Commonwealth v. Read — Trial ArchiveRenee Stonebridge - Direct
116 linesJUDGE CANNONE: All right, thank you. Your next witness, Mr. Lally?
MR. LALLY: Yes, the People call Dr. Renee Stonebridge to the stand.
JUDGE CANNONE: Okay.
COURT OFFICER: Could you please watch your step.
COURT CLERK: You do 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. STONEBRIDGE: Yes.
JUDGE CANNONE: Thank you. So once you sit, I'm going to tell you that you have to keep your voice up. We want to keep our air conditioning on, so just if you'd speak loudly into the microphone, that would be great.
DR. STONEBRIDGE: Yes, thank you.
JUDGE CANNONE: Go ahead, Mr. Lally.
MR. LALLY: Good afternoon.
DR. STONEBRIDGE: Good afternoon.
MR. LALLY: Could you please state your name and spell your last name for the jury?
DR. STONEBRIDGE: Yes, my name is Renee Stonebridge. Last name: Stonebridge, S-T-O-N-E-B-R-I-D-G-E.
MR. LALLY: And what do you do for work?
DR. STONEBRIDGE: I am employed through the chief medical examiner's office at Boston as director of cardiac and neuropathology and medical examiner.
MR. LALLY: Now, if I could ask you just a few questions about sort of your educational and work history background, if that's okay?
DR. STONEBRIDGE: Yes.
MR. LALLY: Starting with your bachelor's degree, where did you go and what, if any, area did you receive a degree in?
DR. STONEBRIDGE: So I went to SUNY at Stony Brook in New York. I was a double major in biology and dramatic languages and literature. I graduated with a Bachelor of Science degree. After that, I went to the American University of Antigua for medical school, and I graduated with honors, Magna Cum Laude. After that, I did a four-year combined Anatomic and Clinical Pathology residency program at NYU Winthrop Hospital in Long Island, New York. After that, I did a one-year forensic pathology fellowship at the Boston office of the chief medical examiner. And after that, I did a two-year neuropathology fellowship program through Brown University at Rhode Island Hospital.
MR. LALLY: And Doctor, are you board certified?
DR. STONEBRIDGE: Yes, I am board certified in Anatomic Pathology, Clinical Pathology, Forensic Pathology, and Neuropathology.
MR. LALLY: And if you could just explain to the jury a little bit about — what does board certified mean?
DR. STONEBRIDGE: Board certification means that every medical specialty has their own board. So for example, the American Board of Pathology dictates whether or not you can be board certified based on certain criteria. So you have to meet certain criteria, meaning that you have to complete a certain number of surgical specimens, a certain number of autopsies, and then once you meet that criteria, you can take an exam, which if you pass leads to your board certification.
MR. LALLY: Now, if I could ask you just a couple — and your board certification is up to date at this point, is that correct?
DR. STONEBRIDGE: Yes, in each of those areas that you just spoke of. Yes.
MR. LALLY: Now if I could ask you some general terms — if you could define them for the jury. First of all, what is pathology in a general sense?
DR. STONEBRIDGE: Pathology is essentially the study of any sort of disease or abnormal state of the body tissues. So anything that can go wrong in the body and any of the body systems is essentially the study of pathology.
MR. LALLY: And now starting with anatomic pathology, what is anatomic pathology more specifically?
DR. STONEBRIDGE: Anatomic pathology consists of the study of surgical specimens. So for example, if someone goes to the hospital to have a tumor removed, that specimen will go to pathology, the pathologist will look at it, cut it, look at specimens under the microscope, order any ancillary tests if necessary, and then make a diagnosis, which is then conveyed to the clinician. Anatomic pathology also consists of cytopathology, which is looking at individual cells, and then it also consists of autopsy pathology.
MR. LALLY: And as far as clinical pathology, what does that mean?
DR. STONEBRIDGE: Clinical pathology is anything that is lab-related in pathology. So if you have to get blood drawn and then the results come back, that is clinical pathology. If there's any sort of blood work that needs to be done — for example, if you're going to have a surgery and they have to crossmatch and type you in case of a blood transfusion, that's considered clinical pathology. Also, microbiology — so anything infectious — so essentially anything that goes through a lab is clinical pathology.
