BY MR. WEINBERG:
Q Now referring to Exhibit One, which is the autopsy Protocol, I had shown you, at the bottom of it, it indicated a series of hematomas present in the medial aspect of the left thigh?
A (Nods head up and down)
Q Do you see that?
Q Now the medial aspect of the left thigh is pretty much in the center of it?
A No, it's in the inner aspect. I's here (indicating). Q Oh, inside --
Q -- the thigh.
Q Okay. So it would be sort of in the crotch.
A Yeah, or if it's in the -- it depends on where the thing is there, see? If it's high, it's in the crotch; if it's low, it's down by the knee.
Q Can you tell me where those are? Can you read them to me?
A It's over the medial aspect of the left thigh; that's all the detail I went into.
Q Do you recall if it was high in the crotch or low toward the knee?
No, but -- well, no, I don't.
Q How big are those bruises there? Can you -- I mean --
A Let's see.
Q -- in English. I mean, I've read this, but I don't know what all that means.
A Yeah, right.
Okay. The intensity of these vary, but generally speaking, one was two and a half inches and the other was a half to three quarters of an inch.
Q Those are pretty -- would you call those fairly -- the two and a half inches a fairly large bruise?
A Everything's relative. I mean, I don't know what you mean by "large."
Q Okay. That kind of bruise that you saw, which you described as old, but that kind of a bruise that you saw, is that consistent with some sort of trauma?
Q And a bruise like that is consistent with -- I mean, one can get bruises like that from traumatic evens like automobile accidents; is that correct?
A Any blunt force can give you a bruise.
Q So the answer was yes?
Q Now trauma to an extremity is a common cause for creating a thrombus? A It might be associated with it.
Q Now the thrombus like the one that you found behind the left knee of Lisa McPherson --
Q -- can a thrombus like that spontaneously break off?
Q And can a thrombus like that, when it spontaneously breaks off, cause instant death?
A Well, you haven't --
Q Want me to define "instant death"?
A It depends on what happens to the thrombus once it breaks off.
Q All right. If you -- if the thrombus in the left popliteal vein breaks off, it is possible for that thrombus to travel into the pulmonary artery in the lung; is that right?
A That's correct.
Q And if it travels to the pulmonary artery in the lung and lodges there, that can cause instant death.
A It can. It's possible, yes.
Q And what is it about lodging in the lung in the pulmonary artery that causes instant death?
A It, ordinarily -- well, if you take a person who is -- who is -- who would say be otherwise, quote, healthy, unquote -- say a young woman, or something like that, with no other problems -- if we had say a major thrombus to the extent that it greatly cut down the blood supply to the lung, that would mean that there's less blood going to the lung, there's less blood that can be oxygenated and then returned to the heart, and that can be associated with what should properly be called a dysrhythmia; a lot of people call it arrhythmia, but it's -- an arrhythmia is a total absence of rhythm, whereas a dysrhythmia can flow to a variety of things, including an arrhythmia -- but, at any rate, that is one possible mechanism.
Another one is if you get a truly massive dislodging of a thrombus, it can produce what's called a, quote, saddle, unquote, embolus, which is to say that it comes up and it essentially forms a fork-like thing that occludes totally the arterial trees of both lungs and so that there's no blood flow.
Q So that would cause sudden death?
Q Okay. How large was the thrombus that you located in the -- behind the left knee?
A Oh, it was -- well, I didn't measure its -- I didn't measure its size, but it was -- I mean, it was there to be observed. We didn't have a free flow of blood. We had a clot there.
Q Did you section the thrombus up behind the left knee?
A I believe I did, but I can't -- to the best of my recollection, I'm not sure that that was done or not.
Q Are there two ways of doing a section? I guess what I'm asking, on occasion, you would cut into something just to see how it cuts; is that right?
Q And then -- then you would also take a piece for the paraffin block slide and all that, as well?
When you say "section", what do you mean?
