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Prosecution Questions Cardiologist in Chauvin Trial; Cardiologist Says, Floyd was Restrained in a Life-Threatening Manner; Cardiologist Say, I Didn't See Any of the Signs of an Opiate Overdose. Aired 11:30a-12p ET
Aired April 12, 2021 - 11:30 ET
THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.
DR. JONATHAN RICH, CARDIOLOGIST: One of the transformations that we have needed to adapt to this past year.
We're getting back to now seeing most of our patients in person. But during the course of this pandemic, to minimize exposures, we've set up a lot of these video visits with patients.
And what came to appreciate is that while there is no substitute to actually putting your hands on a patient, that is still preferable in my opinion to really examine them closely, you can get a lot of information off of a video assessment, even physical examination, by looking at -- have them turn their neck to the side and I can see their neck veins, which is an indicator of pressures. I can see their legs to look if there's any indication of swelling, which might be congestive heart failure. Of course, I can just see the patient, I can see how they're breathing, I can hear how they're talking, if they seem breathless or short of breath.
So we actually have found out that we can do a lot via video assessments.
JERRY BLACKWELL, PROSECUTING ATTORNEY: Were you able to then see Mr. Floyd appear at a time after he was first approached by the police on May 25th, 2020?
BLACKWELL: What were your observations about Mr. Floyd from that initial encounter with the police?
RICH: So from his initial encounter, remembering particularly when he was asked to get out of his car, he appeared fearful but was speaking clearly, answering questions appropriately, didn't see any acute -- what we call acute distress. I saw no indicators at that time that he was suffering from low oxygen, for example, or from any active medical problem. And as I said, you was really trying to keep a close eye on some of the subtleties of his appearance and speech and so forth.
BLACKWELL: Were you able to observe at the point that he was been asked to get into the squad car? RICH: Yes, I was.
BLACKWELL: What were your observations with respect to that period of time?
RICH: Yes. So I watched him walk to the squad car and then I was observing an interaction where they were asking him to get into the backseat of the car. I heard him talking about how he was claustrophobic. There were times he was being pushed into the car or how it was. He even made indicators at that time that he couldn't breathe.
But all of my observations at that point were still that up until the point that he was kind of getting pushed or pulled through the car and ultimately on to the pavement, up until that point, I also saw no evidence that there was anything active going on from a cardiac standpoint. And that was really important for me to conclude (ph).
BLACKWELL: And what sort of active thing might you have been looking for related to the heart over that period of time?
RICH: Yes. So, for example, let's say that he was having, you know, arrhythmia and abnormal heart rhythm, especially if it's originating from the heart, oftentimes, what will happen is you have the heart rhythm that goes abnormal and you go from being totally fine, like hopefully we all here today, to instantly dizzy or passing out. I didn't see any indicators that is happening. I didn't hear him complaining of dizziness or fluttering of the chest. I couldn't see any swelling in his body.
Again, I didn't want to take anything for granted that even from the initial encounter up until that point, what if something developed from point A to point B? And so, again, up until that point, I saw no indicators of low blood pressure, or anything else abnormal with the heart.
BLACKWELL: And turning then to the restraint on the ground that you were referring to, what were your observations then as a cardiologist from your having viewed Mr. Floyd's restraint on the ground by Mr. Chauvin?
RICH: Sure. So my observations were that he was restrained in a life threatening manner, specifically, my observations was that he was on the ground in the prone position, handcuffed, hands behind the back, a knee on the back of his neck, a knee on the back of his upper torso or shoulder, hands pushing his handcuffed hands up into his chest. I observed a knee compressing his -- I thought it was his buttocks or upper thighs. And then at various points, his lower limbs, his lower extremities are being pinned down to the ground. So that my initial observation was what is the position, first and foremost, that he is being subjected to.
BLACKWELL: And did you see at some point in watching the video that Mr. Floyd went into cardiopulmonary arrest?
[11:35:04] RICH: Eventually, yes, I did.
BLACKWELL: Do you know what Mr. Floyd's heart rhythm was when he was taken from the scene?
