seminars, any talks? I12 know you mentioned you sometimes speak with13 residents. Can you just go through that14 again, how are you invited and what do you do?15 A. For the residents?16 Q. Yes.17 A. The chief resident will call me up18 and ask me if I'd be willing to provide a19 lecture on a particular topic. Typically I20 talk about things which they don't otherwise21 get, like independent medical evaluations,22 disability evaluations, things of that nature.23 I think I have given a talk about this kind of24 medical-legal work as a sort of a parallel25 career pathway. I have done that for Mount





291 J. Carfi2 Sinai and I've done that for Long Island3 Jewish residents.4 MS. HARRIS: What was the last one?5 THE WITNESS: Long Island Jewish6 Medical Center, locally here.7 Q. And outside of the resident context,8 do you give any other kinds of seminars or9 talks to groups?10 A. Well, I have been privileged to be11 invited by the Nassau County Bar, Suffolk12 County Bar and New York City Bar Associations13 to provide lectures. I also, last year or the14 year before, gave a presentation to the15 American Academy of Physical Medicine and16 Rehabilitation, gave a workshop. That's all17 that comes to mind at the moment.18 Q. Do you speak to bar associations or19 legal groups on a regular basis or are these20 just a couple of isolated talks?21 A. Couple of isolated talks, not a22 regular thing.23 Q. Publications, do you publish?24 A. I haven't published in decades, so25 no.

311 J. Carfi2 a few reports because when you run the3 inpatient unit, people that are there, some of4 them had had accidents, so I remember writing5 a couple of reports for attorneys. And then6 from there, I think 1991 was my very first7 life care plan, I believe, or '90, '91,8 somewhere around there. And sort of the rest,9 as they say, is history.

10 Q. After the two criminal cases, do you11 recall how you came to receive the first case?12 How did people know your name?13 A. Oh, when I first started in private14 practice, I was interested in doing this kind15 of work, but I didn't know how to meet you16 guys, essentially.17 So somehow or other, I think it was18 through a mutual acquaintance, a gentleman19 introduced himself to me. His name was Al20 Somanga (ph). He presented himself as a21 healthcare consultant, and he made sure that I22 knew that he was the son of the famous Judge23 Somanga, of Suffolk County, I don't really24 know who that is.25 But anyway, I retained him for about

301 J. Carfi2 Q. Have you ever written about any of3 the issues pertinent to Athan Ghannam?4 A. No.5 Q. A few questions about your experience6 in the litigation field.7 Do you remember when you first8 reviewed a case, the year?9 A. Well, I remember my first exposure to

10 the medical-legal arena.11 Q. Okay.12 A. That was actually two criminal trials13 in the late 1980s, when I was at Mount Sinai,14 it was a full-time academic position. I ran15 the inpatient unit and one of my patients had16 been shot in the head and another patient had17 been shot in the neck, and both of the18 perpetrators had been brought to trial and I19 was asked by the DA to come and talk about the20 injuries, things of that nature.21 That was my first exposure and I22 found it all very fascinating to be on the23 stand, so that's actually what piqued my24 interest in this whole field.25 Subsequent to that I believe I wrote

321 J. Carfi2 a year and he basically made introductions.3 He introduced me to some firms, certain4 attorneys within the firms. I think it was5 Pegalis & Wachsman, when they existed, and6 Sullivan & Liapakis. And after about a year,7 I didn't really need his services any longer8 so that relationship ended, but that basically9 was the very beginning and as I have done my

10 work and my business has grown on its own, but11 that was how it first started.12 Q. You said he was some kind of13 healthcare --14 A. That's what he said he was, he was a15 healthcare consultant. That's what he told me16 and his business card might have said that. I17 don't remember anymore.18 Q. Do you know who he worked for?19 A. Well, I think he was by himself. I20 don't recall him working for anybody. He is21 deceased now, I have found out, but I don't22 recall that he said he worked for anyone.23 Q. Did you pay for his service?24 A. I did.25 Q. Do you remember, was it by case or by





331 J. Carfi2 introduction?3 A. It was by quarterly -- it was a4 quarterly arrangement. I paid him by the5 quarter, a set amount, not related to any6 referrals or anything like that.7 Q. Just so I understand it, he8 introduced you to attorneys who might wish to9 call you for services?10 A. Correct. That's basically what it11 was, yes.12 Q. And this was around 1991?13 A. Around there.14 Q. I want to see if I can sort of walk15 through, but without going year by year, how16 your forensic work developed. So in the17 first, say, five years or so, how many cases18 did you review plaintiff versus defendant? Do19 you have any notion of how it developed?20 A. Slowly. Clearly the first several21 years were very slow. I do remember it being22 slowly. If you are asking for the number of23 cases, I can't possibly tell you that.24 Certainly I am busier now than I was -- way25 busier now than I was then, and one would hope

351 J. Carfi2 Q. Those are reviews and depos?3 I just didn't catch what you said.4 A. That's okay. When I say "trial5 testimony," I kind of include depositions6 since I am kind of testifying when I do this.7 Q. So case reviews?8 A. Case reviews, about 75 percent9 plaintiff, 25 percent defense.

10 Q. Let's go with the past five years11 then, any idea -- well, first of all, any idea12 how many cases you've reviewed in total in13 your career, an estimate?14 A. Actually, I have no idea. I can tell15 you what I am currently doing approximately,16 but my total universe -- I have prepared about17 1,500 or so life care plans in my career, that18 I can tell you, approximately.19 Q. Okay.20 A. I can tell you that I currently21 review around -- probably between 150 and 20022 files in a year, approximately. Somewhere in23 that ballpark. I testify 12 to 16 times in a24 year, approximately.25 Q. That's deposition and court?

341 J. Carfi2 so, but I really can't tell you how many.3 Q. Since 1991, would you describe it as4 a steady increase?5 A. More or less steady, yes. It's been6 steady. Sometimes it levels and then it7 increases. There was one year I remember it8 went down for some oddball reason, it was a9 difficult year. But other than that, it's

10 been a pretty steady increase.11 Q. What year do you recall it going12 down?13 A. Just give me a second, I think it was14 about five years or so ago. For some reason15 it was not a particularly busy year. I think16 it was about five years, somewhere in the17 five-year range.18 Q. How about your breakdown of plaintiff19 versus defendant?20 A. In terms of trial testimony,21 certainly it's overwhelming plaintiff, 9822 percent. In terms of file reviews and case23 reviews, things of that nature, it is more 7524 percent plaintiff, 25 percent defense25 interest.

361 J. Carfi2 A. Yes, both. I lump them together.3 Q. The 150 to 200 reviews per year and4 the 12 to 16 times testifying per year, about5 how many years back would you say that stands?6 A. I think that's -- well, the7 testifying, I would say, has been pretty8 steady in the last three to four years or so.9 The case reviews has been busier, it's been a

10 fairly steady increase over the last four11 years. As I said, maybe five or six years ago12 there was a lull, but over the last four years13 it's been sort of a slow, steady increase.14 Q. If I told you that in a prior15 transcript you said you had reviewed about16 2,500 to 3,000 cases in your career at that17 time, does that sound about accurate?18 A. That could very well be accurate,19 sure. I just can't remember everything all20 the time.21 Q. In the last five years, can you22 estimate how many cases you have reviewed23 involving birth injury?24 A. I cannot. I don't have an25 independent recollection of that right now.





371 J. Carfi2 Q. Could you do it this way: Over the3 past five years, about what percentage of your4 reviews involve a birth injury?5 A. That's the same question asked a6 different way.7 Q. I thought that was an easier way, you8 don't have to know the numbers, you just have9 to know about how much time.10 A. I understand. Well, I would say if I11 have to put a percent on it in terms of birth12 injuries or things related to that, at this13 point it is probably 10 or 15 percent, just14 generally speaking.15 Q. 10 or 15 percent of your reviews over16 the last five years or so involve a birth17 injury?18 A. Yes, approximately. It is just an19 approximate number.20 Q. I understand. Do you ever review21 files for standard of care opinions?22 A. I have. I don't do that currently.23 I gave that up a couple of years ago, but I24 have done that, yes.25 Q. Any reason why you decided not to do

391 J. Carfi2 person suffer the brain injury?" Well, it's3 very clear from the records where the brain4 injury came from. But whose fault it is and5 whether something bad was done, I don't have6 an opinion on that. But many times it's clear7 that there was an anoxic injury or a head8 trauma or something, you can see from the9 records what caused the patient's current

10 condition, but whether there was somebody's11 negligence because of that, that I couldn't12 tell you.13 Does that answer your question?14 Q. Somewhat.15 Do you know if you're called upon in16 any cases to give legal causation testimony?17 A. You have to define that for me, I'm18 sorry.19 Q. I will move on.20 Any estimate of the number of21 depositions you have given in your career?22 A. No, not that I can think of right23 now.24 Q. Would you agree the overwhelming25 majority have been on the damages side as

381 J. Carfi2 that?3 A. It is more stressful. It is very4 stressful, actually, to be completely blunt.5 It's a very stressful thing to be involved in.6 I will still do defense matters, it's just7 being on the plaintiff's side for standard of8 care is very, very stressful, and I don't need9 more stress in my life.

10 Q. How is it more stressful than the11 type of reviews that you do ?12 MR. BERKOWITZ: Objection to the13 form of the question.14 A. How is it more stressful?15 Q. Yes.16 A. It's related to you. My learned17 opponent is what makes it more stressful. It18 seems to be more adversarial somehow, that's19 all.20 Q. How about causation testimony? Are21 you called upon to give causation opinions?22 A. Well, from time to time -- when you23 say "causation," can you -- well, I will24 answer as best I can.25 Sometimes I'm asked, "How did this

401 J. Carfi2 opposed to standard of care or causation?3 A. Absolutely, that would be correct.4 Q. Any estimate of the number of times5 you have testified at trial? I know you might6 not separate them, but if you are able to,7 deposition versus trial?8 A. Well, if I have to estimate, I think9 I said I have testified 140, 150 times,

10 something of that nature. 150 times. I would11 say out of that, likely around two-thirds12 would be trial testimony, maybe the balance13 depositions. Again, that's an estimate. I14 just know I testify in court more than15 depositions occur.16 Q. Do you give depositions in New York17 cases?18 A. I can't recall one, no. Federal and19 certain out-of-state cases, but no New York20 State cases per se.21 Q. In the past five years, actually, I22 might have asked this earlier, forgive me if I23 did, can you estimate your breakdown of the24 patient work versus forensic work?25 A. Sure, 40 percent of my time is





411 J. Carfi2 clinical and 60 percent is forensic.3 Q. I apologize, that does sounds4 familiar.5 A. That's okay.6 Q. How about income-wise?7 A. Income, it is a little bit different.8 Income, at this point, it is about 75 percent9 forensic versus 25 percent clinical.10 Q. Do you advertise?11 A. I do not.12 Q. Have you ever?13 A. No, I have not.14 Q. Do you know if your name is listed on15 any online directories?16 A. I believe it's on the SEAK Directory,17 S.E.A.K. It is on the ABIME, A.B.I.M.E., the18 American Board of Independent Medical19 Examiners. It is on that one. Beyond that, I20 don't believe so.21 Q. I am roughly familiar with the SEAK22 website; did you request that your name be on23 there?24 A. Well, I have been to some of their25 seminars and they do solicit you and so, yes.

431 J. Carfi2 actually, in Connecticut. They have sent me3 cases, not recently though, but over the past4 many years I have gotten an occasion case from5 them.6 Q. Mednick?7 A. Mednick, M.E.D.N.I.C.K., Mednick8 Associates.9 Q. Do you belong to a group?

10 A. I'm sorry?11 Q. Do you belong to a Mednick group?12 A. No, I think they are a referral13 service, where attorneys can call up, "Do you14 have an expert in this?" kind of thing. As I15 said, they referred me some cases over the16 years but not in the last year or two.17 Q. Do you ever receive a call from18 either -- from an attorney or service and19 decline to accept a review?20 A. Yes, actually.21 Q. Under what circumstances?22 A. Well, I am getting some e-mails, I23 guess because I am on some of the, you know,24 the SEAK site or whatever, asking me to25 consider doing a particular case, and I will

421 J. Carfi2 So I guess in response to a solicitation, yes.3 Q. Is there a fee for your listing?4 A. Yes.5 Q. Like an annual fee?6 A. And the ABIME, is that the same kind7 of service?8 A. It is similar, yes. Truthfully, I9 don't recall if there is a fee because I am a

10 member of that organization, so I'm not sure11 if there's a fee or not. I don't remember.12 Q. Any other names that you can13 remembering other than those two?14 A. Not that I recall.15 Q. Have you ever been a part of any16 directory that puts you in contact with17 attorneys for a percentage of your fee?18 A. I never heard of such a thing. I19 didn't know that you could do that. It20 doesn't sound kosher but no, not that I am21 aware of.22 Q. Apart from word of mouth, anything23 else you do to obtain work?24 A. There is one organization, Mednick25 Associates, I think they are in your area,

441 J. Carfi2 turn it down, sure. Because sometimes it is3 liability, standard of care, and like I said,4 I don't do that.5 Q. How about on the damages side?6 A. I can't say that, you know,7 occasionally there are cases that are outside8 of my expertise, you know, the issues are such9 that I really wouldn't have any idea what to

10 do with that case. A recent example, somebody11 got hepatitis B or C from a transfusion. And12 clearly there is going to be ongoing cost down13 the road for treatment, but I don't have the14 expertise really to tell you what that's going15 to be. So under those circumstances, if I am16 not comfortable, I'll turn it down, sure.17 Q. So apart from standard of care or if18 it is an area that you feel is outside your19 expertise, any other reason that you would20 decline to accept a review?21 A. Not that I can think of right now.22 Q. Have you ever declined to accept a23 review for a birth injury case?24 A. I don't recall that I have declined.25 Q. How about for defendants? I think





451 J. Carfi2 you said your reviews, it is about 75/25?3 A. Correct.4 Q. Have you ever declined to review a5 case on behalf of the defendant involving a6 birth injury?7 MR. BERKOWITZ: That wasn't related8 to standard of care and causation, right?9 MS. WALTMAN: Yes, thank you.10 A. No, I have not declined such a case.11 Q. What is your current rate schedule?12 A. Well, I am charging you $500 an hour13 for a deposition. I charge for my time, when14 I am reviewing records and things of that15 nature, 390 an hour. A life care plan is16 $2,650. My examination of a patient is $630.17 I charge for trial testimony $8,000 a day,18 half a day is $4,250, half-day minimum. I19 think that covers all my fees.20 Q. And how long has that been your fee21 schedule?22 A. About five years now.23 Q. No increases over the five years?24 A. No, I think this is the fifth year25 but, no, I have not increased in that period

471 J. Carfi2 Q. Do you remember in this case?3 A. I don't recall specifically. That's4 generally what happens, so...5 Q. Do you have any recollection of the6 conversation then, what was asked of you, what7 you said in return, on that very first8 contact?9 A. Not the specifics, no.

10 Q. Subsequent to that first call, who11 have your communications been with at Mr.12 Berkowitz's office?13 A. Mr. Berkowitz.14 Q. Anybody else?15 A. Not that I recall.16 Q. Can you recall how many telephone17 conferences you have had with Attorney18 Berkowitz about the Ghannam case?19 A. Approximately two.20 Q. Can you recall any details of either21 conversation?22 A. Not details. Generally, what the23 subject matter is.24 Q. Generally then?25 A. Generally having to do with -- one

461 J. Carfi2 of time.3 Q. Your work in the Ghannam case, do you4 know how much work you have performed on this5 file?6 A. If I can refer to my file, I can tell7 you, yes.8 Q. Well, why don't we hold off and we'll9 come back then, because we're going to mark

10 and review your whole file, so we'll get to11 that when we do that.12 A. Sure.13 Q. Turning to, then, this case, do you14 recall when you were first contacted?15 A. That would have been back in 2010.16 Q. Do you remember when?17 A. I would have to look at the cover18 letter to know precisely.19 Q. Who contacted you?20 A. That would be Mr. Berkowitz or21 someone in his office.22 Q. Do you remember the communication?23 A. The letter? Generally a phone call24 is made first and then the official letter25 might follow after that.

481 J. Carfi2 conversation had to do with the fact that3 Athan was too young really for me to do the4 work that I needed to do. So we had to defer5 to another -- a future examination, and that6 was one conversation. And the other had to do7 with the -- what you guys were requesting as8 copies of all of my resources. Those were the9 two conversations that I recall.

10 Q. Did you ever e-mail with anyone from11 Attorney Berkowitz's office about the Ghannam12 case?13 A. Yes.14 Q. Are printouts of those e-mails in15 your file?16 A. No.17 Q. Do you have access to print them out?18 A. I may have one that I can print out.19 I don't keep them.20 Q. What's the nature of the one that you21 do have?22 A. It had to do with, again, your23 request for the specific drugstore.com24 website. That was sort of an afterthought25 kind of thing that you wanted that. That's





491 J. Carfi2 what it was related to. What I gave you,3 which we mentioned earlier, that health trans4 at drugstore.com does not offer pricing5 anymore, and I certainly don't have last6 year's data anywhere.7 Q. The e-mails that you no longer have,8 can you recall the nature of the exchanges9 with Attorney Berkowitz's office?10 A. That's really all I recall, is the11 stuff involving you guys and your need for12 those specific resource pages and such.13 Q. Are you reviewing any other cases for14 Attorney Berkowitz's office?15 A. Not currently, no.16 Q. In the past?17 A. I have, yes.18 Q. How many?19 A. I would say approximately 9 to 1020 cases over the past many years.21 Q. How many years?22 A. The past many years.23 Q. Do you know how many years?24 A. I don't really recall the -- how long25 we've had the business relationship. Probably

511 J. Carfi2 Q. Are there any other firms in3 Connecticut, like Attorney Berkowitz's office,4 that you have reviewed multiple cases for5 them? That was a little clumsy question but6 if you understand it, answer it. If not7 I'll --8 A. No, I understand the question. There9 are no other firms that come to mind that I

10 have dealt with on the frequency of Mr.11 Berkowitz.12 Q. Okay. Let's talk about, then,13 today's deposition. What did you do to14 prepare for us today?15 A. Basically just reviewed my file, that16 you see sitting on my lap here, I just kind of17 went through it.18 Q. About how much time did you spend19 reviewing?20 A. About a half-hour this morning going21 through the file.22 Q. Any conversations with Attorney23 Berkowitz or anybody else about your24 deposition testimony.25 A. Well, we did have a pre-depo prep

501 J. Carfi2 at least ten, I would say about ten years, so3 on average a case a year, about.4 Q. Have all the cases been with Attorney5 Berkowitz?6 A. Yes, he is the leader -- primary7 attorney, yes.8 Q. I just didn't know if there were9 cases from his office but you were dealing

10 with another attorney in his office?11 A. No, it was him.12 MR. BERKOWITZ: I like that you13 almost used the word "leader."14 MS. WALTMAN: Funny, I didn't even15 hear that.16 MR. BERKOWITZ: Nobody calls me a17 leader at home.18 Q. Are you currently reviewing any other19 cases from Connecticut?20 A. From the State of Connecticut?21 Q. Yes.22 A. Yes.23 Q. Do you know which firm you are24 working with, or firms, plural?25 A. A name does not come to me, sorry.

521 J. Carfi2 meeting, yes.3 Q. When was that?4 A. Couple of days ago.5 Q. In person or on the phone?6 A. In person.7 Q. Here?8 A. Yes.9 Q. And it was Russ and you?

10 A. Yes.11 Q. Anybody else present?12 A. No.13 Q. About how long?14 A. I would say that we discussed this15 situation about 15, 20 minutes or so.16 Q. What was the nature of your17 discussion?18 A. The nature of the discussion was what19 to expect in terms of the lines of20 questioning, just my file, make sure I had21 what I needed for the deposition, the records,22 which are --23 MR. BERKOWITZ: I moved them over24 there behind you.25 A. -- over here, that sort of the thing.





531 J. Carfi2 Primarily just to let me know about the3 personalities, what was involved, that's all.4 Q. Okay.5 A. I like to know what to expect when I6 come in to testify, who is going to question7 me.8 Q. Sure. You said that was about 15 or9 20 minutes?10 A. Yes, about.11 Q. Did you discuss any other files12 during that meeting?13 A. No.14 Q. Anything else done to prepare for15 today's deposition? You talked about16 reviewing the file this morning and the17 meeting with Russ a couple of days ago.18 Anything else?19 A. No.20 Q. Exhibit A is your notice of21 deposition; have you seen this notice before?22 A. I am pretty sure it is in my file. I23 don't actually -- my office manager takes care24 of these things for me.25 Q. Well, if we can, let's go through

551 J. Carfi2 packet in the back here.3 Q. Let's start with the medical records.4 MS. HARRIS: Before you get into5 that can we take a quick break?6 MS. WALTMAN: Sure.7 (Discussion held off the record.)8 MS. WALTMAN: Back on the record.9 Q. Doctor, you handed me -- what have

10 you handed me?11 A. I handed you the pile of records12 which I had reviewed for my initial narrative13 of November 8, 2010.14 Q. Were these documents sent to you in15 this organization with the yellow pages in16 between?17 A. Yes.18 Q. Is there anything -- was there19 anything taken out of this pile by you?20 A. I didn't take anything out of the21 pile, no.22 Q. Did you add anything to this pile?23 A. No, I did not.24 Q. So this is the complete file that you25 received when you were initially retained to

541 J. Carfi2 this one at a time. Number 1 is your current3 CV, which we have, and it is marked as Exhibit4 D.5 A. Okay.6 Q. You would agree this is current?7 (Handing.)8 A. Yes.9 Q. Number 2, all correspondence to or

10 from you from any person or entity regarding11 this case.12 A. Okay.13 Q. Attorney Berkowitz produced what has14 been marked as Defendants' Exhibit B, which I15 will show you.16 (Handing.)17 A. That's looks about right.18 Q. When we go through your file in a19 second I guess we will see if there is any20 more correspondence.21 A. Sure.22 Q. All documents, records and materials23 related to this case which have been reviewed24 by you?25 A. Yes, and there is a small, little

561 J. Carfi2 review the case?3 A. Yes.4 MS. WALTMAN: I would like to mark5 this, unless anyone has a problem, I will6 just mark the cover letter on top.7 MR. BERKOWITZ: That's fine.8 MS. HARRIS: Fine.9 MS. WALTMAN: Let's mark this

10 Defendants' E.11 (Defendants' Exhibit E,12 File, was marked for13 identification.)14 Q. Now you have another folder on your15 lap? If we can go through those documents?16 A. Do you want the whole thing or just17 records? What would you like?18 Q. Let's do it like this: How many19 different times did you receive documents?20 A. Twice.21 Q. And we have already talked about what22 you received in the first package, so apart23 from what you have created, everything else is24 in the folder? Everything else that you have25 received from Russ is in the folder?





