Trial Day 5

Good morning, everyone.

Good morning.

I hope everybody had a restful weekend. So what I want to do is just kind of tell you, first, I'm going to go through those questions, make sure everybody was able to follow my instructions. Then I'm going to go over what today's schedule is and then we'll return to the Commonwealth's presentation of evidence. All right. And so let me ask those questions. First question, has any member of the jury read, seen, or overheard anything from any source about any aspect of this case that would affect your ability to be fair and impartial?

[inaudible 00:00:36].

All right. Next question. Is there any other serious matter or concern bearing on your service as a juror in this case that anybody needs to bring to my attention? All right. Again, thank you for following those instructions. Now, today's schedule, let me say first thing about the schedule. I know I haven't always been completely correct on some of the schedules we followed, but I want to just let you know that those decisions about the scheduling is on me. All right? And sometimes I have to take into consideration other factors or things that are going on. So what I really wanted to tell you is that don't speculate why we might go a little late or a little early on any certain days, but certainly don't hold it against either side in regards to that. The person who's making those decisions or that decision is me. All right? So you should be aware of that. So that being said, the thought is today, we should go into the afternoon. All right? And if that changes, I'll let you know. And what we're going to do at this point, we're going to return to the Commonwealth's case. And with that, Commonwealth, call your next witness, please.

Thank you, Your Honor. The Commonwealth would call Michael Snyder.

Your Honor, while we're waiting for Dr. Snyder, could we just approach [inaudible 00:02:06]?

Oh, sure. Yeah.

Thank you. Apologies.

[inaudible 00:03:39].

[inaudible 00:03:43]. Dr. Snyder, raise your right hand for the clerk please.

Good morning. Do you solemnly swear that the testimony and the evidence that you shall give to the court and the jury [inaudible 00:03:52] between the Commonwealth and the defendant [inaudible 00:03:54]? Thank you. You may have a seat, sir.

Watch your step, please.

All right. Good morning, Doctor.

Good morning.

All right.

May I inquire?

Attorney Buckingham, please.

Thank you. Good morning, sir. Could you please tell the jurors your first and last name?

Yep. Michael Snyder.

Do you mind spelling your last name for the record, please?

S-N-Y-D-E-R.

And how are you employed?

I'm a physician at Beth Israel.

And how long have you been a physician?

Since 1998.

Can you tell us a little bit about your educational background?

So, undergrad at UMass Amherst. I did medical school at Tufts University, and then I did my residency in emergency medicine at Boston University.

And how long have you worked at Beth Israel?

Since 2014, 12 years.

And do you primarily work in the emergency department?

Yes.

I'm going to draw your attention to January 24th of the year 2023. Do you recall working in the emergency department on that day?

Yes.

And in the evening, were you made aware of multiple pediatric traumas that were coming into the emergency department?

Yes.

And when you are made aware of people coming in, how does that occur?

So we'll typically get a call on the EMS phone that something's coming and that they want us to know about upfront.

And do they provide you with some basic background information about what's occurring or what occurred on scene and what's occurring during the transport?

When possible, yeah.

Okay. And when the emergency personnel, the EMTs or paramedics arrived at Beth Israel, there were three patients, correct?

Correct.

And you were assigned to treat one patient?

Correct.

Do you recall which patient that was?

Cora.

Okay. And prior to EMS arriving, did you learn more about Cora's presentation and what was occurring?

Yeah. So we had heard that all three were in cardiac arrest and Cora in particular, they were still working on doing CPR and doing what we call pediatric advanced life support. So medications to try and restart the heart. And they also mentioned that they had used what we call a defibrillator to shock the heart to try to restart it. And they were still doing CPR when they were arriving.

And is this information important to you as you're assessing a patient coming into the emergency department?

Yeah, yeah. It's important to know what things look like in the field, how long the patient might've been without a pulse or how long they may not have been breathing for, so we can kind of expect or know what injuries to look out for, what we can potentially reverse.

And were you aware of the age of Cora?

Yes.

And she was five, correct?

Yes.

And as far as the medications that you were aware of, what medications had been provided?

So prior to coming to us, she had been given epinephrine, which is the primary medication we use in a cardiac arrest.

And do you know how they had administered that medicine to her?

Yeah. So she had what we call an intraosseous device in her right tibia. Sometimes it's very difficult to get an IV in so we can go directly into the bone or the bone marrow.

And were you aware of whether she had been intubated en route?

So she was not intubated en route.

When she arrived at the emergency department, were you there to greet the ambulance?

Yes.

And what happens when a patient comes in through the emergency department via ambulance?

So when the patient first comes in, we immediately have our team start to sort of take over care so there's no gap. And then we also get a sign out from the paramedics and EMTs and any other staff that had been involved in the case.

And do you and your emergency room staff then perform your own initial assessment of the patient?

Yes.

And what do you do for that?

So initially, we sort of go through our ABCs, airway, breathing, circulation. So initially focusing on the primary things such as making sure we're getting air and oxygen into the patient, keeping the heart going, so continuing CPR at that point.

And as far as Cora went, did you observe that she was breathing?

So she was not breathing on her own.

How about the heart? Did you observe that her heart was beating?

There was no heartbeat.

How about her physical appearance? What observations did you make of her physical appearance?

So initially, when she had come in, some of the things we noticed is sort of a blue tint to the skin, which typically, we can see when there's less oxygen or lack of oxygen. And then the other things on a quick survey is there was some areas of bruising on the neck and around the eyes called petechiae, kind of little bleeding, episodes of bleeding under the skin, and I believe a small amount of blood coming from the nose.

Were you able to make observations of her hands or other parts of her body?

So the hands definitely had that, what we call cyanosis or blue hue.

Now, as far as the eyes, you mentioned petechiae around the face and the eyes as well as the neck. Did you notice anything else about her eyes?

So the pupils were fixed and enlarged.

Why is that significant to you?

So oftentimes, when we see it coming in, it can indicate two different things. Some of the medications like epinephrine can cause the pupils to dilate, but also if the brain is starting to become damaged or not functioning, then you start to lose initially some of the signals that would make the pupils smaller. So they'll tend to start to get enlarged or dilated if there's brain injury starting or has occurred.

