Medical Day at Moultrie
After pushing the schedule from 10:30AM to 1:30PM and ultimately 2:00PM, the trial of defendants Joseph Price, Victor Zaborsky, and Dylan Ward resumed.
The defense team announced it was going to call two witnesses to the stand today: Ms. Tracy Weaver from the DC Fire Department Emergency Medical Services, and Farzad Najam, MD, a cardiac surgeon from George Washington University Hospital.
Ms. Weaver was the first witness to take the stand stating that she has been with DCFD for 13 years as an EMT. Interviewed by defense attorney David Schertler, she was composed and confident in her testimony.
Ms. Weaver stated that as soon as Robert Wone was placed in the ambulance, he was attached to a monitor using leads that were placed on his limbs.
Robert exhibited no signs of a pulse, and the monitor would measure any electrical activity in his heart. The monitor did indicate there was some electrical activity, therefore Robert demonstrated Pulseless Electrical Activity (PEA).
Protocol for a patient with PEA is to administer CPR and attempt to connect an IV line to the patient. Ms. Weaver attempted start an IV line twice in Robert’s arm, but was unsuccessful. her partner, Jeff Baker attempted to insert a line in Robert’s neck, but was also unsuccessful. This emergency call was classified as a Priority 1 call, so information is transmitted directly to the hospital from the ambulance to alert the ER staff of the condition of the incoming patient. Ms. Weaver said the attending ER physician and the triage nurse met the ambulance as it arrived at GWU Medical Center.
Ms. Weaver’s cross-examination by prosecutor Glenn Kirschner was delayed until late afternoon to accommodate the schedule of Dr. Farzad Najam, the cardiac surgeon. Kirschner asked Ms. Weaver what her initial observations were when Robert was loaded into the ambulance. She concurred that there appeared to be a lack of blood even though there were gaping wounds in his chest large enough to insert a finger. Robert’s extremities were pale and cool to the touch.
She re-iterated that she tried to start an IV line into his arm, twice, and was unsuccessful, but did not attempt to start one on his ankles or other sites on his body. That was outside of EMT protocol. Weaver did say that Jeff Baker, her partner attempted to start an IV in Robert’s neck, unsuccessfully. Baker was positioned at Robert’s head and a fireman was at Roberts right side. Baker was administering oxygen and the fireman was performing chest compressions.
When asked if Robert was wearing shirt when loaded into the ambulance, Ms. Weaver stated that Baker would have cut the shirt off. When asked if she actually recalled the removal of the shirt, or whether it was standard operating protocol, Ms. Weaver said she could not recall specifically if this was done.
A review of the log of the ambulance run documented that the EMTs were unable to revive Robert, he showed no signs of respiration, no pulse, and no vital signs. The cardiac monitor showed Robert had PEA, so protocol dictated to continue administering CPR until the patient was received at the hospital.
Using a numerical rating for the EMT logs, Ms. Weaver recorded that Robert showed no eye movement, no verbal communication, and no motor activity, with 1 point assigned for each factor. A total of 3 points meant Robert was deceased.
Defense attorney Schertler began a cross examination of Ms. Weaver, but was cut short by the late hour. He will resume his questioning at 9:45AM tomorrow.
Farzad Najam, MD was next to take the stand. His medical training began in Pakistan where he did his undergraduate and medical studies. In 194, Dr. Najam took the US Foreign Medical Graduate Exam and qualified to apply for residency training in the United States. Dr. Najam became board certified as a general surgeon in 2000 and completed his board certification as a cardiac/thoracic surgeon in 2004.
He has been practicing cardiac surgery at GWU since 2004 performing 6-8 surgeries a week. These procedures include cardiac bypass surgery, repairs and replacements of cardiac valves, and surgery on the great vessels of the chest. In addition to performing surgery, he is a professor of cardiac surgery at GWU, has lectured in Pakistan, and has published in peer review journals, including an article on trauma to thoracic great blood vessels.
He is one of two full-time cardiac surgeons on staff at GWU. He has treated patients with chronic and acute cardiac tamponade, chronic occurring in patients with ongoing heart disease that involved fluid and blood leaking into the pericardial sac, and acute occurring usually in patients during or after cardiac surgery. Dr. Najam stated he has treated over 100 cases of acute cardiac tamponade.
The motion to qualify Dr. Najam as an expert in cardiac surgery and tamponade along with PEA elicited an objection from the prosecutors. The prosecutors felt that he should be qualified as an expert in the former but not as an expert in PEA, citing the scope of the defense team’s Rule 16 filing. After a bench conference, Dr. Najam was accepted as an expert in cardiac surgery and tamponade, but not for PEA due to a Rule 16 violation.
David Schertler led the direct of Najam, starting with the autopsy report of Robert Wone from the DC Medical Examiner’s Office. Dr. Najam stated that he had reviewed the report, autopsy photographs, ER records, EMT logs, and had also examined tissue samples preserved by the medical examiner of Robert’s heart.
Dr. Najam’s testimony included that he was not accustomed to analyzing heart tissue specimens, but was most familiar with the intact heart anatomy. He then proceeded to demonstrate the function and components of the various chambers and blood vessels associated with the human heart, using a large plastic teaching model. Then using exhibits, at the request of Judge Leibovitz, Dr. Najam described the various layers from the skin to the heart:
- subdermal layer of tissue
- cutaneous layer of fat
- connective fascia tissue layer
- pectoral major muscles (“The ones that get bigger from bench presses”, he quipped.)
