Commonwealth v. Read — Trial ArchiveAnthony Flematti — Direct
326 linesPROCEEDINGS May 2, 2024
(Court reporter, A.D.A. McLaughlin and Attorney Little in without the Court at 8:57 a.m. to premark exhibits on the record.)
COURT REPORTER: For the record, this is Nancy King, per diem court reporter, on the record with Commonwealth versus Karen Read, on Thursday, May 2nd. Present with me is A.D.A. McLaughlin and Attorney Elizabeth Little. We are here to mark exhibits that are agreed upon and not objected to.
MS. LITTLE: Yes.
MS. MCLAUGHLIN: Correct. The Commonwealth would move to introduce seven photographs by agreement.
MS. LITTLE: No objection.
COURT REPORTER: No objection to each one?
MS. LITTLE: No objection to each one.
COURT REPORTER: So no objection to Exhibits 372 through 378, correct, Attorney Little?
MS. LITTLE: Correct, no objection, for your records.
(Whereupon, there was a discussion off the record.)
MS. LITTLE: The defense is asking just to mark the wide-screen version of the Saraf and Goode dash cams, which is on this flash drive by agreement.
COURT REPORTER: Is that agreed upon?
MS. LITTLE: Yes.
COURT REPORTER: If you could just jot down what that is for the clerk's record keeping?
MS. LITTLE: Yes.
COURT REPORTER: And that will be Exhibit 379, by agreement, Attorney Little?
MS. LITTLE: No. 379. Yes.
COURT REPORTER: By agreement?
MS. MCLAUGHLIN: Yes.
MS. LITTLE: A wide-screen dash cam of Saraf and Goode, G-O-O-D-E. Thank you.
COURT REPORTER: That is Exhibit 379.
(Whereupon, the following above-mentioned exhibits were premarked by the court reporter, agreed to, and in the presence of A.D.A. McLaughlin and Attorney Little as follows:)
(Whereupon, photographs were entered and marked Exhibits No. 372 through 378 in Evidence.)
(Whereupon, thumb drive was entered and marked Exhibit No. 379 in Evidence.)
(Court in session at 9:11 a.m.)
(Defendant present. Jury present.)
COURT CLERK: Your Honor, this is 2282-117, the Commonwealth versus Karen Read. Can I have counsel identify themselves for the record, starting with the Commonwealth?
MR. LALLY: Adam Lally, for the Commonwealth. Good morning, Your Honor.
JUDGE CANNONE: Good morning, Mr. Lally.
MS. MCLAUGHLIN: Good morning, Your Honor. Laura McLaughlin, for the Commonwealth.
JUDGE CANNONE: Good morning, Ms. McLaughlin.
MR. JACKSON: Alan Jackson, on behalf of Ms. Read. Good morning, Your Honor.
JUDGE CANNONE: Good morning, Mr. Jackson.
MS. LITTLE: Good morning, Your Honor. Elizabeth Little, also on behalf of Ms. Read.
JUDGE CANNONE: Good morning, Ms. Little.
MR. YANNETTI: Good morning, Your Honor. David Yannetti, for Karen Read.
JUDGE CANNONE: Good morning, Mr. Yannetti. Good morning, Ms. Read. Good morning, jurors. So I have to ask you those same three questions: Were you all able to follow the instructions and refrain from discussing this case with anyone? Everyone said yes or nodded affirmatively. Were you also able to follow the instructions and refrain from doing any independent research or investigation into this case? Everyone said yes or nodded affirmatively. Did anyone happen to see, hear or read anything about this case since we left here on Tuesday? Everyone said no or shook their head. Jurors, from time to time, I will give you instructions and talk to you for a few minutes about how evaluate evidence for a couple of minutes today. It's part of my job, where my job is to teach the jury about the law.
So in considering the testimony of any witness, please remember that questions are not evidence, only the answers, which are, in fact, the only part of the exchange between the lawyer and the witness that are given under oath are evidence. So if a witness is asked, isn't it true that after you learned that your uncle left you money in his will you poisoned him, and the witness's answer is no, based solely on that question and that answer, there is no evidence that the witness has an uncle, that the uncle had a will, that the uncle left the witness money, that the witness knew that he did or that the witness poisoned him. So going forward, I want you to consider the evidence in that regard. Also, there were videos shown to you, and I expect that throughout the course of this trial there will be many more videos shown to you. These videos are evidence, and there's audio on these. So what the video shows is for you folks to decide, not me, not any of the lawyers. What an audio recording says is for you to decide, not me, not any of the lawyers, because you find the facts. That is your job. We all have different jobs. But finding the facts in the case is your job. Okay? So with that, please get your Commonwealth witness back on the stand, Mr. Lally.
COURT CLERK: I just need you to raise your right hand one more time.
Whereupon, ANTHONY FLEMATTI, Resuming having been first duly sworn, was examined and testified under oath as follows:
JUDGE CANNONE: All right. Mr. Lally, whenever you are ready.
MR. LALLY: Thank you, Your Honor. Your Honor, before I begin, may I approach the witness to return Exhibit 160?
JUDGE CANNONE: Sure. CONTINUED DIRECT EXAMINATION
BY MR. LALLY:
MR. LALLY: Good morning, sir.
MR. FLEMATTI: Good morning.
MR. LALLY: I believe when we had left off the other day, you had arrived in the area of 34 Fairview Road; is that correct?
MR. FLEMATTI: That's correct.