Now, you indicated that when Cora arrived, she was not intubated, meaning she did not have a breathing tube in. Did you and your team attempt to intubate her?

Yes.

And did you do that on your own or with the assistance of other parts of the emergency department or the hospital?

So we had anesthesia there. After we got the phone calls of multiple patients coming in, typically we'll have all the help that we could possibly need there to be able to take care of all the patients. So I had an anesthesiologist in the room with me who put the breathing tube in.

In instances where an individual might have suffered some sort of injury to their neck, does that complicate the insertion of a breathing tube?

It can, yeah. Because normally, you might need to move or tilt the head to get a direct view where you can put a breathing tube in. But when there's a concern for neck injury, we stabilize it typically with a collar or manually so you don't have the ability to move the head and the neck around to try and get a better view.

Once a breathing tube was put in, were you and your team able to manually give breath to Cora?

Yes.

Now, did you then perform an assessment, a cardiac assessment of her?

Yeah. So in addition to listening to the heart, feeling for a pulse, we'll also tend to use an ultrasound machine in the room where we can kind of get a direct view of heart function.

And you were aware that they had defibrillated her twice in the ambulance. Why is that significant when you're treating a patient that's in cardiac arrest?

So when they defibrillate a patient, it's typically the heart or might be in a rhythm where it can't pump blood. So it might be sort of out of sync or quivering, where we may attempt to use electricity to kind of shock it back into a rhythm.

Once you performed the ultrasound, the cardiac ultrasound, were there any attempts made further to use a defibrillator?

No.

Throughout your course of treatment with her, did you continue with various medications?

Yes.

And was CPR ongoing throughout your entire time with her?

Yes.

Were you consulting with any other colleagues or any other hospitals in regards to the care of Cora?

Yeah. So we actually had, in addition to all my colleagues in the emergency room, we had intensive care physicians from Children's that were on the phone with us kind of working through any things that may have come up in the case. Also expecting that they would be receiving the patients from us.

Is your hospital at the Beth Israel equipped to handle this type of pediatric trauma?

So we can do the initial stabilization, but then we need to ship the patients out to either get a specialty care or continued inpatient care.

And how long did efforts in treating Cora continue?

So in the emergency room, roughly 30 minutes.

And fair to say that all of the efforts that you made were not successful?

Correct.

And at approximately 19:28 or 7: 28, did you finally declare Cora deceased?

Yes.

Thank you. I have nothing further.

Mr. Reddington.

I have no questions. Thank you, Doctor.

Thank you, Doctor.

Thanks.

Commonwealth calls Dr. Andrew Capraro.

[inaudible 00:13:48].

Thank you.

[inaudible 00:13:48] right here, raise your right hand for the clerk, please.

Good morning. Do you solemnly swear [inaudible 00:14:18]?

I do.

Thank you. You may have a seat, sir.

[inaudible 00:14:28], please.

All right. Good morning, Doctor.

Morning.

If I may?

Yes, please.

Thank you. Good morning. Can you please state and spell your name for the record?

My name's Dr. Andrew Capraro. Last name C-A-P-R-A-R-O.

And your date of birth, please?

July 9th, 1970.

What do you do for a living?

I'm an attending physician in the emergency department at Boston Children's Hospital.

And how long have you done that?

For the last 26 years.

Can you just briefly describe for us the training and education you had to qualify for that role?

I went to Providence College undergrad and then went to Brown Medical School. Subsequently, I went to Connecticut Children's Medical Center for my pediatric residency, and then did fellowship training in pediatric emergency medicine at Boston Children's Hospital from 2000 to 2003 and have been an attending there ever since.

And what's involved with being an attending at Boston Children's Hospital?

It means that I am guiding the care and treatment for the patients that I am seeing during my particular shift.

And are you assigned to a specific location or area of the hospital?

I'm always in the emergency department and the emergency department is broken up into different zones of which I am sort of the primary attending for one set of rooms.

I want to direct your attention to January 24th, 2023. Were you working that evening?

I was.

And at some point in time, did you learn that a patient named Callan Clancy was going to be transported to your hospital?

I did.

And do you recall where he was being brought from?

From Beth Israel Plymouth, I believe.

And was he being med-flighted to your facility?

Correct.

And were you provided with some information about the patient in order to prepare for his arrival?

I was.

And what did you learn?

We have a communication center where facilities that are transferring patients to us call to let us know that the patient is coming. And so that comm center had been notified about this patient, who then got in touch with me as the attending who would be caring for the patient to let me know what had happened there and the condition of the patient when he was arriving.

And what did you learn about the condition of the patient, Callan Clancy, as he was being flown to your hospital?

What I was told was that it was believed that the patient had been strangled. And when he arrived at Plymouth, he was in cardiac arrest, that they had intubated him and initiated CPR, and they had gotten return of spontaneous circulation, and that they were then going to transfer him to us for further evaluation and care.

And at some point in time, did Callan arrive at your hospital?

That is correct.

And were you able to observe him physically?

Yes.

What observations did you make about his physical condition?

He was cold on arrival and he was quite limp, was not making any purposeful movements on his own. His pupils were fixed and dilated, and he had ligature marks about his neck with some swelling of the neck.

And his pupils being fixed and dilated, is that medically significant for you?

Yes, it is.

And why is that?

It typically means that significant injury has happened to the brain, such that there is brain swelling that has sort of over... What do I want to say? It has overwhelmed the capacity of the skull, such that the swelling has made the brain sort of herniate through the base of the skull.

Does that mean the brain's swelling so much it's pushing through the skull?

Correct.

And what observations did you make of his heart rate?

His heart was beating and we did have to provide him with an epinephrine to keep his heart rate and his blood pressure within normal limits, but it was beating on its own.

And how did you know that you had to provide the epinephrine for him to stabilize that heart rate?

It was initiated at BI because they had noticed that his blood pressure was low and you need to have normal blood pressure for the blood to perfuse your organs and keep them healthy. And so we were looking for certain parameters to sort of maintain that, which we did on that epinephrine drip.

