CARINA PAZ et al. v. DR. S. VINCENT GRASSO

 

NOT FOR PUBLICATION WITHOUT THE

APPROVAL OF THE APPELLATE DIVISION

SUPERIOR COURT OF NEW JERSEY

APPELLATE DIVISION

DOCKET NO. A-5870-04T55870-04T5

CARINA PAZ and GERSON PAZ,

her husband,

Plaintiffs-Appellants,

v.

DR. S. VINCENT GRASSO,

Defendant-Respondent.

______________________________________

 

Argued May 3, 2006 - Decided June 15, 2006

Before Judges Parker, Grall and Newman.

On appeal from the Superior Court, Law Division, Hudson County, HUD-L-5495-02.

Alan D. Bell argued the cause for the appellants.

Philip F. Mattia argued the cause for the respondent (Philip F. Mattia and Associates, attorneys; Mr. Mattia on the brief).

PER CURIAM

Plaintiffs, Carina Paz and her husband, Gerson Paz (reference to plaintiff is to Carina Paz only), appeal from both a judgment of no cause for action in favor of defendant Dr. S. Vincent Grasso in a medical negligence action and an order denying plaintiffs' motion for a new trial. We now affirm.

Plaintiff, then twenty-seven years of age, was first treated by defendant, a general surgeon, in the emergency room of Palisades Medical Center on April 10, 2001. The hospital visit was occasioned by plaintiff's nausea, stomach pain and difficulty breathing. Laboratory testing and an ultrasound revealed gallbladder disease coupled with stones. Following a night in the hospital, plaintiff underwent a laparoscopic cholecystectomy (lap-choly) by a surgical team lead by defendant. A lap-choly is the removal of the gallbladder by a device known as a laparoscope, a camera plus a light source and small chop-stick like surgical instruments. These instruments are introduced into the abdomen through several small incisions, as opposed to an open cholecystectomy which requires an incision large enough to permit a surgeon to place his/her hands inside the patient. The advantages of a lap-choly over open surgery include a faster recovery, a shorter hospital stay and less physiological trauma.

The hepatic bile duct is a tube-like structure that carries bile from the liver, where it is produced in a weak form. Bile leaves the liver through both a right and left hepatic bile duct which soon merge to form a single, larger hepatic duct or "common duct." Bile aids in the digestion of fatty foods. The gallbladder receives bile from the hepatic duct via the cystic duct. The gallbladder functions to concentrate bile, store it and then secrete it as signaled by the stomach. Bile secreted from the gallbladder returns through the cystic duct, into the hepatic duct and then travels into the intestines.

The lap-choly procedure entails holding the gallbladder with the operating tools and working away from the gallbladder towards the cystic duct. Only after the cystic duct is clipped/stapled, tied and cut is the gallbladder removed. The cystic and hepatic ducts are easily mistaken because of similarity in color, tubular structure, and appearance. Utilizing the lap-choly procedure, defendant removed plaintiff's gallbladder and was confident the procedure went "correctly."

Following the April 11, 2001 lap-choly, plaintiff appeared to be recovering well upon being discharged from the hospital on April 13. As for follow-up care, defendant informed plaintiff that the clip/staple would have to be surgically removed within ten days. Although plaintiff scheduled an appointment for April 17, 2001, she did not appear. In response, defendant telephoned plaintiff and was informed that she was "having no problems except mild incisional tenderness" and indicated "she would call back later that week for a visit."

On April 19, 2001, plaintiff telephoned defendant's office to report that she was vomiting bile. Defendant instructed plaintiff to visit his office or an emergency room at once. Later that day, defendant spoke with plaintiff again in hopes of persuading her to seek immediate medical attention. The following morning, April 20, 2001, plaintiff was re-admitted into the hospital. Plaintiff was exhibiting signs of jaundice, which is caused by leakage in the bile duct system, noticeably altering the color of the skin and eyes.

In evaluating plaintiff, defendant performed a host of diagnostic tests and obtained a gastroenterology consultation from Dr. Harold Tepler. Dr. Tepler performed an ERCP - a video X-ray evaluation of the bile duct system. The testing and ERCP footage led defendant to identify a blockage/interruption in the hepatic bile duct.

