Trial Transcripts

July 30, 1979

Dr. Frank Gemma, M.D.

(Whereupon, DR. FRANK E. GEMMA was called as a witness, duly sworn, and testified as follows:)

D I R E C T  E X A M I N A T I O N  11:20 a.m.

Q  State your name, please?
A  Frank E. Gemma.
Q  Dr. Gemma, if you would, sir, please speak loudly enough, please, sir, so everyone can hear you.  Dr. Gemma, where do you presently live?
A  Presently in Heidelburg, Germany.
Q  What do you do?
A  I am a Surgical Consultant for the Army in Europe.
Q  What is your education and training, sir?  Where did you go to college?
A  I went to college at West Virginia University and graduated in 1956, at the Medical School at West Virginia University, and in Medical College of Virginia, graduating in 1960, with an MD Degree, internship, four years of surgical residency, completed in 1967, at Maddigan General Hospital, Tacoma, Washington.
Q  In February of 1970, did you have an occasion to be working at Womack Army Hospital?
A  Yes, sir.
Q  What capacity did you work in, sir?
A  I was Chief of the General Surgery service.

MR. BLACKBURN:  Your Honor, at this time, we would offer this witness as an expert also in medical science.

THE COURT:  Very well.

Q  Dr. Gemma, directing your attention, sir, to the 17th of February, 1970, did you have an occasion to begin treating one Jeffrey MacDonald?
A  Yes, I did.,
Q  When and how did that initially take place, sir?
A  Some time between 5:00 and 6:00 -- possibly around 7:00 in the morning, I was called by Dr. Bronstein, I believe, and informed that Dr. MacDonald had been injured.  They asked me to see him with regard to treating a chest wound and pneumothorax.
Q  As a result of that call or request from Dr. Bronstein, what did you do?
A  I came to the hospital and saw Dr. MacDonald in the Intensive Care Unit and examined him and discussed the need for a chest tube to, one, re-expand the collapsed lung on the right side and two, provide an exitway for any blood that could accumulate as a result of the stab wound.
Q  Now, when you say that you "examined him in Intensive Care Ward," what do you mean?
A  My examination was primarily the chest, although I observed other injuries, but I didn't have him turn over and examine his legs and a complete physical examination which had been done previously by Dr. Jacobson and somewhat also by Dr. Bronstein.
Q  How many ice pick wounds, if any, did you observe on his body?
A  I did not count or actually pay much attention to any of the ice pick wounds.  There were none of the ice pick wounds that were in any way associated with the chest or were so severe on any part of the body that seemed to cause any complications with his treatment.
Q  Now, you speak of the wounds that you saw on his body, besides the chest area, where were they located, sir?
A  The one primary wound that was the one of concern was the stab wound just under the nipple on the right-hand side of the chest.
Q  Could that also be termed an incised wound?
A  Yes, it could be, but any fairly sharp instrument is going to make a wound.  If an instrument were very dull, it could puncture, say -- say, a dull knife -- a very dull knife -- a thick, heavy, forged steel type of knife which is practically rounded on each edge -- could contuse the wound edges.  That was the reason that in previous testimony, some significance was placed on calling it incised.  It was just that the edges were smooth rather than contused.
Q  Now, how long was it before you examined him that you determined to put a chest tube into his body?
A  Well, the determination was made almost immediately.  The chest x-rays that were taken in the Emergency Room and subsequently with an expiratory film showed at least a 40 percent collapse of the right lung, and the previous radiologist who had been on duty either had not had him expire and take a film or had had that done and possibly not seen it because he had called it 20 percent.
Q  When you speak of "expiratory," what are you talking about?
A  Ordinarily, when you go for a chest x-ray, the technician will tell you to take a deeper breath and hold it and then they snap the film.  The diaphragm goes down when you take a deep breath and the radiologist then is able to see as much of the lung tissue or at least where it should be by that maneuver.  With a pneumothorax, the full extent of it will not be quite as apparent because with a deep breath, frequently, the lung will expand considerably and almost fill up the chest space and not show but a small area of what looks like collapsed lung -- partially collapsed.  Then, when you exhale and let all of that air out of the lung, the full extent of the degree of pneumothorax is better -- you can tell better exactly the degree with letting the air out of the lung by exhaling -- expiratory.

MR. BLACKBURN:  Your Honor, if I may approach the witness?

