3.David Casavant — Direct
145 linesMS. SPRAGUE: Commonwealth calls Dr. David Casavant.
COURT CLERK: Good morning. Do you solemnly swear that the testimony you're about to give shall be the truth, the whole truth and nothing but the truth, so help you God?
DAVID CASAVANT: I do.
COURT CLERK: Thank you. You may have a seat, sir.
BAILIFF: Watch your step there, sir.
DAVID CASAVANT: Thank you, sir.
THE COURT: All right. Good morning, Doctor.
DAVID CASAVANT: Good morning. Good morning, Your Honor.
THE COURT: Attorney Sprague.
MS. SPRAGUE: Thank you. Good morning. Can you please state and spell your name for the record?
DAVID CASAVANT: Surely. My first name is David. My last name is Casavant. It's spelled C-A-S-A-V-A-N-T.
MS. SPRAGUE: And your date of birth, sir?
DAVID CASAVANT: 5/2/63.
MS. SPRAGUE: What do you do for a living?
DAVID CASAVANT: I'm an ICU physician at Boston Children's Hospital.
MS. SPRAGUE: Can you briefly describe for us your educational and training background?
DAVID CASAVANT: Sure. I went to college out at Holy Cross in Worcester, and then to medical school at Boston University. I did my initial pediatric residency at Mass General Hospital, and then went back and did a fellowship in ICU medicine at that hospital as well.
MS. SPRAGUE: And where do you currently work?
DAVID CASAVANT: I currently work at Boston Children's Hospital in the Medical Surgical ICU.
MS. SPRAGUE: And how long have you worked at Boston Children's Hospital?
DAVID CASAVANT: 18 years.
MS. SPRAGUE: And have you always worked in the ICU there?
DAVID CASAVANT: Yes.
MS. SPRAGUE: I want to direct your attention to January 26th, 2023.
DAVID CASAVANT: Mm-hmm.
MS. SPRAGUE: At that point in time, did you take over the care of a patient named Callan Clancy?
DAVID CASAVANT: I did.
MS. SPRAGUE: And prior to taking over the care of Callan Clancy, did you do anything to familiarize yourself with his treatment and care?
DAVID CASAVANT: Yes, I did. One of my colleagues had taken care of him the day before in the ICU, and I spoke with her, and so I was familiar with his case.
MS. SPRAGUE: Okay. And did you also review reports and testing that had been performed while he was at the hospital?
DAVID CASAVANT: Yes, I did.
MS. SPRAGUE: Okay. And after reviewing the reports and the test results and speaking to your colleague, can you tell us what you learned from all of that?
DAVID CASAVANT: Well, it seemed that Callan had had a severe neurologic injury, based on both testing and the examination that I did at the time.
MS. SPRAGUE: And when you say a neurologic injury, is that a brain injury?
DAVID CASAVANT: It's a brain injury. Yes, it is. Yeah.
MS. SPRAGUE: And did you review specifically a head CT scan of Callan?
DAVID CASAVANT: Yes, I did.
MS. SPRAGUE: And what did the head CT scan show you or tell you about his condition?
DAVID CASAVANT: Well, the head CT is a picture of the brain, which was done in the emergency room when he was admitted to Boston Children's Hospital. And the CT scan showed, it showed an enormous amount of swelling of the brain itself.
MS. SPRAGUE: And that, the swelling of the brain, is that medically significant?
DAVID CASAVANT: Very much so. When you have an injury to the brain that is caused by anoxia, which means a lack of oxygen, I describe this with families that the injury is very much like being out in the sun. You don't notice it at the time, but swelling occurs over the course of time. And one of the things with a lack of oxygen to the brain is the injury occurs and then swelling starts to happen over the course of time, typically peaking at 48 to 72 hours. When you see swelling that happens that early in a case, as in Callan's, it means that there's been a very significant lack of oxygen and therefore injury to the brain itself.
MS. SPRAGUE: So for example, some types of injuries that would withhold oxygen from the brain would be more mild and the swelling would occur over time. Is that correct?
DAVID CASAVANT: That's exactly correct, yes.
MS. SPRAGUE: So if a severe injury happens that withholds oxygen from the brain, that's when you see that immediate swelling like Callan had?
DAVID CASAVANT: Very much so. Sort of the comparison of a sunburn to a burn that you might get from a stove. This was a stove. It's very, very profound.
MS. SPRAGUE: Yeah. Did you perform a physical examination of Callan?
DAVID CASAVANT: I did.
MS. SPRAGUE: And what did you observe?
