Commonwealth v. Read — Trial ArchiveIrini Scordi-Bello - Direct (Part 1)
353 linesJUDGE CANNONE: All right, Mr. Lally, your next witness.
MR. LALLY: Uh, yes. The Commonwealth calls Dr. Irini Scordi-Bello to the stand.
JUDGE CANNONE: Okay.
MR. LALLY: Your Honor, as she's coming in, may we approach briefly?
JUDGE CANNONE: Sure. Madam court reporter, what was previously marked as [exhibit] for identification is now the next exhibit in evidence. Thank you. All right. So are you looking for my instruction now, Mr. Lally?
MR. LALLY: Uh, yes, please, your honor.
JUDGE CANNONE: All right. So, jurors — I gave you a similar instruction before about photographs. The Commonwealth intends to introduce into evidence through the next witness certain photographs showing Mr. O'Keefe postmortem. You'll have those photographs with you in connection with this case. I understand that they will — some of them will be shown up on the screen, and that's why I want to sort of give you a warning that that will happen. When they come to you as exhibits, they'll be placed in an envelope — you can, you know, look at them briefly, they'll be covered — is what I'm saying to you. So the photographs are not pleasant. They can be described as graphic.
JUDGE CANNONE: And I instruct you that your verdict must not in any way be influenced by the fact that these photographs will be unpleasant, perhaps sad, and graphic. The defendant is entitled to a verdict based solely on the evidence and not one based on pity or sympathy for Mr. O'Keefe, which might be occasioned by the photographs. So please consider those photographs only as they draw your attention to a clinical medical status, or to the nature of Mr. O'Keefe's injury, or to the nature of the incident itself. Okay. All right. Now, your next witness, please, Mr. Lally.
MR. LALLY: Yes.
COURT OFFICER: [Garbled — directing witness to step up.]
COURT CLERK: Do you solemnly swear that the testimony you shall give to the court and the jury in the matter now pending shall be the truth, the whole truth, and nothing but the truth, so help you God?
DR. SCORDI-BELLO: I do.
COURT CLERK: Thank you.
MR. LALLY: Good afternoon, doctor.
DR. SCORDI-BELLO: Good afternoon.
JUDGE CANNONE: All right, Mr. Lally, whenever you're ready.
MR. LALLY: Good afternoon, doctor.
DR. SCORDI-BELLO: Good afternoon.
MR. LALLY: Could you please state your name and spell your last name for the jury?
DR. SCORDI-BELLO: My name is Irini Scordi-Bello. My last name is spelled S-C-O-R-D-I, hyphen, B-E-L-L- O.
MR. LALLY: And how are you employed, ma'am?
DR. SCORDI-BELLO: I am employed as a medical examiner.
MR. LALLY: And for whom are you employed?
DR. SCORDI-BELLO: I am employed by the Office of the Chief Medical Examiner for the Commonwealth of Massachusetts.
MR. LALLY: And how long has it been that you've been a medical examiner for the Office of the Chief Medical Examiner in Massachusetts?
DR. SCORDI-BELLO: I have been with OCME in Massachusetts since December of 2016.
MR. LALLY: Now, ma'am, if I could take you back and just ask you a few questions regarding your educational background and work history — a little bit prior to working at the OCME in Massachusetts. If I could start with your undergraduate work — where did you go, and what if anything did you receive a degree in?
DR. SCORDI-BELLO: I completed a bachelor's degree in microbiology at the University of California.
MR. LALLY: And after receiving that degree, where did you go?
DR. SCORDI-BELLO: I went on to the University of Miami, where I completed my doctorate degree in immunology. And following that, I moved up to New York City, where I went to medical school and completed four years of medical school at the Mount Sinai School of Medicine. And following medical school, I completed 3 years of pathology residency at the Mount Sinai Hospital.
MR. LALLY: And then following your residency at Mount Sinai, where did you go from there?
DR. SCORDI-BELLO: And from there, I went downtown in New York City, and I completed a one-year fellowship in forensic pathology at the Office of the Chief Medical Examiner for the City of New York.
MR. LALLY: And following that one-year fellowship there, where did you go from there?
DR. SCORDI-BELLO: I worked in New York City until 2016, when I moved here to Massachusetts.
MR. LALLY: Now, are you board certified?
DR. SCORDI-BELLO: Yes, I am.
MR. LALLY: What are you board certified in?
DR. SCORDI-BELLO: I'm board certified in anatomic pathology and forensic pathology.
MR. LALLY: And if you could explain to the jury just briefly — what does it mean to be board certified, and sort of what is entailed in that process?
DR. SCORDI-BELLO: Board certification is actually a voluntary process that a physician decides to go through. It involves completing an accredited program in the specialty of choice — in my case it was pathology and forensic pathology — and then completing a number of requirements, as well as taking and successfully passing exams, and then being able to say that you're board certified.
MR. LALLY: And as that certification at this time, is that up to date?
DR. SCORDI-BELLO: Yes.
MR. LALLY: Now with regard to the time that you've been working as a forensic pathologist, are there any organizations that you belong to in relation to your work in that field?
DR. SCORDI-BELLO: Yes. I am a member of the National Association of Medical Examiners.
MR. LALLY: And that's an acronym — NAME — is that correct?
DR. SCORDI-BELLO: Yes.
MR. LALLY: Now with respect to that time frame as well, what if any experience do you have in regard to teaching the areas related to your work?
DR. SCORDI-BELLO: I've always been interested in teaching. I started teaching as a pathology resident, teaching other residents and medical students. And during my time in New York City, I enjoyed teaching medical students and residents — we had a very active education program in New York City — so I've always been involved with teaching both pathology and forensic pathology.
MR. LALLY: Now to those terms themselves — — if I could ask you briefly just to describe to the jury, as far as pathology in a general sense, what does pathology mean?
DR. SCORDI-BELLO: Pathology is a specialty of medicine. Pathology looks at disease processes, as well as trauma, and the effect they have on the human body.
MR. LALLY: And what is forensic pathology?
DR. SCORDI-BELLO: Forensic pathology looks at disease processes and injuries in the human body and tries to determine the cause of death in deceased individuals.
MR. LALLY: And as far as anatomic pathology, what exactly is it?
DR. SCORDI-BELLO: Anatomic pathology — as opposed to clinical pathology — has to do with any organ that is in the body, versus clinical pathology that deals with fluids, blood analysis, and things like that. So anatomic pathology — a lot of anatomic pathologists are surgical pathologists, that's another term you will hear — these are pathologists in the hospital that look at tissues under the microscope and come to a diagnosis, whether something is benign or malignant. And forensic pathology takes anatomic pathology to another step, to another level, by looking at the whole body and trying to determine the cause of death — instead of being organ-specific, instead of just looking at one organ, forensic pathology looks at the whole body.
MR. LALLY: Now you're also familiar through your work and training experience in regard to forensic pathology with a term called autopsy?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And is that something that you would typically do in the case of your investigation and analysis in regard to a pathological analysis when it came to a body?
DR. SCORDI-BELLO: Yes. An autopsy is a procedure that we do to determine the cause and manner of death.
MR. LALLY: So Doctor, with respect to an autopsy — maybe a term that's pretty well understood, but if you could explain in general terms what an autopsy is, what is involved in it, and what it consists of?
