Ryan and Sarah Widmer, what the Prosecution doesn't want you to know.

Direct Exam: John Arnold

Dr. Rogers is the medical director and attending ER physician at McCullough-Hyde Hospital in Oxford, medical director for Mercy Hospital in Fairfield and the medical director for Springdale Fire Dept. and Oxford EMS services. He's been board certified by the state and also serves on the EMS board for the state of Ohio. He was licensed as a physician in 1985 and has been board certified as an ER physician since 1989. He must be recertified every 10 yrs. and was just recertified in 2009. He works with EMS/paramedic teams and has been a medical director for 4 EMS units. A medical director is responsible for training medics. He's a co-medical director for the Hamilton County SWAT team, which is a volunteer position.   He also works for DART in Hamilton Co. as a pharmaceutical advisor. He has written articles on violence in the emergency department and included suggestions so health care workers and medics can keep from being assaulted. He's also published a chapter on EMS medical and legal issues in a textbook, as well as co-authoring a publication on sexual assault protocol.

He has reviewed photos and autopsy results from Sarah and CDC information on drowning, in preparation for his testimony. He also reviewed Sarah's medical records, prior testimony, the state's testimony and both state and defense autopsies. Arnold handed him Sarah's medical records from the night she died, her OB/GYN records, her Dayton Children's Cardiology records, her last physical exam from June 2008 and her toxicology lab report from Montgomery Co.

Dr. Rogers testified that Sarah took Zyrtec, an antihistamine for allergies. Headaches and drowsiness can be a side effect of taking Zyrtec. There was a history of cancer in her father and maternal grandparents, an uncle had asthma and several relatives had high blood pressure. There was no history of heart failure, lung or kidney disease, and no indication that she had any heart condition or hypertension. Her most recent blood pressure reading was 110 over 62 and her doctor didn't hear any heart murmur.   She also didn't have any neurological problems. Dr. Rogers said family history is important because diseases tend to run in families.  

Looking at the run reports from Aug. 11, 2008 hesaid first responders found her with no heartbeat or pulse. CPR was performed before medics arrived, but she did not respond to any life-saving efforts. His opinion was she was dead when EMTs arrived and she had no chance of survival. There was nothing in her toxicology report that showed a cause of death .

He said he was familiar with intubations and has been involved in the resuscitation of a drowning victim. It can be very difficult because a lot of pink, frothy, fluid and stomach contents are coming out of the nose and mouth. The pink fluid is a mix of blood and water. When asked about defibrillator pads he said the skin has to be dry when they're applied, otherwise the skin can be burned if they’re not applied properly.

Explaining intubation, he said the bag valve mask is the first step in preparing a patient to be intubated although it can cause bruising in the nose or jaw area. When intubating someone, you're trying to open the airway and you need to have three points aligned correctly in the throat to insert the tube. He showed the jury the flexible plastic tube that's used and said it's more rigid than other tubes. Holding it up, he showed how it could be curved and which part went into the trachea. It has a cuff on the end that goes in the mouth to keep fluid from coming back up. The lining of the throat can be injured if it's inserted in the wrong place in a rough manner or the vocal chords can be bruised. These injuries would be inside the throat, not on the outside of the neck.

A photo was put on the screen showing Sarah in a hospital gown with the tracheal tube still in place and Rogers pointed out the bag valve mask over her mouth with the tube inserted through it. There was a blue strap fastener that wrapped around her neck to keep the mask from moving around. Using a blue marker he pointed out cuts and bruises around her mouth and near her teeth and white frothy material in her left nostril. He said the cuts and bruises could be from applying the bag valve mask or inserting the laryngoscope. Arnold asked him about the blue fastener and he said it was made of spongy foam with Velcro fasteners, but wasn't aware that it could cause any injuries.

A photo was shown of the bruising on the left side of Sarah's neck and Rogers said these were likely from the IV attempts into her jugular vein. A diagram of the throat from a medical textbook was shown and he pointed out the hyoid bone, thyroid cartilage, strap muscles and the cricoid cartilage. With vigorous resuscitation attempts and intubation, injuries can be produced, but generally, they do not.

A photo was displayed showing Sarah's chest, neck and lower face with a lot of red bruising on the front and left side of her neck and a smaller bruise on the lower right side of her neck. Arnold asked if these types of injuries could be the result of intubation or the Sellick maneuver. Rogers pointed out the bruising on the right side of her neck and circled it with a blue pen. He said it was not consistent with intubation but rather from a compressive force. Taking a pulse at the carotid artery is done with very light pressure so it would not cause this bruise and minimal pressure is used to the cricoid bone when trying to insert a tracheal tube. Neck bruising is usually seen with strangulation, steering wheels from car accidents, punches to the neck during an attack and a number of other reasons.