571 J. Carfi2 A. In this folder, yes.3 Q. Let's go through what additional4 documents you received from Russ.5 A. Those are documents which I received6 for my second narrative of November 17, 2011.7 Those are additional records that I reviewed.8 Q. Is what you handed me in this paper9 clip a complete package of the additional10 records?11 A. Yes.12 MS. WALTMAN: Mark this F.13 (Defendants' Exhibit F,14 Additional Records, was15 marked for identification.)16 Q. I'm sorry, I know you said it, when17 did you receive these documents?18 A. That would have been prior to my19 second narrative of November 17, 2011.20 Q. Were these documents sent to you upon21 your request?22 A. No. They were sent spontaneously by23 Mr. Berkowitz's office in preparation for the24 follow-up evaluation.25 Q. At any time in this case, have you

591 J. Carfi2 A. And the CD disk, which I assume are3 the records but I am old-fashioned and I like4 paper records.5 Q. Let's start with the CD. Who is this6 from?7 A. I'm assuming it's from Mr. Berkowitz.8 I never looked at the CD because I like paper9 records. I mean, I keep the CD, if they send

10 it to me I keep it, but I ask for the paper11 records.12 Q. Is it your recollection that you13 received the CD along with paper records?14 A. I have no recollection of when it15 came, if it came first and I requested the16 records or it came at the same time. I don't17 remember.18 MS. WALTMAN: Russ, do you know?19 MR. BERKOWITZ: I don't know, but it20 may be in the cover letter when we sent21 the records, it may reference whether it22 says "enclosed are the records and CD." I23 don't really remember. That is something24 my paralegal takes care of.25 MS. WALTMAN: Okay.

581 J. Carfi2 requested additional documents or certain3 documents from Attorney Berkowitz?4 A. I have not.5 Q. Is that typical of you or do you6 usually just review what you receive or are7 there instances when you actually call out and8 request certain documents?9 A. Generally speaking, I review what I

10 have received. If there is something I feel11 that I need to have that I don't have, I will12 certainly call and request it. But most of13 the time I get what I need to do my work.14 Q. Again, no calls in this case, no15 requests in this case?16 A. Correct.17 Q. What else is in your file?18 A. I have my 2 -- my narratives, life19 care plan, I have that packet that you20 requested of my resources that I had or I21 could recover, in any event, fax, receipt22 sheets, letters from the Berkowitz law firm,23 the deposition notice that you showed me a24 minute ago, bills, and that should cover it.25 Q. I will take that whole pile.

601 J. Carfi2 MR. BERKOWITZ: I find it unusual3 that we would have sent him the CD first.4 As you know, I've dealt with Dr. Carfi5 before, I know he likes hard copy records.6 This new technology is usually from a7 younger person in the office who thinks8 that's how the doctors like it.9 Q. In any event, you've never looked at

10 this CD?11 A. No, I have no idea what's on it,12 that's correct.13 Q. Do you have any intention to look at14 it?15 A. No, I do not.16 Q. Why don't I do this: I'm going to17 try not to make this complicated but I am18 going to mark your folder as an exhibit and19 then I'm going to mark individual or groups of20 documents within the folder. Because the CD21 is on here, I want to maintain the integrity22 of this folder. Any problem?23 MR. BERKOWITZ: No.24 MS. HARRIS: No.25 (Defendants' Exhibit G,





611 J. Carfi2 Folder with CD, was marked3 for identification.)4 Q. Now, looking at the documents in your5 file, the first document is a report dated6 November 8, 2010. This was your initial7 examination and report of Athan?8 A. Correct.9 Q. Did you prepare a life care plan with10 respect to your first examination and report?11 A. I did not.12 Q. Why not?13 A. Too young.14 Q. Can you explain, as it relates to15 Athan, did you have a conversation with16 Attorney Berkowitz at what age you felt it17 would be appropriate to do a life care plan?18 A. That was, if you recall, you had19 asked about telephone conversations, that was20 one of the conversations that I generally21 recalled having spoken to him because Athan22 was too young and I said around two years old23 would be the earliest that I could really do24 anything.25 Q. Can you talk to me about the

631 J. Carfi2 that a 10-and-a-half-month-old is not going to3 be able to do. So somebody who is as severely4 involved as Athan, if they are not doing5 certain things, it is easy to predict, well,6 they are not going to do certain things.7 Q. And that explains why you didn't8 prepare a life care plan in November of 20109 but said you would reevaluate him when he was

10 age 2?11 A. Correct.12 MS. WALTMAN: Let's mark the13 November 8, 2010 report.14 (Defendants' Exhibit H,15 11/8/10 Report, was marked16 for identification.)17 Q. Next in the file we have your18 November 17, 2011 report and I have19 paper-clipped two stapled packages which20 constitute your life care plan?21 A. Yes.22 MS. WALTMAN: If we could mark this23 as the next exhibit.24 (Defendants' Exhibit I,25 Letter with Life Care Plan,

621 J. Carfi2 two-year-old mark, was that specific to Athan3 or is that brain injury cases in general?4 A. That's generally speaking. I really5 can't do a proper child evaluation in terms of6 life care plan predicting costs and such7 before two years old.8 Q. What happens around the age of 2 that9 then enables you to estimate?

10 A. Sure. It also depends on the11 individual child. Athan is very seriously12 involved, so it's relatively easy at two years13 old to predict the fact that he is going to be14 needy later in life. Sometimes you have kids15 which are functioning, maybe they didn't make16 all their milestones, and even them, I might17 request them to come back later.18 But specifically at two years old you19 expect children to have -- reach certain20 milestones: Walking, talking, "I want to do21 it" so they get dressed, they take their22 clothes off. They can open containers, they23 can wave bye-bye, they can have a24 conversation, sort of, things of that nature.25 So certain things that a two-year-old can do

641 J. Carfi2 was markedfor identification.)3 Q. Next in your file we have a4 binder-clipped set of documents.5 Can you take a look and tell me what6 that's all about?7 A. These binder-clipped documents are8 what you requested, or Ms. Harris, I don't9 really know which of you actually. These are

10 the resources, pages related to the life care11 plan of 2011. The ones I was able -- either I12 had or was able to retrieve, per your request.13 Q. Just so I am clear, when you say you14 had or you were able to retrieve, did you go15 back online and try to find things or were16 these sources that you -- I am trying to match17 up whether or not they were the actual sources18 that you used with your life care report?19 A. I understand. No, these were the20 actual -- actually what I used. These I21 happened to keep in a file. It is not my22 custom and practice to keep all of my23 resources, I do it for my own purposes, but24 these I had.25 Q. So I am just confused. Which are the





651 J. Carfi2 ones that you were then able to retrieve3 later?4 A. Well, when I said "retrieve," maybe I5 misspoke. For example, the ones -- National6 Fee Analyzer, I kept that book, so when I said7 "retrieved, I retrieved it off of my bookshelf8 and made copies of the sheets I used for you.9 I didn't actually have these in a file for10 you, I had to do work to get it for you.11 Q. I understand. Did you go online and12 print anything off new to add to this binder?13 A. No, because that would have been 201214 pages, not 2011, which is when I did that15 plan.16 MS. WALTMAN: Okay, let's mark this17 as the next exhibit.18 (Defendants' Exhibit J,19 Reports Request, was marked20 for identification.)21 MS. WALTMAN: I may have taken this22 out of order, but I just gathered together23 the various cover letters and I'll just24 read off: There is a fax cover sheet,25 November 8, 2010, six pages. It looks

671 J. Carfi2 A. Sure. These are two bills, one from3 the first report of 2010 and the other from4 2011, which represents the amount of time I5 spent, the charges for my time, the life care6 plan, the examination, and the balance bills7 and the checks.8 Q. So it is four pages, two invoices and9 two checks.

10 A. Yes.11 Q. Have you performed any work on this12 case for which you have not billed, apart from13 the deposition here today?14 A. No.15 Q. And is there any work that you have16 billed for but have not yet received payment17 on?18 A. No.19 Q. Looking at these documents, if you20 need to, Dr. Carfi, can you just run through21 how much time you spent on this file?22 A. Okay, in terms of the time I bill23 for, I have spent three-and-a-quarter hours24 for record review time and report preparation,25 things of that nature. Obviously, I spent

661 J. Carfi2 like the fax confirmation and the fax3 cover sheet. The third page is October4 18, 2011 cover letter. The next page,5 September 27, 2010 cover letter. And6 that's it.7 Mark this as the next exhibit.8 (Defendants' Exhibit K,9 Letter, was marked

10 for identification.)11 MS. WALTMAN: Understanding this may12 be duplicating what we've already marked.13 The next document, and again, I may14 have taken this out of order from your15 file, but the next document in my hands is16 a fax cover sheet and the notice of17 deposition for today.18 Let's mark this as the next exhibit.19 (Defendants' Exhibit L,20 Notice and Cover Sheet, was21 marked for identification.)22 Q. And the last set of documents in your23 file look like the billing documents. I am24 handing them to you, if you could just explain25 what they are?

681 J. Carfi2 time preparing the life care plan, but that's3 not billed, per se. That's billed at a flat4 rate so I don't know how many hours I spent on5 it.6 Q. If I could just walk it through for7 the record, on the November 8, 2010 invoice,8 which was your first invoice, you billed 2.259 hours for your record review and report

10 preparation.11 And those were all the services you12 performed on the first review of this case,13 correct?14 A. Well, I also examined the child --15 Q. I'm sorry, I missed that, clinical16 examination, okay.17 And then November 17, 2011, you have18 one hour for record review and report19 preparation, clinical re-examination, and then20 the flat rate life care plan?21 A. Correct.22 MS. WALTMAN: Before I move on,23 let's mark this.24 (Defendants' Exhibit M,25 Invoice and Checks, was





691 J. Carfi2 marked for identification.)3 Q. Doctor, do you anticipate any4 additional work in this case?5 A. Only if it goes to trial, of course,6 I will prepare myself, but other than that, I7 don't anticipate any more.8 Q. Do you have any plans for a third9 examination of Athan?10 A. I have no plans, no.11 Q. Do you have any plans to update your12 second report?13 A. I have no plans to do so, no.14 Q. How does it usually work in terms of15 updating your report or your opinions prior to16 trial in a case? Is it usually just upon the17 request of the attorneys?18 A. Usually it is upon the request of the19 attorney. Sometimes it makes a different how20 long it has been since I have seen somebody,21 so it is different for every case.22 Q. In this case, trial is scheduled for23 January of 2013. Would it be your expectation24 that you would re-examine Athan prior to25 trial?

711 J. Carfi2 Q. Do you intend to do any medical3 literature research in preparation for any4 further work including trial testimony?5 A. I do not.6 Q. We touched upon this just 30 seconds7 ago, but in your opinion, in order to give8 trial testimony or even deposition testimony,9 you are saying it is not important to you to

10 necessarily have up-to-date medical records?11 MR. BERKOWITZ: Objection to the12 form of the question.13 Q. Is it important to you to have14 up-to-date medical records?15 A. Your question is a little bit16 unclear.17 I would say, generally speaking, to18 prepare my narratives it is important for me19 to have as up-to-date medical records as20 feasible. In terms of a subsequent trial or21 deposition testimony, unless there has been22 some significant change in a person's23 condition, there really isn't any specific24 need to have up-to-date medical records. I25 would not expect Athan to get significantly

701 J. Carfi2 A. I don't think, given what I know3 about him, that would be necessary. I would4 not think that his needs will change in any5 way.6 Q. How about any additional review of7 records?8 A. Again, I don't anticipate having to9 do that. I don't see the specific need to do

10 that unless there has been some change in his11 situation.12 Q. You have no deposition transcripts in13 your file, correct?14 A. Are you talking about -- depositions15 of whom?16 Q. Of any witnesses in this case?17 A. No.18 Q. Have you requested any?19 A. No.20 Q. Are you interested in reading any?21 A. No, thank you.22 Q. Did you rely on any medical23 literature in forming your opinions in this24 case?25 A. No.

721 J. Carfi2 better from a functional perspective than he3 is.4 Q. You wouldn't expect that, say,5 between the ages of 2 and 3 you might see6 development or improvement that could alter7 your opinions in this case?8 A. That's correct; I do not anticipate9 that.

10 Q. Can you explain to me, what is that11 based on?12 A. Well, it is based upon my knowledge,13 my experience; I have been evaluating these14 kids, yes, in this context, for 20 years plus.15 The issue also is that his brain injury is16 static, meaning that his brain is damaged and17 that doesn't get better over time. It won't18 necessarily get worse, certainly, but it's not19 going to get better.20 Will he make some modest21 improvements? Perhaps. Perhaps there will be22 some communication down the road where there23 isn't any now, but do I expect him to ever be24 able to stand up and walk normally? No, that25 would never happen. Do I expect him to be





731 J. Carfi2 able to dress and undress himself? No, that's3 not going to happen. So I don't expect any4 significant functional changes to occur.5 Q. How about from a cognition6 standpoint?7 A. He will always be severely impaired.8 As I said before, maybe he will be able to9 communicate in some very basic way at some10 point in the future, but I don't expect11 anything significant.12 Q. When you talk about the need for13 updated records only if something changes, I14 guess my question is: How would you go about15 knowing if something has changed, thereby16 necessitating review of further records?17 A. Well, generally speaking, I do have a18 conversation prior to any trial testimony, I19 do speak with the retaining attorney, and I20 can get a general sense of the situation.21 Every case is different and when you22 have a brain injury case or a spinal cord23 injury case, things just don't change in terms24 of function and neurological improvement, as25 opposed to a musculoskeletal case where there

751 J. Carfi2 most part, there are certain things that I do3 and a certain pattern -- certain way that I do4 things. But, yes, of course, it's fluid. If5 I see that there is something that I need to6 pursue, I pursue it. If I am starting to do7 something and it is clear that it's not8 practical because the person just can't do9 that thing, then I move on to the next. So,

10 yes, there is a certain pattern that I utilize11 but that pattern is not fixed in cement. It12 is flexible and fluid as I go through the13 examination.14 Q. Sticking to the pattern part of it,15 understanding that you might deviate, what are16 the basic stages or categories of an17 examination on a child such as Athan.18 A. First let's take the history. If the19 child can participate, I let them participate.20 While I'm in the consultation room21 interviewing the parents, I am observing the22 child, to see what they are doing. Are they23 wandering around my office looking at my24 stuff? Are they curious, are they just25 sitting there, not doing anything? So I just

741 J. Carfi2 might have been some intervention and things3 are better now that that intervention has4 occurred. So it's a different situation.5 Q. Can you walk me through, not specific6 to Athan but just in general, walk me through7 the IME report process.8 A. From where to where?9 Q. Well, what is an IME?

10 A. Independent Medical Evaluation.11 Q. What does it entail?12 A. It entails a couple of things. It13 entails reviewing pertinent records. It14 entails taking a history from either the15 individual or the caregiver, or both,16 depending on the situation, a physical17 examination, and then rendering an opinion18 based upon the provided records, experience,19 knowledge, and the history and physical20 examination.21 Q. Is there a standard physical22 examination for children such as Athan or do23 you start in one direction and see where it24 takes you?25 A. Very good question. I think, for the

761 J. Carfi2 have some general observations. Then3 typically I will have the child brought into4 the examination room, disrobed down to the5 diaper and I start with them on the6 examination table, I check them for reflexes,7 range of motion, tone. I get an assessment,8 are they attending to me visually or not?9 Q. Are the parents in the room with you?

10 A. Always. Always, one or both, whoever11 is there comes with me, absolutely.12 I am also observing the interaction13 between the child and the parent, that's part14 of it. If they are able to, I assess their15 strength. I check their sitting balance. If16 they can follow instructions, I ask them to do17 certain things, see if they do them.18 I have some toys that I'll engage19 them with, see how -- what they do with that.20 I have them sit, check their sitting balance.21 I have them stand up, or pick them up, see if22 they can weight bear, to what degree can they23 wait bear, how much help they need to stand in24 place. I'll check any braces that they have.25 Measure head circumference, visual, basic





771 J. Carfi2 hearing. That's the general gist of things3 and it will vary depending on the individual.4 Q. Going back briefly to the interview5 part with the parents or the caretakers.6 Similar question: Is that a form or a7 questionnaire or is it an open-ended dialogue?8 A. I have a cheat sheet that I use to9 make sure that I don't forget certain things,10 like it will have feeding, dressing, bathing,11 diapers, things of that nature, so certain12 things that I need to ask about. Family13 situation, I like to find out if it's an14 apartment or a house, what kind of a house.15 If the parents work, any help at home. So I16 have a cheat sheet that just has some basic17 stuff and then I kind of fill in as I need to.18 Q. The cheat sheet, is that something19 you take notes on?20 A. Yes, generally speaking.21 Q. I didn't see them in your file. What22 happened to your notes?23 A. Once my report has been dictated and24 proofread, I don't keep the handwritten notes25 because they are not legible.

791 J. Carfi2 do make any other notes, please don't3 discard them, even if you do dictate from4 them, please just put them in the file for5 further production.6 THE WITNESS: Sure.7 Q. About how long is the interview part8 of the exam?9 A. Well, I schedule an hour for the

10 entire interaction. It could take less or it11 could take more. If the interview is very12 involved, it can be 15 minutes, it can be half13 an hour, depending upon the complexity. I14 don't recall this specific case.15 Q. Now I'm going to get to this case in16 a second, I'm just trying to get an overview.17 And about how long on the physical18 exam?19 A. Again, it's quite variable. The20 examination can be 15 minutes, it can be 4521 minutes. It just depends upon the specific22 issues at hand.23 Q. When you are doing the physical part24 of the exam, do you do any specific cognitive25 testing?

781 J. Carfi2 Q. Has Attorney Berkowitz or any other3 attorney ever told you that everything in your4 file, if you are retained in the case, has to5 be produced?6 A. It's not in my file, so it wasn't7 produced.8 Q. Did Attorney Berkowitz or anyone else9 ever advise you that anything you prepare or

10 create has to be produced?11 A. Not in those words, no.12 Q. In what words?13 A. The fact that I have to keep every14 scrap of paper that's related to what I do,15 no, I've never been told that.16 Q. Have you ever been told not to17 discard any documents that you prepared?18 A. No, I have never been told that.19 Q. It is your testimony then that any20 notes that you took in this case that didn't21 get dictated in the report are now gone?22 A. That is correct.23 MS. WALTMAN: I will just make a24 request. I don't know if you are doing25 any further work on this case, but if you

801 J. Carfi2 A. Nothing specific other than what I3 told you before, the Mini Mental Status4 examination that I do on adults. But other5 than that, there is nothing specific other6 than my observation of the child or7 interaction with the toys that I have, the8 ability to follow instructions, things of that9 nature.

10 Q. How then, in a pediatric case, and we11 will get to Athan specifically in a moment,12 but in general, how in a pediatric case do you13 go about evaluating cognitive impairment and14 future limitations?15 A. Sure. Well, one thing that I do use16 is when they do early intervention, or a17 preschool or school, the psychology or18 neuropsychology report that goes into the19 various developmental levels, the skill sets20 and domains, so I use that if it is available.21 If that's not available, then there is nothing22 formal but I certainly have an understanding23 of what a two-year-old is supposed to be able24 to do in terms of communication, in terms of25 physical activities, things of that nature.





811 J. Carfi2 So that's how I'll make my assessment.3 Q. So your cognitive assessment is based4 largely upon the medical records?5 A. I do depend upon the medical records6 for that, yes.7 Q. And if -- as those change, your8 opinion could change; is that fair?9 A. Well, obviously if there is a change10 in cognitive status or functional status,11 certainly that would affect my opinion, yes.12 Q. Does anyone assist you at all during13 the examination process, either substantively14 or just clerically?15 A. Just the parents assist me because16 sometimes a kid is so delicate, I actually17 don't want to turn them over myself, I ask18 Mom, "Can you turn the child over on their19 belly?" or something like that, or sometimes20 the children are just more comfortable in21 mom's lap. So in that way they will assist,22 dressing and undressing, things of that23 nature.24 Q. As far as the report you mentioned25 that you dictate and then you have an

831 J. Carfi2 "orthopaedics" with an "ae" instead of an "e"3 so that's why I suspect it's going to India.4 Q. So you use a service?5 A. Yes.6 Q. It's not your office assistant?7 A. No, I use a service, yes.8 Q. Turning then to Athan's examination,9 and just so you know, I am going to separate

10 my questions into the examination and then11 we'll do the life care plan after that.12 A. Okay.13 Q. We've gone through the file documents14 already, and just to be clear, you have no15 other documents apart from the ones that you16 have talked about preparing and then17 discarding, you have no other documents that18 you have prepared or obtained or replied upon19 in forming your opinions in this case other20 than the ones we have already gone through and21 marked, correct?22 A. Correct.23 Q. Prior to this case, had you ever24 heard of Dr. Edwin Cruz-Zeno?25 A. No.

821 J. Carfi2 assistant prepare it?3 A. I dictate it into a Dictaphone, I4 think it gets transmitted to India somewhere5 and then it comes back the next day. I do all6 my own proofreading. Once I proofread it, I7 give it to my person who sits at the front8 desk there, she does all my corrections, I get9 it back, I proofread it again. So once it

10 goes through all that, then I do the very11 final -- I bring it up on Word and I just -- I12 do everything, correct it again, then Desiree,13 my office manager, she is the very final14 final. She goes through it again, looking for15 punctuation and grammar, things that don't16 make sense. And then we go over it together.17 Then it gets finalized. She actually does the18 final one and then it goes out. That's the19 process?20 Q. Were you joking about the21 transcription in India? Do you really22 outsource it that far?23 A. Well, the reason I think it goes to24 India is because sometimes the spellings come25 back that are British-type spellings, like

841 J. Carfi2 Q. You know who he is now, though?3 A. I believe a pediatrician, if I4 recall.5 Q. A pediatric physiatrist.6 A. Okay.7 Q. You have no history or involvement8 with him at all?9 A. No.

10 MR. BERKOWITZ: Doctor, feel free to11 look at your file.12 MS. WALTMAN: Definitely.13 THE WITNESS: She took it from me so14 I didn't know if I could have it back.15 MS. WALTMAN: Let's take a minute to16 put it back together.17 (Discussion held off the record.)18 MS. WALTMAN: Back on the record.19 Q. Beginning with your report of20 November 8, 2010 and the corresponding21 examination, and I apologize that some of22 these questions have sort of been covered in23 different aspects, but I just want to get24 clear testimony from you.25 A. Okay.





851 J. Carfi2 Q. Prior to your first examination of3 Athan, did you request any additional4 documents from Attorney Berkowitz?5 A. I did not.6 Q. Do you recall how the examination was7 scheduled?8 A. Not specifically. I can only speak9 in generalities, what the process is.10 Q. What is the general process?11 A. General process is that all of this12 work goes to my office manager, Desiree, who13 understands my schedule and how I like things14 to work. So she actually schedules these15 sorts of examinations.16 Q. It would be scheduled through your17 office as opposed to Attorney Berkowitz's18 office?19 A. Well, Attorney Berkowitz may call and20 do the scheduling, sometimes the patient will21 call directly, but usually it is through the22 attorney's office, who calls and schedules.23 Occasionally the patient will schedule24 directly.25 Q. Do you ever ask a patient to bring

871 J. Carfi2 the first one, yes.3 Q. If you can give me one second, I will4 pull out my copy.5 A. Sure.6 (Discussion held off the record.)7 MS. WALTMAN: Back on the record.8 Q. Using the records then, can you walk9 me through your interview with Mr. and Mrs.