- pectoral minor muscles
- connective fascia covering the sternum and ribs
- pericardial sac and associated fatty layer
- the heart and great vessel encapsulated into the pericardial sac
When asked to describe the wound to Robert’s chest as wound number 1 in the medical examiner’s report, Dr. Najam stated that the knife had cut through the root of the aorta and through the left anterior descending (LAD) artery. The cut to the aorta was about 7/8″ in length and was described as a slice type wound with entry and exit openings. The LAD was completely severed by the knife. The ramifications of this injury would be to produce a “torrential hemorrhage” leading to cardiac tamponade. The victim would be rendered unconscious in 5-10 seconds.
Dr. Najam’s explanation for this rapid descent into unconsciousness was that the hemorrhage would fill the pericardial sac, with the clotting blood becoming gel-like and unable to escape through a slit-like wound, creating pressure on the heart, rendering it inefficient in pumping blood. It would only take 200-250 cc. of blood in the sac to cause tamponade.
With no blood flowing to the brain, unconsciousness would ensure, leading to neurological death within 3 minutes. Najam stated that this opinion was based on his clinical experience. When defense attorney Schertler asked if Najam had discussed this with his colleague, Frederick Lough, also of GWU, the request was met with an objection from the prosecution. After a bench conference, Judge Leibovitz stated that this could be admitted not for its truth, only a validation of his opinion. Schertler then asked if Lough’s opinion was consistent with Najam’s. Najam said yes, evoking a stern admonishment from Judge Leibovitz to Schertler, “You just ignored my ruling Mr. Schertler.”
Further discussion of the medical examiner’s report was in agreement with what Najam opined: the pericardial sac was distended from the blood, there 200-250 cc. of blood in the sac as a result of hemorrhage from the cut through the aorta.
As Schertler began questioning Najam about the stab wound number 3 which perforated the pancreas, duodenum and superior mesenteric vein, he was met with objections from the prosecution, stating that this line of questioning was outside the scope of the testimony permitted under the Rule 16 filing. This time Judge Leibovitz allowed Schertler to proceed, saying that the Court of Appeals permits the judge some discretion as to the limits of the scope of the testimony.
Najam stated that the medical examiner’s findings were consistent with his opinions with regards to wound number 1 and number 3, that blood could move into the digestive tract 2 feet without a heart beat from venous pressure that would actually increase as the hemorrhage pushed blood into the pericardial sac. When queried whether Robert would have remained conscious for more than 5-10 seconds, Najam replied, “No.” When asked why there would be so little external blood, Najam said that only a small amount from the skin wounds would be present, the rest would have flowed into the body.
AUSA T. Patrick Martin then began his cross examination of Dr. Najam. After a brief bad start by asking Najam about the roles of a cardiology versus a cardiac surgeon as first evaluators of a patient presenting with chest pain or a cardiac condition, Judge Leibovitz, clearly growing impatient with this lengthy discussion, asked Martin to “Please move onto something more relevant.” That propelled Martin to hit his stride.
When questioned how many times Najam had treated patients with tamponade, Najam replied greater than 20 times; for acute tamponade, 5-10 times in a clinical setting, 4-5 times involving a sharp force injury. Najam did not remember any case in which the pericardial sac was perforated.
When asked how long a person with a 7/8″ slit wound through the heart and pericardial sac would remain conscious, Najam replied, “Eight to ten seconds.” adding that blood pressure and blood flow to the brain was more important to maintaining consciousness that any oxygen already present in the brain.
Martin then queried Najam as to how large a perforation to the aorta would have to be to result in tamponade leading to unconsciousness in such a short time. Najam replied that it doesn’t happen that way in clinical practice, and that to relieve the pressure of blood in the pericardial sac, the surgeon creates a “window”, a sizable opening in the sac to relieve the tamponade.
On showing Najam an exhibit of the hole in Robert’s pericardium, Najam stated that the time to unconsciousness was not based on a measure rate of blood flow, but on the amount (200-250 cc.) of blood accumulated in the sac. When asked on how a practitioner would know when the tamponade process began, Najam said lack of vital signs are indicative of tamponade. Martin countered that the process could begin 5, 10, 15 seconds before the effects of tamponade reduced the vital signs and was met with agreement from Najam.
On questioning Najam about the stab wounds to Robert’s abdomen. Najam stated that he was not an expert on these or peristalsis and could not offer an opinion.
Marin then asked Najam if while he was reviewing the medical examiner’s specimens of Robert’s heart, if Najam had difficulty locating or identifying the aortic valve. Najam acknowledged that it did take him 10-15 minutes to find it. When asked if Dr. Najam had ever been qualified as an expert witness in cardiac surgery or any other field, Najam said, “No.”
When asked which wounds were inflicted first on Robert, Najam said he had no opinion as to the timing or sequence of the wounds. With regards to the evidence of blood in the abdomen and their effect on the cardiac tamponade, Najam said he could offer no opinion. When asked what opinion could Najam offer with regards to Robert’ stab wounds, Najam offered based on his clinical experience, a slice to the aorta would lead to immediate tamponade rendering the patient unconscious in 5-10 seconds.
Tomorrow’s session will start at 9:45AM. The continuing cross examination of EMT Ms. Tracy Weaver will lead. Expectations are that Doug Deedrick, fiber analysis expert will be recalled to the witness stand as a rebuttal to defense witness Petraco’s testimony.