And when you say BI, you're referring to Beth Israel?

Yes. I'm sorry about that.

That's okay. And so as far as his breathing, was he breathing on his own?

He had been intubated at the outside hospital and he was needing a ventilator to breathe for him. Occasionally, he would have sort of a breath on his own, we would notice. We were able to see that because when he attempted to take a breath on his own, he would trigger the ventilator to continue that breath. But it was rare, for sure he needed the ventilator to maintain his ventilation.

Would it be fair to say that the majority of his breathing was being done by the ventilator?

Yes, the vast majority of his breathing.

Now, once you have received this information while he's coming in and then you've made your own physical observations of Callan, are there certain tests that you have run on him?

Yeah. Our job, once we received him, was to perform further evaluation and stabilization to help determine what the next steps of his medical care would be. So prior to him arriving, we had contacted our trauma team and our ICU doctors to let them know that he was coming and that we would need their assistance. And then under my care, we performed some routine blood work, a head CT, a neck CT, and a chest X-ray to sort of help us guide the next steps.

And from the head CT and the other testing that you did, what were you able to learn from the results of those tests?

The head CT in particular showed significant brain swelling consistent with hypoxic-ischemic injury, which was the most significant finding that we found.

So could you please explain for us what is hypoxic-ischemic injury?

Hypoxic is just a fancy word for not getting enough oxygen and ischemic is just a fancy word for not getting enough blood flow. And so when your organs don't get enough oxygen and blood, they sort of suffer injury and therefore get to swelling. And so his brain was showing evidence of that.

So would it be fair to say that his brain wasn't getting enough oxygen and blood flow and then because of that, it was damaged and swelling?

Correct.

Now, this type of swelling and injury as you're describing it, can that be caused by strangulation, the injury of the brain?

Most certainly.

And you mentioned earlier that you did see some marks around his neck. Is that correct?

Correct.

And what were those consistent with?

Strangulation of some sort, most likely from an object based upon the linear aspect of the bruising.

And when you say the linear aspect of the bruising, does that mean it's in a straight line?

Correct.

Now, once you had the results of this testing, did you make a decision on what to do next?

Yeah. The main thing was to help us figure out did the patient need to go to the operating room for some sort of other procedure to help with this or was this something that could be dealt with medically? And so once we had the results of the head CT and then the neck CT as well, it was felt that the next appropriate step in his medical care would be to be transitioned to the intensive care unit for them to take over care.

Why was it that surgery was not an option to help Callan in this situation?

Yeah. The neurosurgery doctors were there to sort of help us make that decision. There was no significant bleeding, for example, that would need to be evacuated. There was nothing that they felt from a surgical point of view would help alleviate the problems that we saw on the CT.

Okay. And so was his care transferred to the ICU?

That is correct.

And once Callan was transferred to the intensive care unit, did your care for him end at that point?

Correct.

I have nothing further. Thank you.

Thank you. Mr. Reddington?

No questions. Thank you, Doctor.

Thank you, Doctor. Please step down.

Thank you.

Watch your step, please.

Commonwealth calls Dr. David Casavant.

Good morning, sir. Please stand right there and raise your right hand to the clerk.

Good morning. Do you solemnly swear that the testimony and the evidence you shall give to the court [inaudible 00:23:31] the Commonwealth and the defendant shall be the truth, the whole truth, and nothing but the truth, so help you God?

I do.

Thank you. You may have a seat, sir.

Watch your step there, sir.

Thank you, sir.

All right. Good morning, Doctor.

Good morning. Good morning, Your Honor.

Attorney Sprague.

Thank you. Good morning. Can you please state and spell your name for the record?

Surely. My first name is David. My last name is Casavant. It's spelled C-A-S-A-V-A-N-T.

And your date of birth, sir?

5/2/63.

What do you do for a living?

I'm an ICU physician at Boston Children's Hospital.

Can you briefly describe for us your educational and training background?

Sure. I went to college out at Holy Cross in Worcester, and then to medical school at Boston University. I did my initial pediatric residency at Mass General Hospital, and then went back and did a fellowship in ICU medicine at that hospital as well.

And where do you currently work?

I currently work at Boston Children's Hospital in the Medical-Surgical ICU.

And how long have you worked at Boston Children's Hospital?

18 years.

And have you always worked in the ICU there?

Yes.

I want to direct your attention to January 26th, 2023. At that point in time, did you take over the care of a patient named Callan Clancy?

I did.

And prior to taking over the care of Callan Clancy, did you do anything to familiarize yourself with his treatment and care?

Yes, I did. One of my colleagues had taken care of him the day before in the ICU, and I spoke with her, and so I was familiar with his case.

Okay. And did you also review reports and testing that had been performed while he was at the hospital?

Yes, I did.

And after reviewing the reports and the test results and speaking to your colleague, can you tell us what you learned from all of that?

Well, it seemed that Callan had had a severe neurologic injury based on both testing and the examination that I did at the time.

And when you say a neurologic injury, is that a brain injury?

It's a brain injury. Yes, it is. Yeah.

And did you review specifically a head CT scan of Callan?

Yes, I did.

And what did the head CT scan show you or tell you about his condition?

Well, the head CT is a picture of the brain, which was done in the emergency room when he was admitted to Boston Children's Hospital. And the CT scan showed an enormous amount of swelling of the brain itself.

And the swelling of the brain, is that medically significant?

Very much so. When you have an injury to the brain that is caused by anoxia, which means a lack of oxygen, I described this with families that the injury is very much like being out in the sun. You don't notice it at the time, but swelling occurs over the course of time. And one of the things with a lack of oxygen to the brain is the injury occurs and then swelling starts to happen over the course of time. Typically peaking at 48 to 72 hours. When you see swelling that happens that early in a case, as in Callan's, it means that there's been a very significant lack of oxygen and therefore injury to the brain itself.

So for example, some types of injuries that would withhold oxygen from the brain would be more mild and the swelling would occur over time. Is that correct?

That's exactly correct, yes.

So if a severe injury happens that withholds oxygen from the brain, that's when you see that immediate swelling like Callan had?

