Commonwealth v. Read — Trial ArchiveIrini Scordi-Bello — Direct (Part 1)
455 linesMR. LALLY: Yes, Your Honor. IRINI SCORDI-BELLO, sworn
JUDGE CANNONE: Good afternoon, Doctor.
DR. SCORDI-BELLO: Good afternoon.
JUDGE CANNONE: All right. Mr. Lally, whenever you're ready.
DIRECT EXAMINATION BY MR. LALLY:
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'm 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 medical examiner for the Office of the Chief Medical Examiner of Massachusetts?
DR. SCORDI-BELLO: I have been with OCME in Massachusetts since the -- 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, work history a little bit prior to working at the OCME in Massachusetts. If I could start with your undergraduate work as far as 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 from there?
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 three 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 of the 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: And what are you board certified in?
DR. SCORDI-BELLO: I'm board certified in atomic 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 is 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 as far as NAME; is that correct?
DR. SCORDI-BELLO: NAME, 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 field?
DR. SCORDI-BELLO: I have 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 program -- education program in New York City. So I've always been involved with teaching both pathology and forensic pathology.
MR. LALLY: Now two of those terms themselves, if I could ask you briefly, just to describe to the jury, as far as pathology in a general sense, what is -- what is pathology?
DR. SCORDI-BELLO: Pathology is a specialty of medicine, and pathology looks at disease processes and 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 that?
DR. SCORDI-BELLO: Anatomic pathology, as opposed to clinical pathology, is anything -- any -- has to do with any organ that is in the body versus clinical pathology that deals with fluids and blood analysis and things like that. So anatomic pathology, a lot of anatomic pathologists, are surgical pathologists. That's another term that you will hear. These are pathologists in the hospital that look at tissues under the microscope and they 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 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 and experience in regard to forensic pathology with the term called autopsy?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And is that something that typically you would do in the case of sort of your investigation and your analysis in regard to pathological analysis when it came to a body or a patient that comes in?
DR. SCORDI-BELLO: Yes, an autopsy is a procedure that we do to determine the cause and manner of death.
MR. LALLY: And so, Doctor, with respect to an autopsy, it may be a term that's pretty well understood, but if you could explain in general terms, as far as when a body or a patient comes in to the OCME, as far as what is an autopsy, what is involved in it, and sort of what is that consist of?
DR. SCORDI-BELLO: Yes, when a case -- 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 not natural causes, all accidents, intoxications, deaths of babies and children and deaths in 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, a facility -- these. 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. The body is processed. What that means is that their 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: And as far as an autopsy is concerned, there are two sort of primary components of that 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 and again general terms sort of 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 once we're during the external examination, sometimes we will take evidence. We will collect hair and nails from the body we think that that is necessary or warranted. And once the external examination is done, then we proceed to the internal examination. 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 open. The brain is removed, and we document any disease or injury.
MR. LALLY: Now, turning your attention to January 31, 2022, did you have occasion to perform an autopsy in regard to a patient or a body of John O'Keefe?
DR. SCORDI-BELLO: I did.
MR. LALLY: And do you recall which of -- you mentioned there were three different officers of the chief medical examiner within the state of Massachusetts, correct?
DR. SCORDI-BELLO: Yes, it was in the Cape Cod 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. I -- 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 the 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 of Mr. O'Keefe?
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 sort of what are the different types of manner and death, and how are they sort of classified from a perspective from 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 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. 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, more -- most drug overdoses, most, you know, elderly falls are classified as accidents. The fatal outcome was not intentional.
Homicide is a manner of death when we use when there is injury inflicted by another person, but there is evidence that there was intent to cause fear, harm, or death to the other individual. 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, they 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. 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 --
MS. LITTLE: Objection.
JUDGE CANNONE: So watch the leading questions, Mr. Lally. It's sustained.
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 a -- 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 is manner of death, when, specifically, when I'm talking about something that could be ruled or listed as manner of death as absent, is that -- what, if anything -- what if any determination are you making as far as that is concerned?
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: Thank you. Am I correct in saying that routinely people charge with, say, motor vehicle homicides, it gets classified as a manner of death as accident, correct?
MS. LITTLE: Objection.
JUDGE CANNONE: Sustained.
MR. LALLY: May I approach, Your Honor?
JUDGE CANNONE: Yes.
MR. LALLY: Doctor, I'm showing you a document. Ask you to review it, look up when you're finished.
DR. SCORDI-BELLO: (Witness complies.) Yes.