MR. LALLY: And, when you arrived there, what, if anything, did you do upon arrival?
MR. FLEMATTI: So on arrival, positioning the apparatus is going to be our most important thing, trying to figure out where our patient is and parking our apparatus close enough, especially at nighttime that we can light up the scene as well as we can; trying to figure out how to approach a scene because if we have to track equipment farther distances, it can slow our response down. So we try and make sure our arrival and positioning as best as we can put it.
MR. LALLY: As far as positioning in reference to when you first are sort of pulling up on the scene, where are you in the ambulance again?
MR. FLEMATTI: So I would have been the passenger of the ambulance. Usually the tech that's leading the call will sit on the passenger side to try and mentally get ready for what's going on, whether it's reviewing protocols or just trying to assess the information coming across the radio so you can update your treatment plan as much as you can before you see the victim.
MR. LALLY: And, when the ambulance comes to a stop or it's parked in your position, where is -- what, if anything, do you see sort of as far as the scene is concerned?
MR. FLEMATTI: So we have our fire apparatus that are helping light up the scene. But we also have two female parties going by to the victim on the side of the road, going back and forth between them, that person and the side of the road.
MR. LALLY: And, from the position when you first arrive, are you able to see the person on the side of the road?
MR. FLEMATTI: You can see a shape of a person. So we know that's where the patient is because we reported that there was a party on the side of the road. So seeing a body shape, that clued us that that was where we were headed.
MR. LALLY: And, in addition to the ambulance that you're in, how many other vehicles are on scene when you get there?
MR. FLEMATTI: So when I get there, I believe it is Engine 3 and Car 5.
MR. LALLY: And, beyond sort of the vehicles from your department, what, if any, other vehicles do you see when you get there?
MR. FLEMATTI: If I remember correctly, it was just a personal vehicle. I don't remember if there's any police cars on scene at that time.
MR. LALLY: And, from your orientation when you pull up, where is the body positioned? To your left, to your right or something else?
MR. FLEMATTI: To my left.
MR. LALLY: And so after the ambulance is positioned, what do you do from there?
MR. FLEMATTI: So then it's going to be bringing all of the equipment over to the patient's side to be able to extricate them from that situation, whether it's a house or a street or a road. We assess where they are and then the best tools to get them out into the ambulance to be able to work effectively on the patient.
MR. LALLY: And, when you proceed over to -- now, again, at some point subsequent, later on, are you able to identify who the person on the ground is?
MR. FLEMATTI: Yes. We will try and get a general idea of the age of the patient, the positioning of the patient, how they were found. And, then, when we get him into the ambulance, we can start identifying ways to register that patient in the emergency room. So identifiers, whether it's a license or witnesses or we try and figure out who they are so they can get registered at the hospital.
MR. LALLY: And, at some point, were you able to identify who this person was?
MR. FLEMATTI: That's correct. His wallet was in his pocket and we were able to grab his license.
MR. LALLY: And who were you able to identify him as?
MR. FLEMATTI: John O'Keefe.
MR. LALLY: So with reference to Mr. O'Keefe when you first observed him on the ground, how far away from the street or the roadway is he at that point?
MR. FLEMATTI: I'd say approximately 10 feet away from the road.
MR. LALLY: And how is he positioned, as far as how was his body positioned?
MR. FLEMATTI: I'd have to review, but I believe he was supine, on his back.
MR. LALLY: Just in general terms, first, when you are responding to a call of this nature, what are some of the protocols that you were speaking about? Is it that you're seeking to do or assess when you first arrive?
MR. FLEMATTI: So we are trying to determine if it's a cardiac arrest whether it's a viable transport or workable arrest. We have certain protocols within the Massachusetts protocols for whether we work the patient or we relieve the patient on scene if it's a police matter, if there's injuries nonsustainable with life. So we are trying to make that assessment before we make any decisions.
MR. LALLY: Let me stop you there just for one second. You used the term as far as cardiac arrest. Based on your training and experience, what do you understand that term to mean?
MR. FLEMATTI: So cardiac arrest, to the best of my knowledge, is just the cessation of electrical and mechanical activity in the cardiac muscle. So the cardiac muscle pumps blood throughout the body; and, when that stops, all life stops after that.
MR. LALLY: Now, in particular reference to the conditions, the weather conditions that you find yourself in, what, if anything, else is sort of on the scale or spectrum in regard to diagnosis at this point?
MR. FLEMATTI: So cardiac arrest, depending on where they are found, we try and figure out what led them to be at that point. So we are looking at weather conditions, as well. That can also affect viability of resuscitation. So due to the extreme weather, extreme cold, we will attempt resuscitation on that patient due to the fact that it will prolong viability of the arrest or ability to recover from cardiac afterwards. So weather is definitely a key factor.
MR. LALLY: And are you familiar with the term, based on your training and experience, called hypothermia?
MR. FLEMATTI: Correct.
MR. LALLY: And so what, if any, sort of relationship does cardiac arrest have -- well, let me ask you this first. What is your understanding of the term "hypothermia"?
MR. FLEMATTI: Exposure to extreme cold that lowers your core and extremity temperatures down to below 95 degrees, usually.
MR. LALLY: And what, if any, interplay is there between hypothermia and cardiac arrest?
MR. FLEMATTI: So like I said before, it will prolong how long it will preserve the body after arrest. So if somebody's found in like a cold water situation, there's been multiple reports of patients recovering after being drowned in cold water for up to an hour. So viability is definitely improved by the cold water.
