Ali Al-Bayati, PhD, DABT, DABVT
Toxicologist & Pathologist
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PAGE 4 CONTENTS:
Analysis of the Medical Examiner’s Autopsy
Report and His Court Testimony in the Case
of Baby Alan
IV. Analysis of the Medical Examiner’s Autopsy Report and His Court
Testimony in the Case of Baby Alan
Shashi B. Gore, the Chief Medical Examiner of District Nine Orlando, Florida
performed the autopsy on Alan Ream Yurko (case number: MEH-1064-97) at
10:15 AM on November 29, 1997 in Orlando . The main objective of this
autopsy was to establish the cause(s) of death. He stated that Baby Alan
died because of bleeding in the brain resulting from shaking of the baby
by his father, Alan Yurko. My review of Dr. Gore’s autopsy report
indicates that it lacks the accuracy and the expected minimum scientific
detail to make it reliable and useful to answer the questions about the
cause(s) of death. In addition, he did not provide the medical evidence
in his report and his court testimony in February of 1999 to support his
conclusion that baby Alan died of “Shaken Baby Syndrome.” The
following is a list of medical evidence that supports my assessment.
the baby had diabetes at the time of admission to Princeton Hospital on
November 24th, as described above (III). Dehydration, polyurea, weight
loss, and wasting are symptoms and complications of diabetes mellitus.
His weight on November 24th was 10.05 pounds, and during his stay in the
hospital, despite treatment with a relatively high volume of fluid IV,
he lost 1.05 lb (10% of his weight) in five days. Alan received 725.8
mL of fluid and red blood cells during the first twenty-four hours in
the hospital, and his output during this period was 786 mL of fluid. Net
output was 60.2 mL. Again, he was suffering from dehydration in spite
of being treated with adequate amount of fluid by IV infusion in the hospital
he was treated with antidiuretic hormone (DDAVP) on November 28th to prevent
dehydration (Table 13). Additionally, his average serum creatinine value
on November 24 was 0.45 mg/dL (75% of low normal value), and dropped to
0.2 mg/dL (33% of low normal) on November 27th (Table
12). Low creatinine is an indicator of low muscle mass and wasting
disease. Moreover, Dr. Douglas Radford Shanklin found that the fatty tissue
of baby Alan was mostly pink and granular, which is an abnormal metabolic
state that is consistent with poor development [D4].
Microscopic examination of the heart and liver function tests
description of the histology of Alan’s heart, stated above, contradicts
his statement in court in February of 1999 as well as his findings presented
on page 5 of his autopsy report. He stated in court that Translife removed
the heart with other organs prior to performing the autopsy . He described
in his report that “when the chest and the abdominal cavities are
opened it is noted that the heart, the liver with gallbladder, spleen,
pancreas, mesenteric lymph nodes and parts of the small intestine are
surgically absent as a result of organ harvesting by Translife” .
This indicates that he did not have the chance to examine the heart grossly
and to take samples for pathological evaluation. He also confirmed this
issue in his court testimony in February of 1999. He stated that the liver,
spleen, pancreas, heart and partial small intestine were donated .
blood analysis of November 24, 1997 showed that the baby had a very high
LDH level of 2411 IU/L (1148% of normal), and this indicates damage in
the cardiac muscle. The other indicators of cardiac problems are dysrhythmia,
hypokalemia, and diabetes, which are observed in this case. Also, the
serum levels of liver enzymes were elevated (Table
12). These findings contradict the statements made by the examiner
in his court testimony that the heart and the liver were normal and did
not contribute to the cause of illness and death.
Subdural hemorrhage, brain
description of the nature of the clot and bleeding, stated above, indicate
that the blood was released from the blood vessels in a continuous fashion
during the five days prior to autopsy, or, more precisely, in three stages.
The thickened clotted blood that adhered to the dura mater represents
the first stage of blood release, the clotted blood represents the second
stage, and the blood in the liquid form represents the third stage, which
is the most recent. Dr. Gary Steven Pearl, the state witness, examined
the blood clot and observed the proliferation of fibroblasts in layers.
Based on this observation, he estimated the age of the oldest portion
of the subdural hematoma to be two to five days . I also examined
the H & E stained tissue section of the meninges and observed the
proliferation of fibroblasts in the blood clot in the subdural space and
in the clot attached to the dura matter. I also observed fresh blood in
the subdural space.
the CT brain scan taken at 7:50 PM on November 24th showed the subdural
hematoma present only on the right side of the brain, and no bleeding
was seen on the left. This means that the bleeding on the left occurred
after 7:50 pm on November 24th. These facts contradict Dr. Gore’s
conclusion that the hemorrhage occurred in minutes, or even in a few seconds,
due to vigorous shaking of the head.
the medical evidence indicates that the subdural hemorrhage resulted from
damage to the blood vessel wall due to the excessive use of heparin, and
from severe hypoxia due to severe anemia, hypotension, apnea, and metabolic
alkalosis induced by excessive treatment with sodium bicarbonate (III
11). The facts in the following list support my assessment:
The baby was treated with high doses of heparin (219 IU/kg per hour) on
November 24th and 25th which is 8.8 times the recommended doses for infants.
