Friday, May 5, 2017

Death by febrile seizure?

As the lawyers for Joaquin Rams began to build their case Wednesday that his toddler son suffered a fatal seizure, and wasn’t drowned by his father, a pediatric neurologist testified that febrile seizures could be fatal but admitted he’d never had a patient who died of one.

Then the judge in the murder trial took over.

Circuit Court Judge Randy I. Bellows displayed his deep knowledge of the case, and his experience as a prosecutor and public defender, citing events and documents that haven’t even been discussed in Rams’s murder trial yet. He quizzed the expert witness for more than a half-hour, finally drilling down to one of the most vital questions of the case: Could 15-month-old Prince McLeod Rams have had a fever that caused his father to exclaim “he’s really hot!” in the background of the 911 tape reporting the boy’s collapse, and then be cold to the touch when paramedics arrived five minutes later?...

“That’s exactly right,” said Joseph Scheller, a former pediatric neurologist at Children’s Hospital in Washington now in private practice. “When the body feels something drastic is going on, it shunts blood away from the hands and feet to the main organs. so that may have been going on as well…To me, the fact that Prince feels cold to the touch means there has been a really significant brain injury.”

Bellows asked, “How far back would the brain injury have to occur” to cause a drastic temperature drop?

“If the child’s not breathing,” Scheller said, “it could take only a few minutes.”…

Bellows is deciding a capital murder charge against Rams without a jury, and so may have felt that when neither side asked the questions he wanted answered, he asked them himself, as he has throughout the trial. Prosecutors allege that Rams, 44, drowned Prince in October 2012 in order to collect $524,000 in life insurance policies he’d taken out on the boy shortly after he was born in 2011. The judge’s questions were crucial because the medical examiner ruled Prince had drowned, and she testified that she disregarded the possibility of a febrile seizure because the boy was cold when paramedics arrived, meaning he couldn’t have had a fever as Rams told police.

So Bellows took the trial’s first deep dive into Prince’s medical history, particularly a series of seven febrile seizures starting in June 2012, citing doctors’ and paramedics’ notes which pointed out that the boy sometimes stopped breathing during a seizure and that his mother also had febrile seizures growing up…

Scheller was the first of several defense witnesses who will attempt to refute the prosecution’s case that Prince drowned. He started off by explaining that when electrical impulses in the brain are disrupted, they cause seizures, which can be minor and not particularly noticeable, or major and result in prolonged convulsions. Febrile seizures, caused by a fever and occurring only in small children, are typically benign and not usually indicative of epilepsy or a serious brain condition.

But they’re not always benign, Scheller said. “At least several times a month, there was a child with febrile seizures who was intubated in the emergency room” during his time at Children’s Hospital, Scheller said. “Probably a few times a month, a child with febrile seizures was admitted into intensive care. The official term for it is benign febrile seizures. Like anything that’s benign, it can turn sour and cause very very serious problems or even death.”…

Scheller noted on cross-examination by Chief Deputy Commonwealth’s Attorney James Willett that he no longer practices at Children’s Hospital and spends 60 percent of his time consulting and testifying in child brain injury cases. Scheller said he had treated hundreds of children with febrile seizures. But, Willett noted, “you can’t say with medical certainty that you’ve ever treated a child that died from a febrile seizure?” Scheller replied, “I can’t say I recall specifically.”…

On Oct. 20, 2012, Prince was on a visit to his father’s home in Manassas City, Va., when he was put down for a nap. Records show he had suffered his seventh febrile seizure two days before, and that he was “apneic” during a previous seizure in September. “If a child has a history of being apneic,” 

Bellows asked, “is it more likely if he has another febrile seizure he will also become apneic?”

“Yes,” Scheller said.

“Do you see this of any relevance to whether febrile seizures were a factor in his death?” the judge asked. “Is that relevant to your analysis?”

“Yes,” Scheller said, “because there are infants that have seizures that manifest only during sleep with apnea.”

“Could it be seizures not visible to the naked eye with anything other than apnea?” Bellows asked.

“That is possible,” Scheller answered.