DAVID CASAVANT: Well, one of the first things that I noticed as I approached him was that he had a breathing tube in place. And I knew from my colleague that he was not on any sedation, which is very difficult to tolerate, having a breathing tube through the vocal cords if you're not sedated, and he was not sedated at the time. The next thing is when I approach a patient, such—in their bed in the ICU, we always start with a quick introduction, that we're going to be coming near them in case they were asleep. And I usually start with something along the lines of, you know, "I'm Dr. Dave. I'm just gonna listen to your heart." And I'd usually address them by name and to see if they start to respond. And then I'll go ahead with the rest of the exam, but that's just to sort of warn them that someone might be touching them. And then I'll listen to heart, lungs. And then to move forward to see if, how responsive they are.
So if you get no response at all from the initial, you know, just using your voice, the next thing is to—is, you know... And then from the exam, if they don't move around, then you start to sort of think, "Well, let's see how responsive they are." And so the next thing is sort of a gentle touch, often to the bottom of the foot to see—you stroke the bottom of the foot, and you see if they pull away. And then you can move f- If that, if you get no response from that, we'll do something that's a little bit more noxious or painful, where you can sort of pinch a little bit of skin to see if they start to react, or pushing on the n- the fingernail, on the nail bed pressure, which is actually very noxious. And if... You can see two types or several types of response. Either no response, or you can see a very specific response where they pull away from that area, and that's a specific. Or you can see generalized response, which are all sort of graded—excuse me—graded along those, that are as our—as we're sort of ex- s- getting a sense for what their level of consciousness was.
MS. SPRAGUE: So if I could go over a few of those things that you just mentioned.
DAVID CASAVANT: Oh, sorry.
MS. SPRAGUE: You said that the first thing that you noticed that was significant was that Callan had the breathing tube in place through-
DAVID CASAVANT: That's right.
MS. SPRAGUE: ...the vocal cords-
DAVID CASAVANT: Yes.
MS. SPRAGUE: ... without any sedation. So without sedation, would having a breathing tube in that place cause pain?
DAVID CASAVANT: Yes. No one would be able to tolerate it.
MS. SPRAGUE: And so Callan was able to tolerate it without any sedation?
DAVID CASAVANT: Yes.
MS. SPRAGUE: Would that indicate he wasn't feeling that pain at that time?
DAVID CASAVANT: Yes, exactly.
MS. SPRAGUE: And you mentioned that you would address the patient by name and talk to them. Was there any reaction from Callan when you did that?
DAVID CASAVANT: No, there was not.
MS. SPRAGUE: And then you mentioned you would rub maybe something along the foot. Was there any reaction?
DAVID CASAVANT: No, there was not.
MS. SPRAGUE: And did you do what you described in, you know, pinching the fingernail or pinching somewhere on Callan to see if he responded?
DAVID CASAVANT: Yes.
MS. SPRAGUE: And did he respond?
DAVID CASAVANT: No, he did not.
MS. SPRAGUE: And what did these interactions and tests on Callan tell you about his condition?
DAVID CASAVANT: This told me that he was unresponsive. He was unresponsive to both things that would cause discomfort and things that would cause pain.
MS. SPRAGUE: Did you also do anything in terms of looking at his pupils and any tests on his eyes?
DAVID CASAVANT: Yes. So after all the other things, we look at the pupils. And so one of the things is we have—it's a reflex response. If a light is shone in an eye, the pupil constricts. And what I noted about Callan was that his pupils stayed widely open and did not, did not constrict.
MS. SPRAGUE: And when someone's pupils stay open and wide when you shine a light in them, what does that indicate medically?
DAVID CASAVANT: Well, the eyes are a direct extension of the brain, so that they're... But that's, so that's why we focus a lot on them as an area of investigation. And the lack of a response to light indicates that there's some abnormality to that. And in this case, it was a brain injury. You can also... There's medications that can keep your eyes open if you've ever had an eye exam. But that was not the case with Callan.
MS. SPRAGUE: And just to be clear, when we talk—when you're talking about brain injury, we're not talking about some type of trauma that was inflicted on the brain. You're talking about the lack of oxygen and blood flow causing an injury to the brain, correct?
DAVID CASAVANT: That's exactly correct. Yes.
MS. SPRAGUE: At that point in time, did you work with another doctor to do more in-depth testing regarding his neurological status?
DAVID CASAVANT: Yes. So, at Children's, we have multiple teams that come together for a patient, for many patients. But for Callan, the neurology team was there from the beginning. And when, in a case like this, when we see no response in an unresponsive patient, we start to have the—get our neurology team. And one of the things we start to do is brain death testing to see if they could be what would we call brain dead, meaning that the brain itself is not functioning, and that even though their heart is still beating.
