1 2 3 IPPERWASH PUBLIC INQUIRY 4 5 6 7 ******************** 8 9 10 BEFORE: THE HONOURABLE JUSTICE SIDNEY LINDEN, 11 COMMISSIONER 12 13 14 15 16 Held at: Forest Community Centre 17 Kimball Hall 18 Forest, Ontario 19 20 21 ******************** 22 23 24 May 10th, 2005 25

2
  1                        Appearances
  2  Derry Millar      )             Commission Counsel
  3  Susan Vella        )
  4  Donald Worme, Q. C )    (np)
  5  Katherine Hensel  )    (np)
  6  Jodi-Lynn Waddilove )   (np)
  7  
  8  Murray Klippenstein )  (np)      The Estate of Dudley 
  9  Vilko Zbogar       )   (np)     George and George
 10  Andrew Orkin       )            Family Group
 11  Basil Alexander    )            Student-at-Law
 12  
 13  Peter Rosenthal  )              Aazhoodena and George
 14  Jackie Esmonde   )   (np)       Family Group
 15  
 16  Anthony Ross     )              Residents of 
 17  Kevin Scullion   )              Aazhoodena  (Army Camp)
 18  William Henderson )              Kettle Point & Stony
 19  Jonathon George  )              Point First Nation
 20  Colleen Johnson  )   (np)
 21  
 22  Kim Twohig       )   (np)       Government of Ontario
 23  Walter Myrka     )   (np)
 24  Susan Freeborn   )   (np)
 25  Michelle Pong    )

3
  1                   APPEARANCES (cont'd)
  2  Janet Clermont   )              Municipality of 
  3  David Nash       )   (np)       Lambton Shores
  4  
  5  Peter Downard    )              The Honourable Michael
  6  Bill Hourigan    )              Harris
  7  Jennifer McAleer )
  8  
  9  Ian Smith        )   (Np)       Robert Runciman
 10  Alice Mrozek     )   (np)
 11  Harvey Stosberg  )   (np)       Charles Harnick
 12  Jacqueline Horvat )   (np)
 13  Douglas Sulman, Q.C. )           Marcel Beaubien
 14  Trevor Hinnegan     ) (np)
 15  
 16  Mark Sandler       )            Ontario Provincial 
 17  Andrea Tuck-Jackson )            Police
 18  Leslie Kaufman     )  (np)
 19  
 20  Ian Roland       )   (np)       Ontario Provincial 
 21  Karen Jones      )              Police Association &
 22  Debra Newell     )   (np)       K. Deane
 23  Ian McGilp       )   (np)
 24  Annie Leeks      )
 25

4
  1                   APPEARANCES (cont'd)
  2  
  3  Julian Falconer  )              Aboriginal Legal 
  4  Brian Eyolfson   )              Services of Toronto
  5  Julian Roy       )   (np)
  6  Clem Nabigon     )   (np)
  7  Adriel Weaver     )   (np)       Student-at-Law
  8  
  9  Al J.C. O'Marra  )              Office of the Chief
 10  Robert Ash, Q.C. )    (np)       Coroner
 11  
 12  William Horton   )              Chiefs of Ontario
 13  Matthew Horner   )
 14  Kathleen Lickers )   (Np)
 15  
 16  Mark Frederick   )   (np)       Christopher Hodgson
 17  Craig Mills      )   (np)
 18  Megan Mackey     )
 19  
 20  David Roebuck    )   (Np)       Debbie Hutton
 21  Anna Perschy     )   (np)
 22  Melissa Panjer   )
 23  Danya Cohen-Nehemia ) (np)
 24  
 25

1 TABLE OF CONTENTS 2 Page 3 Exhibits 6 4 5 ANDREW LEMAY MCCALLUM, Affirmed 6 Voir Dire Commences 7 Examination-in-Chief by Ms. Susan Vella 9 8 Voir Dire Concluded 9 10 Examination-In-Chief by Ms. Susan Vella 18 11 Cross-Examination by Mr. Andrew Orkin 84 12 Cross-Examination by Mr. Peter Rosenthal 90 13 Cross-Examination by Mr. William Henderson 104 14 Cross-Examination by Mr. Julian Falconer 116 15 Cross-Examination by Ms. Karen Jones 123 16 Cross-Examination by Mr. Al O'Marra 131 17 Re-Direct Examination by Ms. Susan Vella 140 18 19 JOHN FREDERICK CARSON, Sworn: 20 Examination-In-Chief by Mr. Derry Millar 143 21 22 Certificate of Transcript 280 23 24 25

1 LIST OF EXHIBITS 2 No. Description Page 3 P-390 Curriculum Vitae of Dr. Andrew Lemay 4 McCallum. 11 5 P-391 Document Number 5000004, Coroner's 6 Investigation Report into the death of 7 Anthony "Dudley" George, Feb 17/03. 20 8 P-392 PowerPoint presentation of Dr. Andrew 9 McCallum. 29 10 P-393 NAEMSP Guidelines for resuscitation in 11 penetrating TCPA (Traumatic Cardiopulmonary 12 Arrest), published in 2002. 52 13 P-394 "Minimal Volume Resuscitation", Bickell NEJM 14 1994:331:17:1105-1109. 60 15 P-395 Two (2) page Addendum to Document Number 16 5000004, page 391, by Dr. Andrew McCallum. 76 17 P-396: Curriculum vitae of Deputy Commission John 18 Frederick Carson. 144 19 P-397 Book of handwritten notes by Deputy 20 Commissioner John Carson, 1990, 1993 21 and 1994. 167 22 P-398 Document Number 2000658, Land dispute 23 Kettle and Stony Point First Nations 24 and Ipperwash Beach cottage owners. 187 25

1 LIST OF EXHIBITS (cont'd) 2 Exhibit No. Description Page No. 3 P-399 Document Number 2001062 MSGSC Briefing 4 Note, May 19/93 Re: Native demonstration 5 Camp Ipperwash. 221 6 P-400 Document Number 2002678 OPP Number 1 7 District Operational Plan, Occupation 8 of Canadian Forces Base, Ipperwash, 9 Revised 28 May, 93. 271 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

1 --- Upon convening at 9:00 a.m. 2 3 THE REGISTRAR: This Public Inquiry is 4 now in session. The Honourable Mr. Justice Linden 5 presiding. Please be seated. 6 MS. SUSAN VELLA: Good morning, 7 Commissioner. 8 COMMISSIONER SIDNEY LINDEN: Good 9 morning. 10 MS. SUSAN VELLA: The Commission calls as 11 its next witness, Dr. Andrew McCallum. 12 THE REGISTRAR: Good morning, Dr. 13 McCallum. 14 THE WITNESS: Good morning. 15 THE REGISTRAR: You can have a seat 16 there, sir, if you like. Do you prefer to swear on the 17 Bible, sir, or affirm. 18 THE WITNESS: I'll affirm. 19 THE REGISTRAR: Very good, sir. Could 20 you state your name in full for us please, for the 21 record? 22 THE WITNESS: Andrew Lemay McCallum. 23 M-C-C-A-L-L-U-M. 24 25 ANDREW LEMAY MCCALLUM, Affirmed:

1 (VOIR DIRE COMMENCES) 2 3 EXAMINATION-IN-CHIEF BY MS. SUSAN VELLA. 4 Q: Good morning, Dr. McCallum. 5 A: Good morning. 6 Q: I want to thank you for driving the 7 six (6) hours to be with us today. 8 A: You're welcome. 9 Q: Dr. McCallum, I understand that you 10 are currently in the Regional Supervisor Coroner for 11 Eastern Ontario. 12 A: That's correct. 13 Q: And have you produced a curriculum 14 vitae which accurately sets out your qualifications of 15 your professional background? 16 A: I have. 17 Q: And I wonder if you could get that 18 document. Do you have it in front of you? 19 A: I -- I don't have it with me. I 20 provided it in advance. 21 22 (BRIEF PAUSE) 23 24 COMMISSIONER SIDNEY LINDEN: Okay. 25 MS. SUSAN VELLA: I thought I didn't hear

1 an echo. 2 3 (BRIEF PAUSE) 4 5 COMMISSIONER SIDNEY LINDEN: Do you want 6 to try it again? 7 8 CONTINUED BY MS. SUSAN VELLA. 9 Q: All right. I apologize for that, Dr. 10 McCallum. I'll just start over again. 11 I understand that you are currently the 12 Regional Supervising Coroner for Eastern Ontario? 13 A: That's correct. 14 Q: And you have been since September 15 2003? 16 A: That's also correct. 17 Q: Now have you produced to the 18 Commission, a curriculum vitae which accurately reflects 19 your qualifications and background experience? 20 A: I have. I sent it electronically, in 21 advance. 22 Q: All right. And, Commissioner, I 23 wonder if you have a copy of that before you? I'd like 24 to make the curriculum vitae of Andrew Lemay McCallum the 25 first exhibit of the morning.

