| Trial Testimony - Day 7 |
| Saturday, 12 September 2009 19:33 |
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Tuesday March 31, 2009 Defense continues..... DEFENSE WITNESS: Max Roy Smith, Hamilton Township Fire Department ...Responded to Widmer home on night of Sarah's death. ...Drove fire truck to scene. ...Helped place Sarah on backboard to transport her to ambulance, but that's all he did. Saw Ryan upstairs, and he was upset and crying the entire time. Main focus was on patient, though. Ryan thought that she fell asleep in the bathtub again and drowned. "He was upset the entire time,” Smith says. ...Saw Ryan again in the ambulance front seat, and Smith drove ambulance to Bethesda Arrow Springs. Made sure Ryan was wearing a seat belt. Smith suggested that Ryan call loved ones if he had a cell phone. Heard him tell someone that Sarah might be dead. ...Thinks he got another phone call, possibly speaking to Sarah's mother. ...Ryan sounded pretty upset, Smith said. ...Smith IDs statement he presented to police on Aug. 11. Matter of procedure, basically. ...Prosecutors objected because they said the statement didn't qualify as medical records, so it sounds as if the two sides agreed on some ground rules going in. (Reporter's Comment- That's how it usually works, with the judge as final arbiter.) ...Defense attorney Dziech asks Smith what happened when they arrived at hospital. Smith says Ryan followed medics, Sarah into ER. Upset the whole time, Smith says. ...Smith did not perform any life-saving maneuvers on Sarah, but did not notice any improper maneuvers by anyone else. Smith only took part in log roll of Sarah onto backboard. --------------------------------------- PROSECUTOR CROSS EXAM: "How many people were involved in placing Sarah on the backboard?" asks prosecutor Vieux. “Four or five I can’t remember exactly,” Smith says. ==================================================== ==================================================== DEFENSE WITNESS: Monica Peppard, facilitator for Sarah and Ryan's pre-marital program. Monica Peppard and her husband were Sarah and Ryan’s facilitators in a program for new married couples sponsored through the Widmer’s church. The couples would meet five or six times during the course of two to three months. “They seemed like the typical engaged couple,” says Peppard. “The key areas that were highlighted were the religious differences, but the two were extremely compatible.” Prosecutors object, but Bronson overrules. Jurors allowed to consider that Peppard believed they were compatible. Joint Exhibit 108 is shown to the jury, an envelope addressed to Ryan and Sarah, titled “In case of a marriage emergency.” Peppard IDs the envelope labeled, "In case of marriage emergency," and says she wrote it and gave items to Sarah and Ryan. Included a note from Peppard and her husband, and a brochure about marriage counseling. Urged them to put letters into bedside tables so each could read without other's knowledge in case they ever encountered trouble. Those letters are given to engaged couples as standard part of pre-marriage counseling, she says. ------------------------------------------ PROSECUTION CROSS EXAM: Prosecutor Arnold asks if the point of pre-marriage counseling is intended to show couples that help is available? Part of it, yes, says Peppard. "Don't always know what happens behind closed doors, right?" asks Arnold. Correct, Peppard says. Defense objects, not sure how the issue was resolved. Arnold started to ask another question, interrupts himself before finishing a word, and said nothing further. ============================================== ============================================== DEFENSE WITNESS: Dr. David Smile, ER Physician at Mercy Fairfield and a facility at Washington Courthouse. Background information: Residency at Emory University in Atlanta, Board Certified in Emergency Medicine. Smile also teaches a program that focuses on advanced cardiac arrest support. He’s an ACLS (Advance Cardiac Life Support) instructor. They've dragged the CPR dummy out into the middle of the floor, and now defense attorneys are talking to a fireman and another man. Dr. Smile says he examined EMS and ER records, as well as scene photos. “I was not surprised at the injuries at all based on the prolonged CPR and intubation attempts,” Smile says. “In establishing an air way in the mouth it can be very difficult and there’s potential for injuries around the mouth and teeth. I was surprised there weren’t more injuries.” Smile also says he read