MR. LALLY: And do you recognize that document, Doctor?
DR. SCORDI-BELLO: I do.
MR. LALLY: 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 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 of death?
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 did you not determine that this was either suicide or natural causes, correct?
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?
DR. SCORDI-BELLO: The two manners of death that remain are accident and homicide.
MR. LALLY: Your Honor, may I approach?
JUDGE CANNONE: Yes.
MR. LALLY: The Commonwealth would seek to introduce and admit as the next exhibit.
MS. LITTLE: No objection.
JUDGE CANNONE: Okay.
(Whereupon Exhibit No. 642, Death Certificate of John O'Keefe, was marked as an exhibit.)
MR. LALLY: 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 -- blunt force injury?
DR. SCORDI-BELLO: Blunt force injuries are caused by any blunt object that is 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, where -- whereabout, 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 death -- 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, or there was -- it was associated with an abrasion, a scrape.
MR. LALLY: Now in terms of the extremities, and I'll start with 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, he had a number of somewhat linear, somewhat patterned abrasions, scrapes, varying sizes ranging from small - 2 to 3 millimeters - to, I believe, 5 or 6 centimeters, 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 that I measured and documented. He had some other -- 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 sure.
JUDGE CANNONE: You can go ahead and look at your notes anytime you need to, Doctor.
DR. SCORDI-BELLO: I can go into my notes?
JUDGE CANNONE: Yes. A So as far as his extremities, I noted a 3 centimeter superficial abrasion to his right medial upper arm. That would be the medial aspect would be the inner aspect of the right arm. I noted the abrasions on his posterior right arm and forearm. Those ranged from 3 millimeters to up to 7 centimeters. 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. Q Now, I think you've defined it fairly well so far, but I'm just going to ask you this 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 from a medical perspective? A 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, I -- and I break blood vessels and 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? I-N-C-I --
DR. SCORDI-BELLO: Incised, yes.
MR. LALLY: If you could explain the difference between sort of the mechanism and sort of what you observe between a laceration and an incised wound?
DR. SCORDI-BELLO: So an incised wound is what I 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, 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 a -- an incised wound, it's a -- 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.
MR. LALLY: So the opposite of posterior would be what?
DR. SCORDI-BELLO: Would be anterior and it would be this area right here that cleans up.
MR. LALLY: And as far as --
DR. SCORDI-BELLO: Or forward.
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? A I, again, I noted in my -- 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 I instead of examining it right then and there, I saved it in a special solution, and I sent it to our office in Boston for a 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: Yes.
MR. LALLY: And with reference to the fractures there, 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 exam?
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, what, if anything, as far as your observations of the skull in that point and the -- I'm sorry. Which part of the skull was the originating fracture?
DR. SCORDI-BELLO: This would be the back of the skull, slightly right of midline.
MR. LALLY: Is that the medical term that that's referred to as?
DR. SCORDI-BELLO: I'm sorry?
MR. LALLY: Is there a medical term that that's referred to as far as the right rear, sort of?
DR. SCORDI-BELLO: 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 multiple fractures in the skull that you observed?
DR. SCORDI-BELLO: Again, observing or looking at the skull fractures and their pattern, there appear 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: And would that be sort of the point of impact between the blunt object and Mr. O'Keefe's head?
DR. SCORDI-BELLO: Right.
MR. LALLY: Now, with reference to the fractures that you would observe, 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.
MR. LALLY: May I have a moment, Your Honor?
JUDGE CANNONE: Yes.
MR. LALLY: Now, when you're conducting this internal examination, is there a sort of 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 examination?
DR. SCORDI-BELLO: 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. Doctor, you can step down if you'd like, too. You don't have to but you can step down if you want to, and I'd ask that you just follow the jurors.
DR. SCORDI-BELLO: I'll hold this. Thank you.
(Jury out.)
JUDGE CANNONE: I'll see counsel at sidebar.
(Sidebar commences:
JUDGE CANNONE: Court Order: Jurors or Juror Issue So we’ll take a five minute break. How much longer do you think you have with this witness? I’m not rushing.
MR. LALLY: No, no. Half-hour, 40 minutes. Somewhere in there. How long do you think you might have?
MS. LITTLE: I would say a half-hour.
JUDGE CANNONE: All right. So maybe we’ll –
MR. YANNETTI: Is it the Court's intention to hear the required finding argument today or tomorrow.
