Direct Exam: John Arnold

Dr. Lee is a Doctor of Osteopathic Medicine.   For his medical school training he went to the same classes and learned the same things as MDs.   Michigan State University combined their programs until the DOs eventually went to separate classes. They view the body as one whole machine. He did a one-year fellowship with a medical examiner in South Carolina and he's now the chief forensic pathologist and deputy coroner for Licking County, Ohio. He's been a forensic pathologist since 1998 and investigates deaths that are suspicious or traumatic. He does all of the coroner's autopsies in Licking County--120 to 140 per year. They also take consultation autopsies from surrounding counties. He has done almost 2,200 complete autopsies in his career and has testified in trials over 100 times in Ohio.   A coroner is required for each county in Ohio, but there are only about 10 forensic facilities in the state, so all counties send autopsies to those facilities. This is why Sarah's autopsy was done in Dayton.

He goes to a lot of natural death scenes like many investigators do because he's usually on-call. Deaths are classified into five categories: homicide, suicide, accident, natural, undetermined. He didn't participate in Sarah's autopsy, but has reviewed her medical records and both autopsy reports, Dr. Uptegrove's and Dr. Spitz's. He also reviewed the ER records, the EMS emergency run sheet and records back to her teenage years. He likes to know a patient's background before he performs an autopsy, so he would go to the hospital, ask for a run sheet and medical records, as well as the chart. Then 3-4 days later he will request a full copy of the chart, as well as an additional EMS run sheet that is completed and the patient's medical records from their primary care physician. He has received incomplete run sheets before and said,  he would take it because he wanted some information going into the autopsy. Medics sometimes have to finish filling out their run report at a later time so he would then request a completed copy.

He identified, one by one, the reports from the night Sarah died and also identified her personal medical report from her doctor, the toxicology report and the pediatric cardiologist's report from 1984. He said he didn't have the 1984 report when he first reviewed the case in January of 2009. He agreed with the conclusion that Sarah's death was caused by drowning. As coroner, he also has to determine a manner of death and that's done by autopsy AND investigation. He reviewed the autopsy photos and noted marks and bruises on Sarah that were not consistent with drowning or life-saving efforts.

Looking at a series of photos from the autopsy, he began by describing an abrasion inside her left armpit as a red "triangular" area.   A bruise on the back of her neck, was located an inch or two below the hairline.  It was barely visible on the surface but under the skin, it's fairly large. Another photo showed a deep incision into the neck showing the bruise and the doctor said it was from compression force or blunt-force trauma. He's never seen a bruise in that location associated with life-saving attempts.

A photo showing the inner portion of Sarah’s lip showed some lacerations and tears to her upper lip; one on the left and one on the right. He said sometimes these cuts result when doctors try to insert a breathing tube but can also be caused by someone placing a pillow or hand over the mouth.  The doctor pointed out some faint bruising on Sarah's right forehead near her hairline which he said is not unusual in a drowning victim but it's not likely the result of resuscitation efforts.

In a photo of Sarah, with the tracheal tube still held in place by the elastic strap, and the IV still in her neck, Lee pointed out the frothy, bloody fluid on her face, which is common in drowning victims. He said the strap wouldn't usually cause any injuries. He pointed out some discoloration on her neck, where the IV was inserted and said the IV may have caused blood seepage or bruising.

He noted small bruises on her thigh, forearm and near her ankle, which wouldn't have been caused by medical intervention. A photo of Sarah's eye with the lid pulled open showed petechia in her eye, which Lee said are small red spots caused by blood vessels that swell up from pressure and burst. They are seen in hangings, strangulations, drownings and from CPR.

He explained that bruises are caused by blunt force, which could be either compression force or a jab or punch. Small blood vessels under the skin rupture and cells in the tissue under the skin can also be damaged but bruises don't occur after death because the heart isn’t pumping any more. If the heart is not beating, you don't see an injury as a bruise.

A photo of Sarah's scalp showed bruising on the underside of her scalp near her right ear which was probably covered by her hair. He noted four bruises which were not caused by medical intervention and probably happened before she died.