1 THE REGISTRAR: Exhibit P-390, Your 2 Honour. 3 COMMISSIONER SIDNEY LINDEN: P-390. 4 5 --- EXHIBIT NO. P-390: Curriculum vitae of Dr. 6 Andrew Lemay McCallum. 7 8 CONTINUED BY MS. SUSAN VELLA. 9 Q: And I understand that you obtained 10 your M.D. from McMaster University in 1980? 11 A: Correct. 12 Q: You then received -- is it the 13 F.R.C.P.C. in emergency medicine? Perhaps you could just 14 tell us what that is? 15 A: It's a higher degree in medicine 16 conferred by the Royal College of Physicians and Surgeons 17 of Canada in the specialty of emergency medicine. 18 Q: And you received that in 1987? 19 A: Correct. 20 Q: I understand that you also in 1988 21 received the diploma of the American Board of Emergency 22 Medicine? 23 A: Yes. 24 Q: Since July of 2000 you have been an 25 associate professor with the Department of Medicine at

1 McMaster University? 2 A: Yes. 3 Q: And since October 2003, you have also 4 been an associate professor, Department of Emergency 5 Medicine at Queen's University? 6 A: Correct. 7 Q: You are a member of a number of 8 professional organizations including the Royal College of 9 Physicians and Surgeons of Canada? 10 A: Yes. 11 Q: The American Academy of Forensic 12 Sciences? 13 A: That's correct. 14 Q: -- and the Canadian Association of 15 Emergency Physicians and you have held the science -- 16 scientific Co-Chair of that organization since 2002? 17 A: Actually, that was a -- that was a 18 self-limited appointment for a conference that was -- 19 that I assisted in organizing. 20 Q: Thank you. From July 2001 to August 21 2003 you were Chief of Staff at Hamilton Health Sciences 22 Corporation? 23 A: Yes. 24 Q: From 1998 to July 2001 you were the 25 Chief of Emergency Medicine at Hamilton Health Sciences

1 Corporation? 2 A: That's correct 3 Q: And the Medical Director of the 4 Emergency Program at that organization? 5 A: That's correct 6 Q: You were also the Vice-Chair of the 7 Medical Advisory Committee of the Hamilton Health 8 Sciences Corporation? 9 A: Yes. 10 Q: From December 2000 to January 2002, 11 you were the Regional Medical Liaison? 12 A: That's correct. 13 Q: And from November 2000 to the present 14 you have been a coroner for the Province of Ontario, 15 Ministry of the Solicitor General. 16 A: That's right. 17 Q: As well, over the course of your 18 career you have been a consultant in varying capacities 19 with respect to emergency medical services? 20 A: That's correct. 21 Q: That includes, for example, having 22 been the Consultant to the Minister of Health in the 23 state of Kerala, India in association with their med and 24 -- sorry, in -- in connection with designing an emergency 25 medical services system for that state?

1 A: That's right. 2 Q: In February of 2000 you were a 3 consultant in Mount Sinai Hospital in their utilization 4 of ambulance diversion? 5 A: Yes. 6 Q: In February of 2001 you were a 7 consultant to the University Health Network to provide an 8 external review of their Emergency Department? 9 A: That's correct. 10 Q: And to provide a review of the 11 University Health Network's emergency services? 12 A: That's right. 13 Q: You have conducted numerous reviews 14 of care -- medical care -- conducted for the Chief 15 Coroner for Ontario in -- in various Emergency 16 Departments? 17 A: That's right. 18 Q: From 1993 to 1998 you were the 19 Director for the Department of Emergency Services for 20 Sunnybrook Health -- Health Science Centre? 21 A: Yes. 22 Q: You were also a Medical Director for 23 the Advanced Cardiac Life Support Instructional Program 24 at Sunnybrook? 25 A: That's correct.

1 Q: Prior to that from 1990 to '93 you 2 were the Chief of Emergency Medicine for St. Joseph's 3 Community Health Centre in Hamilton? 4 A: That's right. 5 Q: And prior to that, an emergency 6 physician at St. Joseph's Hospital? 7 A: Yes. 8 Q: And before that, an emergency 9 physician for the Toronto General Hospital? 10 A: That's right. 11 Q: You've also received various honours 12 from your colleagues from time to time -- 13 A: Yes. 14 Q: -- as listed at page 6 of your 15 curriculum vitae? 16 A: That's -- that's correct. 17 Q: You've also held and been engaged in 18 many professional development activities outlined at 19 pages 7 to 8 of your curriculum vitae, including the 20 Chair of the Board of Examiners in Emergency Medicine of 21 the Royal College of Physicians and Surgeons of Canada 22 from 1994 to 1996? 23 A: That's right. 24 Q: A member of the Board of Examiners in 25 Emergency Medicine of the Royal College of Physicians and

1 Surgeons of Canada from 1989 to 1984 -- to '94? 2 A: Yes. 3 Q: And a member of the Specialty 4 Committee in Emergency Medicine for the Royal College of 5 Physicians and Surgeons in Canada from 2001 to the 6 present? 7 A: Actually, that terminated in 2003; 8 that's -- that's -- yes. 9 Q: Thank you -- thank you very much. As 10 well, you have been a member from time to time of various 11 university committees? 12 A: Yes. 13 Q: That's listed at page 8 of your 14 Curriculum vitae and that would include from 1990 to 1993 15 being a member of the Emergency Medicine Post Graduate 16 Education Committee for McMaster University? 17 A: That's right. 18 Q: And as well, you've been on a number 19 of hospital committees listed at pages 8 through 10 of 20 your curriculum vitae including from 2001 to 2003 the 21 Chair of the Medical Advisory Committee for Hamilton 22 Health Services? 23 A: That's correct 24 Q: From 1993 to 1998 you were a member 25 of the Trauma Physician Management Group for Sunnybrook?

1 A: Yes. 2 Q: And from 1988 to 1993 you were a 3 member of the Acute Care Committee for St. Joseph's 4 Hospital in Hamilton? 5 A: Also correct 6 Q: You are also the recipient of 7 research awards, which are -- are listed at page 10 of 8 your curriculum vitae? 9 A: Yes. 10 Q: And you are the author or a co-author 11 of a number of peer reviewed publications listed at pages 12 10 to 11 of your curriculum vitae? 13 A: Yes. 14 Q: That would include, for example, the 15 author of -- of a article in the Canadian Association of 16 Emergency Physicians Review entitled "Negative Diagnostic 17 Lavage in Blunt Abdominal Trauma"? 18 A: Yes. 19 Q: And in 19 -- the 1991 Canadian 20 Medical Association Journal, co-author of a comment 21 called "A Survey of resuscitation Training in Canadian 22 Undergraduate Medical Programs"? 23 A: That's correct. 24 Q: As well in 1996, you were co-author 25 of an article entitled "Pre Hospital Interventions:

1 Critical Resuscitation's Number 1"? 2 A: That's correct. 3 Q: And also the author of a -- editor of 4 a non-peer reviewed document entitled: "The Road to 5 Survival: A Review and Recommendations for Enhancement 6 of Emergency Medical Services System in the State of 7 Kerala, India"? 8 A: Correct. 9 MS. SUSAN VELLA: Commissioner, I would 10 like to at this time, tender Dr. McCallum as an expert in 11 emergency medicine, including emergency procedures and 12 pre-hospital and in-hospital assessment and treatment of 13 penetrating trauma to the torso. 14 COMMISSIONER SIDNEY LINDEN: Does anybody 15 have any comment or question? That's fine. 16 MS. SUSAN VELLA: Thank you. 17 18 (VOIR DIRE CONCLUDES) 19 20 EXAMINATION-IN-CHIEF BY MS. SUSAN VELLA: 21 Q: Dr. McCallum, were you asked by the 22 office of the Chief Coroner to undertake a project in 23 relation to the circumstances relating to the death of 24 Anthony O'Brien George, also known as Dudley George? 25 A: I was.

1 Q: What were you asked to do? 2 A: I was asked specifically to review 3 the -- Mr. Commissioner, may I refer to my -- my report? 4 Q: Certainly. 5 6 (BRIEF PAUSE) 7 8 A: I was asked specifically to review 9 the -- the circumstances surrounding the care that Mr. 10 George received after he had been shot. 11 Q: So from the point of the gunshot 12 wound to the -- to the moment he was pronounced? 13 A: Correct. 14 Q: Thank you. And did you write a 15 report which sets out your key factual findings, 16 conclusions, and opinions in that regard? 17 A: I did. 18 Q: Is your report dated February 17, 19 2003? 20 A: That's correct. 21 Q: And it accurately sets out all of 22 your factual findings, conclusions and opinions? 23 A: There is -- there are a couple of 24 minor typographical errors but, yes, it does. 25 Q: Thank you. Commissioner, I'd like to

1 tender the expert report of Dr. Andrew McCallum, dated 2 February 17, 2003, as the next exhibit. 3 THE REGISTRAR: P-391. 4 COMMISSIONER SIDNEY LINDEN: P-391. 5 6 --- EXHIBIT NO. P-391: Document Number 5000004, 7 Coroner's investigation 8 report into the death of 9 Anthony "Dudley" George, 10 February 17/03 11 12 CONTINUED BY MS. SUSAN VELLA: 13 Q: For the record, that's Inquiry 14 Document Number 5000004. 15 Now, in preparation of your report, did 16 you review certain documents? 17 A: Yes, I did. 18 Q: Can you advise the Commission as to 19 what documents you reviewed in preparation of your 20 report? 21 A: I reviewed the medical chart for Mr. 22 George. I reviewed the repot of the post-mortem that was 23 done after the -- after his death. I -- I had some 24 information as well from the investigator who 25 investigated on behalf of the office of the Chief