MR. LALLY: And what is forensic pathology?
DR. STONEBRIDGE: Forensic pathology is the study of autopsies in a medical-legal sense. It doesn't necessarily mean that it's always going to be something that is legal. Sometimes it may be just a person who has not seen a doctor in many years, dies at home, there's no physician that is willing to sign a death certificate, so we work on those types of cases — plus anything that is non-natural.
MR. LALLY: Now, neuropathology. What is that?
DR. STONEBRIDGE: Neuropathology is the study of the brain, spinal cord, eyes, muscles, and nerves.
MR. LALLY: And if you could, just again in general terms, as far as case work is concerned related to your work as director of neuropathology — can you explain to the jury sort of what it is that you do with respect to neuropathology?
DR. STONEBRIDGE: Yes. So my job primarily entails me to be a consultant for the medical examiner. So the medical examiners have a certain set of criteria that they follow in order to determine whether or not a brain needs to be saved for a neuropathologic analysis. So upon following that criteria, if the brain is saved, it gets put into formalin, which essentially fixes the brain — it firms it up — so it makes it easier to analyze.
DR. STONEBRIDGE: So after the brain has been fixed, I usually let them fix about two weeks — sometimes it could be a little more, a little less, depending on circumstances — I will then look at the brain, take photographs of it from all sides, and then cut the brain, take photographs, document any sort of abnormalities, and then if I feel the need to take sections to look at under the microscope, then I will take those sections. They will be processed through histology. I will look at the slides. Sometimes you may have to add in additional testing — for example, immunohistochemistry — to see if there's anything in particular that you cannot maybe diagnose solely on looking at the histology.
DR. STONEBRIDGE: And then once that is done, I will issue a report to the medical examiner, and then they use it in terms of determining their cause and manner of death, if necessary.
MR. LALLY: Now, as far as that formalin process — as far as the solution is concerned — is there a typical time period that the brain would have to be in that solution prior to you examining it, cutting it, or any of those other things?
DR. STONEBRIDGE: Usually about two weeks, give or take, maybe a few days here and there, but I usually try to let them fix at least 10 days minimum.
MR. LALLY: And again, in general terms, with respect to the types of cases that are referred to you — what types of cases are typically referred to you?
DR. STONEBRIDGE: So part of the criteria that we use is that any cases for children or babies under the age of two years, those always come to me. Also, if there are any cases that have blunt head trauma that may be suspicious or homicidal in nature, those will typically come to me as well. Some of the other cases may be just a difficult neuropathologic entity that a non-neuropathology-trained medical examiner may not be able to really diagnose. And then sometimes there are cases that are just surprise cases where the medical examiner opens up the head and they see something interesting or abnormal and they decide to save that case for me to look at further.
MR. LALLY: Now, with respect to the cases that you do see, at some point did you become involved in analysis or testing of a brain belonging to a John O'Keefe?
DR. STONEBRIDGE: Yes.
MR. LALLY: And who was the doctor — the medical examiner — that made that referral in this case?
DR. STONEBRIDGE: It was Dr. Irini Scordi-Bello.
MR. LALLY: And with respect to your analysis here, obviously you looked at the brain — what, if any, other sources of information did you review or look at in ultimately formulating your opinion in this case?
DR. STONEBRIDGE: So at the time when I was able to cut the brain of Mr. O'Keefe, I had information that was relayed to us from our intake department. So when a case gets called into the medical examiner, it gets taken by an intake department and they're given kind of just a rough summary of the case. I also had the police report, I had the EMS report, I had the medical records from when Mr. O'Keefe was in the hospital, I also had medical records from the primary care physician, I had autopsy photos, and I also had — let me just refer to my notes here because I had a lot of notes — I also had the inventory and tracking sheets, which are notes created by the medical examiner, and the neuropath request itself.
MR. LALLY: Now, are you familiar with some terms in relation to injuries that you would observe, from a neuropathological perspective, as far as injuries being acute, subacute, or remote?
DR. STONEBRIDGE: Yes.
MR. LALLY: And can you explain to the jury what those are and what those mean?
