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Prosecution Questions Cardiologist in Chauvin Trial. Aired 11- 11:30a ET

Aired April 12, 2021 - 11:00   ET

THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.

DR. JONATHAN RICH, CARDIOLOGIST: In the intensive care unit.

[11:00:03]

The second part of my clinical duties is I see patients in the outpatient setting in the office, in the clinic. Where I evaluate, diagnose, and treat patients.

Close to 50 percent of the patients, the new ones that I see in the clinic, are referred by other cardiologists because these patients can sometimes have pretty complex medical conditions.

And then the third part of my clinical work is I perform procedures in a procedural suite we call the cath lab, where I measure pressures inside the heart and inside the lungs. And sometimes I will also take small biopsy samples of the inner lining of the heart for diagnostic purposes.

JERRY BLACKWELL, PROSECUTING ATTORNEY: Given that you deal with a number of patients who could be really sick, do you ever have patients that will pass away?

RICH: So I work with a tremendous team at Northwestern and my colleagues save countless lives. But unfortunately, many patients do die.

BLACKWELL: Do you ever have any involvement in determining the cause of death?

RICH: Oh, yes I do.

BLACKWELL: Could you explain?

RICH: Sure. One of the most important parts of my job, in fact, is to determine what's wrong with a patient including if they do actually die, how did they die? And so, there are a number of ways in which I participate in that role of figuring out what happened to a patient, how did they die?

BLACKWELL: Are you involved in any hospital committees that have as their purposes determining the cause of why people die or pass away?

RICH: Sure. I do. So outside of being in the trenches, taking care of the patients at the bedside and figuring out what's going on and trying to discern what might have happened, I also participate on a committee. That means regularly and what we do is we review all of the cases in the cardiac intensive care unit. We look at any near deaths and any deaths.

And we review looking at the medical chart and all the evidence to try to figure out what might have happened for quality purposes to figure out if there was something else we could have done, and also to improve just our overall knowledge of the field.

BLACKWELL: Do you have experience with patients who sometimes pass away during what is called clinical trials?

RICH: Yes. So I also participate in clinical trials where we try to determine if a certain medication or a certain device is worthy of being approved to help patients. In the course of clinical trials, sometimes there are deaths.

And so in my role, I have sat on committees and our purpose on that committee is to review any death that's do occur. Look at all the evidence to figure out, number one, why did the death happen? And number two, sometimes this is one of the more important parts to distinguish was it a cardiac cause or was it for a reason that is not related to the heart?

BLACKWELL: We're bringing this further home to this case. Do you have experience with cardiac patients who die from what we call low oxygen?

RICH: Most certainly I do.

BLACKWELL: Could you tell us about that?

RICH: Yeah. So because I am a cardiologist who takes care of patients in the intensive care unit, having low oxygen levels is not uncommon. A lot of disease processes can cause it. And low oxygen levels can be very detrimental.

Some of our patients require ventilators and respirators. And so in the course of caring for the patients, sometimes they succumb to their illness because their body is not able to get enough oxygen.

BLACKWELL: Do you ever have to determine cause of death in the heart transplant context?

RICH: Yes. So in the field of heart transplant, what happens is when you get a phone call that somebody has died and they want to be an organ donor. So what I need to do is look at the case from afar, but try to look at all the records as closely as possible to really sort out how that individual died and if there's any issues related to their heart or other parts of their body to make absolutely sure that that heart would be a good match for my patient who we're trying to help.

And so that's another element where you have to be really meticulous as you go through. You don't want to miss anything here, right? I mean the stakes are way too high.

BLACKWELL: We've heard from a couple of pathologists in the trial. Does your job require you to work with pathologists?

RICH: Yes, it does.

BLACKWELL: In what way?

[11:05:01]

RICH: So I work with cardiac pathologists closely, more so than other general cardiologists. I mention that I take biopsy specimens, the inner lining of the heart, and I send those specimens to the pathologist to review under the microscope. We participate in conferences that include reviewing autopsies.

One of the things that I have learned over the years and I've been taught this by the cardiac pathologies is why they can look under the microscope and give us very important information, I work with a world renowned cardiac pathologist who reminds me nearly every day, please tell me as much clinical information as you can. Put it in clinical context because how I diagnose and interpret what I see under the microscope is very much influenced by the clinical story.

And so we work very closely together because my pathologist looks under the microscopes and sees the tissue at that level. I can provide all the clinical information, the timelines, et cetera, so we can truly get it right.