Very much so. Sort of the comparison of a sunburn to a burn that you might get from a stove. This was a stove. It's very, very profound.

Did you perform a physical examination of Callan?

I did.

And what did you observe?

Well, one of the first things that I noticed as I approached him was that he had a breathing tube in place. And I knew from my colleague that he was not on any sedation, which is very difficult to tolerate having a breathing tube through the vocal cords if you're not sedated. And he was not sedated at the time. The next thing is when I approach a patient such in their bed in the ICU, we always start with a quick introduction that we're going to be coming near them in case they're asleep. And I usually start with something along the lines of, "I'm Dr. Dave. I'm just going to listen to your heart." And I'd usually address them by name to see if they start to respond. And then I'll go ahead with the rest of the exam, but that's just to sort of warn them that someone might be touching them. And then I'll listen to heart, lungs, and then to move forward to see how responsive they are. So if you get no response at all from the initial, just using your voice, the next thing is to... And then from the exam, if they don't move around, then you start to sort of think, "Well, let's see how responsive they are." And so the next thing is sort of a gentle touch often to the bottom of the foot to see, you stroke the bottom of the foot, and you see if they pull away. And then you can move. If you get no response from that, we'll do something that's a little bit more noxious or painful where you can sort of pinch a little bit of skin to see if they start to react or pushing on the fingernail and the nail bed pressure, which is actually very noxious. And if you can see two types or several types of response, either no response, or you can see a very specific response where they pull away from that area. And that's a specific... Or you can see generalized response, which are all sort of graded along those that as we're sort of getting a sense for what their level of consciousness was.

So if I could go over a few of those things that you just mentioned.

Sorry.

You said that the first thing that you noticed that was significant was that Callan had the breathing tube in place through the vocal cords without any sedation. So without sedation, would having a breathing tube in that place cause pain?

Yes. No one would be able to tolerate it.

And so Callan was able to tolerate it without any sedation?

Yes.

Would that indicate he wasn't feeling that pain at that time?

Yes, exactly.

And you mentioned that you would address the patient by name and talk to them. Was there any reaction from Callan when you did that?

No, there was not.

And then you mentioned you would rub maybe something along the foot. Was there any reaction?

No, there was not.

And did you do what you described in pinching the fingernail or pinching somewhere on Callan to see if he responded?

Yes.

And did he respond?

No, he did not.

And what did these interactions and tests on Callan tell you about his condition?

This told me that he was unresponsive. He was unresponsive to both things that would cause discomfort and things that would cause pain.

Did you also do anything in terms of looking at his pupils in any tests on his eyes?

Yes. So after all the other things, we look at the pupils. And so one of the things is we have a, it's a reflex response. If a light is shown in an eye, the pupil constricts, and what I noted about Callan was that his pupils stayed widely open and did not constrict.

And when someone's pupils stay open and wide when you shine a light in them, what does that indicate medically?

Well, the eyes are a direct extension of the brain, but that's why we focus a lot on them as an area of investigation. And the lack of a response to light indicates that there's some abnormality to that. And in this case, it was a brain injury. You can also, there's medications that can keep your eyes open if you've ever had an eye exam, but that was not the case with Callan.

And just to be clear, when you're talking about brain injury, we're not talking about some type of trauma that was inflicted on the brain. You're talking about the lack of oxygen and blood flow causing an injury to the brain, correct?

That's exactly correct, yes.

At that point in time, did you work with another doctor to do more in-depth testing regarding his neurological status?

Yes. So at Children's, we have multiple teams that come together for a patient, for many patients, but for Callan, the neurology team was there from the beginning. And in a case like this, when we see no response in an unresponsive patient, we start to get our neurology team. And one of the things we start to do is brain death testing to see if they could be what we call brain-dead, meaning that the brain itself is not functioning and that even though their heart is still beating.

How is it that someone's heart can be beating if their brain is dead?

It's a really good question. So...

... of their brain is dead.

It's a really good question. So there's actually two parts to the nervous system. The one is the part that we see the most in people when they react, and they react to us, and they speak and they do things. The other one is the autonomic or automatic system. And the automatic system is largely in charge of the things like the heart if the heart has not been injured. And so it was sort of continuing on.

And does that give you any indication, the fact that the heart was still continuing on, about where the injuries were in the brain?

Yes, it does actually. Yeah.

Where would that be?

Yeah. So the large part of the brain that we sort of think of is when we see the pictures of the brain, that's the cerebellum. And that's the biggest thing in humans that is most developed. And that's in charge of our consciousness, our reaction to things. Whereas the brain stem, which is another part, and that's really part of the autonomic system. And that's the same in almost all vertebrates and mammals. And it's much more automatic. And so it tells me that it seemed the cerebellum, which is that part that makes us sort of the human side of what we do, that's much more sensitive to a lack of oxygen, to an anoxic injury. And it told me that that was really where that injury was, was in that part of the brain, much less so in the brain stem itself.

So would it be fair to say that the brainstem itself that controls those automatic responses was still functioning somewhat, but the part of the brain that made Callan, Callan was not functioning?

That's exactly correct. Yeah.

And could you describe for us the brain death testing?

Sure. So the brain death testing at Boston Children's it's a very strict testing that includes some of the things that I just mentioned. But we work with our... There's a checklist that we work on with our neurologic colleagues. And we sort of go through each of what we would expect for responses from someone. And we actually then work through different of the nerve sets that we would expect them to respond to. We have it set up so that there's an ICU physician is there, and then a neurologist is there. And the neurologist and the neurology team, they're the ones who perform the brain death testing. And then the test is then repeated again 24 hours later, just to make sure that there's no piece of that that is different or incongruous with a diagnosis of brain death.

And while the neurologist is doing this testing, are you there present watching the testing and seeing the results as it happens?

Absolutely. Yeah. So we're sort of committed to being there for the whole time. And the brain death testing itself goes through some really basic things. Again, as I described earlier, the things that would be painful and do they pull away or not? The eyes, looking at the reflexes of the eyes. There's also other reflexes too. Things like if you stroke the cornea, which is the front of the eye, people blink. So the blink reflex, cough, gag. There's also a reflex where they actually put cold water into an ear and that gives people a disequilibrium. And so those are all the things that we think about. And then also too, there's some breathing components to that as well.

