Direct Exam: John Arnold

He works for The Ohio State University College of Medicine. He specializes in sleep issues and epilepsy, working with EEGs which monitor brain activity. He has a Master's Degree in Public Health from Ohio State, has studied neurology and epilepsy and is board certified in sleep medicine. He's a member of several honor societies and is an endowed professor. He said he's been called the "best doctor in America" in neurology for the past two years and was hired at OSU to set up an epilepsy surgery center. He does some lecturing to residency students, sees outpatients three days week, and also sees inpatients at the Epilepsy Monitoring Unit [EMU] at OSU. He spent several years going to sleep clinics and studying sleep disorders and has published between 35 to 40 articles in epilepsy and neurology and also gives presentations at medical societies. He said about 80 percent of his practice deals with epilepsy.

He began by talking about sleep disorders, including narcolepsy, restless legs syndrome and sleep apnea. It takes time to diagnose these conditions and doctors begin with heart and lung function. It often requires specialists to diagnose some of these disorders.  

He explained that sleep is an "active" process, not a "passive" process, and sleep is "healing". He explained about the human's natural biological clock; that it's natural to sleep during the night and be awake in the day but biological clocks can be disrupted, such as from jet lag or working the night shift or odd hours, but the body can adjust to those changes. Sleepiness is a huge problem in the US and 100 years ago, we averaged an hour more of sleep per night. He said sleepiness is a bigger problem in young adults. He went on to explain that neurologists treat diseases of the brain, spinal cord, muscles and pain disorders. They study seizures, and related diseases, fainting, etc.  

Dr. Moore has reviewed the medical records for Sarah Widmer, as well as the ER report from the night she died and the autopsy reports from Dr. Uptegrove and Dr. Spitz

In his opinion, none of the records indicated Sarah had a sleep disorder or epilepsy and he described her as "very healthy". Her records showed that she went to the doctor on a yearly basis. The report showed that Sarah never reported stomachaches, or severe headaches to her doctor and her neurological exams were normal.   Her heart exams were also normal; there was no indication of murmurs or other problems. There was nothing abnormal about Sarah's blood work other than her cholesterol was a little high. He did recall however, a notation on an exam that Sarah slept a lot during the day, but Moore said that sleepiness is a chronic problem from stress or not getting enough sleep. He said stress can also cause stomachaches, irritability and headaches.

Along with her current medical records, Moore also reviewed Sarah's toxicology report and her 1984 cardiology report from when she was a child. He said there was nothing in the toxicology report to cause her death. A report from a pediatric cardiologist at Dayton Children's Cardiology Center, was for a heart murmur when Sarah was 10 months old. The doctor thought it was a "functional murmur" and said he'd see her again in a few years. There wasn't any indication of the murmur as Sarah got older. After reviewing all the reports, Moore said that in his opinion there was no evidence of health issues and she appeared healthy.

Falling asleep and drowning in a bathtub is not consistent with any sleep disorders. When the face goes under the water and there's a lack of oxygen, the person is stimulated to wake up. It's the same as patients with sleep apnea who wake up abruptly from lack of oxygen. Falling forward also stimulates the inner ear to wake a person up.

In Moore's opinion, based on Sarah's medical history, she was not at risk for a "medical calamity". Head injuries, strokes, infections near the brain or spinal cord, drug abuse, and family history can all cause seizures, but none of those were in Sarah's medical records that he reviewed.

Moore said seizures can come in different severities. There are two main categories;   generalized and partial, but many subcategories. Generalized seizures affect the whole body at once, but partial seizures affect smaller areas of the body and consciousness may or may not be affected. A generalized seizure causes stiffening and shaking of the body so in his opinion, a person could not flip over in a bathtub and he didn't think Sarah could have fallen asleep in the tub, or suffered a seizure and drowned. Drug use can trigger epilepsy or seizures and family history is another risk factor. Alcohol withdrawal can trigger them, but only if a person is an excessive drinker.   Head injuries and bleeding is another risk factor but there was no evidence of these factors in Sarah's records.

Moore said he’s treated many people with headaches. There were claims that Sarah suffered headaches and Moore said it's a common complaint and can often be attributed to allergens and sinus problems.

If a person suffers a seizure in a bathtub while standing, Moore said there may be injuries if they fall, but if they are lying down, there may not be any. Injuries may include biting the tongue or injuries to the back of the head. Nothing further.