RICH: Well, so, in the course of the restraint, I was looking to see if his deterioration occurred rapidly, like I was just talking about, for example, a primary cardiac event. The most common arrhythmia is what we call ventricular fibrillation or V.F., for short, V Fib. When that happens, the individual will look relatively okay, meaning, they're alert, they're talking and then they will immediately become unconscious.
On the other hand, if the cause of the cardiopulmonary arrest was from something else, for example, low oxygen levels, you will typically see that deterioration happening much more gradually and slowly. So my observations were the second that you can see at least I could see his speech starting to become less forceful, his muscle movements becoming weaker. Until, of course, eventually, his speech became absent, eventually, his muscle movements were absent. And then as we later discovered by the heart rhythm, he was in a PEA cardiopulmonary arrest.
BLACKWELL: So I'd like to talk with you about two concepts, the one being PEA, which is pulseless electrical activity, and the other one being a thing called asystole.
So, first, Dr. Rich, will you tell us what pulseless electrical activity is?
RICH: Sure. So, pulseless electrical activity, or for short, PEA, is a chaotic heart rhythm that you can see on the EKG or on the cardiac monitor. But there is an absence of a pulse. And so it doesn't meet criteria for this asystole, that I think we'll talk about in a minute, or for ventricular fibrillation.
Ventricular fibrillation, if I'll just use my fingers, is basically the heart rhythm looking like this. Okay, it's this little subtle fluttering but basically is nothing else going on.
Pulseless electrical activity, if you are a clinician, a doctor, or a nurse or anyone for that matter, who's ever been trained in cardiac arrest, one of the things that will come to mind immediately is whenever you see a PEA arrest, you need to think about what's causing it, because nearly all PEA arrests are being caused by something relatively specific. And if you can identify what that is, it can be reversed.
BLACKWELL: And what is the most common cause of PEA?
RICH: So you might have heard of others talking about the Hs and the Ts. So one of those Hs, the most common cause for a PEA, cardiopulmonary arrest, is hypoxia, not enough oxygen levels.
BLACKWELL: Low oxygen?
RICH: Low oxygen.
BLACKWELL: And what about asystole?
RICH: So, asystole is the flat line. So, you know, when any human dies, they will eventually go into asystole, where there would be absolutely no heart rhythm occurring, even this chaotic rhythm. That is, again, sometimes called a flat line. So V Fib is this kind of thing, PEA, can have a variety of chaotic-looking rhythms without a pulse and asystole is the absolute absence of any cardiac electrical activity.
BLACKWELL: If Mr. Floyd is in a PEA state, or generally anyone, is PEA reversible?
RICH: So it is important to put it into context. So we see PEA cardiac arrests in the hospital all the time. Whenever you see a PEA cardiac arrest, you rush to it, of course, and you begin the protocol, and that protocol is the Hs and the Ts. And so you give oxygen if you don't think they have enough oxygen. That is the most critical thing to do.
Depending on the other Hs, for example, hypovolemia or hemorrhage, if you think they're bleeding out from a trauma, you would actually give them blood. And we're doing these things, of course, simultaneously because time is of the essence.
So we resuscitate patients with cardiopulmonary arrest from PEA, not infrequently. Unfortunately, PEA can also be a devastating cardiac arrest, and despite all of our best abilities, sometimes it's not reversible.
BLACKWELL: Dr. Rich, did you see any evidence at all that George Floyd had had a heart attack?
RICH: No, none whatsoever.
BLACKWELL: What about this notion of something called a silent heart attack?
RICH: A silent heart attack? Well, so a silent heart attack, you know, a silent heart attack is sometimes referred if it looks like someone might have had a heart attack but there were no clinical signs to suggest it. It's a relatively uncommon finding. It tends to happen in patients who have diabetes. Because when you diabetes, one of the problems with diabetes is you lose some sensation in the nerve endings.
And so, typically, when you're having a heart attack, you'll see people clutch their chest. Oh, my God, I'm having chest pressure, chest pain. Sometimes diabetics won't have that. And it's possible that they can have a silent heart attack.
But there was no evidence that Mr. Floyd had any type of heart attack, a silent heart attack or non-silent heart attack. BLACKWELL: And so you talk about this a little bit about the notion of the cardiac arrhythmia, the fluttering of the heart. I think you referred to it as the Hs and the Ts, ventricular fibrillation and ventricular tachycardia.