From various reports, defendant concluded that the lower-half of the hepatic bile duct was obstructed. Based on this conclusion, defendant was prepared to perform the surgery because the lower-half of the duct is much easier to repair than the upper-half. Defendant did not have the expertise to perform surgery on the upper-half of the hepatic duct, nor did the hospital have the resources necessary to perform such a surgery.

In retrospect, the parties' experts and defendant agreed that the actual location of the obstruction was in the upper portion of the hepatic duct, closer to the point at which the right and left hepatic ducts merge. Plaintiff's liability expert, Dr. Michael Drew, asserted that this information should have been secured before defendant initiated the second surgery, and thus plaintiff should have been immediately transferred to the more experienced surgeons at Columbia Presbyterian Hospital in New York.

Defendant's liability expert, Dr. Richard S. Nitzberg, disagreed. He testified that defendant acted appropriately because obstruction appeared to be in the mid- to lower-portion of the hepatic duct, the appropriate surgical team had been assembled, and plaintiff was reluctant to be treated elsewhere.

A recognized risk of a lap-choly is accidental damage to the hepatic bile duct. According to medical literature relied upon by defendant's expert, injury to the hepatic bile duct occurs during a lap-choly between .3% and .7% of the time; or, approximately 1 out of 200 cases. Approximately 75% of these injuries are not recognized at the time of surgery. Even plaintiff's expert agreed that injury to the hepatic duct was a "well known" risk of a lap-choly. Plaintiff's expert acknowledged that while discussing the intricacies of a lap-choly with his own patients, he informs them of the risk of injury to the hepatic duct. Further, plaintiff's expert acknowledged that while he had never caused damage to the hepatic duct, it could "absolutely" happen to the best of surgeons.

A second surgery was scheduled for April 23, 2001. Unlike the first, this surgery would be an "open" surgery. Nonetheless, defendant recognized - and explained to plaintiff prior to surgery - that if his team could not repair the hepatic duct because the damage was higher than expected, she would have to be transferred to Columbia Presbyterian.

During the six hour exploration procedure, defendant determined that the surgery could not be safely accomplished and that plaintiff needed to be transferred to Columbia Presbyterian which "has more advanced capabilities for more complicated surgeries." Plaintiff was transferred the following morning, April 24, 2001, and operated upon two days later. As even plaintiff's expert recognized, the third surgery at Columbia Presbyterian was "successful." Defendant's expert opined that plaintiff's ultimate recovery was not affected by the second surgery.

In denying plaintiff's motion for a new trial, the trial judge addressed the issues now raised on appeal. Plaintiff argued that she was entitled to a conditional res ipsa loquitur charge. Defendant's expert was of the opinion that an injury could occur to the bile duct without negligence on the part of the surgeon. Plaintiff's expert held a different view. In rejecting plaintiff's argument, the court stated the following:

Just because an expert takes the stand and says this can't happen unless they're negligent? That would mean you would give a res ipsa charge in every medical malpractice case because every plaintiff's expert in a medical malpractice case takes the stand and says, this wouldn't have happened unless the defendant was negligent. So if I follow that logic, in every medical malpractice case I am required to give them a conditional res ipsa charge because that medical malpractice case will never go to the jury unless an expert takes the stand and says the defendant was negligent. And that's exactly what your doctor said. And that's what's said in every medical malpractice case. This injury would not have occurred unless the defendant doctor was negligent.

Plaintiff also argued that the trial court should not have permitted Dr. Nitzberg to testify from an abstract entitled "Surgeons' Anonymous Response After Bile Duct Injury During Cholecystectomy." In rejecting plaintiff's argument, the trial judge found that the abstract represented a summary of the article, that Dr. Nitzberg was cross-examined at length on that particular issue, and that it was up to the jury to accept Dr. Nitzberg's testimony or not. He also pointed out that the survey indicated that 50% of the doctors reported that there had been an injury to the common bile duct during their surgical lifetime. He viewed the issue as one of weight to be given to the article in evaluating Dr. Nitzberg's opinion.