1 Coroner. 2 I had the toxicology report that was done 3 -- report of the toxicologic examination, I should say. 4 And there were some other documents, I don't have the 5 list of them here with me, but there were other documents 6 as well. 7 Q: And you indicated you relied on 8 interviews conducted by an investigator on behalf of the 9 Chief Coroner. Was that Detective Armstrong? 10 A: That's correct. 11 Q: Did you also bring to bear your 12 general expertise in developing your findings, 13 conclusions, and opinions? 14 A: I did. 15 Q: Did you make any key assumptions 16 underlying your -- your opinion? 17 A: No. 18 Q: And are there any important 19 limitations to your opinion? 20 A: Well, the obvious limitation is that 21 I wasn't there for the events and therefore wasn't a 22 direct observer. 23 Q: All right. 24 A: And all of what I received was after 25 the fact recording and/or account by the detective

1 involved with the witnesses statements. 2 Q: As a result of your review, did you 3 form any factual findings underlying your conclusions and 4 opinions? 5 A: Well, obviously the -- the -- the key 6 fact was that Mr. George had been shot and that his -- 7 that -- that the gunshot that caused his death had 8 entered his chest, the -- the bullet had entered the 9 chest and had severely lacerated -- or, I should say 10 lacerated the pulmonary arteries on the left side. 11 And it was my opinion after viewing the 12 documents that that was what caused Mr. George's death. 13 Q: And did you set out the -- your key 14 factual findings under the heading "Review of Events" in 15 your expert report? 16 A: I did. 17 Q: Can you summarize your key findings 18 in relation to the means and timing of Dudley George's 19 transport from the Ipperwash Provincial Park to the 20 Strathroy Middlesex General Hospital on the evening of 21 September 6th, 1995? 22 A: My understanding is that he was, 23 after being shot, was loaded into a car and driven to the 24 actual Army Base itself. And at that point he was 25 transferred to another private vehicle.

1 The private vehicle was -- I think he was 2 accompanied by three (3) individuals at that time. My 3 information was that he was accompanied by three (3) -- 4 three (3) individuals. And the vehicle left the Army 5 Camp and drove -- and I think in my original report I 6 said drove north, but in fact, I understand because of 7 later information I received that the car was taken 8 almost directly south immediately, and then drove -- 9 driven on back country roads towards Strathroy. 10 I believe that the occupants of the car 11 were -- were very aware that -- how seriously injured Mr. 12 George was, and felt that they needed to get him to 13 hospital, based on the information provided to the -- to 14 -- to Detective Armstrong. 15 It proceeded along the back country roads, 16 and at a point stopped, and assistance was sought from 17 the occupants of a nearby farmhouse. 18 And the reason I gather that this -- that 19 the car was stopped is because they had a flat tire, and 20 they were concerned whether or not they'd be able to 21 continue on. And an ambulance was called at that point, 22 according to the information I received. 23 They waited some period of time, several 24 minutes I understand, but I -- I gather became concerned 25 that further waiting would be harmful to Mr. George and

1 therefore elected to proceed in their car again towards 2 Strathroy. And that they did, even though my information 3 was that the tire had burned back to the rim. They 4 proceeded southbound. 5 The information I received was that during 6 the first part of the trip, Mr. George was making some 7 movements. But that by the time they got to the 8 farmhouse, and -- and this time is difficult to estimate 9 but I gather it was some ten (10) or fifteen (15) 10 minutes, he had stopped making any kind of movement. 11 The occupants -- the -- the rear seat 12 occupant who was sitting next to him felt that there was 13 still some -- some heartbeat that -- that could be heard, 14 but I -- the information I have on that was not clear to 15 me. 16 They did ask for assistance at the 17 farmhouse in the form of some bandages, and I believe 18 they received some clean cloth and attempted to continue 19 to apply pressure to the wound around Mr. George's 20 collarbone area. 21 The vehicle continued southbound, and my 22 information was that it reached Strathroy, and the 23 Strathroy Middlesex Hospital some minutes after midnight 24 -- several minutes after midnight. 25 At that point, Mr. George -- the -- the --

1 the car stopped in the parking lot and my understanding 2 is that the other occupants of the car were taken into 3 custody. 4 Mr. George was removed. I believe there 5 may have been several minutes delay into the hospital 6 where resuscitation was commenced. 7 The -- as it happened, my understanding is 8 that by coincidence there was a general surgeon in the 9 hospital as well as the physician on duty in the 10 emergency department. And together they attempted to 11 resuscitate Mr. George using what would, in my opinion, 12 be conventional means of resuscitation -- 13 Q: All right, can we just -- 14 A: Certainly. 15 Q: -- back up, and I'll just stop you 16 there for a moment, thank you. Now, is it your 17 understanding that -- or, did you form an understanding 18 as to whether any medical intervention or first aid 19 intervention was attempted en route to the hospital, 20 aside from the application of pressure to the wound and 21 the application of the clean cloth in that respect? 22 A: I understand that was the limit of 23 the first aid at the time. 24 Q: All right, and now can you summarize 25 your key findings concerning what medical care was

1 provided to Dudley George once he arrived at the 2 Strathroy Middlesex General Hospital, including the -- 3 the -- at the time of arrival to the time of 4 pronouncement? 5 A: My understanding is that he was 6 brought into their resuscitation area in the Emergency 7 Department. It was discovered that he had no vital 8 signs, and -- and that means that he had no respiratory 9 movements, no -- no breathing; he had no audible heart or 10 pulse, that could be palpated. 11 Further, he had a rhythm, on the 12 electrocardiograph, when the monitor leads were 13 connected, that's known as a systole, which means cardiac 14 standstill. There was no electro-cardiographic activity 15 of the heart at all. 16 The first therapy was that he had a tube 17 inserted into his trachea, or his windpipe, to assist in 18 breathing. And he had what's known as positive pressure 19 ventilation, with a bag, to insufflate, or force air into 20 the lungs to allow for oxygenation. 21 Q: This is where you have a mask put 22 onto the -- the face of the subject, and an air bag 23 that's squeezed to force oxygen? 24 A: Well, when the tube is placed in the 25 trachea, the mask is no longer necessary.

1 Q: Okay. 2 A: You can connect the bag directly to 3 the tube. 4 Q: Okay. 5 A: It's a -- you get a better seal, and 6 -- and better air insufflation into the lungs when that's 7 done. As well, he had two (2) large bore, which means 8 large-sized IV catheters inserted. And that's important 9 because larger catheters can infuse fluid faster, just -- 10 the basic laws of physics allow that; and so that was 11 done. 12 It's not, based on the records that I had 13 available to review, clear how much liquid was actually 14 infused during the resuscitation attempts. He had chest 15 compressions, or CPR as well, as I mentioned positive 16 pressure ventilation started, and the cardiac rhythm 17 remained a systole throughout. 18 Q: Meaning that there was absolutely no 19 -- no functioning of the heart at that time? 20 A: That's correct. 21 Q: And lastly, would you summarize, 22 then, your factual findings with respect to the -- the 23 cause of death and impact of the gunshot wound on the 24 various bodily functions and parts of Dudley George? 25 A: Mr. -- Mr. George died because of

1 severe intrathoracic haemorrhage caused by laceration of 2 the pulmonary arteries on the left side, due to the 3 bullet, which entered his chest above the left clavicle 4 or left collarbone. 5 Q: Can you -- can you explain in 6 layperson's language what -- what that means, please? 7 A: What happened was that Mr. -- Mr. 8 George suffered a significant amount of blood loss, into 9 the cavity of his chest, as a consequence of laceration 10 of the pulmonary arteries. 11 The pulmonary arteries -- the heart, 12 you'll remember, has two (2) sides; it has a right side 13 and a left side. The right -- 14 Q: I'm wondering -- I'm sorry, just 15 before you carry on, would it be helpful to go to any of 16 your slides in this respect? 17 A: I think it may be useful to go to 18 Slide 14. 19 Q: All right. And just before we do 20 that, Dr. McCallum, I understand that you have prepared a 21 PowerPoint presentation to assist in your testimony 22 today? 23 A: That's correct. 24 Q: And you did that at our request? 25 A: I did.

1 Q: And I'd like to make the PowerPoint 2 presentation of Dr. Andrew McCallum the next exhibit, 3 please? 4 THE REGISTRAR: P-392, Your Honour. 5 COMMISSIONER SIDNEY LINDEN: P-392. 6 7 --- EXHIBIT NO. P-392: PowerPoint presentation of 8 Dr. Andrew McCallum 9 10 THE WITNESS: If you just punch in "14" 11 and enter, it'll go to the... 12 13 (BRIEF PAUSE) 14 15 THE WITNESS: I think you can just page 16 up to it -- to slide one (1). There we go. And then if 17 you just put it back in the slide show that will -- the 18 bottom left -- the bottom left little slide icon there, 19 on the bottom left of the... 20 MS. SUSAN VELLA: Right. 21 THE WITNESS: Just above your arrow. 22 Right there. Just go one (1) -- there you go, that's the 23 one. Thank you. 24 This -- this is a schematic diagram of the 25 thorax, and I apologize in advance, I recognize that

1 these may be difficult images for -- for some in the room 2 to see so I want to -- I want to acknowledge that. 3 But these -- this schematic diagram shows 4 the -- 5 COMMISSIONER SIDNEY LINDEN: Excuse me. 6 Is the sound -- some folks are having difficulty hearing 7 you. 8 MS. SUSAN VELLA: Perhaps you would use-- 9 COMMISSIONER SIDNEY LINDEN: There is a 10 microphone. 11 MS. SUSAN VELLA: -- the hand microphone 12 there -- 13 THE WITNESS: Oh, certainly. 14 MS. SUSAN VELLA: -- that would be a 15 little bit easier. Thank you. 16 THE WITNESS: Is that better? 17 COMMISSIONER SIDNEY LINDEN: I don't 18 know, we'll see. I'm not sure if it is. Is the hand mic 19 working? 20 MS. SUSAN VELLA: Could you just test it 21 again? 22 THE WITNESS: Test, test. 23 24 CONTINUED BY MS. SUSAN VELLA. 25 Q: Thank you.

