Commonwealth v. Read — Trial ArchiveDr. Aizik L. Wolf - Direct/Cross
279 linesJUDGE CANNONE: You are unmuted. All right. Could I see counsel at sidebar, please? All right. So, let's bring the jurors in, please. Leave us for now. All right. So, court — jury's entry. Please be seated. Good morning, jurors. So, an issue has come to my attention that it is going to make it necessary that I talk to each one of you individually over at sidebar with counsel. So, that process will take a little while. So, I'm going to — don't speculate as to what I'm going to talk to you about. Please, when you go back to the deliberation room, talk about anything but this case, and I'll see each of you individually and the process may take — the cameras will be shut off and going across to the lawyers — whether we know — filming. All right, send them back and thank you very much, counsel.
JUDGE CANNONE: Please be seated. All right. So, jurors, I still have a couple of questions for you. Were you able to follow the instructions and refrain from doing any independent research or investigation into this case? And we've discussed the other two questions, but I do need to stress for you that it's very, very important that no one discuss this case. Don't let anyone talk to you about the case. No comments about the case. You've seen how hard the lawyers have worked to pull this case together for you and everybody's given it so much time. So, please let's make sure that we follow that. That means each other. So, with that, I know we're late getting started. We're going to have an abbreviated lunch today. Only 30 minutes and abbreviated breaks. So, no morning break.
JUDGE CANNONE: We're going to start now and go till 1. All right, Mr. Brennan. And we're taking a witness out of order. I apologize. We've got a witness here. Sometimes we take witnesses out of order. Miss Hanley will be back later for the rest of her testimony, but we've got a witness here that we'll call out of order.
MR. BRENNAN: Thank you, Mr. Brennan. Thanks. Thank you, your honor. The Commonwealth calls Dr. Wolf.
COURT CLERK: Do you swear to tell the truth, the whole truth and nothing but the truth, so help you God?
MR. BRENNAN: Thank you. Good morning, doctor.
MR. BRENNAN: All right, whenever you're ready, Mr. Brennan.
JUDGE CANNONE: Thank you, your honor.
MR. BRENNAN: Good morning, sir.
MR. BRENNAN: Could you please introduce yourself to the jury? Spell your first name and last name for the court reporter.
DR. WOLF: Sure. My first name is Isaac. A-I-Z-I-K. It's phonetic. Last name is Wolf. W-O-L-F, like the real thing.
MR. BRENNAN: What do you do for a living?
MR. BRENNAN: Is there a special part of medicine that you study?
DR. WOLF: Well, my main interest in brain surgery is brain tumors and trigeminal neuralgia, but I also specialize in movement disorders. I do pediatrics and adults.
MR. BRENNAN: Are you an active working neurosurgeon?
DR. WOLF: I am a very active working neurosurgeon. I get up every day at 4:30 in the morning to go to work five days a week. I take call 300 days out of 365 days a year.
MR. BRENNAN: Did you work yesterday?
MR. BRENNAN: What type of work did you do yesterday?
MR. BRENNAN: Are you working tomorrow?
DR. WOLF: I have four surgeries scheduled for tomorrow, which is why this is a little bit delayed for me. And I have four on Friday.
MR. BRENNAN: And what type of surgeries do you have tomorrow and Friday?
DR. WOLF: I have three brain tumors, one trigeminal neuralgia, and on Friday I have four patients with movement disorders.
MR. BRENNAN: You're here today as a witness. How much of your practice, how much percent of your income is from being a consultant or a witness for a case?
MR. BRENNAN: I want you to take us through some of your education and background. Could you share with us where you went to medical school and where you graduated from?
MR. BRENNAN: Is that in 1981 that you graduated?
MR. BRENNAN: After medical school, did you begin internships in medical residency?
DR. WOLF: I did an internship at Hennepin County Medical Center, which is a trauma center in Minneapolis. I then did five years of neurosurgical residency at the University of Minnesota.
MR. BRENNAN: And was that in Minnesota?
MR. BRENNAN: Is there something about that hospital that has some specialty?
DR. WOLF: It was one of the number one training centers for chairmen in neurosurgery at the time.
MR. BRENNAN: Did you in your residency and your fellowships do any work or study in pathology?