JUDGE CANNONE: We’ll do that tomorrow morning, if the Commonwealth rests. You're more optimistic than I am. All right. Thank you. So we’ll take a five or ten minute break.
end of sidebar.)
(Jury out.)
(Court in recess.)
(Court in session.)
(Defendant is present with counsel.)
(Jury in.)
JUDGE CANNONE: All right, Mr. Lally.
MR. LALLY: (By 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 give -- 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 hyperthermia?
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 and based on other types of literature that you've reviewed in regard to hypothermia, what is as far as these Wischnewski spots -- and thank you very much for saving me for 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. There -- 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 these 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 and 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 hypothermic diagnosis?
DR. SCORDI-BELLO: When the case was called into our office and when we accepted the case, it was -- 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, and 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 death.
MR. LALLY: Now, I probably should have asked this first as a precursor, but when you use the term hypothermia, what do you understand -- what does hypothermia mean from a medical diagnostic?
DR. SCORDI-BELLO: Hypothermia is a term used to describe low body temperature - by definition 35 degrees 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 degrees or 37 degrees centigrade, so anything higher than that is considered a fever or hyperthermia. Anything lower, lower than 35 degrees centigrade or 95 degrees Fahrenheit, is considered hypothermia.
MR. LALLY: Now, if you could explain to the jury sort of a little bit about the type of diagnosis that is involved in hypothermia, and sort of what other sort of 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 degrees and 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 goes out to shovel their driveway, suffers a heart attack, and drops to the ground and is dead within seconds, and no one discovers their body for a few hours during the storm. When they're found, their asystolic -- their core body temperature is 80 degrees. But the autopsy shows another reason for their death. It shows 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. It 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, that goes out into bad weather, gets confused, loses their direction, doesn't -- 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. 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 what if any other materials did you review in relation?
DR. SCORDI-BELLO: I was provided with a police report and an 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, as I mentioned, all the information from the investigators, the autopsy findings, the neuropathology findings, and came to 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 with regard to Mr. O'Keefe?
DR. SCORDI-BELLO: Mr. O'Keefe 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 .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 sort of what that is, where that sample is taken from and why it is?
DR. SCORDI-BELLO: Yeah, 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, you know, the individual is.
MR. LALLY: And so based on sort of the disparity between the vitreous humor level and the -- I'm sorry I may not have asked. What was the level in the vitreous humor?
DR. SCORDI-BELLO: I believe it was higher point -- I'm sorry. I just have to find it. It was .26. I'm sorry. I can't find it in this notes. I don't know if you have the --
MR. LALLY: Your Honor, may I approach?
JUDGE CANNONE: Yes.
MR. LALLY: Showing you a copy of the toxicology report?
DR. SCORDI-BELLO: Yes, it was 0.28.
MR. LALLY: Now, Doctor, with respect to the disparity between what was contained as a BAC in vitreous humor versus the other number from his blood, what, if anything, does that indicate to you as far or what if anything did you take from??
DR. SCORDI-BELLO: That suggests that the level in Mr. O'Keefe's blood had been higher than .21, and that's reflected by the .28 that was in the vitreous. The vitreous metabolism of alcohol lags. It's a little slower, lags behind that of the -- 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 have reviewed the EMS reports of Mr. O'Keefe as well as his medical records from 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 with 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 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, as far as certain vital signs were taken in the course of his treatment at the 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, or what if any relationship does that have to 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 taken to -- 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. 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 be or lack of strength be one of those manifestations as well?
DR. SCORDI-BELLO: Yes.
MR. LALLY: And how many different sort of stages of hypothermia are there from the beginning of or onset of progression to the end?
DR. SCORDI-BELLO: There is mild hypothermia to extreme severe hypothermia.
MR. LALLY: If may I have a moment, Your Honor.
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 the 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: What if any information did you have as far as how Mr. O'Keefe was dressed when he was found in the snow on the morning of 29th?
DR. SCORDI-BELLO: 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 with the condition of the clothing -- what I'm asking there is more sort of the dryness versus wet clothing, what if any relationship would that have?
DR. SCORDI-BELLO: 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 regard to Mr. O'Keefe having sort of alcohol on board in his system at the time that hypothermia onsets, what if any relationship does that have in respect to the onset of hypothermia and the rapidity of that?
DR. SCORDI-BELLO: Alcohol intoxication, it has been shown to inhibit some of the mechanisms that the body uses to maintain heat. So it's definitely a factor that is a negative factor when it comes to hypothermia.