1 A: This schematic diagram shows the -- 2 the anatomy of the chest in very simplified terms, but 3 the key things to look at are the -- the blue and the red 4 vessels that emerge from the heart. 5 The red side is the arterial side, the 6 high pressure, oxygenated blood that is pumped from the 7 left side of the heart. The blue side is the venous 8 system. The -- the blue vessels here bring blood back to 9 the right side of the heart, to the right atrium, where 10 it is then transmitted through into the right ventricle. 11 And the right ventricle pumps the blood 12 through the pulmonary arteries into the lungs where it's 13 oxygenated. 14 15 (BRIEF PAUSE) 16 17 Q: Which slide would you like next? 18 A: Slide 15, please. That's great. You 19 can see, in this slide, that I've -- that I've inserted 20 an arrow which schematically represents the path of the 21 bullet that -- that entered Mr. George's chest. 22 And where the arrowhead is situated, one 23 can see where the pulmonary arteries would have been 24 injured. And that again, this -- this is not an exact 25 representation, but more of a conceptual one, to assist

1 the Commission in understanding the injury. 2 Next slide please. 3 4 (BRIEF PAUSE) 5 6 Q: Which number; 16? 7 A: That would be 16. 8 Q: Yeah, thank you. 9 A: Mr. O'Marra, if you just type in 10 sixteen (16) it'll go automatically to it -- sixteen (16) 11 enter. 12 MR. AL O'MARRA: No. I'm not sure we can 13 get it. 14 MS. SUSAN VELLA: For some reason my 15 numbering isn't -- isn't working. 16 THE WITNESS: Maybe your number lock is 17 on. I suspect that's what it is. 18 19 CONTINUED BY MS. SUSAN VELLA. 20 Q: There you go. 21 A: This is another diagrammatic 22 representation of the chest itself, and this one has 23 obviously a lot more vessels evident in it. It's less 24 schematic, and this is probably closer to the true -- I 25 know it's closer to the true anatomy of the -- of the

1 chest itself. Next slide please. 2 What happened, in Mr. George's case, was 3 that as a consequence of the bullet entering his chest, 4 and damaging the pulmonary arteries here. He had 5 bleeding in the amount of about one (1) litre of blood 6 that was found at autopsy. 7 And the critical thing is that in a -- in 8 a normal sized individual, which Mr. George was, a person 9 of average stature, a male, there are some five and a 10 half (5 1/2) to six (6) litres of blood in the total 11 blood volume that's circulating, ordinarily. 12 Mr. George lost a litre of blood, but the 13 key thing, in his case, was the speed with which it was 14 shed. And that resulted in a number of deleterious 15 physiologic affects, in my opinion. 16 So although the amount of blood shed was 17 only about a litre, and that, though a significant amount 18 of blood, would -- would not ordinarily -- if it was shed 19 slowly, had been fatal in his case. Because it was shed 20 quickly, I believe that this led to the fatal outcome. 21 Q: And what were the physiological 22 results of the rapidity of the blood loss here? 23 A: If we could go to, just bear with me 24 a second here, if we could go to slide 2. If it would be 25 all right, I'll outline that. In order to understand

1 that, one has to understand some basic physiology and I 2 apologize to -- to those of you who have left science a 3 long time ago. 4 To understand this, you need to understand 5 that the major force, it affects all this, and the body 6 is osmosis. And osmosis is defined as the -- is the 7 passage of water from a region of high water 8 concentration through a semi-permeable, meaning it's only 9 partly permeable to the passage of either water or 10 solutes, to a region of low water concentration. 11 All body fluids are solutions, all of them 12 have dissolved substances, so therefore osmosis is always 13 working in the body. 14 The strength and concentration, or 15 concentration of a solution, is inversely proportional to 16 the water concentration. The higher the salt 17 concentration in any water, for example, the lower the 18 water concentration; it just makes -- they're both 19 opposites. 20 And we know that the cell membrane 21 permeability isn't constant, it's not always the same, 22 like in the old experiments we used to with sugar and the 23 potato in the classroom, it changes. And it changes in 24 the body due to a number of factors, but one (1) -- the 25 most important one is energy.

1 And energy in the body is supplied through 2 the provision of substances like sugars, proteins, to the 3 cells. The blood supplies that, and so when the blood is 4 not pumping normally, those energy stores and -- and 5 supplies are significantly affected. And therefore the 6 cell membrane -- cell membrane is affected as well, and 7 its permeability changes. 8 If you look at the composition of the 9 body, I'll just try to represent this diagrammatically. 10 Next slide, please. The body is 60 percent water, 11 ordinarily, and of that water -- next slide, please. 12 Q: And for the record, this is now slide 13 4. 14 A: Yes. The body fluid is about one 15 third (1/3) found outside the cells. These are the 16 fluids that bathe the cells, and this includes the fluid 17 that's found in the bloodstream itself. 18 Two-thirds (2/3) of the body's water is 19 found inside the cells of the body. 20 Next slide, please. 21 Q: Slide 5. 22 A: A quarter of the fluid that's found 23 in the extra cellular, or outside the cells, is actually 24 inside the blood vessels. And that's important when one 25 considers how one resuscitates a person from shock,

1 because whatever fluid ones gives to this -- to the 2 person will equilibrate, because of osmosis, throughout 3 the entire fluid outside the cells. 4 The fluid inside the cells is largely 5 unaffected by resuscitation, at least in the early stages 6 of care. 7 Next slide, please. And go one (1) more, 8 please. 9 The major solute found in the extra 10 cellular fluid, the fluid outside the cells, is sodium 11 chloride and that's why the -- all the substances that we 12 use to resuscitate people are based on that salt. 13 Standard -- normal saline, Ringer's Lactate, they're all 14 based on that -- on those salts. 15 Inside the cells the major solute is 16 different. It's potassium phosphate. We don't use -- we 17 use very little phosphate in acute resuscitation, and the 18 reason is that we're not really worried about this fluid 19 at the early stage of our resuscitation. We're really 20 worried about this fluid, the extra cellular fluid, and 21 in particular, the fluid that's found inside the blood 22 vessels. 23 Q: All right, which is the one-quarter 24 (1/4) mark that you've got there. 25 A: That's correct.

1 Q: One-quarter (1/4) of sodium chloride 2 is within the blood? 3 A: That's right. One-quarter (1/4) of 4 the total sodium chloride found in the extra cellular 5 fluid, yes. 6 What keeps the fluid inside the blood, and 7 inside the cells, is the presence of large proteins which 8 exert osmotic pressure, and they keep fluid inside those 9 cells, ordinarily. 10 Next slide, please. 11 Now shock -- and this is quite important; 12 colloquially, shock is often referred to the state that 13 happens after a traumatic event, the stunned, or kind of 14 numb feeling that one gets. 15 But, in fact, physiologically, shock is 16 something quite specific. And it is the presence of 17 inadequate tissue blood flow, leading to irreversible 18 tissue damage and death, if not treated. 19 Next -- next, please. 20 Clinically, this is observed by 21 physicians, and nurses, and ambulance people, as the 22 presence of low blood pressure, high heart rate, 23 confusion, blue extremities, and death. I've put 24 confusion in twice. Next slide, please. 25 Now ordinarily, a person can respond to

1 haemorrhage or shock, physiologically, by the -- by a 2 number of mechanisms. The presence of clotting, clotting 3 is an important means of stopping the flow of blood, 4 obviously. 5 It would not have been very effective in 6 Mr. George's case, because he had a large vessel injury 7 in the right side -- low pressure circulation and 8 bleeding would have occurred quite quickly in that 9 situation. 10 Second is the ability of blood vessels to 11 constrict. They're not hoses like the garden hose, they 12 can actually vary their calibre and constrict down. And 13 the benefit of this is that, of course, at the site of 14 the bleeding can stop the bleeding, but also the 15 constriction occurs selectively to divert blood to what 16 are called the noble organs, the -- the organs that are 17 critical to life. The heart, kidneys, liver, and brain. 18 And that's why the extremities become 19 blue, because the blood flow to the extremities is shut 20 down; those areas are non-essential. Next please. 21 Also, shock hormones are released and the 22 heart and breathing rate increase. Shock hormones 23 include things like adrenaline -- adrenaline, which 24 causes further constriction of the blood vessels, speeds 25 up the heart and allows for the body to -- to compensate

1 to some degree. 2 Cortisol is hydrocortisone; it's a -- it's 3 a -- it's a beneficial substance in shock. What one 4 sees clinically again is an increase in the heart and 5 breathing rate; blood pressure falling. And the reason 6 blood pressure falls is because the blood -- blood 7 vessels are constricted maximally; and fluid shift. And 8 this is beneficial because it allows fluid to shift into 9 the blood vessels and augment or replace in part at 10 least, the blood that's been shed. 11 Q: All right. So, -- so just before we 12 get to the next shot, just so that I understand, perhaps 13 we go back, these are -- these -- these are bodily 14 responses which will occur as soon as, or should occur, 15 as soon as there is unusual blood -- blood loss from a 16 blood vessel? 17 A: That's correct. 18 Q: And the -- the point of these 19 interactions or interventions is to slow down -- 1. Slow 20 down the rate of blood loss because the vessels are being 21 constricted. 22 2. Divert existing blood supplies to the 23 most important organs. 24 And 3. The heart beats faster in order to 25 more effectively pump or circulate a restricted or a