Cross Exam: Jay Clark

Clark asked Moore to explain the different types of seizures again so the jury can fully understand. The Grand Mal, is when a person shakes or stiffens and the seizure affects the whole brain. Simple partial seizures don't cause loss of consciousness, and someone may not even notice it's a seizure because there is no shaking and the person could just sit and stare. Complex partial seizures are when someone does have a loss of consciousness. The seizure starts at a certain point of the brain and spreads to other parts.

Everyone has a seizure threshold for a high body temperature; heat or light can trigger seizures and high fevers make seizures more likely. About 10 percent of people will have one seizure in their lifetime and 3 percent of those will have more than one.   Some seizures are unique to children and others are "adult onset". One seizure at age 24 would not be enough to diagnose a person with epilepsy, but more than one, would. Clark showed Dr. Moore a copy of the toxicology report dated 9/24/2008 and Moore said, that was the date it was signed, but he didn't know the date the tests were done.

Clark showed him the report from the pediatric cardiologist where the cardiologist said he wanted to see Sarah again in 2 or 3 years. Moore acknowledged that this was the only report he reviewed and there was no follow-up report from the cardiologist. He agreed that he had to rely on the accuracy of the reports he was given since he didn’t see Sarah or treat her.

He did his residency in neuropathology and said some seizures may not show up in an autopsy but they could be found if the correct portions of the brain were examined under a microscope. He said Dr. Spitz took slides of organ tissue from Sarah's autopsy but he didn't review those himself, he only read the reports on them. His opinion that Sarah didn't suffer a seizure was based on those records but he agreed that a head injury could cause a brain scar that could later trigger a seizure.

Clark asked Moore if he saw more patients who are alive, rather than those who are deceased and he agreed. He explained how he uses a device that monitors brain waves. [EEG electroencephalogram] It measures brain activity by recording electrical impulses from the brain to the scalp. This would not work on a dead person, he said, but a microscopic sample from the right portion of the brain could theoretically turn up evidence of a seizure that would have been undetectable otherwise.

Clark then asked him about narcolepsy and Moore defined it as falling asleep at inappropriate times. It's a neurological disorder triggered by the hypothalmus gland and causes "excessive daytime sleepiness".   Clark asked him if inappropriate times could include being at a bar, at a family Christmas party, at a bachelor party, going out for dinner with friends or a Bengals tailgating party. "They may fall asleep if they're drunk," said Moore but if they're not drunk, then it would be inappropriate.

Clark ask Moore if he knew anything about methadone--which Arnold objected to--so Clark asked about his experience in pharmacy and Moore said he's an adjunct professor of pharmacy at Ohio State University but his area of expertise is anti-epileptic drugs. He's had patients who have taken methadone, but he never prescribes it himself. The patients who took methadone had it prescribed by another doctor, but Moore saw them in the epilepsy clinic. Clark asked what he meant when he said he didn't prescribe methadone and Moore said he doesn't treat pain patients. Clark asked what else it's used for, but Arnold objected.

Clark asked him what his opinion would be if a patient complained of severe headaches with vision disturbances plus daytime sleepiness. Moore said he has read that headaches are the number one reason people seek medical care, but doctors are trained not to jump to a specific diagnosis based on one complaint, otherwise they could miss something important. He said headaches are a pretty general complaint, so he would take all the information he can gather including personal and family history to help determine a diagnosis but a medical event can happen even if a family history isn't present. Moore admitted that just because Sarah or her family did not have a history of seizures, doesn't mean she didn't have one the night she died. He also agreed that it's possible to suffer a first seizure at age 24 but if the person died of that seizure, they wouldn't be diagnosed as an epileptic.

Clark asked if Sarah could have stepped into the tub, had a seizure and fell face first and Moore agreed it was possible. Clark then asked if bruising would be possible if she had a seizure in the tub and her head hit the wall or the back of the tub and Moore said it could happen.

Clark asked if during a grand mal seizure, the airway is temporarily blocked until the seizure is over. Moore agreed that a person stops breathing when suffering a grand mal seizure because the diaphragm also convulses during the duration of the seizure. The brain tries to tell the body to breath and if the person is in water and they take that breath, they would aspirate water which would get into the lungs. If they didn't get any oxygen, they would drown, said Moore.

Moore said he has read in medical literature that many doctors believe narcolepsy is under diagnosed but in his experience, he's not sure about that. Sleepy people are sent to him for evaluation, but he can't always diagnose them with narcolepsy because they don't have all the symptoms.

He told John Arnold that Sarah was not a likely candidate to have a seizure, but he also agreed that this didn't mean that she didn't have one. He said that seizure victims don't always bite their tongue or suffer from mouth lacerations and a seizure won't always show up in an autopsy.  He found no evidence in the reports he reviewed that Sarah had a seizure but "It's theoretically possible she had a seizure," he admitted. "It can't be ruled out.”