Plaintiff also argued that the court abused its discretion by allowing the jury to hear evidence that she was an illegal alien. The judge concluded that the mention of plaintiff's alien status did not substantially outweigh the probative value. The alien status went to the damage issue of whether plaintiff suffered from post-traumatic stress disorder because of the injury to the bile duct or other stressors, such as her status as an illegal alien. It also went to the issue of whether plaintiff was reluctant to be transferred to Columbia Presbyterian because her illegal alien status might be uncovered in the process. The trial judge gave a limiting instruction to the jury, expressly mentioning the purpose for which this testimony could be utilized, that plaintiff's immigration status did not affect her right to recover in her personal injury action and cautioning the jury that "immigration status is of no moment as to as to whether or not she is entitled to prevail in this case." The jury was also instructed that it should not "play any role in your deliberations regarding their right to present a claim against Dr. Grasso."

In rejecting plaintiff's argument that the jury was prejudiced by the reference to plaintiff's receiving her medical care free of charge or as a charity case, the trial judge pointed out that a cautionary instruction was provided as part of the jury charge. Even more significantly, the trial judge instructed the jury that they could award damages for medical expenses which completely eviscerated the contention that plaintiff was a charity case. The trial judge gave the following instruction:

A plaintiff who is awarded a verdict is entitled to payment for medical expenses which were reasonably required for the examination, treatment, and care of injuries proximately caused by the defendant's negligence.

Now you have heard her testimony in this case regarding the issue of charity care. I specifically instruct you that you should disregard any testimony that you may have heard in reference to charity care and should not allow charity care to influence your decision regarding the award of medical expenses in this case. The parties have stipulated that these medical expenses were fair and reasonable in amount and were reasonably necessary for the examination, care, and treatment of Carina Paz. In this case, Carina Paz is seeking the sum of $90,997.81 in medical expenses. As a result, the upper limit of the award which you may make for medical expenses is $90,997.81 since you may not award more than Plaintiff Carina Paz is seeking.

The entire issue surfaced because of plaintiff's expert Dr. Richard Gallina commenting that plaintiff's medical care for surgery was provided free of charge. Plaintiff's counsel had no bills indicating there was any charge. Later in the trial, he produced a bill indicating there would be a lien against any recovery, which he analogized to being similar to a worker's compensation claim where there was a recovery in a third party action. The trial judge pointed out that she received medical care in the case and had not paid for it, which was an accurate statement. The trial judge was of the view that his charge cured a comment that was made by plaintiff's own expert and dissipated any prejudice, if there was any to begin with.

On appeal, plaintiffs raise the following issues for our consideration:

POINT I: THE TRIAL JUDGE FAILED TO CHARGE RES IPSA LOQUITUR. THIS CONSTITUTED PLAIN AND REVERSIBLE ERROR. (NOT ARGUED BELOW).

POINT II: THE TRIAL COURT ERRED IN PERMITTING THE DEFENSE EXPERT TO READ TO THE JURY EXCERPTS FROM AN "ABSTRACT" ENTITLED "SURGEONS' ANONYMOUS RESPONSE AFTER BILE DUCT INJURY DURING CHOLECYSTECTOMY." THE ARTICLE "ABSTRACT" (A POLL OR SURVEY) DID NOT QUALIFY AS A RELIABLE AUTHORITY UNDER RULE 803(c)(18) AND EVEN IF IT HAD, IT SHOULD, NONETHELESS, HAVE BEEN EXCLUDED UNDER RULE 403 AFTER A 104 HEARING.

POINT III: THE TRIAL COURT ABUSED ITS RULE 403 DISCRETION BY PERMITTING THE JURY TO HEAR EVIDENCE THAT PLAINTIFF WAS AN ILLEGAL ALIEN.

POINT IV: THE JURY WAS ADVISED DURING THE CROSS EXAMINATION OF DR. GALLINA THAT PLAINTIFF'S MEDICAL CARE FOR HER SURGERIES WAS PROVIDED FREE OF CHARGE. WHEN IT LEARNED THAT ASSERTION WAS UNTRUE, THE TRIAL COURT REFUSED TO PROVIDE A CAUTIONARY INSTRUCTION AT THE TIME OR SHORTLY THEREAFTER. WHEN A CAUTIONARY INSTRUCTION WAS PROVIDED AS PART OF THE JURY CHARGE, IT WAS INADEQUATE IN THAT IT DID NOT CONFRONT THE PREJUDICE INHERENT IN THE REFERENCE AND IT DID NOT TELL THE JURY THAT PLAINTIFF'S MEDICAL CARE WAS NOT FREE OF CHARGE.

