Overcoming Untrue Defenses in Abusive Head Trauma

Matthew J. Torbenson Deputy District Attorney Milwaukee County Special Thanks to… National Center on Shaken Baby Syndrome Mission The National Center on Shaken Baby Syndrome is committed to prevent shaken baby syndrome and to promote the well- being of infants generally through the development and implementation of programs, policy and research; and to support and educate families, caregivers and professionals. Copyright Notice

This presentation contains the creative works of others which are being used by permission, license, or under a claim of fair use (17 U.S.C. 107). This presentation was prepared under the fair use guidelines for multi-media presentations and further use or distribution of it is not permitted. Who am I (not a wizard…) • Deputy District Attorney – 2 years • Assistant District Attorney – 12 years • Team Captain of Child Protection & Advocacy Unit • Prosecute complex child abuse and child neglect cases, with specialization in: • Child homicides • Abusive head trauma • Inflicted burns • Child sexual abuse • Child torture • Complex child neglect (medical neglect) • Presenting child testimony State v. Edmunds

Audrey Edmunds - convicted of First Degree Reckless Homicide 1995 • Caring of 7-mth old Natalie when Natalie collapses • State • Presented numerous experts @ trial • Shaking and/or shaking + impact • Defense: • Expert agreed – abuse, argued “lucid interval” • Convicted of First Degree Reckless Homicide State v. Edmunds

Post conviction motion 2007 • Motion for a new trial – newly discovered evidence • “Significant debate” within medical community as to whether SBS caused injuries – other potential causes • Trial court – evidentiary hearing: •State’s evidence [of defendant’s guilt] is as strong, if not stronger than it was at the original trial. State v. Edmunds “Indeed, the debate between the defense and State experts reveals a fierce disagreement between forensic pathologists, who now question whether the symptoms Natalie displayed indicate intentional head trauma, and pediatricians, who largely *392 adhere to the science as presented at Edmunds's trial. However, it is the emergence of a legitimate and significant dispute within the medical community as to the cause of those injuries that constitutes newly discovered evidence.” At ¶ 23. (2008 WI App. 33) J. Crooks: Dissent, ¶ 84, fn. 4 State v Ward, 2009 WI 60 “. . . This is especially troubling in this type of case. Medical evidence in so-called “shaken baby” cases is very much in dispute at the moment, and the risk of wrongful convictions based on powerful but ultimately discredited expert testimony is significant. Given the evidence of prior brain injury, it is relevant, but not dispositive, that Ward was the person who was with the baby when he died. . . .” Then cites to Edmunds Overcoming Untrue Defenses

A small cadre of defense “experts” are working in conjunction with defense attorneys in an effort to create… •Courtroom controversy •False belief that there is disagreement within the medical community concerning the validity of an AHT diagnosis Overcoming Untrue Defenses

Geddes & “The Unified Hypothesis” • Hypoxic event – lack of oxygen – causes brain swelling (edema), results in increased intracranial pressure = resulting in SDH & RH • Geddes – • Has testified that her theory was only a hypothesis • “… I would be very unhappy to think that cases were being thrown out on the basis that my theory was fact.” Overcoming Untrue Defenses

Common Defenses: (1) SBS doesn’t exist; no evidence base; (2) Retinal Hemorrhages (RH) caused by many things; (3) Re-bleeding of a cSDH caused by incidental trauma (short fall/birth/rough-housing kids) (4) Short Fall (5) Bio-Mechanics: Can’t shake ‘em hard enough- need neck trauma Overcoming Untrue Defenses Common Defenses: (6) SDH caused by birth trauma (7) “SODDI” & TODDI (8) Lucid Interval/Can’t time injuries (9) Resuscitation efforts (CPR/CCR) (10) Temporary Brittle Bone disease & or Osteogenesis Imperfecta (11) Vitamin deficiency “K” “D” Overcoming Untrue Defenses Common Defenses: (12) Metabolic disease (13) Bleeding disorders (CVST v. Coagulopathy) (14) Clotting disorders (ITP) (15) Accidental trauma (16) The ‘Unified Hypothesis' of Geddes et. al. & (17) Dysphagic Choking etc. Barnes, Galaznik, Gardner, Shuman https://web.stanford.edu/~pbarnes/docs/publications/DysphagicChoking.pdf Irresponsible Testimony By Medical Experts In Cases Involving Physical Abuse and Neglect Of Children