A diagram of the throat was shown and Lee described the hyoid bone [where chin merges with neck], thyroid cartilage [surrounds the voice box--aka adam's apple], cricoid cartilage [stabilizes lower front of neck], sternal notch [soft area where neck meets sternum], and clavicle [collar bone], are located. He said he observed bruising in the muscle over the thyroid cartilage but not on the cartilage itself.

A series of photos was shown of Sarah's throat opened by an incision, exposing thyroid cartilage, and Sarah's chest with skin and muscles pulled open, revealing tissue beneath. Lee pointed out various bruises in these areas and said they were not from intubation but from blunt-force injury by a compression or a "blow".

Arnold asked what type of injuries the doctor would see from intubation and Lee replied that lip, tongue, epiglottis, and the upper part of the airway are sites that typically receive injuries from intubation.

A photo of Sarah's neck showed a large bruise on the left side which he said was from the IV, but another photo of the right side of the neck showed a small bruise which Lee said was from blunt-force and not related to CPR, compression, or IV.

Asked to explain manual strangulation, Lee replied it meant being strangled by hands--not by a rope, strip of cloth, wire or other device. Evidence of it may or may not be visible at death because some bruising takes time to develop.   After the body is put in the cooler, more bruising may show up later. A photo of the front of Sarah's neck showed bruising where the thyroid cartilage is and Lee said this was from compression force trauma because there was some evidence of manual strangulation on the front and right side of her neck.

Arnold asked if there were any other physical injuries apparent in strangulation victims and Lee replied fingernail marks and bruises that are linear or curved, where the person held the victim's neck with their hands. Fingernail marks may be from the victim trying to get the person's hands off their neck. There are also fractures or injuries to the hyoid bone but because Sarah was only 24, she would be less likely to have injury there because it's more flexible at her age. He added that just because there was no injury to the hyoid bone, didn't mean that she couldn’t have been strangled.

Asked to explain "dry drowning", Lee said some people are very sensitive and have their airway close up, or "spasm" if they inhale water--even just a small amount.

Arnold asked about fingernail marks and Sarah's fingernails and Lee replied that one photo showed two or three fingernails, but not her whole hand. In the photo he saw, they were short, shiny and had no injuries. They appeared as if they had been professionally done because they had a French manicure.

Lee said there was nothing in Sarah's blood tests that would indicate a disease or medical issue. Looking at the report of her June 2008 visit, she had a history of allergies and sinusitis. Her cholesterol was slightly elevated but there were no notes pertaining to heart or neurological problems such as seizures or excessive sleepiness. He said doctors would look for severe headaches, numbness, or loss of balance if a patient had a seizure disorder. There was no mention in her record of severe headaches and no evidence of high blood pressure or diabetes. He didn't recall seeing an EKG in her medical records but those are normally done for a sports physical. In Lee's opinion she was a healthy young woman.

He looked over her toxicology report and said the only item that showed in her blood was caffeine but it was a relatively low level. He agreed that medics gave her Atropine and Epinephrine in her IV, but the drugs were not present in the toxicology report. The blood for the report is drawn from the groin but if blood wasn't efficiently pumped through her veins, the drugs would not have made it to her groin to be detected because CPR is intended to pump blood to the brain. He thought she was already dead.

Arnold pointed out that her ER records had a notation of cardiac arrest and Lee replied that it meant the "heart has stopped." Cardiac arrest was the final outcome but it's the coroner's job to figure out why she died. Looking at the family medical history is important to determine what could be wrong with a person but he didn't see anything about heart disease in Sarah's family medical history.

Lee agreed that the run report showed that medics arrived about 6 minutes after the 911 call, finding Sarah unresponsive, with wet hair and a dry body. He said that someone who was taking a bath would not just have wet hair and all that information is important for determining a cause and manner of death.

Arnold asked Lee his opinion of Sarah's cause of death and Lee replied drowning. Based on his review of the reports and his own experience, he could say with a degree of medical certainty, that her manner of death was homicide.