MS. SPRAGUE: How is it that someone's heart can be beating if their brain is dead?
DAVID CASAVANT: It's a really good question. So there's actually two parts to the nervous system. The one is the part that we see the most in people when they react, and they react to us, and they speak, and they do things. The other one is the autonomic or automatic system, and the automatic system is largely in charge of the things like the heart, if the heart has not been injured. And so it was sort of continuing on.
MS. SPRAGUE: And does that give you any indication, the fact that the heart was still continuing on, about where the injuries were in the brain?
DAVID CASAVANT: Yes, it does, actually. Yeah. That—
MS. SPRAGUE: Where would that be?
DAVID CASAVANT: Yeah. So the large part of the brain that we sort of think of is when you—we see the pictures of the brain, that's the cerebellum, and that's the biggest thing in humans that is most developed. And that's in charge of our consciousness, our reaction to things. Whereas the brain stem, which is another part, and that's really part of the autonomic system, and that's the same in almost all vertebrates and mammals. And it's much more automatic. And so that's... It tells me that it seemed the cerebellum, which is that part that makes us sort of the human side of what we do, that's much more sensitive to a lack of oxygen, to an anoxic injury. And it told me that that was really where that injury was in that part of the brain, much less so in the brain stem itself.
MS. SPRAGUE: So would it be fair to say that the brain stem itself that controls those automatic responses was still functioning somewhat, but the part of the brain that made Callan Callan was not functioning?
DAVID CASAVANT: That's exactly correct, yeah.
MS. SPRAGUE: And what... Could you describe for us the brain death testing?
DAVID CASAVANT: Sure. So the brain death testing at Boston Children's is a—it's a very strict testing that includes some of the things that I just mentioned. But we work with our—we have, it's... There's a checklist that we work on with our neurologic colleagues. And we sort of go through each of the—what we would expect for responses from someone. And we actually then work through different, of the nerve sets that we would expect them to respond to. We have it set up so that there's a—an ICU physician is there, and then a neurologist is there. And the neurologist and the neurology team, they're the ones who perform the brain death testing. It's... And then the test is then repeated again 24 hours later just to make sure that there's no—there's no piece of that that is different or incongruous with a diagnosis of brain death.
MS. SPRAGUE: And while the neurologist is doing this testing are you there present watching the testing and seeing the results as it happens?
DAVID CASAVANT: Absolutely, yeah. So we're sort of committed to being there for the whole time. And the brain death testing itself goes through some really basic things. Again, as I described earlier, the things that would be painful, and do they pull away or not? The eyes, the—looking at the reflexes of the eyes. There's also other reflexes, too. Things like, if you stroke the cornea, which is the front of the eye, people blink. And there was a n- n- and that's... So the blink reflex. Cough, gag. There's also a reflex where they actually put cold water into an ear, and that gives people a disequilibrium. And so those are all the things that we think about. And then also, too, there's some other—there's some breathing components to that as well.
MS. SPRAGUE: Is one of those breathing components an apnea test?
DAVID CASAVANT: Yes, it is. Yeah.
MS. SPRAGUE: And what is an apnea test?
DAVID CASAVANT: So apnea is a word that just describes not... It describes a lack of breathing.
MS. SPRAGUE: And how do you test that?
DAVID CASAVANT: So, in a patient such as Callan, what we do in any patient when we're doing brain death testing, what we're... We actually disconnect them from the ventilator. And the reason that we do that is we wanna see if that autonomic system in the brain will start to react as the carbon dioxide starts to increase. So our body makes carbon dioxide all the time, and the way we get rid of it is by exhaling and where we breathe in fresh oxygen and then we breathe out CO2. And what we do is we disconnect from the ventilator to see if, knowing that their carbon dioxide will start to rise, and the normal response for that autonomic part of the brain would be to sort of increase breathing. That's why we breathe when we sleep. Because our... as we go to sleep, the conscious part of our brain stops, but the autonomic part kicks in, and then we breathe right through our sleep because that carbon dioxide rises.
MS. SPRAGUE: So in a patient who has brain death, would it be accurate to state that as the carbon dioxide level increases, the automatic response would be to take a breath to get more oxygen, but a patient who's brain dead won't do that?
DAVID CASAVANT: That's correct.
MS. SPRAGUE: And did you do all of these tests, or did the neurologist do all these tests on Callan while you observed?
DAVID CASAVANT: Yes, they did. Yeah.
MS. SPRAGUE: And did he have any response to any of the physical tests where you were looking for a reflex or a reaction?
DAVID CASAVANT: No, he did not. No response to any.