Is one of those breathing components an apnea test?

Yes, it is. Yeah.

And what is an apnea test?

So apnea is a word that just describes a lack of breathing.

And how do you test that?

So in a patient such as Callan, what we do, and in any patient when we're doing brain death testing, we actually disconnect them from the ventilator. And the reason that we do that is we want to see if that autonomic system in the brain will start to react as the carbon dioxide starts to increase. So our body makes carbon dioxide all the time. And the way we get rid of it is by exhaling. And where we breathe in fresh oxygen and then we breathe out CO2. And what we do is we disconnect from the ventilator, knowing that their carbon dioxide will start to rise. And the normal response for that autonomic part of the brain would be to sort of increase breathing. That's why we breathe when we sleep, because as we go to sleep, the conscious part of our brain stops, but the autonomic part kicks in, and then we breathe right through our sleep because that carbon dioxide rises.

So in a patient who has brain death, would it be accurate to state that as the carbon dioxide level increases, the automatic response would be to take a breath to get more oxygen, but a patient who's brain-dead won't do that?

That's correct.

And did you do all of these tests or did the neurologist do all these tests on Callan while you observed?

Yes, they did. Yeah.

And did he have any response to any of the physical tests where you were looking for a reflex or a reaction?

No, he did not. No response to any.

And what was his reaction or results on the apnea test?

So the apnea test, again, we do all the brain testing one day, and then we wait at least 24 hours for the second one. And what we expect with the carbon dioxide is that it will increase. We have it written in our... So it's all in writing for our protocol, that it will increase by 20 or get to a level of 60. A normal CO2 would be around 40. And the first time we did that on the first day, it actually went to 59.7, not 60. And again, it was in our protocol as it has to get to 60 or increase by 20. And I actually talked to my colleagues, including neurology. I said, "I know this is very close. It's 59.7, but it's not 60." I repeated that piece of the test later on that day to make sure that it was valid. And as I say, I checked with everyone to make sure that I was doing the right thing. And they all agreed that we should just... And the second time it went to 87. So everything else was the same. And we made sure that there's things that we look at too to make sure that there's not on any medications, that there's no changes in his temperature, there's no abnormalities of the salts and the blood, what we call the electrolytes. So all those conditions were the exact same. And I repeated that later on in the day and it did come back positive.

Why is it so important that you meet that specific criteria? Why is three tenths of a point so important?

Well, I wanted to make sure that there was no question about the data that we were gathering at the time.

And you said that this testing is again repeated 24 hours later, correct?

Yes, it is.

Why is that?

Well, that's just to make sure that if there were any lingering effects of medications, if there was anything that else might've changed in the patient's level of alertness or level of response, to make sure that it still meets all those requirements 24 hours later.

And is it because you want to be sure that there's brain death before you remove life support?

Yes. And again, it's too important. It's too important, a discussion and a gathering of data to not be very exact about it.

And so when you observe the testing and then the following day, on Callan, were the results the same in terms of no reaction and the carbon dioxide increasing?

Yes, they were.

And at that point in time, did he meet brain death criteria?

Yeah, he did. So we had determined that he had met death by neurologic criteria.

And at that point in time, was a decision made to stop life support?

Yes. Yes, it was.

And that's done in consultation with the family, his father, correct?

Yes, that's true.

Okay. And was life support ended for Callan Clancy on January 27th, 2023?

It was. And one of the things is when you determine that someone has met criteria for neurologic brain death, although we know that their brain is not functioning at that point, there's often a period of time where we don't have to... His heart is still beating, so we don't have to remove the endotracheal tube at that time. And we often will give families, once it's been confirmed that the brain is no longer functioning, we often give families a period of time to be able to process it and a window of time. Sometimes his relatives will need to travel and things like that. And so we'll often then choose a time later on to accommodate the rest of life, knowing that they're stable at the time to when we would actually remove the tube. And that would be the declaration of death.

And was that done in this case? Family was given an opportunity to see him and then life support was ended and then his heart stopped.

Yes, that's exactly.

And he was declared deceased?

Yes.

Thank you.

Attorney Reddington.

Thank you, sir.

Thank you, doctor.

Thank you so much.

Your Honor, at this time, the Commonwealth would move to admit the Boston Children's Hospital records for Callan Clancy into evidence. There's two volumes.

Any objection?

Your Honor. I have no objection because we both have the records. We both want them in evidence. So I have no objection to any of the records that they have. We signed releases for them for like Beth Israel, Brigham and Women's, South Shore. They all can go in.

That's a yes.

It may be admitted.

Exhibit 137.

Yeah, I went to A and B. Yeah. ‍

137, A and B.

All right. Thank you.

The commonwealth would call Kelly McDonough as its next witness.

I'm sorry, can you say the name again?

Kelly McDonough.

Okay. Sure.

Morning, ma'am.

Good morning.

Do you solemnly swear that the testimony and the evidence you shall give to the court and the jury [inaudible 00:45:05] shall be the truth, the whole truth, and nothing but the truth, so help you God?

I do.

You may have a seat.

Hey, good morning.

Good morning.

Hi.

May I inquire? Thank you.

Yes, please.

Good morning. Could you please tell the jurors your first and last name?

Kelly McDonough.

Can you spell your last name for the record?

M-C-D-O-N-O-U-G-H.

And what do you do for a living?

I'm an emergency medicine physician.

And how long have you been a physician?

11 years.

Can you tell us a little bit about your educational background?

I went to medical school at the University of New England in Maine. I did my residency at Kent Hospital in Rhode Island. I subsequently worked at Carney Hospital in Dorchester, and I've been at South Shore Hospital since 2021.

Are you primarily in the emergency department at South Shore Hospital?

Correct.

Have you been in any other department at South Shore Hospital?

No.

Are you licensed to practice in Massachusetts?

Yes.

I'm going to draw your attention to January 24th of 2023. Were you working in the emergency department that evening?

I was.