Asked if he was familiar with Dr. Spitz he said yes, he has the third and fourth editions of his textbooks. In one book, Spitz wrote that intubation difficulty may be caused from rigor mortis, which can begin to set in anywhere from 30 minutes to one hour in small muscles. After about 4 hours, it can be seen in larger muscles and 18 to 24 hours later, the whole body is stiff. Based on the medic reports, there were approximately five attempts to intubate her, so he agreed they had difficulty intubating her. Spitz also wrote that hemorrhaging in the anterior neck could be the cause of strangulation and should be investigated. Lee agreed that bruising was present on the front of Sarah's neck.

Lee was given a couple of letters and a cardiac exam of Sarah from 1984 to look over. The cardiologist did an X-ray exam of her chest and EKG and in the cardiologist’s opinion, the patient had a functional murmur or "innocent" murmur. Lee explained that a murmur can be present in an infant but it's often related to the physiology of a growing baby. These murmurs usually disappear within a few months or a year. No further mention of a murmur is made in Sarah's subsequent medical exams.

Arnold asked Lee to give the most common injuries of CPR and Lee replied that fractures of the breast bone and ribs from chest compressions, but Sarah had neither of those.   He added that young age is a factor because bones aren't as brittle but a big difference in size and weight between a patient and medic is also a factor.  Sarah was 5/2 and weighed 140 lbs. so if a 280 lb. medic was doing compressions you'd see fractures, Lee said. There was no bruising to the midline area [the area between the nipples] of Sarah's chest but if she had been breathing and had a heartbeat, there would probably have been bruises.

Arnold asked Lee about hemodilution and Lee replied that it meant diluted blood and it occurred in drowning victims.  During drowning, water goes into the lungs and is absorbed into the blood making it thinner or more watery.

Lee said it's common to obtain brain tissue slides for examination during an autopsy, but more common if there is a tumor present. He wouldn't do a brain tissue slide in a drowning investigation unless there was other evidence of a neurological problem. The brain is soft and should be preserved in formaldehyde for a few days so it firms up, making it easier to slice. Usually about six samples are taken and affixed to slides.   Lee concluded by saying he found no other medical cause that would lead to Sarah's death. Nothing further.

Cross-Exam: Jay Clark

Clark began by asking questions about Lee’s training, background and how he and Uptegrove knew each other in medical school. Lee said he did a forensic fellowship in South Carolina at the same time Dr. Uptegrove was doing his residency at the medical university in 1996--1997. He and Uptegrove both did their fellowship training at the same place, but not at the same time. Uptegrove did his fellowhip a year ahead of Lee and then did his residency but they knew each other at the time. He did his residency in Michigan but didn’t know where Uptegrove did his. However, they both ended up working as coroners in Ohio.

He agreed he is board certified in osteopathic medicine, but not board certified by the American Board of Pathology. He said board certification requires a person to take a test in their field of study or training and if they pass they are board certified. He didn't know if Uptegrove was board certified. Board certification may be necessary for certain positions in the forensic pathology field, but he's never taken the test. He looked into it but learned he would have to do another fellowship. The test has to be taken within three years of completion of training and he completed his fellowship in 1998.

He's been a member of the National Association of Medical Examiners (NAME) since 1998 or 2000, but Clark pointed out membership in that association is voluntary;  members aren't drafted, and they don't have to take a test to become a member.   The goal of NAME is to improve the overall quality of the medical system by offering new protocols for research and continuing education. He reads and relies on the American Journal of Forensic Pathology and has 10-12 years worth of issues that he uses. The Journal published articles on standard autopsy procedures but it's been a few years since he read them.

Clark told him that one of the articles said that medical examiners should operate without the influence of law enforcement and Lee agreed with that. Another article stated that ME's should use all information available to them before making a determination of the cause of death, but Lee said he didn't necessarily agree with that because he would make conclusions as he went along.

He said he is sometimes called to the scene of the death or he goes to the hospital to get a report, talk to EMS workers, doctors, nurses, family members and police officers, trying to get medical and family history about the person who died. "You can't get too much information," he said.

Sometimes he would only get partial records from the hospital or EMTs and then go back a few days later to get the full records. "I'm not going to sign the case out until I have everything I need". If he doesn't have all the requested records, he will start making phone calls.

Clark asked if arrest warrants should be issued before all the information is available and Lee said it's sometimes done in situations where law enforcement knows it’s a probable homicide before the medical examiner completes his report. Most of the time the lead detective in the case attends the autopsy.