A photo of the interior of Sarah's scalp was put on the screen showing three areas of bruising and Rogers said extra care is taken with the patient's head during emergency procedures.

The next photo, showed the dissected airway and Rogers pointed out bruising near the thyroid and cricoid cartilages. Another photo of the airway was shown and Arnold asked if the bruises were from CPR.  Rogers replied no, these injuries are outside the trachea, under the skin. Intubation procedures cause injuries inside the throat and not enough pressure is used for the Sellick maneuver to cause injuries.

He didn't see any injuries to Sarah's chest or sternum area that would have been caused by chest compressions. He didn't see any history of fainting or light headedness in Sarah's medical records. He has patients in his practice with seizure disorders so he's familiar with them, but he didn't see any indication in Sarah's medical records that a seizure would have caused her death. Also, no indication a heart malady caused her death. Arnold asked if many people die of sudden death from a cardiac event and he replied cardiovascular disease is the leading cause of death across all age groups, but young healthy people have less risk. Arnold then asked if there were many cardiac deaths in 24-yr-old females and he replied "no", but the CDC compiles death statistics which are broken down by race/age/sex. Drowning is not a leading cause of death because over a nine year period, there were 1,222 deaths in Ohio from all causes; nine of those were drowning deaths, but only two drowned in the bathtub. Seizures, brain swelling, bleeding and pressure to the brain caused 1.8% of the 1,222 deaths in young women.

Arnold then questioned Rogers about heart murmurs. They are diagnosed using a stethoscope and listening for abnormal sounds related to blood flow. They are generally caused by structural abnormalities in the heart. Newborns often have them but in his experience, they often resolve themselves. If they don't resolve, then surgery may be required.  Anemic patients or those with an enlarged heart can have a heart murmur. Looking at Sarah's pediatric records, Rogers said Sarah had a "benign" heart murmur when she was 10 months old. Heart murmurs can cause shortness of breath, easy fatigue or wheezing. She was seen by a pediatric cardiologist and it was suggested that they watch and wait to see if further treatment was needed and the cardiologist suggested they return in 2 to 3 years for follow up. A heart murmur is different from a heart arrhythmia.

Now looking at Sarah's EMS records, Arnold asked Rogers if he was familiar with the terms, "Play and stay" vs. "load and go". He said the former phrase means the patient will be transported to the hospital quickly for further treatment. This would be used for high trauma situations such as stabbings, shootings, and falls from high places but the method isn't necessarily used for cardiovascular or respiratory events or drownings.

"Staying and playing" will get medicine to a patient faster increasing their chance for survival. Restoring breathing and restarting the heart can be done at the scene to save the patient. He didn't see a problem with the way EMS workers treated Sarah, when they took her to the back of the medic. He reviewed the Hamilton Twp. reports from that night and saw that medics attempted to intubate Sarah in the back of the ambulance before they left, trying to restore oxygen to her brain. It's easier to intubate a patient on a cot than on a floor.

Arnold then asked Rogers about the incomplete versions of the EMS report and he said it's common when bringing in a full-arrest CPR patient to have no records filled out. He expected the medics to tell him verbally what they did to the patient. Every medic has their own way of keeping notes and paperwork is usually completed as doctors and nurses work on the patient. It's common practice for medics to call the dispatcher to get on-scene times, hospital times, etc. He found no fault with the way the EMTs kept the records of what they did because drownings are very difficult resuscitations.

Rogers said, in his opinion, "There is no explainable medical event that caused Sarah's death". Both autopsies showed drowning and both indicated unexplained bruises that were not consistent with medical intervention. No further questions.

Cross Exam: Jay Clark

Clark began by asking Rogers about his opinion that no medical event caused Sarah's death. He replied he didn't find anything in her medical records that would suggest anything different, based on his training and experience.

Clark asked about his past as a police officer and he said he's been one for 30 years. He was a reserve deputy sheriff in San Bernadino, CA, working road patrol and in the narcotics division then came back to Ohio.  He said he doesn't work for Warren County, he's a volunteer.

He said he has worked with people addicted to drugs, including opiates. In his work with DART, he specializes in people addicted to pain medications. Clark asked about drug addicts and their credibility, but Arnold objected/sustained. In his current position, he works with a pharmaceutical unit and agrees that Oxycontin/Oxycodone is in the opiate class of drugs.  Clark asked if they are drugs that people become addicted to and he replied "yes". Are drug addicts reliable people? Arnold objected.

Do drug addicts lie? Arnold objected. Do you have contact with anyone who uses narcotics? Arnold objected. Anyone who uses methadone? Arnold objected/overruled.   Rogers replied "yes", it's a Schedule II opiate narcotic like Oxycontin and Oxycodone.