Q  Dr. Gemma, if you would, sir, take a look at what is Government Exhibit 973.  I don't see the pointer, but if you would, perhaps with your finger, point out where the incised wound to Dr. MacDonald was located?
A  It was approximately in this area here (indicating).  The nipple is usually over the fourth interspace.  This was in the sixth interspace, so it was two ribs below where the nipple usually is approximately and right in line with the nipple.
Q  When did you put the first test tube in -- almost immediately?
A  According to my notes, it was around 7:00 or 7:30 in the morning.
Q  And for what purpose were you putting the chest tube in?
A  At first, to get full re-expansion of the lung.  If there is a leak from the perforation of the lung, it could continue to accumulate, and if it did not escape through the stab wound itself, it could become a serious complication called tension pneumothorax.  That is one reason.  The other reason, if you allow the lung to expand slowly on its own, as this air gets absorbed, if you have a case where there isn't a stab wound and there is a spontaneous collapse of the lung from some defect on the surface -- a rupture like a blowout on a tire -- if a pneumothorax develops in that way so that there is no possible entry of air from the outside but just through lung tissue, then you conceivably might allow a small pneumothorax to resolve by itself watching carefully that a tension pneumothorax doesn't develop.  However, with a stab wound, there is always a chance of air either going one way or another through the stab wound.  There is always a chance of bleeding that is unrecognized from the chest x-ray.  A hemothorax developing might have an accumulation of up to a pint of blood that would not show up on x-ray early.  It would have to accumulate more than that.  It would be hidden more or less behind the way the lung comes down over the liver on either side, so for that reason, a chest tube was placed in the seventh interspace over from this side at this point (indicating) and directed upward in hopes of taking care of any blood that would accumulate as well as release the air that was accumulated and would have come to the outside.
     There were really three reasons -- first, to get the lung to expand as quickly back to normal as possible.  This keeps you from developing pneumonia for one thing; two, to allow an exit for any blood if secondary hemorrhage from a blood vessel that had been lacerated and stopped bleeding would start bleeding in the middle of the night while the patient was asleep.  There could be significant hemorrhage that he would not recognize, and the nurse would have a way of recognizing it right away before any shock developed -- possibly, because it would flow right to the outside into the chest bottle; and thirdly, the reason of having the lung completely expanded prevents the possibility of adhesions forming and sort of trapping the lung and keeping it from expanding in the future and impairing your ability to breathe well.
Q  How long did you remain Dr. MacDonald's doctor?
A  For the extent of his hospitalization and possibly for a week or so later while he was around to be sure that there were no complications from the treatment.
Q  How long did he stay in the hospital?
A  Approximately eight or nine days.
Q  Now, during the time that you were Dr. MacDonald's doctor, did you ever see evidence of a hemothorax?
A  No, not really.  The first tube did not function well.  Dr. MacDonald, at some time earlier in his life, had had some pneumonia on that side and probably some adhesions had formed along this area, so when I inserted the first chest tube, it only got up to about this level (indicating) where we would link it up way up at the top to relieve all of the air, and although the lung expanded somewhat with the first chest tube, it never completely re-expanded.  By the next morning, there was further collapse because this tube had sort of been enveloped by the expanded lung and sealed all of the holes so that no further air from higher up could escape through it.  The holes were not functioning as far as showing any blood coming out.  There was blood-tinged fluid that just could have been from the insertion of the chest tube, so it was elected to put another tube in the second interspace.  I discussed this with Dr. MacDonald because nobody likes to have these procedures done.  I would not have it done on myself if I did not need it.  We tried a lesser procedure of taking a small needle and catheter which is ordinarily used to start intravenous fluids and inserted it and tried to withdraw air from this space to see if that would let the lung expand.  This was unsuccessful; and therefore, it was necessary to place the second tube.  When the second tube was placed, we then removed the lower tube.
Q  During the time that you treated Dr. MacDonald, did he ever have a tension pneumothorax?
A  No, he never had a tension pneumothorax, and the second tube was completely successful.  The lung did expand fully, x-rays showed later, and we were able to remove the second tube in approximately three days and the lung remained expanded.
Q  This means then that from the time Dr. MacDonald went into the hospital, it was three days before all tubes were removed; is that what you are saying?
A  Well, it was approximately four days before all tubes were removed.  The exact dates are in the record, but they are not really that pertinent.
Q  Well, you have testified this morning that one of the reasons for putting in a chest tube into his body was to prevent a tension pneumothorax; is that correct?
A  That is right.
Q  Dr. Gemma, in your professional opinion, do you have an opinion satisfactory to yourself, sir, as to the statistical chances of receiving a tension pneumothorax once a chest tube is inserted into the body and working properly?
A  As long as the chest tube functioned properly, there was no chance of a tension pneumothorax developing, but as you can see, the first tube did not function completely properly.  Nothing is ever foolproof.  Consequently, you have to monitor the fluctuation of the fluid in the bottle to which the chest tube is attached.  If this is not fluctuating with every respiration, the nurse knows to call the doctor and you can examine by listening to the lung and percussing it as well as checking blood pressure, pulse, and so on if you are concerned about the possibility of developing a tension pneumothorax.  If his lung had been completely re-expanded the next morning with the other tube not functioning, we still may have removed that tube and not inserted another tube at that point in time because at least 24 hours had passed and the likelihood of hemorrhage -- secondary hemorrhage from a lacerated vessel -- would be that much more remote.  Since the tube was no longer functional, it would have been removed at the time we removed it; however, the second tube was necessary again for the very same reasons to re-expand the lung to be sure that a tension pneumothorax would not develop because there was a good possibility that there was still further leakage of air from lacerated lung from the initial stab wound.
Q  I believe you testified already this morning that you never saw any evidence of blood leaking out; is that correct?
A  No, I didn't.  I said no evidence of a hemothorax which would imply a significant amount of blood.  This fluid that came out was blood-tinged.  It does not take but a few drops of blood in the body fluids that sort of lubricate the lung surfaces to make the entire bottle of water rather bloody, but it was not an amount that concerned me that he had any undue bleeding more than might have been from the incision that I made to insert the chest tube.
Q  Now, I believe you did testify that he stayed in the hospital eight or nine days; is that correct?
A  That is right.
Q  What was the purpose of his staying in the hospital those days after the final chest tube was taken out?
A  Well, the main reason was the investigation that was going on as well as no real home for him to go to to relax and recuperate.
Q  Now, I believe you stated that you spent most of your time observing the chest wound?
A  That is correct.
Q  Did you ever examine any of his other wounds at all?
A  The only other significant wound -- well, I shouldn't -- the only other significant wound that I examined thoroughly to a certain extent was the head wound.  This was a contusion, abrasion that quite possibly was enough to render him unconscious.  There was another wound -- probably this one -- that I am embarrassed to say that I did not examine it as thoroughly as I probably should have in light of what is going on now because Dr. Bronstein said that this wound went down to the fascia.  There is no record that this, in fact, is true.  This is what he remembers.  Dr. Jacobson, at least, in what I reviewed in the record, did not show that wound going to the fascia; therefore, I said that all of the other wounds were superficial and none of them into more than the subcutaneous tissue.  In other words, none of them required any suturing.  This one, in fact, might have been sutured if it were a definitely clean wound, but not knowing the contamination that was there, it was safer to leave it open and let it heal by itself.
Q  So, that is what had happened in this case?
A  Right.
Q  How would you classify, sir, Dr. MacDonald's general condition in the hospital?  Was it good, fair, or poor?
A  It was satisfactory.  As far as his wounds were concerned from the time that we initiated treatment, there were no real complications that set in except for the failure of the initial chest tube to work.