Clark asked if he would at least wait for a toxicology report to make a determination of death. Lee replied that sometimes it's hard to wait 3 or 4 weeks for a report but he agreed he would wait for it before declaring a death a homicide. Clark asked if the toxicology report showed a drug overdose , would police have locked up an innocent man? Arnold objected/sustained.

Clark read excerpts from a Journal article stating that body fluids and the body's electrolytes should be tested so Clark asked about procedures for storing and maintaining tissue, blood samples, urine and vitrious fluid [from inside the eyeball]. Lee agreed that vitrious fluid should be tested for potassium and other electrolytes because electrolyte deficiencies can cause problems with electrical activity in the heart.

Clark handed Lee a report which Lee identified as the toxicology results, which are always included in the autopsy report. Sarah's vitreous fluids were tested for alcohol but Clark didn't see it on the report. Lee said it was on line 2, but after looking closely at the report, Lee said the vitreous fluid was tested for drugs, but not electrolytes.   Lee agreed that labs can't test what they don't have.

Pathological changes in the body are not necessarily visible to the naked eye but could be seen under the microscope with a slide. Lee said that before he finalized and signed out the case, he would want to look through all the slides and take at least overnight to put everything together in his mind. Clark asked which portions of Sarah's brain did Dr. Uptegrove take, and Lee replied, "That is not spelled out in the report". Clark then asked, "How many samples did he take?" Lee replied, "It doesn't say. There are no indications in the report of what he tested."   Lee said he was taught to take 5 or 6 slides from different locations in the brain; one slide from each location but additional slides could be taken from a specific area, if needed. Notations should be made of which portion of the brain was taken because medical examiners look for certain things in specific areas of the brain.   He was taught this in his Michigan Residency.

There are 5 manners of death in Ohio: Accident, Homicide, Suicide, Natural and Undetermined -- meaning the coroner couldn't determine the manner of death at that time but it leaves the door open if additional information is found later. Lee agreed that "Undetermined" is equally acceptable as the other four manners of death.

Clark read the standards promoted by the medical examiners' association that he and Uptegrove belong to and they stated that when autopsies exceed more than 350 per year, it leads to short cuts and mistakes. Lee agreed with that number and added that 250-300 is usually the limit for forensic pathologists. Clark asked if doing a partial autopsy when a full autopsy is warranted would be a mistake. Lee replied, "Yes". Clark continued to read a list of mistakes; errors of omission, failing to test an organ and failing to document findings. Lee agreed those were mistakes.

He said in Licking County, the coroner is in charge of him and others, but he has charge over his investigators. Most coroners are not forensic pathologists, but family practitioners and most of their coroner duties are administrative. Clark showed him a print-out from the Public Documents section of the Licking Co. Coroner website and Lee said that a coroner's report is a public document. In homicide cases it's released once all the results from testing are finished. He doesn't finalize his report until all the tests are in.

Lee agreed he was paid to examine records and testify. Asked how much he was paid, Lee said $4,700 for the 1st trial and $4900 for the 2nd trial. In this trial, he charged a $3000 retainer fee and his rate was $400 an hour.

Clark asked if it's important for doctors to stay "current in their field" and Lee agreed. He said he reads "general type journals" to get a broad array of information. When making a diagnosis, he has to look at all aspects of what is affecting a person. "Just because they had a cough doesn't mean they had lung cancer", but when test results come back, different conditions can be ruled out.   Doctors should look for the simplest explanation first but don't exclude more serious conditions.  For example, if a patient has chest pains, you can't just assume it's indigestion. You have to go to the next step, ask questions and run tests to rule out a heart attack. The process is the same whether the patient is alive or dead.

He agreed that he was not present at Dr. Uptegrove's  or Dr. Spitz's autopsies. His opinion was based on their work and their reports. He has to trust that they followed proper procedures because there's no way to make a determination of a medical condition if test results aren't available or reliable. He agreed that there were other tests that Uptegrove could have ordered and he didn't write any notations about what conditions he did not test for. He agreed that he told Arnold that he believed Sarah didn't suffer a brain disorder but admitted he based that opinion on the reports he reviewed.