MR. LALLY: And, as far as viability is concerned, you talk about doing your assessment. What are sort of the steps that go into your assessment?
MR. FLEMATTI: So we are looking for obvious signs of death. So we are looking at exposure of brain matter. We are looking at traumatic injuries, decapitation, things that would basically be nonlife sustainable. We are looking at signs of lividity and rigor to basically show us how long the patient has been down for.
MR. LALLY: And the age of a particular patient, what, if any, relationship does that have to your assessment?
MR. FLEMATTI: So it will show the extent of frailty the patient has. If somebody is an elderly patient, a severe cancer patient, their ability to sustain a cardiac event like that is less. So somebody that's younger or middle aged will have a much better chance of recovery afterwards, but that would really be the only key that we are looking at.
MR. LALLY: And what, if any, observations did you make of Mr. O'Keefe during your assessment of him initially?
MR. FLEMATTI: Just that he was a middle-age male, and that was all we had.
MR. LALLY: And, as far as the other things that you were talking about as far as viability or resuscitation, what, if anything, did you observe with reference to Mr. O'Keefe in regard to that?
MR. FLEMATTI: So with the viability, we were looking at any rigidity or rigor in the body or lividity or separation of blood. You'd have a pooling of blood or bruising it would look like at the lower parts of the body, depending on how the person is positioned, basically. If they are supine, you'd have positioning or pooling underneath the body. And then you would have stiffness of the arms, leg, jaw, neck to be able to move the body. We're looking to -- if they don't have those things present, it's another check mark of saying this is viable, we can work this.
MR. LALLY: Specifically as it applies to your assessment of Mr. O'Keefe, what, if anything, do you recall in regard to that initial assessment as far as viability?
MR. FLEMATTI: So his limbs were able to be moved, jaw was able to be moved. The posterior area of his body was red. So not indicative of the lividity that we're looking for. So we termed it to be a viable arrest and continued to work.
MR. LALLY: Now, you mentioned as far as sort of gathering your equipment and bringing it over to Mr. O'Keefe, what, if any, equipment did you get?
MR. FLEMATTI: So equipment initially is going to be our scoop stretcher to be able to pick the patient up, break apart, put it underneath him. We have a first-in bag, airway bag, cardiac monitor. We will bring all of that over to the patient's side to be able to do as much as we can in that situation. But, due to the weather, we wanted to get him out of the weather because that was one of the things that was hurting him at that point, was getting him into the warmer ambulance and beginning the warming process. So getting into an area where we can assess the patient thoroughly with good lighting and to be able to expose the patient and begin the warming process.
MR. LALLY: And, when you go over to where Mr. O'Keefe is about 10 feet off the roadway, who, if anyone, from your department goes along with you?
MR. FLEMATTI: So I have Matt Kelly with me and Tim Nuttall. I also have Frank Walsh, Katie McLaughlin and Greg Woodbury and Captain Robery.
MR. LALLY: And, as far as this sort of initial assessment on the ground with Mr. O'Keefe, what, if anything, were sort of each of those respective people doing with regard to Mr. O'Keefe?
MR. FLEMATTI: I would have to review the specific interventions as far as who did what when. That's why we document things immediately afterwards so it's all fresh. So CPR was initiated by me and ALS assessment as well. I can go over individual interventions if you'd like, but it's really --
MR. LALLY: And, for the record, sir, you're looking at Exhibit No. 160. And what page of that are you looking at?
MR. FLEMATTI: It says two of five of my EMS report, but there is also the report on the top, as well.
MR. LALLY: So initially when you go over to Mr. O'Keefe, how many other people are sort of in that area at that time?
MR. FLEMATTI: So in the area, we have the first responders. Then we have the two female parties on scene.
MR. LALLY: Where were the two females in relation to Mr. O'Keefe?
MR. FLEMATTI: So as we are approaching the scene, they were kind of in between us and the patient. So we try to gather as much information as we could from them as we could.
MR. LALLY: And so once you make that determination as far as viability of resuscitative efforts, sort of specifically what are you and the other firefighters doing in regard to those efforts with Mr. O'Keefe?
MR. FLEMATTI: So beginning CPR, we are trying to establish good quality CPR, get the patient onto our stretcher, begin an IO, start medications, start ventilating the patient. All of the conditions that the body has, we are trying to remedy through intervention. So we are trying to breathe for the patient. We are starting to press on his chest to do CPR, to cause the cardiac muscle to compress, spread blood through the heart, cardiac muscle, cerebral brain. And we are trying to reverse what's happening in the body.
MR. LALLY: Now, as far as when Mr. O'Keefe, you observe him on the ground, what, if any, snow did you observe on or around him in that area?
MR. FLEMATTI: The snow was probably up to the mid-axillary point. So we are looking at probably halfway up his rib point. The top of his body was clear.
MR. LALLY: And do you know about how much snow was covering his body up to the mid axillary?
MR. FLEMATTI: I'd say about four inches, four to six inches.
MR. LALLY: Now, as far as your observations of Mr. O'Keefe when he's on the ground, what, if any, observations did you make as far as how he was dressed?
MR. FLEMATTI: For the exposure, I would say he was pretty underdressed, long-sleeve tee shirt, jeans, nothing really substantial to be out in that type of weather.
MR. LALLY: And at this point or any subsequent point, what, if any, observations did you make of Mr. O'Keefe's footwear?