A Okay, ordinarily -- ordinarily, I guess the only way I can answer your question is to say what I would do, would be to make a cut through it and the underlying vessel and then to make the sections narrow enough or small enough -- okay -- so that it could be put in a thing we call a cassette and the cassette then could be submitted for a microscopic exam.
Then if you were fortunate enough to have significantly more tissue, you could excise that tissue and you could throw it in your -- well, you could put it in the gross cup.
Q Do you recall what you did, in this case?
Q Would there be any reason for you to have sectioned the embolus that you found in the pulmonary artery and not section the thrombus that you found behind the left knee?
A In most cases, I believe I would section both.
Q And --
A Or at least would have the vein, if necessary, in the gross cup.
Q And we'll be able to determine that when we actually see what the slides were of?
A I'm sorry?
Q We'll be able to determine that when we get access to the slides and the gross cup?
A The -- okay. that may or may not be possible.
If, for instance, we don't have -- if, for instance, there's a small section of -- or say it's a fairly small vein where the section is taken in the lung and you don't see pulmonary tissue around it, then it's hard to make a distinction between that and a vein that would be behind the leg. Do you see what I mean?
Q Did you age either the thrombus in the leg or the emboli in the lung? A I don't believe I did,no.
Q Is it possible to do that? Can you do that?
A In my opinion, you can do that certainly with well-established thrombi -- okay -- with old ones.
Okay. With more recent ones -- in other words, ones that, as you said, may cause sudden death -- okay -- over something like that --- that, to me, is very problematical and it is -- it's possible -- it's possible, in recent thrombi, to either over-call or, in other words, to be mistaken.
Ordinarily, I will try and look at whether the clot is readily shed, and if you will, from the arterial tree or the arterial area, and if it comes up very readily, then that is post-mortem, after death; whereas if there's a little degree of adherence, it may well be ante-mortem. The well-established ones are easier than the more recent ones.
Q You described -- well, how did you describe this one?
A Okay. "For showing loosely adherent blood to the endothelium of the underlying vessel. Focally, a layer of fibrin is present at the endothelium blood interface."
Okay, that would be -- at least we have some degree of reaction between the vessel -- okay -- and the clot.
Q Which means?
A Which would mean that that is relatively more recent -- okay -- that a, quote, old, unquote; but, again, bear in mind, the old can -particularly, if the patient's asymptomatic; it could have been there for months or something like that.
Q And the more recent might be indicative of what I've been referring to as sudden death.
A Yeah, up to hours.
Q Now if you go to page two --
Q -- of the report, under the Respiratory System, you describe the -- it is a partially occlusive well-established thrombus which is multifocal.
What did you mean by "well-established thrombus?"
A My gross impression was it was well-established. When I had the microscopic, I could not establish that.
Q It appeared more recent?
A It appeared more recent, yeah.
Q And the microscopic is at the end of the report when you actually looked at the sections under the microscope; is that what I understand?
A That's right?
Q That's the more accurate way of making the determination?
A Of age, yeah.?
Q And the reason to age an embolus or a thrombus is what?
A That's a good question. We do it, you know.
MR. WEINBERG: After four hours, you know, I've got to get in one good question --
THE WITNESS: I know. I know.
MR. WEINBERG: -- what the hell?
THE WITNESS: The reason to do it is because of the fact that if you see something that could be significant -- okay -- ordinarily, you'll go ahead and take a section of it.
BY MR. WEINBERG:
A At least a gross section of it.
Q Did you -- do you recall discussing with Dr. Wood your findings with regard to the pulmonary embolism? Do you remember talking to her about that?
A I don't specifically remember that, no.
Q Did Dr. Wood show any more interest in -MR. WEINBERG: Well, strike that.
BY MR. WEINBERG:
Q Do you recall whether there was any effort to age the thrombus found behind the left knee as opposed to the embolus found in the lung?
A I don't independently recall.
Q Would one be able to go through the same process as you did with the embolus and look at the thrombus behind the left knee under a microscope to make some determination as to how long it had been behind the left knee?
