Physicians offer differentiating opinions on day two of Gipfert trial

Medical experts for both the prosecution and defense testified Thursday regarding possible causes of internal head injuries to the alleged victim in the case of the State of Nebraska vs. Nancy Gipfert.

Gipfert is charged with one count of child abuse causing serious bodily injury, a felony for her alleged part in the incidences leading up to the hospitalization of an infant who had been at her daycare prior to suffering seizures and brain injury on Sept. 13, 2011.

The then two month old child suffered a subarachnoid hemorrhage and subdural hematoma, as well as retinal hemorrhages, according to earlier testimony. The National Library of Medicine defines a subarachnoid hemorrhage as bleeding in the area between the brain and the thin tissue that covers the brain and a subdural hematoma as a collection of blood on the brain.

Dr. Ronald Uscinski, a medical doctor and neurosurgeon trained at Georgetown testified for the defense.

Uscinski reviewed the alleged victim's medical records and brain scans and concluded that the injuries were not acute, but due to a prior chronic condition, caused during birth. The infant simply experienced a re-bleed, he said. He observed new blood as well as old blood on the scan. Additional brain damage occurred due to oxygen loss when the infant was seizing, he said.

The fact that there was bleeding in the lower part of the brain, below the tentorium was significant to Uscinski.

"That's typically associated with the birth process," he said.

A human pelvis isn't wide enough for a baby's head, so the head has to deform somewhat to fit through it.

"You take a rounded structure and change it to an oblong structure," Uscinski said.

All of this tension and pressure on the head can cause bleeding, he added.

"It doesn't happen in everybody, but it does happen," he said.

Normally the blood would reabsorb into the body.

There is at least one study that claims bleeding above and below the tentorium is usually caused by birth, he said. Don Miller, attorney for the defense asked if there would be symptoms of this bleeding directly after birth.

"There may and there may not be," Uscinski answered.

Most babies don't show symptoms because the body takes care of the problem on its own.

At least one study found that a significant portion of adults with subdural hemotomas experienced re-bleeding after the initial injury. There doesn't necessarily need to be additional trauma for this bleeding to occur, Uscinski said.

He also stated that retinal hemorrhages can be caused by a sharp increase in intracranial pressure. He found no evidence of trauma to the brain or skull in the child.

Generally, to cause a subdural hematoma, one would have to bang one's head against something, and there were no external injuries, he added.

Uscinski disagrees with some in the medical community about the existence of shaken baby syndrome.

"It's been shown on two different occasions that humans can't shake babies hard enough to cause subdural hematomas," Ucsinski said.

Ucsinski admitted that he had been censured by the American Association of Neurological Surgeons after testifying for only the defense in several shaken baby cases. The organization said it censured him because it believed he provided biased testimony, although he disagreed with that finding. Uscinski said he does turn down requests to testify when facts don't match up with the story and has never been asked to testify for the prosecution.

When questioned by prosecuting attorney William Tangeman about his censure, Uscinski said he was impartial and devoted to science.

Uscinski cited two studies in which humans shook dolls with instruments attached to measure force of the shaking. These studies found that humans were not capable of shaking hard enough to cause subdural hematomas, he said.

Tangeman then cited multiple cases in which a hospital diagnosed an infant with non-accidental trauma and Uscinski said the bleeding in the brain was caused by birth.

State witness, Dr. Lisa Niebergall, a pediatric radiologist and chair of her department at Rocky Mountain Hospital for Children testified next. She was not the alleged victim's treating doctor, but consulted with others at the hospital on images of his brain.

The CT taken in Sidney was shown in court. Niebergall identified blood around the brain in this scan, which included subarachnoid and subdural blood.

"It's bright white blood and that means it's new," she said.

Blood appears this bright on a scan 20 minutes to three days following any injury, she said. At the point when this scan was taken, on Sept. 13. 2011 when the infant first began showing symptoms, the brain was normal and healthy, she added.

"A normal healthy baby does not have blood to this degree all over his head at two months of age," Niebergall said.

She did not recognize any old blood. Birth can cause this trauma, she said, but it usually resolves within 2-4 weeks. Niebergall reviews many brain scans of children soon after birth. The subdural hematomas she's encountered are almost always resolved within that time frame. She denied evidence of any direct blows to the infant's head.

The fact that the brain isn't very swollen in this scan means the injury occurred within 24 hours of the scan, she said.

An MRI taken three days later was also shown to the jury. This scan displayed swelling on the back of the brain.

Some studies say blood will show up brightest on day three after trauma, and this scan was taken three days after the infant's initial trip to the hospital on Sept. 13, 2011.

"They're incredibly bright, this is as bright as it gets," she said.

In this image Niebergall could see that the back of the brain was normally developed but it had lost some of its blood supply.

Another MRI from December 2012 was shown in court Thursday, as well.

"What was nice, normal plump brain in the back parietal is now shrunk and scarred," Niebergall said.

It is atrophied, she said, which is caused by loss of oxygen and means it's partially dead.

"I believe this baby was shaken," she said.

She also opined that the shaking took place on the day the symptoms appeared.

On cross examination, Niebergall admitted that doctors sometimes disagree about scans, because of different training and what they hold to be more or less important.

If the subdural hematoma grows large enough, it's possible for the body's healing mechanisms to delay and for the injury to get out of hand, she said, causing it to continue for longer after birth.

She admitted she could not tell the jury if the infant suffered a subdural hematoma at birth. She also acknowledged that an infant could lose oxygen during a seizure, but to cause the damage she saw in the MRI images, it would have to last several minutes. Niebergall also confirmed that some physicians have issue with a shaken baby diagnosis when there is no apparent trauma to the neck. There was no apparent neck trauma in this case.

Niebergall disagreed with Uscinski that the area where blood is found was of significance. The area of the bleed doesn't matter, she said. There are many spaces in the brain for blood to trickle into, she said.

The state then called Dr. Michael Matthews, a family practice physician out of Sidney Regional Medical Center, where he's worked since 1992. He delivered the alleged victim, and did pre-natal checkups prior to that. It was a normal uncomplicated birth, Matthews said. There were no concerns at his checkup visits in July and the end of August. His growth and weight gain were normal.

Matthews is still the boy's primary care doctor. His initial concern after the incident in Sept. 2011 was a lag in development.

"At that point, you wanna know what's different, what has changed," Matthews said.

On cross examination, Matthews confirmed that the infant was not given a brain scan after birth to check for subdural hematomas and that he was unaware of any studies about normal birth causing hematomas.

The next witness for the state was Kathy Hickox with the Nebraska Department of Health and Human Services. She has worked licensing child care facilities in the panhandle for the past 27 years. Hickox had inspected Gipfert's in-home day care many times in the past.

Gipfert contacted Hickox after she learned that the alleged victim was hospitalized. Gipfert told Hickox that the infant cried most of the morning on Sept 13, 2011, would eat, sleep and then wake up and cry, Hickox said. The baby had been sleeping for three hours and was lethargic when his mother arrived to pick him up, she added.

Hickox said during many of her previous inspections Gipfert had commented she was thinking about retiring. After the investigation began Gipfert said she wished she had retired a few years ago and would give up child care no matter the results, according to Hickox.