MR. LALLY: Your Honor, may I approach?
JUDGE CANNONE: Yes.
MR. LALLY: So, Doctor, I'm showing you a single-paged document. If you could just review that, and look up when you're finished.
DR. SCORDI-BELLO: (Witness complies.) Yes.
MR. LALLY: And 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: 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. LALLY: Commonwealth would seek to introduce it as the next exhibit.
MS. LITTLE: No objection.
JUDGE CANNONE: Thank you.
(Whereupon Exhibit No. 643, Diagram of Injuries on Body from Medical Examiner, was marked as an exhibit.)
MR. LALLY: And, Your Honor, with the Court's permission, if we could publish that 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.
MR. LALLY: Ms. Gilman, if you could mark that just a bit, if you could focus in towards the top of the head.
MR. LALLY: Now, 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 the weight of Mr. O'Keefe?
DR. SCORDI-BELLO: He was weighed by our staff as 216 pounds and measuring 73 inches, which is 6 feet 1 inch.
MR. LALLY: Now, Doctor, if you could using the laser pointer before you, direct the jury's attention to starting with the front or the 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?
DR. SCORDI-BELLO: In terms of injuries?
MR. LALLY: Yes.
DR. SCORDI-BELLO: Would you like me to point out the injuries? So as I mentioned, there were ecchymosis. 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 centimeter laceration. So this is the right side. It would be towards, you know, the back lower side on the right side of the head.
MR. LALLY: And that laceration on the black(sic) lower side or 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 -- 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: Ms. Gilman, if you wouldn't mind scrolling down to sort of the middle of the torso.
MR. LALLY: And, Dr. Scordi-Bello, if you could again using the laser pointer just direct jury's attention to what if any injuries you noted in this sort of middle torso or upper extremity portion of this photo?
DR. SCORDI-BELLO: So on the right upper extremity, and, again, 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 centimeters and extended from the upper arm down to the middle of the forearm.
MR. LALLY: If I could interrupt you for one second. May I switch with you?
DR. SCORDI-BELLO: Thanks. This would be the abrasions.
MR. LALLY: And, Ms. Gilman, if I could ask you to scroll down for the lower extremities.
MR. LALLY: Again, Dr. Scordi-Bello, if you could again using the laser pointer direct the jury's attention to what, if any, injuries you observed on the lower extremities in regards to Mr. O'Keefe?
DR. SCORDI-BELLO: The lower extremities, didn't have 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 bruise on the left.
MR. LALLY: Ms. Gilman, you can take that down. Your Honor, 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 and look up when you're finished.
DR. SCORDI-BELLO: (Witness complies.) Yes.
MR. LALLY: 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. LALLY: Commonwealth would seek to introduce and admit as the next exhibit.
JUDGE CANNONE: Any objection?
MS. LITTLE: No objection.
JUDGE CANNONE: Thank you.
(Whereupon Exhibit No. 644, Diagram of Injuries on Head from Medical Examiner, was marked as an exhibit.)
MR. LALLY: And, Your Honor, may I return that to the witness?
JUDGE CANNONE: Yes.
MR. LALLY: With the Court's permission, if we could publish that for the jury.
JUDGE CANNONE: Okay.
MR. LALLY: May I have moment, Your Honor?
JUDGE CANNONE: Yep.
MR. LALLY: Dr. Scordi-Bello, do you recognize what's depicted up on the screen as 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 ecchymosis 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, .5 centimeters. The other one was 1 centimeter and it was linear, and I noted them right there.
MR. LALLY: Ms. Gilman, if you could scroll down a bit.
MR. LALLY: And again from the bottom right diagram before you, Doctor, if you could using the (indiscernible) direct the jurors' attention to what if any injuries or significance you noted in that portion of that 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 the laceration is what makes it different from an incised wound or from a cut because again, the skin is crushed, and now 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: And, Ms. Gilman, if I could have the next page of that.
MR. LALLY: Doctor if I direct you to the next page of that exhibit before you.
MR. LALLY: And, Ms. Gillman, if you could (indiscernible) top left diagram?
DR. SCORDI-BELLO: Yes.
MR. LALLY: Now, Doctor, before we get into a 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: Ecchymosis are a word that we use to describe bruising, orbital ecchymosis or periorbital ecchymosis, or supraorbital ecchymosis, just referred to the location of the bleeding in relation to the eye. And when we see ecchymosis or bleeding around the eyes, one of the differential diagnoses, 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 what you're seeing here is the base of the skull.
