MA v. Lindsay Clancy Day 5

Judge William Sullivan (00:00):

Good morning, everyone.

Court (00:00):

Good morning.

Judge William Sullivan (00:01):

I hope everybody had a restful weekend. So what I want to do is just kind of tell you, first, I'm going to go through those questions, make sure everybody was able to follow my instructions. Then I'm going to go over what today's schedule is and then we'll return to the Commonwealth's presentation of evidence. All right. And so let me ask those questions. First question, has any member of the jury read, seen, or overheard anything from any source about any aspect of this case that would affect your ability to be fair and impartial?

Court (00:33):

[inaudible 00:00:36].

Judge William Sullivan (00:35):

All right. Next question. Is there any other serious matter or concern bearing on your service as a juror in this case that anybody needs to bring to my attention? All right. Again, thank you for following those instructions. Now, today's schedule, let me say first thing about the schedule. I know I haven't always been completely correct on some of the schedules we followed, but I want to just let you know that those decisions about the scheduling is on me. All right? And sometimes I have to take into consideration other factors or things that are going on. So what I really wanted to tell you is that don't speculate why we might go a little late or a little early on any certain days, but certainly don't hold it against either side in regards to that. The person who's making those decisions or that decision is me. All right? So you should be aware of that.

(01:29)
So that being said, the thought is today, we should go into the afternoon. All right? And if that changes, I'll let you know. And what we're going to do at this point, we're going to return to the Commonwealth's case. And with that, Commonwealth, call your next witness, please.

Shanan Buckingham (01:49):

Thank you, Your Honor. The Commonwealth would call Michael Snyder.

Kevin Reddington (01:52):

Your Honor, while we're waiting for Dr. Snyder, could we just approach [inaudible 00:02:06]?

Judge William Sullivan (02:05):

Oh, sure. Yeah.

Kevin Reddington (02:05):

Thank you. Apologies.

Court Officer 1 (02:05):

[inaudible 00:03:39].

Court Officer 2 (02:05):

[inaudible 00:03:43]. Dr. Snyder, raise your right hand for the clerk please.

Clerk (03:46):

Good morning. Do you solemnly swear that the testimony and the evidence that you shall give to the court and the jury [inaudible 00:03:52] between the Commonwealth and the defendant [inaudible 00:03:54]? Thank you. You may have a seat, sir.

Court Officer 2 (03:58):

Watch your step, please.

Judge William Sullivan (04:02):

All right. Good morning, Doctor.

Dr. Michael Snyder (04:03):

Good morning.

Judge William Sullivan (04:05):

All right.

Shanan Buckingham (04:06):

May I inquire?

Judge William Sullivan (04:07):

Attorney Buckingham, please.

Shanan Buckingham (04:08):

Thank you. Good morning, sir. Could you please tell the jurors your first and last name?

Dr. Michael Snyder (04:12):

Yep. Michael Snyder.

Shanan Buckingham (04:14):

Do you mind spelling your last name for the record, please?

Dr. Michael Snyder (04:16):

S-N-Y-D-E-R.

Shanan Buckingham (04:18):

And how are you employed?

Dr. Michael Snyder (04:20):

I'm a physician at Beth Israel.

Shanan Buckingham (04:23):

And how long have you been a physician?

Dr. Michael Snyder (04:26):

Since 1998.

Shanan Buckingham (04:28):

Can you tell us a little bit about your educational background?

Dr. Michael Snyder (04:30):

So, undergrad at UMass Amherst. I did medical school at Tufts University, and then I did my residency in emergency medicine at Boston University.

Shanan Buckingham (04:40):

And how long have you worked at Beth Israel?

Dr. Michael Snyder (04:44):

Since 2014, 12 years.

Shanan Buckingham (04:49):

And do you primarily work in the emergency department?

Dr. Michael Snyder (04:52):

Yes.

Shanan Buckingham (04:53):

I'm going to draw your attention to January 24th of the year 2023. Do you recall working in the emergency department on that day?

Dr. Michael Snyder (04:59):

Yes.

Shanan Buckingham (04:59):

And in the evening, were you made aware of multiple pediatric traumas that were coming into the emergency department?

Dr. Michael Snyder (05:07):

Yes.

Shanan Buckingham (05:08):

And when you are made aware of people coming in, how does that occur?

Dr. Michael Snyder (05:15):

So we'll typically get a call on the EMS phone that something's coming and that they want us to know about upfront.

Shanan Buckingham (05:23):

And do they provide you with some basic background information about what's occurring or what occurred on scene and what's occurring during the transport?

Dr. Michael Snyder (05:34):

When possible, yeah.

Shanan Buckingham (05:35):

Okay. And when the emergency personnel, the EMTs or paramedics arrived at Beth Israel, there were three patients, correct?

Dr. Michael Snyder (05:42):

Correct.

Shanan Buckingham (05:43):

And you were assigned to treat one patient?

Dr. Michael Snyder (05:46):

Correct.

Shanan Buckingham (05:47):

Do you recall which patient that was?

Dr. Michael Snyder (05:48):

Cora.

Shanan Buckingham (05:48):

Okay. And prior to EMS arriving, did you learn more about Cora's presentation and what was occurring?