1 limited volume of blood? 2 A: That's correct. 3 Q: Is that essentially what happens? 4 A: That's -- that's essentially it. 5 Q: And that's the -- that's the natural 6 bodily process without any medical -- 7 A: Right. 8 Q: -- intervention? 9 A: That's correct. And that occurs 10 within seconds to minutes of the injury actually 11 occurring. 12 For example, clotting is essentially 13 complete within eight (8) minutes after -- after one gets 14 cut, and you know that if you cut your finger. 15 And so that -- that -- that occurs even in 16 major injuries. Unfortunately, with large holes in 17 vessels, clotting's not enough to stop the bleeding. 18 Q: All right. And that's because the -- 19 the blood loss is just too quick -- 20 A: Well, the hole -- 21 Q: -- for the clotting to function? 22 A: -- the hole is too big. 23 Q: Okay? 24 A: So, a clot can -- clotting is most 25 effective at the capillary or very small blood vessel --

1 blood vessel level. 2 Constriction, on the other hand, is more 3 effective in bigger blood vessels so it's a -- it's a -- 4 very much a -- a complex interplay between all the 5 factors that -- that come to bear. 6 Now, unfortunately in some people if the 7 shock proceeds far enough, the massive dead or dying 8 cells reaches a critical point, and at that point shock 9 can not be recovered from. There are too many cells that 10 have been damaged. 11 Next please. Salvage, unfortunately, at 12 that point is impossible. 13 Q: In other words, notwithstanding any 14 intervention, any resuscitation events, no matter how 15 much fluid you pump into the system, it's too late? 16 A: That's correct. This -- one (1) of 17 the markers of this is the presence of cardiac arrest, 18 and it's well known among the group of people who 19 resuscitate trauma victims that cardiac arrest is 20 something to be avoided at all costs, because once it's 21 occurred it's -- it's a -- it's a very important marker 22 of a dismal prognosis. 23 Q: In other words -- 24 A: So, that if one -- when resuscitating 25 someone has someone who is very, very ill during trauma

1 resuscitation, the key thing is to keep that person's 2 heart going, and -- and this is obviously, intuitively, 3 would -- would seem to make sense. 4 But, in fact, it makes physiologic sense 5 as well, because if it occurs, if arrest occurs even if 6 one is able to resuscitate the person from that cardiac 7 arrest, it's likely that down the road that death will 8 still occur -- 9 Q: All right. 10 A: -- because it's an important marker 11 that there's been irreversible shock. 12 Q: And just to ensure that, for the 13 record, cardiac arrest is when the heart stops? 14 A: That's correct. 15 Q: Okay. 16 A: Next please. Obviously the goal in 17 shock resuscitation then is to restore adequate tissue 18 blood flow and oxygenation. 19 It's -- contrary to what one might think 20 watching the television shows, it's not just to give IV 21 fluid and -- and to get the blood pressure up to where 22 it's in the normal range. 23 It's, in fact, to get proper blood flow to 24 the organs, and there are many ways to measure that 25 beyond just taking blood pressure, that go beyond the

1 scope of this discussion. 2 Q: All right. And just blood flow means 3 not -- not necessarily the volume of blood, but getting 4 blood from point A to point B, that process? 5 A: That's correct. 6 Q: And oxygenation is ensuring there's 7 sufficient oxygen in the blood cells in order to be 8 functional? 9 A: That's right, and if -- the next 10 slide will I think make that clear. 11 How's this done? Well, the heart is a 12 pump, and like any pump the heart needs to be primed. So 13 having an appropriate amount of blood coming back to the 14 heart through the venous system is almost as important as 15 having enough blood in the -- in the system itself, 16 because the heart responds to the -- the fluid that's 17 presented to it; it will pump more if more fluid is 18 there. 19 So that's the first thing. And that's 20 what the IV fluids do, they prime the pump. 21 However, in very severe shock, there may 22 be too many red blood cells lost to allow for oxygenation 23 to occur normally and in those cases it's necessary to 24 give transfused blood, to give red blood cells from 25 outside the body in order to restore and ensure adequate

1 tissue oxygen delivery. 2 The oxygen delivered to tissues actually 3 varies with the -- we've heard already about the 4 haemoglobin level, but also the cardiac output, which is 5 why the heart beats faster, because the heart rate and 6 the amount of blood pumped with each contraction of the 7 heart are the two (2) major determinants of cardiac 8 output. 9 And then finally, the oxygenation of the 10 blood. It's why oxygen is given to all people who are in 11 extremis, especially from trauma, to ensure that there's 12 no deficit of oxygen going to the haemoglobin. 13 Q: And what is, "extremis"? 14 A: Extremis means somebody who's near 15 death. Next, please? 16 How is this done, then? Practically 17 speaking, there are a series of steps which are followed 18 in almost every case, in logical order and this is what 19 people learn in -- they're very much akin to what learn - 20 - people learn in basic cardiac life support, so it's A, 21 B, C. 22 The airway's opened and in very severely 23 old people the trachea would be intubated; this was done 24 in Mr. George's case. Respirations need -- are assisted 25 using the bag valve mask or bag valve tube device.

1 Oxygenation is ensured by giving extra oxygen at that 2 point. Haemorrhage is controlled with external pressure 3 where possible. 4 Unfortunately, in Mr. George's case, 5 despite the best efforts of the people who were with him, 6 that wasn't possible because the bleeding was internal, 7 inside the chest cavity. 8 The chest cavity, itself, is a large 9 space, in the normal person it's between five (5) and 10 seven (7) litres volume, so one could literally bleed an 11 entire blood volume in there with no pressure possible 12 and that's -- that's an important factor here. 13 Q: So, in other words, the individuals, 14 no matter how they press on the skin surface, they're not 15 going to be able to stop that bleeding? 16 A: Correct. The -- the bleeding source 17 was deep inside his chest. Internal control is possible 18 in some circumstances and we'll come to that later on. 19 Q: Yes. 20 A: Priming the heart, as I mentioned 21 before, by giving intravenous fluid is important as well 22 in -- in managing shock. And finally, replacement of 23 shed blood by giving transfusions if the haemoglobin 24 count has gotten too low to provide normal oxygen 25 transport. Next slide, please.

1 You'll -- you'll remember from the 2 schematic diagram of the body fluid composition that I 3 emphasize that only a quarter of the extracellular fluid 4 is inside the blood vessels and fully three-quarters 5 (3/4) is in fluid bathing the tissues; that's important 6 when one's giving crystalloid because we've heard that 7 it's the same composition as the extracellular fluid. 8 So, it equilibrates throughout the 9 entirety of the extracellular fluid, meaning one has to 10 give significantly more IV, normal saline for example, to 11 replace a blood volume than if one was replacing that 12 bloodshed with whole blood. 13 So, for example, if a litre is lost, one 14 has to give three (3) litres of normal saline to 15 satisfactorily prime the pump and replace that fluid. 16 In very severe shock, and this is what's 17 known -- there's a classification of shock, Class 3 and 18 Class 4 shock means that there's been between 35 and 50 19 percent of the entire blood volume lost. In those cases, 20 the convention is that one gives whole -- gives 21 transfused blood -- 22 Q: Hmm hmm. 23 A: -- packed blood -- red blood cells, 24 plus the IV that I've mentioned earlier. 25 Q: And -- and did the -- the blood loss

1 for Dudley George reach that level? 2 A: It did not and -- and the reason it 3 didn't was because -- in my view was that the rapidity of 4 the bloodshed was the critical factor in Mr. George's 5 case; it simply overwhelmed his ability to compensate for 6 that blood loss and therefore he couldn't -- he couldn't 7 cope with that. 8 Q: In other words, for the natural 9 bodily response to shock that we've outlined -- 10 A: Correct. 11 Q: -- constriction of the veins, the 12 blood clotting, et cetera; that just couldn't happen at a 13 quick enough rate here because of the rapidity of the 14 blood loss? 15 A: That's correct. 16 Q: Okay. 17 A: And the other factor -- one -- just 18 to put it slightly differently, the rate of blood loss 19 can be as important as the amount of blood loss. So, if 20 the blood is shed very quickly, that may be a critical 21 factor and that's what I believe happened in Mr. George's 22 case, because he lost about a fifth or 20 percent of his 23 blood volume, which is in the -- which, in some cases, 24 would be survivable, but I believe the rate at which it 25 was lost was critical.