BLACKWELL: Was there any evidence that he had any one of those?
RICH: No, there was no evidence that he had any of those.
BLACKWELL: When somebody is suffering from ventricular fibrillation or tachycardia, could you describe that as what we might refer to as a sudden death event?
RICH: Yes. So, ventricular fibrillation can certainly cause sudden cardiac death. That absolutely could be described as that.
BLACKWELL: And, again, in viewing Mr. Floyd and his encounter on the videos of May 25th, did Mr. Floyd die a sudden death?
RICH: Mr. Floyd died a gradual death. It would not be considered the classic sudden death from the standpoint of how you're putting into that context, meaning, when people have that ventricular fibrillation, that V.F. arrest, the literally go from being fine one moment to completely out the next. I don't know what happened. I was sitting next to him and he keeled over and was on ground. And then that could have been a V.F. arrest.
So sometimes there is semantics in terms of this. But in the case of Mr. Floyd, yes, he did have a cardiopulmonary arrest but, no, there was no evidence of a sudden cardiac death from the V Fib or any other malignant heart arrhythmia.
BLACKWELL: Okay. So we've talked about your review of the medical records and we've talked about your review of the video. The third thing you said you reviewed was the autopsy report and findings.
BLACKWELL: What were you looking for with respect to the autopsy report and findings?
RICH: Sure. So, we're talking about the autopsy report here towards the end. I actually looked at the autopsy report first. Then I went back to the medical records that we've already talked about in the videos, and then I went back to the autopsy again.
So what I was looking for in the autopsy was, first of all, everything. When we get an autopsy, oftentimes, you'll get it because you're looking -- could there be something that we weren't aware of that could have happened?
But in addition to looking at all the findings, my major focus, of course, as a cardiologist, was anything and everything related to the heart. BLACKWELL: What did you find?
RICH: You know, it's interesting. I think what was most important was not only what I found but what I did not find.
So what I found was that his heart architecturally looked normal.
He had a description of coronary artery disease, which I found notable, because as I mentioned before, he had carried (ph) a diagnosis of coronary artery disease.
Now, I mentioned that I found it notable, I certainly didn't find it unusual because, unfortunately, coronary artery disease is so common. I mean, statistically, not to scare anybody, many of us in this room likely have coronary artery disease. I looked at whether there was any evidence whatsoever that Mr. Floyd could have had a heart attack based on autopsy.
So when I looked at those arteries around the heart, I not only looked to see how narrow they were and what the composition of that narrowing was, but also whether there were any platelets or clotting factors or anything else of that nature in the arteries, which is what would be there if there was a heart attack.
BLACKWELL: And then did you see evidence of the platelets you would expect to see in Mr. Floyd had had a heart attack?
RICH: No. There were no description of any of the platelets or clotting factors or anything that would block off an artery. None of the arteries were totally -- the word we often used is occluded, totally blocked off, which is what happens in a heart attack.
BLACKWELL: I want to ask you about some of your specific findings in this regard. But, first, for the jury, would you just tell them whether you excluded coronary artery disease as a cause of Mr. Floyd's death?
RICH: Yes. I have excluded that with a high degree of medical certainty.
BLACKWELL: Now, you talked about looking for evidence of platelets from the autopsy report and that you would expect it to have seen those if he had died from a heart attack and you didn't see them, right? What else did you see?
RICH: Well, so what I also saw was I looked at the heart muscle itself. So not only did the heart muscle itself not show any evidence of any injury at all, which you would see, like you mentioned the silent heart attack? What about a few years ago, somehow he had a mini heart attack? You would see evidence of that in the heart. You would see a scar tissue, et cetera.
So not only did I not see any evidence of a heart attack, the pathologist did it very good job, in my opinion, actually of describing what is called the endocardium. The endocardium is the inner most lining of the heart. And that is the most susceptible part of the heart to cardiac injury. Even the smallest of heart attacks will always originate on that endocardium interlining.
And endocardium was not only described as normal, it was described as smooth and glistening, a completely normal finding, no evidence at all of even small microscopic injury.