Dr. Michael Snyder (05:59):

Yeah. So we had heard that all three were in cardiac arrest and Cora in particular, they were still working on doing CPR and doing what we call pediatric advanced life support. So medications to try and restart the heart. And they also mentioned that they had used what we call a defibrillator to shock the heart to try to restart it. And they were still doing CPR when they were arriving.

Shanan Buckingham (06:32):

And is this information important to you as you're assessing a patient coming into the emergency department?

Dr. Michael Snyder (06:35):

Yeah, yeah. It's important to know what things look like in the field, how long the patient might've been without a pulse or how long they may not have been breathing for, so we can kind of expect or know what injuries to look out for, what we can potentially reverse.

Shanan Buckingham (06:51):

And were you aware of the age of Cora?

Dr. Michael Snyder (06:54):

Yes.

Shanan Buckingham (06:55):

And she was five, correct?

Dr. Michael Snyder (06:56):

Yes.

Shanan Buckingham (06:57):

And as far as the medications that you were aware of, what medications had been provided?

Dr. Michael Snyder (07:04):

So prior to coming to us, she had been given epinephrine, which is the primary medication we use in a cardiac arrest.

Shanan Buckingham (07:12):

And do you know how they had administered that medicine to her?

Dr. Michael Snyder (07:16):

Yeah. So she had what we call an intraosseous device in her right tibia. Sometimes it's very difficult to get an IV in so we can go directly into the bone or the bone marrow.

Shanan Buckingham (07:29):

And were you aware of whether she had been intubated en route?

Dr. Michael Snyder (07:33):

So she was not intubated en route.

Shanan Buckingham (07:36):

When she arrived at the emergency department, were you there to greet the ambulance?

Dr. Michael Snyder (07:39):

Yes.

Shanan Buckingham (07:40):

And what happens when a patient comes in through the emergency department via ambulance?

Dr. Michael Snyder (07:46):

So when the patient first comes in, we immediately have our team start to sort of take over care so there's no gap. And then we also get a sign out from the paramedics and EMTs and any other staff that had been involved in the case.

Shanan Buckingham (08:01):

And do you and your emergency room staff then perform your own initial assessment of the patient?

Dr. Michael Snyder (08:07):

Yes.

Shanan Buckingham (08:07):

And what do you do for that?

Dr. Michael Snyder (08:09):

So initially, we sort of go through our ABCs, airway, breathing, circulation. So initially focusing on the primary things such as making sure we're getting air and oxygen into the patient, keeping the heart going, so continuing CPR at that point.

Shanan Buckingham (08:26):

And as far as Cora went, did you observe that she was breathing?

Dr. Michael Snyder (08:30):

So she was not breathing on her own.

Shanan Buckingham (08:32):

How about the heart? Did you observe that her heart was beating?

Dr. Michael Snyder (08:35):

There was no heartbeat.

Shanan Buckingham (08:38):

How about her physical appearance? What observations did you make of her physical appearance?

Dr. Michael Snyder (08:42):

So initially, when she had come in, some of the things we noticed is sort of a blue tint to the skin, which typically, we can see when there's less oxygen or lack of oxygen. And then the other things on a quick survey is there was some areas of bruising on the neck and around the eyes called petechiae, kind of little bleeding, episodes of bleeding under the skin, and I believe a small amount of blood coming from the nose.

Shanan Buckingham (09:14):

Were you able to make observations of her hands or other parts of her body?

Dr. Michael Snyder (09:19):

So the hands definitely had that, what we call cyanosis or blue hue.

Shanan Buckingham (09:25):

Now, as far as the eyes, you mentioned petechiae around the face and the eyes as well as the neck. Did you notice anything else about her eyes?

Dr. Michael Snyder (09:35):

So the pupils were fixed and enlarged.

Shanan Buckingham (09:39):

Why is that significant to you?

Dr. Michael Snyder (09:41):

So oftentimes, when we see it coming in, it can indicate two different things. Some of the medications like epinephrine can cause the pupils to dilate, but also if the brain is starting to become damaged or not functioning, then you start to lose initially some of the signals that would make the pupils smaller. So they'll tend to start to get enlarged or dilated if there's brain injury starting or has occurred.

Shanan Buckingham (10:11):

Now, you indicated that when Cora arrived, she was not intubated, meaning she did not have a breathing tube in. Did you and your team attempt to intubate her?

Dr. Michael Snyder (10:19):

Yes.

Shanan Buckingham (10:20):

And did you do that on your own or with the assistance of other parts of the emergency department or the hospital?

Dr. Michael Snyder (10:28):

So we had anesthesia there. After we got the phone calls of multiple patients coming in, typically we'll have all the help that we could possibly need there to be able to take care of all the patients. So I had an anesthesiologist in the room with me who put the breathing tube in.

Shanan Buckingham (10:47):

In instances where an individual might have suffered some sort of injury to their neck, does that complicate the insertion of a breathing tube?

Dr. Michael Snyder (10:55):

It can, yeah. Because normally, you might need to move or tilt the head to get a direct view where you can put a breathing tube in. But when there's a concern for neck injury, we stabilize it typically with a collar or manually so you don't have the ability to move the head and the neck around to try and get a better view.

Shanan Buckingham (11:15):

Once a breathing tube was put in, were you and your team able to manually give breath to Cora?

Dr. Michael Snyder (11:21):

Yes.

Shanan Buckingham (11:22):

Now, did you then perform an assessment, a cardiac assessment of her?