MR. FLEMATTI: By the time we -- so our first priority is obviously going to be treating the patient. His clothes do matter, but it's on the list of priorities not huge. So by the time we figured out he was missing one of his shoes, we were already at the hospital at that point.
MR. LALLY: And do you recall which of his shoes he was missing?
MR. FLEMATTI: I don't.
MR. LALLY: And, as far as that missing shoe, was that something that you or any of the firefighters, paramedics would have needed to have removed on scene pursuant to any sort of treatment?
MR. FLEMATTI: Nothing would have been done through the feet. It would have been just exposure of the patient to see possibly the extent of frostbite, if it had started affecting extremities, fingers, nose, that type of things. Hypothermic reaction there.
MR. LALLY: And would that be something that would have been removed by one of you or by one of the other firefighters while he was on the ground?
MR. FLEMATTI: If it would have been removed, both of them would have been removed. To assess that, it wouldn't do much good to just remove one and leave it there on the scene.
MR. LALLY: Now, as far as the two females that you observed, did they sort of remain in the same position that you initially observed them? Did they move around or something else?
MR. FLEMATTI: They kind of cleared a little bit away from the scene. I would say they moved off to the right of the apparatus so we could work on the patient at that time.
MR. LALLY: And what, if any, conversation or what, if anything, did you ask either of those two females?
MR. FLEMATTI: So how the patient was found and what brought them to that situation is critical. So we are trying to figure out as much information, past medical history that we can of the patient. So we are trying to find somebody who has knowledge of the event. So as we approach a scene, we begin to talk to one of the females, what is going on, why are they there, just what happened.
MR. LALLY: So you say you're speaking to one of the two females; is that correct?
MR. FLEMATTI: That's correct.
MR. LALLY: Okay. And do you see any of those females in the courtroom today?
MR. FLEMATTI: That's correct. Ms. Read.
MR. LALLY: Could you just identify as to where Ms. Read is seated or an article of clothing she's wearing?
MR. FLEMATTI: Right there.
MR. LALLY: Your Honor, I'd just ask the record reflect identification of the defendant by the witness.
JUDGE CANNONE: Okay.
BY MR. LALLY:
MR. LALLY: Now, with regard to one of the two females that you were talking to, was that Ms. Read or was that somebody else?
MR. FLEMATTI: That was Ms. Read.
MR. LALLY: And why, if at all, were you talking to her versus one of the other females that you observed?
MR. FLEMATTI: She seemed to be the one that was most personally affected by it. So I figured she had the most information about why the person was there?
MR. LALLY: And what, if any, observations did you make of her in regard to your conclusion that she was the one who seemed the most personally affected by it?
MR. FLEMATTI: She was the most distressed on scene, obviously upset. So personally related to or had a relationship with the person.
MR. LALLY: Now, before we get to any conversations, what, if anything, did you observe Ms. Read or any of the females doing with reference to Mr. O'Keefe's body when you first started to come out to the scene?
MR. FLEMATTI: So I would characterize it as an attempted resuscitation. You're attempting to -- she was attempting to do CPR. But, due to the erratic behavior -- she was running back and forth between the other female on scene and the body, back and forth, trying to press on his chest, wake him up, talk to him -- just to no event.
MR. LALLY: And, as far as your conversation with Ms. Read, what, if any, questions did you ask in regard to either demographics or anything else?
MR. FLEMATTI: I said, do you have any information of who this is, how are they here. I tried to get any type of information we could from her at that time but with no luck.
MR. LALLY: When you say "with no luck," what, if any, response did you receive from Ms. Read in regard to your questions?
MR. FLEMATTI: So the only response that I was personally given was just, I hit him. I hit him. Oh, my God, I hit him.
MR. LALLY: And, when she is saying, I hit him, I hit him, oh, my God, I hit him, how loudly is she saying that?
MR. FLEMATTI: So she was within two feet of me but very loud. Any type of follow-up questioning: did you hit him with your hand, did you kick him, what happened, she just repeated the phrase over and over again, I hit him. I hit him.
MR. LALLY: And, just to be clear, where does this conversation occur?
MR. FLEMATTI: This was as we are bringing equipment over to the patient. The interventions are going to be started, basically whoever gets over to the scene first. I'm trying to gather information as a lead paramedic to try and coordinate interventions and therapy to kind of holistically be the team leader in that situation and treat and transport the patient. So it was on approach to the patient, probably halfway between the ambulance and the patient.
MR. LALLY: And, with regard to that treatment of Mr. O'Keefe, and you do reference it earlier being in your report, what were sort of those steps or what, if anything, did you and the other firefighters do with regard to treatment?
MR. LALLY: Before you answer that, Your Honor, may I request -- may the witness just refer to his EMS report as he goes?
JUDGE CANNONE: Yes, if need be. Yes.
MR. FLEMATTI: Thank you. So I try and document through our flow chart all of the interventions that we are doing. So CPR is obviously going to be our first priority. CPR is initiated, unchanged but successful, and the intervention, itself, no complications. We do our ALS assessment that we talked about of any further indications of this is not a viable arrest. We determined it was a viable arrest, and we move on. We are going to start we refer to it as a bag valve mask, 15 liters per minute on oxygen. The patient is not breathing on their own. So we are trying to assist to ventilate that with high-flow oxygen, as well. An EZ 10, which is a needle we put into the bone of the tibia of the patient. The right tibia was the first one that we put in. We were going to be putting in warm fluid. We have a warmer in the bag to be able to bring up the core temperature. Then we start with epinephrine, Img, through that IO.
