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State v. Combs9/25/2002
abnormal mental condition, including an arterial blood gas test. The gas test revealed a condition called metabolic acidosis, which indicated that the patient's blood was highly acidic. With this information, Dr. Stiefel narrowed the problem down to approximately five potential disease processes, one of them being ethylene glycol poisoning, and started Esther on an ethanol drip with bicarbonate, the treatment of choice when ethylene glycol ingestion is suspected. Over time, Esther's condition began to improve.
Dr. Kenneth Emile Ferslew, an expert in the area of pharmacology and toxicology, testified that ethylene glycol, the chemical compound commonly known as antifreeze, is toxic if ingested. If the toxin is not removed from the person's system, two things typically occur. First, the central nervous system is depressed, the effect of which resembles alcohol intoxication. Second, the liver metabolizes the compound to form various acids, or metabolites, including oxalic acid. In a period of two to three days, the oxalic acid will bind with calcium to form calcium oxalate crystals, which causes kidney failure. If left untreated, death usually occurs within several days of ingestion. After reviewing the hospital records and studying the symptoms presented by Esther on February 18, 1997, Dr. Ferslew concurred with Dr. Steifel's opinion that she was suffering from ethylene glycol poisoning and concluded that she was also treated appropriately. During cross-examination, Dr. Ferslew was asked whether a specific test for ethylene glycol poisoning existed and whether it was performed in this case. Dr. Ferslew replied that such a test existed but, according to the medical records, it was not performed. On redirect, he explained that this was because the Medical Center did not have the ability to perform the test on site and it would have taken several days to get the results back. In a case where the symptoms of ethylene glycol toxicity are observed, as in this case, a confirmation test would be senseless because the phase of renal toxicity, which then causes death, would already have occurred.
With regard to Esther's physical state, Dr. Steifel's "head to toe" examination revealed the following: Esther was responsive to tactile stimulation, i.e., any type of touch would startle her. Old scars ran the length of her body, front and back, with the area of greatest concentration being the back and buttocks. The length of the scars varied and they appeared to be distributed horizontally. Many overlapped each other. None of the scars were recent, and the causative injuries appeared to have occurred at different times. In response to questions about the origins of Esther's scars, Evangeline Combs informed Dr. Stiefel that "Esther was a very clumsy child. She played rough. She fell a lot. And she was a very active child." Evangeline claimed that Esther had been born with clubbed feet, which contributed to her clumsiness. An examination of Esther's feet revealed "no clubbing," however. Dr. Stiefel also reported that Esther's teeth were in "horrible" condition. She had multiple dental caries (also known as "cavities"), a severe overbite, and clearly had received no dental care in recent years. Dr. Stiefel noted that, at approximately 90 pounds, Esther was emaciated and underweight for her height and build. She was also unable to fully extend her left arm, due to an injury of some kind. A pelvic examination revealed that her hymenal ring was intact with smooth borders--a finding she claimed was not inconsistent with penile penetration of her vagina.
The prosecutor asked Dr. Stiefel if, based upon her experience and training and within a reasonable degree of medical certainty, she could state whether the s
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