Dr. Michael Snyder (11:27):

Yeah. So in addition to listening to the heart, feeling for a pulse, we'll also tend to use an ultrasound machine in the room where we can kind of get a direct view of heart function.

Shanan Buckingham (11:40):

And you were aware that they had defibrillated her twice in the ambulance. Why is that significant when you're treating a patient that's in cardiac arrest?

Dr. Michael Snyder (11:48):

So when they defibrillate a patient, it's typically the heart or might be in a rhythm where it can't pump blood. So it might be sort of out of sync or quivering, where we may attempt to use electricity to kind of shock it back into a rhythm.

Shanan Buckingham (12:06):

Once you performed the ultrasound, the cardiac ultrasound, were there any attempts made further to use a defibrillator?

Dr. Michael Snyder (12:14):

No.

Shanan Buckingham (12:17):

Throughout your course of treatment with her, did you continue with various medications?

Dr. Michael Snyder (12:21):

Yes.

Shanan Buckingham (12:22):

And was CPR ongoing throughout your entire time with her?

Dr. Michael Snyder (12:26):

Yes.

Shanan Buckingham (12:27):

Were you consulting with any other colleagues or any other hospitals in regards to the care of Cora?

Dr. Michael Snyder (12:32):

Yeah. So we actually had, in addition to all my colleagues in the emergency room, we had intensive care physicians from Children's that were on the phone with us kind of working through any things that may have come up in the case. Also expecting that they would be receiving the patients from us.

Shanan Buckingham (12:52):

Is your hospital at the Beth Israel equipped to handle this type of pediatric trauma?

Dr. Michael Snyder (12:57):

So we can do the initial stabilization, but then we need to ship the patients out to either get a specialty care or continued inpatient care.

Shanan Buckingham (13:07):

And how long did efforts in treating Cora continue?

Dr. Michael Snyder (13:12):

So in the emergency room, roughly 30 minutes.

Shanan Buckingham (13:17):

And fair to say that all of the efforts that you made were not successful?

Dr. Michael Snyder (13:25):

Correct.

Shanan Buckingham (13:26):

And at approximately 19:28 or 7: 28, did you finally declare Cora deceased?

Dr. Michael Snyder (13:34):

Yes.

Shanan Buckingham (13:35):

Thank you. I have nothing further.

Judge William Sullivan (13:35):

Mr. Reddington.

Kevin Reddington (13:38):

I have no questions. Thank you, Doctor.

Judge William Sullivan (13:39):

Thank you, Doctor.

Dr. Michael Snyder (13:40):

Thanks.

Jennifer Sprague (13:46):

Commonwealth calls Dr. Andrew Capraro.

Court Officer 1 (13:47):

[inaudible 00:13:48].

Dr. Andrew Capraro (13:47):

Thank you.

Court Officer 2 (13:47):

[inaudible 00:13:48] right here, raise your right hand for the clerk, please.

Clerk (13:47):

Good morning. Do you solemnly swear [inaudible 00:14:18]?

Dr. Andrew Capraro (13:48):

I do.

Clerk (13:48):

Thank you. You may have a seat, sir.

Court Officer 2 (13:48):

[inaudible 00:14:28], please.

Judge William Sullivan (14:30):

All right. Good morning, Doctor.

Dr. Andrew Capraro (14:31):

Morning.

Jennifer Sprague (14:33):

If I may?

Judge William Sullivan (14:34):

Yes, please.

Jennifer Sprague (14:35):

Thank you. Good morning. Can you please state and spell your name for the record?

Dr. Andrew Capraro (14:38):

My name's Dr. Andrew Capraro. Last name C-A-P-R-A-R-O.

Jennifer Sprague (14:43):

And your date of birth, please?

Dr. Andrew Capraro (14:45):

July 9th, 1970.

Jennifer Sprague (14:47):

What do you do for a living?

Dr. Andrew Capraro (14:48):

I'm an attending physician in the emergency department at Boston Children's Hospital.

Jennifer Sprague (14:52):

And how long have you done that?

Dr. Andrew Capraro (14:54):

For the last 26 years.

Jennifer Sprague (14:55):

Can you just briefly describe for us the training and education you had to qualify for that role?

Dr. Andrew Capraro (15:01):

I went to Providence College undergrad and then went to Brown Medical School. Subsequently, I went to Connecticut Children's Medical Center for my pediatric residency, and then did fellowship training in pediatric emergency medicine at Boston Children's Hospital from 2000 to 2003 and have been an attending there ever since.

Jennifer Sprague (15:19):

And what's involved with being an attending at Boston Children's Hospital?

Dr. Andrew Capraro (15:23):

It means that I am guiding the care and treatment for the patients that I am seeing during my particular shift.

Jennifer Sprague (15:31):

And are you assigned to a specific location or area of the hospital?

Dr. Andrew Capraro (15:35):

I'm always in the emergency department and the emergency department is broken up into different zones of which I am sort of the primary attending for one set of rooms.

Jennifer Sprague (15:44):

I want to direct your attention to January 24th, 2023. Were you working that evening?

Dr. Andrew Capraro (15:51):

I was.

Jennifer Sprague (15:51):

And at some point in time, did you learn that a patient named Callan Clancy was going to be transported to your hospital?

Dr. Andrew Capraro (15:57):

I did.

Jennifer Sprague (15:59):

And do you recall where he was being brought from?

