Direct Exam: Jay Clark  

Dr. Smile completed his residency in 1982 and has been working in emergency medicine ever since. He first worked in Akron and then moved to Cincinnati in 1985. He's an Emergency Medical Physician at Highland District, Fort Hamilton, and Mercy Fairfield Hospitals. He's a member of the American College of Emergency Physicians, both national and Ohio chapters. He's licensed to practice in Ohio and is board certified which meant he had to take both a written and oral test in his specific field. A national board oversees certifications in each specialty. Smile said that ER doctors are trained to handle almost anything including cardiology, pediatrics, and neurological situations, such as seizures which are the most common types of neurological emergencies. He's a member of several professional societies and teaches advanced trauma life support to physicians. He has been a board examiner for the American Board of Emergency Medicine since the late 1980's. For continuing medical education, he attends medical conferences, subscribes to the Audio Digest of Emergency Medicine and does quite a bit of teaching. He has had some of his work published in the Annals of Emergency Medicine and is also the medical director for the West Chester EMS. He oversees the proper protocol that the emergency workers follow and participates in their training. He is head of the quality improvement committee, which reviews all of the EMS runs and was Ohio's Emergency Physician of the Year in 2002.  

He has testified in trials before for both the prosecution and defense. He's consulted as an expert and is paid to do so. His hourly rate is $250. He didn't recall what he was paid to testify in Ryan's first trial, but in the second trial, he thought it was about $5,000. He's not accepting any pay for testifying in this trial. Clark asked, "Why are you helping Ryan for free?" and he replied, "I'm testifying because after looking at all the evidence now for a third time..."   He was interrupted by Travis Vieux who objected/sustained.

He is familiar with airway maintenance, intubations, CPR, sudden cardiac deaths and sudden death due to seizures. The first thing first responders are supposed to do is establish an airway if the patient isn't breathing. When a patient comes into the ER with a complaint or a group of complaints, the doctor will do a history, and physical examination and then create a list of possible causes. There is a concern that some conditions can mimic others, but by doing a history and physical exam, they can narrow down the possibilities. Some diagnoses aren't necessarily excluded because they are rare, but they are put at the bottom of the list. For example, there are 25 causes of chest pain, but tests can narrow down the list as well as asking the patient about their history. There are times when, despite doing a history, physical exam and lab work, doctors can't find the problem.

Clark asked him about "mechanism injuries" and he replied different medical procedures cause different injuries. The number one priority is always the airway. There are different techniques used to open an airway but positioning the head backward is the most common. It's also possible to position the head by lifting the back of the neck. Sometimes a rolled up towel is placed under the neck to hold the head in the correct position. He said he's performed "thousands" of intubations and also teaches the procedure.

Clark asked him to demonstrate how medics position a patient's head backwards to straighten the throat and the doctor grasped his own jaw line with his fingers, showing the jury how the head was moved. He also placed his hands on the back of his neck, showing how the head is tilted to straighten the airway. This is called the "sniffing position" he said, and Clark placed a diagram of that position on the screen. Using the intubation equipment, (laryngoscope, tube, etc.) he demonstrated the intubation process and said this would get oxygen directly to the patient's lungs. Once the tube is inserted and secured with a strap or tape, it shouldn't come out, but sometimes it does.

Using a red laser pointer, and with a diagram on the screen, he showed the jury where the tube is placed. "If you put a tube into the esophagus instead of the trachea, you've basically killed the patient," he said. A gurgling sound from the stomach can be heard if the tube is in the esophagus.

He went on to say that the main problem with intubating a patient is not being able to see where you're placing the tube. The head might not be in the correct position or the airway may be blocked with fluid or vomit. He teaches intubation techniques in this order;  1) Be certain the head position and blade position are correct; 2) Suction out any fluid or debris;  3) Visualize the trachea; 4) Insert the tube. If the trachea can't be seen press on the throat ( Sellick maneuver) to open it. To demonstrate, he used the thumb and forefinger on one hand to pinch his own throat, squeezing the cricoid cartilage slightly and pushing slightly down and back. The pressure applied should be "fairly hard" and he said to "squeeze the bridge of your nose as hard as you can until it hurts". That's the pressure that is needed to push down on the cricoid cartilage. Too much pressure could cause bruising and bleeding of the windpipe, he said.  The cricoid cartilage is used because it's the "sturdiest" and it's the only tracheal "ring" that goes all the way around;  the rest of the cartilages are horseshoe shaped.