Bellows noted that Prince’s blood was found on his crib sheet in his father’s home on Oct. 20, after Rams swept into his room, claimed he saw the boy seizing and rushed him to the bathtub and began splashing water on him to cool him down. He also observed that in Prince’s seizure on Oct. 18, medical records showed “blood came out from [Prince’s] mouth.” Scheller said blood in the mouth was “very common” after a febrile seizure, and more likely to be caused by blood leaking from capillaries as the body reacts to lack of oxygen, rather than someone biting their tongue. “I believe it’s a hypoxic event,” Scheller said of the blood found on Oct. 20…

Bellows referred to the 911 call and asked, “As a result of a febrile seizure, could an individual go from a parent indicating he’s really hot to medical personnel indicating he’s cold to the touch in a period of about five to seven minutes?” Scheller said he thought the observation that Prince was cold showed he had suffered a brain injury, and “the inability of the brain to regulate temperature. I’m not at all surprised by that.” He said the intensity of Prince’s previous seizures did not show a trend, but six seizures in six weeks was “a lot of seizures in a short time.”

When the judge was finished, both sides sat stunned. He asked if they had follow-up questions. Robin only asked one, if blood in Prince’s nose — noted by the paramedics — made it likely to be a “hypoxic event” involving lack of oxygen to the brain. Scheller said yes. Willett stood and asked Scheller, “Drowning is a hypoxic event, is it not?” Scheller said yes. “As well as suffocation?” Willett added. “Yes,” Scheller said.

https://www.washingtonpost.com/news/true-crime/wp/2017/03/22/rams-trial-day-6-judge-questions-witness-at-length-on-deceased-boys-febrile-seizures/?utm_term=.1d7cb70dc46b 

3 comments:

  1. Four and a half years after 15-month-old Prince McLeod Rams was found unresponsive, cold and without a pulse by paramedics responding to a 911 call, his father was found guilty of his capital murder. Judge Randy I. Bellows, hearing the case without a jury in Prince William County Circuit Court, explained his decision April 13 in a 62-page opinion that methodically sorted through the evidence and definitively answered questions surrounding the case. No, the judge concluded, the boy did not die from a febrile seizure or any natural cause, but was drowned or suffocated by his father — who stood to benefit from more than $500,000 in life insurance...

    Ms. McLeod, as she wrote recently in a Post essay, faults the family court system that made her son vulnerable to harm. She had sole legal and primary physical custody of her son and fought fiercely to prevent Mr. Rams from having unsupervised visits. But a Montgomery County Circuit judge allowed them, and Prince died on the fourth one. “Parents,” Ms. McLeod wrote, “should not have to prove beyond a reasonable doubt that the other parent is dangerous.”

    Part of the problem, according to lawyers experienced in custody cases, is an inherent bias, even distrust, of parents — in most cases women — who without physical evidence raise safety as a reason to limit or prevent contact with the other parent. “I hate it when I have to tell a client who genuinely fears for her child that she risks appearing as an alarmist and alienating the court,” one attorney told us. “I hate it even more when I have to tell her she has no choice but to abide by the court’s order.”

    https://www.washingtonpost.com/opinions/a-childs-father-killed-him-for-life-insurance-after-the-conviction-theres-still-more-to-learn/2017/04/30/06e9b41c-2a9f-11e7-b605-33413c691853_story.html?utm_term=.2a6d72ee964b

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  2. Dr. Shlomo Shinnar, a professor of pediatric neurology at Albert Einstein College of Medicine in New York, told the court he believes beyond a “shadow of a doubt” that a febrile seizure did not contribute to Prince’s death. The doctor also said the scenario Rams described leading up to Prince’s death “does not make sense medically,” because he couldn’t have witnessed the toddler having a seizure if he already had cardiac arrest in his crib before that.

    Dr. Robin Foster, director of the Child Protection Team at Children’s Hospital of Richmond at Virginia Commonwealth University, testified the boy’s change in weight between his last visit to a doctor’s office and his autopsy points to a critical clue.