MR. BLACKBURN:  Just one second, Your Honor.


MR. BLACKBURN:  Your Honor, that completes our Direct Examination.  Defense may cross-examine.

THE COURT:  About how much time do you think you will need for this?

MR. SMITH:  Your Honor, I would say there is a good possibility that I can complete my examination by 1:00 o'clock if that is what you had in mind.  I will certainly try.

THE COURT:  We have sort of a modified schedule on Monday, so I believe that I will take that now and we will recess for lunch and come back today -- instead of 2:30, we will come back at 2:10 today.

MR. SMITH:  I can probably think of some more questions over lunch.

THE COURT:  Wait a minute.  I may reconsider.  Take a recess until 2:15.  Make it 2:15.  That is a good round number to remember.

(The proceeding was recessed at 12:42 p.m., to reconvene at 2:15 p.m., this same day.)

F U R T H E R  P R O C E E D I N G S  2: 15 p.m.

(The following proceedings were held in the presence of the jury and alternates.)

THE COURT:  Good afternoon, ladies and gentlemen.  Any questions?

MR. SMITH:  Very briefly, Your Honor.

THE COURT:  Very well.

(Whereupon, DR. FRANK E. GEMMA, the witness on the stand at the time of recess, resumed the stand and testified further as follows:)

C R O S S - E X A M I N A T I O N  2:16 p.m.