DR. WOLF: During your residency as a neurosurgical resident, you do six months in neurology. You do three months of neuroradiology. You do three months in pathology, which includes autopsies on brains. And then you do rotations through a trauma center as a chief resident, through a VA hospital, and then ultimately at the university hospital for elective cases. We also do six months of pediatric neurosurgical residency.
MR. BRENNAN: Did you do a fellowship at New York University?
DR. WOLF: Yeah, at NYU I did a fellowship before I went to the University of Maryland as a professor in brain transplantation. The interest was in using cells to create dopamine centers in rat brains with the concept of Parkinson's being curable with transplantation.
MR. BRENNAN: I'd like you to take us through some of your faculty positions so you can share with us some of the progression of your training and experience. And did you begin at the University of Maryland Hospital?
DR. WOLF: Yes. In 1987, the University of Maryland recruited me to start their epilepsy surgical program and skull-based program. And then part of our responsibilities as assistant professors was to cover shock trauma.
MR. BRENNAN: Could you explain for us what shock trauma means and whether the University of Maryland hospital was a shock trauma hospital?
DR. WOLF: So the University of Maryland and shock trauma were actually two separate entities when I started. A man named Cowley had basically developed the concept of the golden hour. So prior to Dr. Cowley, most trauma was just taken locally. That meant as a community hospital, if a patient had been in a motor vehicle accident, they needed an orthopedic surgeon. They had to call the orthopedic surgeon in. Could take 15 minutes, could take three hours. The same thing for a vascular surgeon. The same thing for a neurosurgeon. Dr. Cowley came up with a concept that you needed a center that was strictly for trauma and every attending had to be in the hospital 24/7. So that was the concept of shock trauma back in the 80s.
DR. WOLF: When I got there, we were transitioning from a very small center to a 125-bed hospital that was completely committed to trauma.
MR. BRENNAN: In that experience, in the years you worked there, did you have an opportunity to treat a number of people with brain injuries?
DR. WOLF: We treated well over a hundred patients a year—a month, basically—with brain injuries at shock trauma, along with spinal cord injuries.
MR. BRENNAN: Did you perform surgeries in different types of brain trauma and brain injuries?
MR. BRENNAN: After Maryland in 1993, did you move to Miami Neuroscience Center?
DR. WOLF: Yes. In 1993 I left academics. I went into private practice in Miami and I started the Miami Neuroscience Center. We were the first private community hospital to have what's called the Gamma Knife. So we were the seventh—no, 13th—in the country, but the only one that was non-university based, and Gamma Knife radiosurgery is using radiation to operate on the brain.
MR. BRENNAN: Are you presently the director of the Miami Neuroscience Center at Larkin Hospital?
MR. BRENNAN: You conduct a number of surgeries a year there.
DR. WOLF: Correct. So I spent 19 years at Doctor's Hospital. Then we moved to Larkin Hospital 13 years ago, developing the new radiosurgical unit called Zap and also another machine called high-frequency ultrasound to treat the movement disorders.
MR. BRENNAN: You've noted that you have a number of professional memberships. I don't want to go through all of them. I'd like to point out a few. Are you a professional member of the American Association of Neurological Surgeons?
MR. BRENNAN: Are you a Fellow of the American College of Surgeons?
MR. BRENNAN: Are you a member of the North American Skull Base Society?
MR. BRENNAN: And is that brain related?
MR. BRENNAN: Are you a member of the Society for Neuro-Oncology?
MR. BRENNAN: Are you a member of over—or at least—34 different professional memberships?
MR. BRENNAN: In your career, have you engaged in research?
MR. BRENNAN: Has that research focused or centered on brain injury?
MR. BRENNAN: Is some of your research as a principal investigator for THAM for treatment of brain tissue acidosis and severely head-injured patients?
MR. BRENNAN: Did that research as a principal investigator help you in your diagnosis and treatment of brain injuries?
DR. WOLF: It actually was in the treatment of severe head injury patients who are unconscious—the concept of trying to relieve the increased intracranial pressure that occurs from the injury and to increase blood flow, thereby increasing oxygen to the brain.