Asked about Spitz's book, Lee said it's the bible of forensic medicine and the one he relies on the most. He added that it's one of the oldest and since it's frequently updated, it remains relevant. He didn't know if Uptegrove ever wrote any books.

Clark asked Lee if he could explain the different portions of the brain and what they are responsible for, but Lee replied he didn't know. Pathologists are trained to examine the brain, but neuropathologists are better trained to know all the functions of the brain. He said he would sample 6 different areas of the brain that determine if a seizure has occurred. He wasn't sure which part of the brain controls narcolepsy. Clark asked if he would ever not order a test because it was too expensive and Lee replied, "Oh, no.” He said all 6 sections of the brain should be tested for different problems.  

He said there are simple blood tests to determine a heart condition. He's never done one, but he knows of them. He said they are important to let family members know if it's a genetic condition that could affect other family members. He agreed he would not let cost get in the way since some disorders can only be detected postmortem by a DNA test.

Lee said he's never worked as a paramedic or in an ambulance. The last time he did an intubation was 1993 during his internship. He was last certified in CPR in 1997 when he worked in a hospital.

Clark pointed out in the EMS report that Sarah had a lot of froth, blood, and vomit present in her mouth and throat. Lee agreed and said EMTs would have used suction frequently to clear Sarah's throat because it's hard to visualize the cords if there's a lot of fluids. Clark asked him to point out on the EMS report where it said they had trouble intubating Sarah because of rigor mortis, but Lee said it wasn't noted anywhere in the report.

Lee agreed that he saw bruising on Sarah's left forearm but it wasn't noted in either autopsy report. He saw it in one of the photos and it was probably the result of IV attempts in both arms.  Asked to explain how bruises are formed from IV sticks, he said that a hole is poked in the blood vessel and bruises are formed when blood leaks out of a broken or damaged vessel. Clark asked if a person could bruise after death and Lee replied, "You cannot get a true bruise if you are dead."   The heart pumps blood throughout the body and the goal of CPR is to get blood circulated in a patient whose heart has stopped. If there is damage to the tissue or blood vessel, blood will be forced out of the broken or damaged vessel while compressions are done.

Lee was familiar with hemodilution, which is the theory that water-diluted blood overburdens organs and increases the force and volume in the cardiovascular system. Capillaries are smaller, veins are bigger and some veins are bigger than others.

A photo from Spitz's autopsy showed Sarah's forearm with a bruise at the inner bend of the elbow. Another photo of the same area showed the bruise opened by an incision, which revealed a deep, dark area identified as a hemorrhage. Pointing to the photo, Clark asked if blood came out of the circulatory system after the heart stopped, making it look like a bruise. Lee replied that when a vein breaks, blood will come out. Blood in tissues could leak out, but that does not make it a bruise.

Clark then read a statement out of Dr. Spitz's 4th ed. book: "Bruises are sometimes seen in the upper arm and shoulder area after rigor mortis, without any evidence of trauma anywhere else on the body." Lee emphasized again, "A bruise is not going to form after death, tears in a vein do not make a bruise. "I think we're having a debate about what a bruise is," Clark said and Lee agreed.  Referring again to the large area of discoloration on Sarah's inner elbow, Lee said the size and severity of the hemorrhage wasn't noted on Uptegrove's report.

Clark asked if blood will come out of damaged tissue after death? "It can." replied Lee. Referring to the forearm bruising, Clark asked if Lee would typically see that much bleeding from an IV stick, and he replied "No". He agreed, however, that hemodilution could have been a factor in its size but wanted to make it clear to the jury that it was not a bruise.   Lee added that it wasn't noted on Uptegrove's report.

Clark showed two photos side by side for Lee to explain neck bruising. One photo was of her neck where the IV was put in. The other was the front of Sarah's neck opened with an incision. Clark asked if the hemorrhaging in the front of Sarah's neck was part of the same area as the discoloration on the side of her neck and Lee replied it was not. The discoloration was a "bloody infusion," not a bruise, and it was a little more than would normally be seen.

