Jun 8, 2011

CNN Shows Up Late to James Ray Sweat Lodge Trial

CNN Schedule Showing James Ray Trial

Promises, promises... So 12:15 came and went and CNN continued it's cutting edge news offerings of empty feeds and weather maps. Eventually, they revised their schedule listing a 5:00 PM arrival. Meanwhile, back in Camp Verde, Dr. Ian Paul took the stand where he was questioned by that precocious tween Truc Do. Oh, how I wish I could have heard the esteemed forensic pathologist explain how the none of the patients had heatstroke.

Thanks to some occasional tweets from April Santiago, we know that Dr. Paul found the symptoms consistent with organophosphate poisoning. He did not find that there was evidence of severe dehydration or that high body temperature of 105° F. Dr. Paul did not think the medical records support a finding of heatstroke or that organophosphate testing was done in a timely fashion.

So, thanks to April Santiago, we know that the defense's paid medical expert is testifying to the key elements of their case. But I have been waiting for weeks to hear how strongly he endorses the organophosphate theory that isn't in his official report and that, according to Truc Do, he has only said he couldn't "rule out." I was really looking forward to Do's examination of the heavily credentialed Dr. Paul and thrilled to learn that he was testifying on this one final day of CNNLive's streaming of the trial. Oh well... I guess CNN had far more important news to cover.

Or not.

CNN did eventually start streaming the trial much later in the afternoon covering the bitter end of Truc Do's direct examination of the defense's star witness and the beginning of Bill Hughes's cross.

Frankly, I expected to be more impressed with the Medical Examiner Dr. Mosley compared to Superman. Mostly, I expected him to talk like a medical science professional; not a shill for the defense. Every other medical expert we've heard from, including the State's paid witness Dr. Dickson, has been at least somewhat circumspect. Dr. Dickson expressed the closest thing to certitude of any of them but he supported his conclusions with research documentation and very specific elements of his own clinical experience to justify that 99% certainty. Dr. Paul on the other hand contradicted his own research sources and gave evasive, if impressively technical sounding non-answers, when questioned about those inconsistencies.

Truc Do has said repeatedly that Dr. Paul came to the defense and offered his services even though he has never testified for a criminal defendant before. During her questioning of Dr. Mosley, Do described Dr. Paul as a State Medical Examiner and not "available for private hire." He made an exception in this case, the defense has implied, because he was so troubled by the incorrect conclusions of heat related death reached by Drs. Mosely and Lyon that he felt compelled to come forward and set the record straight.

After watching Dr. Paul in action for ten minutes or so I began to doubt that he was offering his testimony out of any such moral imperative. He just struck me as too slick by half. I rapidly came to the conclusion that while he may never have been available for hire by criminal defendants before, Ray will not be the last. I got the sense that this is just the beginning of his budding career as a professional witness. That intuitive leap was at least partially confirmed when another trial watcher posted a link to his new and still under construction website where he will advertise his services as a "Forensic Pathology Consultant."

So, as Dr. Paul embarks on this new career trajectory, I'd like to pass along a few tips from my wealth of experience in forensics, which is to say, competitive public speaking:

  Firstly, visual aids are a real asset in an informative presentation but they shouldn't upstage you. This is one case where bigger isn't necessarily better. Especially if they're so large that people have trouble seeing you.

  Or if they evoke nothing so much as one of those giant, novelty checks people get when they win the Publishers Clearing House or Lotto. Remember. You're being paid for this now. Best not to draw too much attention what a cash cow this is for you.

  Or if they dwarf the visual aids prepared by your employers in both size and quality.

  Finally, when answering difficult questions from opposing counsel, it's best not to keep looking nervously at the defense table. Look at the jury. They're your intended audience; not your employers.

