Direct Exam: Lindsey Gutierrez

Dr. Spitz had two surgeries in December and was still recovering at the time of the trial so he was unable to testify. However, Judge Bronson ruled that his testimony was deemed reliable from the second trial in 2010, so it was permitted to be read and entered into the transcript of this trial.

Lindsey Gutierrez took her place at the podium as the judge explained how the testimony would be read. Dr. Spitz's testimony was read by Jim Spaeth, Clerk of Courts and the judge asked the jury to treat Mr. Spaeth as if Dr. Spitz was on the stand. However, Mr. Spaeth wasn't permitted to make the gestures, indicated in the transcript. Mr. Spaeth was not sworn in, but Dr. Spitz was sworn in on May 24, 2010 and was directly examined by Hal Arenstein. Defense questions were read by Lindsey Gutierrez and prosecution questions were read by Travis Vieux.

The clerk stated Dr. Spitz’s name and background to the jury. He lives in Michigan and is a forensic pathologist. Spitz testified about his education, memberships and awards.

He was the medical examiner for Wayne County, Michigan. He has been on the editorial board for a number of American and European journals. He grew up speaking German because he was born in Germany, but he writes and lectures in German, French, Swiss and Hebrew.   He is a professor of pathology at Wayne State University Medical School. He's published 14 articles related to drowning because it's been an area of great interest to him and several other pathologists. Michigan is a shoreline state so they have many drownings. He's written a text book about forensic pathology that is circulated worldwide. It's now in its fourth edition and he's working on a fifth edition. He's served as a lecturer for several groups and organizations worldwide. He worked on the assassination of President Kennedy and testified in the civil case against O.J. Simpson. He also testified in the Jon Benet Ramsey case in Boulder, Colorado and in the Mary Jo Kopechne civil case against Ted Kennedy. He has testified as an expert in all 50 states and Canada. Asked if he remembered how many times he's been qualified to testify as an expert in court he replied, "To tell the truth, I can't remember a time when I wasn't qualified".   He was board certified in 1965 and has remained certified. He's done an estimated 60,000 autopsies in his career, although he does fewer now. He's licensed to practice medicine in many states, the District of Columbia and "all of the European countries."   His hourly rate is $400 which is for travel time (he hires a driver), and he charges $5000 per day.

Spitz said determining the cause of death is very important. Did the victim drown in a lake or did he have a heart attack in the lake?   The manner of death is classified in one of five categories; homicide, suicide, natural, accidental and undetermined.  

He became involved in this case when he was called by an attorney and asked to perform a second autopsy on a person who died under suspicious circumstances.   He did this on Aug. 15, 2008 and said a second autopsy is more difficult because the first autopsy is disruptive to the body. He brought an assistant along to take photos. After he finished, he reviewed the first report from Dr Uptegrove, the hospital, EMS records and photos from the crime scene. He prepared a report, Oct. 29, 2008, and sent it to the attorney.

When he arrived to do the autopsy, Sarah's body was zipped up inside a body bag and her hands were bagged to preserve evidence.   Placing a photo of Sarah's face from the second autopsy on the screen, Spitz identified it.

He began the autopsy by doing an external exam of Sarah. He noted the needle marks in her neck and extensive bleeding in the arm bends of her left and right forearms. He didn't recall seeing a tracheal tub in her throat, but there were bruises on the right side of her neck that continued to the front of her neck and shoulders. He didn't notice any injuries to her hands or feet. Her fingernails had an in-tact French manicure and her toenails were in good condition also; no cracks or breaks. However, "Whenever there are bruises on the body, they raise questions", he said. There was no damage to her hair or evidence that it had been pulled out. He also didn't see any scratches on her body.  

He noticed petechia in Sarah's eye, and said it was probably caused by CPR because there is usually no petechia in drowning. It can occur with CPR and sometimes with strangulation.  He explained that a capillary breaks in the eye and then it leaks leaving a small red spot; that is petechia.