10 Ghannam?11 A. Yes. Do you want me to read it or do12 you want me just to tell you generally how the13 process went with this specific patient?14 Q. The latter.15 A. The latter, okay, very good. First I16 inquired as to the age. 10-and-a-half months17 of age.18 I wanted to find out what kind of19 house they live in, where he sleeps, how he20 sleeps, that sort of thing. If both parents21 are employed. If any additional help at home,22 which they do not have.23 I found out about his eating. He was24 not feeding himself, could not manage finger25 foods, he is very dependent. At 10-and-a-half

861 J. Carfi2 documents or items with them, anything you3 need from them?4 A. No.5 Q. In this case, I take it, same thing,6 you didn't ask Mr. or Mrs. Ghannam to bring7 anything other than their son with them?8 A. Correct.9 Q. Do you have a specific recollection

10 of your examination of Athan?11 A. Not other than what is memorialized12 in my examination here, no, I don't.13 Q. Well. I think that was my question.14 Apart from the documents, do you have a15 specific recollection of Athan?16 A. I have a general recollection of him17 and what he looks like, but I don't remember18 the examination per se. I think I would19 recognize him if I were to see him.20 Q. How about, same question with respect21 to the interview part of it. Do you have a22 specific recollection of your interview23 exchange with -- I don't know who was present24 at the first one, was it just Mrs. Ghannam?25 A. Parents, both parents were there at

881 J. Carfi2 you would expect everything to be done for him3 anyway, so you would expect him to be doing4 nothing for himself.5 Inquired as to his sitting, he could6 not sit unsupported.7 Q. Is it all right if I interject with8 questions?9 A. Sure.

10 Q. So on the eating part of it, anything11 developmentally delayed as far as the eating12 habits at 10-and-a-half months?13 A. He was not feeding -- at 10 months14 old you would expect kids to be able to grab a15 cookie and chew on a cookie, or finger foods,16 things of that nature, which he was not. At17 that age I would expect kids to be holding18 their own bottle, drinking from a bottle, but19 he had to be hand-fed.20 He could not come from a laying-down21 position, he could not come to sitting.22 Q. That's something you would expect?23 A. At that age, usually about six24 months, they are sitting. They're getting up,25 they're sitting on their own. He could be





891 J. Carfi2 placed in a prop-sit position, meaning the3 parents place him in the position, put the4 arm -- propping means you put the arms down,5 so more like a tripod. But he would typically6 fall forward from that.7 Q. Fall forward, you mean his arms would8 give out?9 A. His arms would give out, he would be10 folded in half, essentially. He could not lay11 down in a controlled fashion, he would fall12 over. At that age kids should be able to sit13 up and lay down at will.14 He could roll from prone, meaning15 face down to his side. But he could not --16 eventually he might fall one way or the other,17 but he could not roll from face down to face18 up, or face up to face down. At that age kids19 should have full mobility, being able to roll20 over at will.21 Could not crawl, at 10 I would expect22 him to be crawling, but usually at23 10-and-a-half they're starting to pull24 themselves up and stand in their crib. But he25 wasn't able to crawl and he could not pull to

911 J. Carfi2 Q. That would be great.3 A. Do you want me to get it for you now?4 Q. When we take the next break.5 A. Absolutely.6 So they told me that a rattle could7 be placed in his left hand and he would shake8 it bit and then drop it. He would not pass9 from one hand to the other. At that point you

10 would expect midline play, you would expect11 kids to be passing objects from one hand to12 the other. He was not doing that. He was not13 doing any grasping with his right hand.14 Reportedly he would look towards a noise. At15 that time he was wearing eyeglasses; the16 diagnosis at that time was bilateral lazy eye.17 The parents told me he was mimicking some18 sounds and babbling quite a bit. At that age19 you would expect babbling and mimicking, you20 know, within a couple of years they should be21 speaking. At 10-and-a-half months you would22 expect "mama" and "dada" and some basic23 two-syllable words.24 He was getting early intervention25 services, and the parents were private-paying

901 J. Carfi2 stand; I noted that.3 Not reaching for objects, although he4 would bat -- I describe that he would bat at a5 jungle gym, but at 10-and-a-half months, you6 would expect them to be reaching for things7 that they want, grasping things, manipulating8 items. He had no grasp.9 Q. Just to be clear, this is information

10 that you elicited from Mr. and Mrs. Ghannam11 during the interview portion?12 A. Other than my comments on what kids13 should be doing at this time, yes, his14 functional status is elicited from them.15 Q. And you have a worksheet that you16 kind of work off of to prompt you on certain17 skills?18 A. That worksheet I don't think is that19 specific; it's just a sort of a cheat sheet so20 I don't forget certain things, but not21 everything that I told you is on that22 worksheet.23 Q. Do you have a blank worksheet that we24 could look at?25 A. Sure, would you like that?

921 J. Carfi2 for additional services as well. He had a3 seizure disorder, taking medicine for4 seizures, not having had any seizures since5 birth. And he was described as a happy baby.6 That's the history portion.7 Q. Okay. What happened after that?8 A. Then physical examination.9 Q. Same kind of deal, if you can walk me

10 through, using your report if you need to,11 what you did and what you observed.12 A. Well, first thing, having him lay on13 the examination table, typically in supine --14 lying-on-the-back type of position. I15 describe him moving all four limbs, left16 slightly more than right side. His hands17 remain fisted, with cortical thumbs. Cortical18 thumbs means thumbs inside the fingers.19 Q. Any significance to that?20 A. That's not natural. At that age21 thumbs should be outside. That's very22 primitive, having your thumbs inside. It's23 very non-functional.24 Q. You said his hands were fisted?25 A. Yes, so thumbs inside fingers.





931 J. Carfi2 Generally at that age you should be seeing3 them having the hands open.4 Could not elicit deep tendon reflexes5 in the upper limbs. Knee jerks were 3-plus,6 which is overactive. 2-plus at the ankles,7 normal. Check for clonus, which I could not8 elicit. Babinskis were absent.9 Q. What is clonus?10 A. Clonus is an overactive -- it is11 evidence of spasticity. Basically, the way12 you do it is you hold the leg, you push the13 foot up sharply towards the nose, and what14 happens is the ankle starts to bounce. That's15 clonus, you see that spasticity. He did not16 have that.17 Q. Is that a good thing or a bad thing,18 that he didn't have it?19 A. It is not a good thing to have. The20 fact that he doesn't have it doesn't mean he21 is normal. I'll leave it like that.22 Q. But it is a positive finding, not a23 negative finding? I am not saying he's normal24 because he didn't have it but I'm trying to25 get at --

951 J. Carfi2 But in any event, with him, his tone, other3 than the right arm which was a little bit4 elevated, his tone appeared to be normal.5 Q. And contractures?6 A. No contractures.7 Q. What is that?8 A. A contracture is a restriction of9 range of motion passively. In other words,

10 the doctor is trying to move the various11 joints through their range. He had no12 shortening of that range. The range was13 normal at that time, at 10-and-a-half months.14 Pull to sit, I described, he had no15 independent sitting balance. He had to be16 supported. He had no righting reflexes and no17 self-protective reflexes in the sitting18 position.19 I attempted to prop him, and he20 immediately fell over. I could not get him to21 sit.22 Standing, he required maximal23 assistance, meaning I had to pick him up and24 hold him there. But he could maintain his --25 he was able to extend his legs and support his

941 J. Carfi2 A. Well, that's a better finding than3 finding it present. The fact that it's absent4 is better than if it was there, absolutely.5 Passive range of motion. That's why I move6 the limbs, he has an increased tone in the7 right arm. Appeared normal elsewhere. He had8 no contractures. When I did a pull-to-sit,9 that's when you grab the child and you lift

10 them up by the arm to a sitting position he11 had a head lag, meaning his head flopped12 backwards.13 Q. Can I stop you and ask you a few14 questions? When you say "tone," what does15 that refer to?16 A. That refers to -- first of all, our17 muscles, when I move -- when I hold people's18 limbs and I move the arms and legs, it's not19 like a wet noodle. There is a certain plastic20 resistance that your muscles have, we call21 that "muscle tone." If tone is excessive,22 that is, there is extra resistance to my23 passive range, we call that "spasticity."24 Sometimes it can be the opposite, low tone, as25 well. Some of these children have low tone.

961 J. Carfi2 weight, as I described it here. And3 assistance -- minimal assistance to maintain4 his balance, so I put my hands on his side so5 that he didn't fall over but he was doing the6 work of supporting his weight.7 Place him in a prone position, that's8 face down, he could not bring his arms under9 him to push him up. He could turn his head.

10 When I did put his arms in the midline,11 instead of pushing up his arms immediately12 went outwards and he couldn't bring them back13 to the midline.14 Q. What does that indicate?15 A. That's abnormal. Children at that16 age should be able to start bringing their17 arms to the midline. In fact, at 10 he should18 be crawling. The way you crawl is you bring19 your arms to midline, you push up and you move20 your arms and legs. He is clearly not doing21 that.22 He had this reflex called the23 asymmetrical tonic neck reflex on each side,24 which is abnormal.25 Q. What is that?





971 J. Carfi2 A. With that, what you do is you take a3 child's head and you turn the head to the4 right and what happens is the right arm and5 the right leg straighten out and the left arm6 and left leg curl up; you take the head and7 turn it to the left, then the left arm and8 left leg straighten out and the right arm and9 right leg curl up. That reflex is usually10 gone at about six months. Persistence of that11 abnormal reflex is not normal.12 There is a startle reaction to a13 clap. I do that to see if they can hear. He14 didn't seem to be able -- I have some noisy15 things that I use, he wasn't tracking the16 sound from side to side but he clearly could17 hear the sound. So when I clapped he would18 startle.19 I could not engage him visually,20 looking from side to side. He did smile at21 daddy's voice, I made a note, but he didn't22 turn towards daddy's voice. He was making a23 lot of noise babbling and cooing and drooling.24 Checked his pupils, equally round and25 reactive to light. There was alternating

991 J. Carfi2 intervention, Pre-K, whatever is available in3 that regard.4 Q. Were there any records that were5 wholly impertinent to your evaluation?6 A. Okay, let me see. That's a unique7 question, Counselor. I have to hand that one8 to you. I will have to look.9 I mean all records have some value

10 but I would say the least pertinent records,11 perhaps, are the general pediatric records12 that I looked at. I guess ENT records and the13 audiology records are probably the least14 pertinent.15 Q. Were there any findings or16 information from the parents that were not in17 concert with the medical records? In other18 words, were there any inconsistencies between19 what you were seeing and hearing versus what20 was recorded in the medical records?21 A. I can't say that I looked at that22 specifically, that would require a lot of work23 to do that. But generally speaking, I did not24 see any inconsistencies between the reported25 abilities that they gave me versus what was

981 J. Carfi2 exotropia, which means one eye is going out,3 then the other eye goes out, you know, they4 would alternate which eye is pointing5 outwards.6 Head circumstance 39-and-a-half7 centimeters, and that was the physical exam.8 Q. Any significance to this head9 circumstance measurement?

10 A. Very microcephalic. At 10-and-a-half11 it should be in the mid-40s somewhere.12 Q. Were there any medical records that13 you reviewed -- withdrawn.14 Let me put it this way: What medical15 records were most significant to you in16 preparation of your first report?17 A. All the records I had were important18 but in terms of most significant, certainly19 the Danbury Hospital records were very20 important to me. I also have a prejudice for21 looking at the physiatry records, so Edwin22 Cruz-Zeno's records and what is documented23 there.24 Also, the next most important would25 be any of the therapy records, you know, early

1001 J. Carfi2 documented in the records, or my own physical3 examination, for that matter.4 Q. Does it happen in other cases from5 time to time where you will speak to6 caretakers or examine a patient and what you7 see and what you hear is inconsistent with8 what is in the medical records?9 A. I will say that has happened on

10 occasion and it is primarily adult patients,11 more orthopedic multi-trauma than12 neurological, so that doesn't really happen13 with kids.14 Q. When do your physical exam, are you15 specifically looking to confirm findings in16 the medical records?17 A. No, I am looking to confirm whether18 or not the history -- that my physical19 examination is consistent with the history20 that I elicited from either the patient or the21 caregiver. I am not doing detective work,22 going back and looking, unless I am23 specifically asked to do that. Sometimes I am24 specifically asked to do that, especially on25 defense side, "Please, Doctor, do a real





1011 J. Carfi2 forensic detailed analysis," then I will go3 back and I'll do that. But unless I'm4 specifically asked to, then I don't do that,5 no.6 Q. In that case, for your role, what is7 the purpose of your review of medical records?8 A. That gives me the background9 information, it gives me the basis for10 understanding what the damage -- if there is11 an accident or an incident or whatever you12 want to call it, what the damage is, the13 extent of the damage, is that damage static or14 is it progressive, what -- since I understand15 brain injury and spinal cord injury and things16 of that nature very well, what are the17 implications of the damage and the location of18 the damage versus what I would anticipate down19 the road, so it assists me in my evaluation of20 the patient.21 Q. Returning to your first examination22 of Athan, did you review your findings with23 Mr. and Mrs. Ghannam?24 A. No.25 Q. Did you review your findings with

1031 J. Carfi2 Q. When would Attorney Berkowitz then3 have first received your findings in this4 case?5 A. Well, that would have been when the6 report was sent to him, in this case, November7 8, 2010, he would have received it within a8 day or two after that.9 Q. Just so you and I are clear, I am not

10 talking about where you, yourself, make edits11 or your assistant makes edits and you're12 cleaning up the report. I am talking about13 going through the drafting process with a give14 and take with the attorney.15 A. I understand what you are saying.16 Q. Do you do that?17 A. Not in this case.18 Q. In other cases sometimes?19 A. I have done it rarely, yes.20 Q. Do you know if you ever advised21 either Attorney Berkowitz or Mr. and Mrs.22 Ghannam of the fact that you were not going to23 be doing the life care plan with that first24 examination because of Athan's age?25 A. Can you repeat the question, please.

1021 J. Carfi2 Attorney Berkowitz or anyone from his office3 before you prepared your report?4 A. That's not my custom and habit, so,5 no.6 Q. Do you recall if you showed Attorney7 Berkowitz or anyone from his office an initial8 draft of your report before it was finalized?9 A. I do not recall, no.

10 Q. Do you ever do that?11 A. Sometimes I do that, but it is not my12 habit to do so.13 Q. In this case, if you had done that,14 would your first draft be in your file?15 A. Well, first of all, I didn't do that16 but I do not keep each and every draft17 because, as I said, I go through five separate18 proofreadings. I can't have five narrative19 reports for my file.20 Q. I understand that. I am trying to21 get it if you go through a review process with22 the attorney for certain corrections or23 additions or subtractions; do you do that?24 A. I don't do it in that level of25 detail. I did not do it in this case.

1041 J. Carfi2 Q. Sure, let me make it simpler.3 Did the plaintiffs or the attorney4 know that he was going to have to come back5 for a second exam?6 A. Not until I completed the7 examination. I didn't know beforehand, but8 Mr. Berkowitz knew afterwards, after I did it9 and I realized I couldn't do what was being

10 asked.11 Q. When you were initially asked to do12 an examination of a 10-,13 10-and-a-half-month-old, was it your thought14 that perhaps you could do the life care plan15 at that time?16 A. No, it would have been my thought17 that likely I would not be able to do it, but18 I would have to see the level of devastation19 in the particular child.20 Q. So then we already discussed you sent21 your report, you advised Attorney Berkowitz22 you'd like to see him back, or you'd need to23 see him back when he was about 2?24 A. Correct.25 Q. Any other work on this case? I know





1051 J. Carfi2 we reviewed your billing, but any work on this3 case between your first exam and the second4 exam?5 A. Other than reviewing the records,6 there was no work. My custom and habit is I7 try to review the records before I see the8 person, so that would have been the work that9 I did before they come back.10 Q. In this case that would have been --11 would it have been the original records and12 the new records?13 A. Just the new records. I wouldn't14 have re-reviewed the old records again, no.15 Q. And the new records that you16 received, just to be clear, these were not17 records that you requested; you were just sent18 them as updated information?19 A. Yes.20 MR. BERKOWITZ: Excuse me, when you21 are ready to go into the second report,22 can we take a break for a couple of23 minutes?24 MS. WALTMAN: Yes, that's now, so25 let's take a break.

1071 J. Carfi2 full time.3 So, diet had advanced, he could eat4 chunky, pureed types of food, anything soft5 that could be chopped up, you know, soft6 pieces of chicken, that sort of thing could be7 eaten. He would drink water from sippy cup,8 milk from a bottle.9 Q. So far on eating, is Athan still

10 behind?11 A. He is behind because he cannot12 self-feed. At two years old you would expect13 kids to be feeding themselves. You give them14 food, they eat it. But he could not do that.15 He could not manage finger foods, couldn't use16 utensils, obviously, so, yes, he is behind.17 Q. Okay.18 A. He remained dependent in dressing and19 bathing. He could not come to sitting from20 supine -- from laying down he could not sit up21 independently. He was able to maintain a22 prop-sit, that is being placed arms in front23 of him, a tripod type of situation. He could24 maintain that for a period of time. But,25 again, he would fall forward, folding himself

1061 J. Carfi2 (Discussion held off the record.)3 MS. WALTMAN: Back on the record.4 Q. Dr. Carfi, turning now to the second5 report, dated November 17, 2011, the exam of6 October 25, 2011. Do you have that?7 A. Yes, I have it.8 Q. Independent of your report, do you9 recall this second interview and exam?

10 A. No, not specifically. As I said, I11 believe I would recognize Athan if I were to12 see him again, but the specifics of the exam,13 I would have to refer to my report.14 Q. Well, then if we can do it the same15 way we did before, can you walk me through16 first the interview portion of the exam?17 A. Yes. First, he is about two years18 old and I just confirmed that they still live19 in the same place as they did before. He20 still had difficulty sleeping through the21 night. When he woke up, he would typically be22 brought to the parents' bed.23 I also determined that the mother had24 stopped working so that she could care for25 Athan, whereas the father continued to work

1081 J. Carfi2 in half, but at this point what was different3 is that he could get his legs out from under4 him, get his legs behind him.5 Q. You mean when he's falling or when6 he's --7 A. Once he's folded in half, forward, he8 is able to work his legs out and get them9 behind him, which was not described when he

10 was 10-and-a-half.11 He can prop on his arms at that point12 so in the prone face-down position he could13 get up on his elbows and hold his head up. I14 also described that even when he is in the15 seated position, he cannot lay down in a16 controlled fashion; he would fall over one way17 or the other.18 He was able to roll over from prone19 face-down to supine face-up, which he couldn't20 do at 10-and-a-half. He is unable to roll21 from face-up to face-down. That he couldn't22 do.23 He was not crawling. He was not able24 to pull to stand. With assistance he could25 bear weight on his legs. He was using a gait





1091 J. Carfi2 trainer in therapy. He was doing some3 reaching while in the seated position. He4 would continue to bat at objects; no grasp was5 described, no play in the midline. An object6 placed in his left hand, it would stay there7 until he got tired of it. He would also bring8 it to his mouth. He could hold something in9 his right hand, but he did not bring it to his10 mouth. And there was no passing of objects11 from one hand to the other.12 The parent described that he was at13 that point exhibiting some understanding of14 cause and effect, so he would hit a button to15 generate a light or make some noise from a16 toy. He was turning to voice and noise. If17 an object was bright or shiny or colorful, it18 would attract his visual attention. He wasn't19 wearing glasses anymore because his diagnosis20 had changed from bilateral lazy eye to21 cortical visual impairment. He was continuing22 to mimic sounds, babbling. I determined he23 was at that point receiving early intervention24 services, again, he was receiving vision25 therapy. They were still paying out of pocket

1111 J. Carfi2 treatment.3 Q. That was my next question. What is4 your evaluation of the treatment he was5 receiving at that time, adequate?6 A. Well, no. My plan does recommend7 five days a week -- five treatments a week.8 Clearly, with physical therapy, it looks like9 he is getting the requisite five a week, but

10 the rest of the therapy isn't up to what I11 think would help maximize whatever functional12 potential this child or any child would have.13 Q. What happened after the interview;14 can you walk us through the exam?15 A. Sure. All right. Again, the16 examination begins on the examination table,17 laying down face-up. I note him moving all18 four limbs. His hands, again, are fisted with19 cortical thumbs. I was able to elicit20 reflexes in the upper limbs, 2-plus, that's21 normal. I did not elicit Hoffman's reflexes.22 Knee reflexes remain 3-plus, ankles 2-plus. I23 did obtain sustained clonus at this point at24 the ankles; that's where the ankles are very25 bouncy. A right Babinski reflex is present.

1101 J. Carfi2 for a couple of physical therapy treatments a3 week.4 He had had a few seizures that year,5 associated with fever. He was still on the6 antiseizure medication. And he continued to7 be a happy baby.8 Q. Before we go on, what is or was your9 understanding of his therapy schedule at that

10 time?11 A. I was told he gets physical therapy12 twice a week, occupational therapy twice a13 week, speech-language therapy twice a month.14 He received visual therapy or vision therapy15 once or twice a month, special education once16 a week.17 Then through insurance, the parents18 indicated he got an additional physical19 therapy treatment, as well as aquatic therapy,20 which is pool therapy. And then paying out of21 pocket, they obtained two additional -- what22 is called Feldenkrais physical therapy. It is23 a different form; I don't really understand it24 myself, but two additional physical therapy25 treatments a week. So he is getting a lot of

1121 J. Carfi2 Left was absent. I did note now increased3 tone of all four limbs on passive range of4 motion but, again, no contractures.5 Q. Is increased tone a positive or a6 negative?7 A. That's a negative thing, that means8 the spasticity, that has developed over time.9 With pull-to-sit there remains a head lag, the

10 head flopping backwards. Again, no11 independent sitting balance, no righting, no12 self-protective reflexes. I did attempt to13 prop him but I couldn't. I had his mom try14 but she was unsuccessful getting him to sit in15 a propped position. Maximal assistance16 required to get him into standing, which means17 I literally picked him up to stand. He was18 able to maintain his weight with assistance to19 maintain his balance. I noted at that point20 he tended to lean to the left a lot and then I21 would straighten him up and then he would tend22 to lean over to the left.23 Placed in a face-down position, with24 his arms downward, he could not bring them up25 under him. When arms were placed under him,





1131 J. Carfi2 he was able to push up a little bit. He could3 lift his head, turn it from side to side. I4 noticed while he was sitting in his mom's lap,5 after a while his head would just fall6 forward.7 At this evaluation he was tracking8 the sound from side to side. He alerted to9 his father's clucking tongue, turning to take10 a look. He calmed to his mother and smiled to11 his mother's singing. I could not induce him12 to visually fix and follow something. And I13 noted he was ticklish. Again, he had the14 bilateral exotropia, the out-turning of the15 eyes to a mild degree. And the head16 circumference was 40.5 centimeters. And that17 was the examination18 Q. And on the head circumference?19 A. Should be around 50. So it is low,20 it is microcephalic.21 Q. If you compare your findings from the22 first exam and your findings from the second23 exam -- well, let me ask you: Were your24 findings from the second exam expected or were25 they more or less than you expected?