DR. SCORDI-BELLO: Yes. When a death is first reported to the medical examiner's office, we make a determination as to whether that death falls under our jurisdiction. Cases that fall under the jurisdiction of the medical examiner include all violent deaths, all deaths that are due to non-natural causes, all accidents, intoxications, deaths of babies and children, and deaths of individuals that were not under the care of a physician when the death occurred. So once a case is accepted and it falls under our jurisdiction, it is given a numerical number, and then the body is transported from either the location of the death or the hospital to our facility. We have three facilities in the state of Massachusetts. Once the body comes to our facility, then there are a number of steps that are taken.
DR. SCORDI-BELLO: The body is processed — what that means is that pictures are taken, a weight is taken, a height is taken, everything is input into our computer system — and then a determination is made as to whether an autopsy is required in order for us to determine the cause and manner of death. If the answer is yes, then we proceed with the autopsy.
MR. LALLY: Now as far as an autopsy is concerned, there are two sort of primary components — as far as an external examination and an internal examination — is that correct?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And can you describe to the jury again in general terms what the process is in reference to both external and internal?
DR. SCORDI-BELLO: Yes. So the autopsy, or the postmortem examination, has two main parts. The first one is the external exam, and it is basically what it sounds like — we do a very thorough exam of the outside of the body. We document physical characteristics, eye color, hair color, we document any scars or tattoos that may be on the body, we take pictures, we make notes, we look for any signs of disease and any signs of injury. All that is, as I mentioned, documented. And during the external examination, sometimes we will take evidence — we will collect hair and nails from the body if we think that that is necessary or warranted. And once the external examination is done, then we proceed to the internal examination.
DR. SCORDI-BELLO: That involves making surgical-type cuts on the body, what's known as the Y-incision, that goes from shoulder to shoulder and down the middle of the body. And the organs of the neck, the chest, the abdomen are examined thoroughly, again looking for and documenting signs of disease or signs of injury. We do the same thing with the head — the head is opened, the brain is removed, and we document any disease or injury.
MR. LALLY: Now turning your attention to January 31st, 2022 — did you have occasion to perform an autopsy in regard to the body of John O'Keefe?
DR. SCORDI-BELLO: I did.
MR. LALLY: And do you recall — you mentioned there were three different offices of the chief medical examiner within the state of Massachusetts — which office was that?
DR. SCORDI-BELLO: It was in the Cape and Islands office.
MR. LALLY: Is that the office that you typically work out of?
DR. SCORDI-BELLO: No, that's not the office I typically work out of. My permanent position is in the Westfield office in western Massachusetts. I was covering the office that day because we were short-staffed.
MR. LALLY: And in reference to the autopsy that you performed with regard to Mr. O'Keefe, was that in conformity with what you were speaking about just before generally as far as how you conduct autopsies?
DR. SCORDI-BELLO: Yes.
MR. LALLY: Now during the course of the autopsy that you performed in reference to Mr. O'Keefe, during the course of the external examination, what if anything did you note in reference to that external examination?
DR. SCORDI-BELLO: First I noted that there was evidence of medical intervention. Mr. O'Keefe's body was transported to our facility from the hospital, and he had evidence of attempted resuscitation. After I documented that, I proceeded to document some injuries that I saw on Mr. O'Keefe's body.
MR. LALLY: And before we turn to that, if I could just ask you a couple more general questions — you've made some mention earlier in your testimony as far as the cause and manner of death. In general, that's two things that you're trying to determine during any sort of forensic pathological examination, correct?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And what I'm going to ask you first is just in reference to manner of death — can you describe for the jury what are the different types of manner of death and how are they classified from the perspective of your office?
DR. SCORDI-BELLO: Okay, yes. So the manner of death are the circumstances that led to the cause of death — the cause of death being the disease or the injury that initiated the sequence that led to the fatal events. So the manner of death is circumstance-dependent. There are five general manners of death, or five umbrellas. The first one is natural — when we determine a manner of death to be natural, it means that the death was caused exclusively by natural disease; that would be heart disease, liver disease, cancer, aging, Alzheimer's, dementia, et cetera.
DR. SCORDI-BELLO: The second manner of death is accident — that means that the cause of death was due to an injury or due to an intoxication, either a physical injury or a chemical injury, but the circumstances show little or no evidence that that intoxication or that injury was intentional. So most motor vehicle accidents, most drug overdoses, most elderly falls are classified as accidents — the fatal outcome was not intentional. Homicide is a manner of death when there is injury inflicted by another person and there is evidence that there was intent to cause fear, harm, or death to the other individual.
DR. SCORDI-BELLO: And suicide is due to either an injury or an intoxication, and again the circumstances and the evidence suggest or point strongly to the fact that that was a self-inflicted intentional act on behalf of the person, with the intent to cause harm to themselves or cause death to themselves. So most hangings, intentional overdoses by prescription medications, are classified as suicides. And then we have — I'm sorry — and then we have one more manner that we call undetermined. Some jurisdictions call it "could not be determined" — that means that evidence pointing towards one set of circumstances or one manner is no more compelling than evidence pointing towards another manner of death.
DR. SCORDI-BELLO: So if we don't have enough information to know whether something, or to be able to determine the circumstances, then we are left with an undetermined manner of death.
MR. LALLY: Now, am I correct in stating that the cause of death is something that's more like a medical determination? Is that correct?
DR. SCORDI-BELLO: Yes, the cause—
JUDGE CANNONE: So watch the leading questions, Mr. Lally.
MR. LALLY: How would you characterize the determination that you make in regard to a cause of death?
DR. SCORDI-BELLO: The cause of death is based on my findings at the time of autopsy, along with any medical information that I may have on that deceased individual.
MR. LALLY: Now as far as the manner of death, how are you making that determination?
DR. SCORDI-BELLO: The manner of death, as I mentioned, is circumstance dependent. I make that determination based on investigative information that is provided to me by law enforcement, by the people who did the investigation.
MR. LALLY: And what, if any, legal determination are you making as far as when you classify something as either of those five categories in a manner of death?
DR. SCORDI-BELLO: I am not making a legal determination. I'm making a medical determination.
MR. LALLY: And so as far as the medical determination — as manner of death — when specifically I'm talking about something that could be ruled or listed as manner of death as accident, what if any determination are you making as far as that?
DR. SCORDI-BELLO: I'm making the determination that the information that I have either shows no evidence or very little evidence that the injury that led to the cause of death was intentional. So I don't have any information to suggest that that was an intentional act.
MR. LALLY: And am I correct in saying that routinely people charged with, say, motor vehicle homicides — it gets classified as a manner of death as accident? Right?
MR. JACKSON: Objection.
JUDGE CANNONE: Sustained.
MR. LALLY: May I approach?
JUDGE CANNONE: Yes.
MR. LALLY: [unintelligible — exhibit introduction] And do you recognize that document, Doctor?
DR. SCORDI-BELLO: I do.
MR. LALLY: And what do you recognize that to be?
DR. SCORDI-BELLO: This is a copy of the death certificate for Mr. John O'Keefe.
MR. LALLY: That's signed by yourself? Is that correct?
DR. SCORDI-BELLO: Correct.
