Mar 30, 2011

James Arthur Ray Sweat Lodge Trial: Day 21

Crossposted from Reflections Journal.

Joel Swedberg

Joel Swedberg is a flight paramedic. He was part of a team that came to the scene by helicopter and transported patients to the Flagstaff Medical Center. He arrived on scene -- he was told roughly three hours after the incident -- to find numerous fire trucks, EMTs, paramedics, and other aircraft. He explained to prosecutor Bill Hughes that helicopter teams are called in when the conditions "preclude ground transport." In other words, when patients' conditions are extremely critical and they need more speed than an ambulance can provide.

Such was the case with Liz Neuman to whom Swedberg attended.

Neuman was unconscious when Swedberg's helicopter team arrived. She was brought to him strapped to a spine board, not because of any spinal injury, but because they provide overall stability.  None of the medical personnel knew quite what had happened and they took every precaution.

Swedberg described Neuman as not responsive or alert; in other words, not conscious. She exhibited a rapid heartbeat and low blood pressure. She had been started on IV fluids before he arrived which had caused slight improvement. But he administered a lot more fluid, in the form of IVs -- 500 cc's an hour -- and a fluid bolus. The IV was run with the clamp completely open to rush the fluids into her body.

She also exhibited Kussmaul, or labored, breathing and irregular cardiac rythm She received oxygen through a mask.

Because there was no explanation for her altered state of consciousness -- no obvious external injury -- narcotics were assumed. And at some point he administered Narcan (Naloxone), an anti-narcotic. She also had pinpoint pupils which can indicate use of narcotics.

There is some confusion as to her temperature as the obviously incorrect number of 207.5º was entered on the paperwork due to celsius/fahrenheit conversion error. (This confusion was later compounded under Do's cross.)

Swedberg determined Neuman to be a 7 on the Glasgow Coma Scale. For reference, 15 is normal and 3 is dead or virtually dead. Neuman was completely unresponsive.

Trembling in her upper extremities was also noted by Swedberg.

He was unable to obtain any medical information on site. There were, as discussed, no medical history taken by JRI. So there was no knowledge regarding health condition, medication, allergies, etc.

Neuman deteriorated further during the flight to the hospital. On intake she was intubated and medicated. 

Asked if he thought Liz Neuman's symptoms were consistent with heat exposure, he said yes. Asked if he thought her symptoms were consistent with pesticide poisoning, he said no. Among other reasons, she did not exhibit a lot of mucus.

Do objected to this line of questioning because Swedberg is not a doctor. She also objected to any discussion of his Navaho wife and participation in numerous sweat lodges. Go figure.

On cross, Do immediately took up the issue of Swedberg's credentials describing the difference between paramedics and EMTs. (Paramedics can break the skin.) And, of course, Swedberg is not a medical doctor. So he's not qualified to make a medical diagnosis. And he would defer to a doctor's opinion.

I may have been imagining it but I thought Swedberg bridled at her questioning about his credentials. I bridled at it, more because of her tone than the questions themselves. We saw more of the edgy, ballbusting Do, as opposed to the more coquettish Do, today.

There were moments of pure hilarity during Do's cross. The first when she asked if the temperature of 207.5º could be considered inaccurate. (Seriously???) She dug a little deeper on the issue of temperature, as one might hope she would after that. He had measured her temperature, using the less accurate armpit reading, as 97.5º. But Do pointed out that a rectal read of 38.7ºC was recorded as soon as she was admitted to the hospital. This, by the way, works out to 101.66ºF.

Now that's interesting, isn't it. If Swedlow arrived anywhere close to the three hours post event that was reported to him, and she arrived at the hospital some time after that, that could be up to four hours after she was dragged from that sweat lodge. We already know that she was aggressively cooled and that the outside temperature was becoming chilly. If that time-frame is anywhere near accurate, you really have to wonder what her temperature was when she first came out of the sweat lodge.

In more bizarre questioning, Do asked him if there were a thousand cc's in the thousand cc bag? This caused him to blink in confusion.

Finally, Do got to the pinpoint pupils and the Narcan.  It rapidly became apparent that she didn't understand what Narcan does at all. In her usual, leading manner, she attempted to draw a time-line that would preclude the Narcan having been the cause of the pinpoint pupils. She pointed out, quite logically, that the pinpoint pupils were observed at least half an hour before the administration of the Narcan.

Swedberg was more confused by her questions than ever. He finally asked her, "Are you asking me if Narcan causes pinpoint pupils?"

Narcan, of course, does exactly the opposite. Narcan is administered to counteract the effects of narcotic drugs, one of which is pinpoint pupils.

