An Almost Perfect Murder (22 page)

The next morning, Wednesday, June 20, 2007, Christopher Hicks called REMSA paramedic Benjamin Pratt to the witness stand to provide testimony regarding the morning that he and his partner, Manuel “Manny” de Jesus Fuentes, responded to Kathy Augustine’s residence on Otter Way after the dispatch center had received the 911 call from Chaz Higgs. After going through the formality of his qualifications, education, time on the job, and job duties, Pratt told the jury about his Code 3 lights and sirens call regarding the state controller being down with a cardiac arrest. He described how he had seen Chaz Higgs from a couple of blocks away, standing out in front of the house and waving them toward him. Upon their arrival, Pratt said, Chaz had seemed calm. He went through all of the steps that he, Manny, and the accompanying firefighters had gone through, including placing Kathy on the hard surface of the floor from her bed, to continue the CPR. They needed to do that, he said, to get better compression, which, in turn, would provide better blood circulation. He described how they had given her medication, including epinephrine and atropine because she had been a flatliner on the monitor, how they had gotten a breathing tube into her and an IV started, all the while someone was performing CPR. It had taken two rounds of the medications to get her heart beating again, he said.

In a lengthy question-and-answer session, Pratt explained how he and a firefighter had closely monitored Kathy’s vital signs on the way to the hospital. At one point, he said, they had “shoved” another IV of normal saline into her arm during the trip, but otherwise had managed to keep her heart beating. Upon arrival at the hospital, she was taken into the emergency department. His testimony included the fact that Kathy hadn’t remained at South Meadows very long, perhaps forty-five minutes or so, before doctors recommended that she be moved to the main hospital because of a suspected heart condition. Hicks took him through a lengthy process in which he identified many of the items used that morning to treat Kathy, including the drugs used, tubes and breathing devices, tape to hold her head in place so that the intubation remained intact, and so forth. He also testified that it had been he and his partner who had transferred Kathy from South Meadows to the main hospital.

 

 

During cross-examination, Houston seemed intent on unraveling Pratt’s testimony with regard to how calm Chaz Higgs had appeared that morning, by using Pratt as an example.

“Mr. Pratt . . . how much experience do you have on the job?” Houston asked.

“About two-and-a-half years,” Pratt responded.

“And do you think after you’ve had about twenty-two years’ experience, you might have a little bit different demeanor while you’re on the job?”

“You could, but . . . with these calls—”

“—you don’t know,” Houston interrupted.

“—you don’t know,” Pratt agreed.

“But we do know certainly that you haven’t had fifteen years as a medic in the military, part of that as a battlefield medic, correct?”

“No, sir.”

“And you haven’t had experience as a critical care nurse or an emergency room nurse for another five, six years after that, correct?”

“No, sir.”

Houston switched his approach at that point to focus on how Pratt and his associates would normally gain entry into a residence upon their arrival. Pratt indicated that they would usually go in through a front door. If it was locked, they would check other doors. If they couldn’t get inside, and no one answered the door, the fire department would bust it down for them.

“So to avoid getting the door broken down if it’s locked, it’s a wise idea of the occupant to at least let you in, right?”

“Sure.”

“And if you’re doing CPR and the ambulance is on the way and somebody hears a siren, a good idea would be to go to the door, let you in, let you know this is the house?”

“Could be.”

“Okay. And that’s what happened in this case, isn’t it?”

“Yes.”

Houston pointed out that the bedroom where Kathy had lain that morning was not that far from the front door, and Pratt agreed that it was about fifty feet. Houston ascertained that it might take five to ten seconds for someone in a hurry to traverse that distance. It seemed to be a defense move to diminish the impact in the jury’s eyes of why Chaz had left Kathy to go outside and meet the paramedics. He also focused on how small the bedroom was—and with two paramedics and four firefighters in the room with Kathy, it had become crowded very fast. This was a reason why Chaz might have chosen to be in another area of the house, or outside, while emergency personnel had worked on Kathy.

 

 

“Did Mr. Higgs seem happy when you got a heartbeat?” Hicks asked Pratt upon redirect.