Okay. At some point, were you advised that a patient was being brought into your emergency department?

I was.

And were you aware of that patient being Lindsay Clancy with a date of birth of 8/11/90?

Yes.

And what kind of information were you given upon learning that the patient was coming here? What were you expecting to receive?

I was expecting a trauma one response. A patient who had fallen out of a window from a height, and didn't know much more than that.

Okay. And so when you say trauma one, what does that mean for you?

So we have two designations for trauma responses, a trauma one and a trauma two, and there's certain criteria for each. And there's a long list of criteria that are determined by the resource nurse who receives the EMS call.

Okay. And so when we say one and two, which is more serious than the other?

Trauma one.

Okay. And so what do you do to prepare when a patient is coming in, and you know coming in that it's likely a trauma one situation?

So we gather in the trauma room and make sure that we have all available staff needed to take care of the patient.

And what kind of staff are with you in the room, in the trauma room?

So, for a trauma one response, it would be the emergency medicine physician. It would be anesthesia, the trauma surgeons. Sometimes neurosurgery will be there.

And fair to say you also have a whole host of other staff, including nurses, emergency room techs. All of those people are also available to assist if you need it?

Correct.

Now, when this individual came in, when Lindsay Clancy came into the emergency department, were you aware from EMS that she had already come in with some sort of neurological deficits?

I think that from my best recollection, we knew that she was unresponsive, found down outside of her home.

Okay. Were you advised that it appeared she might have a spinal injury?

Yes.

And that she may have been moving her arms and her head, but not her legs?

Correct.

Now, when the team was assessing her in the emergency department, what types of steps do you take to perform that assessment of the patient?

So there's a series of steps that we go through to assess a trauma patient that are followed every single time. ABCs: airway, breathing, circulation, and then we do a secondary survey.

Okay. And in this circumstance, was the patient breathing?

Yes.

And when she came into the emergency department, was she breathing on her own or intubated?

She was breathing on her own.

At some point, did the ER staff have to intubate her?

Yes.

And why was that?

For airway protection. There was a concern that maybe she would have a head injury and she would decompensate later. And so, to protect her airway, she was intubated.

Now, is that a standard protocol when there's concern for head injury?

Yes.

Did you see any obvious signs of a head injury when she arrived into the emergency department?

No.

What kinds of things would you see if somebody had an obvious head injury?

You might see bleeding or lacerations or abrasions.

Now, did you observe any other obvious injuries to this patient?

I did. She had some superficial lacerations of her neck and wrists bilaterally.

Do you recall if she came in on a backboard with a C-collar?

She did.

And do you remove the C-collar at some point to assess the patient for injuries?

We didn't completely remove it. We remove it temporarily to visualize and feel her neck and then put it right back on.

Okay. And you said you did observe some injuries to her neck, correct?

Yes.

I'm just going to show you some photos that have been already marked, if that's okay? On the screen next to you. This has been marked as exhibit number 111. Is that an accurate representation of the neck injuries you observed?

Yes.

You also indicated that she had some other injuries to her wrists?

Yes.

And I'm just going to show you 112. Is that accurate as to the injuries to the wrist you observed?

Yes.

Now you described the injuries as superficial. The injury that's kind of in the middle of the photograph there. Can you describe what part of the body that injury is?

You're describing the one that's sort of open?

Yes.

Yeah. So that's the anterior aspect of her wrist.

And were you able to examine that injury?

Not in detail.

Okay. Was it something in your emergency, your assessment of the trauma one situation, was that something acute that you had to address?

No.

And is it fair to say that that injury goes through kind of the subcutaneous tissue of the skin?

Yes.

Did you observe any injuries to an artery or a vein or anything in that area?

I did not.

And then just showing you exhibit 113, which is the other wrist. Same thing. Did you observe anything in your assessment, your trauma one assessments, to say whether these were acute at the time?

I assume that they're acute.

Okay. But as far as treatment of them, did they require you to immediately address it?

No.

To manage blood flow?

No.

What was the more serious, or what was the focus of your assessment of her in the emergency department?

I think the main concern was for a head injury and/or a spinal cord injury.

And you said that as part of the assessment team, you had a neurosurgeon available as well as a trauma surgeon, correct?

There was no neurosurgeon there that day.

Okay. Was there a trauma surgeon?

There was.

Who was that?

Dr. Christina Carpio.

Did you order any, a series of tests in order to help you assess the nature of whether there was any head injury or what the extent of the spinal injury could have been?

Yes.

What kinds of tests did you order?

CAT scans.

As part of the emergency room protocol, do you also draw blood for patients that come in?

Yes.

And how is that usually done?

It's usually done on arrival by the nursing staff.

And do they draw blood according to a physician's orders or do they draw blood for various purposes? Explain to us how that works.

So it's usually like what we call a rainbow. So they just draw all the tubes of blood as soon as the patient arrives in anticipation for orders.

Okay. And so what happens to the blood after somebody in the emergency department takes it from the patient? Where does it go?

It gets tubed to the lab.

And fair to say that at South Shore Hospital, they have a pneumatic tube system, correct?

Correct.

And that it goes to a separate laboratory?

Correct.

And once a physician then assesses a patient and determines what kinds of testing needs to be done on those samples, how do you communicate that to the laboratory?

So orders are put into a computer, and they go through the computer to the lab.

And as you're treating a patient, is it oftentimes necessary to change the orders or order additional tests?

Yes.

And so, in this particular case, blood and urine was collected from Lindsay Clancy upon her arrival, correct?

Correct.

And then sent to the lab?

Yes.

Okay. Now going back to the imaging tests, you said that there were some CT scans that were ordered?

Correct.

What areas of the body were the CT scans for?

It was her entire body. Her head, her neck, her chest, her abdomen, and her pelvis.

Now, as far as the CTs for her head, were there more than one CT test for the head?

I don't remember. I'd have to look at my record.

Okay. Well, what are the normal, or what are the options for CT head scans?

Usually just a CT head plain, but you could also do a CT angiogram depending on your concern for injury.

And do you recall which one you ordered here?

For a trauma one, it would be a plain CT head.

And why do you order that particular test?