MR. LALLY: And as far as the listing related to a cause of death, what did you list as cause of death on Mr. O'Keefe with regard to his death certificate?
DR. SCORDI-BELLO: Cause of death was blunt impact injuries of head and hypothermia.
MR. LALLY: And with reference to manner of death, what if anything did you list on Mr. O'Keefe's death certificate in relation to manner?
DR. SCORDI-BELLO: I listed could not be determined.
MR. LALLY: And as far as that listing for could not be determined, if you could explain to the jury why it was that you have that listed as a manner of death with relation to Mr. O'Keefe—
DR. SCORDI-BELLO: Again, the cause of death is something that I can determine by the autopsy. I did the autopsy on Mr. O'Keefe and determined that he had injuries to his head as well as signs of hypothermia, so the combination of those two was the cause of death. The manner of death has to do with the circumstances under which Mr. O'Keefe sustained those injuries, and I did not have enough information to be able to determine whether those injuries were accidental or not, and so my manner of death was undetermined, or could not be determined.
MR. LALLY: And just from the spectrum that you had just talked about — sort of the five different manners of death — fair to say you did not determine that this was either suicide or natural causes?
DR. SCORDI-BELLO: Correct.
MR. LALLY: And so as far as your determination of manner of death being could not be determined, which of the two were you sort of in between? The two manners of death that remain are accident and homicide. May I approach?
JUDGE CANNONE: Yes.
MR. LALLY: [unintelligible — introducing next exhibit] Now, Dr. Scordi-Bello, you had made reference as far as cause of death being a blunt force injury — is that correct?
DR. SCORDI-BELLO: Correct.
MR. LALLY: At least one of the contributing causes. If you could explain to the jury sort of what you understand that to mean — as far as what is a blunt force injury?
DR. SCORDI-BELLO: Blunt force injuries are caused by any blunt object — that is a very big category of objects. A microphone could be a blunt object, this bottle if heavy enough could be a blunt object, the ground can be a blunt object. So anything that doesn't have a sharp edge or a razor edge — not a knife, not a scalpel — is a blunt object. Blunt impact injuries are categorized into contusions, which are bruises; abrasions, which are scratches; fractures, which are a break in the bone; and lacerations, which are tears in the skin. So when we say blunt impact injuries, we could be referring to any of those or a combination of those four types. And all those are the result of impact of the body with a blunt object.
MR. LALLY: Now we'll get more into specifics in a moment. Just in general terms, as far as from your external examination of Mr. O'Keefe's body, whereabouts — sort of geographically on the body — did you observe these blunt force injuries?
DR. SCORDI-BELLO: The majority of the blunt force injuries were to the face and the head, as well as to the upper extremities — the arms.
MR. LALLY: Now starting with Mr. O'Keefe's head, what was it specifically — or where was it — that you observed blunt force injuries to Mr. O'Keefe's head?
DR. SCORDI-BELLO: Okay, I observed a number of different injuries on Mr. O'Keefe's head. Starting with his eyes — he had hemorrhage, or bleeding, on the upper eyelids of both eyes, as well as swelling of the eyes. He had a small laceration, a small tear in the skin, on the right eyelid, again associated with the bleeding. He had some abrasions — abrasions are superficial scratches — on the skin on the left side of his nose, I believe. And when I looked at the back of Mr. O'Keefe's head, he had a laceration — that's a tear in the skin — that was surrounded by, or associated with, an abrasion, a scrape.
MR. LALLY: Now in terms of the extremities — and I'll start with the upper extremities, as far as his arms — what if anything did you observe in regard to blunt impact injuries to his arms?
DR. SCORDI-BELLO: He had on the right upper extremity a number of somewhat linear, somewhat patterned abrasions — scrapes — of varying sizes, ranging from small, 2 to 3 mm, to I believe 5 or 6 cm, both on the upper arm and part of his forearm. He had some contusions, or some bruising, on the dorsal aspect of the right hand, which I measured and documented. He had a very small abrasion, I believe, on the lower extremities near the right knee, but I would have to look at my notes to be absolutely
MR. LALLY: Sure. You can go ahead and look at your notes anytime you need to, Doctor.
DR. SCORDI-BELLO: Okay. Yes. So as far as these extremities — I noted a 3 cm superficial abrasion to his right medial upper arm; that would be the medial aspect, the inner aspect, of the right arm. I noted abrasions on his posterior right arm and forearm; those ranged from 3 mm to up to 7 cm. I noted two red contusions on the dorsal aspect of the right hand — again, that's the back of the hand. A faint abrasion, a faint scratch, on the dorsal aspect of the left hand. And a small, half-a-centimeter abrasion on his right lateral knee — on the side of his knee, on the right side.
MR. LALLY: Now I think you've defined it fairly well so far, but I'm just going to ask you, just for delineation purposes, if you could explain to the jury sort of what is the difference between an abrasion versus a contusion versus a laceration.
DR. SCORDI-BELLO: Okay. An abrasion is a scrape — it's a scrape of the superficial layers of the skin. A contusion is a bruise — so if I hit myself hard enough on my nightstand and I break blood vessels under the skin, then I can end up with a bruise, or a contusion. A laceration is a tear — not necessarily a cut. There's a distinction between a cut and a tear. A tear in the skin is due to a blunt object — maybe the corner of the nightstand that's sharp enough to tear my skin but not so sharp as a blade that would actually cut the skin smoothly. So we differentiate between lacerations and cuts because cuts are due to sharp objects; lacerations are due to blunt objects. And fractures are basically a break in the bone, again due to blunt trauma.
MR. LALLY: Are you familiar with what is termed as an incised wound?
DR. SCORDI-BELLO: I'm sorry, I didn't hear you.
MR. LALLY: Incised.
DR. SCORDI-BELLO: Yes.
MR. LALLY: If you could explain the difference between, sort of, the mechanism and what you observe between a laceration and an incised wound.
DR. SCORDI-BELLO: Yes. So an incised wound is what I previously called a cut. So the analogy I like to give is: if you have a loaf of bread and you're trying to cut the bread — if you take a very good bread knife, a sharp knife, you will be able to smoothly cut the bread. If you take a hammer, which is a blunt object, and you try to cut the bread, you're going to shred it up. So an incised wound — it's a smooth cut. Knives, razors will cause incised wounds on the skin. A blunt object will cause a laceration — it will break the skin and the edges will not be uniform, and there might even be some bruising around it.
MR. LALLY: Now with respect to the injuries that you talked about as far as the — abrasions on Mr. O'Keefe's right arm — how was that located in reference to sort of the circumference of the arm, and what I'm asking there is, was it on top, on the bottom, or everywhere?
DR. SCORDI-BELLO: I describe them as being on the posterior right arm and forearm. So when we examine a body, we examine the body in what's known as the anatomic position, which is the body on the table with the palms upwards, and so the posterior right arm and forearm would be what would be facing the table as the body is laying on the table — the backside of the arm and the forearm. So the opposite of posterior would be what would be anterior, and it would be this area right here that points up.
MR. LALLY: And as far as the anterior of Mr. O'Keefe's right arm, what if anything did you observe as far as injuries there?
DR. SCORDI-BELLO: I — again I noted in my diagrams and my charts that they were mostly on the posterior right arm and forearm.