Q  Dr. Gemma, in preparation for your testimony today, I wonder if you had an opportunity to review your narrative summary that you prepared back in 1970?
A  Yes, sir; I have.
Q  Do you have a copy of it with you now?
A  Yes, sir.
Q  I wonder if I could ask you to turn to what appears to be page six -- at least marked on my copy -- it may not be that on yours -- but it is the first typewritten portion of the hospital record.  Is that summary prepared by you or was it prepared by you?
A  Yes, sir; it was prepared by me and was a reflection of my own examination, the examinations as were documented in the chart by other examiners, as well as the laboratory examinations.
Q  Yes, sir.  When was that prepared?  Does it indicate -- is there a date indicated so that we could know when you dictated it?
A  Yes.  If you look at the progress notes, they are the most accurate.  These are the handwritten notes.  On the last handwritten note, 26 February, 1970, my entry is: "Discharged today to duty.  Return prn NS dictated." I dictated it on the 26th, the day of discharge.
Q  The day you dictated this would have been, in fact, a day when the events you had observed would be fresh in your mind?
A  Yes, sir.
Q  Dictated, as a matter of fact, on the very day he was discharged?
A  Yes, sir.
Q  I notice under "Physical Examination" on the document, you indicate that Dr. MacDonald was in moderate distress.  What does that mean?  Could you describe that in terms so that laymen can understand it?
A  Yes.  His breathing was a little bit labored as a result of the trauma and the pneumothorax and probably some of the emotional effects of what had transpired, but the moderate distress is merely to reflect that he was not laying there comfortably as would be entirely possible if someone had not been injured.
Q  Yes, sir.  You also indicate a hematoma -- you use that word -- in the mid-line of the forehead.  Could you tell us what a hematoma is, Doctor?
A  Hematoma reflects an accumulation of blood in the subcutaneous tissues.  This means that the small capillaries or venules have probably been ruptured by the blow.  The blood flows into the tissue.  This, in turn, causes a reaction that causes more tissue fluids to accumulate.  Frequently, the swelling will be much larger.  There will be very little blood and a lot of other swelling.  Other times, there may be a whole lot of blood and very little tissue fluid.  The difference being if it were mostly blood, it would take a lot longer to go down.
Q  Yes, sir.  I think you indicated on your direct examination that based on your examination of the injuries to his head, it was possible that he had suffered unconsciousness or had experienced unconsciousness.  Would that have been a result of the blow he would have experienced which caused the hematoma?
A  Probably.
Q  Yes, sir.  Could you tell in looking at that hematoma whether it could have been caused by a blunt object?
A  Yes.  I would almost be willing to say that it was definitely caused by a blunt object because there was no laceration associated with it, but even a blunt object can cause a break in the skin that would make it look like it was a sharp edge of a piece of wood or something as opposed to the flat edge.
Q  Yes, sir, but this would be what you would characterize, I assume, as blunt trauma?
A  Yes, it could be called blunt trauma.
Q  You also indicated, I believe, Doctor, that you observed dried blood around his mouth?
A  That is right.
Q  Do you remember that well enough so that you could tell us a little bit about what you saw, or do your notes refresh your recollection in that regard?
A  I don't believe my own notes -- let's just see -- my notes didn't reflect this, whether it was mentioned in Dr. Jacobson's -- and my copy of Dr. Jacobson's physical examination is missing, so it is entirely possible that it could have been extracted from that piece of information.  My recollection is very vague.  I mean, there was not any gross bleeding.  As far as whether any teeth were knocked out, I am sure we looked in his mouth -- whether any were broken.  The blood that was around the face was dried.  Either this stuck in my mind and I put it in the narrative summary or I extracted it from Dr. Jacobson's physical.
Q  Dr. Gemma, while you could not say that you know that he had dried blood around his mouth, do you have a recollection that when you dictated this document, that it was dictated correctly as far as you knew?
A  Yes, sir.
Q  So, you got dried blood around the mouth from somewhere in the hospital or medical records?
A  Yes, sir.
Q  You also indicate two or three lines below that the following wording: "One centimeter stab wound in the sixth intercostal space in the mid-clavicular line."  Did you observe the stab wound at the sixth intercostal space as you described there?