Well, we're trying to assess for skull fractures, intracranial bleeding, things like that.

And when you say a plain CT, what's the exact order that's put in for that type of a CT?

CT head.

Okay. And are there CT heads with contrast?

There are.

And are there CT head scans without contrast?

Yes. Okay.

May I approach the witness?

You may.

I'm going to show you some documents, if that's okay.

Sure.

I apologize. There's no series of paginations. So I'm just going to draw your attention to this page that's black. If you could just take a look at it.

Sure.

Okay. And I'm just going to flip to the next page as well. The next page is blank, but is this the extent of what you would have received as far as information regarding a head CT that was done without contrast?

Yes.

And I'm going to just draw your attention again to another flagged page here towards the end. It's actually two pages from the end of the document. If you could take a look at that? And does that reflect the report you would have received for the head CT ordered with contrast?

Yes.

And in addition to getting a report from imaging, you also receive some actual images, correct?

Yes.

And do you review those?

Yes.

In this particular circumstance, when it came to the patient of Lindsay Clancy, was there anything remarkable in either of those head CTs?

Not that I recall.

And in fact, the head CT with contrast indicated the impression was unremarkable. CTAF had no evidence intracranial aneurysm, arteriovenous malformation or abrupt occlusion, correct?

Correct.

What does that mean?

It essentially means it's a normal study.

Okay. Now, as far as the other CT scans that were conducted, there were findings, remarkable findings on some of the others, correct?

Correct.

And what did they reflect in your experience as far as her injury goes?

From what I can recall, I know she had a thoracic spine injury.

And how about the CT that was done of the chest area?

I don't recall.

Okay. If I may approach. Document.

Thank you.

Does that refresh your memory?

Yes.

And what was the extent of the results on the chest CT?

So it talks about her thoracic spine injuries.

Okay. Now, after reviewing all of the images, all of the CT scans that were done here, the cervical spine, the head CTs, the thoracic spine, what was the plan for this particular patient? Was she able to be treated further at South Shore Hospital?

The decision was made by the team that her injuries were too severe to stay at South Shore Hospital, and the decision was made to transfer her to a tertiary care center.

Were you able to stabilize her before transporting?

Yes.

Is that something that's important to make sure a patient is stable before sending them off in the ambulance or a helicopter?

Yes.

And so as far as this particular patient goes, are you aware of whether any surgical intervention had to be done before she was stabilized and transported?

I was not aware of any intervention being done.

And again, you had Dr. Carpio, who was also there to assess that?

Correct. We work as a team.

Kind of going back to those injuries on her neck and her wrist very briefly, can you explain to us the difference between bleeding in maybe an artery or a vein and how that might present itself in an emergency situation?

Venous bleed would be a little bit slower. Darker blood and arterial bleed would be pulsatile and bright red.

And is it fair to say that when you strike either an artery or a vein that they're of different pressure systems and so the manner in which the blood comes out is different?

Yes.

In either a circumstance where an artery or a vein is struck or nicked or cut, would that be something that you'd have to stabilize for a patient in order to make sure that they don't bleed out?

Yes.

Was that done here?

It wasn't necessary.

Now, this particular patient at some point, was noted to be, I think it was referred to as hypothermic. Do you recall that?

Yes.

Do you recall at what point in your treatment of her was that noted? Was it as she was coming into the emergency department or did that develop while she was in the emergency department?

I don't recall.

What was the course of treatment for a low body temperature?

We placed something called a bear hugger on them, which is a warming blanket.

And can you explain to us what could cause a person's body temperature to drop to, I think it was 82.1?

There are many reasons, but it could be a metabolic disarray or exposure.

In this circumstance, did you know what the source of the drop in the body temperature was for Ms. Clancy?

No.

And do you recall how long she was in the emergency department before she was transported approximately to the Brigham?

I think it was about four hours.

At this time, Your Honor, I would move to enter into evidence a copy of the South Shore Hospital medical records for Lindsay Clancy from January 24th, 23 as the next exhibit.

Is that by agreement? All right. They may be admitted, or they may be admitted.

138

And I would also move to enter as the next exhibit a certified copy of imaging records from the South Shore Hospital for Lindsay Clancy from January 24th, 2023.

All right. It may be admitted.

Exhibit 139.

So finally, Dr. McDonough, did this defendant receive surgery at South Shore Hospital?

Not that I'm aware.

Okay. Did you observe any cuts, abrasions, or blood on the area of her head?

No.

And based on your review of those findings on the CT scans, was there any noted injury from the head CTs that you could tell?

No.

And were you able, after using that bear hugger device, able to get her core body temperature back up to normal?

I don't recall.

Did you ever observe those wounds that you observed on her neck or her wrists ever start bleeding actively again?

No.

Okay. I have nothing further.

Mr. Reddington.

Good morning.

Morning.

So would you agree with me that when Lindsay was brought into the South Shore Hospital that she was unconscious?

I recall her eyes being open, but she was nonverbal.

Okay. So, as an experienced emergency room doctor, can you tell me when someone's unconscious, what are the symptomatology of it? What does that mean?

Usually means they're completely unresponsive with eyes closed.

Okay. Was she responsive?

Not verbally.

Was she responsive at all?

She was responsive to pain.

So that means that you would do something to cause pain, perhaps the bottom of the foot or whatever it is, to see if they have a reaction?

Correct.

And would you agree with me that when people even have very, very serious brain injuries, that they can respond to pain stimuli?

Sometimes.

Sometimes. So her eyes were open. Were her pupils equal and reactive to light?

I don't recall.

You don't recall. What does it mean with PERL, pupils, equal, reactive to light? What does that mean?

Exactly what you just said. It means her pupils are equal and reactive to light.

And as a doctor, what does that tell you?

It tells me that there's no significant neurologic injury.

And in this case, you don't recall if her pupils were equal or reactive to light?

I don't.

Okay. And that's when you take the little flashlight sometimes, and you put it over the eye and see if there's constriction of the pupil?

Correct.

Did you do additional evaluations of her to see what her neurological function was?

She was pretty quickly intubated from what I recall. So after that, it would be difficult to assess her neurologically.