There is a technique where pressure is applied to the thyroid cartilage (the area around the Adam's apple) but the thyroid cartilage is thinner and there's a greater chance of injuring the vocal chords. He demonstrated by placing his thumb on the right side of his neck with two fingers on the left side, grasping the thyroid cartilage.

Clark showed a photo of a 3-person team attempting to intubate and Smile explained one person is manipulating the cartilage, one person is intubating and one is grasping the back of the neck to elevate the head, putting it in the "sniffing position". If there are only two people, one manipulates the head and cartilage and the other intubates.

Because the distance between thyroid and cricoid cartilage is different depending on the size of the patient, the fingers might be positioned too high or too low. The emergency room is the best place to attempt an intubation because the patient is at waist level and more help is available if there's any difficulty. Intubation is more difficult in the field especially if the patient is lying in a small, cramped area or wedged in a bathroom and even more difficult in the back of a moving ambulance because you can lose your balance.

Asked what kind of complications occur from an improper intubation, the doctor replied that teeth can be chipped or cracked or the base of the tongue or cheeks can be lacerated if the blade is placed incorrectly; also bruising or bleeding of the trachea. "It's not always as easy as it looks in the diagram," he said, and with each failed intubation attempt, a sense of urgency develops, especially if it's a young person. Injuries can be sustained if an EMT begins to get frantic. The focus changes from preventing an injury to saving a life. "Establishing an airway is the first and most important task. If the airway isn't established immediately, the patient can suffer irreversible brain damage in about ten minutes and if no airway is established at all, the patient will die," he said.

An autopsy photo of Sarah's mouth was shown with a gloved finger pulling up her lip. The doctor pointed out a small bruise on the outside of her mouth and lacerations on the inside. The laryngoscope could have caused these injuries, he said.

Clark asked Dr. Smile if he was certified in CPR and he replied, yes.   Clark then asked about the injuries and complications of improper chest compressions. Dr. Smile said the current compression rate is 100 compressions a minute. He's seen CPR performed in the field, and in a moving ambulance. Anything done in a moving vehicle is more difficult, if it's going around curves or over bumpy roads.

He teaches the complications of improper CPR and the most common injury is rib or breastbone fractures, which can be caused by incorrect placement of the hands or the amount of pressure applied. The current standard for compressions is to press hard enough to press the breastbone. The previous standard in August of 2008 was to compress the chest one to two inches. But even if the hand placement and compressions are done correctly, injuries can still be sustained especially if the patient is elderly. The older the patient, the more factures can occur. It's almost impossible to fracture a rib in a child, but internal organs under the rib cage can be bruised. Someone in their mid-20's would probably not suffer any rib or breastbone fractures.

Clark asked how an IV line is started and the doctor said a plastic catheter is placed into a vein, using a very sharp needle. Sometimes a tourniquet is tied around the upper arm to raise a vein. In some people their veins are deep and difficult to access. Starting an IV in an obese or cardiac patient is the most difficult . If the patient doesn't have a heartbeat, the vein can't be seen, but the same problem can be present with a living patient. There are several complications that can result when placing an IV. Nicking a vein, or going too deep and puncturing through the vein can cause internal bleeding/bruising at the site. Sometimes a vein is missed entirely and the medic has to make several attempts.

A peripheral IV will go into the arms or legs;  a central line will go into a larger vein in the neck or groin. An IV in the jugular is a central line and leads straight to the heart. Physicians usually insert an IV in a central line and EMTs usually insert an IV in a peripheral line.

Clark handed the doctor some paperwork which he identified as Dr. Spitz's autopsy, Uptegrove's autopsy, the toxicology screen, the ER record, Sarah's medical records and the EMS run sheet. He said he reviewed all of them including the report from the pediatric cardiologist when she was a baby.

He described the resuscitation attempts on Sarah as "exceptionally long"--- 48 minutes of chest compressions from the time first responders arrived until they stopped at the hospital when she was pronounced dead. Most resuscitation efforts don't last that long. He also added that six attempts to intubate were unusually high. He was not surprised by Sarah's injuries but was surprised at the lack of injuries. He would have expected more injuries to the teeth and fractures to her breastbone or ribs.