“You know, I don’t recall,” Pratt responded. “Like we just kind of—we put her on the gurney, we started wheeling her out, and he was just standing there.”

“Same demeanor as—”

“Same demeanor as before,” Pratt said.

“Mr. Houston had asked you . . . if you were administering CPR to someone at a residence, the importance of unlocking the door so that emergency personnel can get in. If you were administering CPR to a person, based on your training, and you had to unlock your front door so that emergency personnel could get in, would you then go out and wait on the street for them?”

“No, sir.”

 

 

The next witness that day was Marlene Swanbeck, an emergency room nurse who had been on duty the morning that Kathy was brought into South Meadows. Swanbeck testified that Kathy had arrived in the ambulance with Pratt at 7:15
A.M.
, and that she had withdrawn a urine sample from her at 7:35
A.M.
According to medical records, Swanbeck said, Kathy had been given heparin, a drug that is used to prevent blood clots, at 8:10
A.M.
, after the urine had been taken.

“Did anybody in that facility . . . administer succinylcholine to that patient?” Hicks asked.

“No.”

“Would there be any reason to administer succinylcholine to that patient?”

“No.”

“And why not?”

“Because we give succs when a patient is intubated, and this patient arrived intubated,” Swanbeck said.

“Were there any injections, new injections, administered to the patient when she was in the emergency room, aside from the IV she already had?” Hicks asked.

“No.”

In response to questioning, Swanbeck said that she had discovered the identity of the patient when Chaz had come into the emergency room. She said that she had been surprised to see him there.

“Could you please explain the circumstances of him coming into the room?” Hicks asked.

She explained that as they had been treating the patient behind a closed curtain, Chaz had appeared from behind the curtain. When she had asked him what he was doing there, he had said that the person they were working on was his wife, Kathy.

“What was his demeanor?” Hicks asked.

“He acted like it was just another day,” Swanbeck responded.

“Was he sobbing?”

“No.”

“Was he excited?”

“No.”

“Was he asking any questions about her well-being?”

“No.”

Hicks wanted to know whether Chaz had explained anything to her and the others present about what had happened to Kathy, and Swanbeck said that he had gone into “great detail.”

“And what was he explaining to you?”

“That he had been out in the garage earlier in the morning,” Swanbeck said. “That Kathy had been under a lot of stress, so [he] was letting her sleep in. And he went into the bedroom after having made coffee and was bringing her coffee. And the room was dark, and he tried to rouse her, and she didn’t rouse. So he opened up the curtains, checked for a carotid, and found that she had no pulse.”

“Now, did he volunteer this information?”

“Yes.”

“Did it seem odd to you?”

“Yes.”

“And why was that?”

“Just his position, the way he was standing. That she had been healthy, and now she’s suddenly down. He was removed from what was happening, it seemed.”

Even though she said that he had indicated to her that he had been working on his car that morning, Swanbeck said that he didn’t have any grease or oil on him. It was also clarified later that she didn’t know whether he was working on the engine or other parts of the car that could have gotten him dirty, or whether he was working on something inside the passenger compartment.

After Kathy had been transferred to the main hospital, Swanbeck said, she hadn’t seen Chaz again that day. She saw him the following day, however, when he returned to South Meadows to thank everyone for taking care of his wife. He had brought them doughnuts, and said that he wanted to pick up his paycheck. He had actually called Swanbeck and asked her to meet him in the parking lot to get the doughnuts, and to bring him his paycheck.

“To need your paycheck when your wife is ill and to bring us doughnuts,” she said, “the timing didn’t feel right to me.”

She recalled telling a coworker that Chaz had asked her to meet him outside in ten minutes and had said, “You know where I am if I don’t come back.”

“What did you mean by that?” Hicks asked.

“I think that we were all sufficiently suspicious and we had been talking amongst ourselves that it didn’t feel right to us, so it was just kind of—for me, it was just a smart-ass comment that if I don’t come back, you know, maybe I was next,” she said.