1151 J. Carfi2 cognitively he is more preserved but just3 can't communicate or physically act out?4 A. Based upon the brain damage as5 described in the medical records, I would not6 expect him to have what you are describing as7 a locked-in syndrome. That's a completely8 different situation where somebody is9 cognitively in tact but they can't command

10 their body to do things. It's a totally11 different condition and the MRI scans that I12 had from the previous records suggest a much13 more global damage and a very specific lesion14 that would cause what you are talking about.15 Q. Would you agree that at least on16 cognition, though, time would tell if he has17 more cognitive preservation?18 A. Time would tell, absolutely, you are19 going to know by the time he is 5 or 6, you20 can then do neuropsychological types of21 testing which will have long-range predictive22 active value. Based on the work that I have23 done over the years, evaluating these kids, he24 will continue to have significant cognitive25 deficits, but you are quite correct, really

1141 J. Carfi2 A. They were about expected. I did3 anticipate that Athan would develop greater4 signs of spasticity. I also anticipated that5 certainly with the therapies that he would6 engage or interact with the environment a7 little bit more. Meaning, reaching, which he8 did, generate an understanding of cause and9 effect, you know, he hit the button and the

10 thing lights up, you know, kids like that kind11 of thing. So I certainly expected some12 improvements in that regard, yes.13 Q. How about cognitively? How were you14 able to evaluate his cognition?15 A. Again, it is the same as I indicated16 before. At two years old you would be17 expecting a child to be speaking and18 understanding, following instructions,19 interacting with you in a much more consistent20 way, which he clearly was not doing. So21 generally those sorts of functional things,22 things that he should be doing functionally as23 a two-year-old, running, talking, climbing,24 all these things that he simply was not doing.25 Q. Are you able to determine if

1161 J. Carfi2 you have to wait until he is a little bit3 older to do formal testing and get real4 quantitative data.5 Q. And I know you kind of grimaced at6 this question earlier, but I'm going to ask7 again anyway. Were there any records -- which8 of the records that you received for the9 second exam were most pertinent to your

10 evaluation?11 A. As I said before, that's a very12 unique question so I have not had that one13 before.14 Well, in this particular case, all15 the records other than the general16 pediatrician records were valuable to me17 because it had -- the Easter Seal18 rehabilitation therapy records are important19 and, as I said, I am particularly biased20 towards the rehabilitation physician so Dr.21 Cruz-Zeno's records are pertinent, and then22 the physical therapy records from Danbury23 Hospital. I always find that the therapists'24 records are valuable to me.25 Q. Were there any records that you were





1171 J. Carfi2 looking for or that you would like to have3 reviewed but didn't have?4 A. No.5 Q. You mentioned, and I see this,6 Feldenkrais, F.E.L.D.E.N.K.R.A.I.S. I know7 you said that you are not entirely familiar;8 what is your understanding because I am even9 less familiar?10 A. I couldn't even begin, I would have11 to look it up on the Internet. I have done it12 several times and I can never remember. I13 just don't recall.14 Q. I take it, then, it's nothing you15 would prescribe?16 A. Correct.17 Q. Is it something that you are opposed18 to?19 A. Not at all.20 Q. Or it's just not in your regime?21 A. It's not in my regimen of prescribed22 therapies. It's nothing I am opposed to,23 though.24 Q. Okay.25 MS. WALTMAN: Let's go off the

1191 J. Carfi2 month." It doesn't work that way.3 Q. So you would agree this is a product4 of litigation?5 A. I have used it for other purposes,6 but, yes, primarily it is used for litigation7 purposes, yes.8 Q. Apart from physiatrists, are there9 other types of specialists who perform life

10 care plans?11 A. Well, actually, finding a physician12 to do this is relatively unusual. There are13 not a whole lot of us out there that do this.14 Most of the people who do this are -- RNs do15 it; CRCs do it; you'll see an occasional OT,16 occupational therapist, who does it.17 Q. What was the second one?18 A. CRC, certified rehabilitation19 counselor, that's just the letters. That20 about covers it. RNs, CRCs and OTs.21 Q. What is a certified life care22 planner?23 A. A certified life care planner is24 somebody who's gone through the educational25 process. I think the University of Florida

1181 J. Carfi2 record for one second.3 (Discussion held off the record.)4 MS. WALTMAN: Back on the record.5 Q. Doctor, then turning to your life6 care plan -- first of all, what is a life care7 plan?8 A. A life care plan is a document which9 details the medically necessary services,

10 equipment, therapies, medications and such11 that are required for the care of somebody who12 has been seriously or catastrophically13 injured.14 Q. Do you prepare these with your15 patients?16 A. Not in the formal sense as you see17 here. I certainly discuss the components with18 my patients, meaning my spinal cord patients,19 "You need to see the urologist every year, and20 these are the tests that would be recommended,21 this is the type of wheelchair that you22 require, these are the leg braces that would23 be appropriate." So I discuss the components24 with them; I don't hand them a plan and say,25 "Here is your plan, I will see you next

1201 J. Carfi2 has a course. There's also the International3 Association of Life Care Planning or Planners,4 and so they -- that's a professional5 organization of life care planners. So there6 is a certification process that one can7 undergo if one chooses to do so.8 Q. Okay. My next question is something9 we've kind of touched upon in bits and pieces,

10 but when you have child or a patient with11 special needs, at what age do you feel that an12 accurate life care plan can be prepared?13 A. Depends on the child. The more14 involved the child is, the earlier you can do15 that. The less involved the child is, the16 longer you have to wait to get an17 understanding of what the ultimate functional18 outcome or cognitive outcome will be. So the19 more impaired, the easier it is to do it20 earlier. The less impaired, you have to wait21 because things can change dramatically. In22 this particular case, since Athan is so23 significantly involved, I am able to determine24 earlier than someone that has a simple spastic25 diplegic cerebral palsy. You have to see





1211 J. Carfi2 those people later down the road.3 Q. You would agree that when you do a4 life care plan at two or two-and-a-half years5 of age, you cannot factor in what kind of6 improvements the child will make from the very7 therapy you think he needs, correct?8 A. Let me answer it this way: Clearly,9 we all hope that a child like Athan will make10 improvements and I would anticipate that there11 will be improvements -- sitting balance may12 improve, the ability to open his hand and13 grasp may improve, but we are talking about14 very subtle improvements which are not going15 to have significant impact on functional16 abilities: walking, able to hold a job, being17 able to prepare meals or feed themselves,18 things of that nature.19 So, yes, we all hope that children20 like Athan make improvements; that why we21 provided the treatment or therapy, but he is22 never going to be anywhere near normal and23 will always be, in my opinion, wheelchair24 bound, primarily, for transportation, among25 other significant needs issues.

1231 J. Carfi2 problem I have with most plaintiffs' plans,3 and forgive me for tooting my own horn, but I4 think my plans are generally reasonable and5 conservative plans, and we may differ on that6 opinion, but I've certainly seen plaintiffs'7 plans where they've put in all sorts of8 services and goods and things which are really9 not necessary.

10 So I provide the same opinions and11 the same work, whoever is retaining me, they12 get the same thing out of me. But when I am13 critiquing plaintiffs' plans, frequently the14 level of care is inappropriate or they are15 suggesting an entire new house should be built16 for somebody or ridiculous things like that.17 Q. Okay. Now, I know there has been18 production, we haven't yet looked at it, of19 some resources you consulted for your cost.20 Can you walk us through -- do you perform all21 the research personally? Do you make all your22 telephone calls personally or do you have23 assistance from others? How is the price24 component prepared?25 A. Generally speaking, I do most of the

1221 J. Carfi2 Q. When you are including a certain3 piece of equipment or a certain course of4 therapy, are you looking for adequate care for5 the patient or the child or are you looking6 for optimum? How would you describe the7 standard you are using to determine what8 should be included in a life care plan?9 A. I like the latter, optimum care, as

10 opposed to adequate. I am not talking about11 the Rolls Royce of care, I am talking about12 optimum care.13 Q. Are you given any guidance -- let's14 take it out of the hypothetical. Were you15 given any guidance by Attorney Berkowitz as to16 adequate versus optimum? To me optimum is17 Rolls Royce but maybe you make a distinction.18 A. Absolutely not, there was no19 guidance.20 Q. In the cases where you have opined on21 behalf of the defendant, where you were22 probably critiquing a plaintiff's life care23 plan, are you looking for optimum or looking24 for adequate?25 A. I am still looking for optimum. The

1241 J. Carfi2 research myself. The things that I get help3 with is the -- if I have to get the cost for a4 home -- from an agency, a home health aide or5 registered nurse, something like that,6 generally Desiree, who you met, will make7 those phone calls for me. I trained her how8 to do this when she started working for me ten9 years ago, spent about a year training her,

10 and she does a great job.11 With respect to facility care, which12 you will see some of that in this, there is a13 social worker that consults for me, and14 typically I will call up and present the case15 generally, so that I am not revealing any16 HIPAA-restricted information, where the person17 lives, and because his experience is decades18 in the rehabilitation field, he knows the19 types of services and facilities that would be20 appropriate and he will get those names and21 per diems or whatever the appropriate thing22 is.23 Other than that, I do all the24 research myself for the pricing.25 Q. In reviewing some prior transcripts,





1251 J. Carfi2 I came across the name of Patrick Innis; is3 that the man you are referring to?4 A. That's the man, yes.5 Q. You said he is in assisted living?6 A. No, what I said was he is a social7 worker with extensive experience in the8 rehabilitation field.9 Q. And you still utilize his service?10 A. Yes.11 Q. Do you pay him for his service?12 A. I do.13 Q. What does he charge; what do you pay?14 A. He charges 225 an hour, so I pay him15 on the 15-minute increments, you know,16 whatever he tells me it takes for him to do17 the work.18 Q. Again, his work is limited to the19 facility cost-part of this?20 A. Yes.21 Q. And Desiree's work is limited to22 calling for the home health aide or the RN23 costs?24 A. Correct.25 Q. Does she do any other cost

1271 J. Carfi2 her the geographical area, where the person3 lives, and then I let her go with it.4 Q. Now, when you obtain the same5 information from multiple sources -- let me6 rephrase.7 When you obtain multiple quotes, how8 do you go about determining which quote to9 use?

10 A. I use the average. We try, not11 always successful, but I try for home health12 agencies to get three and then average,13 sometimes I can only get two or one, depending14 upon the area, but I use an average. So if I15 get three home health aides, $17 an hour, $1916 an hour, $17.75 an hour, I will average the17 three and then for all the resources that I18 use, of course.19 Q. Is it your opinion that everything in20 Athan's life care plan are services or pieces21 of equipment, et cetera, that he would not22 need but for his birth injury?23 A. Correct, yes.24 Q. So, in other words, there is no care25 in there that he would have needed anyway as a

1261 J. Carfi2 preparation?3 A. No.4 Q. And Mr. Innis, any other cost5 preparation?6 A. No.7 Q. Anybody else anything?8 A. No.9 Q. You said you trained her. Just very

10 briefly, what did that entail?11 A. Well, that entails how to find the12 agencies, how to research, geographically13 speaking, sort of a script, what to say when14 you call, that sort of thing. I am sure she's15 evolved that since she does it herself, so I16 can't state for certain what she says on the17 phone, you know, you sort of learn as you go18 along, but that's pretty much it. I would do19 it several times and watch her do it. But,20 like I said, that was ten years ago.21 Q. Do you typically give her the names22 of facilities to call or she researches and23 calls?24 A. No, she researches. I give her the25 nature of the situation of the case. I give

1281 J. Carfi2 little boy growing up?3 A. Correct.4 Q. Let's start with -- and feel free to5 refer to your plan if you need to. Let's6 start with the medical care portion.7 A. Sure.8 Q. Can you walk us through -- you have9 three services: Rehab specialists,

10 neurologists and orthopedists. Can you walk11 us through why you picked those three?12 A. Sure. First of all, a rehabilitation13 specialist is someone like me. Athan is and14 will remain a disabled person and will require15 ongoing equipment, services, that sort of16 thing. Now, when you look at the plan, you17 will see I stop the therapies at 21 years old18 but it is certainly possible down the road19 that he may need some temporary services, but20 I didn't really account for that in the plan.21 In any event, somebody like myself just to22 monitor his functional status, equipment,23 making sure that the level of care is24 appropriate, that sort of thing.25 Q. Every three months?





1291 J. Carfi2 A. It says here four times -- yes, every3 three months, correct.4 Q. What is your basis for every three5 months?6 A. Well, the basis certainly is that I7 am a rehabilitation specialist and if I have8 somebody who has a permanently disabling9 condition, this is how often that person10 should be seen.11 Q. And you might have this later, and I12 apologize, but is that for life, four times a13 year for life?14 A. Yes, you can assume everything in the15 plan is for life unless there are specific16 time periods denoted or some other17 restrictions.18 MS. WALTMAN: Off the record for a19 second.20 (Lunch recess taken.)21 MS. WALTMAN: Back on the record.22 Q. I think we left off with we were23 going through the three medical care24 specialties, and I think you were talking, Dr.25 Carfi, about rehabilitation specialists and

1311 J. Carfi2 years you see somebody more often, others less3 often. Currently I have adults who are4 disabled with M.S. and spinal cord injuries5 and I see them with that frequency, yes.6 Q. 155.25 per visit, what is the basis7 of that?8 A. The basis of that is -- check my9 resources, that was the National Fee Analyzer,

10 2011. Based upon the CPT code, the procedural11 code, it gives you the 50th and the 75th12 percentile of the charge, nationally speaking.13 I picked the 50th percentile. And then14 another index in that book, it gives you, by15 region, a conversion factor that you would16 multiply the national number by the conversion17 factor for the local area, and that gives you18 the 50th percentile, essentially average cost19 in that geographic location.20 Q. We have these pages, that's in the21 binder clip?22 A. Those pages you have, yes.23 Q. Anything else on the rehabilitation24 specialist?25 A. No, ma'am.

1301 J. Carfi2 four times a year and I believe you said3 unless otherwise noted, it is for life on this4 plan?5 A. Correct.6 Q. And so if I could briefly summarize,7 you feel that a rehabilitation specialist is8 needed, is it for coordination of Athan's9 various services?

10 A. Well, certainly for that initially,11 as well as just monitoring his overall12 functional status should that change, or13 additional equipment be needed going forward,14 if equipment wears out, replacement,15 prescribing, medical necessity. There are a16 lot of things that are involved in taking care17 of somebody with a disability.18 Q. And if you had a patient -- I know19 your pediatric population is a small part of20 your practice, but if you had a patient two21 years old in Athan's condition, would you want22 to see him four times a year? Would that be23 too much or too little?24 A. No, that would be -- I believe would25 be adequate. Certainly there may be some

1321 J. Carfi2 Q. Neurology. You have twice a year3 155.25; can you explain that service?4 A. Yes, the neurologist is to monitor5 the seizure disorder, primarily, because you6 have to make sure that the medication is doing7 its job, you know, seizure is a very serious8 medical condition. So you need to stay on top9 of that.

10 Q. What is your understanding of Athan's11 current seizure status?12 A. Current -- my understanding is when I13 first saw him at 10-and-a-half months of age,14 he had not had any seizures since around15 birth. When I saw him in follow-up, he had16 had three seizures that year, 2011, related to17 fevers, but seizures nevertheless. He is18 currently on -- at the time I saw him he was19 on antiseizure medication.20 Q. Anything else, any other reason or21 basis for the neurology service?22 A. No.23 Q. And the orthopedist service?24 A. Orthopedist, Athan is particularly at25 risk for contractures; that is loss of range





1331 J. Carfi2 of motion of the joints. It hasn't developed3 yet, good, we don't want that to happen. So4 the orthopedist will assist in monitoring5 that, along with the physiatrist, a doctor6 like myself. He is also at significant risk7 for hip problems. Hip dislocation, lack of8 development of the cup where the ball sits in,9 things of that nature. At risk for scoliosis10 because of muscle imbalances. So the11 orthopedist will keep an eye on those sorts of12 problems, hopefully preventing progression,13 something that requires aggressive treatment.14 Q. In a patient such as Athan, when15 would you expect to see evidence of16 contractures, if they are to develop?17 A. Generally speaking, you can see them18 as early as now, two years old. I have19 certainly seen my share of kids that have20 contractures at this age, so it can happen21 really anytime.22 Q. If you don't see them by age 2 or23 2-and-a-half, is it more likely that he will24 not develop contractures?25 A. No, not necessarily. He still

1351 J. Carfi2 so why don't you tell us about it?3 A. That's called oxcarbazepine; that is4 an antiseizure medicine. It's given to him in5 a liquid form; this is his current dose, 7 cc6 a day. Then you have the base cost, and doing7 the math, you can figure out the annualized8 cost for it.9 Q. Is that a category of medication or

10 that's a specific medication?11 A. It is an antiseizure medication.12 Q. Okay. What is your opinion on how13 long he will need to be taking antiseizure14 medication?15 A. Well, unless I am given any other16 information, he has a seizure disorder so he17 would need some sort of seizure medication for18 the balance of his life. I mean, the truth of19 the matter is his dose will increase or become20 more expensive as time goes on, but I have no21 way to predict that, so I don't -- when kids22 have the medications for children, I can't23 possibly predict their increasing doses and24 greater expenses over time.25 Q. So this is his current dose?

1341 J. Carfi2 remains at significant risk for it. You may3 recall when I first examined him, at4 10-and-a-half, his tone was pretty normal5 except for the right arm. Then when I saw him6 a year or so later, 2011, he was having7 increased tone, more evidence of spasticity,8 so clearly things are developing9 neurologically sort of in a negative direction

10 in terms of tone and spasticity, so he becomes11 even more at risk.12 Q. If any of Athan's treaters,13 specifically his physiatrist, his neurologist14 or an orthopedist, if their recommendations15 differed from yours in terms of frequency,16 would you defer to their recommendations?17 A. No, it's still my -- my opinion is my18 opinion. This is what I feel a child like19 Athan needs. Whether or not the treating20 doctors choose to do something else, it's21 certainly up to them, but if Athan was my22 patient, this is what I would want to do for23 him.24 Q. The next category is medication, and25 you have -- I don't know how to pronounce it,

1361 J. Carfi2 A. Correct.3 Q. And the cost is based on his current4 dose?5 A. That's correct.6 Q. What is the basis -- I think we7 looked at it, but do you have it in your file?8 A. You mean the resource?9 Q. Yes.

10 A. Well, the resource originally was11 drugstore.com, which, first of all, I12 discovered a month ago they do not offer13 pricing online anymore. I have been using14 this resource for 15 years. What I gave you15 was an alternate site that I currently use.16 The pricing is a little bit different, which17 you will see if you compare, so I don't have18 that original resource for you. I gave you an19 alternative so at least you have some idea.20 Q. What was the alternative? I just21 don't have it in front of me.22 A. Sure. The alternative is something23 called healthtrans, H.E.A.L.T.H., T.R.A.N.S.,24 healthtrans.com.25 Q. What is the amount?





1371 J. Carfi2 A. A little bit less, actually. It is3 for the same 750 cc. It's $414.43 as opposed4 to what I have here as $425.96. So if you5 wanted to use that number, you have to6 recalculate it, that's all.7 Q. Okay. The 425.96, I understand it's8 from a source that no longer lists the prices.9 Do you know when that number was listed?10 A. Yes, that would have been around11 October 17, 2011, when I developed the plan,12 within a week prior to that, when I was13 probably developing this whole thing.14 Q. When you are developing a specific15 life care plan, do you ever go back and use --16 well, re-use numbers from another case or do17 you look them up fresh every time?18 A. Excellent question. Generally19 speaking, I do use -- if I have already done20 the work, I will use the numbers that I have.21 Come January, all research starts all over22 again. Everything is redone, the wheelchairs23 and the braces, everything is redone again.24 And I will use those number throughout the25 year. If I happen to have used on a plan,

1391 J. Carfi2 manifest, but it's good to know if it's there3 or not, because you may want to adjust4 medications accordingly. And that's $4565 every couple of years divided by 2, so that's6 the annualized cost of 228.7 Q. What kind of doctor performs the8 first antiseizure level test?9 A. Well, typically the neurologist will

10 be very interested in that. Obviously, the11 pediatrician can do that if push came to12 shove, but the neurologist will do that at the13 time of the office visit.14 Q. If it is done by the neurologist,15 does it constitute a separate charge from the16 neurology medical care?17 A. Yes, it does.18 Q. How does that work?19 A. Well, it's a lab test so you charge20 separately, the CPT code for that and you bill21 for that.22 Q. And the same thing with the second23 test?24 A. Yes, EEG is typically done by a25 neurologist, usually in their office, but

1381 J. Carfi2 yes, I can actually cut and paste certain3 things, which I do. Medications I look up4 each and every time because the dosing is5 different, medications vary greatly from6 patient to patient, so I just look it up every7 time I do it.8 Q. So apart from medications, you can9 re-use the other information but you'll only

10 do it for a year -- that year?11 A. Correct. Generally I -- most of the12 information I try to re-use as best I can,13 yes.14 Q. Next page is lab work. Can you walk15 us through your opinions on lab work?16 A. You bet. The first thing is the17 oxcarbazepine level, that's the blood level of18 the antiseizure medication. That's twice a19 year. The cost is 43.05, twice a year, that's20 86.10 for the year.21 The next is the EEG,22 electroencephalogram, to actually monitor the23 seizure activity. When people are on24 antiseizure medication, you can actually see25 seizure activity in the brain. It may

1401 J. Carfi2 there is a separate fee for that, yes.3 Q. And the basis of your frequencies at4 twice a year and once twice a year?5 A. As far as the blood level of the6 medication, I, myself, treat patients who had7 brain disorders, whether it's stroke or TBI,8 and some of them are -- do have seizure9 disorders, cared for by a neurologist, so this

10 is my familiarity with how often the tests are11 done and how often they are seen. The same12 thing with the EEGs. Frankly, some13 neurologists aggressively do it every year,14 which is probably unnecessary, but twice a15 year is sufficient to monitor.16 Q. I think I misread this. You are17 saying once every two years?18 A. Yes, ma'am.19 Q. My mistake.20 A. That's okay.21 Q. Medical supplies and equipment. Let22 me ask you just couple of general questions23 before we delve into it. We touched upon this24 earlier when we had the dialogue "adequate25 versus optimum." How do you go about deciding





1411 J. Carfi2 what products to include?3 Let me ask you this: I assume there4 are probably thousands of products available5 for children and adults with special needs to6 make their lives easier or help them in tasks,7 correct?8 A. Well, there are thousands. Not in9 each specific product type, but in the global10 world of things available for people with11 disabilities, yes, there are thousands.12 Q. So how do you whittle it down and13 decide something should or should not be on a14 life care plan?15 A. In terms of the should or should not,16 it is based upon my knowledge and experience17 in caring for people who have disabilities.18 It's what I do for a living, it's what I was19 trained to do, it is what I do. So how I20 determine what specific item is appropriate21 for a particular person is based upon that.22 Q. I guess my confusion or my inquiry23 is: How do you go about deciding something24 should be on a life care plan versus this25 might be helpful but it's not necessary? Or

1431 J. Carfi2 A. Each child is individualized, yes.3 As I stated before, I can certainly cut and4 paste because there are similarities across --5 brain injuries or spinal cord injuries or6 amputations, I'm able to use information, but7 each plan is individualized for the person8 that I am evaluating.9 Q. Are there categories of items that

10 you look into? I guess I am just trying to11 understand the vast scope of different things12 out there. How do you decide what goes on a13 life care plan?14 A. Again, I am not trying to be15 difficult, but it is based upon the particular16 individual that I am looking at, my training17 and knowledge and experience in caring for18 people with disabilities. There is no19 cookbook per se. Although you would expect20 someone who is not ambulatory, well, they're21 going to need a wheelchair. That's a general22 category for you. If they are not walking, I23 know they need a wheelchair. That's how I24 make that decision.25 If they are unable to stand

1421 J. Carfi2 is that not the standard you use?3 A. I don't put anything that is not4 medically necessary on my plans.5 Q. What is your definition of "medically6 necessary"?7 A. You ask very interesting questions,8 Counselor. You are making me work here.9 Medically necessary would be, in my

10 view, something which is required to optimize11 the -- either the medical or surgical care for12 somebody or optimize their ability to function13 or somebody else being able to care for that14 person.15 Q. And it is your opinion that16 everything on here is medically necessary, not17 just helpful, but it's actually necessary for18 the patient?19 A. Yes, ma'am.20 Q. Do you have a standard form or21 template that you work from for brain injury22 children, as far as equipment?23 A. No, not at all.24 Q. So, you start from scratch with each25 child?