An autopsy photo of Sarah's forehead was shown with a bruise near her hairline. The doctor called it a "slight bruise" which could be consistent with an EMT placing his forearm on Sarah in order to hold her head during an intubation attempt. "It would depend on the amount of pressure," he said.

Another photo was shown of Sarah with the bag valve mask still on and held in place by a foam strap. Smile said that was the normal placement of the strap which is around the bottom of her face and to the back of her head. A photo was shown of Sarah's armpit with a bruise and the doctor said it was an odd place for a bruise and not consistent with CPR efforts but possibly from moving her to the backboard or situating and tightening the strap that went across her chest.

Showing a photo of the large bruise on the left side of Sarah's neck, Smile said the discoloration was consistent with the IV inserted in the jugular vein. The bruising could be from a nicked vein or a needle poked through a vein, leaking blood inside. It was not bruising from compressive force.

A photo from the second autopsy was placed on the screen showing discoloration on the front and right side of Sarah's neck. The doctor said, "this indicates to me compressive force." He said the discoloration on the right side of her neck looked like a thumb mark that could have been from an emergency worker.  The front of the neck looked like direct pressure had been applied and along with the thumb mark on the side of the neck would be consistent with pressure to the cricoid or thyroid cartilages while attempting the Sellick maneuver. Clark then placed a diagram of the neck next to the photo of Sarah’s neck and the doctor said the center of her neck, is where the cartilage is.

Clark asked the doctor if he was familiar with Sudden Unexplained Cardiac Death. He said he learned about it during his residency and saw it happen in the emergency room a number of times. It occurs within 24 hours from the onset of symptoms. Some cases are explainable, but sometimes the autopsy doesn't indicate any kind of problem. The death is usually caused by an irregular rhythm in the heart that could be caused by a number of factors. An electrically unstable heart can be caused by "membrane abnormalities" and strenuous exercise, or an emotional upset can trigger a cardiac arrest. He also read a Japanese study that said taking a hot bath has been associated in a sudden death.

He said the older you get, the more likely you are to have sudden cardiac death, but it does occur in young people too (those who are 35 and under). Sometimes there are warning signs such as a person having a dizzy spell or fainting spell. An electrically unstable heart can have 200 beats a minute and make the person dizzy, pass out, or have palpitations in their chest.

He said he's performed thousands of 12-lead electrocardiograms which give doctors a complete picture of the heart in 12 different areas. The test takes electrical photos from different angles of the heart. There are some conditions where the configuration in the leads is normal, but the duration of the intervals is abnormal. The most common cause of an electrically unstable heart is "Long QT Syndrome". The electrocardiogram records electrical activity of the beating heart so the patient must be alive. Some conditions can be detected in an autopsy; others cannot. The presumption is, if the autopsy is normal and the toxicology is normal, then the patient had an electrical event that caused cardiac arrest.

He's familiar with cases where people who have died from Sudden Unexplained Cardiac Arrest were in their mid-20s with no family history of heart conditions, no personal medical history and they had normal autopsies. Even though sudden death is most common in elderly people, about a 1,000 people a year, under the age of 35, die from this in the United States and he believes it's possible Sarah had an electrically unstable heart beat.  If genetic tests can turn up evidence of chromosomal abnormalities in patients who have died, the patient's family can be tested for the disorder. It's done with a tissue test, not a blood test and is an exciting new area of research in medicine.

Clark asked him about seizures and the doctor described it as an "abnormal electrical discharge in the brain”. Epilepsy is a condition where there are repeat occurrences of seizures but there's no structural or metabolic reason for them. He said a "generalized seizure" or "grand mal" will affect both sides of the brain and cause the patient to jerk or twitch, the eyes roll back in the head and the person can lose consciousness. It generally lasts about 2 minutes. A "partial seizure" will not cause a person to lose consciousness but one part of the brain is affected and the patient's arm or leg may jerk while the patient is fully conscious. Some partial seizures can be related to head injuries, strokes, brain infections or tumors. Temporal lobe seizures start in the part of the brain that processes emotions, fight or flight reactions, and short-term memory. The petit mal seizure, also known as the absence seizure, involves a brief, sudden lapse of conscious activity. The person may look like they are staring into space for a few seconds and must be careful while swimming or bathing because of the danger of drowning. First time seizures can occur at any age, he said, even when there is no family history. He didn't know any way that a seizure can be detected in autopsies.