MR. LALLY: Now, Dr. Scordi-Bello, if I could turn your attention to the internal examination — as far as the injuries that you observed there, what if anything did you observe during the course of your internal examination of Mr. O'Keefe?
DR. SCORDI-BELLO: Okay. The internal examination — I will start with the head. Once the skull was open and the head was examined, I noted that there were skull fractures in Mr. O'Keefe's skull, both in the back and the front aspect of his skull. I noted that there was recent subdural hemorrhage — that is blood that is under the dura, and the dura is a very tough protective cover that sits over the brain. I noted that there was subarachnoid hemorrhage — that's hemorrhage that is directly on top of the brain under the leptomeninges, which is a very thin membrane that covers the brain. And at that point I removed the brain and, instead of examining it right then and there, I saved it in a special solution and sent it to our office in Boston for our neuropathologist to fully examine.
MR. LALLY: And is it your understanding that a neuropathologist ultimately conducted a fuller examination of Mr. O'Keefe's brain?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And who was that neuropathologist within your office?
DR. SCORDI-BELLO: Dr. Stonebridge.
MR. LALLY: Now, with reference to the head — as far as the skull, you indicated that there were fractures, as in plural, correct?
DR. SCORDI-BELLO: Correct.
MR. LALLY: Yes. And with reference to the fractures — what if any relationship did you note between the fractures that you observed and the laceration to the back of Mr. O'Keefe's head that you spoke about in your external examination?
DR. SCORDI-BELLO: So the laceration on the scalp that I observed was overlying the area of the skull that appeared to be fractured, or at least appeared that the fractures were originating from that point of impact and extending into the rest of the skull.
MR. LALLY: Now, if anything as far as your observations of the skull — and that point — I'm sorry, which — which part of the skull was the originating fracture?
DR. SCORDI-BELLO: This would be on the back of the skull, slightly right of midline.
MR. LALLY: Is that the medical term that — that's referred to as — I'm sorry, is there a medical term that that's referred to as, as far as the right rear?
DR. SCORDI-BELLO: Sort of — it's the right occipital.
MR. LALLY: And what if anything led you to that opinion that that was sort of the originating source of the multiple fractures in the skull that you observed?
DR. SCORDI-BELLO: Again, observing the skull fractures and their pattern, there appeared to be a central point with fractures radiating or originating from that central point and going into other parts of the skull.
MR. LALLY: Now, in reference to that laceration in the area of the originating fracture in the back of the skull, what if anything did you determine in regard to impact in regard to that area of the head?
DR. SCORDI-BELLO: Well, the laceration — along with — so the tear in the skin, along with the scrape, because they were adjacent, are both evidence of blunt impact. So I knew at that point that Mr. O'Keefe's head had come in contact with a blunt object.
MR. LALLY: Would that be sort of the point of impact between the blunt object and Mr. O'Keefe's head?
DR. SCORDI-BELLO: Right.
MR. JACKSON: Yes.
MR. LALLY: Now, with reference to the fractures that you had observed, how extensive were the fractures that you observed — the multiple ones?
DR. SCORDI-BELLO: Well, there were multiple fractures, so by definition multiple fractures in multiple chambers or parts of the skull, so I would say they were extensive.
JUDGE CANNONE: Have a moment.
MR. LALLY: Now, when you're conducting this internal examination, is there sort of a division of the body that you're doing as far as what you're examining and in what order, and sort of things that you're looking at from the internal
DR. SCORDI-BELLO: Examination? Well, we examine everything, and usually we start — in the external examination we start from the head and work our way down. During the internal examination we're doing two things at the same time sometimes, and so I start with the chest, move to the abdomen, and then the pelvis, while at the same time we're working on the head.
JUDGE CANNONE: All right, I'm going to pause you there for a minute — we're going to take a short recess and we'll be back. — You don't talk to anyone, but you can step down if you want to. And I'd ask that you just — [unintelligible]. I'll just — thank you. I'll see counsel at sidebar.
COURT OFFICER: All rise for the court please. broadcast: You are muted.
JUDGE CANNONE: Thank you. Be seated. You're back. All right, Mr. Lally, thank you.
MR. LALLY: Now, Doctor, as far as the internal examination was concerned with regard to Mr. O'Keefe — starting with his stomach, what if anything did you observe of any significance in that area?
DR. SCORDI-BELLO: I observed that there were some small hemorrhages — small areas of bleeding in Mr. O'Keefe's stomach.
MR. LALLY: And are those described in medical literature as a specific type of spot?
DR. SCORDI-BELLO: They are — they have a name. They're called Wischnewski spots, W-I-S-C-H-N-E-W-S-K-I. And they have been associated with cases of hypothermia.
MR. LALLY: And how so — how have they been associated with cases of hypothermia?
DR. SCORDI-BELLO: They have been seen in cases of hypothermia — it's one of the findings that supports the diagnosis of hypothermia. They are not always there, and their presence doesn't definitively diagnose hypothermia, but they are one of the findings that, if present, suggest the diagnosis of hypothermia.
MR. LALLY: And based on your training and experience, based on other types of literature that you've reviewed in regard to hypothermia — what if anything does it say as far as these Wischnewski spots — and thank you very much for saving me saying that until after you had said it — with regard to that, what if anything does it say as far as the causality of that, or how that occurs or is related to hypothermia?
DR. SCORDI-BELLO: We don't really know the pathophysiology of these spots — there have been various hypotheses. People have suggested that they are a response to stress; some people have suggested that hypothermia increases secretion of acid in the stomach and that leads to the spots. But their exact pathophysiology is still under investigation.
MR. LALLY: Now, in addition to these areas of small hemorrhage in Mr. O'Keefe's stomach, what if anything did you observe in the pancreas?
DR. SCORDI-BELLO: In the pancreas, I again observed some more diffuse hemorrhage of the pancreas and the tissues around it.
MR. LALLY: And same question with regard to the spots or the hemorrhages you observed in the stomach — what if any relationship do the hemorrhages or the bleeding in the pancreas have in relation to hypothermia?
DR. SCORDI-BELLO: Again, it's one of the findings that, if present, should alert the medical examiner to consider the possibility of hypothermia.
MR. LALLY: And as far as the observations that you made — as far as the hemorrhages in the stomach area of Mr. O'Keefe and the hemorrhages in the pancreatic area of Mr. O'Keefe — the sort of juxtaposition of those, what if any significance did that have in regard to your hypothermia diagnosis?
DR. SCORDI-BELLO: When the case was called into our office and when we accepted the case, it was reported to us that this was an individual that was found in the snow, covered with snow, and it appeared that he may have been there for a period of time. So one of the questions for me as a medical examiner is to determine whether there are any signs of hypothermia. In addition to what I had already observed — which was the blunt impact injuries — the combination of the gastric — the stomach — and the pancreatic hemorrhages strongly suggested, given the circumstances and how the body was found, that hypothermia did in fact play a role in his
DR. SCORDI-BELLO: — death.
MR. LALLY: Now, probably should have asked this first as a precursor — when you use the term hypothermia, what do you understand — what is hypothermia — from a medical diagnostic standpoint?
