Monday, September 25, 2006

Understanding SANE, II

One of the most talented students I ever taught was John Makaryus, who double majored in history and pre-med. In his senior year, John received the history department’s top student award, was elected to Phi Beta Kappa, and was admitted to medical school. Since he also experienced a taste of academic groupthink while at Brooklyn College, John really would be the perfect person to do this blog; his range of intellectual interests overlaps almost entirely with the issues exposed by this case. But, as a first-year medical resident, he has other things other things on his plate right now.

For those of us who have some background in procedural or academic matters but who, unlike John, are also scientifically challenged, Kathleen Eckelt is of tremendous assistance. I posted ten days ago on some of her early writings on the Duke case; she recently completed another post, and privately answered several other questions from me. Eckelt’s findings raise serious questions about the validity of Mike Nifong’s case.

1.) In her most recent post, Eckelt explains in greater detail about the dubious nature of the Gottlieb “straight-from-memory” notes. This typewritten document, produced months after the fact without any contemporaneous handwritten notes, claims that in a March 21 conversation, SANE nurse-in-training Tara Levicy told the sergeant that her physical exam of the accuser indicated “blunt force trauma,” that she diagnosed the accuser with anal edema, and that an unidentified male hospital employee walked in to the exam room, causing the accuser to scream uncontrollably. No notation of any of these items appeared in Levicy’s written report.

Regarding the latter issue (the unnamed man who allegedly entered the exam room), Eckelt notes the following,
The name of any person in that room, besides the nurse, must be documented. If it’s an unlocked room, the door is shut and the curtain is pulled to protect the patient’s privacy. The staff know not to enter and the nurse must remain in the room with the evidence until it’s locked up. The only other persons we [in our unit] allow in the room, would be either a physician or another nurse the FNE has asked to come in to assist with something. They’re usually only in the room a few minutes. Once certified, we function independently, so there’s no need to have anyone else in the room with us.
From all reports, neither Gottlieb nor those among the New York Times journalistic staff who considered his notes the key to the case indicated that Levicy ever documented an unidentified male entering the exam room.

Meanwhile, Eckelt contends that the accuser’s symptoms are inconsistent with blunt force trauma. (Times reporter Duff Wilson, who made a great deal of Gottlieb’s version of events, gave no indication in his article of checking to determine the medical plausibility of Gottlieb’s tale.) “You usually do not see edema by itself,” she reports, “as a result of BFT. You usually see other symptoms as well.”

Finally, Eckelt dismisses the claims of anal edema absent Levicy having documented them at the time. “If there is nothing checked off next to rectal trauma on the SANE’s report,” Eckelt comments, “then there was no trauma.”

Of course, Gottlieb’s version of events might be truthful. But his truthfulness would have to come at the expense of Levicy’s competence–thereby calling into question the validity of the entire medical exam.

2.) The accuser’s injuries appear inconsistent with her version of events (even if we employ the Nifong-shortened new timeline). In what “was supposed to have been an extremely violent assault–one in which the accused claimed that she was choked, beaten, and kicked, raped, and forced to engage in oral and anal sex,” Eckelt asks, “Is it logical that [the accuser] would have no red marks anywhere on her body? No bruises, no abrasions or lacerations, no swelling - no pain - anywhere?”

Eckelt presents a convincing and detailed argument as to why the injuries documented by Levicy–“edema, and only edema, of the inner vaginal walls, without having redness and edema showing on the outer vaginal area first”–do not seem to correspond with the description of the alleged attack. While “it’s common knowledge that most rape victims have no injuries . . . in an extremely violent case like this, to have only one symptom - edema - of the vaginal walls alone, and nowhere else, with absolutely no other injuries or symptoms, defies logic.”

3.) The question of who supervised Levicy, a SANE nurse-in-training, remains unanswered.

In response to my previous post on this topic, some commenters suggested that the M.D. who also examined the accuser functioned as Levicy’s supervisor. Eckelt casts doubt upon this theory, though she notes that, perhaps, North Carolina employs different rules than her home state of Maryland.