Chadwick and Krous, Child Maltreatment, Vol 2. No.4 (1997). Irresponsible Testimony By Medical Experts

• Absence of proper qualifications • Unique theories of causation • Unique or unusual interpretations of medical findings • Alleging non-existent medical findings Irresponsible Testimony By Medical Experts

• Flagrant misquoting of medical journals or texts • Making false statements • Deliberate omission of pertinent facts or knowledge John Lloyd: Biomechanic Specialist

PANAMA CITY — The only witness for the defense in a recent child abuse case was arrested and charged with perjury this weekend. John Lloyd: Biomechanics “expert”

Lloyd stated he was a “professor of medicine” at the University of South Florida College of Medicine. However, the interim chair at the institution told investigators that Lloyd is not now nor has he ever been a professor of medicine there and they are in the process of issuing a cease-and-desist letter to Lloyd regarding his claims. John Lloyd: Plea Deal

John Lloyd won’t be serving as an expert witness anytime soon after he entered a provisional plea of no contest to two felony counts of perjury . . . But the provisional plea means that if he completes his probation the charges ultimately will be dismissed. Overcoming Untrue Defenses

When the defense attacks the TIMING OF THE INJURIES $32,800

Why is this number up here? Dr. Janice Ophoven

• Wisconsin taxpayers via SPD paid Ophoven $32,800 to testify for the defense in two cases, just in Milw. Cty • Makes over $180,000 per year – testifying for the defense Overcoming Untrue Defenses

• Defense “Experts”: • Have testified many times – professional witnesses • You must have a working knowledge of the underlying medicine; • You must have the ability to dig into the “experts” background, history, and biases; • You must have good working relationship with your medical experts; • Review the defense expert reports with your experts • Develop a trial strategy to confront the defense experts • Decide on the best method of cross examination of the expert Overcoming Untrue Defenses

State v. Jennifer Garcia Overcoming Untrue Defenses

• “T” • By age 3, T has lived with multiple different relatives; • T’s parents constantly in/out of custody • Spring of 2014: • Both of T’s parents are in custody; • T is living with his paternal grandmother – ill equipped to care for a young, energetic child; • June 7, 2014: • T is dropped off at Jennifer Garcia’s home Overcoming Untrue Defenses • Jennifer Garcia – • Latin Queen gang member; • Has multiple children with T’s father, all girls; • T is the only boy, known to be father’s favorite; • T’s life = reminder of father’s infidelity to Garcia • By June 21, 2014: Overcoming Untrue Defenses

• Upon admission to Children’s Hospital of Wisconsin: • Too numerous to count bruises, abrasions, hypopigmented injuries • Subdural hematoma with resulting mass effect, including midline shift of the brain & edema; • Grade II liver laceration; • Total of 161 photos taken to document T’s physical injuries • Many pattern injuries • Many suspected burn injuries Overcoming Untrue Defenses

• 9 year old “Savannah” • Was staying with Garcia for the summer • Witnessed Garcia beat T regularly • June 20, 2014: • T asked for a cookie – in response…. • Garcia punched T repeatedly in the head • T threw up • Garcia took T into the kitchen • Savannah – instructed to get Mr. Clean from bathroom • Savannah – retrieves Mr. Clean and upon entering the kitchen… Overcoming Untrue Defenses “Savannah” • T – unresponsive • Garcia – put T into a bath in an attempt to revive T • T’s fists clenched tight to chest • “Decorticate Posturing” • June 21, 2014: • Garcia calls her mother and friend over to concoct a story that T was dropped off at Garcia’s house injured • Garcia attempts to convince “Savannah” to lie • For hours, T remains unresponsive on the floor Overcoming Untrue Defenses