1441 J. Carfi2 independently, depending on the situation,3 they would likely benefit from a stander.4 There are a lot of benefits to standing5 instead of laying down all the time or sitting6 in a chair all the time. So that's sort of7 how I make my decisions.8 Q. Okay. Let's start from the top then.9 And I'll try to group these or maybe you can

10 help me group these together where11 appropriate.12 Routine supplies: Gloves, I don't13 know what Chux is. Powder, wipes, lotions, et14 cetera.15 What are Chux?16 A. Chux are waterproof pads. Typically17 there is plastic on one side and kind of a18 cloth-papery kind of thing on the other side19 that you put down when you're doing bowel care20 or bed bath, whatever you might be doing that21 might be wet.22 Q. And for these all together, you have23 given a cost of $70 month?24 A. Yes.25 Q. Is there backup for this in that





1451 J. Carfi2 binder clip?3 A. No.4 Q. How did you go about getting $70 a5 month?6 A. That comes from the resource, which I7 believe is henryschein.com. That is a medical8 supplies website. So basically what I do is I9 look at what it costs to buy the waterproof10 pads and the baby powders and gloves.11 Obviously, gloves come a hundred to the box,12 so we figure out, you have to take care of him13 three times a day, that's six gloves a day.14 So that's sort of how I do my math, figuring15 out all the supplies, figure out what it's16 going to cost to care for this person over the17 course of a year, divide it by 12, and get18 approximately $70 a month.19 Q. What is your information or basis --20 I'm sorry.21 What is your understanding of Athan's22 continence or incontinence?23 A. Well, first of all, understand that24 this starts at 4 years old, if you look under25 purpose.

1471 J. Carfi2 for transportation. Can you explain?3 A. Yes. First of all, as we have4 discussed, Athan doesn't really have any5 independent sitting balance. That stroller6 typically is much more supportive for people7 who don't have any sitting balance. They're8 also -- if necessary, these things can be --9 have bus tie-downs, public transportation

10 tie-downs. They are crash rated. They also11 are foldable, so it's much easier for the12 parents to handle this if they want to go13 someplace quick with Athan, to put him in the14 stroller, keeps him in a good posture, they15 can fold it up, throw it in the trunk and go.16 Q. What's the difference between the17 stroller and a wheelchair?18 A. Wheelchair is larger. In his19 particular case, he would need a wheelchair20 that has a tilt-in-space feature so you can21 change the weight-bearing features. It is22 designed for him to be in it for a much longer23 period of time. The adapted stroller is24 strictly for transportation, get from point A25 to point B. When you get to point B, you

1461 J. Carfi2 He is 2, so I would expect him not to3 be toilet trained. But I would expect a child4 of 4 years old to be toilet trained, which is5 why it begins at 4. By then if they are not6 toilet trained, then they have a problem.7 They are likely not going to become toilet8 trained.9 Q. Is it your opinion that Athan will

10 never be toilet trained?11 A. That is my opinion, yes.12 Q. Have you worked with or observed CP13 patients who are toilet trained?14 A. Well, that's a very broad category.15 One CP isn't equal to another. I have not16 seen someone as neurologically involved as17 Athan become toilet trained. I've seen less18 involved, spastic diplegia, that sort of19 thing, yes, but not someone like him.20 Q. Is there any question in your mind21 that he could acquire some degree of22 continence and control?23 A. There is no question in my mind that24 he will remain incontinent.25 Q. The next item is an adapted stroller

1481 J. Carfi2 take him out of the stroller, or if you go to3 shop, you come back home. But the wheelchair4 is something he can stay in all day, if he5 goes to school or some other full-day6 activity, so it is much more supportive, safer7 transportation. This had tilt-in-space so you8 can tilt it to alleviate the pressure points.9 Q. Is there any reason why a patient

10 such as Athan can't use the wheelchair for11 point A to point B?12 A. It is big, it's heavier than the13 stroller. It is much more convenient for the14 parents, if they want to take a quick run to15 the mall or something, to put him in the16 stroller than the wheelchair, much easier to17 handle.18 Q. Do you think, though, by a certain19 age -- you have both of them up to age 16.20 A. Yes.21 Q. Do you think by a certain age he will22 be out of the stroller and into the23 wheelchair?24 A. 16 years old, you'll see that there25 is no stroller after the age of 16. Then it





1491 J. Carfi2 is strictly the wheelchair.3 Q. You believe the stroller can be used,4 though, for a teenager?5 A. Up until the age of 16, up to adult6 stature. I assume adult stature is 16 years7 old for the purposes of wheelchairs as we go8 through the plan. So at adult stature,9 stroller is no longer appropriate.10 Q. Pediatric super core contour cushion11 for stable positioning.12 What is that?13 A. That's a specialized positioning14 cushion for him. There are a couple of issues15 you have to be concerned about with child a16 like Athan is -- first of all, he has no real17 ability to correct his sitting posture, so the18 cushion maintains him in a good posture,19 number one.20 Q. Is this on the stroller or the21 wheelchair?22 A. It's on the wheelchair, it's not --23 the stroller is the stroller.24 It also -- the other thing you have25 to worry about since he cannot really change

1511 J. Carfi2 category. So when you look at the features3 and all that, they are slightly different, the4 adult wheelchair is a little different from5 the pediatric wheelchair, so you see that6 there is a slight difference in price, not7 much, a slight difference in price and --8 Q. Is it the same basic equipment but9 it's for the next size?

10 A. It is pretty much basically the same,11 yes, but it is for an adult as opposed to --12 Athan will be growing so the wheelchair has to13 be replaced a little bit more frequently as he14 grows, but once you become an adult, they are15 fairly durable, you know, if you use it, it16 does wear out in about five years so you have17 to replace it every five years or so.18 Q. The five-year replacement, is that19 based upon your experience or is that the20 manufacturer's recommendation or a21 combination?22 A. It is a combination. I have taken23 care of lots of people in wheelchairs and they24 can get pretty ratty-looking by five years if25 you use them.

1501 J. Carfi2 his position, you have to be concerned about3 pressure and pressure sores and things of that4 nature. So the cushion helps to moderate all5 those things.6 Q. And cushion cover to prevent soiling.7 A. Well, again, Athan is incontinent,8 number 1. Number 2, you'd rather the cushion9 cover become dirty than the cushion itself.

10 The cushion you can't really clean very well,11 so it's just to protect the cushion.12 Q. This is for the wheelchair?13 A. Yes, ma'am.14 Q. Is it the cover for the cushion, it's15 the contoured cushion?16 A. Yes.17 Q. Next is lightweight manual18 wheelchair, this is every five years from age19 16, so is it that this replaces the earlier20 wheelchair.21 A. Yes.22 Q. How does that wheelchair differ from23 the earlier wheelchair?24 A. Not substantially, I mean it is an25 adult chair, so you come out of the pediatric

1521 J. Carfi2 Q. Then we have the contoured cushion3 and the cushion cover; those are the same two4 we just talked about?5 A. Yes, adult size, but, yes.6 Q. Next page, right and left ankle-foot7 orthoses. We have every 12 to 18 months,8 every 5 years? Can you walk us through those9 two.

10 A. Yes. First of all, he is growing.11 As kids grow, you have to really replace them12 very frequently, every 12 to 18 months, as I13 have here. So, once they hit adult stature,14 as we discussed before, I assume 16 years old,15 adult stature, then they'll last five years.16 They are quite durable in that regard.17 Q. Backing up for one second, Doctor, is18 Athan using an adapted stroller now?19 A. I don't know the answer to your20 question.21 Q. Do you know if he is using a22 wheelchair now?23 A. Again, I do not know specifically24 whether he is or he isn't.25 Q. Does that factor at all into your





1531 J. Carfi2 analysis, at least at the pediatric level?3 A. No, not really. Just because4 somebody doesn't have something doesn't mean5 they wouldn't benefit from having a particular6 device.7 Q. What exactly are the ankle-foot8 orthotics?9 A. Basically they are braces.10 "Orthosis" is a fancy word for brace. In this11 particular situation, it's a brace that goes12 under the foot, around the heel, in back of13 the calf. It helps prevent contractures,14 it's -- one of the ways to prevent your feet15 from pointing south forever is by supporting16 them at a 90-degree angle. And they are17 custom made to fit Athan so typically it's18 done either through casting or now they also19 have a laser way where they actually scan the20 leg and the foot with lasers and make a model.21 Q. Do you know if he is using these now?22 A. I would have to look at my report. I23 don't remember. Certainly at 10-and-a-half24 months he didn't need them, but with the25 increased tone that I saw at 2 years old -- I

1551 J. Carfi2 A. Some of them are on wheels, yes. You3 can move them around, absolutely.4 Q. Do you know if he's ever used a prone5 stander?6 A. I don't know if he's used one. I7 know that as of the last time that I saw him8 he was starting to use a gait trainer. But9 whether or not they actually put him into a

10 stander, I don't know. Certainly it will be11 beneficial for him for a lot of good reasons,12 but I can't say that I know that he is using13 one.14 Q. What are the medical benefits of the15 prone standers?16 A. Well, there are several medical17 benefits: One, it is good for your18 circulation; two, it's good for your bone19 density because it stimulates the bones;20 three, it's good for your hip sockets because21 that's part of what forms the socket part,22 where the ball sticks into the pelvis, is the23 weight that's on the legs, so that helps24 develop and mold the sockets. It also helps25 in terms of preventing contractures because

1541 J. Carfi2 don't see that he has. At least I didn't3 document that he has it, so I would have to4 say that I don't know.5 Q. There are two prone stander6 categories; what is that?7 A. Well, again, it's the same thing, as8 he is growing, the standers actually change,9 you can see it's less expensive, the smaller

10 ones are less expensive than the adult size.11 So the pricing is a little bit different.12 Q. What is a stander?13 A. A prone stander specifically,14 basically it's a standing frame, where you15 actually can get somebody up in a standing16 position, you bolster their legs and their17 butt, usually there is a bolster behind the18 butt, there's something in front of the knees19 to push the knees back, a foot plate for the20 feet, there's a tray so that the arms can be21 on the tray, they can do activities. So there22 are a lot of benefits to standing, but that's23 basically what it is.24 Q. Is it something that gets moved25 around?

1561 J. Carfi2 you stand them up, you bolster them into3 place, stretch the joints, so it's good for4 all those reasons.5 Q. Would you expect at different ages he6 would be advised to use a stander for X number7 of hours per day? Does it work like that? Or8 is it just at his convenience, depending on9 what he is doing?

10 A. It should be done on a daily basis.11 I'm sure that is physiatrist or therapist12 would advise the family as to how often and13 for how long to have him up, but he should14 stand every day, absolutely.15 Q. What is the gait trainer?16 A. A gait trainer is something -- it's a17 supportive ambulation. It's typically a18 bucket or a sling. If you remember, if you19 had little kids, they sit in this little20 rolling thing, with their legs through it, a21 tray around it.22 Q. Yes.23 A. It's analogous to that, a little bit24 more complicated, obviously, because it's for25 disabled children. But it allows them to





1571 J. Carfi2 begin the process of mobility, of moving their3 legs and seeing, "Oh, if I do this with my4 legs, then I can go over here." It teaches5 them a little bit about cause and effect. Not6 as good as a stander for weight bearing7 because you're kind of sitting in a bucket,8 really, but it does certainly encourage at9 least your feet on the ground and doing some10 pushing and exercise.11 Q. What about from age 16 on, the gait12 trainer?13 A. Well, it's the same idea. I don't14 see Athan as someone who is going to be able15 to use a typical walker with hand-held bars16 and walking along. He will always need17 something that gives him that full support18 around him and under him. So even as an19 adult, they do have such trainers that they20 can use.21 Q. Is that something he would be able to22 use on his own, after someone helps him in?23 A. Well, somebody has to put him into24 it, would have to help him into it, but, yes.25 Q. Mobile floor sitter including feeder

1591 J. Carfi2 him into the position?3 A. I'm sorry, food, meals. I'm sorry, I4 am being unclear about that.5 But it does give him an option to sit6 at a regular table with the family, but it is7 a supported seat that goes onto a regular8 seat. And he can be put into that and sit at9 the table with everybody else while he's being

10 fed.11 Q. How is that different or better than12 a wheelchair?13 A. Well, first of all, it is different14 because it is a specifically designed -- are15 you talking about the floor sitter or the16 feeder seat itself or everything together?17 Q. I guess everything together.18 A. Well, first of all, the floor sitter19 is more of a chair, so instead of having the,20 quote, stigma of sitting in a wheelchair,21 you're actually sitting in a chair. It22 happens to have small casters on it so you can23 move it around, but it is a chair. Your feet24 are typically on the floor, it's that low to25 the ground, so it is more of a normal sort of

1581 J. Carfi2 seat?3 A. Yes, what that is, it's sort of -- as4 opposed to a high chair, you can think of it5 as a low chair. It's a low seat, probably a6 little bit lower than what you're sitting in7 there, it's on wheels, and it does several8 things: You can -- it allows the individual9 to be put in front of the TV and then you can

10 roll them into some -- whether there be some11 family activity going on, it gives them12 mobility and very easy for the family to move13 them around.14 The feeder seat part, typically the15 feeder seat is attached to a rolling base, so16 it's really a feeder seat that's in a wheeled17 base, so you can actually use it to feed. You18 can just attach it and put it on a regular19 chair and get Athan up into a regular chair,20 in the feeder seat, which gives him the21 support because he doesn't have the22 independent sitting balance.23 Q. I am confused by the whole feeder24 seat. When you say "feed," are you talking25 about food or are you talking about seating

1601 J. Carfi2 thing to be sitting in. And it's easier for3 the family, because the casters have 3604 degrees, it's much easier for the family to5 roll all around, or even a younger sibling to6 push Athan around, should they ever be blessed7 with more children.8 Q. So, as I understand it, you would use9 the mobile floor sitter at home; that's a

10 chair that would stay at home?11 A. Yes, at-home mobility. It doesn't12 leave the house. It stays home, yes.13 Q. Next page, and by the way, we didn't14 talk about this, but we are in the category of15 at-home care, right? Facility care is a whole16 other --17 A. Facility care is a little different,18 yes. You will see the asterisk that refers to19 items which are required at home only. If it20 has no asterisk, then that would mean that if21 Athan were to go to a facility, if you were to22 go to a facility, they provide different23 things.24 Q. Let me go back so I understand it.25 For example, on the orthotics, it does not





1611 J. Carfi2 have an asterisk.3 A. Yes. So what that means is that the4 orthoses, since they are custom-made for him,5 that would be outside of the purview of the6 nursing facility or the residential facility7 for kids, because I have been to many, many8 nursing homes in my work and basically9 everybody has the same wheelchair, and the10 same braces, it's more of a cookie-cutter11 approach. So the brace is specifically made12 for him, so I take that out as a personal pay13 kind of an item, even if he is in a facility.14 Q. All these other items that don't have15 an asterisk, it is your opinion that they16 would be included in a facility care plan?17 A. Let me clarify. If it has an18 asterisk, that is something that the facility19 would provide as part of their per diem. If20 it does not have an asterisk, that is21 something that I would expect the family would22 want to provide for their child, as a private23 pay, separate from the facility.24 Q. So things like the stroller and the25 wheelchair and the cushions, even if the

1631 J. Carfi2 are two examples.3 Q. We are on 6 of 10, I think?4 A. Correct.5 Q. Home renovations: Elevator, ramp,6 widened doors and hallways, accessible7 bathrooms, et cetera?8 A. Yes.9 Q. That does have an asterisk, so that

10 would be a home care option only?11 A. Correct.12 Q. Walk me through: What does Athan13 have now; why is this necessary?14 A. Well, first of all, they live in a15 colonial-style house. Colonial-style house is16 a two-story house. Colonial-style house means17 the bedrooms are upstairs. So basically he is18 currently not in a wheelchair-accessible19 environment. So what he needs is a20 wheelchair-accessible environment, which means21 that the doors have to be at least 36 inches22 wide. Because of his type of deficit, he23 would need, essentially, a wet room, a big24 bathroom with a drain in the middle which has25 a shower head and bring in a special chair

1621 J. Carfi2 patient is living in a facility, you would3 expect the facility not to cover those items4 and the family would have to pick up the cost?5 A. Pick up the cost because they would6 want to get something specific for Athan, not7 what all the other kids on the floor have8 because that's what the facility provides,9 correct. You analyzed that correctly.

10 Q. Just as an example, take the11 wheelchair, if Athan was in a facility as12 child, what is your understanding of the13 deficits of the wheelchair you would be14 provided at an institution?15 A. My concern about the wheelchair16 provided at the institution, a couple, first17 of all, it wouldn't necessarily be18 lightweight, which is more expensive. If it's19 a lightweight wheelchair, it is easier for the20 family to handle it. I would be concerned21 that it wouldn't have the tilt-in-space22 mechanism, which is very expensive, but very23 important for somebody who can't otherwise24 move. I have not seen facilities provide25 tilt-in-space types of wheelchairs, and those

1641 J. Carfi2 that he can be bathed, that sort of thing,3 ramp access to the house, elevator access to4 the second floor where the bedrooms are. So5 that's what this is about.6 Q. And the basis for the cost, is that7 in the binder?8 A. No, that came from -- no, I don't9 have my -- how I worked that out. The

10 resource is something called the 2010 Bluebook11 Cost Guide, which basically is a contractor's12 cost which gives you the cost in various13 geographical areas, things of that nature. I14 had worked this out based upon a -- I think it15 was about a 10-by-15 room, and what it would16 cost to actually put in a room like that, plus17 the bathroom, what it would cost to renovate18 an existing bathroom into a wet room. And19 there is a range here because the book would20 indicate that the profit margin or the -- I21 guess I will use "profit margin" for lack of a22 better word -- goes from a lower percentage to23 a higher percentage and that's really what24 that's for. There is a fudge factor, because25 contractors need to have something in there





1651 J. Carfi2 just in case of cost overruns and things of3 that nature. That's where that came from. I4 don't have the worksheet for that.5 Q. Do you have it somewhere where you6 could produce it to Russ later?7 A. I don't. If I had it, I would have8 given it to you. I don't have that.9 Q. Do you know where you pulled these10 specific numbers, then, for this case? Was it11 from another --12 A. It was from what I had here, from the13 book of 2010. There is no 2011 edition. So14 it is the 2010 Bluebook Cost Guide. The other15 thing, the tkaccess.com on resource number 8,16 is a home elevator vendor, and I don't have17 that sheet either.18 Q. I just want to understand so later19 when I can't remember all of this, these are20 documents you once had and you don't have21 anymore?22 A. Yes. Well, clearly, when I worked23 out the pricing for the home renovations, I24 had a piece of paper that I was scrawling25 across, but once I worked out that cost, no, I

1671 J. Carfi2 chair.3 A. Yes.4 Q. So just up to there. Can you walk us5 -- some of this is self-explanatory, but --6 A. Sure, no problem.7 Hand-held shower, obviously, Athan is8 not mobile so the shower head is mobile, to9 allow to clean all the spotty parts, so that's

10 a $39.20 item. They do wear out because of11 the tube and the connections, every two years,12 so that's a $13.17 annualized item.13 Let me go through all the prices and14 just tell you why I picked these particular15 things, Counselor.16 Q. I am actually interested in both. I17 am especially interested in why you picked18 these things, but from time to time I am19 interested in if there is a specific price20 reference.21 A. And you'll let me know?22 Q. Yes.23 A. So the grab bars clearly are not for24 him, it's for whoever is caring for him. It's25 wet in there, so somebody can hold on while

1661 J. Carfi2 did not keep that paper.3 Q. But the 2010 Bluebook Cost Guide?4 A. I have that.5 Q. You do have that?6 A. I do have that book, yes.7 Q. Do you have the pages or the charts8 that you used to get these numbers?9 A. I'm sure they're in the book,

10 somewhere.11 Q. How big is the book?12 A. About that thick (indicating). But I13 don't have the specific pages that I used, you14 know, I don't have that chicken scratch15 worksheet that I scrawled on to work things16 out.17 Q. Okay.18 A. I am not sure if I gave you a cover19 title sheet for that book, but I can get that20 to you at the end. I can give you the title21 sheet so you can see all the particulars of22 the book.23 Q. Okay. The next items, a couple of24 items have to do -- look like bathroom types:25 Hand-held shower, grab bar, adaptive bath

1681 J. Carfi2 they're dealing with Athan.3 The adaptive bath chair is a4 waterproof chair, it's kind of made out of a5 sling-mesh material, and it's for positioning6 him so that he can be bathed. It's almost7 like a recliner chair in the way it looks,8 that you might see on a beach or something9 like that, but it's a little more specialized