POINT V: THE JURY VERDICT WAS AGAINST THE WEIGHT OF THE CREDIBLE EVIDENCE, PREDICATED UPON PASSION, PREJUDICE AND ANIMUS TOWARD THE PLAINTIFF.

POINT VI: A NEW TRIAL IS AN APPROPRIATE SANCTION FOR DEFENSE COUNSEL'S FAILURE TO DISCLOSE TO PLAINTIFF'S COUNSEL A MATERIAL CHANGE IN DR. NITZBERG'S TESTIMONY FROM HIS DEPOSITION TESTIMONY.

I.

In arguing in Point I that the trial judge should have provided a res ipsa loquitur charge, we note that no such charge was requested in the charge conference. During the motion for a new trial, however, plaintiff unsuccessfully argued that the court erred in failing to provide what would have been a sua sponte conditional res ipsa charge to the jury. Roper v. Blumenfeld, 309 N.J. Super. 219, 232-33 (App. Div.), certif. denied, 156 N.J. 379 (1998); but see Saks v. Ng, 383 N.J. Super. 76, 91 (App. Div.), certif. denied, ____ N.J. ____ (April 13, 2006)(stating that "conditional" charge is not required absent satisfaction of all three factors of the res ipsa loquitur doctrine).

In Buckelew v. Grossbard, 87 N.J. 512, 526 (1981), our Supreme Court applied the res ipsa doctrine to medical malpractice trials:

The doctrine of res ipsa loquitur permits an inference of defendant's negligence "where (a) the occurrence itself ordinarily bespeaks negligence; (b) the instrumentality was within the defendant's exclusive control; and (c) there is no indication in the circumstances that the injury was the result of the plaintiff's own voluntary act or neglect."

[quoting Bornstein v. Metropolitan Bottling Co., 26 N.J. 263, 269 (1958).]

When surgery is at issue, the first element is a virtual litmus test for determining the applicability of the doctrine: whether the act complained of "ordinarily bespeaks negligence." Buckelew, supra, 87 N.J. at 526. "Resolution of this issue requires a full appreciation of the role of expert testimony in the res ipsa loquitur context." Ibid.

In non-technical negligence suits, the question of what "ordinarily bespeaks negligence" can be resolved by the common knowledge of jurors. In medical malpractice actions, the "requisite probability of negligence may exist quite independently of the awareness or 'common knowledge' of the lay community." Id. at 527. "Expert testimony to the effect that those in a specialized field of knowledge or experience consider a certain occurrence as indicative of the probable existence of negligence is at least as probative of the existence of such a probability as the 'common knowledge' of lay persons." Ibid. The Court in Buckelew ruled that "expert testimony to the effect that the medical community recognizes that an event does not ordinarily occur in the absence of negligence may afford a sufficient basis for the application of the doctrine of res ipsa loquitur." Ibid.

Caution must be exercised, however, so as not to automatically accept a plaintiff's expert's opinion of what constitutes "common-knowledge-within-the-medical-community." Id. at 528-29. Indeed,

[t]here must be some evidential support, experiential or the like, offered for the expert's conclusion that the medical community recognized that the mishap in question would not have occurred but for the physician's negligence. If the plaintiff's expert's direct and cross-examination provide no basis for the witness's "common knowledge" testimony other than the expert's intuitive feeling - in other words, no more than a flat-out statement designed to satisfy the "common knowledge" test - then the court should not apply the res ipsa doctrine to the proceedings.

[Id. at 529.]

Buckelew "was not an invitation to a broader use of res ipsa loquitur in medical malpractice cases than occurs in ordinary negligence matters." Smallwood v. Mitchell, 264 N.J. Super. 295, 298 (App. Div.), certif. denied, 134 N.J. 481 (1993). Instead, the doctrine is "fashioned for limited application in special situations [and not] meant to be applied in every situation in which a medical procedure has an untoward result with an unknown cause." Ibid.

Applying these principles, it is evident that plaintiff was not entitled to a res ipsa charge because Dr. Drew failed to establish that the medical community recognizes that a lap-choly does not ordinarily result in a damaged hepatic duct absent negligence. See Buckelew, supra, 85 N.J. at 527. Instead, Dr. Drew conceded that damage to the hepatic duct is a "well known risk" that can "absolutely" happen to the best of surgeons during a lap-choly, and he instructs his patients accordingly. While it is true that Dr. Drew testified elsewhere that an injury to the hepatic duct ought to be equated with negligence, this assertion was substantially flawed on two grounds: (1) it was unsupported by medical literature; and (2) it was counterbalanced by Dr. Nitzberg's testimony that this untoward result happens to approximately 1 in 200 patients.