• Fantastic Investigation by Police • Cigarette Incident – witnessed by neighbor • Elaborate conspiracy to cover up abuse • Result: • Garcia is charged with: • 7 counts of child abuse (including two counts GBH) • 1 count of child neglect resulting in GBH • 1 count inflicting mental harm • 3 counts of conspiracy to intimidate a victim Overcoming Untrue Defenses

Enter the wicked witch…. • Curriculum Vitae • “Pediatric Forensic Pathologist” • MD from U of Minnesota • Former Director of Children’s Hospital of Minn - Laboratories • Former Deputy Director – Hennepin County ME’s Office • Forensic Pathologist, St. Louis County ME’s Office • Former - Child Mortality Review Panel Member • Consultant – Midwest Resource Center for Child Abuse • “30 years of experience” in the evaluation, investigation, and interpretation of injuries in childhood Overcoming Untrue Defenses

Ophoven’s “History”: • T was dropped off @ Garcia’s house 3 days ago (false); • “Savannah” took T into the kitchen, where T slipped on his vomit and fell (false); • Garcia put T to bed – T was alert (false); • Tramonte did not lose consciousness (false); • Morning of June 21, 2014 – T was alert and moving (false); • T went unresponsive just prior to first responders being called (false); Overcoming Untrue Defenses

Ophoven’s report: • “Preliminary Report” • Pre-existing (chronic) subdural hemorrhage • Trauma from a minor fall = re-bleed • Suspected cigarette burns = really bug bites • Bruising & abrasions = “abnormalities” that do not suggest a pattern of recent assault • Cannot be timed to the time frame with Garcia Overcoming Untrue Defenses

Begin digging – • Research true history of defense expert; • What biases and/or prejudices do they bring to the stand? • What does prior testimony of the expert reveal? • How much was the expert paid $$$$$? • Consulting on a case vs. report vs. testimony • Prior work history? • Prior presentations (defense) and unlisted professional relationships? Overcoming Untrue Defenses

Janice Ophoven – what can we learn from digging??? • Last time clinically saw a child = 1970’s (less than 5 yrs) • Since 2007, has testified ONLY for the defense • Was asked by head medical examiner in Minn. to stop testifying for the defense in infant cases • Law enforcement in Minn. did not want Ophoven performing autopsies on infant cases • Makes $180,000 per year on defense consultations • Charges $5,400 to consult, $5,400 for a report, and $5,400 to testify to contents of the report • Financial incentive for a pro-defense report Overcoming Untrue Defenses Janice Ophoven – what can we learn from digging??? •“Preliminary Report” – prior strategy •Testimony from Nebraska case • Attributed skull fx to birth trauma • Child born via C-section Overcoming Untrue Defenses Overcoming Untrue Defenses

Janice Ophoven – what can we learn from digging??? • Prior to cross on the specifics of this case – expose • Financial Bias - • Perceived Bias as an Assistant Medical Examiner – • Not a pediatrician, radiologist, hematologist • As a consultant, has always testified for the defense • Prior testimony – • Attempt, through transcripts, to establish a common theme or defense used • NDAA – invaluable resource – significant database • NY Prosecutor’s Training Institute – online resource • Lay the foundation for your theme for the defense Overcoming Untrue Defenses

Janice Ophoven – what can we learn from digging??? • Do not be afraid to “dig” at trial – • Through cross – learned Ophoven did NOT review: • Surveillance video of T being struck June 20, 2014 • Forensic Interview of “Savannah” • As a result, Ophoven had to testify that: • Medical history is not that significant • History she did “rely” on was false & from defendant • Expose and highlight her biases • Financial ($16, 200) • History of testimony for defense • Pattern to previous testimony – • old injury exasperated by minor trauma Overcoming Untrue Defenses