that some of the medics were having difficulty extending the head and the neck. He says that not everyone has the same anatomy, and that Sarah’s death was a difficult situation and was complicated because there was a lot of water. Drowning made efforts difficult for medics, frothy spew, etc. Smile tells the jury that CPR, especially when done in the field, carries the potential for a lot of injuries: There is a lot of pressure on the head and neck. Rib fractures, chest injuries too. Intubation also carries injury risk for neck, throat. He was surprised not more injuries to that area, too. Rittgers asks, “In your practice, have you seen similar injuries?” CPR with compressions, along with IV insertion, could likely cause injuries seen on Sarah. Injuries from CPR very common, Smile said. ...Medics at the scene are first supposed to see if patient is conscious, then check heartbeat, other vitals. CPR is begun, and then an oral airway is created,” Smile says. ...No heartbeat detected for Sarah, Smile says. ...The process of intubation is then explained to the jury. It is when you pass a tube into the mouth and trachea. Rittgers asks Smile to demonstrate to the jury the intubation efforts to save Sarah’s life. Smile steps down from the witness stand kneels on the floor, demonstrating intubation on the CPR dummy. He says by placing the scope in the mouth, you can cause injuries to the lip and teeth. Smile says it's Extremely difficult to intubate with all the water and debris in the airway. Smile is still explaining the process for intubation, focusing right now on Adam's apple or thyroid cartilage. In this particular case, Smile tells the jury they had an extremely difficult time. They had four attempts at intubation. Rittgers ask Smile if he needs assistance. Steve Coley from the Forest Park Fire Department assists Dr.Smile. Now a fireman is performing chest compressions on the dummy, with Dr. Smile demonstrating simultaneous intubation efforts. The jurors are leaning forward and watching. Prosecutors object, and the judge sustains it. Judge Bronson characterizes the doctor's and the medic's comments during their efforts (counting off, etc.) as testimony, and says it goes beyond a demonstration. Bronson says the witness and the volunteer are making rescue comments that the jury can not understand. He then tells the jury to disregard the presentation. Smile is back on the stand, explaining how errors can occur during CPR attemtps, particularly in the field (vs. the ER). “If the hands are too low on the chest, that can cause damage to organs such as the liver,” Smile says. “The voice box is pushed down, so that the person inserting the tube can have a better look. We teach how to find the landmarks for the tracheal cartilage, but not everyone’s anatomy is the same,” Smile adds. He also says that he’s seen where fingers are placed too far up or too low on the neck. Prosecutor Arnold objects when Rittgers asks to show a photo from the Internet of the Sellick maneuver being performed. Rittgers says he's not entering it as evidence, and he's allowed to show it. (Definition of Sellick Maneuver - The Sellick maneuver is performed by applying gentle pressure to the anterior neck at the level of the cricoid cartilage. The Maneuver is used to help align the airway during endotracheal intubation. The reason for performing the Sellick maneuver is to provide a means to prevent gastric contents from leaking into the pharynx, by external obstruction of the esophagus, which would cause inhaling of substances into the lungs and vomiting during ventilations in an unprotected airway.) Smile suggests that the Sellick maneuver could have caused injuries to the front of Sarah's neck. “In trying to develop an emergency airway path, there’s a potential for a lot of injuries,” he says. “The head can be hyper-extended.” Rittgers asks Smile about the contusions found on Sarah’s head. He says the contusions were due to blunt injury to the back of the head and that it could be consistent with an injury during resuscitation efforts. He says a blunt force caused those, but said they were consistent with resuscitation efforts, including moving her onto a backboard. ...Smile says the needle stick during the resuscitation period caused most of bruising on Sarah's neck, but the Sellick maneuver could have caused that if not done properly. Says he doesn't know whether it was done properly or not. He says her neck was manipulated several times during resuscitation. All you can say is that there was excessive force on