Pediatrician testifies for prosecution in Gipfert trial

A child abuse pediatrician who headed the team that worked to determine the cause of the alleged victim’s injuries testified during day four 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 part in the incidences allegedly causing the two-month-old baby’s seizures and brain injuries in Sept. 2011.

Expert witness for the prosecution, Dr. Lisa Griss out of Rocky Mountain Hospital for Children where the boy was hospitalized from Sept. 13-Oct. 4, shared her theories about the infant’s injuries yesterday afternoon. This is her second time as an expert witness and she has never been asked to testify for the defense.

The infant seemed healthy on the morning of Sept. 13, 2011, but his mother discovered he was ill when she picked him up from Gipfert’s daycare that afternoon, according to the history provided to Griss. It was important to obtain a history from his parents to rule out alternative possibilities besides abuse, she said.

“[The boy] was a healthy child,” Griss said.

He had no history of trauma to explain the injuries. Although he suffered a seizure at Sidney Regional Medical Center on Sept. 13 after he was first brought to the emergency room, he did not seize again until Sept. 15, two days after he was flown to Denver. Doctors then placed the boy on IV fluids, a ventilator and a feeding tube. By the end of his stay in Denver he was breathing and eating without medical intervention.

A ventilator was necessary after his seizures became more severe to prevent oxygen loss while he endured them. Doctors had a difficult time controlling these seizures, Griss said.

Although she agreed with Dr. Ronald Uscinski, an expert witness for the defense who testified last week, that a seizure could cause oxygen loss, the one the alleged victim suffered in Sidney would not have compromised his respiratory system, she said.

“It’s my opinion that his seizure did not cause any loss of oxygen to his brain,” Griss said.

After viewing his brain scans doctors confirmed that the alleged victim suffered subdural hematomas, a subarachnoid hemorrhage and an ischemic area in the brain.

An ischemic area has lost oxygen which means the tissue is damaged or dead and will not grow back. A subarachnoid hemorrhage is bleeding in the area between the brain and the thin tissue that covers the brain and a subdural hematoma is a collection of blood on the brain, according to the National Library of Medicine.

Griss believes these injuries were caused by acceleration and deceleration. It would be very difficult to tell what the long term effect of these injuries will be in the boy’s future, Griss said.

Doctors at Rocky Mountain Hospital for Children ruled out infection as a possible cause for the injuries. The infant was put on antibiotics out of fear of a possible infection, but doctors never determined that he had one. The boy had jaundice as a baby, which is a common problem for newborns, Griss said. He received photo therapy and recovered quickly. This would not have caused these injuries, she added.

The alleged victim was discharged to his parents at the decision of law enforcement and child protective services. His discharge diagnosis was non-accidental trauma. Doctors reviewed his birth records, prior health records and the records from his initial trip to the ER in Sidney before reaching this conclusion, Griss said.

“[The infant’s] diagnosis is abusive head trauma,” she said.

This diagnosis was called shaken baby syndrome in the past, but that name is limiting because the same trauma could also be caused by a car accident, for instance.

Prosecuting attorney William Tangeman asked what the effect of shaking the baby would have.

“According to perpetrator reports, the child stops crying,” Griss said.

In Griss’s opinion, the injuries occurred sometime in between when the parents last saw the alleged victim and he appeared to be healthy until the time when he became critically ill.

“A child with these injuries is not going to appear well,” Griss said.

If a baby is fussy, but is still able to be consoled, he does not have the injuries the alleged victim suffered, she said. The amount of force required to cause this injury would be much more than that exerted during normal child care, Griss added. She was not aware of any studies that determined the level of force needed to cause these injuries to infants.

Running up the stairs and possibly bouncing the baby would not cause these injuries, Griss said. She had never seen injuries like this caused by other children around four or five years old, either.

Uscinski testified last week to his opinion that the injuries were caused by a subdural hematoma that occurred at birth and then experienced a re-bleed in Sept. 2011. Griss disagreed with this determination.

“My opinion is that it was not a result of a birth re-bleed,” Griss said.

These injuries, when they happen at birth resolve quickly, she explained. The doctors on her team observed only new blood and no old blood. Old blood would be present if it was a re-bleed, she added.

Griss confirmed that a baby born with an asymptomatic subdural hematoma would pass its well baby checks. Reports of the alleged victim’s high pitched cry on the evening he was taken to the hospital seemed consistent with the diagnosis, she said.

“Children who have traumatic brain injury often have a high pitched cry,” she said.

Don Miller, representing the defense asked Griss why she had testified that the alleged victim suffered multiple subdural hematomas while the paperwork only indicated one hematoma. She clarified that this paperwork was wrong and the boy had more than one hematoma. She confirmed that her theory as to the timing of the injury was based on the history given by the parents and not on any information about the events of the day from Gipfert. It’s inappropriate to obtain a medical history from a non-relative, she explained.

Miller asked if one were to set aside the history provided by the family, could one conclude that the injuries might have occurred over a longer time frame. Griss informed him that they could have occurred within one to three days of his arrival at the emergency room, based only on the medical information.

The symptoms of this injury would have appeared very quickly after the injury. They would begin immediately, according to perpetrator confessions, she added.

Miller asked if these injuries could be caused accidentally.

“I can tell you the force is outside the routine care for an infant and it’s violent,” Griss said.

Doctors ruled out many other potential causes for these injuries. This specific constellation of injuries is usually associated with trauma, she explained.

The majority of the literature supports that acceleration and deceleration without impact can cause these injuries, Griss said, even though some in the medical community, including Dr. Uscinski disagree with this.

Although one radiologist characterized the blood on the alleged victim’s MRI as acute and another called it sub-acute, this did not change Griss’s opinion about the timing of the injuries. Acute blood is from an injury one to three days old while sub-acute could be from an injury up to two weeks old.

“Overall, their impressions are the same,” Griss said.

These were minor differences, she said, but the radiologists were in general agreement.

In addition to an expert for the prosecution the state continued its case with testimony from other parents of children present in Gipfert’s daycare on Sept. 13, 2011. Of the 15 parents who testified, many of whom were husband and wife pairs, none noted any unusual behavior from Gipfert during drop off and pick up that day. Many testified to the cleanliness of her home and the high level of care she gave their children.

None of the parents in the home that day admitted to direct contact with the alleged victim or witnessing any interaction between him and the other adults. None of them ever noticed their children suffering any unexplained injuries during their time in Gipfert’s care.

“She kept her home immaculate,” Jessica McCormick said.

Most of them were not aware that there was a new baby at the day care and had never heard of the alleged victim.

Ben Dailey did notice the alleged victim that morning, who he said was in a swing when he and his wife arrived to drop off their daughter, who was two months old, the same age as the alleged victim at the time.

“He looked like a normal, healthy baby boy,” Dailey said.