MR. LALLY: Now, Doctor, if you could using that diagram up on the screen, explain to the jury -- well, let me ask first. Were you able to formulate an 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. This is -- 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 the skull -- one of the skull fractures to be originating or 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.
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 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 and that particular manifestation has a name. It's called raccoon eye because it resembles, I guess, 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 or it could mean that there's a much bigger injury inside the skull, and that that is not just some bleeding around the eyes, that it actually is associated with a skull fracture.
MR. LALLY: So the ecchymosis itself, as far as the sort of drainage or seepage of blood that's coming into, that's what causes the eyes to sort of swell up; is that correct?
DR. SCORDI-BELLO: Correct.
MR. LALLY: And, Doctor, if I could ask you with reference to -- if you could illustrate with the laser pointer on the diagram up on the screen, as far as the subarachnoid hemorrhage, 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 the 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 I guess one of the effects, the 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 you can cause significant shift in to 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. So it was due to bridging veins in 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. You know, spinal cord connects, obviously, the brain to the rest of the body, and this is one of the few spaces that the brain can try and squeeze into because he 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: And, Ms. Gilman, thank you very much. You can take that down and put the lights back on. Your Honor, may I approach just to retrieve?
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 Mr. O'Keefe?
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 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 that 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 some 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 that the hypothermia would continue along with, you know, 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 as to the sort of in contrast to sort of 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: If I may have a moment, Your Honor.
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, limited number of photographs that I saw and I 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 sort of disruption in the snow around where Mr. O'Keefe's body was found, what if any significance would that have for you as far as 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 your extent of your examination of Mr. O'Keefe's body, what, if anything, that you -- did you observe that would indicate any sort of altercation or a fight or anything like that Mr. O'Keefe was in?
DR. SCORDI-BELLO: I didn't see any signs, 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 in the diagrams, I did document that there were some contusions on the dorsal aspect, very vague and faint contusion on the left, and 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 very commonplace. 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 origin -- 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 the -- 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 can be fractured in resuscitated efforts?
DR. SCORDI-BELLO: Well -- I don't understand the question.
MR. LALLY: Let me rephrase. What is the difference sort of between thickness of the bone and the skull versus the thickness of the bone and 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 vessel. So vasodilation is the opening up of blood vessels to bring more blood to the extremities or any part of the body.
MR. LALLY: And again, that's a bit of an unfair question as me as far as relations, but -- 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: 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 extremities so there's no heat loss. Anyone who has Raynaud's knows what that feels like. 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 make 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: And can you explain to the jury, sort of why that is?
DR. SCORDI-BELLO: So for two reasons. In this particular reason, 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 on 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. 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: May I approach, Your Honor?
JUDGE CANNONE: Yes.
MR. LALLY: Doctor, I'm showing you a series of five photographs. I'd ask you to review those and look up when you're finished.
DR. SCORDI-BELLO: (Witness complies.)
JUDGE CANNONE: I'm actually going to see counsel at sidebar for a minute, please.
(Sidebar commences:
JUDGE CANNONE: So it's 4:15. We've got a series of five photographs.
MR. LALLY: I was actually going to ask if it makes sense to display these. It's --
JUDGE CANNONE: You won't finish in five minutes, right?
MR. LALLY: No.
JUDGE CANNONE: All right. So it seems like it's a good place -- I was not going to (indiscernible) so it seems like a good place to stop. I'm looking at the photos. So these are the groups of photographs that I don't necessarily think should be thrown right up on the screen, and we'll send the jurors home. Does it make sense to break now?
MR. LALLY: I'm fine with that.
MS. LITTLE: I'm fine with that.
end of sidebar.)
JUDGE CANNONE: Before we get into this next area and having looked at the photographs, it makes sense that we break for today and we'll start fresh with us tomorrow, rather than showing these to folks 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, probably because of staying all day tomorrow and some of the work we did today and on Tuesday. 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 morning.
(Jury out.)
JUDGE CANNONE: And, Doctor, you can file out right out after.
(Witness exits.)
JUDGE CANNONE: Thank you. It does seem like the appropriate place to stop. Does anybody –
COURT OFFICER: Quiet, folks.
JUDGE CANNONE: So we're still in session. Does anybody need me for anything now?
MR. LALLY: If we could just approach briefly just regarding scheduling, Your Honor.
JUDGE CANNONE: Yep.