the side of her neck. Rittgers asks Smile for an explanation about the bruise on the back of Sarah’s neck. “I guess all you can say is that there was a blunt injury to the back of the neck,” Smile confirms. CPR efforts could have caused chest injuries, Smile says. Rittgers asks about the abrasion found on Sarah’s armpit. Smile says since Sarah’s body was picked up several times, the injury could be a result from that. Rittgers asks Smile about the “sudden death syndrome.” Smile gives his synopsis of “sudden death syndrome.” He says sudden death occurs in all age groups. The doctor recently looked at a review article on sudden death and tells the jury these facts. Sudden death can occur over all age groups, and causes are different by age group. Cause for seemingly healthy young adults, 20-30 years old, about 300,000 episodes per year. About 1 to 2 percent occur in people under 35 years old. About 2/3 of those people have autopsies that explain that sudden death, but 1/3 have normal autopsies with no evidence of heart or other problems. That represents about 1,000 to 2,000 people per year, Smile says. Smile says you could expect 2 to 3 patients per state, per month to die suddenly and without explanation. ------------------------------------------------------ PROSECUTION CROSS EXAM: Prosecutor Arnold indicates there were no injuries found on Sarah’s vocal cords. Dr. Smile agrees. He also asks Dr. Smile if he saw any internal injuries to the trachea. “I did not,” Dr. Smile says. Arnold asks Dr. Smile if he found any indication of broken teeth. “I did not. Both autopsies that I reviewed stated the teeth were intact,” Dr. Smile says. How far is the laryngoscope inserted into the throat? "Past the tracheal ring, almost to the vocal cords," Smile says. ...Dr. Smile is aware that Sarah was never successfully intubated until she got to the hospital. Smile says chest compressions are supposed to be performed between woman's breasts, which Prosecutor Arnold says witnesses testified to doing. Arnold asks if past medical records would be a vital source of info? Particularly, an exam performed not long before death? Very helpful, Smile says. Family history is also very helpful because sudden death syndromes have been known to run in families. Sarah’s physical examination from March 2007 is shown to the jury and to Dr. Smile. Prosecutor Arnold shows the courtroom Sarah’s physical. Smile says the exam appears to be fairly normal except complaints about tiredness and elevated cholesterol levels. Says the doctor probably would have recommended diet and exercise for cholesteraol, not meds. Arnold asks if father's death around the time of exam might be related to sleep trouble. Smile agrees that such events can interrupt normal sleep patterns. "One cause of sleepiness or insomnia is depression,” Dr. Smile says. Smile says these records had not been provided to him during his investigation but agrees that EMT's testimony about CPR efforts sounds as if they followed proper procedures. "Have you heard the 9-1-1 call?" Arnold asks Dr. Smile. “No, I have not,” Dr. Smile says. Arnold tells Dr. Smile that based on the 9-1-1 call Ryan pulled Sarah out of the bathtub and drained the water. ...Rittgers objects, Bronson sustains and tells Arnold that is not this witness expertise and to move forward with the next question. "Was there anything about the medical procedures that you described to us, that would cause her to be dry?" Arnold asks Dr. Smile. ...Rittgers objects, and Bronson agrees, says that question is outside the doctor's expertise. Arnold tries again, and Smile says those efforts would not necessarily cause body to dry, only passage of time. Dr. Smile says that the temperature in the room could have caused Sarah’s body to dry. Smile says you can kneel next to patient, to perform CPR and down on the floor, he agrees, you are possibly in a position to notice if carpet or Sarah's body was wet. Smile says he doesn't know enough about whether the sheriff's deputy who arrived first might have performed CPR improperly. Says he hasn't reviewed Hamilton Township's training guidelines about these procedures. He says he's offering no criticism. He says they did the best they could under difficult circumstances. One in 5 patients does not respond to life-saving efforts, he says. Smile would expect person to be wet if pulled from tub and would also expect body to transfer water to carpet and be detected by first responders. Prosecutor Arnold asks Smile to step down and go look at the tub, which Smile has