Dr. Andrew Capraro (16:01):

From Beth Israel Plymouth, I believe.

Jennifer Sprague (16:04):

And was he being med-flighted to your facility?

Dr. Andrew Capraro (16:06):

Correct.

Jennifer Sprague (16:07):

And were you provided with some information about the patient in order to prepare for his arrival?

Dr. Andrew Capraro (16:12):

I was.

Jennifer Sprague (16:13):

And what did you learn?

Dr. Andrew Capraro (16:15):

We have a communication center where facilities that are transferring patients to us call to let us know that the patient is coming. And so that comm center had been notified about this patient, who then got in touch with me as the attending who would be caring for the patient to let me know what had happened there and the condition of the patient when he was arriving.

Jennifer Sprague (16:34):

And what did you learn about the condition of the patient, Callan Clancy, as he was being flown to your hospital?

Dr. Andrew Capraro (16:40):

What I was told was that it was believed that the patient had been strangled. And when he arrived at Plymouth, he was in cardiac arrest, that they had intubated him and initiated CPR, and they had gotten return of spontaneous circulation, and that they were then going to transfer him to us for further evaluation and care.

Jennifer Sprague (16:58):

And at some point in time, did Callan arrive at your hospital?

Dr. Andrew Capraro (17:01):

That is correct.

Jennifer Sprague (17:03):

And were you able to observe him physically?

Dr. Andrew Capraro (17:04):

Yes.

Jennifer Sprague (17:05):

What observations did you make about his physical condition?

Dr. Andrew Capraro (17:09):

He was cold on arrival and he was quite limp, was not making any purposeful movements on his own. His pupils were fixed and dilated, and he had ligature marks about his neck with some swelling of the neck.

Jennifer Sprague (17:24):

And his pupils being fixed and dilated, is that medically significant for you?

Dr. Andrew Capraro (17:30):

Yes, it is.

Jennifer Sprague (17:30):

And why is that?

Dr. Andrew Capraro (17:32):

It typically means that significant injury has happened to the brain, such that there is brain swelling that has sort of over... What do I want to say? It has overwhelmed the capacity of the skull, such that the swelling has made the brain sort of herniate through the base of the skull.

Jennifer Sprague (17:52):

Does that mean the brain's swelling so much it's pushing through the skull?

Dr. Andrew Capraro (17:56):

Correct.

Jennifer Sprague (17:57):

And what observations did you make of his heart rate?

Dr. Andrew Capraro (18:01):

His heart was beating and we did have to provide him with an epinephrine to keep his heart rate and his blood pressure within normal limits, but it was beating on its own.

Jennifer Sprague (18:10):

And how did you know that you had to provide the epinephrine for him to stabilize that heart rate?

Dr. Andrew Capraro (18:14):

It was initiated at BI because they had noticed that his blood pressure was low and you need to have normal blood pressure for the blood to perfuse your organs and keep them healthy. And so we were looking for certain parameters to sort of maintain that, which we did on that epinephrine drip.

Jennifer Sprague (18:31):

And when you say BI, you're referring to Beth Israel?

Dr. Andrew Capraro (18:33):

Yes. I'm sorry about that.

Jennifer Sprague (18:34):

That's okay. And so as far as his breathing, was he breathing on his own?

Dr. Andrew Capraro (18:40):

He had been intubated at the outside hospital and he was needing a ventilator to breathe for him. Occasionally, he would have sort of a breath on his own, we would notice. We were able to see that because when he attempted to take a breath on his own, he would trigger the ventilator to continue that breath. But it was rare, for sure he needed the ventilator to maintain his ventilation.

Jennifer Sprague (19:03):

Would it be fair to say that the majority of his breathing was being done by the ventilator?

Dr. Andrew Capraro (19:08):

Yes, the vast majority of his breathing.

Jennifer Sprague (19:11):

Now, once you have received this information while he's coming in and then you've made your own physical observations of Callan, are there certain tests that you have run on him?

Dr. Andrew Capraro (19:23):

Yeah. Our job, once we received him, was to perform further evaluation and stabilization to help determine what the next steps of his medical care would be. So prior to him arriving, we had contacted our trauma team and our ICU doctors to let them know that he was coming and that we would need their assistance. And then under my care, we performed some routine blood work, a head CT, a neck CT, and a chest X-ray to sort of help us guide the next steps.

Jennifer Sprague (19:53):

And from the head CT and the other testing that you did, what were you able to learn from the results of those tests?

Dr. Andrew Capraro (19:58):

The head CT in particular showed significant brain swelling consistent with hypoxic-ischemic injury, which was the most significant finding that we found.

Jennifer Sprague (20:09):

So could you please explain for us what is hypoxic-ischemic injury?

Dr. Andrew Capraro (20:14):

Hypoxic is just a fancy word for not getting enough oxygen and ischemic is just a fancy word for not getting enough blood flow. And so when your organs don't get enough oxygen and blood, they sort of suffer injury and therefore get to swelling. And so his brain was showing evidence of that.

Jennifer Sprague (20:34):

So would it be fair to say that his brain wasn't getting enough oxygen and blood flow and then because of that, it was damaged and swelling?

Dr. Andrew Capraro (20:43):

Correct.

Jennifer Sprague (20:46):

Now, this type of swelling and injury as you're describing it, can that be caused by strangulation, the injury of the brain?