1 The other factor that may have been 2 important in Mr. George's case was his -- his pre- 3 existing cardiac situation. 4 Q: What was it about his pre-existing 5 medical situation that -- that was a negative? 6 A: At -- at autopsy he was found to have 7 75 percent blockage of his left anterior descending 8 coronary artery, one (1) of the three (3) main arteries 9 that supplies the heart. 10 If we've heard that the ability of the 11 heart to compensate is really critical in compensating 12 for the first stages of shock, someone who has some heart 13 disease will not be as able to do, for example, as a high 14 endurance athlete, a highly -- a highly trained athlete. 15 So, younger people, particularly children, 16 compensate for shock very well, whereas older people who 17 may have coronary disease, do not so as well and that may 18 have been a factor in Mr. George's case. 19 Q: All right. Thank you. 20 A: I think that concludes the -- the 21 section of slides on that. 22 Q: I appreciate that. Now, based on 23 your review of this matter then, and your expertise, did 24 you form an opinion that had Mr. George been transported 25 to the Strathroy Middlesex General Hospital by ambulance

1 in the care of paramedics and provided with paramedic 2 intervention en route, whether his chance of survival 3 would have been materially improved? 4 A: I don't believe so. 5 Q: And what is the basis of your 6 opinion? 7 A: Well, the -- the total time, and I 8 recognize that it's hard to ascertain this with 9 precision, but the total time from the initial wound to 10 arrival at hospital in Strathroy was fifty (50) to fifty- 11 five (55) minutes. 12 The transport method to the hospital was 13 not relevant in my view. I think, in fact, that the 14 decision of Mr. George's companions to load him in the 15 car and go was probably the correct one. 16 Q: Why is that? Why -- why would you 17 not recommend or why would the paramedic intervention not 18 likely improve his chance of survivability? 19 A: That's based on studies that have 20 been done throughout the world which have showed that the 21 most important determinant of outcome from pre-hospital 22 arrest, is time of arrival at the hospital. 23 So, despite the fact that one might 24 intuitively believe that the intervention of paramedics 25 in these cases wold make a tremendous difference, the

1 evidence doesn't support that. 2 In fact, it seems to be that those who are 3 going to survive are those who arrive at hospital in a 4 very short time. 5 Unfortunately the proximity of Mr. George 6 at the time of the gunshot wound to hospital was not -- 7 wasn't close and he had some distance to be transported. 8 The provision of all the advance life 9 support manoeuvrers that are done in the pre-hospital 10 setting, in this particular group, in terms of its 11 benefit, is highly controversial, but the evidence to 12 support benefit is lacking. 13 Q: And do you have any -- so what I'm 14 understanding -- if I'm understanding you then, your 15 evidence, the -- the nature and extent of this particular 16 injury, which was a penetrative trauma, was such that the 17 usual medical interventions such as supply of intravenous 18 fluid for example, would not likely have -- have enhanced 19 his chance of survival? 20 A: That's correct. 21 Q: And do you have any studies which 22 support this position? 23 A: Well, there are two (2) -- there are 24 two (2) that are, I think, important to refer to and they 25 are in the PowerPoint presentation as well, at Slide 18.

1 I could ask you to go to that. 2 3 (BRIEF PAUSE) 4 5 Q: Now, just before we go to your 6 PowerPoint presentation, the article that you're 7 referring to is a position paper by the National 8 Association of -- of EMS physicians -- 9 A: That's correct. 10 Q: -- from the United States, and it's a 11 document which was published in 2002? 12 A: That's correct. 13 Q: All right. And did you -- is this 14 document or is this study an authoritative study in your 15 field of expertise? 16 A: It is. It's actually a guideline 17 based -- it's a position paper based on a review and 18 analysis of the literature in this area. 19 Q: And did you -- do you adopt this 20 position paper as part of your opinion? 21 A: Yes. 22 Q: Commissioner, I'd like to make the 23 position paper entitled, Guidelines for Withholding or 24 Termination of Resuscitation in Pre-Hospital Traumatic 25 Cardio-Pulmonary Arrest, the next exhibit.

1 THE REGISTRAR: P-393, your Honour. 2 COMMISSIONER SIDNEY LINDEN: P-393. 3 4 --- EXHIBIT NO. P-393: NAEMSP Guidelines for 5 resuscitation in penetrating 6 TCPA (Traumatic 7 Cardiopulmonary Arrest), 8 Published in 2002 9 10 CONTINUED BY MS. SUSAN VELLA: 11 Q: Perhaps you can explain what this 12 position paper sets out and how it applies, in your 13 opinion, to Dudley George's situation? 14 A: Certainly. The paper was prepared by 15 the National Association of Emergency Medical Services 16 Physicians, which is a group in the United States of -- 17 professional group, composed of physicians who provide 18 medical direction and guidance to ambulance personnel 19 working in large or small systems in the United States. 20 There are Canadian members as well. And 21 it is an authoritative group in this field. The paper 22 was put together based on the review of a series of 23 research studies that had been in this area looking at 24 whether -- whether or not one should continue or 25 terminate resuscitation of people who have suffered

1 cardiac arrest in the pre-hospital setting and in fact 2 due to trauma. 3 So specific -- this is not this is not a 4 group of people who have had cardiac based ventricular 5 fibrillation or sudden cardiac arrest. It's people who 6 have been injured and who have an arrest. 7 And based on their review of the 8 literature, they've come to a number important 9 conclusions. The first is that when one is going to 10 attempt advance life support manoeuver such as putting in 11 an endotracheal tube into the trachea or putting an 12 intravenous infusion in. 13 This should be done during transport. In 14 other words, transport should not be delayed because 15 transport is the key benefit that's offered to these 16 people. 17 The next slide, please. The next is that 18 where arrest has occurred in the pre-hospital setting due 19 to trauma, one should consider termination of 20 resuscitation attempts when the arrest has persisted for 21 more than fifteen (15) minutes. 22 The reason for that is that the chance of 23 resuscitating the person is virtually zero. The chance 24 of -- 25 Q: So -- so once the -- sorry, once the

1 heart has stopped -- 2 A: Correct. 3 Q: -- and there's no activity -- 4 A: Correct. 5 Q: -- and that's happened for fifteen 6 (15) minutes, then there's no chance of resuscitation 7 successfully? 8 A: That's -- that's the virtual 9 situation. 10 Q: Thank you. 11 A: The other thing is that when one is 12 being transported in that circumstance, of course the 13 ambulance is proceeding at breakneck speed with lights 14 and sirens on and there is a risk to public safety and to 15 the occupants of the ambulance. 16 So, one has to consider that balanced 17 against the needs of the person inside the vehicle, the 18 patient. 19 Next please. If the person has arrested 20 and the transport time is known to be fifteen (15) 21 minutes or greater, then the ambulance personnel should 22 consider that individual non-salvageable. 23 And again the same logic applies; that 24 fifteen (15) minute window is really the maximum time at 25 which someone could be -- could be hoped to be

1 resuscitated. 2 Next please. If the person has no vital 3 signs, no blood pressure, no pulse, no respiratory 4 effort, and also has no signs of life, and those are 5 distinct entities as you may have heard previously in 6 testimony, the signs of life would include pupillary 7 response, gasping, movements or evidence of the 8 electrocardiogram activity, resuscitation should not be 9 started at all. 10 And again, the reasoning is that there's 11 no hope of meaningful resuscitation. Meaningful 12 resuscitation refers to the fact that the person will 13 leave hospital with their cognition, their -- their 14 faculties intact with -- 15 Q: And just for clarification, over what 16 period of time or what's the -- the maximum period of 17 time for which a person can be absent vital signs and -- 18 A: And survive? 19 Q: -- and then still be resuscitated? 20 A: That fifteen (15) minute window is 21 really the maximum time. The physiologic time for brain 22 death is between six (6) and ten (10) minutes, but there 23 are recorded instances of people surviving as long as 24 fifteen (15) minutes. There are other factors that don't 25 apply in Mr. George's case such as hypothermia which can

1 prolong survival time, but again, that's usually not the 2 case. 3 Finally, if there are clear signs of 4 death, an injury that's incompatible of life, then 5 resuscitation obviously shouldn't be attempted and that's 6 part of a position statement. 7 The reason that the NAEMSP put forward 8 these position statements is that -- next slide, please - 9 - the reality is that the presence of traumatic 10 cardiopulmonary arrest is associated with a dismal 11 prognosis. 12 There really is even in the best of hands, 13 close to trauma centres, a very, very grim outlook for 14 someone who has an arrest due to trauma in the pre- 15 hospital setting. 16 Q: So, even if the person arrives at a 17 trauma centre within less than fifteen (15) minutes or 18 less than ten (10) minutes even, the survival rate is 19 between point eight (.8) and 4 percent? 20 A: That's correct; that's under optimal 21 circumstances. And the reason I say that is that these 22 studies of course are done next to trauma centres. 23 They're done by academic physicians who are interested in 24 the outcome of what happens. 25 In the United States, of course, in large

1 urban areas penetrating trauma is not rare, in quite -- 2 in distinct contrast to Canada, and therefore they have a 3 good deal of experience with it. They're used to doing 4 the manoeuvres that need to be done. 5 For example, one (1) of the things that 6 can be done for people who have penetrating trauma to the 7 chest is an Emergency Department thoracotomy, which is an 8 operation where the chest is entered through a large 9 incision that's made very rapidly in the left side of the 10 chest, and a variety of manoeuvres may be tried. 11 So, for example, if there's a hole in the 12 heart, they might literally put a plug there, either a 13 finger or a catheter, such as a urinary catheter and blow 14 the balloon up and try and stop the bleeding. 15 They may clamp the aorta, the large vessel 16 that comes off the left side of the heart, to try and 17 staunch the blood flow. 18 A manoeuvre, incidentally, which would not 19 have worked for Mr. George, because he had a pulmonary 20 artery laceration, so therefore it wouldn't have been -- 21 wouldn't have been helped at all by that. 22 Q: Hmm hmm. 23 A: And bleeding can be a -- bleeding 24 control can be attempted. the problem with the procedure 25 is that it requires a great deal of experience and skill.