seen in photos. Arnold shows autopsy photos of Sarah's face and chest, showing jagged incision. Smile IDs bruise on lower right of her neck. Smile says he's seen silmilar injuries, and says injury consistent with force placed on neck. Arnold suggests that these are the types of injuries seen in manual strangulation or choking. Dr. Smile agrees. Smile says the choke hold can cut off breathing and cause incapacitation. He's not familiar with arm hold, but Arnold describes it and he says he's familiar. Says arm over mouth and nose can interrupt breathing. Smile says he knows Dr. Wiliam Rogers through his work at the hospital in Oxford. Says Rogers is an excellent physician. (Rogers testified for prosecution earlier in trial.) Arnold asks if Smile can explain why Sarah's body was dry when first responders arrived. Rittgers objects but is overruled. Smile says life-saving efforts would not have caused drying, but temperature in house and other conditions, length of time, would influence drying. Says a few minutes not likely enough to cause drying. He says he can't find any reason for Sarah's body to be dry, based on what he's seen. Smile says epilepsy can be the cause of sudden death syndrome, but is unsure of how frequently it's found. Smile saw no indication that Sarah had epilepsy or cardiac trouble. ---------------------------------------------------- DEFENSE REDIRECT: Does the fact that he hasn't examined previous medical records change his testimony? No, he says. Smile agrees that Rittgers told him that Sarah was a relatively healthy 24-year-old. Rittgers asks about Witness Teague's statement that the body was relatively dry. Arnold objects, is overruled, and Smile says he remembers reading about that. Rittgers starts to introduce the lab technician's testimony about wet carpet, but Arnold objects. Bronson tells Rittgers to phrase it as question, but he moves on to the 911 operator's testimony. Rittgers says the 911 call lasted 6 minutes, and Smile says length of that time would impact body's dryness. Passage of time and ambient room conditions would influece drying, he says. Drained bathtub would also influence this, he says. ----------------------------------------------------- PROSECUTION REDIRECT: Smile says, the longer the passage of time, the dryer he'd expect. If the body was never submerged in water, that would also change his opinion about whether body would be wet or dry. (Note from Reporter: Ryan called 911 at either 10:43 p.m or 10:46 p.m. and the deputy arrived at 10:49 p.m. The first medics arrived at 10:51 p.m.) Bronson excuses the witness, and Rittgers tells him that the next witness won't be available until 1 p.m. Bronson's got something at 1:15, but hopes to get going quickly after that. ==================================================== LUNCH BREAK ==================================================== DEFENSE WITNESS: Dr. Michael Balko, Pathologist from Wright State University Licensed in Ohio and Kentucky, Dr. Michael Balko is trained in the area of forensic pathology. He attended the University of Kentucky for undergrad and attended medical school at the University of Louisville. He’s had some additional training with University of Cincinnati. He currently teaches at Wright State University, is a staff neuropathologist at St. Elizabeth Hospital North and is board certified on the American Board of Pathology. Performing about 200-300 autopsies per year, Balko's specialty is evaluating tissue samples. He’s worked with Hamilton County Coroner Dr. O’Dell Owens. He performs brain autopsies (about two per week) and serves as deputy coroner in Hamilton County. Balkco says he usually testifies for prosecutors. Balco has reviewed autopsy, ER and medical records of Sarah Widmer, and also viewed photos of the crime scene. Rittgers ask Dr. Balko what injuries did he notice on the autopsy photos? Balko says that he noticed injuries that are associated with resuscitation. ...He says lacerations on upper lip and hemorrhaging in windpipe are associated with trachea tube and intubation efforts. Dr. Balko also says the bruising found on Sarah’s neck and arms were injuries from resuscitation efforts. Subcutaneous bleeding in left neck are the result of efforts to insert IV tube, Balco says. Bruising on inside of elbow also the result of IV tube insertion. “There was leakage of blood from where the needles were inserted in Sarah’s arm,” Dr. Balko says. Rittgers shows the jury the remaining lesions that were found on Sarah’s body. Balko says the contusion pattern visible on the