Dr. Andrew Capraro (20:53):

Most certainly.

Jennifer Sprague (20:55):

And you mentioned earlier that you did see some marks around his neck. Is that correct?

Dr. Andrew Capraro (21:01):

Correct.

Jennifer Sprague (21:02):

And what were those consistent with?

Dr. Andrew Capraro (21:04):

Strangulation of some sort, most likely from an object based upon the linear aspect of the bruising.

Jennifer Sprague (21:12):

And when you say the linear aspect of the bruising, does that mean it's in a straight line?

Dr. Andrew Capraro (21:16):

Correct.

Jennifer Sprague (21:19):

Now, once you had the results of this testing, did you make a decision on what to do next?

Dr. Andrew Capraro (21:29):

Yeah. The main thing was to help us figure out did the patient need to go to the operating room for some sort of other procedure to help with this or was this something that could be dealt with medically? And so once we had the results of the head CT and then the neck CT as well, it was felt that the next appropriate step in his medical care would be to be transitioned to the intensive care unit for them to take over care.

Jennifer Sprague (21:52):

Why was it that surgery was not an option to help Callan in this situation?

Dr. Andrew Capraro (21:58):

Yeah. The neurosurgery doctors were there to sort of help us make that decision. There was no significant bleeding, for example, that would need to be evacuated. There was nothing that they felt from a surgical point of view would help alleviate the problems that we saw on the CT.

Jennifer Sprague (22:10):

Okay. And so was his care transferred to the ICU?

Dr. Andrew Capraro (22:15):

That is correct.

Jennifer Sprague (22:16):

And once Callan was transferred to the intensive care unit, did your care for him end at that point?

Dr. Andrew Capraro (22:22):

Correct.

Jennifer Sprague (22:23):

I have nothing further. Thank you.

Judge William Sullivan (22:32):

Thank you. Mr. Reddington?

Kevin Reddington (22:32):

No questions. Thank you, Doctor.

Judge William Sullivan (22:32):

Thank you, Doctor. Please step down.

Dr. Andrew Capraro (22:32):

Thank you.

Court Officer 2 (22:32):

Watch your step, please.

Jennifer Sprague (22:42):

Commonwealth calls Dr. David Casavant.

Court Officer 2 (23:30):

Good morning, sir. Please stand right there and raise your right hand to the clerk.

Clerk (23:31):

Good morning. Do you solemnly swear that the testimony and the evidence you shall give to the court [inaudible 00:23:31] the Commonwealth and the defendant shall be the truth, the whole truth, and nothing but the truth, so help you God?

Dr. David Casavant (23:31):

I do.

Clerk (23:31):

Thank you. You may have a seat, sir.

Court Officer 2 (23:32):

Watch your step there, sir.

Dr. David Casavant (23:32):

Thank you, sir.

Judge William Sullivan (23:32):

All right. Good morning, Doctor.

Dr. David Casavant (23:32):

Good morning. Good morning, Your Honor.

Judge William Sullivan (23:34):

Attorney Sprague.

Jennifer Sprague (23:35):

Thank you. Good morning. Can you please state and spell your name for the record?

Dr. David Casavant (23:38):

Surely. My first name is David. My last name is Casavant. It's spelled C-A-S-A-V-A-N-T.

Jennifer Sprague (23:46):

And your date of birth, sir?

Dr. David Casavant (23:47):

5/2/63.

Jennifer Sprague (23:49):

What do you do for a living?

Dr. David Casavant (23:50):

I'm an ICU physician at Boston Children's Hospital.

Jennifer Sprague (23:53):

Can you briefly describe for us your educational and training background?

Dr. David Casavant (23:56):

Sure. I went to college out at Holy Cross in Worcester, and then to medical school at Boston University. I did my initial pediatric residency at Mass General Hospital, and then went back and did a fellowship in ICU medicine at that hospital as well.

Jennifer Sprague (24:13):

And where do you currently work?

Dr. David Casavant (24:15):

I currently work at Boston Children's Hospital in the Medical-Surgical ICU.

Jennifer Sprague (24:19):

And how long have you worked at Boston Children's Hospital?

Dr. David Casavant (24:23):

18 years.

Jennifer Sprague (24:24):

And have you always worked in the ICU there?

Dr. David Casavant (24:26):

Yes.

Jennifer Sprague (24:28):

I want to direct your attention to January 26th, 2023. At that point in time, did you take over the care of a patient named Callan Clancy?

Dr. David Casavant (24:38):

I did.

Jennifer Sprague (24:39):

And prior to taking over the care of Callan Clancy, did you do anything to familiarize yourself with his treatment and care?

Dr. David Casavant (24:48):

Yes, I did. One of my colleagues had taken care of him the day before in the ICU, and I spoke with her, and so I was familiar with his case.

Jennifer Sprague (24:58):

Okay. And did you also review reports and testing that had been performed while he was at the hospital?

Dr. David Casavant (25:05):

Yes, I did.

Jennifer Sprague (25:06):

And after reviewing the reports and the test results and speaking to your colleague, can you tell us what you learned from all of that?

Dr. David Casavant (25:18):

Well, it seemed that Callan had had a severe neurologic injury based on both testing and the examination that I did at the time.

Jennifer Sprague (25:30):

And when you say a neurologic injury, is that a brain injury?