BLACKWELL: Just a little bit more background, Dr. Rich. Have you published in the field of cardiology?

RICH: Yes.

BLACKWELL: Can you characterize what kinds of publications and how many?

RICH: Sure. So to date I've published more than 200 combined abstracts, original manuscripts, reviews and book chapters. And the topics have been pretty wide-ranging in the field of cardiology from coronary artery disease, hypertension which is high blood pressure, congestive heart failure and other disease actually called pulmonary hypertension.

BLACKWELL: And what is pulmonary hypertension?

RICH: Pulmonary hypertension is high pressures that are specific to the blood vessels in the lungs. All right? So when the blood flows from the heart to the lungs, the pressure is high in those blood vessels, we refer to that as pulmonary hypertension.

BLACKWELL: Doctor, would you generally describe for the jurors what is cardiology as a science?

RICH: Sure. So cardiology is the study of the heart, the most basic level. It's the study of how the heart functions, what happens when the heart develops disease. Pretty much everything heart related and how it interacts with the rest of the body in order to sustain life.

BLACKWELL: How do you go about assessing a patient with a cardiology issue?

RICH: Sure. So when you assess any patient with or without a cardiology issue, but in this context, a cardiology issue, you typically begin by meeting the individual in the office, taking the history, doing a detailed physical examination, reviewing all the medical records and the charts, looking at past procedures, tests they may have had, and sometimes speaking to other colleagues who you are caring for that patient with together, and then sometimes ordering your own tests for evaluation and diagnostic purposes.

BLACKWELL: Are some of your patients referred then from other cardiologists?

RICH: Yes. Because of my specialty in advanced heart disease, close to half the patients who are -- I'm seeing in at the office as new patients have been referred to me by other cardiologists. Typically in the community or in the region, and I will assist them in consultation to figure out what is going on and what we need to do to help that individual.

BLACKWELL: In the ICU, do you take care of patient who's have problems beyond the heart?

RICH: Yes. So, you know, it's interesting. As a cardiologist, I think part of the important reasons why they require of us to do that internal medicine residency training is because no organs work in isolation. And so my patients who have heart disease who also require the intensive care unit, they will usually have issues with many other organs, their lungs, their kidneys, sometimes brain, the liver.

And so you really have to be adept and have a really good understanding of not just the heart but all the organs of the body and really how they interact.

BLACKWELL: Dr. Rich, let's talk about your role in this litigation? How did you become to be involved in this case?

RICH: I was contacted by the state of Minnesota and I was asked as a cardiologist if I could review the facts of this case to help determine how Mr. George Floyd died.

BLACKWELL: Have you been compensated by the state for the bulk of the work you've done on this case?

RICH: No, up -- up until my time here now at trial, I have not received compensation.

BLACKWELL: And why not.

[11:10:02]

RICH: Well, probably for a couple of reasons. Mostly I felt that my job as a cardiologist could really help inform the facts of this case. Every year I take on a number of professional activities without compensation.

I actually think it's a duty of our field. And so in this case, I felt I could make a meaningful contribution to the medical field.

BLACKWELL: So for your compensation for your time while here at trial, you are being compensated at $1,200 a day?

RICH: Yeah, $1,200 a day while I'm missing work back at home.

BLACKWELL: So, let's talk about then your opinion, or opinions in this case. Before we do, can you tell us what work you did? What did you review before forming opinions in the case?

RICH: Sure. So I was provided with a lot of evidence to look through. But mostly, I looked through the medical records, interviews, all the videos that were provided to me and the autopsy report.

BLACKWELL: Did you review some journal articles as well?

RICH: Yeah. As I was formulating my opinion and creating my expert report, I also looked up journal articles and embedded them into my report for references.

BLACKWELL: Have you formed any opinions in this case, to a reasonable degree of medical certainty as to the cause of Mr. Floyd's death?

RICH: Yes, I have.

BLACKWELL: Would you tell us your opinion or opinions?

RICH: Sure. In this case, Mr. George Floyd died from a cardiopulmonary arrest. It was caused by low oxygen levels and those low oxygen levels were induced by the prone restraint and positional asphyxiation that he was subjected to.

BLACKWELL: Let's discuss your opinion, Dr. Rich, and let's start with a general discussion of the circulatory system and the heart.

So I'd like to talk about the right side of the heart, left side of the heart and also the alveoli. Would you start off and just tell the jury, just remind them, what are the alveoli?