“Once all the [educational] requirements are completed,” Eckelt informed me, “the nurse in training (in our area anyway) has to be observed and checked off on doing 3 exams on her own. It takes an average of 8 mos. to one year to complete all the requirements. On our unit, the new nurses are observed, and checked off, by an experienced FNE, not a physician . . . We work totally independent of the physicians, except that we have a medical director who oversees the program . . . Besides, many of the physicians in the ER are residents in training themselves (in a teaching hospital). If they haven’t received SANE training themselves, I don’t see how they would be qualified to observe and check off a new SANE nurse.”

4.) The combination of drugs and alcohol that the accuser acknowledged using is a potent one. Eckelt states:
Her taking Flexeril was a big deal to me. There are many factors which should be looked into. First, Flexeril is a muscle relaxant, used to treat acute (not chronic) pain, stiffness, and limited movement from some injury to the muscular skeletal system . . . Flexeril is supposed to be used only for 2-3 weeks - not long term. So, what happened to her in the 2-3 weeks preceding the alleged rape? Something must have in order for her to get a prescription . . . Not only is Flexeril a muscle relaxant, but it also has properties very similar to tricyclic antidepressants. People shouldn’t be drinking alcohol when on this medicine. Alcohol can substantially increase the effects of the medication: drowsiness, dizziness, mental confusion, decreased coordination, etc. Can be very dangerous to mix the two!
5.) It’s possible and even probable that Levicy was basing her information on incomplete information from the accuser regarding previous sexual partners. Eckelt explains the procedure:
Patients are asked right out, "When was your most recent consensual sex within the last 2 weeks?" They are asked the date & time. This is documented in the chart as well as on the front of the crime lab envelope for the first vaginal swab. I always tell my patients: “Normally, most adult patients are sexually active. The crime lab needs to be able to differ the assailants' DNA from those of your normal relationships.” My patients have always given the info freely.
In this case, the initial DNA test included only lacrosse players. Only after that test came back negative did Nifong ask for DNA samples of the people the accuser listed as her previous three sexual partners.

We now know that a match occurred with one of those people, the accuser’s boyfriend, with whom she claimed to have last had sex a week before the alleged attack. In Friday’s court session, the defense strongly hinted that there might be DNA matching other people. And, on April 6, Jarriel Johnson stated that the accuser performed with a vibrator shortly before the lacrosse party. How much (if any) of this information was known to Levicy at the time she performed her exam?

In light of this mountain of physical (non-)evidence, how could Mike Nifong have remained faithful to his requirement to function as Durham County's "minister of justice" and simultaneously have repeatedly asserted in late March that no doubt existed that a rape occurred? That's a question I doubt even Kathleen Eckelt could answer.


Anonymous said...

This should be very helpful to the defense attorneys. It's more evidence of the shakiness of Nifong's case. It also makes the local newspapers look lame for not reporting this on their own.

Anonymous said...

Thanks KC, and let me also add a big thanks to Kathleen. Her posts at Forensics Talk have been very informative. covering the SANE Exam questions in a manner all can understand.

Anonymous said...

The clueless Duff Wilson weighs in with a short piece on Friday's court action. Nifong's best talent may be his ability to spin reporters.

Anonymous said...

We should remember that a large part of the purpose behind the development of SANE programs was to prevent exactly the situation that Gottlieb is trying to create. All of the emphasis on chain of custody issues and careful recording of findings is aimed toward producing trial-worthy medical evidence, not he said - she said. And, like all Medical Records, the gold standard is what is written down by the responsible personnel at their first opportunity.
Either the DMC SANE unit is utterly incompetent or Gottlieb is guilty of what it looks like - making up whatever he needs after the fact and claiming he heard it somewhere.

AMac said...

When were the 33 pages written?

I understand that Sgt. Gottleib wrote 3 pages of handwritten notes at the time of his initial investigation (late March, perhaps into early April?).