Dr. David Casavant (25:33):

It's a brain injury. Yes, it is. Yeah.

Jennifer Sprague (25:35):

And did you review specifically a head CT scan of Callan?

Dr. David Casavant (25:42):

Yes, I did.

Jennifer Sprague (25:43):

And what did the head CT scan show you or tell you about his condition?

Dr. David Casavant (25:48):

Well, the head CT is a picture of the brain, which was done in the emergency room when he was admitted to Boston Children's Hospital. And the CT scan showed an enormous amount of swelling of the brain itself.

Jennifer Sprague (26:07):

And the swelling of the brain, is that medically significant?

Dr. David Casavant (26:14):

Very much so. When you have an injury to the brain that is caused by anoxia, which means a lack of oxygen, I described this with families that the injury is very much like being out in the sun. You don't notice it at the time, but swelling occurs over the course of time. And one of the things with a lack of oxygen to the brain is the injury occurs and then swelling starts to happen over the course of time. Typically peaking at 48 to 72 hours. When you see swelling that happens that early in a case, as in Callan's, it means that there's been a very significant lack of oxygen and therefore injury to the brain itself.

Jennifer Sprague (27:05):

So for example, some types of injuries that would withhold oxygen from the brain would be more mild and the swelling would occur over time. Is that correct?

Dr. David Casavant (27:18):

That's exactly correct, yes.

Jennifer Sprague (27:19):

So if a severe injury happens that withholds oxygen from the brain, that's when you see that immediate swelling like Callan had?

Dr. David Casavant (27:26):

Very much so. Sort of the comparison of a sunburn to a burn that you might get from a stove. This was a stove. It's very, very profound.

Jennifer Sprague (27:38):

Did you perform a physical examination of Callan?

Dr. David Casavant (27:40):

I did.

Jennifer Sprague (27:41):

And what did you observe?

Dr. David Casavant (27:43):

Well, one of the first things that I noticed as I approached him was that he had a breathing tube in place. And I knew from my colleague that he was not on any sedation, which is very difficult to tolerate having a breathing tube through the vocal cords if you're not sedated. And he was not sedated at the time. The next thing is when I approach a patient such in their bed in the ICU, we always start with a quick introduction that we're going to be coming near them in case they're asleep. And I usually start with something along the lines of, "I'm Dr. Dave. I'm just going to listen to your heart." And I'd usually address them by name to see if they start to respond. And then I'll go ahead with the rest of the exam, but that's just to sort of warn them that someone might be touching them.

(28:34)
And then I'll listen to heart, lungs, and then to move forward to see how responsive they are. So if you get no response at all from the initial, just using your voice, the next thing is to... And then from the exam, if they don't move around, then you start to sort of think, "Well, let's see how responsive they are." And so the next thing is sort of a gentle touch often to the bottom of the foot to see, you stroke the bottom of the foot, and you see if they pull away. And then you can move. If you get no response from that, we'll do something that's a little bit more noxious or painful where you can sort of pinch a little bit of skin to see if they start to react or pushing on the fingernail and the nail bed pressure, which is actually very noxious.

(29:19)
And if you can see two types or several types of response, either no response, or you can see a very specific response where they pull away from that area. And that's a specific... Or you can see generalized response, which are all sort of graded along those that as we're sort of getting a sense for what their level of consciousness was.

Jennifer Sprague (29:40):

So if I could go over a few of those things that you just mentioned.

Dr. David Casavant (29:43):

Sorry.

Jennifer Sprague (29:44):

You said that the first thing that you noticed that was significant was that Callan had the breathing tube in place through the vocal cords without any sedation. So without sedation, would having a breathing tube in that place cause pain?

Dr. David Casavant (30:03):

Yes. No one would be able to tolerate it.

Jennifer Sprague (30:06):

And so Callan was able to tolerate it without any sedation?

Dr. David Casavant (30:08):

Yes.

Jennifer Sprague (30:09):

Would that indicate he wasn't feeling that pain at that time?

Dr. David Casavant (30:12):

Yes, exactly.

Jennifer Sprague (30:14):

And you mentioned that you would address the patient by name and talk to them. Was there any reaction from Callan when you did that?

Dr. David Casavant (30:21):

No, there was not.

Jennifer Sprague (30:23):

And then you mentioned you would rub maybe something along the foot. Was there any reaction?

Dr. David Casavant (30:29):

No, there was not.

Jennifer Sprague (30:30):

And did you do what you described in pinching the fingernail or pinching somewhere on Callan to see if he responded?

Dr. David Casavant (30:37):

Yes.

Jennifer Sprague (30:38):

And did he respond?

Dr. David Casavant (30:39):

No, he did not.

Jennifer Sprague (30:41):

And what did these interactions and tests on Callan tell you about his condition?

Dr. David Casavant (30:50):

This told me that he was unresponsive. He was unresponsive to both things that would cause discomfort and things that would cause pain.

Jennifer Sprague (30:57):

Did you also do anything in terms of looking at his pupils in any tests on his eyes?

Dr. David Casavant (31:03):

Yes. So after all the other things, we look at the pupils. And so one of the things is we have a, it's a reflex response. If a light is shown in an eye, the pupil constricts, and what I noted about Callan was that his pupils stayed widely open and did not constrict.

Jennifer Sprague (31:26):

And when someone's pupils stay open and wide when you shine a light in them, what does that indicate medically?