(Sidebar commences:
MR. LALLY: Your Honor, I'm sorry. Just if I could inquire of counsel just as far as now that we're anticipated on going a full day tomorrow, what --
JUDGE CANNONE: Let me just ask you, Dr. Scordi-Bello is your last witness, right?
MR. LALLY: Yes.
JUDGE CANNONE: All right. So how much longer do you have? Your estimate of half hour, forty-five minutes was way off.
MR. LALLY: It was and I apologize.
JUDGE CANNONE: That's okay. But how much time -- how much more time --
MR. LALLY: I would say covering the photos 20, 25 minutes. I don't think there's much left.
JUDGE CANNONE: All right. So that's a half an hour, 45 minutes, an hour. How much time -- do you need an hour, Ms. Little?
MS. LITTLE: I'd say 30 to 45 minutes.
JUDGE CANNONE: All right. So that takes us to probably. And then who are your witnesses for tomorrow? Is it Mr. Green?
MR. JACKSON: It is. We'll start with Mr. Loughran, then go to Mr. Green. I just made, while I was a counsel table, I was able to make flight arrangements for Dr. Russell.
JUDGE CANNONE: You don't have anyone in your office that could do that for you?
MR. JACKSON: Wouldn't that be nice?
JUDGE CANNONE: I did not see that. If I didn't see that, I don't think the jurors did.
MR. JACKSON: I was undercover. So those are the three witnesses we have. The only other thing procedurally that we have is I need ten minutes of the Court's time to make a motion that we need to make statutorily, and that's it. So in that order: Loughran, Green, and Russell.
JUDGE CANNONE: So how long is Loughran? I'm just figuring out mid-morning break.
MR. YANNETTI: He's my witness. I can't imagine with direct and cross he'll be longer than an hour.
JUDGE CANNONE: Okay. And how long is Dr. Green.
MR. YANNETTI: That's mine as well. I mean, I don't know how lengthy the cross will be. Maybe I'll be an hour with him on direct.
MR. JACKSON: And the Court had a really good indicator of Dr. Russell's direct and I'm going to leave it basically at that. What the voir dire was is going to mirror what I'll do with Dr. Russell.
MR. YANNETTI: We don't have any other witnesses tomorrow other than those --
JUDGE CANNONE: I'm not sure we'll get through them all.
MR. JACKSON: We're not going to -- I hope we get to. I don't think so.
JUDGE CANNONE: All right. Assuming we don't get to them, when is your best estimate, Mr. Jackson, as to when you would then -- so who do you have after?
MR. JACKSON: After Dr. Russell, we will have Dr. Sheridan and the two individuals from Parca.
JUDGE CANNONE: Okay.
MR. JACKSON: And we're done.
JUDGE CANNONE: Okay. So it sounds like maybe Tuesday.
MR. JACKSON: Tuesday or going into the morning on Wednesday.
JUDGE CANNONE: Okay. And if there's any rebuttal, have that ready for Tuesday or Wednesday.
MR. LALLY: Sure.
JUDGE CANNONE: All right.
MR. JACKSON: How long is the charge --
JUDGE CANNONE: Probably -- oh, the charge conference?
MR. JACKSON: Yes, ma'am.
JUDGE CANNONE: However much time we need.
MR. JACKSON: Is it an hour or two hours?
JUDGE CANNONE: Oh, God, not two hours.
MR. YANNETTI: I think what he's getting at is what do you anticipate in terms of the timing of, you know, close of evidence and charge conference, closing argument.
JUDGE CANNONE: Let's maybe have the charge conference before the close of evidence if it makes sense timing-wise. So I'm not going to stop everything to have a charge conference because then I can't charge immediately after you argue. So we'll figure it out. I'm sure there will be sometime early next week where we can.
MR. YANNETTI: And just for my co-counsel's sake, do you anticipate last witness testifies, both sides rest, and going immediately into closings, or do you anticipate the next morning, or?
JUDGE CANNONE: It depends. If it's now, it's next morning.
MR. YANNETTI: Yeah.
JUDGE CANNONE: If it's noontime, it's that day.
MR. YANNETTI: Got you.
JUDGE CANNONE: If it's two o'clock it might be that day, too.
MR. YANNETTI: We just don't know if we don't ask the question.
JUDGE CANNONE: And nobody will know until we get to that point.
MR. YANNETTI: Understood.
JUDGE CANNONE: Okay. All right.
MR. JACKSON: Thank you, Your Honor.
JUDGE CANNONE: See you tomorrow.
(Court in recess.)