Clark asked if there was a possibility that Sarah had a seizure, causing her to lose consciousness and drown. The doctor replied that it was possible and continued by saying there was nothing in the reports he reviewed to rule out a seizure, or to rule out a cardiac event. Sarah's cardiac records from 10 months old were shown and Clark asked why the QTc information wasn't given.

Electrocardiogram report for Sarah:                                                                                                                         PR Interval is .12                                                                                                                                                      QRS Interval.05                                                                                                                                                         QTc: (no information given)

Dr. Smile said QT intervals are measured in an electrocardiogram. Each letter on an ECG tape signifies a wavelength or pattern measuring the heart's rhythm. If the waves are too long or too short, there is a concern that the pattern could be part of Long QT syndrome. The waves for Sarah were either not measured or the data wasn't entered into the report. If Sarah had a prolonged QTc, it could have been a clue to an electrically unstable heart and as a doctor he would have been very upset that the data wasn't included.   Nothing further.

Cross Exam: Travis Vieux

Dr. Smile began by agreeing that he was not a forensic pathologist, cardiologist or neurologist, and didn't do any research. He agreed that CPR is a skill that anyone can learn and injuries can occur from anyone performing CPR, no matter how experienced they are, but they are more likely to occur from those who are untrained. CPR training states that chest compressions should continue if practical, but should be stopped during intubation attempts, if the patient needs to be moved or if the patient shows a heartbeat. "But in general you want to avoid as many interruptions as you can," he said.

Vieux asked about injuries from chest compressions and Smile replied there could possibly be rib fractures, contusions to the heart, bruising to the soft tissue of the sternum, fracture of the sternum or bruising to the chest wall. None of these injuries were noted on Sarah.

Referring to Sarah's liver puncture, Smile said it could be caused by CPR, but Uptegrove said he accidentally nicked it when he was removing Sarah's chest cavity. The laceration was on the right but Smile said it would be more common for the injury to be on the left if it was caused by CPR. He found nothing in the autopsy report about internal bleeding from the liver laceration.

Asked about the bag valve mask, Smile said it's difficult to get a good seal on a patient so it's important to have downward pressure to seal it and upward pressure on the jaw bone. He said in his experience it took two people to apply it properly. There could be possible bruising along the bridge of the nose but not likely. There was also no bruising under Sarah's jaw line but one photo showed blood on her nose.

Vieux pointed out there were five attempts to intubate on record from EMS and one from the ER doctor. Smile said the record doesn't specify how many of those intubation attempts were inserted into the trachea. He said it would not be improper to re-use the tube after an intubation attempt unless it was dropped on the floor. Ideally, a new one would be used, however, this was a life/death situation and time would be wasted opening a new package. There was no damage to the palette, tongue or teeth in Sarah's mouth, he said, and no evidence of injuries to the epiglottis, trachea or vocal chords.

Asked about the Sellick maneuver, the doctor said that thyroid pressure is "not" the Sellick maneuver;  it is cricoid pressure. Vieux asked if the doctor would agree that there is some dispute with the term Sellick maneuver; whether it’s applied to the thyroid or cricoid cartilage. The doctor replied, no, pressure on the cricoid cartilage is the Sellick maneuver. He went on to say that the only information he got from the records was that the Sellick maneuver was used twice but he has no knowledge if it was done to the thyroid or cricoid cartilage. He said he never spoke to the EMS and never reviewed the transcripts of any testimony from trials. Pressure to the crycoid and thyroid are used routinely done in emergency rooms but when asked if he often saw discoloration similar to Sarah's, he said, "usually not".

Vieux showed an autopsy photo of what Smile described as a 'finger mark' on the right side of her neck and Smile said if the EMT was pressing on the thyroid or cricoid cartilage where that mark was, he would be in the wrong spot. He agreed that Sarah was unresponsive the entire time medics were working on her and agree she was "clinically dead" when medics arrived. Another photo of Sarah was put up, showing her head and shoulders and the doctor agreed there was bruising. When a person dies and their blood pressure drops and veins collapse, it's difficult to insert an IV.