A  Yes.
Q  Did you actually observe it?
A  Yes.  I examined that wound in particular because, as I say, it is in about this location here and the significance being it was a relatively clean wound.  The tendency -- the temptation -- was to consider whether we might insert a chest tube through that in order not to have to induce more trauma.  The danger, of course, being infection, that with a foreign body in there.  So, as I say, it was more or less only a temptation to consider that, because it violates several basic surgical principles.  But it was a relatively clean wound.  The wound also had to be examined to see if any air were going in or out of the chest at that time.
Q  What is the difference between the mid-clavicular and the anterior axillary area of the chest?
A  The clavicle, that goes from almost the center of the chest over to the shoulder, is just a landmark, and so about the center of the clavicle, if we divide the body in half from the middle down here, then you would divide it sort of into fourths.  So, you say the mid-clavicular line is about halfway then from the midline to the edge of the chest.  That is just a convenient landmark to try and delineate where something is on one side of the chest or the other.  It just happens that the nipples usually fall in the mid-clavicular line too.
Q  Yes.  Do you recall then that the injury that you observed on Dr. MacDonald was under the right nipple in the midclavicular area of his chest?
A  Yes.  And the record reflects that and some of the photographs that I reviewed later seemed to show, or gave the impression that it might be a little bit lower.  But sometimes a photograph is harder to pinpoint because at the bedside and on the patient, you can feel the ribs beneath and be a little bit more certain as to exactly which interspace it may be in.
Q  Yes, sir.  On the same chart you are looking at, Dr. Gemma, the first figure, the one to my left, would indicate the right side, I believe, of the patient.  Can you point out on that figure the anterior axillary area for the jury?
A  All right.  There would be -- the axle is under the shoulder, so it might be easier to show it on myself.  It is at the mid-axillary line.  That would be somewhere right about the middle of this figure.  Then, if you come halfway to the front of the chest, there is an imaginary line that we call the anterior axillary line, and this is the area that we usually try, or consider putting a low chest tube in, and that is probably why it was mentioned as the area that I probably inserted the one chest tube.
Q  Yes, sir.  You may return to the witness stand.  Thank you.  Now, the anterior axillary is several inches away from the mid-clavicular, would that be correct?
A  Yes.
Q  Did you insert the chest tube in the anterior axillary?
A  Yes, I did.
Q  Did you make a new incision there, into which to place the chest tube?
A  That is correct; a new incision.  This is another -- let me correct myself here.  The chest tube was inserted in the seventh right intercostal space in the mid-clavicular line, not the anterior axillary line.  I was questioning myself too.  One of the principles is that it should be further posterior because someone laying back, blood will tend to accumulate posterior, so if you had an anterior, theoretically some blood could accumulate and not find its way out of the tube.  So most drainage tubes -- not for the treatment of the pneumothorax now but the treatment of a potential hemothorax, is better placed more posteriorly.  Some people might even, if they had a hemothorax, might consider putting it even further posteriorly.
Q  All right.  Dr. Gemma, you indicate that the wound was in mid-clavicular on the notes?
A  That is correct.
Q  All right, the wound was mid-clavicular?
A  That is right.
Q  Now, what number chest tube did you use, if chest tubes do have a number?
A  They do.  Number 36 is what was used.  In the best way to think of that, this pointer is probably about a centimeter, and Number 30 French anything, chest tube, urinary catheter, is exactly one centimeter in diameter, and a centimeter is a little less than a half inch.
Q  If I hand you here a Number 36 tube, could you illustrate to the jury on your own body approximately the position the tube was inserted?
A  Certainly.

MR. SMITH:  Your Honor, may I have this identified as a Defendant's Exhibit so we can hand it up to the doctor?


Q  Dr. Gemma, I hand you here an item previously marked for identification as Defendant Exhibit Number 34 and ask you to examine it, sir, and state whether or not you can identify what it is.

(Defendant Exhibit No.  34 was marked for identification.)