A That could be -- it could be possible, but, again, I think that -- I think you've got to -- that you're looking at a range, you know?
Q Like what?
A Well, as you know, there can be overlap as a function of say, a microscopic appearance, in particular.
Q You mean a range of days?
A A range of hours -- yes, a range of days.
Q Okay. What can cause a thrombus to become an embolus?
A Okay, first of all, it can occur spontaneously; just the regular meaning of the word "spontaneous."
Q It just happens.
A It can just break off because it's going to break off.
You can have some kind of trauma. You can bump it. You can be in a situation where you're particularly prone to thrombi and you can have so-called propagation of a thrombus, in which case it moves, the clot itself can move, particularly if it moves proximally, or moves up.
And then there's -- from that standpoint, there can be a difference in the potential for dislodgement between areas of the thrombus.
Q Okay. You could not tell from your examination, both during the autopsy and microscopically, what caused the thrombus to move?
Q Now going to the first page of the autopsy report --
A You mean of Dr. Wood's report?
Q Yeah. The -- yeah. Not the one with your notes on it, but the one that says Report of Autopsy and it's got Manner of Death, which we've already talked about, "Undetermined"?
A Oh, okay, one distinction here.
Q All right.
A You're not talking about page one?
Q No, I'm talking about the cover page, how about that? A Front sheet.
Q Front sheet.
A All right.
Q Just to make this clear, you didn't discuss with Dr. Wood, before she signed out this report, as to the manner of death?
A That's correct.
Q She didn't clear with you the final conclusion that the manner of death was undetermined.
Q Sow it says "Immediate Cause of Death, thromboembolism left pulmonary artery." She didn't discuss that with you, either, before she signed this out; is that right?
A That's correct.
Q And then she says, "Due to thrombosis of the left popliteal vein." She didn't discuss that with you, either; is that right?
Q Then she has, "Due to bed rest and severe dehydration." Did she discuss that with you before she signed it out?
Q Now -- now, what are the due to's for? What's the purpose of that?
A Oh. That is a -- okay. At least in the format that Dr. Wood has, this is a correlation, if you will, with a standard death certificate; in other words, the standard death certificate will be just like this.
Q You need to -- that doesn't get picked up on the --
A Oh, I'm sorry.
Okay, it'll be Immediate Cause of Death and then it'll be due to something else; due to something else.
In some situations, there may be no need for other due to's, see.
If I shoot you in the head and you fall over dead, then the immediate cause of death is a gunshot wound to the head, see, and there's no real reason to do anything else.
If we do an autopsy and we find that you've got bad lung disease but you've got a clearly fatal head injury, your immediate cause of death still is the gunshot wound to the head.
Q Now, let's take the first one, "Due to thrombus of the left -- how do I pronounce that? "Popliteal"? --
Q -- popliteal vein."
Am I correct that you did not make a final determination that the pulmonary embolism was as a result of a thrombosis in the left popliteal vein; is that correct?
A That's correct.
Q Then she has "due to bed rest." A Hmm-hmm.
Q Do you see that?
Q Did you discuss bed rest with Dr. Wood?
Q And what was the nature of that discussion or those discussions?
A Okay. The -- if a person is relatively bedridden or relatively immobilized, that can set the stage, if you will, for a possible thrombosis occurring, particularly in the lower extremities.
Q And the way to avoid that is to periodically get up and move?
A If you're -- if that's possible and/or have a co-consult -- and, again, this is getting back to what Ms. Carlucci had pointed out; I'm perhaps somewhat out of my field -- but, basic physical-therapy type things. I don't think they still use foot boards, but something to try and get -- to avoid prolonged passive stasis, if you will, or just leaving it sit there.
Q What is "prolonged passive stasis"? What are we talking about?
A In other words --
Q How long?
A "How long." A range, again, I'd say days.
Q I mean, people go to sleep at night and that's eight hours. You're not talking about that.