Clark described the injuries Sarah had and asked if they could possibly be interpreted to show that she had a seizure and fell. Moore admitted that this could not be ruled out. He said a person is usually confused right after having a seizure. Their thinking is impaired, but they're not physically impaired. They might experience weakness in the area of the seizure and they won't respond appropriately. Moore said as an example, they might become combative.

Clark showed him a note of a phone call from Sarah to her doctor's office complaining of lower abdominal cramping. Moore said that wasn’t mentioned when he was questioned by the prosecutor. On notes from Sarah's visit to her doctor in 2008, it said "no known allergies." Allergens are a common cause of headaches in this area but this notation usually means no known medical allergies.

People often think that seizures cause disruption to the electrical signals to the heart. Heart function can be interrupted during a seizure, and the heart can stop or pause. If this happens in the hospital the interruption may be recorded by an EKG monitor.

Moore has had a few patients who have had sudden unexplained deaths but a forensic pathologist will see more.   Clark asked if 1 out of 1000 people could have a sudden unexplained death from epilepsy and Moore said that didn't seem unreasonable. He also said that studies have been going on since the 1980's about the interruption of the heart beat during a seizure. Clark then asked what happens before the seizure--does the patient see an "aura". Moore replied that sometimes it happens but not always. He described the aura as a breeze or a "warning before a seizure" such as a funny taste in the mouth or a physical sensation or dizziness.   Sleep deprivation could be a trigger for a seizure and during certain types of seizures a person may not be able to catch themselves if they fall.

Clark asked if a doctor could make a determination of sudden unexplained death if he wasn't familiar with it. Moore replied that doctors need to stay current with their training and with current medical research. He did a study with 40 patients about the effect of sleep deprivation on seizures. He's still in the early stages of gathering the research, but he's seen one study that said sleep deprivation didn't cause seizures. He wasn't sure if he believed that because he didn't like the study's protocol.

He agreed that body temperature could go up after a prolonged seizure because the stiffening or convulsions cause the muscles to generate more heat. The person can also suffer the loss of bowel control, particularly during a grand mal. Clark asked if Moore read literature about an epileptic seizure happening to someone sitting in hot water and he replied that he hasn't but he has heard about it.

Clark then asked Moore about his testimony in a previous Widmer trial where he testified that Coroner Uptegrove didn't do microscopic exams on Sarah's brain during her autopsy. Moore said it could have been helpful in looking at her brain and determining if she had a seizure. He also said he had trouble finding the page that listed the tissue sample slides taken by Uptegrove.  Nothing further.

Redirect: John Arnold

Moore recalled an exchange with Clark about 10 percent of the population having seizures and agreed this includes infants and children.   He testified again that there was nothing in Sarah's medical records that would appear to provoke a seizure.

Moore said the criteria for diagnosing narcolepsy would include feeling sleepy. A sleep latency test would be done to determine how long it takes to fall asleep and how fast the patient gets into the REM cycle. He said that someone falling asleep here in court wouldn't necessarily be a narcoleptic, but someone falling asleep while performing a serious task or driving would be a cause for concern.

When Arnold asked about drinking Moore said drinking may make you fall asleep faster, but not necessarily sleep longer.  Sarah's doctor record from her June 2008 visit showed her lower abdominal pain may have been caused from a urinary tract infection.

Moore was asked to clarify the term "theoretically possible" and he said it's something that could happen, but it’s not likely.

When a person is coming out of a seizure, Moore said it's the time when a patient is strongly motivated to breathe. Arnold went back to the "no known allergies" on Sarah's doctor report, which Moore again said he thought referred to drug allergies. Arnold pointed out that her report showed she took Zyrtec and Nasonex and Moore replied that doctors need to know about drug allergies so they don't prescribe the wrong medication.

The most common reason for someone to have a fever after a seizure is because they are sick. He said most patients who report seizures don't have elevated body temperatures. Arnold then asked if he saw anything that would cause him to disagree with the finding and Moore said he did not. Nothing further.

Re-Cross: Jay Clark

Clark asked if there was anything in Sarah's medical records that would cause Moore to rule out narcolepsy and Moore said no history of narcolepsy and nothing in medical literature would suggest it, but the history of Sarah falling asleep that Clark cites could be relevant to such a diagnosis. Clark then asked if falling asleep in odd places could lead to that diagnosis and Moore said, "if that were true, yes."

Moore agreed that a patient who is hot to the touch would be consistent with being pulled from a hot tub of water. Nothing further.