Treatment with such doses of heparin usually leads to bleeding in and
individual already suffering from anemia, hypotension, and hypoxia.
The platelet count was reduced by 30% following the treatment with heparin,
due to clot formation induced by heparin.
The fibrinogen split product and prothrombin time were found to be elevated
on November 24th, but returning to normal on November 26th. These changes
coincide with the use of heparin on November 24th and cessation of heparin
treatment on the 26th.
The blood vessels of the meninges were swollen, as reported by Drs. Pearl
and Shanklin in their court testimony. This indicates that these blood
vessels were damaged as a result of hypoxia, metabolic changes, and/or
The brain was edematous. Fluid was released from the blood vessels because
of damage to their wall from hypoxia, inflammation, hypotension, and the
excessive use of sodium bicarbonate.
Hemorrhage was also observed in the lungs and the subdura of the spinal
cord. This shows that the damage in the blood vessels was not limited
to the brain, and resulted from metabolic changes and inflammation that
affected many sites.
The subdural hemorrhage observed in the left side of the brain on November
29th, that was absent on November 24th at 7:50 PM, also indicates that
the subdural bleeding and the bleeding in the brain occurred in the hospital.
Subdural hemorrhage, spinal cord
Gore stated that the bleeding was present only in the subdural space of
the lower thoracic, lumber, and the sacral regions of the spinal cord.
There was no bleeding found in the cervical and upper thoracic portions
of the spinal cord. Gore’s observation indicates that the bleeding
in these regions of the spinal cord occurred independently of the bleeding
that occurred in the brain. The blood did not come down from the brain
through the spinal canal. This fact is also supported by the observations
of two pathologists: Dr. Shanklin observed a fresh hemorrhage (6-12 hours
old) in the subdural space of the spinal cord. And Dr. Pearl indicated
that there was a spinal cord injury, that blood vessels were swollen and
nerve cells damaged. I also examined the H & E stained tissue section
of the spinal cord and found a fresh hemorrhage in the subdural space.
Dr. Gore and other physicians examined the entire vertebral column of
the baby, and they did not find any injury caused by trauma. These observations
indicate that the bleeding occurring in the subdural space resulted from
damage in the blood vessels due to hypoxia and from the treatment with
excessive doses of heparin.
Bleeding in the brain
information described above indicates that the hemorrhage in the brain
was very minor and only microscopic. It also shows that the brain was
edematous. The edema fluid leaks into the extracellular space either through
damaged capillary endothelial cells that have lost their barrier function
or through newly formed capillaries that have not established barriers.
Fluid in the brain increases the intracranial pressure (ICP) and this
pressure causes brain damage. ICP causes either focal or diffuse flattening
of the cortical gyri, sometimes associated with compressed or distorted
ventricles. Relatively rigid dural folds form the flax cerebri and the
tentorium cerebelli partitions in the cranial vault. Localized expansion
of the brain causes it to be displaced in relation to these portions,
producing brain herniations . On section, the white matter may appear
soft and gelatinous, and the peripheral layer of gray matter is widened.
The ventricles are usually compressed. Microscopically, there is considerable
widening of the interfibrillar spaces of the brain, which gives a loose
appearance to the white and gray matter. Swelling of the neural and glial
cells may also be present [11, p. 87-88].
baby Alan’s case, the brain edema was severe and diffused. The ICP
pressure reduced ventricle size and made the differentiation between the
cortex and medulla appear poor. The ICP in this case is certainly capable
of causing damage to the tiny blood vessels in the brain that were damaged
by hypoxia. It seems that Dr. Gore overlooked these established medical
facts and incorrectly stated that the minor bleeding observed in the brain
was caused by shaking the baby.
Douglas Shanklin examined the meninges, finding the blood vessels distended
and the meninges tremendously thickened, perhaps to eight or ten times
normal. Also present were hundreds of inflammatory cells (acute and chronic
inflammatory cells). He also observed damaged nerve cells in the brain,
and inflammatory cells in the walls of the blood vessels. Dr. Gary Pearl
also observed swollen blood vessels and chronic inflammatory cells in
the meninges. In addition, he found damaged neurons in the cerebellar
dentate nucleus. Also, cerebral edema was confirmed by Dr. Gore.
changes in tissues described above, with the presence of fever (105.8
F) and an elevated white blood cell count (20, 900/µL) that were
observed on November 24th (Table
12), indicate that the baby suffered from acute meningitis. However,
the severity of the acute inflammation in tissue was reduced by the treatment
with high therapeutic doses of antibiotics. On November 24th, baby Alan
was treated with three types of antibiotics to fight bacterial infections.