10 than that. As he's growing -- it is a lesser11 expensive item, but it has to be replaced a12 little more frequently because of his growing.13 Then once he is an adult, it will last five14 years because the size doesn't change anymore,15 it just wears out and gets moldy and things16 like that.17 Q. And the price source on that?18 A. That would be adaptivemall.com. I19 believe I gave you those. That should be in20 the packet.21 The adaptive car seat, again,22 automotive safety. Now, that stops at 1623 years old, and the reason why, because when we24 get down a little bit further, you will see25 now there's going to be a wheelchair-adapted





1691 J. Carfi2 van, so all you're going to do is just roll3 the wheelchair onto the van and lock it down.4 So he doesn't need the carseat anymore. The5 wheelchair will serve as his carseat, as it6 were.7 Q. Okay.8 A. Then, the diapers, again, this begins9 at 4 years old, I would expect a 2-year-old to10 be in diapers but I would not expect a11 4-year-old to be in diapers, so this cost12 doesn't start.13 Nine times a day is the frequency14 that he's wet or dirty, and the cost is there.15 And Then, adults, the same thing, as I16 testified earlier, I would not anticipate that17 he is going to become toilet trained. That he18 will continue to require adult diapers, which19 is a little bit different cost.20 Q. Okay. Next, electric hospital bed.21 A. Next, they start at 16 years old,22 there's a little caveat just below the header23 there, "The following will be needed at adult24 stature, 16 years old."25 So electric hospital bed, now Athan

1711 J. Carfi2 up and doing that, so the lift device is an3 electrical mechanical device that will allow4 that to take place.5 The replacement sling, because slings6 do wear out and become soiled. I have two7 here and the reason is because generally you8 keep one under the person so that all you have9 to do is hook up the chain and lift them, so

10 basically one is under the person and one is11 in the wash or ready for the next -- to be12 used, and you can switch them out.13 The last item on this page is the van14 for wheelchair access. Again, rolling him on15 up, and either have an elevator or ramp, get16 him into the van and lock the chair down, and17 off you go, to the family event or wherever18 you go with Athan.19 Q. These items, both on this page and20 actually the other pages, am I correct that21 these are all assuming very limited mobility22 on Athan's part?23 A. Yes, which is what I anticipate, but,24 yes, of course.25 Q. So if that changes, the plan would

1701 J. Carfi2 is getting big, it becomes more challenging to3 position him in bed and to care for him, so4 the hospital bed allows the bed to be changed5 to different positions so that he can be cared6 for.7 The incontinence mattress cover, that8 is to, again, prevent mattress soiling.9 Pressure-reducing mattress. Now,

10 Athan does not move very well, and so you11 don't want him to develop bed sores, so the12 purpose of that is to prevent him from13 breaking down on his butt or his hips or14 heals, that sort of thing.15 Q. That's a type of mattress or16 something that you put on a mattress?17 A. That's something you put on a18 mattress. It's typically air cells that19 alternate pressure points, so that's how that20 works. It's plugged into the wall.21 Lift device. He's going to be 16,22 he's going to be an adult, he's going to be a23 big boy, so transferring him from the bed to24 the wheelchair to the bath chair, that's not25 something that somebody could be picking him

1721 J. Carfi2 change?3 A. If his mobility were to change,4 components of the plan may change. I don't5 anticipate that his mobility will change to6 any significant functional degree. He's not7 going to become a functional ambulator. In my8 opinion, he is not going to stand up and move9 from the bed to the chair without significant

10 assistance. So there may be some improvements11 but nothing significantly functional.12 Q. I take it then you don't think he13 will ever walk?14 A. Correct. Not in a functional way.15 When I talk about functional walking --16 (Discussion held off the record.)17 Q. You were talking about functional18 walking.19 A. Yes. Functional walking, to me, is20 somebody being able to get up and walk into21 the bathroom. He's not going to be able to do22 that. Is there a small possibility that23 Athan -- you may be able to get him -- you may24 be able to stand him up briefly and pivot him25 into the chair, that's within the realm of





1731 J. Carfi2 possibility, we call it a "stand-pivot-3 transfer." So maybe you would be able to get4 him up onto his feet because he does bear his5 weight, if you recall, when I had him, and6 then spin him around and sit him on a chair.7 I wouldn't call that walking, obviously, but8 that's within the realm of some possibility.9 But I have certainly seen situations, kids, as10 they get bigger, they get heavier and they're11 not as able to support their weight as when12 they are younger. That changes.13 Q. I think that covers the equipment.14 A. Yes, it does.15 Q. Let's turn to the therapies. Before16 we go through the four individual therapies, I17 think I touched upon this earlier, but if you18 don't expect Athan to progress physically,19 what is the purpose of all of these therapies?20 A. Well, first of all, I didn't say he21 would not progress. What I said was I don't22 think he would progress in a significantly --23 in a significant functional way. He will24 make, I am sure, improvement. That's why we25 provide the kids with therapy. Even if it's

1751 J. Carfi2 on him to date? In other words, have they3 been helping him? Have they been having no4 effect on him?5 A. My understanding is that there has6 been some benefit in the sense that he is able7 to grasp better with one hand, I think the8 left hand, I'm sorry I'm not remembering, but9 certainly one hand's grasping skills have

10 improved. It seems that he is, about 5011 percent of the time, if I recall, getting the12 cause-effect thing, so he pushes a button and13 something happens. So clearly there are14 benefits, again, subtle but these are the15 building blocks upon which you build, perhaps,16 additional benefits from the treatment.17 Q. When you are putting together a18 therapy plan, well, with Athan, have you taken19 into account his parents' ability to, say,20 transport him to this number of appointments21 per day, their ability to afford what22 insurance doesn't pick up? Do you take into23 account any of the personal aspects of Athan's24 life?25 A. Well, I don't take into account,

1741 J. Carfi2 something as simple as getting him to be able3 to enjoy a cause-and-effect type toy, you4 know, you hit the button, you hit the key and5 music plays or the lights flash. He can enjoy6 something like that but he has to learn that7 if he does something, something will happen.8 That can take repeated intervention over and9 over again.

10 The ability to utilize, for example,11 the gait trainer and be able to transport12 himself from over here to over there. It's13 small stuff for you and I, but for someone as14 disabled as Athan, that's significant. It15 gives him a kind of mobility, in a way.16 So you hope for improvements, but as17 I stated earlier, the improvements aren't18 going to be to the point where he is going to19 be walking through the apartment or down the20 street or things of that nature, so it is to21 give him whatever functional potential he can22 possibly attain, given his neurological23 condition.24 Q. What is your understanding of the25 effectiveness that Athan's therapies have had

1761 J. Carfi2 truthfully, who is paying for what. I put3 into the plan what I feel a child or adult or4 whatever I am working with really needs from a5 medical and rehabilitation, et cetera6 perspective. I can't -- it is what the person7 needs, although, of course, in the real word8 you have to be concerned about what things9 cost, but this is what he needs and how that

10 is effected is another matter. As far as11 transportation, again, I am not thinking about12 how he is getting to where he's got to be, I13 am just thinking about this is what the child14 needs.15 Q. Fair enough. Let's start with the16 physical therapy. Generally, what is the17 purpose of physical therapy? What are the18 goals of a physical therapy plan?19 A. Physical therapy generally is20 concerned with the gross motor functions of21 balance, strength, coordination, things of22 that nature, as it relates to positioning,23 mobility, sitting ability, things of that24 nature. So that's kind of what they are25 concerned about.





1771 J. Carfi2 Q. And you have five times a week from3 ages 2 to 21?4 A. Correct.5 Q. What's the basis for five times a6 week?7 A. Basis is that, again, repetition is8 the name of the game in terms of being able to9 build upon any skills that you developed or10 lessons learned or whatever you have been able11 to input into a particular disabled12 individual. The more you repeat it, the more13 ingrained it can become, number one. Number14 two, you want to provide these disabled15 children with the maximal therapy to give them16 the maximum potential functional benefit that17 they can attain. You know, at 21, therapy is18 over, so you hope that whatever skills you can19 ingrain into them, that becomes useful for20 them.21 Q. Are there therapies or techniques22 that can be taught to the parents so that you23 go somewhere one or two days a week and you do24 the rest at home?25 A. Well, you are talking about a home

1791 J. Carfi2 about as good as it's going to get.3 Q. When you include physical therapy in4 your life care plans for children such as5 Athan, do you always opine five days per week?6 A. Not always. Most of the time, yes,7 but some children are so devastated,8 truthfully, so devastated, that there is9 nothing to build on. There are no lessons to

10 be learned, so to speak. So in those11 situations, of course, I have therapy as less12 frequently but for someone like Athan, who has13 some potential, whatever limited potential14 there is, there is some potential there, yes,15 five days a week.16 Q. What is occupational therapy?17 A. Occupational therapy is very18 functionally oriented, it's not occupational,19 when you're thinking vocational. Occupational20 therapy is what do you do with the strength21 and what do you do with the coordination, what22 do you do with your sitting balance. And in a23 situation like this, occupational therapy will24 get involved with things like feeding skills,25 things -- they tend to concentrate on the

1781 J. Carfi2 exercise program, but that's really not a3 skilled intervention. Physical therapists are4 medically trained and skilled at providing a5 skilled service. What we're talking about is6 really not a skilled service, so it is just7 not as good, truthfully, as having a therapist8 do it.9 Q. Why do you have -- let's start with

10 physical therapy although they are all the11 same, why do you cease therapy at age 21?12 A. Because at the age of 21 he will have13 had skilled treatment his entire life, pretty14 much, I mean 20 years of therapy, so he would15 have attained whatever benefit he was going to16 get from the therapy, he would have attained17 at that time. I didn't put anything in here18 for treatment beyond the age of 21. I am not19 suggesting that he wouldn't need a, quote,20 tune up, unquote, from time to time or21 something else may develop, but, again, that22 can be speculative. I don't like to23 speculate; I would never do that anyway. So24 that's the reason why, he would have had 2025 years of treatment and that's going to be

1801 J. Carfi2 upper limbs, so they'll do some of the grosser3 things: Range of motion, things of that4 nature, functional positions, being able to5 prop, for example. They are the ones that6 will do the play therapy with cause-and-effect7 toys, and things of that nature. So that's8 what they do.9 Q. Is there overlap between physical

10 therapy and occupational therapy?11 A. There is some overlap, in fact, many12 times they try and work together to try and13 encourage kids to do bit better; they do a14 team effort. There is overlap in the sense15 that the physical therapist is involved with16 strength, coordination and endurance and the17 lower limbs, all four limbs. The occupational18 therapist typically concentrates on the waist19 up, so there may be some overlap in terms of20 those things.21 Q. Can one therapist provide both types?22 A. No, they're different skill sets,23 because training is different, they're24 certified differently. So the answer is no.25 Q. Have you been involved in cases,





1811 J. Carfi2 either litigation-related or your own3 patients, where physical and occupational4 therapy, either by one person or two different5 people, are sort of done simultaneously in one6 session?7 A. Well, as I said, they can work as a8 team, two therapists. They're doing different9 things within the therapy session, but, yes, I10 certainly am familiar with them working11 together.12 Q. And the same question I had with the13 physical therapy, it is your opinion that14 these are not skills that the parents can be15 taught, such that you can do a home-based16 component?17 A. Yes, that is my opinion. They can18 certainly provide a sort of a maintenance home19 exercise type of thing and do range of motion,20 but what the purpose of the therapy is to21 progress as best you can with the skill sets22 to the degree possible. So parents can23 maintain, but they don't have the skills to24 progress.25 Q. What is speech-language therapy?

1831 J. Carfi2 system. Vision is a very, very complex --3 very complex function.4 Q. Is this vision therapy widely5 accepted?6 A. Sure. It is used very commonly in7 children who have what he has, cortical visual8 impairment. Cortical visual impairment means9 that the part of the brain that actually

10 processes the information is defective, is not11 working properly. That's different than the12 eyeball -- the eyeball is like a camera, that13 might be working great, but if the part of the14 brain that takes that data and interprets it15 is not working properly -- the camera can be16 great but you are not getting anything out the17 other end. So they work on enhancing that18 processing part of it.19 Q. To your knowledge, is there any20 debate in the medical community about the21 effectiveness of vision therapy?22 A. Not to my knowledge, no, there is23 not.24 Q. What would be the specific goal of25 vision therapy for Athan?

1821 J. Carfi2 A. Speech-language therapy generally has3 two components. One is communication, through4 whatever means, there's oral communication,5 sign language, technology, things of that6 nature. They are also involved in feeding7 therapy, how do you advance the diet,8 swallowing techniques, things of that nature.9 They typically do both of those. And Athan

10 clearly has some feeding issues, being11 restricted to a soft, ground-up, chopped-up12 kind of diet. So they would be involved in13 all those things.14 Q. And, again, you are saying that is15 not a skill set the parents could learn so16 there could be a home-based component?17 A. Correct. Other than maintenance,18 that is correct.19 Q. What is vision therapy?20 A. Vision therapy, I don't pretend to21 necessarily understand the inner workings of22 how they do what they do, but they do visual23 stimulation techniques through lights,24 contrasting, patterns and things of that25 nature, in an effort to stimulate the visual

1841 J. Carfi2 A. Well, a specific goal -- well, I can3 give you really more of a general goal. A4 general goal would be his ability to visually5 interact with the environment, in other words,6 to see and recognize familiar things like his7 parents or siblings. His ability to be able8 to be able to see something he wants and at9 least -- and then through that and with

10 speech-language therapy and OTV to be able to11 indicate the need that he wants that thing,12 that sort of thing. All these things work13 together. Ultimately the skills need to come14 together.15 Q. You also have five days a week on16 that?17 A. Yes, I do.18 Q. Any specific basis on five days a19 week?20 A. Again, it's just what I said before,21 attempting to repeat the same interventions in22 an effort to ingrain into the individual as23 well as maximize the benefits and any24 potential functional outcome for him.25 Q. Could you estimate, on your pediatric





1851 J. Carfi2 population, how many patients with brain3 injury get four therapies five times a week?4 A. Well, look at -- first of all, I5 could not really base it on my clinical6 pediatric population. The individuals that I7 see for evaluations for situations like this,8 I see people from all different sorts of9 school districts and the truth is that it is10 more the exception than the rule that they are11 getting four- and five-day-a-week therapy.12 There are places that do that, I have seen13 that, it's very generous benefits, but most14 often it is less than that.15 Q. Do you expect Athan to be attending16 school at all?17 A. Sure. Yes, I would think that he18 would be going to school. Special education,19 small classroom, but I would anticipate he20 would be going to school, yes.21 Q. If he is going to be in school, do22 you think it is realistic to have him at four23 therapies five times a week plus full-time24 school; is that a realistic schedule?25 A. First of all, the school district,

1871 J. Carfi2 physical therapy three times a week at school,3 your opinion would be that he should have two4 more sessions per week?5 A. There you go; you got it. Yes, that6 is correct.7 Q. But you include the full cost because8 you are saying you don't how much he is going9 to get at school?

10 A. That's correct.11 The next footnote, since you didn't12 ask me, you should know that that has to do13 with the fact that the referenced pediatric14 facility on facility care happens to include15 therapy as part of their per diem. So that16 would be, if he was in a facility, up to the17 age of 21, which I don't anticipate that he18 would be necessarily, but if he would be, that19 particular facility, therapy is included in20 their cost so there is no additional cost for21 the therapy, should he be in a facility.22 Q. Do you know typically how many23 therapies, how many different types of24 therapies and the frequency of therapy that a25 residential facility would provide to Athan?

1861 J. Carfi2 and that goes to the number sign, number3 footnote there, the school district is going4 to be providing a certain number of these5 treatments. And they pull them out of a class6 for that or it may be given in the classroom7 setting. So, likely, we are not speaking8 about 20 sessions outside of school; it will9 be something less than that.

10 Yes, it would be a busy schedule, but11 my experience has been parents will do pretty12 much anything for their kids to try and help13 them to get better to the degree possible.14 Q. Talking about the number sign15 footnote, you either discount or you don't16 include services provided by the school17 district?18 A. That's correct, because that can vary19 from year to year. I have no way to know what20 year -- one year they may give twice a week,21 another year three times a week. So,22 basically I give the cost of the entire23 program and then that would be discounted by24 whatever the school district may provide.25 Q. So, hypothetically, if Athan gets

1881 J. Carfi2 A. I can't know that. I know they3 provide all of these types of therapies, but4 at what frequency, I couldn't tell you.5 Q. So you don't know if it is more or6 less than five times a week?7 A. I would not know, correct.8 Q. How about Athan's stamina, any idea9 on whether somebody with Athan's physical

10 ability can tolerate four therapies five times11 a week, plus school, plus family, plus12 everything else?13 A. Generally speaking, kids tolerate it14 fine. The Therapies, these are all priced out15 at half-hour sessions as opposed to full16 hours, so that makes a difference. But I have17 never had a parent tell me that their kid was18 too tired for therapy. Don't forget,19 therapists want to also make it fun, it is20 interaction, it is a happy time, so they21 tolerate it pretty well.22 Q. How about the parents? I know we23 spoke about this earlier, but do you have any24 idea about whether Athan's parents could25 possibly adhere to a schedule of four





1891 J. Carfi2 therapies five times a week?3 A. Well, the mother did stop working so4 that she could focus on and care for Athan, so5 I would imagine that, yes, she would make it6 her business to make sure it is taken care of.7 Q. Do you individualize plans based on8 the parents like that or you are going to put9 in four therapies five times a week10 regardless?11 A. Well, I only put in the therapies12 which are appropriate. So if vision therapy13 is not appropriate, or speech, I don't put it14 in there, obviously, but I don't generally15 take into account the parents' availability.16 It is what the child needs.17 Q. The next item, page 9 out of 10, has18 the home health aide services and the home19 care manager nurse service? Walk me through20 this; what are we doing?21 A. First of all, you can see I don't22 start the home health aide until 6 years of23 age.24 Q. Why is that?25 A. Well, I am going to tell you. My

1911 J. Carfi2 and more care to reflect the parents'3 inability to step back in a progressive way4 and let the child do more for himself, and5 that just won't happen with Athan.6 Q. But your plan assumes that the parent7 is not going to keep up with the same amount8 of care, that the parent is going to be9 replaced by a home health aide?

10 A. What I assume is that the parent11 should not have to continue to physically care12 for a very dependent child. That's not the13 natural order of things. The natural order of14 things is that the parents should be able to15 progressively let go, let the child do more16 and more. I mean still supervise, of course,17 I mean my 18-year-old I still have to18 supervise, but he does everything for himself.19 So I am not suggesting the parents should be20 going our to parties while the home health21 aide is taking care of business, but I am22 suggesting that the home health aide does the23 physical stuff. The parents still provide the24 parental supervision and the love and the25 warmth and the interaction, while the home

1901 J. Carfi2 rationale is this: As a child ages, you3 expect children to be able to do certain4 things for themselves. Clearly, a kid who is5 2 years old, 3 years old, maybe even 4,6 totally dependent upon the parent for pretty7 much everything. But at 6 you would expect8 kids would be getting dressed themselves, at 69 they can pretty much take their own shower,

10 they can make themselves a bowl of cereal.11 There are things they can do that Athan will12 not be able to do.13 So what you see in the plan is a14 progressive increase in home health aide,15 which reflects the inability of the parents to16 progressively step back. Part of the17 parenting process is the progressively letting18 go of the child, letting them do more and more19 for themselves, to flower and bloom and do20 whatever, but Athan will always be the same.21 His parents will never ever be able to step22 back and let Athan do because he won't be able23 to do the various things that I just24 discussed. So as they get older and a child25 like this gets older, you'll see I put in more

1921 J. Carfi2 health aide does the things that the child3 should otherwise be able to do for himself but4 cannot.5 Q. I understand what you are saying but6 at what point do you switch over from what the7 child needs to what will be easier or better8 for the parents?9 A. Well, I always focus on what the

10 child needs, not necessarily what is better11 for the parents, although I am not really12 understanding the point as how the parent13 continuing to have to care for the dependent14 person as they get older, as their needs15 continue to increase, how that's better.16 Q. No, I am just trying to understand,17 you go from 4 to 8 and 16 to 24 hours a day.18 A. Yes.19 Q. And I thought I understood you saying20 that the reason it increases is because the21 child still is going to need the assistance22 and the home health care is going to -- you23 didn't use this word, but -- spell the24 parents, gradually?25 A. Well, in essence, yes. But the point





1931 J. Carfi2 is the parents shouldn't have to be the ones3 to care for needs which would not have4 otherwise been there except for the fact that5 Athan is neurologically devastated. They6 would have been able to step back and let the7 kid dress themselves or make themselves a8 sandwich for lunch, or go down the street and9 play with Mary, or whatever the situation10 would be. They can't do that. They always11 have to be there and be vigilant. So using12 the word "spell" kind of minimizes the thing,13 but in essence it is allowing the parent to14 continue to conduct their lives as a normal15 parent would if they had a, quote, normal16 child, unquote.17 Q. Do you account for whether or not the18 parents are interested in being relieved of19 their duties gradually over time?20 A. I do not, no.21 Q. So if the Ghannams said, "Well,22 that's all very nice but we don't see anybody23 else taking care of our child as long as we24 are able to," that idea wouldn't be reflected25 in your plan?

1951 J. Carfi2 going, or whatever the situation is. But3 Athan is still going to be the same dependent4 child, just like he was 2 or 3 years old.5 That's not going to change substantially.6 Q. What's the basis of the increase, 47 to 8 to 16? I mean the general explanation,8 but those specific hours, what made you say 49 to 8 as opposed to 4 to 6?