RICH: Sure. So you might remember hearing about this. But the alveoli are the grape like structures that are at the very bottom of the lungs. The alveoli is where the gas transfer occurs. Meaning that is where when we take a breath in, oxygen gets across the lungs and into bloodstream, and then the carbon dioxide that needs to leave the body crosses that same barrier into those alveoli so when we take our deep breath out, that's how the carbon dioxide is removed.

So, it's the alveoli of the lungs that serve that purpose.

BLACKWELL: Again, what does a heart do in the body?

RICH: What does the heart do?

Well, the heart is the major pump, of course, of the body. The best way to think of the heart in my view is to actually think of it as two pumps, sort of a right side and a left side. So if we start with the right side of the heart, after all that blood

got pumped to the body and coming back to the part, blood is always returned to the right side of the heart. So this is now blood that presumably does not have much oxygen in it and it needs to get more oxygen.

So the right side of the heart, its job is singular. It is to pump blood to the lungs to those alveoli. So, the blood when it heads towards the lungs, it can pick up that oxygen that it doesn't have right now and it can deliver carbon dioxide and other acids and waste products to be expelled from the body.

Once that blood from the right side of the heart has picked up the oxygen that it needed, it sends it to the left side of the heart. Now the left side of the heart gets all the glory. Because it is what then pumps all of that oxygen and nutrient rich blood to the entire body, meaning, to the lungs, to the kidneys, to the brain, to our muscles, to deliver oxygen, because every organ, every tissue that body needs oxygen in order to function. And then once that process occurs, it repeats back to the right side and so forth.

BLACKWELL: And what happens if the lungs can't deliver sufficient oxygen to the heart? That is if there is a low oxygen situation?

RICH: Okay. Well, the heart is only as good as the fuel that it is provided with. So, when that right side of the heart sends blood to the lungs and says, okay, can I have some oxygen please?

If there is no oxygen there or not enough oxygen there, there is nothing the heart can do to extract more from the lungs. So it has to take that deoxygenated blood that, that blood that does not have enough oxygen and pump it to the left side of the body.

The left side of the body says, OK, this is what I have.

[11:15:03]

This is what I'm going to pump now.

So, what ends up happening is if the lungs don't give enough oxygen to the body, the heart that has to pump insufficiently oxygenated blood to the tissues of the body and that's when problems occur.

BLACKWELL: Returning to your opinion, cardiopulmonary arrest caused by low oxygen induced by positional asphyxia. What caused the low level of oxygen in the case of Mr. George Floyd?

RICH: Well, in his case, it was the truly the prone restraint and positional restraints that led to his asphyxiation. In a nutshell, he was just simply unable using all of his muscles and respiration, his chest wall, what we call accessory muscles of respiration, which are extra muscles that will be triggered in the event that you're having trouble breathing. He was trying to get enough oxygen and because he was unable to because of the position he was subjected to, as we just discussed, the heart thus didn't have enough oxygen either which then means the entire body is deprived of oxygen. BLACKWELL: So low oxygen induced by positional asphyxia. Did you

consider other possible causes of Mr. Floyd's death?

RICH: Sure. I tried, of course, to be as thorough as possible. I focused mostly on two other potential causes. Number one, is whether there could have been a primary heart contribution to George Floyd's death. And the second was whether a drug overdose could have caused his death.

BLACKWELL: So, Doctor, would you tell the jury what is a primary heart event?

RICH: Sure. A lot of things can injure the heart. For example, if you do not take in enough oxygen, that will injure all of the organs including the heart. When I use primary heart event, I mean something that originated from the heart itself.

So, for example, a heart attack, all right? One of the arteries of the heart just subtly got blocked completely and a heart attack occurred. Or the heart just without any explanation, nothing else secondary inducing it went into a serious ventricular arrhythmia, OK? So, the bottom part of the heart, the part that we were talking about that needs to pump blood to the body went into a chaotic rhythm on its own.

If any of those things happened, then I would consider that a primary heart issue. Not being caused or secondary to something else.

BLACKWELL: So you consider whether or not Mr. Floyd might have passed away from a primary heart event or a drug overdose. Did you reach an opinion or conclusion to a reasonable degree of medical certainty as to whether either those two causes explained Mr. Floyd's death?

RICH: Yes, I did.

BLACKWELL: Would you tell us your opinion?