All of her internal organs had been stored in a heavy-duty bag and put inside the body after the first autopsy. He re-opened the Y-incision from the first autopsy and took out the bag. He didn't see any sign of disease, but her lungs were filled with foam, there was a slice out of her liver and there was significant bruising on her neck and upper chest. He also noticed some bruising on her scalp.

He explained that the CPR would have pumped blood through the veins causing them to burst and then causing the bruising. The foam in her lungs was a mixture of water and protein and is usually present in drowning victims. He noted the bruises on the underside of Sarah's scalp and said they were in a circular pattern. Three were noted on the original autopsy, but he described four.

Referring to a photo showing the back of Sarah's neck, he said there was a faint 1-inch bruise on the nape of her neck but it was not a serious injury, and would not cause someone to lose consciousness, he said.

He noted the tear in the liver that he said could have been caused by CPR. The tear is not unusual when "aggressive CPR" is applied because the liver is a solid organ. When he reviewed Uptgrove's report, he noticed that Uptegrove didn't document the tear.   (Uptegrove testified that he accidentally nicked the liver when removing Sarah's chest cavity).

He had been told Sarah had been found unconscious in a filled bathtub. Many times when a person drowns, they swallow water but drowning is the inhalation of water. He ruled that Sarah's cause of death was drowning. The water in the lungs dilutes the blood, the red blood cells burst open because they aren't used to all that water, and when the water mixes with the blood it creates a frothy fluid called edema which is all red fluid. Sarah's lungs and air pipes were filled with edema. Once blood is diluted, it's harder on the heart, which goes into a "haywire rhythm", organs lose oxygen, there's increased pressure and volume in the blood stream, and the patient dies. This diluted blood process is called hemodilution which he has done research on. In drowning victims, any injury is magnified because of the increase in hemoglobin from the red blood cells bursting.

He went on to explain Injuries to the inside of her elbows. There were two needle marks and a large area of hemorrhaging in the right arm. He made an incision in the hemorrhage and took a photo, which was put on the screen. He called it a bruise because it's an injury to the blood vessel when blood "oozes" out. It was about 5 inches in diameter. Another photo is shown of the inner elbow bend of the left arm showing a large bruise about 7 inches in diameter and a needle stick in the middle. He said the bruises look larger because of the hemodilution. Hemorrhaging isn't always present for IV sticks because it depends on the skill level of the person sticking them and the amount of fat on the patient.

A photo of Sarah's mouth was placed on the screen and Dr. Spitz pointed out the diluted blood in her mouth and the cuts on her lips. He said they could have been caused by placement of the endotracheal tube during the intubation attempts.

Another photo showed the left side of Sarah's neck with bruising present. He said the photo doesn't show the full size of the bruise, which extends to the chest. "It's a huge bruise", he said, however, the size of the bruise isn't caused by just a stick of the IV needle, but because of the dilution of the blood, like he explained for the large bruises on Sarah's elbow bends.

He said that he reviewed the intubation attempts and EMTs tried 6 times. The Sellick maneuver, and pressure on the cricoid cartilage could have left the bruising on the front of the neck, especially from people who bruise easily. He said in his book that intubation can be difficult when rigor mortis begins but there was no notations of rigidity and there was "no rigidity" when the ER doctor intubated her without a problem. The bruise or hemorrhage in the throat could have been caused by the coroner removing the organs in the first autopsy.

An autopsy photo of Sarah's face and chest is put on the screen showing a large bruise extending through her lower neck into her upper chest to her fourth rib. It was all one hemorrhage that could have been caused by CPR.  "There was a lot of CPR," he said. He explained that CPR is an aggressive, traumatic procedure. In a drowning victim, there is increased pressure and increased volume in the blood because of hemodilution.

Dr. Spitz explained the process of livor mortis, which is the settling of blood when the heart stops. As a result of gravity, when the heart stops pumping, the blood will pool toward the back if the body is lying on its back.