right side of Sarah’s head can be attributed to moving the body during rescue efforts. Bruising on back of neck, below hairline, could be attributed to strap used with breathing tube, Balco says. He notes superficial scrape in Sarah's armpit, likely attributed to efforts to move body. "Very superficial," he says. A picture of Sarah on the autopsy table with the intubation tube in her throat is shown to the courtroom. Rittgers says there was a circular bruise found on the right side of the neck. ...He says bruise on Sarah's right lower neck likely result of resuscitation efforts. No evidence of brain injury. Bruising likely result of bump on the head, Balco says. “They are what they are, there’s nothing major there,” Balko says. Balko says there were no signs of fractures anywhere. ...Autopsy photo of Sarah’s epiglottis is shown. ...Autopsy photo of Sarah’s tongue is shown. Balco notes some bleeding at back of tongue that he says came from the placement of tracheal tube. Rittgers asks Dr. Balko if the injuries found on Sarah was as a result from an assault? “No,” Balko says. Result of extensive efforts (up to 45 minutes) to resuscitate Sarah. “If you are looking for evidence of assault or attack, you want to look for a pattern of bruising." Evidence of assault would show patterns of bruising, defensive wounds, injuries to upper back, broken fingernails. Prosecutors objected when Balko started disucssing this, seemingly unbidden, but Bronson overrules and he continues. Balko believes the cause of death in this case is drowning because the autopsy found pulmonary edema and water in Sarah’s lungs. Rittgers asks him about the manner of death. ...Given findings, I would list manner of death as undetermined, he says. Can't tell if her death was natural, suicide, homicide or otherwise. All the findings informed his opinion, Balko says. Rittgers asks if he's familiar with sleeper holds? In a general sort of way, he says. Choke holds? Somewhat, he says. Rittgers asks if Sarah’s injuries were as a result from sleeper hold or choke hold. Balko says there is no pattern of injury suggesting choke or sleeper hold. He's never performed an autopsy on the victim of one, but is familiar with literature on such injuries. A Journal article describes 14 autopsies conducted on choke/sleeper hold victims, Balko begins. Prosecutors object and ask to approach. Journal Article describes pattern of injuries from choke/sleeper holds, but Balko doesn't elaborate. Says Sarah's injuries not consistent with that. -------------------------------------------------------- PROSECUTOR CROSS EXAM: Vieux asks if Dr. Balko was contacted to be a witness in this case after the trial started. Balko first examined autopsy reports March 25, after the trial began. Never reviewed witness statements. Balko says he has conducted autopsies without reviewing witness statements. Has not talked to first responders, and not aware of their testimony. “You never spoke with any of the first responders to the 9-1-1 call?” Vieux asks. Dr. Balko says no. Rittgers objects that Vieux not allowing Balko to finish answers. The prosecution reveals that Dr. Balko has never spoken to Sarah’s family and he has never listened to the 9-1-1 call. He received a transcription of the call prepared for by the defense. “Correlating the autopsy findings with the findings from the investigation is essential, would you agree?” Vieux asks. Dr. Balko confirms. “If a body was removed from the tub filled to the overflow, then that body would still be wet, minutes later right?” Vieux asks. Dr. Balko begins to tell the jury how when he took a shower today, he got out and timed to see how long it would take. He says it took about 7 minutes. He admits it's not scientific, and Vieux asks to strike. Bronson declines, saying Balko is answering prosecutor's own question. “If a wet body was moved to the floor, then the floor should still be wet,” Vieux asks. Balko confirms. Vieux asks if other places in the house, such as the carpet should still be wet. Balko says damp or wet body moved to another location likely would transfer some water to new location. ...Vieux asks if evidence that floor and body are dry indicate that more time than 7 minutes had elapsed? Balko says he doesn't know. ...Vieux says it might suggest a period of time had elapsed?, Balko agrees. Vieux asks Dr. Balko if he is familiar with the process of pruning. Dr. Balko says he is familiar. Vieux asks if the warmer the water the sooner the pruning on the body? Balko agrees that body in water for a