Plaintiff relies heavily on Yerzy v. Levine, 108 N.J. Super. 222 (App. Div. 1970), with its somewhat analogous factual background. The reliance is misplaced. Yerzy involved an open cholecystectomy, not a lap-choly and its enhanced technical demands. The res ipsa doctrine was neither implicated nor mentioned in Yerzy. Further, the critical issue was when, in the context of a medical malpractice case, the statute of limitations begins to run. Id. at 226. Significantly and contrary to plaintiff's contentions, no rule of law was announced in Yerzy that if there is accidental damage to the hepatic duct during gallbladder surgery, then, ipso facto, negligence must be found.

Indeed, we agree with the trial judge's observation that

[j]ust because an expert takes the stand and says this can't happen unless they're negligent? That would mean you would have to give a res ipsa charge in every medical malpractice case because every plaintiff's expert in a medical malpractice case takes the stand and says, this wouldn't have happened unless defendant was negligent.

Plaintiff failed to establish that a lap-choly resulting in an injury to the hepatic duct "ordinarily bespeaks negligence." Without the first element of the res ipsa doctrine in place, there was no basis for providing a sua sponte conditional res ipsa charge to the jury.

II.

Plaintiff asserts that the trial court erred in permitting Dr. Nitzberg to rely upon the abstract of an article from the American Journal of Surgery entitled "Surgeons' Anonymous Response After Bile Duct Injury During Cholecystectomy." Plaintiff filed an in limine motion challenging the admissibility of this abstract, but the trial court deferred deciding the issue. Plaintiff, however, did not challenge Dr. Nitzberg's testimony that the journal article was "the type of material which is [] relied upon by experts in the field of general surgery."

N.J.R.E. 803(c)(18), referred to as the learned treatise rule, provides:

LEARNED TREATISES. To the extent called to the attention of an expert witness upon cross-examination or relied upon by the expert in direct examination, statements contained in published treatises, periodicals, or pamphlets on a subject of history, medicine or other science or art, established as a reliable authority by testimony or by judicial notice. If admitted, the statements may not be received as exhibits but may be read into evidence or, if graphics, shown to the jury.

Plaintiff did not dispute Dr. Nitzberg's testimony that the American Journal of Surgery is a peer-reviewed journal. Nor did they contest Dr. Nitzberg's testimony that the paper is the type of material relied upon by experts in the field of general surgery, the threshold qualification for use of a learned treatise.

Moreover, Dr. Nitzberg was extensively cross-examined regarding his reliance on the article abstract. The cross- examination included the fact that he had only reviewed an abstract of the article. Dr. Nitzberg was also cross-examined on statements that appeared in the article but not summarized in the abstract, which supported plaintiff's claims. These included statements that 43% of the surgeons polled in the survey believed that bile duct injuries "are always a surgical error," that bile duct injuries are often referred to as "the worst complications" which can lead to "major morbidity of patients and much soul-searching for a surgeon" and that a number of surgeons interviewed for the poll suggested that "more liberal use" of a certain type of testing not used by Dr. Grasso could avoid bile duct injury. The publication was not a one-sided paper that totally supported the defense.

Plaintiff contends that the abstract should have been excluded because it was published in 2003 and reported results of a survey conducted in 2002, both of which occurred after the alleged malpractice in this case. The argument is beside the mark. The article abstract concerned a survey that asked the participating physicians to provide information regarding their experience with laparoscopic bile duct injuries during their careers. Although the survey was conducted in 2002 and published in 2003, it pertained to events which pre-dated plaintiff's surgery and was, therefore, properly considered.

III.

Prior to opening statements, plaintiff made an in limine motion seeking to exclude any reference to her immigration status. Plaintiff did not legally reside in the United States as she lacked both a green card and a social security number. Defendant opposed the motion since plaintiff's immigration status was relevant to two aspects of his defense: (1) before the second surgery, plaintiff resisted the idea of being transferred to Columbia Presbyterian because of concerns that her immigration status might be detected; and (2) with respect to plaintiff's claim for emotional distress, evidence that her immigration concerns were a contributing source of psychological discomfort was part of defendant's proof on damages.