DR. STONEBRIDGE: So it depends on circumstances. Acute generally is something that happened within a very short time frame. So when I refer to something as being acute, I usually refer to that as something that's occurring from the time of an injury to maybe a day or so afterwards. As I said, it's variable, dependent on circumstances. Subacute is something that has not happened within the last few minutes, few hours, maybe even a day, and maybe something that is now in the process of healing. And then chronic is usually something that has happened a while ago in the past. You may see some sort of evidence of some type of injury in a chronic state; you may also not see any evidence because it may have completely healed by that point.
MR. LALLY: And so from your analysis in this case, how did you characterize, in your opinion, from everything that you reviewed, the injuries you observed to Mr. O'Keefe?
DR. STONEBRIDGE: The injuries I observed were acute injuries, meaning that they probably occurred minutes to hours.
MR. LALLY: Now, if I could turn your attention to your findings — when you conducted your analysis and your testing in this particular case, what, if anything, did you find as far as injuries to Mr. O'Keefe?
DR. STONEBRIDGE: So when I look at the brain, what I do is I look at all surfaces from all sides. And one of the things that I look for is anything grossly obvious, meaning anything I can look at the brain and see that there's something there that shouldn't be there. So one of the first things I noticed was a subarachnoid hemorrhage. And a subarachnoid hemorrhage is something that occurs when you have bleeding within the leptomeninges. The leptomeninges are a very thin membrane that encase the brain and the spinal cord, and there should not be blood freely floating within the leptomeninges. So if you have a subarachnoid hemorrhage, most of the time the causes are either a ruptured aneurysm — which is something I would see upon cutting the brain — or some type of trauma. So that was the first finding.
MR. LALLY: Can I stop you there just for a second? For those taking notes and for our court reporter, could you spell the type of hemorrhage and the membrane?
DR. STONEBRIDGE: Yes. Subarachnoid is S-U-B-A-R-A-C-H-N-O-I-D, and leptomeninges is L-E-P-T-O-M-E-N-I-N-G-E-S.
MR. LALLY: Thank you very much.
DR. STONEBRIDGE: You're welcome.
MR. LALLY: Now, with regard to anything related to the aneurysm that you indicated you would have seen — what, if anything, did you see during the course of your review or testing or analysis of Mr. O'Keefe's brain?
DR. STONEBRIDGE: So aneurysms are typically seen in the cerebral vessels that sit around the base of the brain. So there's something called the Circle of Willis, which is the main arterial supply — it sits around the base of the brain and it's kind of shaped like a circle that has vessels that come off that extend to other areas of the brain. So typically if there is an aneurysm that is ruptured, it's going to be located somewhere in one of those vessels. So upon observing those vessels, I did not see any evidence of any aneurysm or any sort of natural disease state that might have led to a rupture in one of these vessels.
DR. STONEBRIDGE: Also, sometimes these vessels, since they do go deep into the brain, you may only see the rupture upon cutting the brain, and I did not see any evidence of any rupture of any of these vessels anywhere in the brain.
MR. LALLY: Now, as far as the subarachnoid hemorrhage that you observed — where was that located within the brain? And if you could —
DR. STONEBRIDGE: So the subarachnoid hemorrhage was on the frontal poles, which is essentially right here in the front of the brain. So the frontal lobes obviously sit in the front, and then the poles are the very frontmost portion of the brain. So it was on the frontal poles. It was also on the left temporal pole — so the temporal region is right here in the temporal region, and because of the way that the temporal lobe is shaped, it kind of has a little loop right in the front, so it has a pole as well. So it was on the left temporal pole, and then it was also in the left lateral fissure. So you have a frontal pole here, you have the temporal lobe right here, and then the lateral fissure goes kind of in between the temporal and the frontal lobes.
DR. STONEBRIDGE: So you have the hemorrhage here, hemorrhage here, and then hemorrhage right there — so it's kind of all concentrated almost in one area. But then there was also hemorrhage of the posterior surface of the right temporal as well, so on this side.
MR. LALLY: Now, Doctor, I'm probably going to butcher this horribly, but — just as far as the bilateral unci, are you familiar with that?