Dr. David Casavant (31:33):

Well, the eyes are a direct extension of the brain, but that's why we focus a lot on them as an area of investigation. And the lack of a response to light indicates that there's some abnormality to that. And in this case, it was a brain injury. You can also, there's medications that can keep your eyes open if you've ever had an eye exam, but that was not the case with Callan.

Jennifer Sprague (31:59):

And just to be clear, when you're talking about brain injury, we're not talking about some type of trauma that was inflicted on the brain. You're talking about the lack of oxygen and blood flow causing an injury to the brain, correct?

Dr. David Casavant (32:12):

That's exactly correct, yes.

Jennifer Sprague (32:15):

At that point in time, did you work with another doctor to do more in-depth testing regarding his neurological status?

Dr. David Casavant (32:23):

Yes. So at Children's, we have multiple teams that come together for a patient, for many patients, but for Callan, the neurology team was there from the beginning. And in a case like this, when we see no response in an unresponsive patient, we start to get our neurology team. And one of the things we start to do is brain death testing to see if they could be what we call brain-dead, meaning that the brain itself is not functioning and that even though their heart is still beating.

Jennifer Sprague (32:57):

How is it that someone's heart can be beating if their brain is dead?

Dr. David Casavant (33:02):

It's a really good question. So...

Attorney Shanan Buckingham (33:00):

... of their brain is dead.

David Casavant (33:02):

It's a really good question. So there's actually two parts to the nervous system. The one is the part that we see the most in people when they react, and they react to us, and they speak and they do things. The other one is the autonomic or automatic system. And the automatic system is largely in charge of the things like the heart if the heart has not been injured. And so it was sort of continuing on.

Attorney Shanan Buckingham (33:29):

And does that give you any indication, the fact that the heart was still continuing on, about where the injuries were in the brain?

David Casavant (33:38):

Yes, it does actually. Yeah.

Attorney Shanan Buckingham (33:40):

Where would that be?

David Casavant (33:40):

Yeah. So the large part of the brain that we sort of think of is when we see the pictures of the brain, that's the cerebellum. And that's the biggest thing in humans that is most developed. And that's in charge of our consciousness, our reaction to things. Whereas the brain stem, which is another part, and that's really part of the autonomic system. And that's the same in almost all vertebrates and mammals. And it's much more automatic. And so it tells me that it seemed the cerebellum, which is that part that makes us sort of the human side of what we do, that's much more sensitive to a lack of oxygen, to an anoxic injury. And it told me that that was really where that injury was, was in that part of the brain, much less so in the brain stem itself.

Attorney Shanan Buckingham (34:33):

So would it be fair to say that the brainstem itself that controls those automatic responses was still functioning somewhat, but the part of the brain that made Callan, Callan was not functioning?

David Casavant (34:44):

That's exactly correct. Yeah.

Attorney Shanan Buckingham (34:49):

And could you describe for us the brain death testing?

David Casavant (34:52):

Sure. So the brain death testing at Boston Children's it's a very strict testing that includes some of the things that I just mentioned. But we work with our... There's a checklist that we work on with our neurologic colleagues. And we sort of go through each of what we would expect for responses from someone. And we actually then work through different of the nerve sets that we would expect them to respond to. We have it set up so that there's an ICU physician is there, and then a neurologist is there. And the neurologist and the neurology team, they're the ones who perform the brain death testing. And then the test is then repeated again 24 hours later, just to make sure that there's no piece of that that is different or incongruous with a diagnosis of brain death.

Attorney Shanan Buckingham (35:52):

And while the neurologist is doing this testing, are you there present watching the testing and seeing the results as it happens?

David Casavant (35:58):

Absolutely. Yeah. So we're sort of committed to being there for the whole time. And the brain death testing itself goes through some really basic things. Again, as I described earlier, the things that would be painful and do they pull away or not? The eyes, looking at the reflexes of the eyes. There's also other reflexes too. Things like if you stroke the cornea, which is the front of the eye, people blink. So the blink reflex, cough, gag. There's also a reflex where they actually put cold water into an ear and that gives people a disequilibrium. And so those are all the things that we think about. And then also too, there's some breathing components to that as well.

Attorney Shanan Buckingham (36:44):

Is one of those breathing components an apnea test?

David Casavant (36:47):

Yes, it is. Yeah.

Attorney Shanan Buckingham (36:48):

And what is an apnea test?

David Casavant (36:50):

So apnea is a word that just describes a lack of breathing.

Attorney Shanan Buckingham (36:59):

And how do you test that?

David Casavant (37:02):

So in a patient such as Callan, what we do, and in any patient when we're doing brain death testing, we actually disconnect them from the ventilator. And the reason that we do that is we want to see if that autonomic system in the brain will start to react as the carbon dioxide starts to increase. So our body makes carbon dioxide all the time. And the way we get rid of it is by exhaling. And where we breathe in fresh oxygen and then we breathe out CO2. And what we do is we disconnect from the ventilator, knowing that their carbon dioxide will start to rise. And the normal response for that autonomic part of the brain would be to sort of increase breathing. That's why we breathe when we sleep, because as we go to sleep, the conscious part of our brain stops, but the autonomic part kicks in, and then we breathe right through our sleep because that carbon dioxide rises.