In the small amount of direct testimony I was able to hear today, there wasn't much in the way of surprise. Although Dr. Paul did in fact hew more closely to the defense's case than I'd expected. I don't know where I got the idea that he'd convey some intellectual independence. At times this sounded more like the scripted dialog in an infomercial than an interview. One slightly unexpected answer came when Do asked him if pinpoint pupils can occur in heatstroke and he said that they could, echoing Dr. Dickson's testimony about the range of pupil presentations in heatstroke patients. But he was still confident that miotic pupils are a hallmark of a toxidrome and that that was what was indicated here.

I've also found it very interesting to hear how different Do sounds with a defense witness. It turns out that she doesn't always talk faster than the speed of sound and is capable of a conversational tone. I've also learned that she doesn't always end sentences with "correct?" Sadly, even with her more measured and less dictatorial tone, she's still nigh well unbearable to listen to.

Bill Hughes Cross Examines Dr. Ian Paul

Bill Hughes went straight for one of my biggest questions. Why weren't organophosphates suggested in Dr. Paul's written report? Dr. Paul said it was because he had still been waiting for information on Stephen Ray and the report was, therefore, incomplete. He said organophosphates were always part of his differential diagnosis. So, he felt confident enough to say it was a toxidrome, not heatstroke, without Stephen Ray's medical record but not confident enough to say what likely toxin he was contemplating? This makes no sense whatsoever but he said it with a patina of such reasonableness, it was hard not to accept the answer... He's really smooth.

As questioning went on, however, he began to look uncomfortable. Hughes confronted him directly on some of the central planks of his case.

Under direct Paul had claimed that the surviving victims had recovered fully and that this was consistent with organophosphate poisoning, whereas heatstroke would likely cause long-term neurological damage. Hughes pointed out that both Stephen Ray and Sidney Spencer described a litany of symptoms: memory problems, ringing in the head, trouble swallowing, numbness in the limbs, kidney pain, malaise, blurred vision, disequilibrium... Paul seemed to go out of his way to discount each symptom as unlikely caused by heatstroke because he would expect to the see the brain injury confined to the cerebellum instead of the parts of the brain indicated by those symptoms, or because they could be caused by other things, or because they are not specific to heatstroke -- anything but admitting that they could, in fact, be caused by heat related brain injury. Although he allowed that he was not a neurologist so he couldn't be certain.

Dr. Paul had claimed that Liz Neuman's "clammy" skin was an indication that she did not have heat stroke. Hughes pointed out that his own attached article said that not all heatstroke patients present with anhidrosis -- lack of perspiration. Rather than concede the point, he cited a problem with his own reference material. The article didn't differentiate between exertional and non-exertional heatstroke.

Hughes: Can you show us the article then that says that that would only apply to exertional heatstroke.

Paul: I'm not saying that it would only apply to exertional heatstroke but it would be much more common, uh, finding in exertional heatstroke, uh, and this area's not differentiating between the two.

Hughes: Okay, can you show us the article that says that it'd be much more common in exertional heatstroke as opposed to non-exertional.

Paul: Uh, I'm not exactly sure what source or I couldn't identify the, what source I read that in.

Hughes: Is that do you believe in one of the articles that you provided to Ms. Do when you were asked to provide the articles you had relied upon in making your report.

Paul: Yes.

Hughes: You believe it's in here?

Paul: Oh I don't know if it's in there or not.

Hughes: Well, are there other articles then that you relied upon that you didn't provide to Ms. Do?

Paul: I've had training in heat related injury. Um. I'm an ER physician. Uh, it would be a very common subject for me to read either during my training, um, or after my training. And I can't tell you exactly where I read that source, um, it would be basically understood in the medical literature, uh, that there's a clear differentiation between exertional and non-exertional heatstroke. I think it's imperative that you make that difference because they can present in different ways and they affect a completely different group of patients.

Hughes: Do you believe that's an important distinction?

Paul: Yes.

Hughes: Would it surprise you not a single one of these articles on heatstroke you provided make that distinction?

. . .

Hughes: Doctor, can you point out to me then a single article that you provided that make that distinction?