MR. BRENNAN: Did you also serve as principal investigator for research for the PEG-SOD and severe head injury?
MR. BRENNAN: Could you describe that very briefly?
DR. WOLF: Basically the same. You know, one of the biggest problems in brain injury is the fact that blood flow ceases to exist as the brain swells up. And so one of the things we try to do is preserve the neurons by making sure that they have enough oxygen and blood flow to them. All these are agents that try to assist that.
MR. BRENNAN: I won't go through all of your research and principal investigator roles, but I want to ask you about one more, and that is did you serve as principal investigator relative to the IRB protocol for brain pathology?
MR. BRENNAN: And what did that do? What was that about?
DR. WOLF: It was about looking at what happens after brain injury to blood vessels and tissue as the intracranial pressure increases in the brain.
MR. BRENNAN: Have you been part of publications of a number of different books?
MR. BRENNAN: I won't list parts of all 16 books, but can I point out a few?
MR. BRENNAN: Were you the author of a book chapter regarding head injury, difficult medical management?
MR. BRENNAN: Were you the author of a book chapter on pediatric neurosurgical emergencies?
MR. BRENNAN: Were you the author of a book chapter on complications of head injuries in adults?
MR. BRENNAN: Were you the author of a book chapter imaging of craniocerebral trauma?
MR. BRENNAN: Were you an author of a book chapter in emergency room assessment of the head injury patient?
MR. BRENNAN: Were you the author of a book chapter on intracranial injuries?
MR. BRENNAN: I won't list or ask you about the other book chapters that you've been the author of. Have you been involved in journal articles?
MR. BRENNAN: I'd like to ask you just about a few of the 70 journal articles that you have published.
MR. JACKSON: Your Honor, objection.
JUDGE CANNONE: Go ahead and ask the question without a comment first.
MR. BRENNAN: Were you an author of a journal article on intracranial pressure and non-traumatic ischemia and hypoxic cerebral insults?
MR. BRENNAN: Were you the author of a journal article on post-traumatic cerebral infarction?
MR. BRENNAN: Were you the author of the journal article Fractures of the Clivus?
MR. BRENNAN: Could you tell me a little bit about that paper?
DR. WOLF: We used thin-cut CT scans to identify fractures of the skull base. Prior to this, prior to CT scans, it was very difficult to actually identify radiologically a skull fracture with plain X-rays. The idea was to see if we could identify them more clearly, and so we classified them and delineated them in the paper and discussed the outcomes that were relative to those types of injuries.
MR. BRENNAN: In the last journal article I'll ask you about, were you the author of a journal article regarding acute traumatic midbrain hemorrhage?
MR. BRENNAN: Were you the presenter in a number of presentations regarding head injury and brain injury?
MR. BRENNAN: You've listed 93. I'll ask you just about a few. Were you a presenter in Fractures of the Clivus, clinical and radiographic features?
MR. BRENNAN: Am I pronouncing that correctly?
MR. BRENNAN: Thank you. Were you the presenter in acute head injury?
MR. BRENNAN: And a separate presentation, Fractures of the Clivus, classifications and clinical features?
MR. BRENNAN: Do you lecture?
MR. BRENNAN: Do you have peer-reviewed publications?
MR. BRENNAN: And are you heavily involved in clinical research?
MR. BRENNAN: Over your career and your study and your clinical experience, have you treated different types of brain injuries?
MR. BRENNAN: Are you familiar with a number of different types of brain injuries?
MR. BRENNAN: Were you asked to review materials relative to this case?
MR. BRENNAN: And do you recall the materials that you reviewed?
MR. BRENNAN: Could you share with us some of the materials that you reviewed?
DR. WOLF: I reviewed the chief medical examiner's assessment of the case. I reviewed pictures that I'm assuming the medical examiner took of the autopsy, and I reviewed the report from the forensic pathologist.
MR. BRENNAN: And before I ask you about your review of specific materials and your opinions in this case, is there a benefit to your clinical experience in studying brain injuries as opposed to the experience you had as a fellow simply with pathology?
DR. WOLF: Well, I think that for the jury to understand — as a clinician, I understand the process from the time the injury occurs till the patient either leaves the hospital or dies, and it's a process, and as a neurosurgeon I have a tremendous amount of experience with that, if that's what you're asking me.