Be prepared for what is not in the report: • On the stand – Ophoven testified about “yellowing” of T’s external skull • Attributed “yellowing” to staining from “old blood” • Evidence of older head injury, then… • Inexplicably linked evidence of “older injury” to internal head injury; • Thus, internal injury must be old! Overcoming Untrue Defenses

Confronting the defense medical “expert”: • “Yellow” staining of skull – How does one date staining on the skull???? • Learn about that day one of medical school • Ophoven then moved focus to attempting to date the clot inside of Tramonte’s head • Ophoven reviewed three stained slides of the blood clot removed from the SDH Overcoming Untrue Defenses

Confronting the defense medical “expert”: • Neurosurgeon – •The person who removes skull & visualizes and removes clot = acute! Overcoming Untrue Defenses

Confronting the defense medical “expert”: • Ophoven (reviewing three slides…) • Presence of macrophages and fibroblasts – clear indication that the clot is weeks old, thus injury is old; • Hubris of this statement – Ophoven –examines three slides and her assessment of the injury is better than the neurosurgeons! Overcoming Untrue Defenses

Confronting the defense medical “expert”: • Few studies that examine changes in SDH through the healing process…. BUT…. • Pathomorphological staging of subdural hemorrhages: Statistical Analysis of posttraumatic histomorphological alterations, Legal Medicine, 2009, Vol 11, Walter et. al. • In almost 80 cases examined, 60 cases had macrophages present within one day of the traumatic event • In almost 80 cases examined, 20 cases had fibroblasts within one day of the traumatic event Overcoming Untrue Defenses

Confronting the defense medical “expert”: • Jury is left with the following regarding Ophoven: • As a medical examiner, law enforcement did not want her performing autopsies on child cases; • As an expert witness – always testifies for the defense; • Financial incentive to generate report and testimony favorable to the defense; • Generates a report that does not contain all of her conclusions and findings – why? • Did not consider ANY of the evidence consistent with child abuse • Did not consider accurate historical account of T’s care; • Hubris - her assessment of three slides is better than the neurosurgeon’s visualization of the entire injury; Overcoming Untrue Defenses

• Result – after a weeklong trial….. • Garcia convicted of 12 of 13 charged offenses including • Physical Abuse of a Child – Intentionally inflicting Great Bodily Harm Overcoming Untrue Defenses

You MUST be prepared to invest time into…. • Understanding the medical evidence of your case • Understanding the medical explanation proffered by the defense – and its shortcomings • Understanding – any medical literature cited in support of your case or the defense case • Understanding who the defense “expert” is, background, employment history, biases, prejudices Overcoming Untrue Defenses Your Expert Witness(es): • Part of the treatment team • Worked with, consulted with other treating physicians • Excellent resource for medical literature • Learned Treatises – in support of abuse diagnosis • Knowledge of weaknesses of defense medical literature • Excellent network - access to other cases involving defense experts • Demonstrate a pattern of testimony on the part of the defense expert = hired gun Overcoming Untrue Defenses

What to do when the defense goes ALL IN Overcoming Untrue Defenses

Most Common Defense Strategy • Provide a non-abusive medical cause for each diagnosed injury sustained by the victim Overcoming Untrue Defenses

• The simplest explanation is the Best!!! • One explanation for the victim’s entire clinical presentation: Overcoming Untrue Defenses

Only ONE cause explains your victim’s entire clinical picture: • Emphasize: • Doctors who made diagnosis of AHT/Child Abuse were part of the victim’s treatment team; • Individual expertise + expertise of each consulting physicians; • CAC Expert – considered and ruled out all plausible (and implausible) alternative explanations; • No financial incentive to make a child abuse diagnosis; Overcoming Untrue Defenses