A  Yes, this is a Number 36 French Argyle Thoracic Catheter.
Q  Would it be the same kind of tube that was used in the treatment of Dr. MacDonald or the same size?
A  Definitely the same size and in all likelihood, almost identical.
Q  I wonder, Dr. Gemma, if you would be kind enough to stand and just show the jury how that tube would be inserted.  Of course you don't have to make an incision.
A  The skin over the area between ribs, in this case, about the seventh interspace is infiltrated with a local anesthetic, xylocaine in this case, similar to what the dentist uses when he numbs a tooth to pull it.  
A  small incision is made a centimeter or two centimeters usually, enough that this tube can easily be inserted without having to stretch a lot and cause a lot of resistance.  This incision is carried down through the skin, the subcutaneous tissue, right down to the pleura and the pleura is incised, if possible, under direct vision in many cases.  In an emergency, a tube being inserted up here, you can make a more forceful direct entry because nothing is underlying the chest wall here with a collapsed lung.  However, down here immediately under the rib cage, in the space, is the diaphragm and the liver.  So, if there is not a great deal of caution exercised here, chest tubes might be actually inserted in the abdomen, because someone inadvertently went through the diaphragm and was in the abdominal cavity in this area.  So it is very close proximity.  So you try to be sure -- you are sure -- you are in the thoracic cavity before inserting this tube.  Then it is placed in this way and slid upward.  Ideally it would have gone clear above the clavicle, but because of the adhesions, it got hung up right about here.  To withdraw it and try to push it back would introduce contamination, so it is better to leave it in place and to see if it was going to do the job, which it did not.
Q  I notice that there are holes in the end of that tube.  What function do they serve?
A  They serve to let either air or fluid drain through this tube, and this is why in this particular case I cut a few extra holes further down so that those holes would be about at the lower-most level.
Q  All right.  Let me be sure I understand now where that tube wag inserted.  Was it inserted in the axillary part of his body -- mid-axillary -- anterior axillary?
A  Mid-axillary.
Q  Mid-axillary.
A  If you imagine dividing the chest, looking at it from the slide, into two parts, it was right in the middle.
Q  All right.  Now, therefore, for our purposes could you say that the wound Dr. MacDonald experienced was on the front, and the incision you made to insert the tube was on the side; would that be fair to say?
A  That is correct.
Q  Now, you mentioned an adhesion.  I think you mentioned it on direct examination.  I'm not sure I understood that.  What caused the adhesion which created the problem inserting the tube?
A  It was probably due to pneumonia which is an inflammation of the lung or the surface of pneumonia is the lung tissue itself -- pleuritis -- the surface of the lung -- something like that in the past had probably resulted in scar tissue forming which caused portions of the surface of the lung to adhere both to itself, adjacent lobes -- the middle and upper lobe -- and also to the chest wall such that these little fibers or bands or webs, if they were, could get caught, and I had no way of knowing if I forced the tube if I were forcing it just through adhesions or might actually be forcing it into or tearing lung tissue.
Q  Now, as a matter of fact, I believe you indicated that the Number 36 Argyle tube did not work; is that correct?
A  It worked initially.  The second note showed that the tube was passed to the level of the third interspace anteriorly and that there still was a 30 percent, by my estimation, pneumothorax, so we had Dr. MacDonald positioned on his left side, the reason being air rises, fluid settles, so if he is on his left side and the tube is up and the air is up, hopefully the air would all find its way to these holes and be evacuated.  We also had him cough and take a deep breath and try to what we call valsalvate, try to exhale your breath or pretend like you are, like you are straining to have a bowel movement.  This forces the lung to try and expand without lowering the diaphragm at the same time.  This was fairly successful because there was a lot of air that came out at that time.  However, at 4:00 o'clock the same afternoon there was no bubbling in the chest bottle and there was just what I call a ten percent cap, so I was fairly happy that things might work out at 4:00 o'clock on the afternoon of the 17th.  However, at 7:00 o'clock the next morning, the X-ray taken at 6:00 a.m.  showed that the lung was down again.  That's how I wrote that, and so this just meant that the pneumothorax was almost as bad as it was to begin with.  I didn't bother to say how bad because it really didn't matter.  It was a matter of trying to get the air out and so we inserted a venacath, a little catheter I explained earlier, with new air, repeated the film at 4:00 o'clock on the 18th, showed no improvement, and at that time a Number 34, just a little bit smaller, chest tube was inserted in the second interspace in the mid-clavicular line, the same area as the initial stab wound but about there.  This was a different type of tube.  It was a right-angle tube which means it is made just like that one but with a 90-degree angle in it so that the end of it is about that long (indicating) and then it bends so that when you put it in this way, you can direct easily that right-angle part up so that it will go to the highest point in the chest cavity to allow the maximum release of air.
Q  Yes, sir.  Did three tubes that were used --
A  (Interposing) Yes, sir; you are correct -- three including that small venacath which is about a sixteenth to an eighth of an inch in diameter possibly.
Q  Doctor, again, I take it that the reason you go ahead and insert the tube is to prevent tension in the pneumothorax; would that be correct?
A  That would be one reason.  As long as you have all the air either withdrawn and a potential route of escape for any accumulation of air, a tension pneumothorax could not develop.
Q  So, as long as you are using those tubes and providing an air escape from the chest cavity, then you can be sure no tension in the pneumothorax will occur?
A  That's right.

