The Autopsy Posts: Blunt Force Injuries to the Head and Unconsciousness

This is my fifth post about autopsies following my first, second, third, and fourth posts. Once again I will be looking at the autopsy report for Hae Min Lee. As I noted on Monday, the autopsy report stated that "[t]here were focal and poorly delineated right occipital subgaleal and right temporalis muscle hemorrhage." As I also noted, "based upon information I have now received from an assistant medical examiner and a pathology resident who has completed extensive rotations in forensics," the conclusion can be drawn that

1. Given the severity of the blunt force injuries, it is likely that Lee was at least stunned, and the injuries are certainly consistent with Lee being knocked unconscious.

So, how can this conclusion be drawn?

Let's start with a basic question: What causes unconsciousness? According to the Affidavit of Bennet I. Omalu, M.D., M.P.H., in Wilkerson v. Kennywood Park Company, Inc., 2007 WL 7552710 (Pa.Com.Pl. 2007),

The part of the brain responsible for consciousness, the reticular activating system, is embedded deep in the brainstem, which is situated at the base of the brain and on the skull base.

Reticular Activating System

The reticular activating system is responsible for the arousal mechanisms that control consciousness, mental alertness, etc. As noted in the Deposition of Gregory J. O'Shanick, M.D., in Jean Paul v. Hines Nurseries, Inc., 2007 WL 5432040 (Fla.Cir.Ct. 2007),

The brain stem, in what's called the reticular activating system, is -- let me take this in half to make it easier -- in this region is the part of the brain where, when an individual is rendered unconscious, is where the disruption in terms of arousal mechanisms occur.

These arousal mechanisms are activated when the reticular activating system sends impulses to the neurons in the cerebral cortex.

According to Watson's Clinical Nursing and Related Sciences,

Interruption of impulses from the reticular activating system, or failure of the cerebral cortical neurones to respond to incoming impulses, produces a loss of consciousness.

Right Occipital Subgaleal Hemorrhage

Given that the reticular activating system is located at the base of the skull in the brain stem, it is unsurprising that occipital blows -- blows to the bottom part of the back of the skull -- would frequently disrupt the arousal mechanisms of the reticular activating system.

Lee's occipital hemorrhage would have been just above the cerebellum

In fact, this is exactly what was described in Fulton v. Secretary, 2011 WL 5928346 at *14 (U.S. 2011): an occipital blow damaging the reticular activating system. As I've noted, the autopsy report for Hae Min Lee states that she had a "focal and poorly delineated right occipital subgaleal...hemorrhage." In many cases in which victims suffered blows causing subgaleal and/or occipital bleeding, they were rendered unconscious.

From Conway v. Power, 2010 WL 2431929 (Mass.Super. 2010):

Judith Conway...was at a home being renovated. The contractor usually placed plywood and blue tarpaulin to cover a stairway he was working on; this time, he placed only the tarpaulin. Mrs. Conway fell about six to eight feet down into an open stairwell, landed just two to three stairs from the bottom, struck her head against the basement wall, and lost consciousness. Upon awakening, she immediately complained of severe back pain and right zygoma. She told emergency responders that she “felt confused,” and “can't think of what she wants to say.” She was immediately transported to the UMass Memorial Medical Center where she was diagnosed with, among other things, a closed head injury and back fractures. X-rays revealed oblique and minimally displaced transverse fractures of the lumbar spine at L2, L3, and L4. She was found to have sustained a subgaleal hematoma in the right occipital region. (emphases added).

From the Affidavit of Gregory J. Davis, MD, FCAP, in Jett v. Eastern American Energy Corporation, 2007 WL 7025184 (W.Va.Cir.Ct. 2007): 

Given the description of blunt force injuries of the head, specifically two areas of subgaleal hemorrhage (contusions) on the right frontal and right occipital regions, as well as the right forehead abrasions (scrapes), it is possible that Mr Murphy lost consciousness upon falling into the slurry pond by striking his head upon some object within the pond. (emphases added).

From the Affidavit of Gerald F. Winkler, M.D., in Moose v. MIT, 1994 WL 16438161 (Mass.Super. 1994):

The admission history was that the patient had been generally healthy, but that he had fallen 12 feet while pole vaulting and had been unconscious for 8 to 10 minutes with a possible seizure....There was a subgaleal hematoma in the left occipital region. (emphases added). 

From the Affidavit of Deborah R, Marth, Ph.D. in Cabassa-Rivera v. Mitsubshi Motor Corporation, 2005 WL 6436172 (D. Puerto Rico):

The victim in a car accident case had injuries including a "subgaleal hemorrhage" and was "presented to the emergency room unconscious." (emphases added). 