period of time would likely prune, especially if water warm or hot. ...Balko says he's moved many dead bodies, and it is difficult to do. Vieux asks about head block that supports skull during autopsy. Balko says block likely didn't cause bruising to Sarah's body. ...Dr. Balko says the neckband from the intubation procedure is what he believes caused the bruising to the base of Sarah’s neck. ...Photo shown and there is talk about strangulation injuries, appearances externally and internally. Dr. Balko identifies the picture as the base of Sarah’s tongue and suggests that the area of hemorrhage was caused from the intubation efforts. ...Vieux tells the courtroom that it is actually a picture of Sarah’s throat and larynx. He then asks Dr. Balko if he was aware that he misidentified the photo. Balko said he was not sure when looking at photo of its proper orientation. Does that change his opinion? Vieux asks. Not really, Balko says. ...Dr. Balko agrees with Vieux saying that there were no internal injuries to the inside of the trachea. Balko says person under 30 might not have hyroid fracture in case of manual strangulation. ...Found no injury of brain injury or disease ...Photo of the incision made into Sarah’s chest is shown to the court room. ...No evidence of heart injuries or disease. Dr. Balko tells the jury that he did previously review Sarah’s medical records. ...No evidence in medical records that she had a seizure disorder or neurological disorder. Balko recalls she was having trouble sleeping. ...Balko agrees that death of Sarah's father just before medical exam in question might have effect on sleep patterns. ...Vieux asks if he's ever seen a case where a suspect tampered with evidence? Yes, Balko says. Nothing further, Vieux says. --------------------------------------------------------- DEFENSE REDIRECT: ...Rittgers places hand on Balko's throat and asks if that's how bruises on right side of neck might have been caused. Yes, Balko says. Only way? Rittgers asks. No, also resuscitation, Balko says. ...Balko says you would find soft tissue damage to throat and eyelid hemorrhaging. Also would find defensive wounds, he says. ...If facing attacker, wounds are usually in front, on forearms. If attacked from behind, on back. He would also expect to see marks on the assailant. Would expect to see signs of a struggle at scene. ...Would you expect to find water on floor of bathroom if a struggle was there? Yes. Balko says he Would expect to see water splashed everywhere. ...Would you also expect to find other signs of struggle? Yes. ...Would you expect to see additional injuries if the head was placed in sink? Yes Discussion takes place about whether questions about toilet may be allowed. Judge lets it go. ...Balko says you would expect to see evidence of defensive wounds or sign of a struggle if Sarah's head was stuck in a toilet. With no evidence, with a reasonable degree of medical certainty, Balko states that such a struggle did not take place. ...Rittger asks about heart, prosecution objects, Rittgers takes exaggerated stagger, and everyone -- including jurors -- laughs. Bronson lets him ask question. ...Balko says he cannot rule out a heart event, cannot rule out a seizure, based on evidence he's examined. ...Rittgers asks if Balko saw in transcript that Ryan said he'd pulled the bathtub plug, and that dispatcher told him to remove her from tub. Yes, Balko says. That adds time to allow the body to dry, does it not? Rittgers asks. Yes, he says. ...Would that accelerate drying process? Rittgers asks. Well sure, Balko says. -------------------------------------------------- PROSECUTION RECROSS: ...Balko says he Cannot make medical diagnosis of a heart problem, but a pathological diagnosis is possible based on existing evidence. Same goes for a seizure disorder. No family history of heart or seizure disorders, he says. Witness excused, and the judge asks both sets of attorneys to approach the bench. Rittgers says the defense has rested. Bronson asks the jury to leave the courtroom but stay until he decides when to call them back tomorrow. Attorneys are reviewing some evidence, and Arnold complains about some testimony early in the trial when, he says, the defense was flashing images on the screen without properly identifying each. Rittgers says he's not offering Firefighter Smith's statement to police as evidence, because prosecutors said it was not part of medical records. Judge says he's going to leave room, but says he'll be available if attorneys need anything resolved. |