Despite her objections to Swedlow being asked his opinions on heatstroke and poisoning, she asked him herself. She asked him about the signs and symptoms of heatstroke and then asked if they were similar to the effects of poisoning. He said no. She quickly reminded him that he was not a medical doctor.

The real doctor, Dr. Cutshall had testified that he couldn't rule out organophospate poisoning. Swedlow just started blinking and looking confused again.

For reasons my nonlawyer mind can't grasp, Do was also very fixated on the fact that Swedlow's company had a sent legal representation with him. She had a number of questions about that, too tedious to enumerate. But this is where Hughes began his redirect.

Was it common practice for his company to send an attorney with any employee testifying in a trial, Hughes asked? Swerdberg believed so. Moving on.

Hughes also asked him to clarify the differences as he understood them between heatstroke and pesticide poisoning. The main difference in this case was the lack of excessive mucus. I also don't think anyone has described her as being "red as a beet." He also explained that skin temperature was not a good indicator of heatstroke an hour or more out.

Do, of course, objected.

The jury had no questions for Mr. Swerdberg and he was excused.

Dustin Chambliss

Next up was another paramedic -- in other words, not a doctor -- named Dustin Chambliss. This Aryan specimen described the code 3 alert that brought him to the site. That's lights and sirens.

Chambliss administered advanced life support to the unconscious Kirby Brown. When he arrived on scene he found the nonprofessional, event participants administering very capable CPR. He asked them to continue while he set up his equipment.

In the confusion, no one seemed able to even to give him her name, let alone any other useful information.

He described her as completely unresponsive. Her pupils were nonreactive. On the previously discussed GCS, Brown was a 3. That's comatose state equivalent to death.

He put her on a CCR, which replaces CPR by doing rapid chest compressions. He set up two IVs, of 1000ml each, and oxygen which were administered concurrent to the CCR compressions. This answers the question once and for all as to whether fluids were circulated through her system, thus alleviating some of her dehydration. This regimen was continued all the way to the hospital.

Her heart was asystolic, meaning there was no electrical activity. He did not check her temperature as he was just trying to get her breathing. He also observed no "foaming at the mouth." (Or frothy sputum, even.) Her skin was warm but no temp was taken and he doesn't know what cooling efforts may have been made. He didn't notice her pupil size.

She was rushed to the hospital as a "full code." On the way, blood started coming out of her mouth.

She was pronounced dead on arrival.

I don't know what it was about this man's extremely factual, dry recollection of Kirby Brown that brought tears to my eyes. But my head filled with little pictures of this woman as they worked so futilely to save her life; of the blood pouring from her mouth. It's going to take a long time for me to get over that image.

Li looked defeated before he even began his cross. "I'll make this quick," he said. More amazing still, he really did.

He also made the point that a paramedic is not a doctor, though he managed to do it without sounding like he was trying to humiliate the man. Good for him.

Other than that, his questions did little more than clarify his direct testimony. I'll be damned if I can see what gain the defense made here... or if that was even the point.

Did he remember the "sturdy" Dr. Jeanne Armstrong? No.

Is the purpose of flushing the system with fluids really for administering medication? Yes.

Did she get epinephrine? Yes.

The only question that seemed at all pointed had to do with whether the medical examiner or other officials had contacted him. Hughes took care of that with his only redirect question. Had the medical examiner ever contacted him about a dead patient? No.

Yes, it was mercifully brief.

The jury had no questions and Mr. Chambliss was also excused.

Judge Darrow Hears Oral Motion

What was left of the day did not go as smoothly. In fact, it exploded.

Having actually moved through two witnesses today -- a record for this trial -- the prosecution was prepared to bring in the next witness on the schedule but the defense objected. The witness in question is Michael Hamilton, who, with his wife Amayra, owns Angel Valley Ranch; the site of this horrific tragedy. The defense's objection stems from the Hamiltons' recent contact with Det. Diskin and their turning over materials pertaining to the poisoning issue. These include some photos of rat poison, information about the wood that was used in the fire, and so forth.

The defense's contention is that the prosecution has violated Judge Darrow's order by allowing communication between witnesses -- Diskin is also expected to testify -- and tipping off upcoming witnesses to trial proceedings that they are not allowed to hear. The defense is also outraged that they only received disclosure notification about this last night, on the eve of Michael Hamilton's scheduled testimony.

Tom Kelly requested the opportunity to question Det. Diskin as to what transpired in conversation with Hamiltons so that he can learn the scope of this egregious impropriety.