BY MR. LALLY:
MR. LALLY: If I could just stop you there for one second. When you say as far as IO and put it into the leg, how is that sort of inserted into the leg of a patient?
MR. FLEMATTI: So we have two different methods we can do. We have a drill, a power drill, that drills through the outer layer of the bone, into the capillary area of the bone, the soft, spongy material. So we drill through that, or we can do it by hand if that fails.
MR. LALLY: When it comes to epinephrine, what is sort of the purpose of that medication and what are you trying to do with that medication?
MR. FLEMATTI: So that medication will improve -- it's a vasoconstrictor. It will cause the vasculature to constrict. So it will improve the quality or the effectiveness on the cardiac muscle, cardiac vasculature, and cerebral area.
MR. LALLY: And, as far as the administration of epinephrine is concerned, is that something that's done once or more than once and is there a protocol for that?
MR. FLEMATTI: So it's going to be serial, every three to five minutes, during a cardiac arrest, to try and bring him over to the hospital. So it continues that entire time unless there is a rhythm change or that can change the algorithm of how we approach the patient if there is a rhythm regain or return of spontaneous circulation.
MR. LALLY: And so how many times or what time was the epinephrine administered via the IO to Mr. O'Keefe?
MR. FLEMATTI: So I have epinephrine at 6:20, 6:25, 6:30, 6:35, 6:40, 6:45.
MR. LALLY: And when was that first administered? Would that have been at some point when he was outside of the ambulance, on the ground, or in the ambulance or something else?
MR. FLEMATTI: It would be dependent on transport time. So first, we were at patient's side at 6:15; transport, 6:27. So the best estimation would have been inside the ambulance at that point.
MR. LALLY: And I'm sorry I interrupted you before. But after sort of the introduction of the epinephrine, what, if anything, did you and the other firefighters do next?
MR. FLEMATTI: After the first round?
MR. LALLY: Yes.
MR. FLEMATTI: So the first round of epinephrine, after that, we would drop in what's called an OPA. That would be to push the tongue out of the way, open up the airway to improve our bag valve mask so as an open way to get the oxygen to the lungs. We begin external warming, stripping the patient, getting the heat turned up in the back of the ambulance. We would then switch over from manual CPR done by hand to a mechanical CPR device to ensure adequate consistent CPR, compressions of the chest. It was a Lucas device. So we put that on the patient. And then we continued with another round of epi. The patient is starting to warm up this time. So we would do suction at that point to try and suction fluid out of the airway to improve ventilation efforts. Another round of epi is done, another suction this time through a deep suction via the endotracheal tube. At 6:22, after warming, we intubated the patient. We have a 7 1/2 tube to pace at 27cm. and then verified through various means, through chest rise, osculation, wave form and total CO2. So we had complications listed as patient vomiting, aspirating. Suction was then done with a rigid tip suction device. After successful intubation, we then suctioned via French tube through the airway established. I'll jump back up to the 6:31. Another IO line was established on the opposite tibia on the left side, and then another three rounds of epi and then arrival at the hospital.
MR. LALLY: Okay. What was the arrival time at the hospital?
MR. FLEMATTI: At destination was 6:45.
MR. LALLY: Okay. And what hospital was that again? I'm sorry.
MR. FLEMATTI: Good Samaritan Medical Center.
MR. LALLY: Now, there is a term that you use in your reports called, and I'll probably butcher this, asystole; is that correct?
MR. FLEMATTI: Yeah. Asystole is going to be a cardiac rhythm when there is no electrical activity in the heart and is referred to as flatline.
MR. LALLY: What, if any, observations did you make in your treatment, diagnosis in regard to Mr. O'Keefe as far as asystole?
MR. FLEMATTI: So that was the rhythm he was found in. Yeah. From initial rhythm, I have an EKG at 6:32 as asystole. So we basically observed that for any changes, whether it's increase of electrical activity, regaining of active pulses. All that can kind of be hinted at with the cardiac rhythm. And then we would change our rhythm based on whether we go down the Ross protocol or we continue down the cardiac arrest protocol.
MR. LALLY: And whether it's on scene or it's in the ambulance, is there sort of a division of task or division of different skill that's being employed in patient care?
MR. FLEMATTI: So patient care will have to do with the level of training and also proximity on the patient. Where you get into the ambulance is just logistically. If you have the training, it's not a huge open ER. It's a small environment. So we try and not have people jump over each other as best as we can.
MR. LALLY: And, if you recall, who was sort of doing what in relation to treatment of this patient, Mr. O'Keefe?
MR. FLEMATTI: So in the back of the ambulance specifically?
MR. LALLY: Yes.
MR. FLEMATTI: Okay. In the back of the ambulance, Tim Nuttall was managing the airway. I was the team lead that was kind of coordinating all of the interventions. Matt Kelly was assisting in gathering equipment, doing CPR before the mechanical device was placed on. Basically, they act as an assistant to hand equipment, place things in strategic areas around so we can actually work without having to go get those physical things ourselves.
MR. LALLY: Now, as far as -- you indicated removal of Mr. O'Keefe's clothing once in the ambulance, correct?
MR. FLEMATTI: Yes.
MR. LALLY: And what was it about sort of the condition of the clothing that led to the removal of that?