MR. BRENNAN: Yes. And so, doctor, you reviewed a number of items of information in this case. Did you have an opportunity to review photographs of a laceration to Mr. John O'Keefe's head?
MR. BRENNAN: With the court's permission, I'm going to ask to display Exhibit 160.
JUDGE CANNONE: Okay.
MR. BRENNAN: Dr. Wolf, I'm going to ask you to take a look at this photograph. Have you seen this photograph before?
MR. BRENNAN: I want you to explain to us what you're seeing here and take us through the process of your observations.
DR. WOLF: Well, what we're seeing is an approximate inch and a half laceration with bridging tissue, and contusions and abrasions. To us, that's just a classic blunt trauma injury. There's nothing other than just vanilla about it. This is what happens when soft tissue hits a solid ground. The skin tears apart a bit, but not through and through. As you can see, there's the bridging. You can see all the bruising or contusions and just the tear, a little bit serrated along the edges.
MR. BRENNAN: Thank you. If you could take that down. Dr. Wolf, as a result of that wound, did you have a chance to further look at information provided to you about the actual inside the skull of Mr. John O'Keefe?
DR. WOLF: Yes. The pictures that I was reviewing showed a non-depressed skull fracture extending linearly through the Clivus and into the frontal fossa of Mr. O'Keefe over the orbital roofs. He had fractures along the temporal fossa as well. So it was a classic linear basilar skull fracture.
MR. BRENNAN: Is "basilar skull fracture" a characterization?
DR. WOLF: Basically, the base of your skull is what it encompasses. So the opening at the very bottom is what we call the foramen magnum, that connects your brain stem to your spinal cord. And then as your brain stem goes up, it goes into the different skull areas — what we call the cerebral cortexes, your occipital lobe, your temporal lobes over here, and then your frontal lobes.
MR. BRENNAN: So can you walk us through what happens when someone incurs this type of injury to the back of the head — how it happens and what are the next steps for a person?
DR. WOLF: So what happens is, you fall backwards and the linear acceleration starts to take you back down with gravity. The skull hits the ground — it gets, in layman's terms, smashed a little bit. And then the brain moves forward as a response to that. And it moves forward because you have cerebrospinal fluid and because you have the deceleration-acceleration again. As it does, your skull — if you were to look inside your skull, it's like mini mountains along your temporal bones and your frontal bones. So the brain is being thrust forward at a fairly good speed and it's getting bruised. You can think of it as if you took a hammer to your thumb — it's really turning black and blue. Those are the contusions. And so the temporal poles and the frontal poles are getting contusions because of that.
DR. WOLF: At the same time, you have a space called the subarachnoid space. And I'm sure they're going to hear about the subarachnoid hemorrhage. And that space is the little — it's a very clear, thin membrane that covers all of your brain and all of your spinal cord. And normally you really don't see it unless you open up the brain and you're operating. But when you either have a traumatic event like this where little vessels are pulling apart underneath that membrane — or, for example, the classic — you know, when you have an aneurysm burst, the space that the aneurysm bleeds to is the subarachnoid space. The other thing that occurs in trauma like this is you can get a subdural. So the dura is the membrane that covers the whole brain and also right down your spinal canal.
DR. WOLF: And it's a very thin membrane that looks like very thin leather. And in that space between the brain and the dura can be a lot of veins that go towards a central vein called the sagittal sinus. And if those tear, you have a venous hemorrhage — which is not arterial, so it's not quick — but that can develop into a subdural as well. If you tear a portion of your brain as well and you get a little arterial bleed, that could create a much faster subdural hematoma. And so when you look at the pathology, the autopsy of his brain, you're looking at a subarachnoid hemorrhage.
DR. WOLF: You're looking at a subdural hemorrhage — neither one of them which was huge or would have required surgery — as well as the contusions that I described in his frontal poles, in his temporal poles, and then the original bang, which was in the occipital area. These are all findings that you would see on a CT scan and an MRI scan without requiring an autopsy if he had made it to the emergency room.
MR. BRENNAN: I want to take a step back. You said that this laceration on the back of his head was caused by a fall. Could this be caused by a fall landing on hard ground?