10 A. Okay. Basically, it is just based11 upon general knowledge, certainly as parents,12 certainly as a clinician, there is no book you13 can look that up in. I can't give you a book,14 so just based upon my knowledge, experience in15 life, and as a clinician.16 Q. All of these home health care from17 age 6 to 21 through life, you are assuming 2418 hours a day care for Athan?19 A. At 21 years old, yes. Prior to 2120 years old, the balance of the 24-hour day is21 taken care of by the parents.22 Q. Right. So, for example, 6 years old23 to 9 years old, you would assume 10 hours --24 I'm sorry, 20 hours for the parents and the25 home health aide is going to come in for four

1941 J. Carfi2 A. That idea is not reflected in my3 plan; that is correct.4 Q. How do you go from -- I understand5 the general basis, but specifically from 4 to6 8 to 16 and 24, why those changes?7 A. Again, it reflects, as I said, the8 static needs of the child despite the fact9 that they're getting older and should do more

10 for themselves. So, just for example, you11 would expect that at 9 years old, the child is12 going to be much more independent than a13 6-year-old. They understand things, they have14 a better understanding of right and wrong,15 what they should and should not do, personal16 safety, things of that nature. And so the17 parents are able to step back even further18 from their intervention and supervisory role.19 So since Athan is never going to change, the20 amount of home health aide care is to21 substitute for the parental care increase.22 At 16 years old, the kids pretty much23 are coming and going almost as they please.24 You hope they tell where they are going, or25 they text you when they get to where they're

1961 J. Carfi2 hours?3 A. Yes, he still needs 24 hours of care4 every day, yes.5 Q. So my question is: When he gets to 96 years old, why do you reduce the parents'7 time?8 A. I reduce the parents' time because9 they will not be able to do so because Athan

10 is still functionally 2 years old, or 3 years11 old. In other words, I increase the amount of12 time for the home health aide to reflect the13 parents' inability to continue to step back in14 a progressive way from caring -- physically15 caring for their child.16 Q. I guess I am not asking the question17 clearly enough. I understand he is going to18 need a total of 24 hours, according to your19 scheme. So when he is 6 to 9, it's going be20 20 hours assigned to the parents, four hours21 to the home health care. And then it goes22 from the home health care is going to get 823 hours, and then he or she is going to get 1624 hours. So I am trying to understand how you25 came up with the numbers 4, 8 and 16, and then





1971 J. Carfi2 the corresponding reduction in the parents'3 hours.4 A. I did try to explain that before, I5 believe, and there is no cookbook. It is6 really based upon my general knowledge as a7 parent, my knowledge as a clinician, also my8 expertise in the rehabilitation field in terms9 of progressively increasing the number of10 hours, and also Athan's condition. There are11 some situations where I have less hours but12 the child is more able than Athan. So, like I13 said, I can't refer you to a book or a study14 where I got those numbers from. It is based15 upon my general experience.16 Q. Okay. Let's talk about pricing then.17 A. Yes, ma'am.18 Q. Where are those prices from?19 A. That would be item 14, resource 14, I20 believe I have those sheets for you, actually,21 in the packet.22 Q. Okay.23 A. So you will be able to look at that,24 14 is these three home care agencies, and I do25 believe that's in this packet for you.

1991 J. Carfi2 clinician, and they have certain skills, they3 are familiar with a lot of these devices that4 I have here, I mean they have some knowledge5 and understanding in those things. And it is6 the nurse who can call up the doctor's office7 and a clinician making the appointments, et8 cetera. I don't think the home health aide is9 appropriate to do that sort of thing.

10 Q. Moving on to option 2, facility care.11 First of all, I take it this is a personal12 choice made by the family, the parents, about13 whether or not to keep Athan at home or have14 him live in a facility?15 A. Absolutely. I am not suggesting one16 versus the other. It is a family matter.17 Q. Do you have any information on the18 Ghannams' current thinking?19 A. I do not, no.20 Q. You don't factor that in at all; you21 are just putting the numbers in?22 A. I just give the options so that the23 choices are there. I am not inquiring one way24 or the other, or recommending one way or the25 other, for that matter.

1981 J. Carfi2 Q. Okay. And home care manager, why do3 we need a home care manager?4 A. Home care manager, you see that5 starts at 21, when Athan is now a complete6 adult. My idea here is that it is a7 surrogate -- a parent surrogate who makes sure8 that the physician appointments are made, that9 the home health aide shows up, that equipment

10 that has to be purchased is ordered, things of11 that nature, that, again, as a minor, parents12 would take care of those administrative13 things.14 It is really to do the administrative15 duties that now this adult, whose parents16 really shouldn't have to do that -- most17 21-year-olds, maybe a little older these days,18 but they take care of their own stuff.19 Q. And is there any reason why an20 experienced home health aide cannot perform21 the same function?22 A. What if the home health aide doesn't23 show up? That's part of what the nurse does,24 is make sure that everybody shows up, the25 agency is contacted. But the nurse is a

2001 J. Carfi2 Q. I am looking at numbers 16 and 17,3 which are you your resources?4 A. Yes.5 Q. Do you know if these are profit or6 non-profit facilities?7 A. I do not know the answer to that8 question.9 Q. Would you expect a non-profit

10 facility to be more affordable?11 A. Not necessarily. I think people12 misunderstand that even non-profits have to,13 quote, make a profit, in order to pay their14 staff and everything else. So I don't believe15 that the different in fees would be16 significant, if anything.17 Q. On either option 1 or option 2, do18 you include or consider any government19 programs or any other programs that would20 provide services, either at no cost or low21 cost to Athan and his family?22 A. I don't consider any collateral23 resources. However this gets paid for,24 truthfully, is not my business, so to speak,25 but this is what it is, this is what it costs,





2011 J. Carfi2 you know. How it is paid for is sort of3 outside my purview.4 Q. Okay. Do you know, as a physiatrist,5 if either in New York or in Connecticut there6 are government programs that provide some of7 these services?8 A. Well, sure.9 Q. Or offer these services?10 A. Yes, there are.11 Q. What is kind of the general12 knowledge?13 A. Well, my general knowledge is that14 the school system is obligated to provide what15 they feel the child requires in terms of16 special needs services. The State of New17 York, if you are a disabled child, you do18 qualify automatically for Medicaid. Medicaid19 does pay for certain services. I don't know20 about Connecticut, truthfully. There may be21 other public assistance programs that are22 available, but those are two big ones that23 come to mind.24 Q. You don't have any specialized25 knowledge about Connecticut services?

2031 J. Carfi2 which is kind of what you are talking about3 are bells and whistles.4 Q. Okay. You have given an opinion that5 you do not believe Athan is employable,6 correct?7 A. Yes, I have said that.8 Q. What is the basis of that?9 A. The basis of that is his current

10 condition, vis-a-vis the documented brain11 damage on the medical record that I have12 available to me, that he is just not going to13 get himself into an employable condition.14 Q. Do you feel comfortable stating that,15 even though he is too young to be cognitively16 tested?17 A. He is too young to be formally18 cognitively tested, but, yes, I do feel19 comfortable stating that, given my knowledge20 and experience and what I see in this21 particular case, yes.22 MR. BERKOWITZ: Doctor, do you need23 a break to stretch your legs?24 THE WITNESS: I am okay so far.25 MS. WALTMAN: I actually probably

2021 J. Carfi2 A. No, other than the federal mandate3 that says the state school system has to4 provide for these services, I don't really5 know the nuance of the Medicaid system in6 Connecticut, no.7 Q. Are you aware of any pieces of8 equipment not already included that could be9 used by Athan to achieve greater independence?

10 A. Equipment that I have not already11 identified?12 Q. Yes.13 A. Well, I mean, look, there are14 technological equipment that may be of15 benefit, augmentative communication devices, I16 mean since he is already getting the sense of17 cause and effect, there is a possibility that18 he might be able to use at some point some19 sort of augmentative communication device.20 Beyond that, I can't think of21 anything off the top of my head. There is so22 much equipment out there, as you said before,23 thousands and thousands of items. My plans24 tend to be on the conservative side, so I25 don't include a lot of bells and whistles,

2041 J. Carfi2 only have a few more questions and then3 I'm going to review my notes and turn it4 over to Rebecca.5 Q. Do you plan on giving an opinion6 about life expectancy?7 A. I haven't been asked to do so, so I8 don't have any such plans at this time, as I9 sit here.

10 Q. So, to date, you have not formulated11 an opinion on life expectancy for Athan?12 A. That's correct.13 Q. Have we covered all of the opinions14 that you have in this case?15 A. Well, based upon the information that16 I have at hand currently, yes, we have.17 MS. WALTMAN: All right. I may have18 a few follow-up questions, but I am going19 to stop now and turn it over to Rebecca,20 and then I will ask at the end if I need21 to. Thank you very much.22 THE WITNESS: Sure.23 MS. HARRIS: Let's take a quick24 break before I ask questions.25 (Discussion held off the record.)





2051 J. Carfi2 MS. HARRIS: Back on the record.3 BY MS. HARRIS:4 Q. Doctor, I have a few follow-up5 questions for you. My name is Rebecca Harris,6 and we have spoken off the record, I represent7 Danbury Hospital.8 I will probably jump around a bit in9 follow-up, so if you don't follow where I am10 going, please let me know. I am going to try11 my best to not repeat everything that was12 already asked by Attorney Waltman.13 I am going to hand you what has been14 marked as Exhibit D, which is a copy of your15 CV. I just want to go through a couple of16 items in there in particular. The CV17 indicates that you are an affiliated attending18 with Winthrop Hospital at the present,19 correct?20 A. That would be correct.21 Q. That is still true?22 A. Yes.23 Q. Was that what you had described to us24 earlier was only a few hours a month?25 A. I'm sorry, repeat the question.

2071 J. Carfi2 A. Yes.3 Q. Is that similar to the position with4 Winthrop University Hospital?5 A. It is similar in the sense that I do6 not have admitting privileges. That's really7 the primary similarity.8 Q. So then what does it mean to be9 assistant attending at Mount Sinai Hospital?

10 A. It means I don't have admitting11 privileges but that I am an attending at the12 hospital so, again, I can access -- actually,13 it's the medical center, I do have an academic14 title, but I can access the medical school15 library, I can go to the grand rounds, I can16 go to any function at the hospital that I17 would like.18 Q. Do you provide any patient care on19 the premises of Mount Sinai Hospital?20 A. Yes, I do.21 Q. What patient care do you provide22 there?23 A. I supervise the brain injury clinic.24 So I do provide patient care in that sense. I25 do not provide inpatient care, strictly

2061 J. Carfi2 MR. BERKOWITZ: That was teaching at3 Mount Sinai.4 Q. I will rephrase.5 As an affiliated attending with6 Winthrop University Hospital, what are your7 duties?8 A. I have no duties. Basically, I do9 not have admitting privileges. It allows me

10 to be on staff and be able to use their11 facilities, you know, the library, go to their12 CME opportunities. And the other thing is any13 insurance plan that the hospital is affiliated14 with, it allows me to be affiliated with those15 insurance plans, whatever they are, I don't16 know what they are. Those are the three17 benefits. But I do not have any admitting18 privileges.19 Q. From what I understand, you do not20 provide patient care on the premises of21 Winthrop University Hospital at all, correct?22 A. You understand correctly.23 Q. Similarly, with Mount Sinai Hospital,24 you had that listed as an assistant attending25 at present?

2081 J. Carfi2 outpatient. It is a teaching responsibility3 so the residents have primary responsibility,4 and I use -- the patients are used as a5 teaching venue to teach about outpatient care6 and things of that nature.7 Q. So on a weekly or monthly basis,8 however it is easier to assess that,9 approximately how much time do you spend doing

10 that?11 A. At this time it actually is every12 fifth Thursday. It used to be once a month,13 every third Thursday, but the two primary14 brain injury attendings would argue who's15 going to cover the fifth, so they decided Dr.16 Carfi will cover the fifth, so it just makes17 it easier for everybody. And I cover other18 clinics intermittently, if they have to travel19 or go to educational things, I will certainly20 pick up more. So on average I am there21 probably in clinic about once every couple of22 months doing a clinic for them.23 Q. And those patients are not patients24 you are simultaneously following in your25 private practice, correct?





2091 J. Carfi2 A. That would be correct. They are3 hospital clinic patients.4 Q. I believe we already discussed your5 position with Mount Sinai School of Medicine;6 is that correct?7 A. Yes.8 Q. So the position that is listed on9 your CV as the supervisor for traumatic brain10 injury clinic, Mount Sinai; is that what you11 just described to me?12 A. Yes.13 Q. Doctor, have you ever had any14 specific training in assessing cognitive15 abilities in children?16 A. The only training that I have had17 would be as part of my residency program,18 which goes back a number of years, of course,19 but during that period we did receive some20 training in that. But nothing -- I have not21 done anything since, other than my own22 readings. Sometimes I do evaluate children, I23 have made it my business to do some, you know,24 scholarly readings on cerebral palsy,25 developmental milestones, things of that

2111 J. Carfi2 follow?3 A. I particularly follow the Journal of4 Medicine, the Archives of Physical Medicine5 and Rehabilitation, a journal called PM&R, the6 Journal of Head Injury and Rehabilitation, the7 Journal of the American Medical Association,8 the Journal of Occupational Medicine, the9 Journal of Life Care Planning.

10 That's all I can think of off the top11 of my head.12 Q. In these hospitals in which you13 currently have some form of privileges, you14 don't have any on-call responsibilities; is15 that correct?16 A. That's correct.17 Q. And you don't have any training as a18 vocational specialist, correct?19 A. That would be correct.20 Q. Doctor, jumping to your November 8,21 2010 evaluation of Athan, did you have any22 conferences, either by phone or in person,23 with any of Athan's providers in relation to24 that?25 A. I did not.

2101 J. Carfi2 nature.3 Q. And the residency, was that just a4 specific rotation through a particular service5 or --6 A. It is a rotation through the7 pediatric rehabilitation service.8 Q. That was at -- how long did that9 rotation last?

10 A. Six months. A total of six months11 pediatric experience, which included12 neuromuscular disease clinic, spina bifida13 clinic, CP clinic, the inpatient service.14 Q. And you just indicated that you15 obtained knowledge on evaluating cognitive16 abilities in children through your readings.17 What sort of readings do those include?18 A. General textbook readings. I can't19 give you specific names, but certainly I have20 read articles in the journals that I receive.21 I always look at the CP articles, the spina22 bifida articles, brain injury articles, of23 course. Doctors are always reading to keep up24 with their skills, so that's what I do.25 Q. Which journals do you particularly

2121 J. Carfi2 Q. Do you have any intention of speaking3 with them for that purpose between now and4 trial in January?5 A. I do not.6 Q. I apologize, I am going to jump7 before I forget to do this.8 MS. HARRIS: Mark this as the next9 exhibit, please.

10 (Defendants' Exhibit N, legal11 client interviews, was marked12 for identification.)13 Q. Doctor, I am going to hand you what14 has been marked Exhibit N. Earlier you were15 discussing with Attorney Waltman what you16 referred to as your "cheat sheet"; is that a17 blank copy of that form?18 A. It is.19 Q. And that is the current form that you20 use?21 A. Yes.22 Q. Has that form changed since November23 of 2010, when you first evaluated Athan24 Ghannam?25 A. No.





2131 J. Carfi2 Q. And you do not maintain your3 handwritten copy, correct?4 A. Correct.5 Q. Earlier you had discussed with6 Attorney Waltman the charges in relation to7 your life care plan and the evaluation and you8 indicated that you charge $630 for examination9 of a patient, correct?10 A. Correct.11 Q. Do you charge that directly to the12 patient, to the attorney or to an insurance13 company?14 A. Attorney.15 Q. Do you charge any of the portion that16 you provide for the life care plan or any of17 your services in relation to the evaluation to18 the child's insurance company or to the family19 directly?20 A. I do not.21 Q. Earlier when we were discussing the22 physical examination of what you generally23 conduct upon a patient, you had indicated that24 you, yourself, have a standard pattern that25 you sort of use. Is that based on any

2151 J. Carfi2 some of the contact involved in obtaining that3 pricing, correct?4 A. I did say so, yes.5 Q. And that -- could you just remind me6 again what specific areas she is involved7 with?8 A. Specifically she inquires as to the9 cost of the home health aide, or an

10 agency-provided nurse, so that if somebody11 rises to the bar of skilled nursing care, she12 will get those costs for me.13 Q. And does your office manager, does14 she have any form of health care training at15 all?16 A. She has not formal health care17 training, no. I trained her to do that very18 specific aspect.19 Q. When you instruct her to obtain that20 cost for a home health care provider, do you21 provide her with the specific abilities or22 services that you are expecting that home care23 service to provide? Do you provide her24 parameters for that?25 A. Yes. I give her a synopsis of what

2141 J. Carfi2 particular protocol or guidelines that comes3 from any formal organization or guide book or4 anything of that nature?5 A. No.6 Q. So that's just something you've7 developed through your own practice?8 A. Correct.9 Q. We were discussing Feldenkrais

10 physical therapy earlier and you had indicated11 you weren't necessarily familiar, not12 unfamiliar, but you could not recall precisely13 what that entails, correct?14 A. Correct.15 Q. Do you have any records or did you16 receive any records from Athan's Feldenkrais17 PT providers?18 A. Not to my knowledge.19 Q. Would those be helpful to you?20 Would you want to see them?21 A. No.22 Q. We were discussing the price23 components of your life care plan. Again, I24 apologize for jumping all over the place. But25 you had indicated that your office manager has

2161 J. Carfi2 the case, quote unquote, is about, the level3 of disability, abilities, inabilities. So she4 has that information. And at times, I don't5 always, but at times I may tell her6 specifically that the home health aide is just7 for light housekeeping and errands or the home8 health aide will be providing personal9 service, depending on the case. That's less

10 often. I always give her sort of a brief11 synopsis of what the needs are, yes.12 Q. Is that a verbal exchange?13 A. Yes, verbal exchange, of course.14 Q. So you don't send an interoffice memo15 saying "look this up"?16 A. No, I do it -- we do a lot of17 interoffice -- intra-office memo-ing, but that18 specifically, no. She knows who's coming in19 and has a familiarity with what is going on.20 Q. Similarly, in relation to your use of21 Mr. Patrick Innis, he is the social worker you22 were talking about earlier?23 A. Yes, ma'am.24 Q. He assists in obtaining information25 on facility costs?





2171 J. Carfi2 A. Yes.3 Q. And did you use him in this4 particular case; do you recall?5 A. I am sure I did, yes.6 Q. Similarly, do you provide Mr. Innis7 with any form of explanation as to particular8 services you want to be sure the particular9 facility provides, or items that you want that10 facility to have?11 A. Well, it is a similar thing. I12 present the case to him. As I said, he has13 decades of experience in the rehabilitation14 sphere, that's what he has done. So I present15 the case to him and I -- depending on the16 individual case, I may indicate that it is17 more medically intensive care, skilled nursing18 care as opposed to something which may be more19 of a residential, educational-type of20 situation. But, yes, if the individual is21 going to require physical, occupational,22 speech therapies, that the facilities he looks23 at has those services.24 Q. So you don't provide Mr. Innis any25 medical records or, for example, the narrative

2191 J. Carfi2 A. Yes, but in addition I also want to3 know, obviously, whether or not that per diem4 includes therapies, medications, neither,5 both, either/or. In this particular case, the6 facilities provided therapies, so there was no7 additional charge on the facility option or8 additional charge for the therapies. Of9 course, I need to know that, if the per diem

10 includes that or not.11 Q. In this particular case, did Mr.12 Innis provide you any documentation as to what13 those facilities provide within the per diem14 cost?15 A. Nothing written that I recall. The16 only thing that, again, that I found out was17 that the therapies are included in per diem.18 Whether that was verbal or written19 documentation, I don't recall.20 Q. If you can look at your life care21 plan, Doctor, if go to page 10 of 10, which22 has your resources listed?23 A. Yes.24 Q. So would resources 16 and 17 that are25 listed on your page 10 of 10 of the life care

2181 J. Carfi2 portion of your report or anything of that3 nature?4 A. No.5 Q. And then you leave it to his6 discretion or experience to decide which7 facilities to contact?8 A. Yes.9 Q. And does he provide you with -- when

10 he responds to you, what does he provide you?11 A. Well, it's either telephone contact12 or it could be an e-mail, with the name of the13 facility and the cost. It goes both ways.14 Q. Do you recall in this case whether it15 was by e-mail or by telephone?16 A. I do not recall.17 Q. If that was by e-mail, would you18 still have that e-mail?19 A. No, I would not. I don't keep my20 e-mails. They get purged. I have a couple of21 thousand deleted e-mails, then I delete them22 permanently.23 Q. So does Mr. Innis just provide you24 the bottom line, the name of the facility and25 the charge?

2201 J. Carfi2 plan, those would be the information that Mr.3 Innis provided to you?4 A. That would be correct.5 Q. And you do not currently have any of6 the written documentation, if he had provided7 you any?8 A. That's correct.9 Q. So, with regard, then, to the

10 items -- let me revise that.11 If you look at page 9 of your life12 care plan, 9 of 10, under residential13 rehabilitation and education program. The14 resource that's listed is number 16, which is15 St. Vincent's Special Needs Services of16 Trumbull, Connecticut, correct?17 A. Yes.18 Q. Do you know if Mr. Innis investigated19 any other institutions, other than that one?20 A. I don't have any knowledge of that.21 Q. Just for the benefit of the record,22 that particular item we just discussed is in23 option 2, of facility care, correct?24 A. Yes.25 Q. In the -- am I correct in





2211 J. Carfi2 understanding that under option 2, with the3 residential programs, the residential4 rehabilitation educational program that 's5 listed there is -- provides for both medical6 needs, food and room and board as well as7 educational requirements?8 A. That would be the pediatric one,9 number 16, yes, correct.10 Q. And that's only through age 21 is11 what you have provided, correct?12 A. Correct.13 Q. And then the option 2 contemplates14 that Athan wouldn't move to a purely15 residential facility without the educational16 components?17 A. Yes. Because you age out -- it's a18 pediatric facility, you age out on that, you19 have to go somewhere else generally.20 Q. Are you familiar, yourself, with the21 St. Vincent's Special Needs Services?22 A. I am not.23 Q. You don't have any documentation as24 to what specific educational programs they25 provide?

2231 J. Carfi2 facility?3 A. Correct. With the asterisks would be4 provided by the facility, yes.5 Q. Are those items that Mr. Innis6 specifically verified or is that a7 presumption?8 A. That's based upon my knowledge and9 experience, having done a lot of nursing home

10 work in the past, what they typically provide.11 Q. So that's based on what programs of12 that sort typically provide as opposed to13 obtaining any sort of item-per-item breakdown14 of the per diem at St. Vincent's?15 A. Correct.16 Q. So, for example, if I am looking at17 page 4 of your life care plan, which has to do18 with medical supplies and equipment, with the19 exception of the routine supplies listed at20 the top, Mr. Innis did not specifically verify21 whether or not those items would be included22 within the per diem charge, correct?23 A. What I had testified to before was24 the fact that I had done quite a bit nursing25 home work. My concern is that Athan has very

2221 J. Carfi2 A. Other than they provide education for3 the children, I don't have the specifics of4 their educational program. I would assume5 they follow whatever the state regulations are6 for providing education, but what that is7 specifically, I don't know.8 Q. Do you have any specific knowledge as9 to -- let me be more clear.