MR. FLEMATTI: So removal of clothing is actually pretty standard for any cardiac arrest, any traumatic injuries. We are basically trying to get further clues because this is all happening very quickly. So we are trying to get more evidence of why are they here. We are looking for extremity injuries, crush injuries, bruising, anything that we could document that we could pass on to the emergency room staff and doctors. So we would strip most patients.
MR. LALLY: And, as far as -- were you involved personally as sort of the cutting of the clothing and stripping the patient?
MR. FLEMATTI: Yes.
MR. LALLY: Okay. And, upon removal of the clothing, what, if anything, did you observe as sort of the condition of the clothing or texture of the clothing at that point?
MR. FLEMATTI: The condition seemed pretty well intact but just wet and cold.
MR. LALLY: And what, if any, relationship would the wet and cold clothing have to any of the diagnoses that you were running through in regard to Mr. O'Keefe?
MR. FLEMATTI: It would really just be the exposure to the weather, would be our biggest trigger off of that or if you had protruding injuries through the clothing, compound fractures. Things like that. The clothing was intact, but we knew it was wet. It was cold. So as we stripped things off of him, we can see underneath, basically, if there are any sub -- not every fracture breaks through the skin. Not everything causes obvious things, obvious signs. So, as we strip the patient, we can begin to further assess.
MR. LALLY: Let me take you back just for a second to outside of the ambulance. What, if anything, specifically were you able to observe with reference to any injuries Mr. O'Keefe had sustained?
MR. FLEMATTI: Injuries are pretty tough to see outside of the ambulance just due to the weather, due to the lighting. We have scene lighting on the ambulance, as well.
MR. LALLY: Let me ask you this as far as what, if any, difference did you note between the lighting in the back of the ambulance versus when you were with Mr. O'Keefe on the ground?
MR. FLEMATTI: So he was still out in the weather at that point. So bleeding wasn't really obvious at that point. As soon as we get him into the back of the ambulance, then we started noticing hemorrhage from different areas of his body.
MR. LALLY: And, when you say "hemorrhage from different areas," which areas specifically did you observe?
MR. FLEMATTI: So mostly from his mouth, his eyes, nose.
MR. LALLY: And, just to be clear for the record, when you use the term "hemorrhage," based on your training and experience, what do you understand that term to mean?
MR. FLEMATTI: Bleeding. External bleeding.
MR. LALLY: Now, you mentioned that there was some suctioning of Mr. O'Keefe's airway; is that correct?
MR. FLEMATTI: Correct.
MR. LALLY: And what, if anything, specifically was suctioned from Mr. O'Keefe's airway?
MR. FLEMATTI: Suctioned from the airway was mostly blood. Blood, sputum.
MR. LALLY: And, as far as how much, what, if anything, do you have to sort of measure how much blood was suctioned out of Mr. O'Keefe's airway?
MR. FLEMATTI: So we have a canister that has marks of milliliters so we determine, as we are suctioning, how much is in that container at different times.
MR. LALLY: And about how much based on that was suctioned from Mr. O'Keefe's airway?
MR. FLEMATTI: Do the initial suctioning with the rigid tip was about 150 milliliters and then subsequently -- so that would have been above the airway, in the mouth, in that type of area. We established the intubation and then deep functioning with that soft tip through the intubation tube would have been another 50 milliliters of fluid.
MR. LALLY: Now, with reference to you mentioned some observations of Mr. O'Keefe's back, correct?
MR. FLEMATTI: What's that?
MR. LALLY: You mentioned some observations you made earlier in reference to Mr. O'Keefe's back?
MR. FLEMATTI: Yes.
MR. LALLY: And what were those again?
MR. FLEMATTI: So that would have been redness of the skin in the posterior of the body.
MR. LALLY: What, if any, significance did that have to you as far as your observation of that?
MR. FLEMATTI: So redness from the skin, if it's general or across the body, can mean certain things. If it's just a particular area and due to the fact that it was cold outside, that would have been the initial stages of frostbite or exposure to cold.
MR. LALLY: And, as far as the remainder of Mr. O'Keefe's body, what, if any, other observations did you make and which areas did you make those observations to in regard to the initial stages?
MR. FLEMATTI: So as far as the cold exposure?
MR. LALLY: Yes.
MR. FLEMATTI: Cold exposure, we're looking at the most exterior parts. Extreme cold exposure can lead to frost nip and frostbite in different areas. The first affected areas are going to be your fingers, your ears, your nose, your toes. That type of -- so that was a cold, waxy, pale, stark white substance, basically, or condition of his skin.
MR. LALLY: And on each of those areas that you just described?
MR. FLEMATTI: Yes.
MR. LALLY: Now, sort of up in the area of Mr. O'Keefe's head, you mentioned some bleeding from the eyes and the nose, correct?
MR. FLEMATTI: Yes.
MR. LALLY: As well as his mouth?
MR. FLEMATTI: Yes.
MR. LALLY: And, beyond that, what, if any, observations did you make of any other sort of injuries to his head or his face?
MR. FLEMATTI: So his eyes were pretty well swollen. We were trying to clear areas of blood to figure out if there were any contusions around the head. I believe there is a contusion on his forehead. He also had some markings on his extremities, as well.
MR. LALLY: And, just as far as your understanding based on your training and experience, when you use the word "contusion," what do you understand that to be?
MR. FLEMATTI: A bruise.
MR. LALLY: Before we get to the extremities, what, if any, observations did you make as far as Mr. O'Keefe's abdomen?
MR. FLEMATTI: The abdomen we noted as significant as distention or swelling of the belly.