MR. BRENNAN: Do you have an opinion to a reasonable degree of medical certainty whether this injury — the laceration and the basilar fracture — was caused by Mr. O'Keefe falling backwards on the ground?
DR. WOLF: My opinion is that that's what caused his whole injury — the pattern of the laceration.
MR. BRENNAN: Do you have an opinion whether that is consistent with hitting the cold hard ground?
MR. ALESSI: Objection. Your honor, may we please —
JUDGE CANNONE: I'm sustaining the objection. No sidebar.
MR. BRENNAN: Do you have an opinion, doctor, about whether that laceration on the back of his head was caused by a particular movement?
DR. WOLF: Well, the only way he could get this kind of an injury was to fall backwards, hit the back of his head, and then the resulting energy forces going into his brain, into his base of his skull.
MR. BRENNAN: Would that type of laceration require Mr. O'Keefe to have hit a line type or ridge type object?
DR. WOLF: A ridge type of object? No. I mean, like I said, the tearing of the skin in that fashion — you could look it up — would be just a classic blunt trauma injury.
MR. BRENNAN: Is there anything about that injury that would suggest to you it had to have been something sharp or ridgelike to cause it?
MR. ALESSI: Objection, your honor.
JUDGE CANNONE: All right, we'll come to —
PARENTHETICAL: [gap: approx. 3.5 minutes of transcript missing between 2:37:04 and 2:40:36]
DR. WOLF: The occipital region. You can see it if patients fall on the forehead. The skin tears, there's still bridging, and then they get bruises.
MR. BRENNAN: Some of your work was in Minnesota, correct? Was it a colder part of Minnesota?
MR. BRENNAN: I'm sorry. Did you often see these type of injuries there?
DR. WOLF: Yes. I mean, we took care of a trauma center, Hennepin County. Very frequently, patients that are drunk fall down on icy sidewalks and could develop lacerations in their head, epidurals — which are blood clots above the dura because they fracture a bone in the temporal area and they can get a bleed from a fractured artery. And it happens when people are shoveling snow and have a heart attack and fall backwards. So there are various ways that people fall resulting in head injuries and lacerations to their forehead or to different areas of their head.
MR. BRENNAN: Can somebody suffer this type of injury simply by falling backwards?
MR. BRENNAN: You had taken us through the process of falling backwards and then talked about what happens to the brain. Can I ask you a couple of detailed questions about that?
MR. BRENNAN: When you explained that the brain upon impact then shifts forward and hits the front of the skull, is there a medical term for that process?
DR. WOLF: Well, the medical term is a coup-contrecoup injury. So the coup is when you first hit. In this case, it was the back of the head, as summarized by the laceration in the back of the head and the contusions that the pathologist and the ME found in the back of the brain. And then the brain shifts forward. And as it's traveling at a certain velocity because it's thrust forward on the floor of the base of the skull, it's getting bumped — and, again, you can think of it as a hammer hitting a thumb — it's getting black and blue in the areas that are sharpest.
MR. BRENNAN: Are there symptoms that result of the coup-contrecoup process?
DR. WOLF: It, you know, this is clinically it varies. I mean, you can go from anywhere from a simple concussion where you sort of are unaware of what happened, but you're still awake. You're confused, all the way to ultimately being in a coma.
MR. BRENNAN: Can this type of injury, the coup-contrecoup, and what you see in the review of your files — could this type of injury happen from an attack by a weapon like a bat or a hammer?
DR. WOLF: Well, he did not have a depressed skull fracture. So, any focal hit like that would more likely than not have caused a depressed skull fracture. Blunt trauma the way he had, the assumption would cause the coup-contrecoup without a depressed skull fracture.
MR. BRENNAN: When the coup-contrecoup process happens with the skull fracture, does anything happen to the front of the skull?
DR. WOLF: Well, the forces, depending on how hard they are, can generate fracture lines all the way to the anterior fossa. So you can have fractures along the lateral temporal area. You can have fractures along the orbital roof. The orbital roof is very thin and so those forces can go all the way to that area.
MR. BRENNAN: Did you see any sign of orbital fractures in Mr. O'Keefe?