Asked about the effects of opiates, Rogers replied there are four opiate receptors in the brain and spinal cords and each one responds differently to the drug. The side effects are shallow breathing, slurred speech, restricted pupils, impaired perception to pain and impaired reaction time to danger.  Clark asked if it impairs memory and Rogers replied it can, but certain variables can apply. Over time, he said, the receptors diminish because they're getting a constant dose of the drug so performance improves as the body becomes tolerant to the drugs. The person would then need higher doses to get the same effect. Asked again if it impairs memory, Rogers replied that people who are given opiates will suffer memory impairment, not by changing the memory event but by taking longer to recall it. Pain is blunted, when on opiates and that's why doctors prescribe them.

Clark then asked how methadone is used as a treatment and he replied that it's used for treating acute pain and to help addicts get off of opiates such as heroin, a Schedule I drug, or oxycodone, a Schedule II drug. It's also used to switch someone from Vicodin, which is a lesser drug. Methadone can be controlled better in a dosing regimen and doses can gradually be reduced without causing withdrawal symptoms.

When asked about his work as an attending physician in the ER, he said he's basically in charge during his shift and different doctors perform different tasks. McCullough-Hyde isn't a teaching hospital so it doesn't use residents.

Clark asked Rogers what he was paid in previous Widmer trials and he replied the first trial was $5000, and the second trial was $6500. He's paid $3000 as a retainer fee and he charges $150 per hour.

Regarding heart/medical conditions that could cause arrhythmia he said, multiple abnormal beats are felt by the patient and an arrhythmia can make a person feel tired.   Clark asked if the arrhythmia could cause a person to lose consciousness, fall into a bathtub and drown but Arnold objected/sustained. Sudden cardiac death is "not necessarily" the most common result of heart disease but many of those patients don't make it to the hospital. He agreed that sudden death is often the only symptom the patient has and the cause of sudden cardiac death doesn't always show up in an autopsy. Even if there's no family history of cardiac problems it's still possible to experience a cardiac event.

Rogers said he's familiar with Long QT syndrome because he's treated two patients with this genetic abnormality. An EKG monitor would not show electrical activity in the heart if a person died as a result of Long QT syndrome. When diagnosing patients, he may not tell them every possibility for their symptoms immediately, because it can take several days to gather test results. He agreed that he had to keep an open mind of what the possibilities could be.

There are some defects present in the heart to explain sudden unexplained deaths from arrhythmias, but they can't be detected without a microscope test of the tissue. He agreed with Clark that if you don't sample them, you wouldn't know, and sometimes even a microscopic test doesn't show the cause.

Clark asked if Uptegrove's autopsy report showed there was a high potassium level in Sarah's system. Rogers replied that he did not see any tests in the report for potassium levels. Looking at Sarah's past medical and family medical history, he also said there was no history of seizures or strokes indicated.

Rogers reviewed Sarah's records from Dayton Children's Cardiac Center where there was a murmur reported. A follow-up visit was recommended in 2-3 yrs but he didn't see any documents showing that a visit was made.

Dr. Rogers looked at a report of an attempted intubation using the Sellick maneuver and Clark asked if the maneuver was attempted over the thyroid cartilage.  A generic photo was put on the screen showing EMTs/paramedics doing an intubation using the Sellick maneuver along with a diagram of the same area. Clark placed two fingers on the diagram asking if this is where the thumbs would be on either side of the cartilage. Rogers agreed that was the correct place and added that he teaches paramedics and EMTs this maneuver. Clark then asked if that's the same way pressure is applied to the cricoid cartilage, but Rogers replied two fingered pressure would be used but the pressure is minimal.

Clark placed a photo of Sarah's neck on the screen from the 2nd autopsy, showing large reddish bruises and circling the area with his blue pen and Rogers agreed that's the area they're discussing. Another photo on the screen showed her dissected throat and as Clark zoomed into the area, he asked Rogers to point out the thyroid and cricoid cartilage. Clark circled a hemorrhage that was found in the cartilage and Rogers agreed this was the same area that showed bruising on the photo of Sarah's neck.   Asked if the hemorrhaging in Sarah's neck could have been caused by the Sellick maneuver during intubation, Rogers agreed but added that she has other hemorrhaging in that area as well. Going back to the photo of her neck, Clark circled a faint bruise on the right side of her neck. Rogers said that the center to left side of her neck had bigger, darker bruising.    After looking at Uptegrove's autopsy report again, Rogers said the faint bruise showing on the right side in the second autopsy photo wasn't noted by Uptegrove. The front bruising and right side bruising are separate because there is a section of clear skin between the bruises, meaning the bruises were two separate bruises.   Rogers said he couldn't tell if the bruises were superficial or deep and there was nothing in the autopsy report indicating the depth of either bruise.