DR. SCORDI-BELLO: Hypothermia is a term used to describe low body temperature. By definition, 35° Centigrade or below. And there are levels of hypothermia, from mild hypothermia to severe hypothermia. It just basically means the body is losing heat faster than it can generate it.
MR. LALLY: And typically, what would be the sort of core body temperature that would determine someone as hypothermic versus not?
DR. SCORDI-BELLO: We're usually at 98°, or 37° Centigrade. So anything higher than that — — is considered a fever. Anything lower — lower than 35° Centigrade, or 95 degrees Fahrenheit — is considered hypothermia.
MR. LALLY: Now, if you could explain to the jury a little bit about the type of diagnosis that is involved in hypothermia, and what other types of information you would be looking at in order to make that diagnosis.
DR. SCORDI-BELLO: Hypothermia is a difficult diagnosis to make. And sometimes it's a diagnosis of exclusion, meaning that all other possible causes of death have been ruled out and you're left with hypothermia. So a body that is found in the snow or in a cold environment and has a core — — body temperature of 85° and it is unresponsive, or asystolic, meaning that there is no heart activity, could be a hypothermic death or it could not be a hypothermic death. And it's up to us to determine, by doing the autopsy, what other factors are at play. So the example I like to give is a person with severe coronary artery disease who goes out to shovel their driveway, suffers a heart attack, drops to the ground and is dead within seconds. And no one discovers their body for a few hours during the storm.
DR. SCORDI-BELLO: When they're found, they're asystolic. Their core body temperature is 80 degrees. But the autopsy shows another — — reason for their death: a massive heart attack, which is what killed them. They just happened to be outside after they died, and they lost heat and their body temperature dropped. Doesn't mean they died from hypothermia. However, if you take a person — an elderly person, or any person — an intoxicated person, a person who is intoxicated with drugs — who goes out into bad weather, gets confused, loses their direction, isn't able to get to shelter, and they die — their body temperature starts to drop, they get more disoriented, they get more confused. You know, their organ systems start to shut down, and eventually — — they die from hypothermia.
DR. SCORDI-BELLO: So that person will also be found in the snow with a core body temperature of 80–85 degrees. But when we do the autopsy, if we see those gastric hemorrhages, if we see that bleeding in the stomach, if we see the bleeding in the pancreas, if we look at their toxicology and we see that they were intoxicated with multiple substances, then we can determine — or we can opine — that the cause of death was at least partly due to the hypothermia, because they were still alive when they started losing heat, as opposed to someone who had the heart attack and was already dead when they started losing heat from the — — body.
MR. LALLY: Doctor, when coming to your opinion in relation to the cause of death of Mr. O'Keefe — in addition to your autopsy, your internal, your external examination — what if any other materials were you provided, and did you review any other materials in relation?
DR. SCORDI-BELLO: I was provided with a police report and investigative report. I was provided with some of his prior medical records. I was provided with records from the hospital where he was first taken by emergency medical personnel. And during the course of the autopsy — of course, I forgot, I didn't mention this — we also, during the autopsy, collect fluids — — from the body that are sent to the lab for toxicologic analysis. And after a few weeks after the autopsy, we get a report from the toxicology lab. And in this case, I looked at the toxicology report, all the information from the investigators, the autopsy findings, the neuropathology findings, and came to a conclusion as to the cause.
MR. LALLY: Now, as part of the documentation that you received from the investigators, did that include photographs of the scene as well?
DR. SCORDI-BELLO: Yes, it did. Some photographs.
MR. LALLY: Turning back to the toxicological findings that you received — what if any indication did those findings have, or did they indicate, in regard to blood alcohol concentration?
DR. SCORDI-BELLO: With regard to Mr. O'Keefe, he had alcohol in his system. And I do believe — I don't have the toxicology in front of me — but in his blood at the time of autopsy, the level was 0.21 grams per deciliter.
MR. LALLY: Now, contained within those toxicology findings, there's also something listed as a vitreous humor. Is that correct?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And can you explain to the jury what that is, where that sample is taken from, and why?
DR. SCORDI-BELLO: That sample — the vitreous humor — is taken from the back chamber of the eye. It's one of the routine samples that we take, in addition to blood from the body — — and urine. And it's again used to look for the presence of different drugs. In cases of alcohol intoxication, sometimes we will get a value for the vitreous, and sometimes that value might not be exactly the same as the value that we get for the blood. It gives us an idea of where in the curve of alcohol metabolism the individual is.
MR. LALLY: And so, based on the disparity between the vitreous humor level and the — I'm sorry, I may not have asked — what was the level in the vitreous?
DR. SCORDI-BELLO: I believe it was higher. Point — sorry, I just have to find it. I think it was 0.26. I'm sorry, I can find it in these notes. I don't —
MR. LALLY: If you have the — May I approach?
JUDGE CANNONE: Yes. Witness provided a copy of the report.
DR. SCORDI-BELLO: It was 0.28.
MR. LALLY: Now, doctor, with respect to the disparity between the BAC contained in the blood and the vitreous humor — what if anything does that indicate to you? What if anything can you take from that?
DR. SCORDI-BELLO: That suggests that the level in Mr. O'Keefe's blood had been higher than 0.21, and that's reflected by the 0.28 that was in the vitreous. The vitreous metabolism of alcohol lags — it's a little slower. It lags behind that of the blood and the circulation. The alcohol is metabolized in the liver. But the fact that it is higher in the vitreous suggests that the level in the blood was also — — higher at some point prior.
MR. LALLY: So at some point, whenever Mr. O'Keefe died, his level of alcohol was on the decrease. Is that fair to say?
DR. SCORDI-BELLO: Correct.
MR. LALLY: Now, with respect to — you mentioned that you had reviewed the EMS reports from Mr. O'Keefe, as well as his medical records. Good Samaritan — is that correct?
DR. SCORDI-BELLO: Correct.
MR. LALLY: And if you could just briefly, for the jury, explain your understanding as far as some of the terms within those medical records — are you familiar, from your review of Mr. O'Keefe's medical records, that he was labeled as being in cardiac arrest?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And can you explain to the jury what that means?
DR. SCORDI-BELLO: Yes. He was labeled as asystolic, or in asystole — — which is basically a flat line. So if you attach leads to the body, there is no electrical activity coming from the heart.
MR. LALLY: Now, with respect to Mr. O'Keefe, certain vital signs were taken in the course of his treatment at Good Samaritan. Is that correct?
DR. SCORDI-BELLO: Yes.
MR. LALLY: Including a core temperature. Is that correct?
DR. SCORDI-BELLO: Yes.
MR. LALLY: Do you recall what that core temperature was?
DR. SCORDI-BELLO: Yes. It was noted as 80.1.
MR. LALLY: And that was a temperature reading that was taken at 7:19 a.m. Is that correct?
DR. SCORDI-BELLO: It was taken — actually, this temperature reading in the records that I'm looking at was taken at 6:57 a.m.
MR. LALLY: And with respect to that 80.1 degree temperature — that's in Fahrenheit. Is that correct?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And so what if any relationship does that have with your hypothermic diagnosis?
DR. SCORDI-BELLO: Well, that is the temperature at this point. Mr. O'Keefe is asystolic, meaning he has no cardiac activity. That is the temperature of his body at the time that he was examined by EMS and taken to the hospital. So it is a very hypothermic temperature. It is well below the 95 degrees which we consider hypothermia.