DR. WOLF: Yes, he had — both the ME and the pictures taken, and the neuropathologist mentioned fractures of the orbital roof.
MR. BRENNAN: Do you have an opinion to a reasonable degree of medical certainty how those fractures occurred from the trauma? Could you just explain a little bit how that would happen?
DR. WOLF: Well, as he fell backwards and he struck his head, it was clearly at a very high speed generated by gravity. The bone, depending on the quality of his bone, the density, then generated forces. There's a certain amount of lateral give and then you get a linear force going forward. It drives all the way up the clivus and forward into the anterior fossa where his orbital roofs lay. And this is why people like this get what they call raccoon's eyes.
MR. BRENNAN: Do you have an opinion whether the brain itself could have caused the orbital fractures?
DR. WOLF: No, the brain is a soft substance. You could literally put your finger through the brain. We often operate on people fully awake. The brain couldn't possibly cause a fracture. The fracture was caused by the forces generated through that clivus, that middle bone in the middle of his base of the skull.
MR. BRENNAN: Do you have an opinion to a reasonable degree of medical certainty whether or not the brain in any way could have caused these orbital fractures?
MR. BRENNAN: In your study of the records and photographs and in your experience treating these types of injuries, do you have an opinion to a reasonable degree of medical certainty whether or not a person would remain conscious or would be immediately unconscious after the impact of the ground?
DR. WOLF: Well, it's impossible to know whether he became immediately unconscious, but his injuries were very substantial. And it's more probable than not that at some point he quickly became unconscious and was unable to do functional activities.
MR. BRENNAN: What does functional activities mean?
DR. WOLF: The ability to, you know, get himself up and about would be one of the functional activities. The ability to call for help would be a very significant cortical function. And that's why I was talking about, you know, that there's a variation on the theme from a simple concussion to a severe concussion like this.
MR. BRENNAN: If a person does not have functional abilities because they are rendered unconscious, could their body still move?
DR. WOLF: Yes. This is the interesting thing about our brain. So the cortex, which is the top portion of your brain, can get separated from your brain stem functionally. And what happens then is that your body is not acting autonomically, meaning vegetative. So why does that happen? We think it's because as we were cavemen, and if a caveman became unconscious as an animal came up to eat it, the animal would touch it. Well, you have these automatic movements. One of them is called decorticate posturing, which is where you draw your arms like this and you throw your feet out. And then a worse neurological situation is when you decerebrate. Now you push your arms out along with your legs, and that would scare off an animal.
DR. WOLF: So we think that over time genetically this is what happened to our brains in order to create these. But those kind of movements are not thought processes. In other words, your brain is not telling you, "Oh, you have pain. Go ahead and decorticate or decerebrate." It's an automatic movement in response to pain.
MR. BRENNAN: I want you to take us back now to after the fall. Would Mr. O'Keefe, in your study and opinion, have died immediately?
DR. WOLF: No. I'm sorry — yes. I'll tell you. There are very few things — injuries — where you would die quote immediately. So if I took a knife and stabbed you in the back of your neck right below your skull and drove it through your brain stem, you would probably die immediately. If I shot you below your ear and went through and through below your ear and shot through your brain stem, you would die immediately. But traumatic head injuries — you would not die immediately. It's a process, and it's a combination of things: brain swelling, which takes a while to develop; decreased blood flow to your brain because you're getting swelling; and ultimately death of the brain stem that controls your heart and your breathing.
DR. WOLF: And so this is why there's a whole big issue about brain death — when is someone brain dead? — because it's not instant and it can take a long time to be conceived. In these injuries that are very severe that we took care of, there was a high mortality rate. In the linear skull fractures, it was about 67%. But it took time for them to die. It could take days to weeks to months. And also these people got to shock trauma. So it was a while — whether it was hours — before they were even starting to be taken care of, and yet they weren't dead yet. That's why I don't think it was immediate.
MR. BRENNAN: Were there any other observations you made about Mr. O'Keefe or his body that support your opinion that he didn't die immediately?
DR. WOLF: Well, the medical examiner took pictures of his periorbital area and diagnosed raccoon's eyes. Raccoon's eyes occur because there's leakage through the orbital fractures into the periorbital space. Normally, it takes about 24 to 48 hours to develop. It has been noted as early as 1 to 3 hours, which would make it not immediate.