RICH: Sure. After reviewing all of the facts in evidence of the case, I can state with a high degree of medical certainty that George Floyd did not die from a primary cardiac event and he did not die from a drug overdose.

BLACKWELL: Thank you, Dr. Rich.

Would you tell us what evidence or facts, documents, what did you look at to help you to reach that conclusion about primary heart event and/or drug overdose?

RICH: Sure. The three aspects of the evidence that I spent the most time reviewing were Mr. George Floyd's medical records, the videos at different angles from the day that he died on May 25th, 2020, and the autopsy report.

BLACKWELL: So the medical records, videos and the autopsy report.

RICH: Yes. BLACKWELL: Let's start with the medical records then of those three.

Would you tell the jury what you were looking for in the medical records?

RICH: Sure. So you get the medical records. Usually pretty thick. But you take it one page at a time.

And at the outset I was looking to see if he had been diagnosed with any medical conditions. Sort of the first step, you know, kind of what you do with a patient in the office. Sort of what medical problems do you have? So, I was looking to see initially what diagnosis George Floyd may have previously been diagnosed with.

BLACKWELL: And what were your takeaways then from having looked at the medical records and done this assessment?

RICH: So, at that level, I felt pretty confident that Mr. Floyd had three medical problems. Number one, he had hypertension, high blood pressure.

[11:20:02]

Number two, it appeared to me that he may have suffered from anxiety. And, three, it looked like he also struggled with substance abuse.

BLACKWELL: Other than those three conditions, did Mr. Floyd have any diagnosis of heart disease while he was still alive?

RICH: No, he did not.

BLACKWELL: So you said you looked at the medical records not only for diagnosis or pre-existing conditions, but also for evidence of medical encounters?

RICH: Correct.

BLACKWELL: And by that you mean hospital visits, clinics, et cetera?

RICH: Emergency room visits, exactly.

BLACKWELL: What did you find in that regard?

RICH: So this is in my opinion was a really important part of the review as well. Because every time Mr. Floyd had an encounter with a medical professional, I view that as an opportunity to see if there was any signs, symptoms, whatsoever, even subtle, that could have indicated, for example, that he had anything going on with his heart.

And so, at the emergency room visits, he had one prolonged hospitalization. I really tried to take a look at everything. I looked at any opportunity I could to see if he ever complained of chest pain which he did not. Palpitations, which is a fluttering sensation of the heart.

I review all of the documented physical examinations of his heart so see if there were any abnormalities noted. There were not number murmurs, nothing found. I looked at all of his labs that get sent to see if there were ever any cardiac markers of injury which he did not have.

I reviewed his EKGs and his other tests. I tried to be as thorough as possible because I view this as -- I view what we do as a clinician in some ways as actually being a bit of a detective. And our job is to try to figure out what might be going on even if it it's not overtly stated so in the chart.

BLACKWELL: Would you tell the jury, by the way, what an EKG is?

RICH: Sure, of course. So, an EKG is shorthanded for an electrocardiogram. That's the test where you see people put the little sticky things on the chest. We call them electrodes.

And what an EKG basically is, is an opportunity at the surface level of the chest but the technology is so fascinating, it can give you a glimpse into the heart itself to see a whole host of things, including is there any evidence of any heart injury happening now or previously? And any abnormal heart rhythms? A whole host of other information that we can get from the EKG at that snapshot in time.

And then sometimes what we'll do is repeat the EKGs down the line so we can compare and contrast and see if anything changed.

BLACKWELL: So you looked at all of this medical information on Mr. Floyd including the EKG. Did you note any cardiac problems that related to Mr. Floyd?

RICH: I noted no cardiac problems in the medical records as far as Mr. Floyd's medical condition was concerned, including everything I mentioned, EKG, even a time where they put him on a continuous cardiac telemetry monitor which they'll do sometimes just to see beat to beat if anything is going on. I reviewed that as well.

BLACKWELL: Did you see any evidence of Mr. Floyd having had any abnormal heart rhythms?

RICH: His EKG showed absolutely no abnormal heart rhythms. The cardiac telemetry I mentioned that he had on for a few days, it did have on rare occasion something you call a PVC, which is a very normal finding. I don't know if anyone ever felt their carotid flutter for a second or something like that. It happens to all of us.

But absolutely no ventricular arrhythmias for the duration of the time he was on the monitor.

BLACKWELL: And PVC is not a kind of plastic pipe. You mean pre ventricular contraction.