MR. LALLY: Now, I believe you alluded to it earlier in your testimony, but with respect to hypothermia — what are some of the manifestations of that type of onset as it progresses?
DR. SCORDI-BELLO: Well, the first evidence of hypothermia — which we have no problem in this room — is shivering. When someone starts to get cold, they start to shiver to conserve heat. But then as the body loses more and more heat, there are neurologic consequences. People can get confused — we see this in the elderly all the time. They can get disoriented. And eventually, at very low temperatures — you know, below 90 degrees — everything ceases to function. The heart stops.
MR. LALLY: And would physical weakness, or lack of strength, be one of those manifestations as well?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And how many different stages of hypothermia are there, from the onset of progression to the end?
DR. SCORDI-BELLO: There is mild hypothermia to extreme — severe hypothermia. I may have a moment —
JUDGE CANNONE: Yes.
MR. LALLY: Now, with regards — as far as the type of clothing that someone is wearing when they're outside in these types of conditions, what if any relationship would that have with regard to the quickness or rapidity of the onset of hypothermia?
DR. SCORDI-BELLO: Clearly, the more layers someone has, the slower they will lose heat from their body. The fewer layers, the faster they can become hypothermic.
MR. LALLY: And what if any information did you have as far as how Mr. O'Keefe was dressed when —
DR. SCORDI-BELLO: He was found in the snow on the morning of the 29th. The information that I was given stated that he was wearing a pair of jeans and a long sleeve shirt.
MR. LALLY: Now with respect to someone — as far as that hypothermia onset and rapidity of it — what if any relationship does the condition of the clothing have? What I'm asking there is more sort of the dryness versus wet clothing — what if any relationship does that have?
DR. SCORDI-BELLO: Well, again, wet clothing or wet conditions will speed up the rate at which the body loses heat.
MR. LALLY: Now lastly with regard to this area, doctor, in regards to this having sort of alcohol on board in the system at the time that hypothermia onset — what if any relationship does that have in respect to the onset of hypothermia and the rapidity of that?
DR. SCORDI-BELLO: Alcohol intoxication has been shown to inhibit some of the mechanisms that the body uses to maintain heat, so it's definitely a factor — a negative factor — when it comes to hypothermia.
MR. LALLY: May I approach?
JUDGE CANNONE: Yes.
MR. LALLY: Doctor, I'm handing you a single page document — you can just review that, look up when you're finished. Do you recognize that, doctor?
DR. SCORDI-BELLO: I do. It is a photocopy of the exam notes that I took at the time of autopsy.
MR. LALLY: Okay, does that also contain a body diagram with relation to your notes as far as where you observed injuries on Mr. O'Keefe?
DR. SCORDI-BELLO: Yes.
MR. LALLY: Your Honor, may I approach?
JUDGE CANNONE: Yes.
MR. JACKSON: No objection.
MR. LALLY: Thank you. And Your Honor, with the court's permission, if we can publish this to the jury at this time.
JUDGE CANNONE: Okay.
MR. LALLY: Doctor, there should be somewhere before you on the desk over there — a laser pointer — if you could just focus on the top of the head. Dr. Scordi-Bello, what's up on the screen — is that what you have before you as the next exhibit?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And on this, as far as the examination that you conducted — that also included certain measurements as far as height, weight, things like that that you did with regard to Mr. O'Keefe's body, correct?
DR. SCORDI-BELLO: Correct.
MR. LALLY: And if you could, what did you record as your measurements for both height and weight of Mr. O'Keefe?
DR. SCORDI-BELLO: He was weighed by our staff as 216 pounds and measuring 73 inches, which is 6 foot 1.
MR. LALLY: Now, Doctor, if you could using the laser pointer before you — direct the jury's attention to, starting with the front or facial area and then to the back of the head, but just with reference to the head area — directing their attention to what if anything you observed in the area of the head of Mr. O'Keefe in terms of injuries.
DR. SCORDI-BELLO: You'd like me to point out the injuries? So as I mentioned, there were ecchymoses — that's another word for collection of blood under the upper eyelids — on Mr. O'Keefe. The ecchymosis on the right eyelid was also associated with a very small laceration. Then there was an abrasion on the left side of the nose, and then on the back of the head there was a 3 cm laceration — so this is the right side, it would be towards the back lower side on the right side of the head.
MR. LALLY: And that laceration on the back lower side, right side of the head — is that in the same area that you observed what you described as sort of the originating skull fracture?
DR. SCORDI-BELLO: Yes. When the scalp was reflected, there was bleeding under the scalp in that particular area, and then when the skull was opened, that's the area that appeared fractured and appeared to have other fractures originating or radiating from it.
MR. LALLY: If you wouldn't mind, Doctor — again using the laser pointer, direct the jury's attention to what if any injuries you noted in this sort of middle torso or upper extremity portion of Mr. O'Keefe.
DR. SCORDI-BELLO: So on the right upper extremity — this is the back of the body — we have this collection of linear abrasions. I think the battery is dead. That measured up to 7 cm and extended from the upper arm down to the middle of the forearm.
MR. LALLY: Can I interrupt you for one second? May I? This would be the abrasions. If I could ask you to scroll down for the lower. Again, Doctor, if you could — again using the laser pointer — direct the jury's attention to what if any injuries you observed on the lower extremities.
DR. SCORDI-BELLO: In regard to the lower extremities, there didn't — there wasn't a lot of injuries. There was a small abrasion on his right knee area on the side. And if you don't mind pushing the diagram just a little bit more up to see the hands — there were some contusions or some bruises on the dorsal aspects of the right hand and some very faint bruises on the left.
MR. LALLY: Thank you. May you take that down. May I approach again?
JUDGE CANNONE: Yes.
MR. LALLY: Doctor, if I could show you what's a two-page document — ask you to just review that. Yes, and do you recognize what that is?
DR. SCORDI-BELLO: I do.
MR. LALLY: And what do you recognize that to be?
DR. SCORDI-BELLO: These are copies of diagrams that I used at the time of autopsy to document some of the injuries on the face and the skull.
MR. LALLY: May I approach again, Your Honor?
JUDGE CANNONE: Yes.
MR. JACKSON: No objection.
MR. LALLY: Thank you. [Exhibit] 64. And Your Honor, may I return that to the witness?
MR. LALLY: Seek to introduce and commit to the next exhibit. Any objection?
JUDGE CANNONE: Yes. With the court's permission, if we publish this for the jury. Okay. One moment.
MR. LALLY: Doctor, do you recognize what's up on the screen — is the next exhibit before you?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And if you could, again using the laser pointer, direct the jury's attention to what if anything you observed or noted of significance in these particular diagrams.
DR. SCORDI-BELLO: So the upper eyelids — the areas of the upper eyelids on both sides — had ecchymoses, or blood, under them. On the right side there was a very small laceration or a small tear associated with that. Both eyes had some swelling to them. And then on the nose there were two abrasions, two scrapes — one was small at 0.5 cm, the other one was 1 cm, was linear — and I noted them right there.
MR. LALLY: Again, from the bottom right diagram — for you, Doctor, if you could direct the jury's attention to what if any injuries of significance you noted in that portion of the diagram.