Considering the opposing arguments, the trial court engaged in a N.J.R.E. 403 balancing test resulting in a decision to admit the evidence because it is "a relevant part of the defense in this case." At the same time, the court assured plaintiff that it would "give the jury a cautionary instruction that they are to consider the immigration status not as to whether or not plaintiff is able to maintain a cause of action."

Two limiting instructions were provided to the jury, one before opening arguments, and another during the jury charge:

Also, there will be testimony in the case about the immigration status of the plaintiff. I want to caution you now that the immigration status of the plaintiff [has] no bearing [on] whether or not the plaintiff has a right to file an action in . . . this court. Obviously, they do. They - the case is filed, and our courts have held that the immigration status of an individual does not affect their right to recover in a personal injury action. But you will hear testimony about the plaintiff's status - immigration status in this country, and in my closing instruction, I will tell you what, if anything, you can use that testimony for. But I caution you that the mere fact of plaintiff's immigration status is of no moment as to whether or not she is entitled to prevail in this case.

Now you have heard testimony regarding the immigration status of the plaintiffs in this case, Carina Paz and Gerson Paz. I specifically instruct you that the mere fact that Mr. and Mrs. Paz may have the status of illegal aliens should not play any role in your deliberations regarding their right to present a claim against Dr. Grasso. Mr. and Mrs. Paz's immigration status was admitted for the limited purposes of the credibility determination regarding the decision to have the second surgical procedure performed at Palisades General Hospital and for any potential impact on Mrs. Paz's psychiatric claims.

Defendant's attorney echoed similar sentiments during summation:

And let's make something clear. People who are illegal aliens have the right unquestionably to come into the courtroom and make a claim. Period. End of story. Simple. If you're an illegal immigrant or if you came over on the Mayflower, you're the same in a court of law. And there's never been a suggestion to the contrary.

Plaintiff asserts that the court "only told the jury that plaintiff's status was not pertinent to plaintiff's right to bring the action, but it did not tell the jury for what purposes or on what issues it was relevant." Plaintiff has characterized the instruction provided as part of the jury charge as "confusing."

We disagree. The trial court made a sound N.J.R.E. 403 ruling since reference to plaintiff's immigration status was a legitimate aspect of the defense. Furthermore, plaintiff's fears of undue prejudice were counterbalanced by two clear and thorough limiting instructions. There was no error, much less harmful error.

IV.

Plaintiff argues in Point VI that plaintiff's counsel failed to disclose that Dr. Nitzberg's testimony at trial would differ from what he provided in deposition and he was under an obligation to do so. We have reviewed the sets of testimony which plaintiff contends are contradictory. While we see some shades of departure between the two sets of testimony, the crux of Dr. Nitzberg's message remained the same; namely, where possible, a physician should identify the common bile duct so as to prevent its injury, but that is not always possible. We also note that plaintiff extensively cross-examined Dr. Nitzberg at trial to point out the differences in his testimony. We do not discern any material change in testimony which could establish harmful error.

V.

With respect to Point IV, the trial judge fully addressed the "charity care" issue in his oral decision of July 22, 2005 and we rely substantially on what he said in rejecting this argument. Even though Point V is styled as a weight of the evidence argument, plaintiff relies upon her other arguments which we have previously addressed in claiming the jury verdict, i.e., the finding that "there was no deviation, could only have been the product of passion, prejudice animus toward the plaintiff." Since the other arguments lacked merit, they do not in the aggregate call for a different result. As noted, the issue of purported deviations in the standard of care was before the jury. The fact that the jury made credibility determinations which, in effect, rejected plaintiff's position does not constitute a miscarriage of justice. Baxter v. Fairmont Food Co., 74 N.J. 588, 598-99 (1977).

Affirmed.

 

N.J.R.E. 403. EXCLUSION OF RELEVANT EVIDENCE ON GROUNDS OF PREJUDICE, CONFUSION, OR WASTE OF TIME.

Except as otherwise provided by these rules or other law, relevant evidence may be excluded if its probative value is substantially outweighed by the risk of (a) undue prejudice, confusion of issues, or misleading the jury or (b) undue delay, waste of time, or needless presentation of cumulative evidence.

(continued)

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A-5870-04T5

 

June 15, 2006