State v. David Allen Overcoming Untrue Defenses

Junior – • Junior’s mother: • Morbidly obese • Gestational diabetes • Minimal prenatal care for Junior • Single artery umbilical cord in utero • 31 weeks in, became dehydrated and went into labor Overcoming Untrue Defenses

July 11, 2012: • Junior is born at 32 weeks = preemie • Junior weighs 3 lbs 14 oz • Hospitalized for 1 month posy birth (feeder & grower) • Blood reported in Junior’s urine • Potential renal disease? • Small subepyndemal hemorrhage post-birth • Two ultrasounds of head used to diagnose/monitor Overcoming Untrue Defenses October 6, 2012: • Junior is admitted to Children’s Hospital of Wisconsin • Actively seizing • Subdural bleeding on the brain - acute • 12 fractured ribs – approx. one week old • CML fractures of left radius and right ulna • Bruise – under right eye Overcoming Untrue Defenses

The “stories” begin: • Fell off the bed – one month ago = fine • Car seat – kicked over while inside = fine • Bumped his head during bath 10/4 = fine Father was consistent: • Junior was only cared for by: • Mother and • Father • Mother • Confirmed this fact Overcoming Untrue Defenses

The Confession: • Father admits to • Squeezing son one week prior to hospitalization • Shaking & dropping son a day prior to hospitalization Case closed(?) Overcoming Untrue Defenses

The Confession: • Mother was also in custody being interrogated • Father – repeatedly told son’s condition was grave • Initially repeatedly denied causing any harm • “I will say I shook him, just let her go” • Talks about Junior as medically fragile • Best parts of confession: • Asks to turn property over to mother • Says 65 + times, “I’m so sorry, my son” Overcoming Untrue Defenses

October 6, 2012: • Junior admitted to Children’s Hospital of Wisconsin October 12, 2012: • David Allen – charged with abuse and neglect of Junior April 12, 2013: • Junior – succumbs to his injuries and passes away • Milwaukee ME - homicide April 25, 2013: • David Allen is charged with homicide Overcoming Untrue Defenses

Over the next two plus years…. Overcoming Untrue Defenses Dr. Waney Squier MD • Neuropathologist from Oxford – 24 years • Specialization in infant brain development • Fellow • Royal Collage of Physicians • Royal College of Pathology • Testified over 160 times (60% for the defense) • Hong Kong, Sweden, Holland, United Kingdom, Australia, and USA Allen case: • Pathology – consistent with cortical venous thrombosis Overcoming Untrue Defenses

Dr. Julie Mack MD • Radiologist – Penn State • Assistant Professor of Radiology • Harvard Medical School Allen case: • Radiological imaging – • Fluid collection – “likely” consistent with chronic fluid collection • Acute blood – low volume and “serpentine” in configuration = consistent with cortical venous thrombosis • Fractures – consistent with bone fragility of prematurity – cupping and spurring of bone ends Overcoming Untrue Defenses Dr. Charles Hyman MD • Pediatrician – through 1999 • Medical Professor – Loma Linda School of Medicine • Independent Forensic Consultant – 1988 – present • Claims – to have testified 45 + times, 70% for state • “Bone expert” Allen case: • Junior suffered from transient bone fragility • Fractures – result of normal care and handling • Files a 135 page report Overcoming Untrue Defenses Dr. Joseph Scheller MD • Pediatric Neurologist • “Extensive” experience, over 20 years, evaluating head injured children Allen case: • Significant head circumference change from birth to hospital admission – consistent with chronic fluid • Acute blood – small volume, consistent with cortical venous thrombosis at multiple sites Overcoming Untrue Defenses

Dr. Lawrence White PhD • Beloit College of WI • Social Psychology – interests in • Eye witness identification – reliability • False confessions and police interrogations • Child suggestibility • Consulted on 250 cases, testified in 40+ Allen case: • Many components of Allen’s interrogation that would establish high susceptibility for a false confession • Length of interrogation, Allen’s intelligence, police tactics Overcoming Untrue Defenses