DR. STONEBRIDGE: Yes. So the unci are the medial portion of the temporal lobes. So the brain is essentially oriented in a way that each hemisphere — the right and left hemisphere — are the same. The unci are the most inner portion of the temporal lobes. So the unci sit just next to the brain stem. So if you have anything that causes herniation of these unci, they start to push inwards onto the brain stem. So say this is the brain stem here — at the unci, they start to push in. And because the brain is within the skull, the skull is hard, you have no room for any sort of expansion of the brain. If there is herniation, it will start to push in that area, because the brain stem turns into the spinal cord and goes out of the skull through the foramen magnum.
DR. STONEBRIDGE: So you have this hole, about this big or so, at the base of the skull where the brain stem turns to the spinal cord and comes out. So that's one of the only areas in which the brain can actually move, because it's encased in the hard skull. So if you have herniation, it'll start to push, and then push downwards.
MR. LALLY: Could I ask you to spell "unci"?
DR. STONEBRIDGE: U-N-C-I.
MR. LALLY: And with reference to this bilateral unci area, what, if any, herniation did you observe?
DR. STONEBRIDGE: So when the unci herniate, it can be subtle. Sometimes, if it's herniated enough, you may see hemorrhages in the brain stem, and this happens because this tissue is now pushing on the brain stem and it's essentially being compressed. So there was herniation noted, and then there was hemorrhage within the brain stem.
MR. LALLY: Now, if I could ask you, Doctor — are you familiar with the medical term "contusion"?
DR. STONEBRIDGE: Yes.
MR. LALLY: And can you explain just in general terms to the jury what you understand that term to mean?
DR. STONEBRIDGE: So a contusion is essentially a bruise. It's blood that's coming out from a blood vessel — it's a blood vessel that has been broken in some way and now there's blood coming out.
MR. LALLY: Are you also familiar with another term, or part of that term, known as a punctate contusion?
DR. STONEBRIDGE: Yes. So punctate is essentially just a way to describe the size of a contusion. When I say punctate, I mean something that's very, very tiny — almost just like a dot.
MR. LALLY: And with respect to punctate contusions, what, if anything, did you observe in Mr. O'Keefe's brain, and where was it located?
DR. STONEBRIDGE: So there were punctate contusions in the frontal and temporal cortices. So frontal, once again, is the front portion right here, temporal is kind of right behind it in this area, and the cortex is the gray matter of the brain. So it's a thin strip that kind of just goes around the brain, and then the white matter is underneath all that. So in traumatic injuries you can see punctate contusions, or even larger contusions, in the cortex — it usually indicates that the brain has been pushed against something, which is now causing these little blood vessels to rupture, hence seeing the contusions, because the blood is no longer contained in the blood vessels.
MR. LALLY: Now, Doctor, with regard to the subarachnoid hemorrhage — is there anything that you're able to do as far as measuring that?
DR. STONEBRIDGE: It's hard to measure because it's usually pretty vague. It's not usually something that is well-circumscribed, meaning I could say it starts here and ends here. A lot of times with subarachnoid hemorrhage, because it's sitting in this space that it's not supposed to be in, it can spread. So it may be thicker in one area, thinner in another. So you may have some that may appear just as a very faint hemorrhage, and then some that might be very thick. which you can physically measure. So I usually just give an area where it is and say it's here, it's here, it's there, because it's almost like measuring something that has blurred edges — you can't really get a completely accurate measurement.
MR. LALLY: And what if anything were you able to observe or measure with regard to the subarachnoid hemorrhage in the area of the left prefrontal lobe?
DR. STONEBRIDGE: So it appeared thicker in that area, meaning that as opposed to it looking just like a faint red color that should not be that color, it was actually thick enough that it was obscuring the underlying brain parenchyma. If I could turn your attention —
MR. LALLY: — doctor, just back for a moment to the punctate contusions that you were testifying about before. As far as your observations of those, was that one or more than one — how many did you observe?
DR. STONEBRIDGE: So there were multiple — there were multiple contusions, to the point where it's not something that you can count. I mean, you could count it, but it would probably take a very long time. If it had been something like one or two, three, four, maybe a handful, it would probably be something I would say there are three here, four there. But there were so many that it didn't serve a purpose to count. And the number of those — what if
MR. LALLY: Now, doctor, what if any significance does that have in regard to your analysis, your observations, or your opinion?