These included 20 mg gentamicin, 300 mg rocephin, and 222 mg Claforan
Treatment with the antibiotics reduced blood white blood cell count from
20, 900 to 13, 600 /µL, and body temperature from 105.8 F to 99.8
F. The antibiotics also caused a significant reduction in number of neutrophils
in the inflamed tissues.
seems that Dr. Gore overlooked the medical facts described above when
he stated that baby Alan did not suffer from meningitis. He stated that
“I examined the meninges in this case and found no evidence of meningitis”.
However, there is no description of a microscopic examination of the meninges
in his report. Also, he did not examine the cerebrospinal fluid (CSF)
at the time of autopsy to check for the presence of inflammatory cells.
He stated in court that he did not examine the CSF because it was mixed
with blood . However, he stated in his autopsy report that the CSF
fluid was clear. He reported that serial cut sections of the brain did
not show any internal hemorrhage in the brain parenchyma grossly. “The
ventricles are slightly reduced in size and the cerebrospinal fluid appears
Diffuse axonal injury
Are there any slides you have that you examined that you could show us
Below is a description of the findings of six studies that show axonal
injury present in the brain in cases of edema, hypoxia, cardiac arrest,
which are observed in Alan’s case. As noted, axonal injury due to
brain trauma cannot be differentiated from axonal injury resulting from
other causes. Therefore, all the causes that lead to an axonal injury
should be considered prior to stating that this axonal injury was caused
by a shaking force, especially in cases with no evidence of trauma.
Gore presented the minor bleeding in the retina of the right eye as evidence
in court to support his claim that baby Alan died as a result of vigorous
shaking. It is very hard to believe that Gore overlooked the medical evidence
described above that provides explanation for the factual causes of the
minor bleeding observed in the retina of right eye. His duty as a medical
examiner is to evaluate the medical evidence that explains the causes
of injuries in this case. I believe that he did not follow the standard
medical protocol in this case as required by his job and the law.
Pneumonia and lung hemorrhage
November 29th, Dr. Gore examined the lungs grossly and found that both
lungs were congested and contained irregular areas of hemorrhagic appearance.
Serial cutting sections of both lungs showed irregular areas of hemorrhages.
He also examined the H & E stained tissue sections of the lungs microscopically
and observed the presence of red blood cells and clumps of inflammatory
cells in the alveolar sacs. The inflammatory cell infiltrates are scattered
throughout one section. He stated that this picture appears to be somewhat
similar to interstitial pneumonitis. Dr. Douglas Shanklin also examined
the H & E stained tissue sections of the lungs and observed inflammatory
cells (white blood cells) present in the alveoli and in the structure
of the lung. He also found the bronchioles filled with inflammatory cells.
He identified this condition as pneumonia and said that the infection
was much older than 75 hours. Furthermore, I examined the H & E stained
tissue section of the lung and observed thickening of the interstitial
septa, bronchioles filled with inflammatory cells, and multifocal areas
of fresh hemorrhage.
The histopathology and the radiology findings described above, and the elevated body temperature (105.8 F) and white blood cell count (20, 900/µL) indicate that the baby suffered from acute pneumonia. However, the severity of the acute inflammation in tissue was reduced by the treatment with high therapeutic doses of antibiotics. On November 24th, baby Alan was treated with three types of antibiotics IV to fight bacterial infections that included 20 mg gentamicin, 300 mg rocephin, and 222 mg Claforan (Table 6, Table 7). The treatment with antibiotics reduced the blood white blood cell count from 20, 900 to 13, 600 /µL and the body temperature from 105.8 F to 99.8 F. The treatment with antibiotics also caused a significant reduction in the number of neutrophils in the inflamed tissue. It misled Gore to believe that the lesions in the lungs on November 24th were minor and not significant.
pathological changes observed in the lungs have two significant clinical
points. 1) Alan had acute pneumonia, which caused hypoxia and respiratory
acidosis; and 2) the hemorrhage in the lungs indicates that the baby was
suffering from a bleeding condition that affected many organs, and that
this bleeding was not caused by trauma. Bleeding was also observed in
the subdural area of the spinal cord, and the examination of the vertebral
column revealed no injuries due to trauma, as described in section IV-D
of this report.