Showing an autopsy photo of the discoloration around Sarah's jugular, Lee said all of it was caused by the IV stick. A photo of the front of Sarah's neck was shown and Clark circled discoloration on the front [thyroid cartilage] and right side of her neck. Lee said it was not noted by Uptegrove, or visible in his photos, but it was noted and was seen in Spitz's photos. Lee said it's an infusion of blood from a vessel and could have been from strangulation.

Clark asked if one condition can mimic another--one thing looks like it was caused by something else, and Lee agreed that it can happen. Rescuers should be asked if they could have caused any injuries on a patient and asked about all the procedures they did on a patient. Clark asked Lee what injuries he has seen as a result of intubation and he said some subdermal neck injuries , petechia in the eyes and injuries on the lips could have been caused by resuscitation efforts. He's also seen chipped teeth and injuries to the tongue but hasn't seen contusions or lacerations in the esophagus, njuries to the epiglottis, rupture of the esophagus or deep neck tissue injuries. Clark said, "that doesn't mean they didn't occur?" and Lee replied, "True".

Clark called his attention to a March 1999 medical article which said that intubation can cause injuries that mimic strangulation. Lee said he couldn’t agree with that because he didn't have experience with it. But, he added, "I could see where it would be possible." Clark then asked if Lee agreed with an article that stated, endotracheal intubation can cause injuries that are subject to misinterpretation. Lee replied that it would depend on what the injuries were. Clark said knowing if intubation efforts were difficult would be "crucial" information to a medical examiner but Lee was non-committal in his answer about whether medical examiners should carefully consider the possibility that life saving maneuvers might have caused injuries that could be interpreted as strangulation. Lee wasn't sure that the experience of the person doing the intubation mattered for causing injuries.

Clark asked Lee about an article on hemorrhaging in the neck during drowning and a statement that apparent "bruising" of the neck can be present in drowning cases, but Lee said he wasn't familiar with the article. Clark quoted another article that stated hemorrhaging in neck muscles has occurred in persons having an epileptic fit but Lee said he's never seen that happen. Clark asked if he would call the Journal reliable, and Lee said he would. Clark continued to read; traumatic intubation injuries to the internal neck, can mimic injuries of strangulation. Lee said there are certain bone fractures that they look for in determining strangulation but Sarah had none of those.

Asked if rigidity and an airway full of fluid can make intubation more difficult, Lee said a flexible neck is needed to view vocal cords to find the airway. Clark asked him about the Sellick maneuver and Lee replied that he has never performed the maneuver or seen it performed. He has read about it though, and explained to the jury what it is, according to "his understanding." The diagram of the throat was placed on the screen and Lee identified the cricoid cartilage, which is above the trachea and below the voice box. Lee said he understood that you press on the cricoid cartilage to prevent stomach contents from coming up during intubation. Clark asked if an EMT would apply pressure to the thyroid cartilage, but Lee said no, because they could fracture it or injure the vocal cords. "It's a fragile area." he said.   He agreed that EMTs didn't write in the report that they used that maneuver and Uptegrove's report didn't mention it either. Lee said he could see why a medic might place their hand underneath a patient's neck to lift the neck and straighten it. He was trained to do that so he could learn to perform an intubation by himself.

Asked if there were any bruises on the back of Sarah's head in Uptegrove's report and Lee replied "No", but he added that he couldn't say if any of Sarah's injuries would have caused her to be knocked unconscious. The size of a bruise on the head wouldn't indicate if someone was knocked out but there was no bruise to the brain.

Clark asked Lee about the "undetermined" category for cause of death and if he was aware of research that said drowning is the leading cause associated with the undetermined category. Lee wasn't aware of the research.

Asked if people with epilepsy are more likely to drown than other people, Lee replied yes, but epilepsy can only be diagnosed when the brain is active--not during an autopsy. He asked Lee if seizures can be brought on by shimmering water and Lee said yes, or by a bright flashing light. Clark asked if a hot bath could trigger a seizure, but Lee said he wasn’t aware of that. Asked if someone could have a seizure causing them to hit their head on a wall or a faucet and Lee said it could happen but there are also cases where a person won't move a lot during a seizure. He didn't know how many seizures it took to declare someone as epileptic. Clark asked him about brain tumors and Lee said when looking at the brain during an autopsy, if there was a tumor, he would take a section of the brain and look at parts of it under a microscope.