DR. SCORDI-BELLO: This is the area where I noted the laceration to the scalp. I noted something called tissue bridging, which is a morphologic feature of a laceration — is what makes it different from an incised wound or from a cut — because again the skin is crushed and it's more irregular, the edges are more irregular. And then above that laceration, I noted that there was a scrape as well associated with it. So that was one injury.
MR. LALLY: Doctor, if I can direct you to the next page of that exhibit before you. And this — if you could, on the top left — yes. Now, before we get into the diagram that's up on the screen, if I could ask just a bit more — if you could expound upon when you use the term ecchymosis, what exactly does that mean in specific reference to the area of the eyes?
DR. SCORDI-BELLO: Ecchymoses are a word that we use to describe bruising. Orbital ecchymoses or periorbital ecchymosis or supraorbital ecchymosis just refer to the location of the bleeding in relation to the eye. And when we see ecchymoses or bleeding around the eyes, one of the differential diagnoses or one of the etiologies is blunt trauma to the head — and specifically fractures to what is known as the base of the skull. And this is what you're seeing here — the base of the skull.
MR. LALLY: Now, Doctor, if you could using that diagram up on the screen, explain to the jury — we ask first, as far as what were you able to formulate in opinion to a reasonable degree of medical certainty as to how the injuries within the skull and the brain sort of interacted with each other — in particular interacted also with the ecchymosis that you described in the orbital region?
DR. SCORDI-BELLO: So the injuries inside the skull — this is the base of the skull — think of it as the tray where the brain would be sitting on top. The brain has been removed and now we're looking at the bones. Right here is where I noted one of the skull fractures to be, originating — starting with fractures. These are linear fractures that are extending or radiating from this one point of impact. This is known as the posterior fossa of the base. These two chambers are known as the middle cranial fossa, and this area is known as the anterior cranial fossa. As you look at this, the eyes would be sitting back here — so the eyes are actually very intimately associated with the anterior cranial fossa, which is very thin and the bones are quite thin and friable.
DR. SCORDI-BELLO: So an impact to the back of the head — as was in this case, because we do have a laceration and we do have an abrasion, so we know that the head impacted something blunt with enough force to break the skull and enough force for those fractures to propagate or radiate into the middle cranial fossa and also the anterior cranial fossa, which is the front chambers of the base. When the anterior cranial fossa are fractured, as I mentioned, they are very thin bones — blood can seep from this area into the soft tissues and manifest as hemorrhage or bleeding or a contusion or an ecchymosis around the eye when you look at the person's face — when you look at their face. So it is a — well-known fact that fractures to the base of the skull can present with orbital ecchymosis.
DR. SCORDI-BELLO: And that particular manifestation has a name: it's called raccoon eyes, because it resembles what raccoon eyes look like. But Emergency Room physicians are always very alerted to any hemorrhage and any bleeding around the eyes, because it could signify — it could mean — that there's a much bigger injury inside the skull, and that it is not just some bleeding around the eyes, that it actually is associated with a skull fracture. So the ecchymosis itself, as far as the sort of drainage or seepage of blood — that's coming in — that's what causes the eyes to sort of swell up —
MR. LALLY: Is that correct?
DR. SCORDI-BELLO: Correct.
MR. LALLY: And doctor, if I could ask you — with reference, you can illustrate with the laser pointer on the diagram up on the screen — as far as the subarachnoid hemorrhage, sub— subdural hematoma, as far as the bleeding within the brain, what if any impact that has on the skull as far as the fractures are concerned, or this building up of pressure itself?
DR. SCORDI-BELLO: Subarachnoid hemorrhage is a thin layer of hemorrhage on top of the brain, directly on top of the brain, under the leptomeninges. The main effect — or one of the effects — that subarachnoid hemorrhage has is that it is very irritating to the brain and can lead to seizures. Subdural hemorrhage is hemorrhage that is due to veins in the dura — that very tough protective cover on top of the brain — that are broken and leak blood into the space between the dura and the brain. That kind of injury, given enough time, you can have accumulation of the blood and it can cause significant shift into the brain. That's not something that we had here. Here we had some subdural hemorrhage, but not enough that it was what we call space-occupying, but it was present.
DR. SCORDI-BELLO: So it was due to bridging veins and the dura being injured from the trauma, from the fractures. And in terms of the effect that all these injuries have — the subdural and the subarachnoid — and the skull fractures: anytime the brain is injured, it responds by swelling. And the skull is a closed space without the ability to expand — unlike the skin, where you can have a bruise or a significant amount of blood accumulate under the skin. In the skull, once the brain starts to react to the injury and it starts to swell, there's nowhere to go except for down, and that's the foramen magnum. That is the area where the brain stem and the spinal cord will run out — you know, the spinal cord connects obviously the brain to the rest of the body.
DR. SCORDI-BELLO: And this is one of the few spaces that the brain can try and squeeze into, because it has nowhere else to go. So herniation — brain swelling and herniation — are a general response that the brain has to any sort of trauma.
MR. LALLY: Thank you very much. We can have the lights back on. May I approach?
JUDGE CANNONE: Yes.
MR. LALLY: Now doctor, with respect to the head injury specifically — the fracture — what if any opinion can you give, or can you say, in regard to the type of force or amount of force necessary to cause the fracture to the skull that you observed with regard to [unintelligible]?
DR. SCORDI-BELLO: I can't really give you a number. I'm not a physicist. I can tell you that the skull is a pretty thick bone — it takes a considerable amount of force to fracture the skull — so that was a pretty considerable impact.
MR. LALLY: Now with respect to the injuries to Mr. O'Keefe's head and the onset of hypothermia, what if any opinion do you have with regard to the timing of those respective to each other?
DR. SCORDI-BELLO: Well, I do believe the injuries — the blunt impact injuries — were sustained first. These are not injuries that are immediately lethal. This is not something that would cause death in seconds. And therefore Mr. O'Keefe may have been incapacitated by the injuries, or knocked out if you will, and was not able to get himself into a warmer environment, and therefore hypothermia set in, given the environmental conditions and given the clothing on the body — or the lack of clothing, I should say — no big jacket or anything like that.
MR. LALLY: Now when you say something as far as a type of injury being immediately lethal — can you give an example of that?
DR. SCORDI-BELLO: The one that forensic pathologists like to use is a gunshot wound to the head that goes from one side to the other, disrupting the neural systems of the brain and causing the person to immediately drop and die within seconds or milliseconds. This is not that kind of injury. This is an injury that took a little bit of time to develop, as is manifested by the fact that we have some bleeding, which means that the heart is still pumping and blood is still coming out of the vessels.
MR. LALLY: And so I guess to that point — as far as what was it, from your examination and your findings and your review of sort of the overall materials — that leads you to believe that the head injuries happened prior to hypothermia setting in?
DR. SCORDI-BELLO: Again, the findings of hypothermia — the blunt impact injuries — if someone is... it's not completely out of the realm of possibility that someone becomes hypothermic and then falls as a result. But the hypothermia would continue, along with the brain injuries that took some time to develop. So in my opinion, I believe the impact — the injury to the head — came first. Mr. O'Keefe was most likely incapacitated, or unable to move into a warmer environment, and then the hypothermia set in.