1 It would not be found, typically, in a place like 2 Strathroy, for example. 3 Although there was a general surgeon 4 there, general surgeons who work in smaller community 5 settings wouldn't have to do a procedure like this, 6 virtually ever, in their careers. And so the chance of 7 them being able to do something useful in the time that's 8 required is very, very small. 9 Q: All right. And we'll certainly 10 explore that procedure a little bit -- a little bit 11 later, but as I understand, then, the penetrating trauma 12 to the chest, that would include, of course, a gunshot 13 wound to -- to the -- to the clavicle area such as -- 14 A: That's correct. 15 Q: -- Mr. George suffered? 16 All right. And do you have any other 17 studies which support your opinion that paramedic 18 intervention would not have materially enhanced Mr. 19 George's rate of survivability? 20 A: Well, there's another study known as 21 the -- there's a study done by Bickell in Houston, which 22 is the next slide, please. 23 24 (BRIEF PAUSE) 25

1 A: And Bickell studied -- and this is 2 rare in this field, because I should emphasise for the 3 Commission that the research that's been in this area is 4 not randomised control trials, such as one would see in 5 the evaluation of a new medicine. 6 Because of the ethical concerns, one can't 7 generally do that kind of research in victims of trauma. 8 They're already injured, and one can't control when 9 they're going to be injured, typically. 10 Q: And just for our information, this is 11 a article entitled, "Immediate Versus Delayed Fluid 12 Resuscitation for Hypotensive Patients with Penetrating 13 Torso Injuries," co-authored, led by William Bickell, and 14 it's published in 1994 in the New England Journal of 15 Medicine. 16 Is that right? 17 A: That's correct. 18 Q: And do you consider this study to be 19 authoritative in your field? 20 A: Yes. 21 Q: Do you adopt it as part of your 22 opinion? 23 A: Yes, I do. 24 Q: Commissioner, I'd like to make this 25 article the next exhibit, please.

1 THE REGISTRAR: P-394, your Honour. 2 COMMISSIONER SIDNEY LINDEN: P-394. 3 4 --- EXHIBIT NO. P-394: "Minimal Volume 5 Resuscitation," Bickell Nejm 6 1994:331:17:1105-1109 7 8 CONTINUED BY MS. SUSAN VELLA: 9 Q: Perhaps you can just explain what the 10 thesis was here, and what the -- the result was and apply 11 that to Dudley George's situation. 12 A: Well, the hypothesis was one that 13 might be counterintuitive to the average person, and that 14 is that the provision of IV therapy, fluid therapy to a 15 person who's bleeding might actually be detrimental to 16 them. 17 Q: How so? 18 A: Well, the concern was that, if one 19 gets -- one gives IV fluid, that may cause dilation of 20 the blood vessels, or raising of the blood pressure and, 21 in fact, lead to increase in bleeding. He -- 22 Q: So in other words, instead of 23 constricting the blood vessel which would normally be the 24 function, you put in more fluid and it expands the blood 25 vessel --

1 A: That's correct. 2 Q: -- and that increases, of course, the 3 -- the loss of blood. 4 A: Correct. And the authors who are 5 surgeons, believe that, or hypothesised, that so doing, 6 might lead to an increase in blood loss if one did it 7 before surgical control of the bleeding had been 8 achieved. 9 It wasn't that they weren't going to give 10 the blood or give the fluid to expand the blood vessels; 11 their belief, though, was that one should -- should gain 12 surgical control of the vessels that were damaged -- 13 Q: So stop -- 14 A: -- before doing it. 15 Q: -- stop the bleeding first? 16 A: Exactly. 17 Q: Okay. 18 A: So, they put together a study where 19 they aimed to get their patients to the operating room 20 very quickly. And if one looks at the study, the time 21 that the -- from the time of injury to actual arrival in 22 the operating room was about forty-five (45) minutes. 23 Now, it's very important to compare that 24 to the time that Mr. George had before he arrived at the 25 Strathroy Hospital, for example.

1 He had some fifty (50) to fifty-five (55) 2 minutes, and that's just the time to arrive at hospital. 3 In my experience, working in two (2) large trauma 4 centres, three (3) actually, it's virtually impossible to 5 get somebody off the the street into the operating room 6 in anything less than fifteen (15) to twenty (20) 7 minutes. 8 It is virtually impossible and the reason 9 is that the -- the portering through the hospital, 10 getting the necessary equipment set up, et cetera, et 11 cetera, just leads to an obligate time period before one 12 can get that person to the operating room. 13 So, these times, it's recognized 14 throughout the trauma -- trauma world, are exceedingly 15 short times to actually achieve; it's very difficult. 16 In any case, Bickell and his group 17 randomized almost six hundred (600) patients to either 18 receive minimal fluid resuscitation in the field; in 19 other words, an IV was started, but almost no fluid was 20 given, or to receive a conventional fluid resuscitation 21 and then being rushed to the operating room. 22 And what they found was that there is a 23 benefit to not giving fluid to these people in the pre- 24 hospital setting; 70 percent of the people who received 25 their minimal volume resuscitation survived, versus 62

1 percent who received conventional treatment. 2 That's important because although it's not 3 a significant increase, it actually runs counter to what 4 one might believe intuitively would be the -- the way 5 things should go. 6 Next slide, please. Now, in order to 7 properly evaluate this study in the -- in the context of 8 the matter we're dealing with today, one has to remember 9 this is study done in Houston, Texas, a large urban 10 setting, significant rate of penetrating trauma, highly 11 skilled surgeons because they see it all the time, they 12 had short transport times to the hospital, all under 13 twenty (20) minutes. 14 These were -- although they were 15 penetrating trauma victims, they were not in cardiac 16 arrest, these people had -- were excluded because they 17 didn't -- they -- they had cardiac arrest, they were 18 excluded. 19 Q: Why -- 20 A: And the reason for that was because 21 there's no hope of survival. 22 Q: And -- and this is -- 23 A: No meaningful hope. 24 Q: -- this is the situation of Dudley 25 George in the sense --

1 A: Right. 2 Q: -- it was a penetrating trauma and he 3 was in cardiac arrest by the time he got to the hospital? 4 A: Correct. I think what it does 5 illustrate that's useful is, the Commission decides what 6 are the appropriate recommendations to follow from the 7 Inquiry, is that this is a controversial issue. It is 8 not a slam-dunk that IV fluid is better. 9 It is not clearly beneficial in all 10 circumstances, but we don't know, for example, in a 11 patient who has vital signs whether or not, if the 12 transport time is long, and this is the situation in much 13 of rural Canada, whether or not we should be giving IV 14 fluids to these patients. This is being studied, but the 15 answers are not clear yet. 16 Q: And so, in other words, it may or may 17 not improve the recoverability, if you will, or 18 survivability of someone with this type of a penetrating 19 trauma? 20 A: Well, I -- with one (1) important 21 caveat, who has not had a cardiac arrest. 22 Q: Who has not had a cardiac arrest. 23 Thank you. 24 25 (BRIEF PAUSE)

1 Q: All right. And, just for the record, 2 I note that the survival rate outcome is at page 1107 of 3 the article and -- and the rationale, if you will, 4 underlying what you've just talked about, is outlined on 5 page 1108 under 'Discussion.' 6 A: That's correct. 7 Q: Thank you. Now, we have heard 8 evidence from the treating healthcare professionals in 9 this case that providing oxygen to Dudley George while 10 en-route would have been advisable. Do you agree or 11 disagree with that? 12 A: It would have been advisable, but not 13 clearly beneficial. 14 Q: And the reasons why it would not 15 clearly have been beneficial? 16 A: Because the research evidence to 17 support that the provision of extra oxygen resulting in a 18 better outcome is lacking. 19 Q: And similarly, I take it from your 20 opinion that providing intravenous fluid while the -- the 21 treating healthcare professionals also testified that 22 providing intravenous fluid en-route would have been a 23 prudent measure. Do you agree or disagree? 24 A: I can't answer that with a simple yes 25 or no. If I might be permitted to digress --

1 Q: Certainly. 2 A: -- I'll tell you why. 3 It would be beneficial to start an 4 intravenous early on because we've heard that 5 constriction of the blood vessels proceeds as one (1) of 6 the compensatory mechanisms and therefore, later on in 7 the course of the patient's care, it may be harder to 8 start an intravenous because there's more constriction of 9 the blood vessels including the veins. 10 So, starting an IV early is a beneficial 11 thing, however, and this is why I can't give you a simple 12 yes or no, there isn't good evidence that starting IV's 13 in the pre-hospital setting results in a better outcome 14 regarding survivability. 15 Q: At the end of the day? 16 A: Yes. So, it would be advisable, yes, 17 generally helpful to start it earlier on, but would it 18 have made a difference to the ultimate outcome, I don't 19 think that can be said. 20 Q: And those are for the reasons you've 21 just outlined? 22 A: Correct. 23 Q: So, in the end, then, Pierre and 24 Caroline George's instincts in getting Dudley George to 25 the hospital as quickly as possible, were the right