Sure. Was she on any pain medication, if you remember?

I don't remember.

Did she have difficulty being intubated? I mean, would you agree with me that if you're not under some type of medication or sedation or unconscious, it hurts to be intubated, doesn't it?

We wouldn't intubate somebody without first giving them some induction medicines.

Okay. So what would the induction medicines be?

They're not universal. It would depend on the case.

What are the induction medicines that you used on Lindsay Clancy?

I don't know. I'd have to refer to my record, and also I wasn't the one who did the intubation.

So she was intubated, had the tube coming out of her mouth, she's laying on the table, and you are continuing an assessment. You were the lead doctor in the emergency room for Lindsay Clancy, right?

I wouldn't say I was the lead. I think the trauma surgeon and I worked together.

Right. Her temperature, her core body temperature was...

All right. Her temperature, her core body temperature was 82 degrees. Is that right?

If that's what the record states, then yes.

I'm sorry?

If that's what her medical record states, then yes.

Well, as you sit here, you don't know what her core body temperature was?

I saw her three years ago. I see about 200 patients a month.

I'm sure you're very busy, but this is a murder trial, Doctor. Did you review your records and your notes?

I'm happy to look at my record if you bring it here.

Did you review your records and notes before you came in here today to testify on this case?

Sir, I did, but I don't have a photographic memory.

Did she regain consciousness at all while she was in your emergency room?

No.

Can you tell me what CSF is?

Cerebral spinal fluid?

Yeah. Is that what that is, CSF?

It could be. I'm not sure in what context you're referring to it.

Well, how about if there's a massive leakage of CSF from her nose? What does that tell you as a doctor?

It could mean that there's a skull fracture.

Did you notice any clear fluid coming from her nose?

I did not.

Is that something you would look for?

Yes.

How quickly do you get the results of the x-rays when you're in the emergency room?

Well, these were CT scans, but fairly quickly in a trauma.

I'm sorry. CT scans, x-rays. So you had CT scans that were able to show you the damage to her neck and upper chest, is that right?

Yes.

And what did those CT scans show you?

Well, what I remember is a thoracic spine injury.

And when you say a thoracic spine injury, would you agree that top part of your neck, your throat area would be cervical, right?

Correct.

And that's when the numbers go C1, two, or whatever they are. That would be the actual vertebrae in the cervical area of the upper body, correct?

Yes, the cervical spine.

Okay. And then below the cervical spine would be the thoracic spine. Is that correct?

Correct.

And the thoracic spine would be... And sometimes they delineate it as T1, T2, meaning thoracic one, thoracic two, all the way down to what, five or six?

12

I'm sorry?

12

12? And the lower portion would be the lumbar, is that right?

Correct.

Now, when you looked at the CAT scans, did you determine the extent of the injury to the spinal cord?

I could determine the extent of the injury to the bony thoracic spine.

Okay. What was that?

I don't recall exactly the level. I would have to look at the report.

What does that mean, the level of the T?

Correct.

Was her cervical spine injured?

I don't recall. I'd have to look at the report.

Were you aware that her thyroid was crushed?

I don't recall.

Do you know that her cervical spine vertebrae was fractured, destroyed?

I don't recall.

Doesn't that control a person's breathing? Does that have anything to do with breathing?

It can.

What do you remember about looking at the damage to the spinal cord depicted on the CAT scan?

What sticks out most in my mind is her thoracic injury.

Okay. And what was the thoracic injury?

I don't recall the exact level.

What does it mean by effect level?

The exact level.

I'm sorry. Were you aware that there was a complete transection of the spinal cord on T5 and T6?

I'm sure I was aware at the time, yes.

Okay. And just can you tell me, what does it mean when it says a complete transection of the spinal cord at a particular... Apparently that would be at thoracic five and thoracic six, right?

Mm-hmm.

What does that mean with a complete transection?

It means the bones are no longer at one on top of the other. They're moved apart.

Were you aware that there was a significant edema noted in her chest?

If that's what the report says.

Okay. And what is edema?

Swelling.

And does it also refer to fluid?

It can.

Did it refer to fluid in this case?

I'm not sure. I would have to read the report.

So in addition to the edema that was noted, was there edema noted around C7, T1, T2, T3 to T4?

Again, I would have to have the report in front of me.

When you noted her base temperature as being 82 degrees, what does that tell you as a doctor?

It means that her body temperature is lower than normal.

And what is normal?

98.6.

And if a person goes from 98.6 to 82 degrees before you place her in the bear hugger, what does that tell you? Does that affect the body at all?

Yes. The body works ideally at 98.6. So anything outside of that range, not ideal.

To what effect? As a doctor, what effect, if any, on the body if a person has an 82 degrees base temperature?

The list of things that could go awry is quite long.

Can you give me an idea, maybe the top three?

She could have a metabolic derangement.

What's a metabolic derangement?

Meaning her body wouldn't be processing things the way that it was before. Her cells are not working the way that they should because it's too cold.

Would you agree with me that when you were looking at the injuries to the wrist and to the... both wrists actually, you noted lacerations in the volar aspect of the wrist?

Yes.

What is a volar? What does that mean?

It's the anterior aspect of it.

Interior? Okay. Thank you. Would you agree that on both wrists there was deep laceration?

I wouldn't characterize them as deep.

You would not? And when you made reference to her being transferred to a tertiary care center, what does that mean?

It means that it's a hospital that has more services and specialized care than we do at our hospital.

Now, when she was at the South Shore Hospital, counsel asked you about whether or not you noted any injuries to her head. You did not notice any bleeding or scrapes or bruises of that nature, right?

Not that I recall.

Did you notice any injuries to her lower body, her legs, her feet, let's say her feet or her buttocks?

I don't recall.

At any time while she was at South Shore Hospital, did she have a cardiac arrest?

Not that I recall.

Do you know if she had a cardiac arrest when brought to the Boston Hospital?

Did not know that.

How about blood? Was there any blood transfusion at South Shore Hospital Medical Center?

I don't recall.

Are you aware that she had a massive transfusion of blood once she hit Brigham and Woman's?