MR. SMITH:  May I have just one moment, Your Honor?


MR. SMITH:  No further questions of this witness.  Thank you.

MR. BLACKBURN:  Yes, sir.  Just a few.

R E D I R E C T  E X A M I N A T I O N  2:37 p.m.

Q  Dr. Gemma, on cross-examination I believe you stated that someone could have become unconscious from the hematoma that Dr. MacDonald received; is that correct?
A  No; that is not correct.  I'm afraid I will have to -- the hematoma would not cause you to become unconscious.  The blow on the head that caused the hematoma would cause you to become unconscious.
Q  With respect to the blow on the head that could have caused the unconsciousness, do you have an opinion, sir, as to how long unconsciousness would occur after such a blow on the head?
A  There would be no good estimate whatsoever.  I am sure it may have been discussed earlier but you can have unconsciousness with no visible blows on the head.  A shock to the head can be rendered in one way or another that leaves no physical effects but the head -- the brain had been jarred and knocked against the inside of the skull to where that shock causes unconsciousness, and I have seen many blows that were much worse than this one that the individual was not rendered unconscious and many lesser ones that the patient remained unconscious for days.  So, it's almost impossible to take this particular or any particular injury and say that the patient could have been unconscious for a certain number of hours.
Q  Okay.  Let me ask you this way.  If I have already asked you, you can correct me.  Do you know how long or do you have an opinion as to how long after someone gets such a blow on the head it will be before he goes unconscious?
A  I would say usually the unconsciousness will ensue immediately upon the blow on the head in almost all instances, but there are exceptions to that.
Q  Now, when you placed the chest tubes into Dr. MacDonald I think that you had to make an incision of some sort?
A  Certainly.
Q  How large an incision did you make?
A  Usually about two centimeters -- about an inch or less.  It can be done through a trochare which is a rather brutal-looking instrument but is quite efficient and that is a sharp pointed instrument with a hole in it that will allow you to insert a tube through an even smaller opening.  In other words, it has a sharp point and it goes through just the skin and you control the depth of entry so you don't damage anything, but once you are through with that you sort of puncture a hole.  Then you slide the tube through that hole and withdraw the instrument to take it away, and this allows you to insert the tube in a much smaller incision, if you will -- puncture wound -- than you would otherwise.  But even with using that trochare, we will usually make a small -- at least one centimeter -- incision for a tube that size.

MR. BLACKBURN:  Your Honor, may I approach the witness?

MR. BLACKBURN:  Your Honor, at this time we would put into evidence and mark for identification Government Exhibit 404, which this witness has previously testified to -- the medical records.

MR. SMITH:  We have no objection.

MR. BLACKBURN:  We move them into evidence.

(Government Exhibit No.  404 was marked for identification and received in evidence.)

Q  Dr. Gemma, when you made the insertion of the chest tube into Dr. MacDonald, do you recall how you made the incision and with what instrument you made the incision into his body?
A  I do not recall specifically, but I recall in general that I would recall if I did not use a scalpel, so I -- now, if you ask me whether it was a disposable scalpel or one of the old iron-handled ones that we had to put the blade on myself, I can't recall; but it was a scalpel, I am sure.
Q  Then I take it you were able to control the depth of the incision?
A  Yes.

MR. BLACKBURN:  No further questions.

THE COURT:  Very well.  Call your next witness.