From the Affidavit of John F. Delaney, M.D., Dr.P.H., C.P.E., F.A.C.P., F.A.A.N., D.L.F.A.P.A., in Metzler v. Abrams, 2013 WL 5669323 (Pa.Com.Pl. 2013):

On November 12, 2009, Mr. Metzler fell approximately 6 feet into an empty pool at a friend's house, striking the back of his head. He had no memory for the accident and there was a questionable loss of consciousness. At that point he was taken immediately to the Emergency Department at Presbyterian University Hospital where he had a Glascow Coma Score (GCS) of 14. At that point he appeared confused but did not show any loss of consciousness on admission. His injuries at that time were listed as a left frontoparietal subgaleal hematoma.... (emphases added) 

From the Affidavit of Dr. Thomas L. Bennett, M.D., in Niemeyer v. Ford Motor Company, 2011 WL 8170101 (D.Nev. 2011):

Dr. Elizabeth Raphael was deposed on 3-8-11. She offered her understanding that the impact speed of the Ford Focus into the tree was 13-14 mph, the delta-V was approximately 16 mph, and an airbag would not prevent serious injury or death in this collision....Based upon testing, a seatbelt would provide no benefit in this case. She opined the likely cause of death was a cardiac event....She listed the findings of Dr. Case's examination. They noted the subgaleal hemorrhage, which she believed was a result of head trauma, was probably a result of head trauma during the crash....She believed Mr. Niemeyer lost consciousness at the time of the cardiac event. (emphases added) 

Now, none of this is to say that a blow causing a subgaleal hemorrhage will automatically render a victim unconscious. Consider the following excerpt from the Deposition of Dr. Mary E. Case in Niemeyer v. Ford Motor Company, 2011 WL 10903203 (D.Nev. 2011), a case involving a car accident:

Q. Subgaleal hemorrhage in the right, frontal parietal area, would that be sufficient in and of itself to render him unconscious? 

A. No.

Of course, this hemorrhage was to the parietal area, which is above the occipital area and thus farther away from the brain stem and the reticular operating system.

A similar scenario can be found in the infamous death of Rebecca Zahau. According to Zahau's autopsy report,

On the right superior parietal scalp there is a 2 x 1 inch subgaleal hemorrhage. On the right lateral frontal scalp there are two subgaleal hemorrhages measuring 3/4 x 1/2 inch and 1/2 x 1/4 inch. On the right lateral frontotemporal scalp, there is a 3/8 inch diameter subgaleal hemorrhage.

Pathologist Cyril Wecht noted after reading Zahau's autopsy report that

Zahau's head injuries – which caused bleeding underneath her scalp – would have occurred while she was still alive or in the minutes shortly after her death. He said it is impossible to determine whether Zahau's head traumas would have rendered her unconscious.

"A blow or blows sufficient to produce subgaleal, subscalpular hemorrhage could be sufficient for someone to be knocked out, just temporarily, not to produce any damage to the brain, not to cause any prolonged unconsciousness; but one cannot say," Dr. Wecht said.  "They are clearly indicia of some kind of blunt force trauma. So, for someone to say there is no evidence whatsoever of any kind of a struggle is not correct."

Again, this case involved hemorrhages to areas farther away from the brain stem and the reticular activating system than the occipital hemorrhage found during Lee's autopsy. That said, what we also have in Zahau's autopsy report is the size of the hemorrhages. This is part of the reason why my experts were only able to conclude that Lee's right occipital subgaleal hemorrhage was consistent with being knocked unconscious; without more information about size, it is tough to say anything definitive.

Right Temporalis Muscle Hemorrhage

The temporalis muscles are located under the temple and are thus farther away from the brain stem and the reticular activating system.

That said, as I noted on Monday, "[t]he temporalis muscle is covered by the temporal fascia, a strong, dense layer of fascia (fibrous tissue)." Therefore, it takes a serious blow to cause a temporalis muscle hemorrhage, such as the one found during the autopsy of Lee. Therefore, it is unsurprising that experts have testified that such hemorrhages can be indicative of disruption of the reticular activating system and loss of consciousness.

From the Deposition of Dr. Howard J. Tucker in Bessick v. Utilicon, 2001 WL 34848686 (Ohio Com.Pl. 2001):

Q. Indeed, Doctor, you cannot show that there was any blunt impact to the head with any degree of medical certainty or that there was damage to the reticular activating system or that there was any damage to the spinal cord; you can't tell that, can you, with any degree of medical certainty? You cannot show that?