Swanbeck testified that she nearly always tried to avoid personal conversations with Chaz when he worked at South Meadows. She said that she always felt a little suspicious of him, that something wasn’t quite right. She explained that she was never comfortable with the way in which he had talked about his wife, and being a mother, she said, she was never comfortable with the relationship that he had with his daughter. What bothered her, she said, is that he never seemed to have enough time to spend with his daughter, in part because Kathy purportedly hadn’t allowed her to come to her house to see him. On one occasion, Chaz had said that his daughter was going to spend her summer vacation at his mother’s home, and when he had been asked if he was going there to see her, he had indicated that he was not. She also said that she never heard him talk about his wife in a loving way, but instead had heard him refer to her as a “bitch.” Sometimes when Kathy called him on the phone, he would become irritated and would let her sit on hold for a bit.

Swanbeck also described for the jury how the succinylcholine had been stored in the refrigerator in the emergency department, and took them through the process of how it is accessed—basically the same information that they had heard before from other witnesses. She confirmed that the rapid-sequence intubation kit kept on a shelf in the refrigerator contained succinylcholine, and that the drug was stored elsewhere in the refrigerator, “just sitting there.”

“You had indicated that once you put in your . . . code, you get into the refrigerator storage area,” Hicks said. “There are vials of succinylcholine stored right in the refrigerator, is that right?”

“That is correct.”

“When you take a drug out of there as a nurse, do you have to write it down, or is there some way that . . . anybody can tell that you’ve taken it?”

“When we access the computer to get into the refrigerator, in theory, we do need to put in the drug that we’re talking about,” she said. “But because the refrigerator opens up and (there are) a whole host of medications, we can take what we want out of there.”

“So, if I understand you correctly, a person could, we’ll say—any nurse could type in their code, type in that they’re going to take . . . tetanus. But then when they go in, they could take succinylcholine, for example, and that would not be tracked?”

“Exactly.”

She also said that succinylcholine and other drugs were stored at other locations within the department and that they could be easily accessed by the nurses. Since Kathy Augustine’s death, access to succinylcholine had been somewhat tightened.

Dr. Stanley Thompson, a Reno cardiologist who began working in that medical specialty in 1970, was called to the witness stand by Tom Barb following a recess for lunch. Thompson explained that he came to be involved in Kathy Augustine’s case when Dr. Arun Kolli had sent her from South Meadows to the Renown Regional Medical Center, as it is now known, for the heart catheterization procedure for an angiogram, which Thompson had been asked to perform. He described the procedure in detail, and discussed the compact disc that was made of the angiogram—in this instance, a cine angiogram. After resolving some technical difficulties regarding the operation of the equipment, the CD was played for the jury. Thompson explained what was happening as the jury viewed the cine angiogram.

“That’s the catheter that goes up into the start of the left coronary artery,” he said. “There we have the start of the dye that goes into the arteries, so the arteries are actually dark and black. Usually what you would expect if there was a problem causing a heart attack would be a blockage in there. And you see that the artery goes for a short distance and then bifurcates into two major branches. And one is called the left anterior descending, and one is called the circumflex. Both those arteries, even though they’re kind of curlicue, have no blockage whatsoever.”

He explained that the angiogram looks at the coronary arteries in multiple angles to ensure that any blockages present are not missed. He pointed out the left and the right coronary arteries, and demonstrated to the jury that there were no blockages.

“So, basically, these arteries were normal,” Thompson said. “Everyone in this room would love to have those arteries.”

While Thompson would not rule out the possibility that Kathy had suffered a heart attack—which are commonly caused by blocked coronary arteries—he did say that she did not suffer from any coronary artery disease and that this was not the type of angiogram one would expect if the patient had had a heart attack.

“You’d expect a blockage,” he said, if Kathy had suffered a heart attack. “Or more likely, if someone had suffered a heart attack, a hundred percent occlusion. But an artery that goes a short distance and then is completely blocked off, and there’s no blood flow getting to the heart muscle . . . that heart muscle would die and produce both symptoms and EKG changes of a heart attack . . . you can say that [Kathy’s] arteries are perfectly normal.”