Rogers agreed some petichae can occur as a result of chest compressions and lip injuries can occur from intubation. Clark asked if a successful intubation was due to the skill level of the paramedic and Rogers said it is a factor, but size of the patient is also a consideration.   Skill level will indicate how much injury is caused and, in his opinion, there would be more injury with less skill. Showing a photo of Sarah's mouth Rogers agreed that the lacerations and abrasions shown could be from intubation. Clark asked if bruising from intubation is similar to bruises caused by strangulation and Rogers replied that they might be the same.

Questioning Rogers about the bruises on the back of Sarah's neck, a photo was shown with the skin opened down to the vertebrae. Rogers agreed this area is protected while a person is lying down, because the neck curves upward. An intubation training photo is then shown containing several people and Clark circled a hand in the photo placed under the head. Rogers said this is a two-person procedure where one person stabilized the head in the correct position while the other person waited to perform the intubation procedure. The patient's head is held firmly, to stabilize it. He went on to say that neither he, nor Hamilton Township teach this technique because it's awkward for the intubator.

Another photo of an intubation was shown--a two person technique where one person applied pressure to the voice box area, while the other person held the laryngoscope, waiting to proceed. Rogers said superficial hemorrhages can occur to neck muscles with intubation, however, they are usually due to other factors. Cricoid hemorrhages are "extremely rare" in intubation. Broken teeth, lip injuries, throat injuries, esophageal rupture, and petichae are more commonly seen as a result of intubation.

Rogers said he hasn't personally treated someone with narcolepsy, but it’s part of ER training. He's not certain which part of the brain should be tested for narcolepsy.  

Clark asked him about seizures and if an epileptic seizure is detectable in an autopsy.   Rogers replied, "not necessarily". When detecting seizure disorders, he replied it was a broad area, much like headaches, because seizures can occur in multiple areas of the brain. Asked if he could rule out that Sarah had a seizure, Rogers replied it couldn't be ruled out 100%, but the common cause of death in both autopsies was drowning. "The probability is small" he said. Clark replied, "But you can't rule it out based on what you have in front of you?" and Rogers replied "No". Clark then asked if he could rule out an electrical disruption to Sarah's heartbeat and he again replied "No, I can't".

By looking at the coroner's autopsy report could he tell what parts of the brain and heart were sampled and tested? Rogers replied, "No sir".  He also couldn't tell from the autopsy report which part of the uterus was microscopically examined at autopsy to determine if Sarah was on her period or where in her menstrual cycle she might have been.

Returning to Sarah's potassium and electrolyte levels, Clark asked if the body needed specific amounts of potassium and electrolytes to function and Rogers replied "Yes".   He agreed that long-term diarrhea can deplete a person's potassium level. Rogers wrote an article called "The Difficult Patient", about patients who don't provide accurate or thorough symptoms to their doctor.  A headache, stomachache or tiredness are generalized complaints, but diarrhea is a more specific complaint, and less likely to be ignored. Patients usually seek treatment within 24 hours. No further questions.

Re-direct: John Arnold

Arnold asked what methadone was used for in modern practices and Rogers replied for chronic pain management in a clinical setting where the patient can be supervised.

Rogers said the term "unexpected" cardiac death, doesn't mean the cause of death can't be explained. Structural heart disease is a typical cause of sudden cardiac death in young people but it's not usually caused by coronary artery disease, or some rare aortic syndrome. Sudden unexplained death, when referring to epilepsy, is hard to diagnose because the patient would have usually been diagnosed prior to their death.

Arnold asked if there were regular blood tests done, including potassium levels, as part of Sarah's yearly exams and Rogers replied the June 2008 blood test showed her levels were normal.

Arnold placed the generic photo of the rescue crew performing the two-person intubation on the screen and Rogers said the technique shown in the photo would most likely not result in bruising on the back of the neck like Sarah had. He said that to his knowledge, that technique was not used on Sarah.

Arnold placed the photo on the screen from Sarah's 2nd autopsy showing bruises on the front and right side of her neck and Rogers said the injuries shown were extremely rare as related to life-saving maneuvers. He didn't know of anything that could have caused the hemorrhaging in the front of her neck. He said some injuries as a result of intubation can be seen on the inside part of the trachea and there was one notation of internal bleeding.

Rogers repeated that he couldn't 100% rule out a cardiac event or seizure in Sarah's death, however, the likelihood that Sarah suffered a seizure or a cardiac event, based on the statistics from the CDC he stated earlier, is not great. Nothing further.

Re-Cross: Jay Clark

Clark asked about hemodilution and Rogers replied there are different opinions among doctors about its effects. The bruising on her arm was present the same day that the bruising on her neck was found and based on seeing patients who've had numerous IV attempts, he agreed that a patient can have bruising to that extent from IV sticks because he has often seen it.

Rogers agreed with Clark that Sarah's electrolyte level was not tested during her autopsy and could be affected by exertion. Potassium levels were normal in June said Clark; could they have been different in August?  Arnold objected/sustained.   Nothing further.