A Oh, no. No, no, I'm not talking about that. I'd say days.
Q I mean, like a week you mean, something like that?
A I wouldn't want to say less that a week or longer than a week. I'd say days.
Q If a person is ambulatory and gets up and moves around --
Q -- that is the way to avoid the problem with being immobile; is that right?
A That would certainly -- that would certainly be a way to minimize the potential -- okay? -- for at least generating a thrombus from the standpoint of bed rest. It still does not preclude, of course, the spontaneous thing. Spontaneous is just spontaneous.
But, yes, to answer your question, if we were looking at that for the pathogenesis or -- which is another way for saying how it develops -- if a person were able to move, then that should certainly minimize the risk.
Q Now you said you had discussions with Dr. Wood about this. The nature of the discussions were what? She asked your opinion and you gave her that or did she have an opinion on bed rest?
A No, the thing we had was that this individual was under care within a facility and we weren't sure exactly what the nature of the care was in the facility.
Q What did you do, before you left, to ascertain the nature of the care in the facility with regard to the issue of bed rest?
A Okay. I'm going to have to -- okay. I did nothing, but I want to make a distinction here, and I'm not sure that all forensic pathologists will agree with this, but I see people as being in boxes or categories, if you will, okay?
Now my category is to look at and to do forensic pathology. My category is not to be a policeman; it's not to be a state's attorney; it's not to be an attorney.
Q Quincy. You're not Quincy.
A Well, no. Okay?
A Okay. But if you understand what I'm saying -Q I do.
A okay. Now if they want to ask me a question in my field, I'll do everything I can to help them, but I don't go out to generate investigation on -- I mean, I'm not trained to do it, number one.
Q That's fine.
What evidence was there that you were aware of, either before you left or after you left, to indicate that a cause of death was due to bed rest of Lisa McPherson? Any?
A No. No.
Q Now, there --
A There was -- I had -- well, the -- our functional history was that this person -- okay -- was under the, quote, care of the facility and that really is all I knew. It was not my job -- okay -- as a medical examiner to go on out and find out why this, that and the other thing.
Q There are certain observations that might be made during the physical autopsy that would indicate that someone had been confined for long periods of time to a bed; is that right?
A Oh, if --
Q Am I right?
A If you get very long periods of time or if you get a debilitated person, you certainly can have things like -- the common word is bed sores or decubitus ulcers or things like that.
Q You didn't find about of that on Lisa McPherson, did you?
A No, I did not.
Q Okay. What other things might you find -- might one find in an autopsy that would be indicative of excessive bed rest, for lack of a better word, since that's the one that Dr. Wood used.
A I don't know.
Q Do you know of any witness who has -- who indicated that Lisa McPherson had been confined to a bed for some extended period of time? Do you know of any witness?
Q Do you know where this cause came from?
A Which cause?
Q Bed rest. Do you know where that came from?
A First of all, I'm not positive and it may have been -- I mean, if you see on my draft, it's not there, okay? It may have been -- well, I have no independent recollection.
A I just don't, okay?
Q Okay. Now she also has on here, "Due to severe dehydration" --
Q -- do you see that?
Did she discuss that conclusion with you before she signed off this report?
Q Do you know what she based that conclusion on that the pulmonary embolism was due to severe dehydration? Do you know?
A She didn't discuss it with me.
Q Okay. As you sit here today as a well-trained medical examiner who actually did the autopsy in this case, can you say with any degree of medical certainty that the pulmonary embolism in this case was caused by bed rest?
A I don't know what caused it.
Q And you -- I take it you can't say with any degree of medical certainty that it was caused by severe dehydration, either; right?
A As I said, I don't know what caused it.
A That's neither a yea or a nay, okay?
Q I understand. No, it's actually -- it's an answer to the question.
Q All right. Now, we're making some progress here.
THE WITNESS: Just a break.
(WHEREUPON there was an off-the-record discussion)
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