Dr. Shaku Teas MD • Forensic Pathologist Cook County 1977-1991 • Assistant Professor – Pathology – University of Illinois • 1980 - present (inactive) • Has conducted thousands of autopsies, including over 800 autopsies on the bodies of children Allen case: • The ultimate cause of Junior’s collapse is unknown, but pathology is consistent with cortical venous thrombosis • Fractures – consistent with rickets Overcoming Untrue Defenses

The “Frequent Flyers” • Dr. Waney Squier: • Changed her position on SBS around 2004 • Since that time, has testified for the defense on AHT where shaking is included in the mechanism • General Medical Counsel – Fitness to Practice proceedings • 6 cases of AHT where Squier testified for the defense • In all 6 cases, Squier is charged with provided dishonest and misleading testimony • One particular example, Dr. Squier was found (court’s decision) to misrepresent material facts about another case to support her position that choking alone could produce injuries consistent with an AHT diagnosis • Has testified to the Geddes hypothesis – which Geddes has rejected Overcoming Untrue Defenses

The “Frequent Flyers” • Dr. Julie Mack MD • Often works in tandem with Dr. Squier • Has written multiple medical articles with Dr. Squier • Does mammograms 9 – 5, NOT pediatric radiology • Testified previously for same defense firm in WI • SLEPT OVER at one of the defense attorney’s homes during trial! • Just finished testifying for defense in AP’s son’s murder trial • Child choked on a fruit snack • Own hospital does not seek her consult on AHT cases Overcoming Untrue Defenses

The “Frequent Flyers” • Dr. Charles Hyman: • Not a radiologist or a orthopedist • Knowledge and diagnosis of bone fragility disorders is not clinically based • Has presented for National Child Abuse Defense & Resource Center • Reports – largely “cut & paste” jobs using medical research articles out of context • Example – the Garcia article… Overcoming Untrue Defenses

The “Frequent Flyers” • Dr. Joseph Scheller: • Lead Paint cases – has testified over 100 times as an expert witness against children claiming harm from lead paint ingestion • Is not used by his own hospital to consult on child abuse cases • Has only testified for the defense in AHT cases • Does NOT believe shaking, alone, can cause AHT Overcoming Untrue Defenses The “Frequent Flyers” • Dr. Lawrence White: • Has only testified for the defense, and on a multitude of issues • Will concede to the literature and studies on false confessions: • Most documented case of false confessions: • Suspect is very young – Allen was 31; • Interrogation lasts for average of 18 hours – Allen’s was a total of 3.5; • Suspect often has significant deficits – Allen had ADHD; • Minimal police experience – Allen had multiple prior arrests/convictions (8 +) Overcoming Untrue Defenses

The “Frequent Flyers” • Dr. Shaku Teas – • Submitted a report in a post conviction matter death was strangulation – could not opine that person intended to strangle the victim • Defers to other experts, her opinion is only as sound as theirs Overcoming Untrue Defenses • The Defense Theory: • Junior had an extra axial fluid collection that slowly grew over time; • Sustained – cortical venous thrombosis at multiple sites on and within the brain • Cortical venous thrombosis causing edema and collapse • Retinal Hemorrhaging – could be birth related, or from increased intracranial pressure • Fractures – result of transient bone fragility • Allen falsely confessed so that “Junior’s” mother could be at his side Overcoming Untrue Defenses

• The Defense Themes: • AHT is a controversial diagnosis • Shaking alone cannot produce AHT • No significant external injuries or bruises – would expect bruising if this was abuse • There is a non-abusive medical explanation here…. Overcoming Untrue Defenses