The story from the prosecution is, naturally, quite different. There was nothing improper, according to Sheila Polk. The entire thing had been cleared with Judge Darrow beforehand. The prosecution was gathering additional information to address the question of pesticide poisoning that has been presented by the defense. The prosecution contends that this is perfectly appropriate and that this is why the state has a "case agent" available to them; in this case Det. Diskin.

Polk also clarified that they did not, in fact, disclose the materials from the Hamiltons on the eve of Michael Hamilton's scheduled appearance. As is their practice, they emailed the photos and other materials as soon as they had them last week. They then followed up with the formal disclosure which was sent yesterday.

Polk fully recognizes that the organophosphate question is a red herring for which no real evidence will ever be presented but that this is what a strong defense does. There is nothing wrong with it. It is their job to create reasonable doubt. Likewise, it is the job of the prosecution to respond to the defense's case, as it develops, by gathering any necessary information.

To Kelly's claim that the prosecution had seventeen months to get their ducks in a row and gather the necessary evidence, Polk explains that the claim of organophospates was sprung on the prosecution in the defense's opening argument. There is almost no mention of organophospates in the existing evidence.

Worse, their references to an EMT suggesting organophosphates as a cause is "classic hearsay." The unidentified voice is in the background on a recording that was transcribed by the defense. The owner of that voice has never been located. He can, therefore, never be called to testify. He can never be cross examined. And yet the defense has referred to this nameless, faceless entity repeatedly, including in its attempts to confuse the medical personal testifying. (And it occurs to me, that by Do's own standard, as outlined to Mr. Swedberg, an EMT isn't even qualified to assess the cause of death and injury.)

Polk also asserts that the defense withheld the witness, Dr. Paul, who theorized organophosphates. The prosecution, despite repeated requests to interview him, was only granted that interview in January of this year. And his claim of organophosphates only came out in that interview. It wasn't even in his original report.

The state, Polk offers, would have tested samples for organophospates if the defense had disclosed their contention in a timely manner, rather than springing this tactic on them during the trial.

Medical records do not cite organophosphates. The only contention of organophosphate poisoning comes from the hearsay in recorded background noise and defense expert Dr. Paul.

The defense never interviewed Hamiltons and at no point asked them about their pesticides; organophosphate or otherwise.

To this rather solidly reasoned argument, Kelly replied, "We have just turned the Constitution on its head."

Dare I say it? I think Mr. Kelly is something of an exaggerator.

Once again, the argument is that the prosecution should have anticipated the defense's argument. In fact, due diligence would require that they disclose all evidence that supports the defense's contention. By not doing so, they have failed to disclose exculpatory evidence. And they should have interviewed their witness Dr. Cutshall and disclosed to the defense that he could not say "to a medical degree of certainty" that it was heatstroke. This, of course, misstates what Dr. Cudshall said. Do asked him if he could rule out organophosphates with certainty. He agreed that he could not.

Let's unpack this, as Do would say. There is a big difference between not being able to exclude another possibility with certainty and being something other than reasonably certain of the conclusion you've already drawn; in this case, heatstroke. There is no such thing as absolute certainty in medicine. To say that no other possibility exists would be bad medicine and bad science. And the law recognizes that, requiring only a "reasonable medical certainty."

While there must be more than a bare possibility, the law does recognize that a degree of uncertainty is present in almost every medical opinion.

It's one thing to try to confuse the jury with these tactics. That's just a defense attorney doing her job. But to try to confuse a sitting judge? That takes guts.  

Judge Darrow appears to be leaning toward the prosecution's position, explaining that his order was designed to keep witnesses from discussing information with each other, especially because of the trial being broadcast. It was never intended to preclude communication between attorneys and witnesses and he seemed a little shocked that Kelly might be suggesting that.

And once again the defense's tactics tried the judge's patience. At various points he ordered both Li and Do to "sit down."

I expect some sort of ruling will be forthcoming tomorrow morning as this and other issues continue to be hashed out.

One other intriguing piece of information emerged during this motion hearing. In reference to defense expert Dr. Paul, Do explained that in his original report he concluded that a finding of heatstroke was inconsistent and pointed to a "secondary process." He did not, at that time, cite organophosphates. That came out later. She connects this later deduction to organophosphates, however. If that's the case, I wonder what he thinks is the primary cause. Because a secondary process or cause is just that. It's an exacerbating factor.

From the medical dictionary:

secondary cause
a factor that assists the primary cause. A cause of secondary importance.

I'm starting to wonder just how strong a witness Dr. Paul is going to be for the defense.

All information on the trial comes from news articles with provided links or live courtroom footage on TruTV's "In Session" or CNN's live feed. All quotes and paraphrased statements that are not linked to a source document are my best attempt to transcribe material from live broadcasts.

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