Instead, the problem that Thompson had found, and that which he had explained to Detective Jenkins, was that Kathy’s heart was not vigorous in its pumping action—it wasn’t contracting as well as it should and therefore not pumping out the amount of blood that it should have been pumping.

“Normally, everyone should pump out at least fifty percent of the blood that is received inside the heart,” Thompson said. “And usually closer to seventy or eighty percent. This heart was pumping out twenty-three percent.”

Thompson’s medical opinion as to why Kathy’s heart was not “rigorous” and pumping out the blood in the volume that it should have been doing was that whatever she suffered from was not a typical heart attack or hardening of the arteries.

“Now, sometimes you see that when someone has not had any oxygen for a while,” Thompson said. “I mean, that’s basically almost a dead heart.”

“When you say a ‘dead heart,’ you mean cells actually in the heart have died or are dying?” Barb asked.

“Well, they’re at least stunned.”

Barb asked Thompson if he was familiar with succinylcholine, and he responded that he had learned about it in pharmacology and medical school, but had never used it. He said that he knew enough about the drug to know that it was a paralytic.

“If a paralytic drug were given to a person and no assistance with breathing was done, would it show as this shows?” Barb asked.

“Yes,” Thompson replied. “If someone were not breathing and became hypoxic, or lack of oxygen, after a while the heart would look like that.”

“Okay. Dr. Thompson, did you have occasion to speak with Kathy Augustine’s husband?”

“I met him. He accompanied her when she was brought to the cardiac cath lab from South Meadows.”

“Did you speak to him at all?”

“Yes. And I stated that I thought the outlook was not good, considering her condition.”

“What was his demeanor, if you recall?”

“Well, I was a little surprised in that he was unemotional, compared to what I would have guessed. In other words, generally, if a family member is—you know, has had an arrest (cardiac) and is in dire straits, you’d expect—I would expect more emotion. And there was not a lot of emotion.”

“Does that go for medical personnel, Doctor?”

“It goes for any person.”

“So the fact that he’s allegedly in the navy for fifteen years and that he’s a critical care nurse, does that change your opinion about emotional ties to what is going on?”

“No. I was in the navy for ten years. I have been very involved with medical situations. I will tell you if my wife were in that type of situation, I would be very emotional.”

 

 

During cross-examination, Alan Baum wanted to know if Dr. Thompson, in his last response, had meant that he would expect every single person on earth who has a loved one going through a crisis to react exactly the same way.

“Surely, that’s not what you meant,” Baum said.

“No, it’s not.”

“And would you, therefore, allow for the possibility that certain people, whatever their background, might react different than other people, or even react different than what you would expect them or how you would expect them to react?”

“That’s a possibility.”

“Was the conversation that you had with Chaz Higgs the first time that you had ever met him?”

“Yes.”

“Had you spoken to him on the phone?”

“No.”

“So you have no idea as to what his general demeanor is—”

“No, I do not.”

“—or was. This conversation is the sole basis for your opinion that he was not acting as you might have expected him to.”

“That’s correct.”

Baum took the cardiologist through a number of questions and scenarios regarding Kathy’s condition, particularly as it related to her heart. By the end of Baum’s efforts, Thompson testified that he could not rule out sudden cardiac death as the cause of death in Kathy’s case.

 

 

Toward the end of the day, Dr. Steve K. Mashour, a pulmonary and critical care physician, was called to testify. He said that he had examined Kathy Augustine when she came back from the cardiac catheterization lab to Washoe Medical Center’s intensive care unit. He said that she had been intubated with an endotracheal tube in place and was on a mechanical ventilator. He explained how her pupils had been fixed and dilated by the time he had seen her, and how he had been told after speaking with one of the cardiologists how her cardiac catheterization—or angiogram—had essentially turned out negative. Similarly, he explained, he had not found any intercranial bleeding, which could have accounted for the pupils being fixed and dilated, and he had been able to rule out a pulmonary embolism, which is a blood clot in the lung that could be fatal because it can block oxygen from getting into the patient’s bloodstream.

“Does one of the tests that you just told me about . . . measure the transfer of oxygen or test lung function?” Barb asked.