MR. LALLY: And if you can — what if anything can you say, in contrast to the bullet to the head or the instantaneous death, what if anything can you say as to the time that this would take to manifest itself, as far as the injury to the head and the hypothermic state?
DR. SCORDI-BELLO: Again, I can't give you specifics. I would say this was definitely in the matter of minutes — many minutes or hours.
MR. LALLY: Let me have a moment.
JUDGE CANNONE: Yes.
MR. LALLY: Now doctor, you had mentioned that at some point you had reviewed some photographs from the scene where Mr. O'Keefe's body was recovered — is that correct?
DR. SCORDI-BELLO: Yes, I was shown some photographs.
MR. LALLY: And from the photographs that you were shown, what if anything of significance did you observe — or lack thereof — in the area where Mr. O'Keefe's body was recovered?
DR. SCORDI-BELLO: Well, based on those photographs — a limited number of photographs that I saw and was shown — there didn't appear to be a lot of disruption around the area where I was told that Mr. O'Keefe's body was found.
MR. LALLY: And that lack of disruption in the snow around where Mr. O'Keefe's body was found — what if any significance would that have to you from a diagnostic perspective?
DR. SCORDI-BELLO: Well, it suggests that he really didn't travel a very long distance once the injury was inflicted.
MR. LALLY: And as far as anything related to footprints, drag marks, anything like that — did you observe anything like that in that area?
DR. SCORDI-BELLO: On the pictures that I saw, no.
MR. LALLY: Now from the extent of your examination of Mr. O'Keefe's body, what if anything did you observe that would indicate any sort of altercation or a fight or anything like that?
DR. SCORDI-BELLO: I didn't see any major signs of what I would call a significant altercation.
MR. LALLY: And with regard to that — as far as signs — what are some of the signs and what would you be expecting to see, and what was lacking as far as your observations of Mr. O'Keefe?
DR. SCORDI-BELLO: I looked at Mr. O'Keefe's hands. As you saw on the diagrams, I did document that there were some contusions on the dorsal aspect — a very vague and faint contusion on the left, and a contusion on the right hand. That particular contusion has a central little pinpoint mark that may suggest that it was due to attempts to get IV access on his hand — that's a very common place. But I didn't see any bruising on Mr. O'Keefe's knuckles. His nails were intact. I didn't see any breaks on his nails, and I didn't see any fractures — or feel any fractures — on any of his hands.
MR. LALLY: Now with respect to the diagrams that were up on the screen before, as well as your observations from internal examination — you observed some fractures to Mr. O'Keefe's ribs, is that correct?
DR. SCORDI-BELLO: Yes. He did have some fractures — I believe to the fourth and fifth ribs near the sternum. It's a very common location for CPR-associated fractures.
MR. LALLY: And so, I believe you just alluded to it right there, but as far as any fractures to Mr. O'Keefe's ribs — what if any opinion do you have as to the origination or causality of those rib fractures?
DR. SCORDI-BELLO: As I mentioned, those are very consistent with resuscitation. We see those quite often. Given the history that I was provided — that extensive resuscitation was attempted — I documented those as most likely due to resuscitation.
MR. LALLY: Now doctor, with regard to — just by way of contrast — you talked a bit about the significant impact or the thickness of the skull. How does that relate to the area of the ribs that you're talking about, as far as what can be fractured during resuscitation?
DR. SCORDI-BELLO: Well, I don't understand the question.
MR. LALLY: Let me rephrase. What is the difference, sort of, between the thickness of the bone in the skull versus the thickness of the bone in the ribs?
DR. SCORDI-BELLO: The skull in general is a thicker bone. It requires more force.
MR. LALLY: Now doctor, if I could — are you familiar with a medical term known as vasodilation?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And can you explain... what that term is and how it relates to Mr. O'Keefe's condition?
DR. SCORDI-BELLO: I can explain what the term is. Vasodilation means opening up — "vaso" refers to blood vessels, so vasodilation is the opening up of blood vessels to bring more blood to the extremities or any part of the body. And again, that's a bit of an unfair question as far as the relation, but —
MR. LALLY: So how does that manifest itself as far as someone who's in colder conditions, or has that sort of onset of hypothermia? What, if any, relation does the vasodilation have to that?
DR. SCORDI-BELLO: Well, you can see vasodilation — you can see vasoconstriction and vasodilation in hypothermia. Initially the blood — vessels will constrict in an attempt to reduce blood flow to the extremity so there's no heat loss. Anyone who has been out in the cold knows what that feels like. But then ultimately the blood vessels will dilate, bringing more blood to the extremities again. The normal regulatory mechanisms that the brain has to maintain our body temperature are disrupted when you get into those very low temperatures, and therefore sometimes in hypothermia you can see very, very red extremities due to vasodilation.
MR. LALLY: And with regard to the redness due to vasodilation, is there also a whiteness — sort of discoloration to the — extremities that can be observed in hypothermic patients as well?
DR. SCORDI-BELLO: That's been described as well, yes.
MR. LALLY: Now, with reference to when you made your observations of Mr. O'Keefe — why is it that — well, let me ask you this: you didn't see any signs of vasodilation or white fingertips or anything like that, is that correct?
DR. SCORDI-BELLO: Correct. I rarely see signs of vasodilation, especially if someone has died in the hospital.
MR. LALLY: Can you explain to the jury sort of why that is?
DR. SCORDI-BELLO: So, for two reasons. In this particular case, Mr. O'Keefe was taken to the hospital and attempts were made at rewarming the body. So he was given warm intravenous — fluids, and attempts were made to bring the body temperature up with the hope that the heart would start working once that happened. Also, I did not physically see the body until Monday morning, and therefore I can't really comment on vasodilation or any effects that hypothermia may or may not have had acutely on the body, because I'm seeing the body hours after death, and already the body has been transferred from the scene to the hospital, stored at the hospital, and then transferred from the hospital to our facility.
DR. SCORDI-BELLO: So there's just too much time between when the body was — discovered to when I looked at the body to make any reasonable comments on whether there was vasodilation or not.
MR. LALLY: Approach?
JUDGE CANNONE: Yes.
MR. LALLY: Doctor, I'm showing you a series of five photographs, ask you to review those — [garbled/cut off]
JUDGE CANNONE: I'm actually going to look at these side by side, please — [unintelligible] — and having looked at the photographs, it makes sense that we break for today, and we'll start fresh with this tomorrow, rather than showing these to the jury now. So thank you. So we are going to end for today. We are on track — maybe — we are definitely on track for finishing this case next week, partly because of staying all day tomorrow and some of the work we did today and on Tuesday. When you do so, please follow the three instructions: do not discuss this case with anyone, don't do any independent research or investigation into the case; if you happen to see, hear, or read anything — about the case, please disregard it, let us know. We'll see you tomorrow. Thank you.
JUDGE CANNONE: Leave your notebooks on your chair, take all your belongings.
COURT OFFICER: All rise. You can file out right after, thank you.
JUDGE CANNONE: May be seated, thank you. It does seem like an appropriate place to stop. Does anybody — so we're still in session. Does anybody need me for anything now?
COURT OFFICER: All rise. The court — please — for —