He agreed that modern ambulances are an "advanced life support unit that has the ability to do cardiac pacing, insert IV lines, establish an airway and administer cardiac drugs. If possible, paramedics should establish an airway in the field and do whatever they can to save a life. He wasn’t aware of any improper technique done to Sarah. "This was an extremely difficult resuscitation," he said. "All we can ask is that the paramedics do their best, and I think they did in this case."

Showing a photo of Sarah's throat, Vieux asked if the bruising was from "compressive force" of the neck and if it could be consistent with strangulation. The doctor replied yes to both questions. He agreed that the finger mark on the right side of the neck could also be consistent with strangulation and the large amount of bruising on the left side could have obscured any finger marks. He also agreed that if there was enough compression on the jugular vein, a person could become unconscious in a few seconds.  

He reviewed Sarah's cardiology record from when she was a child and some reports from routine office visits. He said family medical history is vital when diagnosing sudden death syndrome. Vieux asked him to describe the difference between "unexpected" cardiac death and sudden cardiac death and he replied that 1 or 2 percent of patients under 35 suffer sudden death 24 hours after the first symptom. A small portion of those show no cause of death in an autopsy, which is then presumed to be an electrical cardiac event. Sudden infant death numbers are not included in those studies.

Vieux asked if Long QT syndrome is primarily an inherited trait and Smile replied, some are, some are not and some are drug related. Over-the counter antihistamines can increase QT intervals, he said. Nothing in the family records indicated this condition and there was no indication that Sarah was experiencing a drug overdose.

Asked if the protocol for EMS in Warren Co was to transport a drowning victim to the hospital, he said he didn't know. He agreed that an EMT can call a time of death but would have to consult with a doctor.

He agreed that there was no structural heart disease found in the autopsy and no family history or medical history of cardiac problems or seizures. Smile said that excitement, emotional upset/stress, and exercise are other causes for a seizure. He agreed that he wasn't there to give a medical opinion or diagnosis about what Sarah may or may not have died from.   No further questions.

Re-Direct: Jay Clark

Clark handed Dr. Smile six articles on factors that could contribute to arrhythmias and asked if he could point out the one he read about the Japanese study on hot baths. Smile said he's reviewed two of the articles Clark gave him; one he read, the other he looked over. Clark said, "When you testified earlier you said you reviewed one article" and Smile replied, "Yes, but when I reviewed these six, I recognized two others that I had read." He identified the two that he had read and explained that a case report presents a case, then discusses the case and its ramifications. A review article is a different presentation of the same material. It's a broader, more comprehensive type of literature.

"Is the concept of a hot bath causing seizures new?" Clark asked, and Smile replied, "I don't know if it's new, but it's out there as a risk factor for sudden death but mostly in older people." He acknowledged that he hasn’t seen any sudden deaths from hot baths.

Asked about bruising after death, the doctor said a lot depends on whether CPR was being done. He's seen a deceased patient develop bruising after death while CPR was still being done. In order to bruise from a broken blood vessel, there must be some blood pressure and CPR could be enough for this to happen.

Clark asked about the blood settling when the heart stopped at the time of death and Smile said in livor mortis, if parts of the body touching the surface it's laying on are purple, it's a sign of death and medics are told not to start resuscitation.

Referencing the Sellick maneuver, the doctor said it's often used as a "generic term" so he doesn't know what was done by EMTs on the scene of Sarah's death. He doesn't apply his strict definition of Sellick maneuver when he reads it in reports. Doing the procedure with significant pressure could result in hemorrhaging but no fracture.

Clark asked how many failed intubation attempts, should paramedics allow before they decide to go to the hospital?   Smile said the most recent study in Ohio, showed that roughly 80% of intubation attempts done in the field are successful but 1 in 5 are not. Protocols are in place for unsuccessful intubation, so it's urgent to get the patient to the hospital as "quickly as possible." If an airway can't be established, a rescue airway is put in. He agreed that the bruising found on the front and sides of the neck were compatible with hands placed on the neck to position the head for an intubation attempt.

Smile said some drugs can trigger cardiac arrest as a result of Long QT syndrome. If Sarah had that condition and was prescribed an antihistamine, the drug could trigger cardiac arrest. Dr. Smile said cardiac arrest, a seizure or a neurological event can't be ruled out in Sarah's death.

Nothing further.