Attorney Shanan Buckingham (38:08):

So in a patient who has brain death, would it be accurate to state that as the carbon dioxide level increases, the automatic response would be to take a breath to get more oxygen, but a patient who's brain-dead won't do that?

David Casavant (38:22):

That's correct.

Attorney Shanan Buckingham (38:23):

And did you do all of these tests or did the neurologist do all these tests on Callan while you observed?

David Casavant (38:31):

Yes, they did. Yeah.

Attorney Shanan Buckingham (38:32):

And did he have any response to any of the physical tests where you were looking for a reflex or a reaction?

David Casavant (38:38):

No, he did not. No response to any.

Attorney Shanan Buckingham (38:39):

And what was his reaction or results on the apnea test?

David Casavant (38:43):

So the apnea test, again, we do all the brain testing one day, and then we wait at least 24 hours for the second one. And what we expect with the carbon dioxide is that it will increase. We have it written in our... So it's all in writing for our protocol, that it will increase by 20 or get to a level of 60. A normal CO2 would be around 40. And the first time we did that on the first day, it actually went to 59.7, not 60. And again, it was in our protocol as it has to get to 60 or increase by 20. And I actually talked to my colleagues, including neurology. I said, "I know this is very close. It's 59.7, but it's not 60." I repeated that piece of the test later on that day to make sure that it was valid. And as I say, I checked with everyone to make sure that I was doing the right thing.

(39:48)
And they all agreed that we should just... And the second time it went to 87. So everything else was the same. And we made sure that there's things that we look at too to make sure that there's not on any medications, that there's no changes in his temperature, there's no abnormalities of the salts and the blood, what we call the electrolytes. So all those conditions were the exact same. And I repeated that later on in the day and it did come back positive.

Attorney Shanan Buckingham (40:14):

Why is it so important that you meet that specific criteria? Why is three tenths of a point so important?

David Casavant (40:20):

Well, I wanted to make sure that there was no question about the data that we were gathering at the time.

Attorney Shanan Buckingham (40:29):

And you said that this testing is again repeated 24 hours later, correct?

David Casavant (40:33):

Yes, it is.

Attorney Shanan Buckingham (40:34):

Why is that?

David Casavant (40:35):

Well, that's just to make sure that if there were any lingering effects of medications, if there was anything that else might've changed in the patient's level of alertness or level of response, to make sure that it still meets all those requirements 24 hours later.

Attorney Shanan Buckingham (40:52):

And is it because you want to be sure that there's brain death before you remove life support?

David Casavant (40:58):

Yes. And again, it's too important. It's too important, a discussion and a gathering of data to not be very exact about it.

Attorney Shanan Buckingham (41:08):

And so when you observe the testing and then the following day, on Callan, were the results the same in terms of no reaction and the carbon dioxide increasing?

David Casavant (41:20):

Yes, they were.

Attorney Shanan Buckingham (41:21):

And at that point in time, did he meet brain death criteria?

David Casavant (41:27):

Yeah, he did. So we had determined that he had met death by neurologic criteria.

Attorney Shanan Buckingham (41:38):

And at that point in time, was a decision made to stop life support?

David Casavant (41:46):

Yes. Yes, it was.

Attorney Shanan Buckingham (41:47):

And that's done in consultation with the family, his father, correct?

David Casavant (41:50):

Yes, that's true.

Attorney Shanan Buckingham (41:51):

Okay. And was life support ended for Callan Clancy on January 27th, 2023?

David Casavant (42:01):

It was. And one of the things is when you determine that someone has met criteria for neurologic brain death, although we know that their brain is not functioning at that point, there's often a period of time where we don't have to... His heart is still beating, so we don't have to remove the endotracheal tube at that time. And we often will give families, once it's been confirmed that the brain is no longer functioning, we often give families a period of time to be able to process it and a window of time. Sometimes his relatives will need to travel and things like that. And so we'll often then choose a time later on to accommodate the rest of life, knowing that they're stable at the time to when we would actually remove the tube. And that would be the declaration of death.

Attorney Shanan Buckingham (43:00):

And was that done in this case? Family was given an opportunity to see him and then life support was ended and then his heart stopped.

David Casavant (43:07):

Yes, that's exactly.

Attorney Shanan Buckingham (43:09):

And he was declared deceased?

David Casavant (43:10):

Yes.

Attorney Shanan Buckingham (43:11):

Thank you.

Judge William F. Sullivan (43:11):

Attorney Reddington.

Attorney Kevin Reddington (43:11):

Thank you, sir.

Judge William F. Sullivan (43:16):

Thank you, doctor.

David Casavant (43:17):

Thank you so much.

Attorney Shanan Buckingham (43:30):

Your Honor, at this time, the Commonwealth would move to admit the Boston Children's Hospital records for Callan Clancy into evidence. There's two volumes.

Judge William F. Sullivan (43:39):

Any objection?

Attorney Kevin Reddington (43:40):

Your Honor. I have no objection because we both have the records. We both want them in evidence. So I have no objection to any of the records that they have. We signed releases for them for like Beth Israel, Brigham and Women's, South Shore. They all can go in.

Attorney Shanan Buckingham (43:53):

That's a yes.

Judge William F. Sullivan (43:53):

It may be admitted.

Court Reporter (43:53):

Exhibit 137.

Judge William F. Sullivan (44:09):

Yeah, I went to A and B. Yeah.

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