MR. LALLY: And what, if any, significance did that have to you in regard to Mr. O'Keefe?
MR. FLEMATTI: It's another of our detailed assessments. We go through the body in amore detailed way to try and find more clues that we can pass on for the assessment. Distention in the belly could be due to trauma or bloating. It could be -- those are usually our biggest triggers for distention.
MR. LALLY: Now, you mentioned, as far as the extremities are concerned, what, if anything, did you observe as far as injuries to Mr. O'Keefe's extremities.
MR. FLEMATTI: So we're looking at -- so we had the cold, rigid fingers, hands, feet. Then we had multiple dry blood, lacerations to the right arm.
MR. LALLY: Do you recall specifically where on Mr. O'Keefe's right arm you observed those?
MR. FLEMATTI: It would have been his upper arm.
MR. LALLY: Upper. And you mentioned dried blood; is that correct?
MR. FLEMATTI: Yes.
MR. LALLY: So these were not actively bleeding at the time that you observed them?
MR. FLEMATTI: No.
MR. LALLY: Now, as far as being dried blood versus actively bleeding, what, if anything, does that indicate to you as far as sort of timing?
MR. FLEMATTI: So we had active bleeding from other areas in the body. So the fact that it had already stopped and clotted, I would assume that would have been several hours before the incident that led him to be there. But I would guess earlier in the evening.
MR. LALLY: Now, as far as the history is concerned, your attempts on scene and then what, if any, attempts were made subsequent when you were in the ambulance to obtaining any sort of history of how Mr. O'Keefe came to be there or what, if anything, caused the injuries that you observed?
MR. FLEMATTI: Once we get the patient into the ambulance, there is no family, no bystanders in the back of the ambulance. So then it's going to be solely based on physical assessment.
MR. LALLY: And, within sort of the team of firefighters that you had, who, if anyone, did you direct to try and obtain that information while you were in the back of the ambulance?
MR. FLEMATTI: That would have been Katie McLaughlin.
MR. LALLY: And what did you ask Ms. McLaughlin to do?
MR. FLEMATTI: So Katie was one of our senior paramedics at the time. So we had enough skilled hands working on the patient at that time. So to direct her -- I wasn't able to get as much information and still had a skill to do or still had a task to do to run the cardiac arrest. So I pushed -- I didn't push. I directed Ms. Read over to Katie to try and gather more information as to why they were there, if you could get any more information about who he was, events leading to the jury, how long he was down for, any type of information and then moved on to the patient at that point.
MR. LALLY: And so Firefighter McLaughlin is having this conversation outside of the ambulance; is that correct?
MR. FLEMATTI: That's correct.
MR. LALLY: And this is going on while you're inside of the ambulance, actively treating Mr. O'Keefe?
MR. FLEMATTI: It was a very quick process. So I start the conversation. It wasn't productive. It wasn't moving forward. I moved her over to Firefighter McLaughlin, continued on to the patient and then started treatment, moved the patient in and then Katie came into the back of the ambulance to help. So it was a very quick process.
MR. LALLY: Now, as far as Mr. O'Keefe's eyes were concerned, what, if any, observations further did you make as far as Mr. O'Keefe's eyes?
MR. FLEMATTI: So both eyes were swollen and bleeding.
MR. LALLY: And what, if any, observations were you able to make of his pupils?
MR. FLEMATTI: I'm sorry. What?
MR. LALLY: Pupils.
MR. FLEMATTI: Pupils. So I have it documented as 4mm and nonreactive.
MR. LALLY: What, if any, significance is those observations as far as 4mm and nonreactive?
MR. FLEMATTI: So we are looking for quality between the two. So signs of bleeding can be demonstrated by unequal pupils or if they were restricted would lead us to believe it was as a result of an opioid interaction. But we're looking at whether they react to light, as well, if there's brain activity. If there's still something causing the body to react, you'll have some type of pupillary response. So we shine a light. There was no response. It was fixed and at 4mm.
MR. LALLY: Now, at some point, you leave the scene in route to Good Samaritan; is that correct?
MR. FLEMATTI: That's right.
MR. LALLY: And who is continuing treatment of Mr. O'Keefe in the back of the ambulance during transport?
MR. FLEMATTI: So at the back of the ambulance at transport, Firefighter Kelly, Firefighter Nuttall and myself.
MR. LALLY: And who, if anyone was driving in the ambulance between Fairview and Good Samaritan?
MR. FLEMATTI: So that would be determined by basically just positioning on the engine. So the step driver for that position would then drive as the detail person over to the ambulance, and that was Firefighter McLaughlin.
MR. LALLY: Now, during the transport from Fairview to Good Samaritan, what, if anything, are you and the other firefighters in the back of the ambulance doing as far as continuing treatment of Mr. O'Keefe?
MR. FLEMATTI: We started transport at 6:27. So between 6:27 and 6:45, treatments included epinephrine, additional suctioning, managing the airway, placing another intraosseous line, and then three additional rounds of epinephrine while the mechanical CPR is continuing CPR.
MR. LALLY: And, during the course of the transport, what, if any, changes in Mr. O'Keefe's status as far as the cardiac arrest or the breathing occurred during the transport?
MR. FLEMATTI: No change.
MR. LALLY: Now, that time that it took to get from Fairview to Good Samaritan, is that sort of a typical transport time?
MR. FLEMATTI: Not normally. Due to the weather, it was pretty slow driving. Even though the ambulance is a smaller vehicle than the engine, slow transport compared to normal.