10 You've already indicated that you11 verified that these facilities, particularly12 in this instance St. Vincent's Special Needs13 Services in Trumbull, provided the four14 therapies: Physical therapy, occupational15 therapy, speech and vision therapy, correct?16 A. Mr. Innis confirmed that, so I17 confirmed it through him and his expertise,18 yes. I did not independently call them and19 confirm the work he already did.20 Q. So Mr. Innis determined that and you21 relied on Mr. Innis?22 A. Yes.23 Q. For the other items in the plan that24 you had indicated with asterisks as items that25 would be provided within the residential

2241 J. Carfi2 specific special needs as far as the3 wheelchair is concerned. So rather than let4 the facility get the plain vanilla whatever5 they get for everybody in the facility, the6 type of wheelchair, Athan should be able to7 get the wheelchair that he needs for his8 particular disability. So I took that out of9 the nursing home per diem, so that Athan gets

10 what it is that he needs, both as a child and11 as an adult, not what the nursing home happens12 to provide.13 Q. But as far as your personal knowledge14 goes, you did not personally verify whether or15 not St. Vincent's Special Needs Services16 provides the individualized, for example, the17 wheelchair that you have advised, versus18 whether it is just a presumption that they19 would not?20 A. That's correct.21 Q. And similarly for all those other22 items that are included on that page that do23 not have an asterisk?24 A. Correct.25 Q. To your knowledge, Mr. Innis did not





2251 J. Carfi2 make that verification either?3 A. I know that he didn't, because I4 didn't ask him to.5 Q. And so those same issues as far as6 the adult residential facility applies as7 well; there was no independent verification of8 whether or not those facilities that are9 listed, Village Green Nursing Home and Oak10 Hill School and Group for the Blind, that are11 listed under number 17, whether or not those12 facilities would provide the individualized13 recommendations that you have included, versus14 the presumption they would provide a generic,15 to use your word, vanilla wheelchair and other16 services?17 A. That is accurate, yes.18 Q. Just in general, with those sorts of19 facility care items, either pediatric or the20 adult facilities, do those types of facilities21 usually have more than one type of program or22 a menu, for lack of a better word, that23 patients can select as to how much care24 they may -- how many services are or are not25 provided?

2271 J. Carfi2 that.3 Typically physical, occupational, and4 speech therapies are billed separately. Not5 that at the pediatric facility that we are6 dealing with here, but certainly the adult7 facilities listed should. Athan's need for8 therapy for or whatever, or anybody, there is9 an additional fee for the therapies. So, yes,

10 additional services will cost additional11 money.12 Q. Did these programs typically also --13 the residential facilities, would they14 generally provide, for example, transportation15 for Athan to go see his neurologist or his16 physician appointments as opposed to his17 parents have to come and fetch him?18 A. Generally speaking, the consultants19 come to the nursing facility to be seen.20 Other than that, some facilities do provide21 transportation, yes.22 Q. And we don't know whether the ones23 consulted by Mr. Innis do or do not, correct?24 A. I do not know, correct.25 Q. Jumping to the adapted stroller, I

2261 J. Carfi2 A. I don't know the answer to that3 question. I don't know.4 Q. So it is a generalization that, based5 on your experience with residential6 facilities, you don't know if that's common or7 not?8 MR. BERKOWITZ: Objection to the9 form of the question.

10 A. A menu of services?11 Q. Let me rephrase. I'm sorry, it was a12 very poorly asked question.13 Are most, as a generalization, not14 necessarily speaking specifically to the15 facilities that are listed, but as a16 generalization, for an adult residential17 facility, would those facilities have various18 pricing based on what services the family or19 the patient selects?20 A. That's an easier question.21 Yes. Obviously, you can get a22 private room versus a semi-private, versus23 four-bedded room, so the pricing is different.24 You can get your own personal RN or home25 health aide, so there is an additional fee for

2281 J. Carfi2 know you already discussed this with Attorney3 Waltman, but I was slightly confused. You4 recommended the adapted stroller to age 16,5 correct?6 A. Yes, that's correct.7 Q. And then I believe you indicated that8 after age 16, that would no longer be utilized9 because he would be using the wheelchair

10 primarily; am I understanding that correctly11 or did I misunderstand?12 A. No, you understood it. It's just13 that the stroller is no longer appropriate, as14 an adult, he would be in the wheelchair.15 Q. And the reason that it's no longer16 appropriate once he's an adult is simply17 because it is too large to be wieldy; is that18 correct?19 A. Well, the stroller, first of all, is20 not as stable as a wheelchair. It's not as21 maneuverable. A wheelchair you can tilt and22 move it around. A stroller really is less23 stable. It is a smaller device and you have a24 big person in it, an adult person in it, it's25 just not as safe. Plus wherever you're going





2291 J. Carfi2 to go, typically you're going someplace to3 stay there, be there for a while, so the4 wheelchair is just a more appropriate venue5 for an adult person. I can add another6 stroller in if you'd like me to add more to7 the plan.8 Q. Well, my question is actually more in9 the opposite direction, Doctor. I apologize,10 my confusion is: Why is the stroller11 continued to be used to age 16 as opposed to12 being no longer used at, say, age 10 or 12 or13 14, for example? In other words, by the time14 a person is 14, they are usually well over 10015 pounds or what have you, so why is --16 A. They could be over 100 pounds.17 Again, it has to do with the fact that I use18 16 years old as having attained adult stature.19 Yes, some kids don't become adult-sized until20 19, some kids are big by the time they're 1421 or 15, this is true. I have no way to predict22 when Athan will be truly adult stature, or any23 child, for that matter. So I use 16 years old24 as a reasonable time period to differentiate25 between pediatric and adult equipment. So I

2311 J. Carfi2 made. It's custom made.3 Q. What are the indications for when it4 would be appropriate to begin using orthoses?5 In other words, what are the physical6 indications that signal it's appropriate to7 use those?8 A. Actually, I think it is time, for9 Athan. He's starting to manifest spasticity,

10 he has clonus, he's got increased tone in the11 legs. So if I was his treating doctor, I12 would be starting him now with the braces to13 prevent contractures. You want to prevent14 things from happening rather than having to15 fix them once they occur.16 Q. Following up with regard to the home17 renovations components that were included if18 he's kept at home, did you consult with19 anybody else in arriving at those figures, in20 other words, a contractor or anything of that21 nature?22 A. In this case I did not, no.23 Q. Do you have a recollection as to what24 specific items -- I believe you indicated a25 ramp, so the ramp is for the outside of the

2301 J. Carfi2 put in the stroller because of that aspect,3 you know, using my pediatric cutoff. And a4 stroller is certainly lighter, more5 maneuverable, easier to load and unload going6 to the car, if you are going to go someplace,7 as a child.8 Q. Discussing the orthoses, you had9 indicated these were to prevent contractures;

10 is that correct?11 A. Yes.12 Q. And I think I missed this when you13 discussed this previously, I think you14 answered it, but are those specially fitted to15 the individual child or do those come in16 sizes, kind of like shoes, for lack of a17 better analogy?18 A. No, they're custom made. Typically a19 cast is made of the leg and the brace is --20 then a mold of the -- a model of the leg is21 made and then the brace is made to fit that.22 They also have a laser technology where they23 can actually scan with the laser, it goes into24 a computer and the computer can actually25 generate a model of the leg and a brace can be

2321 J. Carfi2 house, correct?3 A. Yes.4 Q. Getting into the house.5 And widening doors?6 A. Yes.7 Q. Do you recall how many doorways you8 thought would need to be widened or replaced?9 A. I don't have a specific recollection.

10 I generally do four doors, including the front11 door, bedroom door, bathroom door and one12 other passage door to somewhere, that's what I13 generally use.14 Q. And you had indicated installation of15 a home elevator?16 A. Yes.17 Q. Is that like one of the chair types18 that go up the stairs or is that like a box19 elevator that you'd have in a business20 building?21 A. A real elevator, residential as22 opposed to commercial. So that way,23 everything gets loaded onto his wheelchair,24 gets on the elevator, goes up or goes down,25 whatever the situation may be.





2331 J. Carfi2 Q. And I believe you had indicated3 renovating an existing bathroom, correct?4 A. Yes.5 Q. And then you had indicated also6 that -- something I didn't follow and I7 apologize -- it was based on a 10-by-15 room?8 A. Yes.9 Q. Renovating -- what is that; is that10 adding on a new room?11 A. It is constructing -- either adding12 on a new room or consolidating what's in the13 house. The idea is to give plenty of room for14 Athan, his caregiver, his equipment, he's got15 a lot of equipment here, it takes up space, so16 it needs a lot of room in there.17 Q. So that's not renovating or changing18 his existing room in the house, correct?19 MR. BERKOWITZ: Objection.20 A. Not necessarily. It's part of the21 range. As I mentioned before, having to do22 with the profit margin for the contractor,23 fudge factor the contractor puts in, the cost24 overruns, part of it is whether or not it's25 going to be within the four-wall confines of

2351 J. Carfi2 It is not my custom and practice to do so.3 Q. So if I am understanding the custom4 and practices is that the family comes in with5 the child, you take your history, your6 interview, you've already reviewed the medical7 records, you do the exam and then they leave?8 A. Essentially. I mean I give them the9 courtesy, if they ask me a question, I answer

10 the question. Otherwise I don't offer11 anything, no.12 Q. Do you usually, if the parents had13 asked you questions, would that be something14 that would normally be documented in your15 report, what was discussed with the parents?16 A. No.17 Q. Going back to the house renovations,18 the research that's listed in your report is19 the 2010 Bluebook Cost Guide?20 A. Yes.21 Q. Is that a book you still maintain in22 the office?23 A. I still have that book, yes.24 Q. Could I ask you to -- I don't believe25 that that was among the materials that was

2341 J. Carfi2 the house, whether you have to push back the3 house to get a few extra feet to make the4 room. All these things factor into a price5 range.6 Q. And these are things that you did not7 discuss with any contractor?8 A. Correct.9 Q. Did you discuss any of this with the

10 Ghannams as to whether or not that was11 something they thought would be desirable or12 preferable?13 A. I did not, no.14 Q. And you didn't discuss any aspects of15 this with Ghannams, correct?16 A. That's correct. I never showed them17 my plan at any time.18 Q. Did you have any discussion with the19 Ghannams after either of the physical20 examinations, so while they were still present21 here, as to what you thought your22 recommendations would be or what you thought23 the services or additional care he should24 receive?25 A. I don't recall any such discussion.

2361 J. Carfi2 produced to us.3 A. That's correct.4 Q. Are there specific portions of that5 book that you referenced in coming up with6 that analysis?7 A. Likely, but I don't recall the8 specific pages now.9 Q. Okay. May I ask you to get the book

10 and take a look at it to see if that refreshes11 your recollection as to what you looked at?12 A. You can ask me.13 Q. Would you please do so?14 A. Yes.15 (Discussion held off the record.)16 MS. HARRIS: Back on the record.17 Q. Doctor, I am handing you the Bluebook18 that you referred to. Does looking at the19 book refresh your recollection as to what20 specific portions you consulted or what21 specific costs you factored in?22 A. Specifically, no, it does not. But I23 can tell you generally what I would look at24 but I don't recall specifically what I did.25 Q. What generally would you look at?





2371 J. Carfi2 A. Well, I would look at things such as3 demolition of interiors in order to get4 prepared. I mean, there is drywall, doors,5 electrical work, door work, doors, floor work,6 flooring, framing for the walls and such,7 painting, general and mold. Generally that's8 what I looked at. Plumbing for the bathroom.9 But I don't recall specifically which of these10 various things I looked at.11 Q. What pages within the book are those12 listed, according to the table of contents?13 A. Say that again?14 Q. I'm sorry, I was mumbling, I15 apologize.16 Those specific portions that you17 would generally look at that you just18 described to me, are those referenced by page19 in the table of contents?20 A. Yes.21 Q. What pages are those?22 A. First of all, demolition, here it23 says pages 1 through 4. Each section24 apparently starts over again. Doors, pages 325 through 13. Dry wall, pages 2 through 6.

2391 J. Carfi2 on is related to feeding, including advancing3 the diet and swallowing?4 A. Yes.5 Q. I believe you had said something to6 the effect that Athan is restricted in that7 manner?8 A. Currently, yes.9 Q. When -- what did you mean by that?

10 A. Well, he is eating, I believe, a11 mechanically chopped diet, soft foods. At 212 years old, you are eating potato chips and13 apples and corn on the cob, and all sorts of14 things.15 Q. Is it your understanding that Athan16 is not able to swallow those things or is not17 able to chew them, a more advanced diet; is18 that correct?19 A. I did not get into the nuances of20 that, so I don't know if it is a swallowing21 issue or a chewing issue or a coordination22 issue of the mouth or all those things. That23 I don't know.24 Q. If I can direct your attention,25 Doctor, back to the section of your life care

2381 J. Carfi2 Electrical, pages 3 through 4. It talks about3 flooring, pages 6 through 18. Framing, 34 through 11. Lighting, pages 1 through 4.5 Painting, pages 5 through 13. Plumbing, pages6 2 through 13. Wallpaper, page 3.7 That's basically all I can recall8 referencing here.9 Q. Can I ask to have copies made of that

10 after the deposition, you don't have to do it11 right now, and sent to Attorney Berkowitz?12 MR. BERKOWITZ: Copies of what?13 MS. HARRIS: The pages that he just14 listed.15 A. Well, you're going to have to make a16 copy of that, so I can remember what I told17 you.18 MR. BERKOWITZ: I will tell you19 what, why don't you put it in an e-mail to20 me, Rebecca, and we will get it very21 quickly for you.22 MS. HARRIS: That works for me.23 Q. Doctor, earlier when you were24 discussing speech therapy, you had indicated25 that part of what the speech therapist works

2401 J. Carfi2 plan dealing with the home health aides, which3 was on page 9. I just wanted to clarify in4 particular with regard to your recommendation5 that, beginning at age 16, Athan receive 166 hours per day assistance from the home health7 aide.8 A. Okay.9 Q. Do you anticipate that Athan will

10 still be in school at age 16?11 A. Yes.12 Q. So is the home health aide intended13 to accompany him to school as well?14 A. Yes.15 Q. But the health aide would not be16 accompanying him to school, or would he or17 she, from ages 9 through 16?18 A. Not necessarily, nope.19 Q. Why the difference?20 A. Well, the difference is he is21 starting his transition now. He's 16, he's22 adult size, he will be transitioning23 ultimately into -- not an independent living24 environment, but basically not being in school25 anymore. He is a big boy, so he really does





2411 J. Carfi2 require his own person, so to speak, to take3 care of whatever needs he may have while he is4 in school. That's the reason.5 Q. As I understand your testimony6 previously, you do not take into account in7 the life care plan whether or not that would8 be provided by the school system?9 A. That's correct.10 Q. Doctor, do you have the grouping of11 the documents that were supporting documents12 that you had indicated that we marked?13 (Handing.)14 Q. Okay. I just want to go through15 quickly. These have been marked as Exhibit J.16 Starting with the page that starts "Home17 health aide in Bethel, CT, area care"; is that18 the information that was obtained by your19 office manager when she made her phone calls?20 A. That's correct.21 Q. She called those places and that was22 the numbers that she gave you?23 A. Yes.24 Q. Similar for vision therapy?25 A. Yes.

2431 J. Carfi2 cost that you have included in the life care3 plan in the pediatric wheelchair is $5,527?4 A. Correct.5 Q. But the specific cost that is sort of6 checked off at the top there is 2000 and7 something, on the documents that you have8 provided?9 A. The basic wheelchair, yes.

10 Q. So there are other components that11 get added to that to make it appropriate for12 Athan, correct?13 A. Yes, correct.14 Q. Do you recall which specific15 components you recommended for him?16 A. Right here, they are all listed.17 They are all listed right here.18 Q. Oh, okay, I missed that page. Can19 you just read to me what those are because I20 couldn't read your handwriting.21 A. We have the basic wheelchair. We22 have the stroller push handle, footboard,23 six-inch pneumatic caster, anti-tip,24 adjustable armrests, airless insert, headrest25 hardware, head support pad, tray with

2421 J. Carfi2 Q. Just looking at what is still a3 portion of Exhibit J, three pages that appear4 to come from ACCRA, A.C.C.R.A., Cost of Living5 Index?6 A. Yes.7 Q. Are there other pages that you8 referenced in addition to those three pages9 which appears to be the cover sheet and then

10 the residency?11 A. In this specific publication, no.12 Q. So you did not reference other pages13 in preparing the life care plan for Athan14 Ghannam?15 A. In this specific publication, no.16 Q. Can you flip to the pages that deal17 with the wheelchair. I think there was some18 pages in there. I just wanted to get some19 clarification.20 A. Okay, I have them.21 Q. There are two sets of information22 there related to wheelchair, correct? One is23 pediatric, and one is adult?24 A. Yes.25 Q. Looking at the pediatric set, the

2441 J. Carfi2 hardware, padded seatbelt, solid seat insert3 and solid back.4 Q. That's the same for pediatric and for5 adult or are they different?6 A. Slightly different, but generally the7 same because he is an adult so it's slightly8 different.9 Q. And there's two handwritten pages

10 there?11 A. Yes, this one is for pediatrics and12 that one is for adults.13 Q. Okay, I didn't have that before.14 Thank you.15 Doctor, can you just define16 microcephaly for me?17 A. Microcephaly is head circumference18 which is greater than two standard deviations19 below the mean for a given age and gender.20 Q. What is the significance of21 microcephaly?22 A. The significance is that you can23 infer from lack of growth of the head that the24 brain is not growing and developing normally.25 Q. We discussed earlier, Attorney





2451 J. Carfi2 Waltman asked you some questions about3 standardized cognitive testing. Athan is not4 yet at an age where you could do those tests,5 correct?6 A. Not with any degree of reliability,7 correct.8 Q. At what age would those tests9 normally be given?10 A. Well, those types of tests can be11 given from here forward, looking at various12 domains of function. But for predictive13 value, long range, you are really looking at14 about 6, because at that point you have15 reading readiness skills, math readiness16 skills, you've got more things that you can17 evaluate and analyze.18 Q. Do you have any opinion as to whether19 or not Athan will be able to take those tests20 or participate in those tests when he reaches21 that age of 5 to 6 to 7?22 A. I do.23 Q. What is your opinion?24 A. He will be able to participate in25 those tests to the degree that is possible.

2471 J. Carfi2 functional abilities?3 A. I am not aware of any such4 literature, no.5 Q. Doctor, have you ever done any sort6 of retrospective analysis of your own life7 care plans, where you have gone back to see8 how accurate they turned out to be?9 A. I have not, no.

10 Q. Are you aware of any medical11 literature that shows that five days a week of12 physical therapy provides a better result to13 the patient than, say, two days a week?14 A. I am not aware of any such15 literature, no.16 Q. Similarly for occupational therapy,17 are you aware of any such medical literature?18 A. Same response. I am not aware.19 Q. Doctor, you indicated about 25 -- I20 apologize, I am skipping to your expert21 forensic activities now -- about 25 percent of22 your reviews are for defendants; is that23 correct?24 A. That's correct.25 Q. When was the last time you testified

2461 J. Carfi2 The fact that, let's say, he has no reading3 readiness skills will, of course, lower his4 overall score, but, yes, he will be able to5 participate.6 Q. Doctor, have you spoken with any of7 the plaintiffs' other experts in this case?8 A. I have not.9 Q. You have not spoken specifically with

10 Mr. Gary Crakes, C.R.A.K.E.S.?11 A. No, I have not.12 Q. Doctor, you are not relying on any13 specific medical literature in relation to the14 opinions that you are giving today, correct?15 A. Correct.16 Q. Are you aware of any medical17 literature that discusses the predictive --18 whether it is possible to predict a child's19 cognitive abilities at age 2 for the rest of20 their life?21 A. I am not aware of any such22 literature, no.23 Q. Are you aware of any medical24 literature as to at what age a disabled child25 such as Athan normally reaches maximal

2481 J. Carfi2 on behalf of the defendant in court or at a3 deposition?4 A. Testified? I believe I testified5 either a year or two ago, and I believe it was6 a deposition. That was the last time.7 Q. Do you remember the name of the case?8 A. I do not.9 Q. Do you remember the name of any of

10 the attorneys involved?11 A. I do not.12 Q. Prior to that one occasion one or two13 years ago, when was the last time before that14 that you testified on behalf of the defendant15 either in a deposition or in court?16 A. That I don't recall. It is very,17 very infrequent that I am asked to testify.18 Q. Doctor, are you familiar with a legal19 term called the "Daubert Challenge"?20 A. Yes.21 Q. Has any of your testimony ever been22 challenged under the Daubert standard?23 A. Yes.24 Q. Has any of your testimony ever25 been -- have you ever been precluded from





2491 J. Carfi2 testifying as an expert, either in whole or in3 part, under the Daubert standard?4 A. No.5 MS. HARRIS: I think I am done.6 Give me one second.7 I'm done. Do you have any more?8 MS. WALTMAN: I do not.9 MR. BERKOWITZ: No questions.10 (Time noted: 4:42 p.m.)11

12

13 _______________________14 JOSEPH CARFI, M.D.15

16 Subscribed and sworn to17 before me this day18 of , 2012.19

20 Notary Public21

22

23

24

25

2511

2 C E R T I F I C A T I O N3

4 I, Margaret Eustace, a Shorthand5 Reporter and notary public, within and for the6 State of New York, do hereby certify:7 That JOSEPH CARFI, M.D., the8 witness whose examination is hereinbefore set9 forth, was first duly sworn by me, and that

10 transcript of said testimony is a true record11 of the testimony given by said witness.12 I further certify that I am not13 related to any of the parties to this action14 by blood or marriage, and that I am in no way15 interested in the outcome of this matter.16

17 IN WITNESS WHEREOF, I have18 hereunto set my hand this day of19 , 2012.20

21

22 Margaret Eustace23

24

25

25012 I N D E X3 WITNESS EXAMINATION BY PAGE4 J. Carfi Ms. Waltman 4

Ms. Harris 2055

EXHIBITS6

DEFENDANTS'7 EXHIBITS DESCRIPTION PAGE8 A Notice 49 B Cover Letter 4

10 C Prescription Page 411 D CV 1912 E File 5613 F Additional Records 5714 G Folder with CD 6115 H 11/8/10 Report 6316 I Letter with Life Care Plan 6317 J Reports Request 6518 K Letter 6619 L Notice & Cover Sheet 6620 M Invoice and Checks 6821 N Legal Client Interviews 21222

PRODUCTION REQUEST:23

Copies of referenced pages from 23824 2010 Bluebook Cost Guide25

2521 DEPOSITION ERRATA SHEET2 Our Assignment No.: 3274643 Case Caption: STEPHANIE GHANNAM, et al. -v-4 PATRICE S. GILLOTTI, M.D., et al.5

6 DECLARATION UNDER PENALTY OF PERJURY7

8 I declare under penalty of perjury9 that I have read the entire transcript of my

10 Deposition taken in the captioned matter or11 the same has been read to me, and the same is12 true and accurate, save and except for changes13 and/or corrections, if any, as indicated by me14 on the DEPOSITION ERRATA SHEET hereof, with15 the understanding that I offer these changes16 as if still under oath.17 _______________________18 JOSEPH CARFI, M.D.19 Subscribed and sworn to on the ____ day of20 ___________, 20 ____ before me.21 _______________________________22 Notary Public,23 in and for the State of24 _________________________.25





253

1 DEPOSITION ERRATA SHEET

2 Page No.____Line No.____Change to:___________

3 _____________________________________________

4 Reason for change:___________________________


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23

24 SIGNATURE:____________________DATE:__________

25 JOSEPH CARFI, M.D.

254

1 DEPOSITION ERRATA SHEET


3 _____________________________________________



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21 _____________________________________________


23

24 SIGNATURE:____________________DATE:__________

25 JOSEPH CARFI, M.D.





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