BLACKWELL: Were you able by your looking at the autopsy report on the heart to tell whether there is any evidence as to whether Mr. Floyd had ever had a heart attack even going back into the past?
RICH: Yes, no evidence whatsoever of a previous heart attack.
BLACKWELL: Doctor, what is ischemia?
RICH: So, ischemia is a reduction in blood flow to any organ of the body that could be the heart. That could be the heart. That could be the kidney. That can lead to basically insufficient delivery of oxygen for a short period of time. And if ischemia continues to occur for long enough, that can sometimes cause irritability in that organ.
But it's important to distinguish ischemia from infarct. Infarct is actually what we mean when we say a heart attack -- excuse me, a heart attack. When a marathon runner goes on a run, their muscles will get temporarily ischemic. When we live muscles in the gym and they talk about feeling the burn, that means you are feeling ischemia. You're feeling lactic acid build up and it's -- that's what that ischemia is.
BLACKWELL: Any evidence of ischemia?
RICH: Not in the autopsy, no.
BLACKWELL: Let's talk about the blood vessels, the arteries and the plaque that was in the arteries. Were you able then to eliminate the occlusions, blockage in the arteries as a contributing cause of Mr. Floyd's death?
RICH: Yes. I would like to clarify. I saw no blockages, I saw no complete blockages. There were narrow ones. There were narrowings in more than one blood vessel. Importantly, the main coronary artery, it's called the left main coronary artery, there was no description of any narrowings or disease in the left main coronary artery.
BLACKWELL: And why is that, sir?
RICH: Well, because that very first pathway that blood very first pathway that blood travels down that branch off into multiple other arteries. And so left main disease, as we sometimes call it in cardiology, is among all of the vessels, probably the highest risk blood vessel if it were to get blocked off.
BLACKWELL: So how would you characterize the nature of the plaque within the artery? Was it soft, was it fractured? How would you characterize it?
RICH: I would characterize it the way that the medical examiner characterized it. I'm not an expert at characterizing plaque at a microscopic detail. But what I did appreciated was the description of what seemed to be not only relatively conventional-looking artery narrowings, plaque buildup that we all will eventually get in our arteries, but also in one of the arteries, it was described that there was an element of calcium.
And I only mention that because that also indicates that this coronary artery disease didn't just kind of develop right away. It was probably the slow gradual buildup of the narrowings, and that actually is a very clinically relevant finding in the field of cardiology.
BLACKWELL: Doctor, did you make any assessments around the size of this Mr. Floyd's heart?
RICH: Yes, I did.
BLACKWELL: Would you tell the jury about that?
RICH: Sure. So when looking at the size of his heart, not just the size, but the thickness of the heart, it was described as being mildly thick or mildly enlarged. Now, depending on which criteria you use, one criteria would agree with that, that it was mildly thick or enlarged. Others would suggest that it was in the normal range.
I do believe that it was likely mildly thick and mildly enlarged. It is an expected finding in somebody that has high blood pressure. So even though there are some scoring systems that might say it wasn't even enlarged at all, in my view as a cardiologist, I do believe there was just the smallest element of increased heart thickness.
And as I mentioned before, that's important because that's exactly what the heart is supposed to do when there's high blood pressure. That is a normal response. The muscles getting stronger, it's allowing the heart to work and work well.
Now, if that goes on for, like I said before, 20 years, we can have problems. But early on, having a mildly thickened heart is not only a normal finding in someone with high blood pressure, it may actually be beneficial in the short term.
BLACKWELL: Doctor, putting all this together, did you see any evidence at all that the primary cause of Mr. Floyd's death originated in his heart?
RICH: No, I did not.
BLACKWELL: Let's talk about a new subject, whether or not Mr. Floyd suffered from a drug overdose and died from a drug overdose.
BLACKWELL: That was something that you also considered as a cause?
RICH: Yes, sir.
BLACKWELL: Were you or are you familiar with Mr. Floyd's toxicology results?
RICH: Yes, I am.
BLACKWELL: What -- or which substances did you consider in evaluating Mr. Floyd's toxicology history?