RICH: Sorry. Yeah. Premature ventricular contraction, sometimes people refer to it as a skipped beat. A really normal phenomenon. If you drink a little coffee or anything else, you're sleep deprived, it's pretty common for us to have those, totally normal finding. Something that none of you should be concerned about if you feel that from time to time. BLACKWELL: So, did you find any evidence that Mr. Floyd had any

negative heart condition?

RICH: There was absolutely no evidence to suggest that at all.

BLACKWELL: Dr. Rich, isn't high blood pressure an abnormal heart condition?

RICH: So thank you for that question. I think that's an area of confusion sometimes. So high blood pressure in and of itself is not a heart condition.

High blood pressure occurs for basically two reasons.

[11:25:01]

Number one, high blood pressure originates in the blood vessels of our bodies. Oftentimes it is genetically determined why our blood pressure might start to go up overtime.

If you have a strong heart, you can also generate high blood pressures and so those two in combination.

So why -- well, I'll pause there and can explain more.

BLACKWELL: Well, did Mr. Floyd have a strong heart?

RICH: So every indicator is that Mr. Floyd had actually an exceptionally strong heart, because he was able to generate pressures of upwards of 200 millimeters of mercury on some occasions.

We talked a little earlier about my role as a heart transplant cardiologist. One of the problems with patients when they need a heart transplant is the exact opposite. Their hearts are so weak, they can't generate a high blood pressure. The top number might be 80.

The reason why high blood pressure though is important and it is important to treat high blood pressure is because over time if high blood pressure goes untreated, 10, 20, 30 years, the impact of that high pressure on the heart can eventually start to become a bit of a problem.

So the way I explain it to my patients who come into the office and I talk to them about treating their high blood pressure, is I say remember the heart is a muscle. So if you go to the gym and you pick up a couple of dumb bells and you start to lift the weights, initially it feels fine. In fact, you probably get a little stronger.

Your heart -- excuse me, the muscle will likely get even a little thicker, a little bigger which is exactly what it is supposed to do. And initially that might actually be a really good thing.

But if I came back, you know, ten years later and said how is it going? You'd say, man this is getting pretty tough. And then the muscle can start to tire out. So we do want to treat high blood pressure. I can't emphasize that

enough. High blood pressure should be treated. But high blood pressure in and of itself is not a heart condition.

BLACKWELL: So we talked about your review of the medical records. You also looked at video footage in forming your opinions. Would you tell us what you were looking for in the video footage that you examined?

RICH: Sure.

BLACKWELL: So my approach to the video initially was sort of similar to my approach of the medical records. Meaning, I wanted to just do some cursory inspection, observation, basic stuff. What did Mr. Floyd look like? Was Mr. Floyd talking? And if he was talking, was he talking clearly, coherently? Answering questions appropriately?

Did I notice any evidence of abnormal physical exams on the video actually? I was trying to look for as well.

When Mr. Floyd was walking, did he appear like he was walking without difficulty or was it looking like he was perhaps with low blood pressure and maybe going to fall down? I was listening for any opportunity I could to hear him say I'm having chest pain or the palpitations or fluttering sensations.

But basically doing what I do when I assess any person for a possible medical problem. I was looking for any and all of those possible subtle signs.

BLACKWELL: So, this is video footage from Mr. Floyd's encounter of May 25th of last year?

RICH: May 25th, that's correct.

BLACKWELL: Were you focused on things that would give you any insights into his ability to breathe?

RICH: Yes, of course.

BLACKWELL: And the ability to expand what you refer to as his chest wall?

RICH: Yes.

BLACKWELL: Again, to refresh the recollection of the jury, what is the chest wall?

RICH: Yeah, so the chest wall which I'm trying to sort of show with you my hands here, basically makes up the bones and the muscles of the entire rib cage. And it might have been explained previously to you. But the chest wall and the muscles and how they interact along with the diaphragm muscle inside are the key structures that the deferment if someone is able to take in enough air and able to get enough out.

So if there is -- for example, the lungs can be working okay, but if the chest wall is diseased, if the muscles associated with the chest wall aren't able to contract and move and do their job, enough oxygen can't get in that way either.

BLACKWELL: So, Doctor, in our covid-19 world, do you make clinical assessments of your patients in your work life by video?

RICH: Yes, that is -- that is one of the transformation that we have needed to adapt to this past year. We're getting back to now seeing most of our patients in person.