clinical findings support my conclusions that the bleeding in tissues
in this case was caused by treatment with excessive doses of heparin and
sodium bicarbonate, and by hypoxia.
further stated that the cut sections of these masses showed normal appearance
of cartilage. The calluses of healing bone usually contain calcium and
not simply normal cartilage. This indicates that the masses of cartilage
observed by Gore in ribs # 5, 7, and 10 do not represent healing fractures
of these ribs. This assessment is supported by the fact that two radiologists
read the chest x-rays taken on November 24th/25th and saw only one rib
fracture (rib #6). It is also supported by Gore’s statement in court
describing the process of healing in a rib fracture. He stated that the
healing process in a rib usually starts with initial swelling of the rib
and then gradual calcium deposition in the fracture sites . I am puzzled
by the fact that Gore did not show the x-ray film of these fractured ribs
in court, but showed only photographs. He stated that he took the x-rays
and samples for pathology to confirm the presence and positions of these
healing fractures. It seems reasonable that he be asked to explain his
reason for not presenting the evidence that supports his claim.
of the medical literature reveals cases in which rib fractures that occurred
during labor were missed during initial examination of the baby. Below
is brief description of these cases.
Moreover, Fanaroff et al, explained the mechanism of rib injuries during labor as follows: Rib injury is initiated when the anterior shoulder is impacted behind the symphysis pubis, with the other shoulder attempting to descend into the posterior compartment of the pelvis. This results in compression forces on the fetal arm and thorax, leading to spontaneous rib fractures on the same side as the posterior shoulder . They also stated that the specific clinical manifestations of ribs injuries are often absent, making diagnosis difficult .
The four cases with rib fracture described above were born at term or close to term, and they had better health than baby Alan. Alan was born five weeks premature and had respiratory distress and jaundice. His mother was suffering from gestational diabetes and had chronic oligohydramnios. Skeletal and facial deformities in a fetus are some of the risks associated with oligohydramnios pregnancy. Furthermore, pregnancy in diabetics is usually associated with a higher incidence of congenital anomalies (6 to 12 percent vs. 2 to 3 percent in non diabetics) . These data point out the high possibility that Alan’s rib # 6 was fractured during labor.
prosecutor brought the issue that the rib fracture did not occur during
birth, because it was not seen in the x-ray films taken on 9/16-18, 1997.
Alan was born on 9/16/97. A rib fracture occurring during labor would
have been two days old on 9/18, and it takes at least 7 days for the calluses
to form and to show on the x-rays. Cumming reported that when a fracture
is discovered in a newborn infant, it is important to decide whether it
occurred at birth or after birth. Calcification around the fracture site
gives a useful estimate of the age of the fracture. We reviewed films
of 23 patients with fractures resulting from delivery. These fractures
occurred at three different sites: the clavicle, the humerus, and the
femur. Calcification could be seen as early as seven days after birth
and was absent for as long as 11 days after birth .
Dr. Gore stated in court that the bruise under the right eye was about five days old, and the minor contusions about 24 hours old. This means that these contusions occurred no later than November 28th, and that it happened in the hospital. The baby was admitted on November 24, 1997. Also, the baby’s mother explained in court that the bruise under the right eyelid described above was caused by an octagon baby bottle. The baby’s four year-old sister was giving the bottle to her father and accidentally hit the baby in the eye area 
court, Dr. Gore showed three photographs of the bruise under the eyelid
and the two minor contusions, and he spent time describing these minor
superficial injuries. These actions on Gore’s part are quite troubling,
because he knew very well that these minor injuries had nothing to do
with the causes of baby Alan’s illness and death. He stated that
the two minor contusions occurred at about 24 hours prior to autopsy.
This means that they occurred in the hospital and have no impact on this
case. Furthermore, he did not ask the parents of the baby for an explanation
of the minor bruise under the right eyelid. His presentation of the three
photographs of these minor injuries in the court did not serve any medical
objectives, but certainly confused the jury by making them think that
a physical force was used. He mentioned that these injuries were caused
by blunt force. I believe that Gore’s approach is not scientifically
and professionally justified, and that he should be asked to explain his
Gore did not review the case history of baby Alan’s mother during
her pregnancy with Alan. She suffered from several medical problems (gestational
diabetes, oligohydramnios, anemia, infections). Her illness caused health
problems in the fetus, as described in section I of this report, which
made the baby more susceptible to develop adverse reactions to vaccines.
Alan developed an infection and diabetes after receiving six vaccines,
which led to his cardiac arrest on November 24, 1997.
Continue to PAGE 5
Medical records of Francine Ream (1997). Florida Hospital, Orlando Florida.
Continue to PAGE 5
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