Paul: Uh, I don't know if it's in there or not in those articles. I don't recall them.

. . .

Hughes: Would you look through them and tell if it's in any of those articles?

After a brief recess was called by Judge Darrow, Hughes asked Dr. Paul if he'd had a chance to review the articles and locate a citation for his claim.

Paul: So, uh, the point I was trying to make is that in exertional heatstroke... some people maintain the ability to sweat and um, as compared to patients that have non-exertional heatstroke. In non-exertional heatstroke, patients do not maintain the ability to sweat and, uh, that it stated in this article that I provided and, um, I'll read the sentence. "Because their ability to sweat remains intact patients with EHS (which stands for exertional heatstroke) are able to cool down after cessation of physical activity and may present for medical treatment with temperatures well below 41° C."

Hughes: Now where in there does it say that patients with non-exertional heatstroke, uh, will always lose the ability to sweat? 

Paul: Uh, so I'd have to go through this again but the hallmark of non-exertional heatstroke is anhidrosis, mental status changes, and elevated temperature. 

Hughes: And you believe you saw in there that it indicates that a patient with non-exertional heatstroke would always have lost the ability to sweat?

Paul: It's a hallmark of that process but I did not read specifically that they always lose the ability to sweat.

Hughes: Did you look through the article?

Paul: Yes, and um, I don't see it. 

Hughes: Okay.

So that was a lot of time and energy for Dr. Paul to establish that, in fact, he could provide zero documentation to support one of the central claims of his, and by extension, the defense's case.

As I've discussed at length, dehydration, the underlying cause anhidrosis, is not a necessary cause of heatstroke and is not always present in heatstroke. Nor, obviously, is anhidrosis, as this eMedicine article points out. (Like Dr. Dickson, Dr. Paul relies heavily on eMedicine's scholarly articles and he extolled the virtues of the resource Do derided during her questioning of Dr. Dickson.)

Similarly, some patients may retain the ability to sweat, removing anhidrosis as a criterion for the diagnosis of heatstroke. Therefore, strict adherence to the definition is not advised because it may result in dangerous delays in diagnosis and therapy.

. . .

Anhidrosis due to cessation of sweating [in NEHS] is a late occurrence in heatstroke and may not be present when patients are examined.

The discussion is emblematic of most of Hughes's questioning of Dr. Paul. Hughes asked pointed questions in an attempt to clarify Dr. Paul's claims with Paul avoiding directly answering for as long as possible.

When Hughes asked the Medical Examiner why he used a different diagnostic criteria for heatstroke death than the National Association of Medical Examiners to which he belongs, the dance went on for quite some time. Their position paper does not require a determination of dehydration to diagnose heatstroke.

Dr. Paul would not answer how much the bodies of participants may have cooled in the lengthy process of getting them to the hospital where their rectal temperatures could be measured. He refused to try to calculate how much the cool, breezy, evening air, the wetting down with cold water, and the air conditioned ambulance rides, would have lowered their temperatures after upwards of an hour. Probably because it's hard to argue that they would not have cooled substantially. Instead we got a lot doubletalk about how it would impossible to calculate the temperature drop with certainty. It sure would be easy to cite a ballpark figure, though, which he would not do.

Most tellingly, he had no answer as to what quantity and concentration of organophosphates in pesticides would have been necessary to cause the deaths and injuries. He had done no research on what products could have poisoned people. After claiming that organophosphates had always been part of his differential diagnosis -- despite their lack of inclusion in his report -- his response to questions about what sort of exposure could have caused this tragedy he responded, "That's outside my area of expertise."

Dr. Paul testified today that he's never seen an actual case of organophosphate poisoning -- alive or dead. And yet, unlike every other expert to testify he's the only one willing to say that it's the likely culprit. Dr. Dickson remains the only one of the medical experts to testify who has treated patients with organophosphate poisoning and he is the only willing to dismiss the possibility with near certainty. What does that tell you?

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