MR. BRENNAN: Could we please have Exhibit 14? Dr. Wolf, could you share with us what you see here in this picture?
DR. WOLF: So right here you can see the black and blue that sort of configures — if he had his eyes open — like what we describe as raccoon's eyes. Right? And that's not caused by direct trauma to his eyelids. It's caused by what I described as the basilar skull fracture, which went to the anterior fossa, which is right over the orbit here inside, with leakage of blood products into that periorbital area.
MR. BRENNAN: You mentioned that starts — or takes at least 1 to 3 hours to begin, minimally?
MR. BRENNAN: You can take that down, please. If Mr. O'Keefe had been brought to a trauma center or emergency room, what would the process be in your experience?
DR. WOLF: Well, he would have been intubated if he wasn't intubated in the field. One of the first things you need to do in a head injury is control the airway. Why? Two reasons. One, you want to have enough oxygen going to the brain to feed it. And two, you want to keep your carbon dioxide down because that causes increased intracranial pressure if it elevates. So you want to constrict the blood vessels a little bit. Then he would have had a CT scan immediately in order to assess whether he has a surgical headache, meaning he needs to go to the operating room to evacuate something or not. During that process, he's obviously going to be getting medication to decrease the brain swelling.
DR. WOLF: And from there you make decisions based on his neurological function and what you're capable of doing to spare the brain from the rest of the injuries that will result. One of the things that occurs with contusions — a great medical term — is they can blossom, which means they can get bigger, and if they get bigger they might require surgical intervention to decrease the pressure as well as the volume of the blood that's destroying brain. And so you do serial CT scans in these patients over time, anywhere from every six to 12 hours to on a daily basis, depending on what the case-by-case, you know, progression of blossoming is occurring.
MR. BRENNAN: You mentioned that about two-thirds of your patients who suffer this injury pass.
DR. WOLF: Correct. What we saw is that in the patients that suffered linear basilar skull fractures, two-thirds of them ultimately went on to die and one-third lived.
MR. BRENNAN: Is there a commonality on how they pass?
DR. WOLF: One of the common reasons they passed is if they trapped a major vessel in one of the fractures, they would get a significant brain stem infarct, meaning a stroke, meaning lack of blood flow to a very significant portion of their brain stem. And so that was one of the causes of death that ultimately we understood. And then the others died from the increased intracranial pressure that drove the brain stem down through the foramen magnum.
MR. BRENNAN: Did you review any materials that talked about or identified Mr. O'Keefe's body temperature when he was treated?
MR. BRENNAN: Is that significant in the process and development of his injury from the moment he fell and hit his head until —
DR. WOLF: His ultimate passing? Well, hypothermia — he had — I mean, if you define hypothermia, it starts at 95°. Your core temperature is usually about 98, 98.6. 95 is very mild hypothermia. When you get to 82 degrees, you're in severe hypothermia. What happens when you're hypothermic — and I'm not going — I'm a neurosurgeon, but I can tell you that you get into multiple organ failure. Your heart starts to have problems. It can have arrhythmias. You're not breathing. And ultimately at hypothermia, you also become unconscious and go into a coma-like state. Below 80°, you're probably going to die. So all I can tell you, it wasn't helpful that he had a significant head injury and that he was then found hypothermic.
MR. BRENNAN: Is it uncommon in your experience for people that suffer this injury to pass within 5 hours?
DR. WOLF: Well, none of the patients we treated died within 5 hours, but it also didn't mean that we, you know, that we didn't realize that they were going to be in a potentially vegetative state. You know, when someone's hypothermic, you have to warm them up in order to establish a clinical status — meaning you can't declare someone dead with a temperature of 80; you have to warm them up slowly, appropriately, and then re-evaluate where they are clinically.
MR. BRENNAN: I've asked you questions about whether you had an opinion about Mr. O'Keefe and when he died. I want to ask it in the form of a formal opinion. Do you have an opinion to a reasonable degree of medical certainty whether Mr. O'Keefe died immediately or within 15 minutes?