The Wilson/Glater NYT piece references the additional 33 pages of Gottlieb's typed notes on the case. IIRC, Wilson/Glater implies (without explicitly stating) that these 33 typed pages are a near-contemporaneous supplement to the 3 written ones.

Liestoppers states:
First, we cannot begin to comprehend how the lead investigator in a case is allowed to wait until 4 months after an incident to type up notes of his investigation. How can there be 3 pages of handwritten notes and 33 pages of typed notes? Did Gottlieb write it all from memory?

I am unaware of a source that gives an authoritative date (or range of dates) for when the 33 pages were typed. Liestoppers' "4 months" works out to mid-July. Is that when the notes were 'produced' (='typed'), or when they were 'produced' (='handed over for discovery')?

I'm sure that the notes are dated and signed, otherwise they'd be useless in court.

Was Gottlieb the keyboardist, or did someone else (e.g. a unit secretary) do the typing? What is the date on page 33 (or page 1)? Are there reasons to believe that this date is, or isn't, correct?

AMac said...

James 10:27am wrote

The notes were produced last month.

James, do you have a link for that? Also, while the word "produced" in that sentence might mean "written," it also might mean "brought to court." In the latter case, the question of when the 33 pages were written (actually, 'typed') would remain unanswered.

Anonymous said...

The only contemporary notes Gottlieb turned in were 2 pages of notes written on April 27, dedicated to his search for a lab to analyze hair.

Anonymous said...

You are sure those notes are dated and signed? Well, don’t be so sure. According to the defense lawyer Wade Smith, “Smith was troubled by the lack of handwritten notes from Gottlieb, who produced only two pages of handwritten notes to accompany his 33-page typed account. Those two pages, taken on April 27, described a search for a lab to conduct hair analysis.
"This is a pristine white document that fell out of the sky four months later," Smith said. "Where are his notes? How can you interview the most important witness you've ever interviewed in your life and not take notes?"”
So, Smith described it as a pristine white document that fell out of the sky four months later. If you don't like "produced 4 months later" or "typed up 4 months later," how about "fell out of the sky four months later?" Is that better? Furthermore, Gottlieb's contemporary written notes (all 2 pages of it) appear to have not much to do with the rest of 33 page document, as these notes describe a search for a lab to conduct hair analysis, so, I have no idea what Wilson and Glater implied in their “article.”

AMac said...

anonymous 11:54am:

Thanks for the link. That N&O story by Joseph Neff says:

[The] typed, single-spaced, 33-page summary of the case [was] handed to defense lawyers in July. It is not clear when it was written...[Collin Finnerty's defense lawyer Wade] Smith was troubled by the lack of handwritten notes from Gottlieb, who produced only two pages of handwritten notes to accompany his 33-page typed account. Those two pages [were] taken on April 27..."

I checked the 8/25/06 Wilson/Glater NYT article (behind the TimesSelect wall). On the provenance of Gottleib's notes, it says:

Crucial to that portrait of the case are Sergeant Gottlieb's 33 pages of typed notes and 3 pages of handwritten notes, which have not previously been revealed. His file was delivered to the defense on July 17, making it the last of three batches of investigators' notes, medical reports, statements and other evidence shared with the defense under North Carolina's pretrial discovery rules...[Defense lawyer] Joseph B. Cheshire... called Sergeant Gottlieb's report a "make-up document." He said Sergeant Gottlieb had told defense lawyers that he took few handwritten notes, relying instead on his memory and other officers' notes to write entries in his chronological report of the investigation.

Open questions, as far as I can tell:
--When do the Durham police claim the notes were typed?
--Are the 33 pages signed and dated?
--Who typed the notes?

Anonymous said...

"relying instead on his memory and other officers' notes to write entries in his chronological report of the investigation."

How to explain, then, the huge discrepancy between Gottlieb's and the other officer's notes as to the AV's description of her "attackers"?