Rigor mortis is the rigidity that begins at death and shows up in about 30 minutes to an hour depending on the temperature of the environment. In hot or tropical areas, it shows up quickly; in colder areas, it takes longer and should be identified by medical professionals. After examining all of Sarah's reports related to her death and efforts to revive her, he found no mention of rigor mortis or livor mortis in any of them. The intubation at the hospital was successfully completed because there was no rigidity.

In regards to pruning, Dr. Spitz said he did experiments on pruning because he thought it would help him determine how long a person had been in water.  It takes less time in hot water and more time in cold water. He found on average, it takes about 30 to 60 minutes for the skin to prune depending on the thickness of the skin.

Spitz was asked about the testimony that you can't bruise after death and he replied, that's "generally" true, but there are times when blood vessels are compressed after death and bruising can show up. Each beat of the heart produces 2 and 1/3 oz of blood, he said. If there is a continuation of any blood vessel, that blood will come out further.

Asked about seizures, he said he is familiar with them, they can occur at any age and 24 is not beyond that time. Those with seizure disorders are advised to stay away from water. The grand mal seizure is usually manifested by convulsions, contractions of muscles which cause thrashing around and loss of consciousness.   A seizure can also elevate body temperature and skin that is hot-to-the-touch can be evidence of a seizure because muscle contractions can cause an elevated body temperature. A person having a grand mal seizure can fall face-down into a 2-inch deep puddle of water and drown because he's unable to pull himself out. Studies have shown that seventy percent of people who die as a result of a seizure disorder only show mild swelling in the brain.

When asked about Sarah's odd sleep issues he said sleeping habits could be an indication of some kind of sleep disorder and may have contributed to her death but he's not an expert.

Gutierrez ended by asking: With 48 minutes of CPR and 6 intubation attempts, based on a reasonable degree of medical certainty and all the records he reviewed, as well as his own autopsy, what was his opinion of the cause of Sarah's death. He replied, "drowning",  and his opinion of the manner of death: "Undeterminable".     Nothing further.

Cross Exam: Travis Vieux

Dr. Spitz was asked what he was paid to come here and what he was paid separately to perform the autopsy. He replied that he didn't remember how much he was paid to do the autopsy--it's $2,500 in Detroit--but he charges a different amount depending on where he has to travel to. He agreed that he was paid $400 per hour for travel and other work, and $5,000 for every day he's out of his office. He also agreed that he testified in the previous trial. Vieux then asked, "Will you be paid for your travel back to Michigan?" Dr. Spitz replied, "Unless you want to take me in permanently."   Vieux said, "I assure you, I don't", and the courtroom chuckled.

Asked about his latest edition of his book, he agreed he didn't write every article in his textbook, but he and his son edited the book. Some articles were left as they were because he was familiar with them. He didn't read every article but he verified the accuracy of an article when necessary.

He never personally spoke to the EMS workers, hospital workers, Sarah's family or any of the witnesses in the case. He only spoke to Charlie Rittgers (Ryan's first attorney) and to Arnold and Vieux. He said he had a fairly lengthy conversation with Rittgers, when he was told that Sarah's body was found in the bathtub and Ryan was charged with murder, but he didn't recall how much other information he knew about the case when he came to the area. After performing the autopsy, Charlie Rittgers gave him the original records to review.

He said there were general things he looked for in a drowning case, but each case is different and there are different factors in every case. The autopsy had limitations because he didn't see in person what was photographed prior to his autopsy.

He indicated in his report that there was a small bruise on Sarah's lower right leg and a small bruise on her hip, but he couldn’t say where they came from. It was possible they could have been caused when the body was transported. He noted that she was a well-nourished, healthy woman. He didn't see any pruning but said it could begin in 30 minutes to 1 hour--20 minutes if the water was very warm.