Why our expert medical evidence is reliable! • Part of treatment team, working with and consulting with others • Not paid to render an abuse diagnosis • Often rule out child abuse in a significant number of cases • Child abuse diagnosis – increased time preparing and testifying in court, consulting with, educating law enforcement and prosecutors • Considers the ENTIRE clinical picture and history of the patient • Defense – did not consider confessions or evolving history Overcoming Untrue Defenses E = Expected/Common U = Uncommon I = Unexpected finding Junior ’s Injuries Possible Causes Radi us Cause Considered Hypoxic- Ischemic Cervical Spine 12 and Ulna (yes or no) Encephalop athy Diffuse Primary Cephalo- Cerebral Contusio Ligame ntous Healing Rib CML Eye Brain Injury hematoma on SDH ns RH injury Fracture fract ures Bruise vertex Child Abuse Y E E E E E E E E E E Accidental minor E I (unless trauma Y I I U U I I bone I I disease) BEH with minor trauma Y I I I U I I I I I I

Metabolic disorder e.g. GA1 Y U I I U I U I I I I Seizure Y U I U I I I I I I U Birth/chronic SDH with re- bleed Y I I I U I I I I I I Increased ICP Y U I I I I U I I I I Infection E Y U (encephali tis) I U I U I I I U

Thrombosis Y E (focal) I (focal I U I I I I I I only)

Bleeding disorder Y I I U U I U I I I E

Metabolic bone disease Y I I I I I I I U I I Overcoming Untrue Defenses Overcoming Untrue Defenses Venous Thrombosis • Multiple causes including trauma • Usually affects large veins; rare in small veins • Occurrence rate of .0000167 per one study • Presenting symptoms tend to be neurologic – seizures, change in level of alertness • Rarely can cause extra-axial hemorrhage Overcoming Untrue Defenses

Reasons for Excluding Thrombosis as a Cause of Junior’s Findings: • No thrombosis noted by neuroradiologists involved in treating Junior • Implausible that multiple small cortical veins would all clot at the same time unless there was trauma • Cortical vein thrombosis rarely, if ever, causes subdural hemorrhage • Would not explain severe, catastrophic brain injury • Does not cause retinal hemorrhage, long bone and rib fractures, facial bruising, cephalohematoma, cervical spine ligamentous injury Overcoming Untrue Defenses Junior’s Bone Health • No evidence of osteopenia on X-rays • Lab tests: • Alkaline Phosphatase 362 IU/L Slightly elevated with upper normal 320; elevation often seen with healing fractures • Phosphate 4.4 mg/dL Normal • Magnesium 2.6 mg/dL Normal • Ionized Calcium 5.16 mg/dL Normal • Vitamin D (25 Hydroxy) 31 ng/mL Normal • Intact PTH 69.7 pg/mL Slightly elevated with upper limits of normal 53.5 pg/mL (PTH can be elevated early in the course of care for people with traumatic brain injury and fractures – Trentz, OA, et al. Influence of brain injury on early posttraumatic bone metabolism. Crit Care Med 2005;33(2):399-406) Overcoming Untrue Defenses

Maguire 2011 – Systematic Review • Analyzed 6 comparative studies of abusive and non-abusive head trauma in < 3 y/o children • Presence of bruising, seizure, apnea, long bone fracture, retinal hemorrhage and rib fracture – 100% predicted probability of AHT • Presence of all of the above except bruising – 100% predicted probability of AHT • Presence of all except seizure – 100% predicted probability of AHT • Presence of all except apnea – 100% predicted probability of AHT • Presence of all except long bone fracture – 100% predicted probability of AHT Abusive Head Trauma

Important Perspectives: • Extremely tough, emotional cases • Circumstantial cases – child abuse is a crime that occurs behind closed doors – two witnesses, abuser and victim •Sound investigation + the medical evidence allows us to give the victim a voice in court

Overcoming Untrue Defenses Thank You!!! Matthew J. Torbenson Deputy District Attorney Office # 414-278-4638 Cell # 414-915-9622 [email protected]