Clark placed a photo of Sarah's armpit on the screen showing the small abrasion and asked if he knew how patients were secured to the backboard. Lee described how straps similar to a seatbelt were placed on the patient at the chest, hip and ankle areas and said abrasions can happen before or after death but they look different. Clark said that according to Dr. Spitz's book, it's frequently difficult to tell the difference between abrasions that occurred before or after death but the doctor disagreed.

Clark placed a drawing of a woman on the screen, pointing out the sternal notch between the breasts where compressions are performed. The shorter the person, the shorter the distance between those two marks. Sarah was 5'1 so she had a shorter area--less margin for error during compressions? Lee agreed.

Clark asked if he was aware of her bad headache the day she died or her sleep issues and Lee replied, no. Clark asked if he knew she had a sore throat and her neck hurt that day and Lee said it wasn't documented in the papers. He also didn't know about the occasions when she would have to sit in a dark room because of a migraine. He said it wasn't in her medical reports but the information might have made a difference during the investigation.

Clark asked if his opinion would be different if the report said that Sarah was pulled out of a full tub of water rather than an empty one.  Lee said no, unless there was never any water at all. Nothing further.

Re-Direct: John Arnold

Arnold asked the doctor if he would inform law enforcement if he found something "suspicious" during an autopsy, even if he had not received toxicology and lab reports that might change his findings at a later date. Lee replied, yes.

Arnold said Clark read off a “long laundry list” of injuries that could be caused by intubation, but Lee said that he could only attribute the lip injuries as intubation injuries.

Arnold asked if he would order brain slides to ascertain if Sarah had narcolepsy or other neurological problems as a contributor to her death? Lee said additional brain slides would only be ordered if he found something to raise the alarm or if he found no cause of death at all. He considered the possibility of a neurological disorder when he first read the reports, but excluded it because there was overwhelming evidence that something else occurred including blunt-force trauma. He wasn't familiar with symptoms of narcolepsy, but knew it made people fall asleep at odd times. However, there was nothing in Sarah's medical records about her having narcolepsy.

The doctor said if he saw EMTs, he would talk to them at the scene. If not, he would be satisfied with the report. If he needed clarification, he would call them. He didn't know if Uptegrove did that.

Arnold asked if there's a difference between open water drowning and bathtub drowning. Lee said you could get a lot more injuries postmortem from drowning in a lake or river with moving water and debris than you would in a place with no moving water.

Asked if the doctor has seen patients strapped on a backboard, was the injury under Sarah's arm like an injury caused by the straps? Lee replied no.

He said he would expect to see different things in a patient pulled from a tub filled with water vs. a tub drained of water. Arnold suggested the length of the 911 call was just 3 minutes, and Clark objected, saying it's six minutes but Arnold was allowed to continue with a question about 3 minutes.

Asked if pressure to the thyroid cartilage would cause pain, Lee said yes, but he's not familiar with the amount of pressure needed to provide intubation. Nothing was on the report about any injury to the larynx, he said. Asked if there was any evidence in the records that she suffered from epilepsy, Lee replied, No. Asked if she suffered seizures after being in warm water, Lee said there was nothing about it in her medical report from her doctor.

Arnold: Anything that would change your opinion of manner of death from your discussion with Clark? Lee: No, my opinion is that we have a “ drowning by homicide." Nothing further.

Re-Cross: Jay Clark

He handed the witness a document for review and Lee identified it as the final autopsy report which was issued Oct. 8, 2008. Lee agreed that a sentence in the report stated there was some hemorrhaging outside the larynx. Clark asked if Dr. Uptegrove took any steps to rule out narcolepsy, another neurological event or a cardiac event, and Lee said it's not in the report.  

Until test reports are back, would you make a final determination in the autopsy report?   “Not until all tests are back”, Lee said.

Re-Direct: John Arnold

He asked Lee to read the sentence following the statement about hemorrhaging outside the larynx. Lee read, "there was no injury to the larynx itself".    Nothing further.