DR. STONEBRIDGE: So given that there's multiple, it means that there's enough pressure in the brain that there were many surfaces that were pressing on the bony prominences of the skull, which was leading to a lot of blood vessels rupturing, causing these contusions.
MR. LALLY: Now, I think you've talked a little bit, but just in general terms, if you could describe for the jury — what is a hemorrhage?
DR. STONEBRIDGE: So a hemorrhage is essentially blood that's coming out from a vessel. So it's like a bruise — hemorrhage, bruise, contusion, they're fairly similar. Some people use them interchangeably. But it's essentially blood that's no longer contained in a blood vessel.
MR. LALLY: When something is termed medically, based on your training and experience, as a diffuse hemorrhage — what does that mean?
DR. STONEBRIDGE: So diffuse means it's over a very large area. It's not something that's just a tiny little area. You could say, okay, I'm looking at this person's — let's say liver — and there's a 2x2 centimeter hemorrhage sitting right there in the right lobe of the liver. Diffuse would mean there's hemorrhage throughout nearly the entirety of the liver.
MR. LALLY: Now, with regard to — you made a note as far as there being a diffuse hemorrhage within the pons — is that correct?
DR. STONEBRIDGE: Yes.
MR. LALLY: Can you explain to the jury sort of what that means, and where is that located within the brain?
DR. STONEBRIDGE: So the pons is part of the brain stem. So the brain stem starts right in the middle of the brain, and you have the midbrain, the pons, the medulla, and then it turns into the spinal cord. So the pons is kind of in the middle of the brain stem. And when you have hemorrhage in the pons, in this circumstance it was because there was the herniation of those uncae, which began moving closer and closer towards the pons, pressing on it, causing hemorrhage, because now the tissue is compressed, the blood is not going to be able to flow in and out freely, therefore hemorrhage.
MR. LALLY: Now, with regard to the totality of what you reviewed in this case, in regard to Mr. O'Keefe — were you able to form any opinions to a reasonable degree of medical certainty in regard to the injuries that you observed?
DR. STONEBRIDGE: [unintelligible] I was able to determine that these are acute traumatic injuries. I know that based on what I observed, and in combination with the autopsy findings, that this is due to some type of trauma.
MR. LALLY: If I could ask — as far as your findings regarding the intraventricular hemorrhage and occipital horns of the lateral ventricles, correct?
DR. STONEBRIDGE: Yes.
MR. LALLY: If you could please explain to the jury — what exactly does that mean?
DR. STONEBRIDGE: Yes. So the ventricles are almost like a tunnel system of the brain in which the cerebrospinal fluid flows through. So the cerebrospinal fluid serves as a fluid that nourishes the brain — it provides a flow of nutrients, oxygen, things like that — and it starts in the frontal portion of the brain and then it goes backwards towards the occipital, which is the back, and it also flows downward through the brain stem and then into the spinal cord as well. So the occipital horns of the lateral ventricles are in the back of the head, and having hemorrhage in those areas — and in any area of the ventricular system — is usually indicative of some type of trauma. So there should not be blood freely flowing within the ventricular system.
MR. LALLY: Now, Dr. Stonebridge, with regard to your findings — you mentioned that your findings were that the injuries were acute and that the injuries were the result of trauma, correct?
DR. STONEBRIDGE: Yes.
MR. LALLY: What if anything can you say, or can you opine, as to the mechanism for those acute traumatic injuries?
DR. STONEBRIDGE: It was something that required some type of force. Given that there were skull fractures, I can't say what type of force or how much force, but it was definitely something that caused some type of force which led to the skull fractures and then the subsequent brain findings.
MR. LALLY: And the brain findings in particular that you made — were those consistent with a fall?
DR. STONEBRIDGE: They can be, yes.
MR. LALLY: Can they also be consistent with being struck by a vehicle and then going to the ground?
DR. STONEBRIDGE: Yes, they can be.
MR. LALLY: Thank you, doctor. I have no further questions.
DR. STONEBRIDGE: You're welcome.
JUDGE CANNONE: Cross examination? Thank you, doctor. Thank you very much. You are all set. Thank you.
COURT OFFICER: Right, step down. Thank you.