    On Oct. 19, 2012, Prince weighed 19 pounds, 8 ounces. He weighed 23 pounds, 8 ounces at the time of his autopsy. Prince was documented receiving 13.5 ounces of fluid bolus to restart his heart at Prince William Medical Center. He received 84.5 ounces of fluid bolus at Inova Fairfax Hospital. His fluid output was measured at 64.2 ounces at Fairfax. That means there are 33.8 ounces of fluid in Prince’s body that are unaccounted for, Foster said...

    Lenox said in order to find Rams guilty, the judge has to disregard eye-witness testimony from Rams’ housemates and his oldest son. She said the commonwealth asks the court to rely on perjured testimony from a jailhouse informant and ignore Prince’s official cause of death.

    The attorney reminded the court that even though experts said febrile seizures are benign, it also heard testimony the condition can affect breathing and heart rate. Prince’s sleep position on his stomach could have limited his airflow, spiraling into a hypoxic event and cardiac arrest, Lenox argued.

    The thin clear fluid Dr. Constance DiAngelo noted in her now amended autopsy report could be attributed to fluid resuscitation, life support, pneumonia, pulmonary edema or sinusitis, the attorney said.

    Dr. Tracey Corey, a retired chief medical examiner and FBI consultant, testified Prince’s death has the classic markers of Sudden Unexpected Death in Children, Lenox reminded the court, adding the only thing lacking such a diagnosis is that Rams believes his son was still alive when he began efforts to save him.

    “How ironic is it that the fact Mr. Rams checked on his son and tried to save his life is the only thing that kept his death from being diagnosed as a Sudden Unexpected Death in Children case?” Lenox said.

    http://www.fauquier.com/prince_william_times/news/closing-arguments-delivered-in-murder-trial-of-man-accused-of/article_aa9b6ff0-1c54-11e7-9a18-9b0d0a68f81f.html

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  3. Rams’ defense team sought to prove Prince either died from a complication associated with a febrile seizure or that his airflow was blocked after a seizure, sending him into cardiac arrest. Defense expert witnesses also suggested Prince’s death could have been attributed to “Sudden Unexplained Death in Children” or a “Sudden Unexplained Death in Epilepsy" case.

    Bellows didn’t buy those arguments. He ruled febrile seizures are not fatal and that Prince did not have one on Oct. 20, 2012.

    “It is only in this tragic and awful sense that Dr. [Shlomo] Shinnar was wrong when he testified that children do not die of febrile seizures,” Bellows said. “This child did -- not because he had a seizure, but because his prior febrile seizures gave [Rams] his alibi, his way to justify how Prince came to die in his care.”

    The judge said he finds beyond a reasonable doubt that Prince died from having his airflow cut off. For over four years the commonwealth asserted that Prince drowned, but during the trial testimony suggested he could have been suffocated. Bellows agreed with that theory in his ruling, and stipulated that Virginia case law does not require a cause of death to be determined in a murder.

    According to expert witness testimony, it takes between five and 10 minutes to suffocate or drown a child. Both the defense and the prosecution focused their cases on whether Rams had the time to kill Prince after he was put down for a nap in the Jestices' Manassas home on Oct. 20, 2012. However, the judge said he believed the drowning or smothering took place before that.

    “The same bathroom, the same bathtub and the same faucet were as accessible and available to [Rams] before [he] placed Prince in the crib as they were afterwards,” Bellows said.

    Shadow Rams Jr., Rams’ then 13-year-old son, testified Prince was lying in a crib in the same room where he was playing video games with a headphone in one ear. Shadow Rams Jr. told the court his father was alone with Prince only for a moment. Bellows, however, said the teen’s testimony lacked credibility because he testified he didn’t fully remember the events that took place the day his younger brother died, almost five years ago...

    Rams has maintained his innocence for more than four years. Prosecutors have said they also investigated Ram’s involvement in the 2003 shooting death of his ex-girlfriend, Shawn Mason, and the 2008 death of his mother, Alma Collins, alleging Rams is a serial killer who kills those closest to him for death-benefit money.

    http://www.fauquier.com/prince_william_times/news/updated-manassas-father-convicted-of-capital-murder-in-toddler-s/article_992c29e6-2035-11e7-bb24-936c1f4c3c1f.html

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