“No, it does not,” Mashour said. “It’s merely a qualitative test that looks to see if there’s actual evidence of a blood clot there. It does not tell anything about lung function.”

“Did you ever do any tests that would tell you about the transfer of oxygen to the blood or carbon dioxide out of the lungs, or anything like that?” Barb asked.

“Indirectly,” Mashour responded. “From the arterial blood gases you would get some idea of the amount of transfer of oxygen from the environment to the bloodstream.”

“And the arterial blood gases were part of what test?”

“Part of the routine workup. As far as being on the respirator, you would get arterial blood gases to determine if the patient’s carbon dioxide and oxygen levels and pH were—you know, where they were at and if you needed to adjust the respirator to adjust any of those parameters.”

“Were Miss Augustine’s lungs functioning properly with whatever breathing assistance she was having?”

“To the best of my knowledge, they were, yes.”

“So we got no pulmonary embolism, we got no brain bleed, we got functioning lungs,” Barb said. “Is there anything else that you can say about Miss Augustine?”

“Well, at that point . . . the usual differential of limitation would go down in an arrest such as she went down that—those are usually the first two or three that you would consider,” Mashour said. “All of those being negative, then you would have to look at possibly a drug overdose of some kind, which is usually how these patients present.”

“If succinylcholine had been administered in Miss Augustine and she wasn’t properly ventilated, would the results that you saw be consistent with that situation?”

“Conceivably, yeah.”

 

 

“Doctor,” said David Houston upon beginning his cross-examination of the witness, “based upon what you saw, you can’t, of course, rule out sudden cardiac death, correct?”

“Based on the information that I have, it’s possible,” Mashour responded.

“Now, Doctor, Mr. Barb asked you a moment ago about drug overdoses. And drug overdoses certainly can cause those types of conditions that you viewed, correct?”

“Sure.”

“Now, Doctor, in reference to this particular case, you’ve also been advised that the alleged point of injection on Miss Augustine was in the fatty tissue on the left buttock, correct?”

“That’s what I’ve been told. Yes.”

“And you’ve also advised that you feel that would be highly unlikely to be the cause of death in this case. Haven’t you said that?”

“Usually—I think it would. But based on the medication that is being suspected, that would be unlikely to be cause of death in my opinion.”

“And the reason it would be highly unlikely that succinylcholine would be the cause of death is because you would have to administer so much, true?”

“Well, there’s no data to support the administration of succinylcholine in subcutaneous tissue. I don’t even know the data with regard to intramuscular injection. The only time I’ve ever given succinylcholine or have been involved with succinylcholine has always been intravenously.”

“Didn’t we actually discuss the notion that it could be as high as—what was it?—eight hundred milligrams in order to receive any effect whatsoever?” Houston asked.

“That’s a very rough estimate,” Mashour responded. “I mean, again, without knowing the pharmacodynamics in subcu tissue, which has not been studied, that’s a ballpark guess at best.”

“Okay. Now, Doctor, eight hundred milligrams would be forty cc’s, correct?”

“That’s correct.”

“This is a ten-cc syringe?”

“That’s correct.”

“That would mean you’d have to inject four of these just to get the eight hundred milligrams, correct?”

“Correct.”

“And you have a fellowship, or did your fellowship in critical care medicine, true?”

“That’s correct.”

“So, in your opinion, since succinylcholine is unlikely to be the cause of death in this particular case . . . does . . . sudden cardiac arrest seem . . . possibly more likely?”

“It seems more likely based on the information, yes.”

“Thank you very much, Doctor.”

 

 

“Doctor,” asked Barb on redirect, “is it your opinion or Mr. Houston’s opinion that succinylcholine isn’t the cause of death in this case?”

“Well, I think it’s less likely that—”

“Doctor,” Barb interrupted, “has anybody told you that there was succinylcholine present in Ms. Augustine’s urine after her death—or excuse me—when she first came to the hospital?”

“When she first came to the hospital, I was not aware of that,” Mashour said.

“Okay. Does that change your opinion, if that was your opinion?”

“Well, it would change my opinion.”