MS. SPRAGUE: And what was his reaction, or results on the apnea test?
DAVID CASAVANT: So the apnea test, again, we do one... We do all the brain tests, testing one day, and then we wait at least 24 hours for the second one. The first... And what we expect with the carbon dioxide is that it will increase. We have it written in our... It'll... in... So it's in all in writing for our protocol that it will increase by 20 or get to a level of 60. A normal CO2 would be around 40. And the first time we did that on the first day, it actually went to 59.7, not 60. And again, it was in our protocol as it has to get to 60 or increase by 20. And I actually talked to my colleagues, including neurology. I said, "I know this is very close. It's 59.7, but it's not 60." I repeated that piece of the test later on that day to make sure that it was valid.
DAVID CASAVANT: And I, as I say, I checked with everyone to make sure that I was doing the right thing. And they all agreed that we should just... And the second time it went to 87. So that was... Everything else was the same. And we made sure that there's things that we look at, too, to make sure that there's not on any medications, that there's no changes in his temperature. There's no abnormalities of the salts in the blood, what we call the electrolytes. So those, all those conditions were the exact same. And I did, I repeated that later on in the day, and it did come back positive.
MS. SPRAGUE: Why is it so important that you meet that specific criteria? Why is three-tenths of a point so important?
DAVID CASAVANT: Well, I wanted to make sure that there was no question about the data that we were gathering at the time.
MS. SPRAGUE: And you said that this testing is again repeated 24 hours later, correct?
DAVID CASAVANT: Yes, it is.
MS. SPRAGUE: Why is that?
DAVID CASAVANT: Well, that's just to make sure that if there were any lingering effects of medications, if there was anything that else might have changed in the patient's level of alertness or level of response, to make sure that it still meets all those requirements the sec- 24 hours later.
MS. SPRAGUE: And is it because you wanna be sure that there's brain death before you remove life support?
DAVID CASAVANT: Yes. And again, it's too important. It's too important a discussion and a gathering of data to not be very exact about it.
MS. SPRAGUE: And so, when you did the—observed the testing and then the following day on Callan, were the results the same in terms of no reaction and the carbon dioxide increasing?
DAVID CASAVANT: Yes, they were.
MS. SPRAGUE: And at that point in time, did he meet brain death criteria?
DAVID CASAVANT: He did. He met... So we had determined that it was, that he had met death by neurologic criteria.
MS. SPRAGUE: And at that point in time, was a decision made to stop life support?
DAVID CASAVANT: Yes. Yes, it was.
MS. SPRAGUE: And that's done in consultation with the family, his father, correct?
DAVID CASAVANT: Yes. That's true.
MS. SPRAGUE: Okay. And was life support ended for Callan Clancy on January 27th, 2023?
DAVID CASAVANT: It was. And one of the things is, there's, when you determine that someone has met criteria for neurologic brain death, that, although we know that their brain is not functioning at that point, there's often a period of time where we don't have to rem- — his heart is still beating, so we don't have to remove the endotracheal tube at that time. And we often will give families, once it's been confirmed that the brain is no longer functioning, we often give families a period of time to able to process it and a window of time. Sometimes there's relatives who will need to travel and things like that. And so we'll often then choose a time later on to accommodate the rest of life, knowing that they're stable at the time to when we would actually remove the tube, and that would be the declaration of death.
MS. SPRAGUE: And was that done in this case? Family was given an opportunity to see him, and then life support was ended, and then his heart stopped?
DAVID CASAVANT: Yes. That's exactly.
MS. SPRAGUE: And he was declared deceased?
DAVID CASAVANT: Yes.
MS. SPRAGUE: Thank you.
THE COURT: Attorney Reddington.
MR. REDDINGTON: Thank you, sir.
THE COURT: Thank you, doctor.
DAVID CASAVANT: Thank you so much.
MS. SPRAGUE: Your Honor, at this time the Commonwealth would move to admit the Boston Children's Hospital records for Callan Clancy into evidence. There's two volumes.
THE COURT: Objection?
MR. REDDINGTON: Your Honor, I have no objection 'cause we both have the records. We both want them in evidence, so I have no objection to any of the records that they have. We signed releases for them. I—for, like, Beth Israel, Brigham and Women's, South Shore, they all can go in.
THE COURT: All right.
MS. SPRAGUE: That's a yes.
THE COURT: It may be admitted.
COURT REPORTER: Exhibit 137.
MS. SPRAGUE: I think it's 137 A and B.
THE COURT: Hmm?
THE COURT: Yeah, I want two A and B. Yeah.
COURT REPORTER: 137 A and B.
THE COURT: All right. Thank you.