RICH: When I looked at the toxicology reports, I focused mostly on the finding of fentanyl, as well as the finding of methamphetamines.
BLACKWELL: What role, if any, do you feel that the fentanyl played in the cause of Mr. Floyd's death?
RICH: As far as I can tell from reviewing all of the facts of the case, I see no evidence at all to suggest that a fentanyl overdose caused Mr. Floyd's death.
BLACKWELL: As cardiologists, do you occasionally have to care for patients who struggle with opioids or opioid addiction?
BLACKWELL: So, here, you found that the fentanyl, in your opinion, played no role in Mr. Floyd's death, would you tell us why it is you hold that opinion? How do you reach that conclusion?
RICH: Well, I think I would break it down to just two major reasonings. Number one, it appeared to me that Mr. Floyd, who was an acknowledged frequent chronic user of substances, particularly opiates, likely developed a high degree of tolerance.
There's even one emergency room visit that I had reviewed where he came in and he told the emergency room team that, you know, he was tearful and says I'm having trouble with substance abuse. I just took -- I think he said I took eight Percocets within two hours. He had no side effects from that at all. They observed him for a couple hours and discharged him. And just so looking through it looked like he had built up a high tolerance just, in general, to opiates.
But the second, and just as important, maybe more important, was I didn't see any of the signs of an opiate overdose when I reviewed the videos.
BLACKWELL: And when you -- referring to the signs of an opiate overdose, would you tell the jurors or describe for them what are those signs and what didn't you see?
RICH: Sure. So in my experience in the intensive care unit, taking care of patients who come in with an opiate overdose, first of all, they are usually extremely lethargic, oftentimes nearly unarousable. And then you try to wake them up and they're falling right back asleep. They're not talking to you. If they are talking to you, they're often having slurred speech. If they're standing up, which they wouldn't be if they had a fentanyl intoxication, an overdose, they would have to get pretty dizzy pretty quickly. I kind of saw the opposite with Mr. Floyd. I saw that he was alert. He was awake. He was conversant. He was walking. And yet, according to the toxicology, report he had this degree of fentanyl in his system.
So just looking at the clinical story, I didn't see any signs or symptoms of fentanyl overdose.
BLACKWELL: Let's turn to methamphetamine then. What role do you feel that methamphetamine played in Mr. Floyd's cause of death?
RICH: I feel it played no substantive role at all.
BLACKWELL: And why is that?
RICH: Well, all considering it was very relatively low level of methamphetamine in his system, and so when you look at the context of the case and you see a relatively low level of methamphetamine in the context of everything else, I felt very confident that that load degree of methamphetamine was not what was triggering this profound cardiopulmonary arrest and ultimately PEA arrest.
BLACKWELL: So, Dr. Rich, then, taking into account all of the evidence that you reviewed, do you have an opinion to a reasonable degree of medical certainty as to whether Mr. Floyd's death was preventable?
RICH: Yes, I do.
BLACKWELL: Would you tell us what that opinion is?
RICH: Yes, I believe that Mr. George Floyd's death was absolutely preventable.
BLACKWELL: Were there critical points in time during his subdual and restraint on the ground when you feel measures could have or should have been taken that would have preserved his life?
RICH: Yes, I do. I think there were several junctures, actually.
BLACKWELL: Would you tell us about those?
RICH: Sure. Well, the first, of course, was to not subject him to that initial -- that initial prone restraint positioning that he was subjected to. I mean, that is first and foremost. So if that was not the case, I don't think he would have died.
The second though was when he was in that subdual and restraint positioning, and he was stating repeatedly that he can't breathe. And he was getting a little weaker in his speech. There was one moment in the video where I heard one of the officers saying, I think he is passing out. That would have been an opportunity to quickly relieve him from that position of not getting enough oxygen, perhaps turn him into a recovery position and allow him to start to expand his lungs again and bring in oxygen and get rid of carbon dioxide. So, in addition to not putting him in that position in the first place when there were signs that he was worsening, repositioning him, I think very likely would have also saved his life.
BLACKWELL: Was there a point in time, Dr. Rich, when Mr. Floyd was checked for a pulse when he was in the subdual.