DR. WOLF: No, I don't think he died immediately. Neither the hypothermia nor this kind of head injury would kill you immediately in any clinical experience I have.
MR. BRENNAN: Dr. Wolfe. Thank you.
MR. ALESSI: May I, your honor?
JUDGE CANNONE: Yes.
MR. ALESSI: Morning, doctor. I don't think we've had the pleasure of meeting. Uh, welcome.
MR. ALESSI: Sir, can you just describe — you started to do it a little bit on direct — a typical day for you?
DR. WOLF: Uh, I wake up at 4:00, 4:15 in the morning. I go to my center. Uh, I set up patients with frames for their either radiosurgical procedures or stereotactic craniotomies. I go home. I make cappuccino for my wife at 6:00 in the morning. And then I get back to work at 6:30 and move on. I have patients that I'm operating on and I have patients that I'm seeing through the day.
MR. ALESSI: And what type of patients and what type of work? Just in a typical day, what are you doing? What type of patients? And what do you do?
DR. WOLF: It varies. I mean, I see patients with brain tumors. I see patients with hydrocephalus, which is water in their brain. I see pediatric brain tumors. I see subacute and chronic subdural hematomas post-traumatic. I see patients with strokes that are being misdiagnosed. I see patients with cancer, metastatic disease. Um, I used to see patients with cervical problems. I stopped doing that two years ago. Um, I mean, I don't know what else you want me to tell you.
MR. ALESSI: No, that's great. And is that typical day typical of the type of days you've had for the past month, past few years? Is it generally — without specifics?
MR. ALESSI: So none of your typical days, none of the past typical months have involved forensic pathology, have they?
DR. WOLF: You — you could have asked that question very straightforward. I am not a forensic pathologist. I'm a brain surgeon.
MR. ALESSI: Right. And you don't perform autopsies.
MR. ALESSI: You're a brain surgeon.
MR. ALESSI: Right. And is it correct to say that the brains that you see are of living people?
MR. ALESSI: Okay. So what I'd like to do is to go to a different part of the head than was discussed, but sticking with the decedent.
MR. ALESSI: With the topic being Mr. O'Keefe, the decedent in this matter, sir. You testified about raccoon eyes. The medical term for that, sir, is ecchymosis. Right?
MR. ALESSI: And ecchymosis — raccoon eyes — does not cause a laceration to form on an eyelid, does it?
MR. ALESSI: Are you aware that Mr. O'Keefe had a laceration to the outside area of his right upper eyelid?
MR. ALESSI: Now — your honor, I'm going to, with your honor's permission, ask to publish what is already in evidence in a moment.
JUDGE CANNONE: Okay. Mr. Woll. What exhibit number, Mr. Alessi?
MR. ALESSI: We're going to 165, your honor.
JUDGE CANNONE: Okay, go right ahead.
MR. ALESSI: Thank you, Dr. Wolfe. Have you seen this photo depiction before today?
MR. ALESSI: Is it correct that that injury on the upper right eyelid is caused by the application of force directly to that area of the front of the head? Again, namely the upper eyelid.
MR. ALESSI: Is it more than possible? Is it probable that that injury was caused by the application of force directly to that area of the front of his head?
DR. WOLF: Well, an easy answer to that would be is that that's not part of the periorbital ecchymosis.
MR. ALESSI: Thank you, sir. That was exactly going to be my next question. This injury is unrelated to any of what you've been describing — the fall backwards, the force transfer inside the skull, the — as you described it — the dura, the cerebrospinal fluid, all of that dynamic that you so ably described on your direct examination. This injury has nothing to do with that.
MR. ALESSI: Correct. One more moment. Thank you for answering my questions, Dr. Wolfe. A pleasure again. No more questions at this time, your honor.
JUDGE CANNONE: Any brief followup on that?
MR. BRENNAN: No, thank you.
JUDGE CANNONE: All right, Dr. Wolfe, all set. Thank you very much. May we have a moment to get our next witness? Sure. Counsel, have our jurors feel free to stand up and stretch. So jurors, you may realize that went quicker than we thought. So we are ahead of schedule. So why don't we take that morning break. We'll take a 15 or 20 minute [recess].
COURT OFFICER: All rise for the court, please. [unintelligible] Back seated.