A. No. I think you're wrong. Now, repeat that again?

Q. You could not show that there was any blunt impact to the head with any degree of medical certainty or that there was damage to the reticular activating system or that there was any damage to the spinal cord?

A. Well, first of all we have bruises to the face and head and then the face and the cheek and the chin and the neck are all part of the head....

Q. ...The question is simply this: Do you agree that there's nothing in the autopsy consistent with the blunt impact causing the death or a blunt impact that would render Miss Brannon unconscious? You don't read that anywhere in there?

A There is blunt impact to the head.

Q. Okay. We'll go to the next question.

A. Wait a minute. I haven't finished that, then. That was only part of your question. There is a blunt impact to the head.

Q. It would kill her and render her unconscious. That's the rest of the question.

A. The record quite clearly says that there is prominent hemorrhage into the temporal is muscles, that -- these muscles here so there was impact to the head. (emphasis added)

From the Deposition of Carl J. Schmidt, M.D., in Bessick v. Utilicon, 2001 WL 35938169 (Ohio Com.Pl. 2001):

objective evidence for injury is that there was hemorrhage, albeit only a small amount, but there was hemorrhage in the membranes that cover her brain, and especially a portion of the brain known as the cerebellum which is a protected part of the brain. So that when you see hemorrhage in the linings that cover the brain and hemorrhage into temporal muscles, you've suffered a severe blow to the head, which means that you probably lost consciousness almost instantaneously. (emphasis added).

From State v. Davis, 880 N.E.2d 31, 55 (Ohio 2008):

State's exhibit 7–L shows a hemorrhage in the temporalis muscle and an injury in the frontal scalp area caused by two points of impact. State's exhibit 7–M shows a hemorrhage to the back part of her head caused by a separate impact. Using these photographs, Dr. Fardal testified that Sheeler did not suffer a fatal brain injury but may have received a concussion resulting in a loss of consciousness. (emphases added).

From the Deposition of Robert H. Meyer, M.D., in Bakalor v. J.B. Hunt Transportation, 2012 WL 11131015 (S.D.N.Y. 2012), a case in which the victim ws struck by a tractor-trailer:

Q. Is it possible to be unconscious as a result of intramuscular hemorrhaging of the temporalis muscle? 

A. Yes. (emphasis added).

From Wilson v. State, 242 A.2d 194, 205 n.9 (Md.App. 1968):

Internal examination of the head showed bruising or hemorrhage of each temporal muscle. Five ribs on the left side were fractured with ‘subplural hemorrhage’ present. The actual cause of death was that the deceased vomited while unconscious and died of aspiration. (emphasis added).

Stunned/Incapacitated

Of course, as with the occipital hemorrhage, it is impossible to say whether the blow that caused the right temporalis muscle hemorrhage knocked Lee unconscious. What seems likely, however, is that at least one of the two blows rendered Lee stunned and/or incapacitated. For instance, in Neylon v. Wisconsin Community Services, 2007 WL 7758080 (Wis.Cir. 2007), the eighteen year-old plaintiff crashed into the unpadded ceramic cement interior wall of a gym, causing subgaleal bleeding and right temporal hemorrhagic contusional hematomas. According to the Affidavit of Thomas A. Gennarelli, M.D., the plaintiff "'blacked out' and was stunned, with possible brief loss of consciousness but was able to recite a cogent history to medical attendants when taken to St. Francis Hospital Emergency Department."

In many other cases, experts have opined that blows causing blunt force injuries to the head likely or possibly caused the victim to be stunned and/or incapacitated. For instance, in Costley v. State, 926 A.2d 769, 785 (Md.App. 2007), the autopsy report stated that

This 53 year old white female, Helga Nicholls, died of multiple blunt and sharp force injuries. The blunt force injuries consisted of at least two impacts to the head that caused injury to the brain with one area of bleeding. The impacts may have stunned or incapacitated Ms. Nicholls.

Conclusions

Obviously, it would be nice to have something more in the way of definitive answers on the issue of unconsciousness. If it were clear that Lee was knocked unconscious, she couldn't have kicked at her assailant or tried to say something like "I'm sorry" while being strangled. What we're left with instead is the conclusion that Lee's head injuries are consistent with being knocked unconscious and likely indicative of being stunned and/or incapacitated. Probably the most important take-home from this post is simply that the damage to Lee's head was serious, implying that she was struck with something more than a simple punch or elbow. I'll have more on this in my later posts.

-CM