He agreed that Sarah had "froth" in her mouth, not edema. He found no internal injuries to her heart or upper esophagus, but said he didn't feel it was justified to "destroy the body" to reach the back part of her throat. It's a hard area to uncover. The petechial hemorrhages can be evidence of CPR and also strangulation, but one or two petechia doesn't mean much. There were no injuries in the upper esophagus, no broken teeth or external bruising along the jaw line. The larynx and soft tissue of the larynx showed no injury; the chest plate showed no injury.

The interior neck hemorrhage was from the jugular vein needle in her neck. A laceration of the liver would cause internal bleeding but there was none. He examined samples of the brain and heart but didn't find any sign of injury to either. He wasn't able to do microscopic exams of the brain because it was left in poor condition after the first autopsy. The bruise on the right side of the neck was separate but the bruising on the left and front of the neck were all the same hemorrhage.

Vieux asked about the concern of epilepsy and bathing or swimming;  if a person can have a seizure in water, especially from a glare off the water. Spitz said he has heard that, but wasn't certain it was true. However, having a seizure in water can result in drowning if there's no one around to help, so a person should use caution when swimming or bathing. In rare instances, a healthy, robust person can have a fatal cardiac arrhythmia due to exercise or emotional attack, but he wasn't diagnosing Sarah with either of those conditions and there was no information in the reports provided to indicate either of those conditions.

Dr. Spitz said that evidence of strangulation can include finger-shaped bruises on the neck, but the absence of bruises doesn't rule out strangulation. A hyoid bone fracture is not usually present in a 24-year-old. He agreed that a person can drown in as little as 60 seconds. Pressing on the carotid artery on one side could render someone unconscious in as little as 10 seconds, but may not cause any harm at all. Pressure on both sides, can bring on unconsciousness in 3 to 4 seconds.  (The “Sleeper” Hold) He admitted he has never done an intubation or performed CPR.

There is very little cooling of the body in the first hour after death, in fact, some studies show an elevation in body temperature shortly after death. When the body relaxes at the time of death, the bowels and bladder can release. Rigor mortis can be seen 20 to 30 minutes after death, but it depends on the temperature of the environment the body is in. It's not true that rigor mortis begins at the head and ends at the feet. It begins to show up first in small muscle groups.

Dr. Spitz said he was specifically asked for a cause and manner of death when doing the autopsy but he didn't write it on his autopsy report because he wasn't acting as coroner. However, in January 2009 he told Vieux and Arnold that he had no opinion in the manner of death. In March of 2009, he sent a letter to the prosecutors saying he still had no opinion. He stated in court that he didn't know what Sarah died of. The injuries on her neck were caused by CPR or manipulation, but he couldn't say if natural causes, a heart condition, a seizure, or epilepsy was or was not the cause of her death, therefore, he found her manner of death as "undeterminable" and that's his opinion. Nothing further.

Re-Direct: Lindsey Gutierrez

Dr. Spitz said that sometimes medical people are too frantic or "hasty" in attempting to establish an airway and if there's foam or fluid in the mouth it's difficult to see the vocal chords, which is the landmark the intubator looks for. Attempting intubation in a moving ambulance is another difficult factor.

He said he has seen fingertip marks on the body of a strangled person, but he couldn't tell who the fingertip marks belonged to. Sometimes it can be from the victim itself.

There was no mention of livor mortis or rigor mortis in the reports he read. He repeated that his report didn't list the manner of death because he wasn't the coroner but his opinion is still "Undeterminable, which means no one can determine the manner of her death. It's just not determinable."

Re-Cross: Travis Vieux

Dr. Spitz acknowledged that he wasn't present when Sarah was intubated and he didn't know the training of the first responders. He said most of his career has been in a county where a manner of death could be listed as undeterminable. Asked why, in his book, he listed the five manners of death without a mention of "undeterminable", he said it was HIS best advice, not necessarily THE best advice. Nothing further.