MR. LALLY: And, during the course of the transport, what, if any, communication are you having with Good Samaritan in regard to Mr. O'Keefe and his eventual arrival there?
MR. FLEMATTI: Every medical that goes on, we try to give the hospital staff a head's-up, basically, of what's coming in. We'll have different alerts that we give them, whether it's a cardiac arrest, a stroke, a STEMI to have certain appropriate teams come in and be ready, whether it's a trauma alert. There's different specialties within the hospital that will treat those particular different cases. So we will call them five to 10 minutes prior to give that team time to get down to the emergency room to get ready for work.
MR. LALLY: And, when you arrived at Good Samaritan, who, if anyone, were you met by and sort of what happened with regard to Mr. O'Keefe at that point?
MR. FLEMATTI: So we're continuing interventions from the ambulance through the bay, into their code room, where they are met by registration, a registered nurse and the doctor that took care of the patient, as well as a team of other assistants and CNAs.
MR. LALLY: And where do you sort of -- do you physically go with Mr. O'Keefe or how does that work?
MR. FLEMATTI: Yes. So that's referred to as a transfer of care. So there is different people, like I said, at the team base where different people are in charge of different things. You'll have the nurse in charge. That's in charge of documenting our interventions that have been done so far, the time we're down, the patient was down. And then she starts documenting all of the different interventions that were done by the hospital staff, as well. We also give a report to the doctor who is taking over as lead for the cardiac arrest. They are going to start issuing orders for the patient in treatment. And then you have registration that will get the information to register the patient that they can tie all of their interventions to.
MR. LALLY: And, during that sort of process of exchange of information and things of that nature, what, if anything, did you learn in regard to the sort of core body temperature of Mr. O'Keefe?
MR. FLEMATTI: So at that assessment, I believe he had core body temp of 80 degrees.
MR. LALLY: And what, if any, significance does that have in regard to sort of the typical core body temperature?
MR. FLEMATTI: The typical core body temperature is going to be in the high 90s, where body temperature being at 80 with a rectal temp, a core temp, is going to be extreme hypothermia.
MR. LALLY: Now, your records -- for a certain amount of time, correct, before you clear?
MR. FLEMATTI: Correct.
MR. LALLY: And, at that point in time, while your records -- that initial time, what, if anything, did you learn as far as Mr. O'Keefe's status or what had happened to Mr. O'Keefe?
MR. FLEMATTI: As we talked about before with hypothermia and the extreme cold, we're going to work that for an extended period of time. Most cardiac arrests I will try and hang out by the patient or in the area. As new staff come through, different things are found. The doctors and nurses might have follow-up questions. So I try to stay available as an asset that they can bounce those questions off at least for 10, 15 minutes afterwards to make sure the whole process is completely transferred from all the interested parties.
MR. LALLY: And, during that course of time, what, if anything, did you learn as sort of the eventual status of Mr. O'Keefe?
MR. FLEMATTI: We didn't learn anything while we were at the hospital. We then cleared the hospital, returned back to quarters to decon the ambulance and to replenish all the equipment that we had used, get back in service and move on with the shift.
MR. LALLY: And, at some point during the course of the shift, did you have occasion to go back to Good Samaritan?
MR. FLEMATTI: Me, personally, no. It would have been for an additional medical call if there is any calls for service afterwards.
MR. LALLY: And do you recall whether or not you went back to Good Samaritan for any additional medical calls or anything of that nature?
MR. FLEMATTI: I don't recall.
MR. LALLY: Sir, if I could direct your attention to the screen just over there.
MR. LALLY: Ms. Gilman, if I could please have Exhibit No. 9?
BY MR. LALLY:
MR. LALLY: And, sir, directing your attention to what's been previously marked as Exhibit No. 9 up on the screen, do you recognize what's in the photograph?
MR. FLEMATTI: The house.
MR. LALLY: Is that the house that you responded to; is that correct?
MR. FLEMATTI: That's correct.
MR. LALLY: Ms. Gilman, if I could have Exhibit No. 14.
BY MR. LALLY:
MR. LALLY: And, again, sir, what's up on the screen, do you recognize what that is?
MR. FLEMATTI: I see blood, snow, general area.
MR. LALLY: And, lastly, Ms. Gilman, if I could have Exhibit No. 18.
BY MR. LALLY:
MR. LALLY: Firefighter Flematti, do you recognize what's depicted up on the screen as Exhibit No. 18?
MR. FLEMATTI: Yes.
MR. LALLY: May I approach the witness, Your Honor?
JUDGE CANNONE: Yes.
BY MR. LALLY:
MR. LALLY: Sir, I'm going to hand you a laser pointer. Basically, just press on this button here and point in this direction toward the screen. So, Firefighter Flematti, within this photograph on the screen, Exhibit 18, do you see the area in which you observed Mr. O'Keefe supine on the ground when you first arrived?
MR. FLEMATTI: Yes.
MR. LALLY: And, using that laser pointer, could you direct the jury's attention to where in this photograph you observed Mr. O'Keefe when you initially arrived?
MR. FLEMATTI: Initially arrived would have been in this area.
MR. LALLY: Thank you, sir.
MR. LALLY: May I have just one moment, Your Honor?
JUDGE CANNONE: Yes.
MR. LALLY: I have nothing further for this witness at this time, Your Honor.
JUDGE CANNONE: All right. Cross-examination?
MR. JACKSON: Thank you, Your Honor.