1 instincts to follow, given the nature and severity of the 2 brother's injuries? 3 A: I believe so. 4 Q: Now, we have heard evidence that J.T. 5 Cousins, the young man who sat in the back seat with 6 Dudley George and applied pressure to the wound area, 7 believes that he continued to hear a heart beat after 8 they left the Veen farmhouse on Nauvoo Road, right up to 9 the hospital. 10 In your view, is it likely that J.T. 11 Cousins continued to hear a heart beat beyond the Veen 12 residence? 13 A: Well, I stress in answering that I 14 wasn't there -- 15 Q: Yes. 16 A: -- but I have experience in trying to 17 assess patient's vital signs with actually fairly 18 sophisticated equipment, in the back of ambulances and 19 helicopters, both of which are noisy environments. And I 20 believe that it would have been very, very difficult to 21 actually hear a heartbeat in that setting, especially 22 when there was a flat tire and there was the noise of 23 travelling along back roads. 24 And I think it's likely that Mr. Cousins, 25 certainly in good faith, heard something, but I believe

1 he may have been hearing his own heartbeat, for example; 2 that's a -- that's a common -- common illusion that one 3 has. And similarly, when one's feeling a pulse, it's 4 fairly common to feel one's own pulse. 5 So, those two (2) things, I believe, would 6 have -- I believe it would have been very difficult to 7 hear Mr. George's heart in that car. 8 Q: Hmm hmm. And based on your review 9 and your expertise, did you form any conclusion as to 10 whether or not it is likely that Dudley George was absent 11 all vital signs, prior to his arrival at the Strathroy 12 Middlesex General Hospital? 13 A: Well, there was several -- I believe 14 that Mr. George had been absent vital signs for twenty 15 (20) to thirty (30) minutes prior to arrival at the 16 hospital and I base that on several things. 17 The first is that the -- the absence of 18 movement prior to the time that the car actually reached 19 the farmhouse which is recorded by Mr. Cousins, I 20 believe, and that's the information I received. 21 The second is that the -- at the hospital, 22 I read a later addendum and I should have alluded to this 23 earlier in my testimony, that I did receive an addendum 24 from a nurse who was at the scene -- 25 Q: Yes.

1 A: -- who, when Mr. George was turned, 2 observed that he had lividity, what -- what sounds like 3 lividity to me, based on the description of the fixed, 4 bluish discolouration of the skin that she gives. 5 Lividity takes somewhere between thirty 6 (30) minutes and two (2) hours to appear after death. 7 And lividity as you may have heard already, is the 8 pooling of blood in the dependant portion of the body 9 after death, which is a normal phenomenon after death, 10 but it can be of some assistance in timing death. 11 Q: And nurse Derbyshire, by the way, did 12 testify that she viewed Dudley George's skin to be 13 mottled in the back of the car at the hospital ramp and 14 that there was blood swelling, I guess, at -- in the jowl 15 and neck and area. 16 Is that what you're referring to? 17 A: I was referring to the posterior 18 portion of Mr. George, but if that were present as well, 19 that would be important. 20 Q: Okay. Thank you. And so, then, in 21 your opinion, it is likely that he was absent vital signs 22 at a minimum of thirty (30) minutes prior to his arrival 23 at the hospital? 24 A: That's correct. 25 Q: And did you further -- all right.

1 And just to be clear, this conclusion is based on -- on 2 statistical -- the statistical course of this type of -- 3 of lividity? 4 A: That's correct. 5 Q: And given the nature and severity of 6 Dudley George's gunshot wound, what emergency medical 7 procedures would have constituted optimal in-hospital 8 medical care? 9 So, we'll move now from the enroute care 10 to the hospital care. 11 Q: Well, I think what the physicians did 12 was appropriate in the setting that they were working, 13 and that is in a community hospital in a smaller town and 14 with the experience and skills that were present there, 15 and I don't mean in any way to suggest that they weren't 16 appropriate, because I think they were, that is the 17 skills and experience of the physicians who were present. 18 Q: You mean given that this wasn't a 19 full trauma centre? 20 A: Correct. They're not working in a 21 trauma centre and they -- their role would have been, if 22 possible, to stabilise and minimise further damage and 23 evacuate or cause the evacuation of Mr. George, if that 24 were possible. 25 If Mr. George had arrived at a trauma

1 centre, then the appropriate thing would have been to 2 undertake exactly the same treatment that was started at 3 the Strathroy Middlesex Hospital, but in addition to give 4 consideration to an Emergency Department thoracotomy. 5 And that, as I mentioned earlier, is the 6 operation where one enters the chest and controls the 7 bleeding directly using internal methods as opposed to 8 the external pressure that was alluded to earlier. 9 Q: And what was the -- the name of that 10 procedure again? 11 A: Emergency Department thoracotomy. 12 Q: Thoracotomy. 13 A: Yes. 14 Q: And can you just explain in a little 15 more detail what -- what the objective of that procedure 16 is and -- and what it -- what it takes to do it? 17 A: Well, the -- the objective is to gain 18 control of haemorrhage inside the chest. The procedure 19 involves making a semi-circular incision between the 20 fourth and fifth ribs on the left side of the chest 21 following the space between the ribs and then inserting a 22 rib spreader, which is an instrument, to force those ribs 23 apart and thus allowing the visualization of the interior 24 of the chest. 25 And then one follows a fairly -- fairly

1 stereotyped approach, looking first at the heart to see 2 whether or not there's a hole in the heart. And -- and, 3 of course, that wouldn't have been known because it 4 couldn't be known at the time, looking then to see if the 5 covering of the heart, the pericardium, is tense with 6 blood, because that can actually impede the pumping of 7 blood. 8 And then finally, looking for other 9 sources of haemorrhage such as from the great vessels of 10 the chest and then hopefully applying a clamp or putting 11 in something to occlude or stop the -- the flow of blood 12 from those areas. 13 Q: All right. And did you form an 14 opinion as to whether or not the performance of a 15 thoractomy here, emergency thoractomy, assuming of 16 course, that Mr. George was brought to the trauma centre 17 in time, whether -- what the chances were of -- of his 18 survivability? 19 A: Well, the -- the -- again, going back 20 to the document that's been introduced in evidence and 21 that is the position paper of the National Association of 22 Emergency Service -- Medical Services Physicians, on 23 page -- 24 Q: Exhibit P-393. 25 A: Right.

1 Q: Yes. 2 A: On page 144 there's a table which 3 summarizes major studies of emergency thoracotomy. And 4 if one looks at that, one realizes that the survival 5 rate, and going down to the bottom of the chart where it 6 says, "Totals," survival rate from penetrating trauma 7 from a compilation of these studies is 16 percent. 8 So, again, that 's under optimal 9 circumstances, going to a trauma centre with a skilled 10 surgeon and a skilled team, because it's not just the 11 surgeon, it's the team who assists who's -- which is 12 important, the survival rate is 16 percent. 13 So, juxtaposing that against the 0.8 to 4 14 percent versus 16 percent and emphasizing that these 15 individuals were not in cardiac arrest. 16 Q: All right. The -- 17 A: So, the best one could hope for is 18 about 16 percent survival if the person arrives with some 19 vital signs, but is in extremis; near death. If somebody 20 arrives in cardiac arrest, the survival rate is 21 significantly lower. 22 Q: Much lower? 23 A: Yes. 24 Q: 0.8 percent to 4 percent? 25 A: Correct.

1 Q: And in the event that the cardiac 2 arrest has been persisting for fifteen (15) minutes or 3 longer, then there is no chance of recovery? 4 A: That's correct. So, I think that, if 5 I -- I might just say this, that at -- to the Hamilton 6 General or Sunnybrook the chances would not have been 7 better in this circumstance at that time. 8 Q: All right. 9 10 (BRIEF PAUSE) 11 12 Q: Now, had Dudley George arrived at the 13 hospital, the Strathroy Middlesex General Hospital, 14 within thirty (30) minutes from the point of the bullet 15 entering into his body, do you have an opinion as to 16 whether or not a thoractomy would have saved his life? 17 A: The -- again, it's difficult to 18 answer with a simple yes or no, because the critical 19 feature would be if he were in cardiac arrest or not. 20 Q: Right. 21 A: If he's not in cardiac arrest within 22 thirty (30) minutes, then there's -- then there's a 23 chance, but the chance that you see is 16 percent. 24 Q: Do you know where the closest trauma 25 centre capable of performing an emergency thoractomy was

1 to the Ipperwash Provincial Park? 2 A: Well, there are two (2) trauma 3 centres, Windsor and London. I'm not exactly sure which, 4 geographically, is closer, but London is a university 5 centre and would be more likely to have a surgeon onsite 6 because it's a teaching centre, so there would be 7 residents in-house and the ability to mount the trauma 8 response would be faster there than, say, in Windsor. 9 Q: And then, in the -- in the 10 circumstances presented to the Emergency Department at 11 the Strathroy Medical General Hospital shortly after 12 midnight on September the 7th, 1995, did the health care 13 professionals present provide competent emergency medical 14 care to Dudley George recognizing the limitations faced 15 by that department as you have described? 16 A: I think they did. 17 Q: Now I understand that you received 18 information relevant to your task after you wrote your 19 report? 20 A: I did. 21 Q: And can -- the new information you 22 received, can you please describe what that information 23 was? 24 A: Well, I was -- I mentioned earlier 25 that I received a statement of Jacqueline Derbyshire

1 regarding her observations of Mr. George's body. I also 2 was able to review the transcript evidence of Dr. Marr 3 and Dr. Saettler. 4 Q: And as a result of receiving that new 5 information, have you, in any way, altered any of the 6 opinions or conclusions or findings which you have 7 testified to today? 8 A: I did not. 9 Q: All right. And with respect to the 10 information received through the interview of nurse 11 Derbyshire by Detective Armstrong I believe, did you -- 12 did you write an addendum to your report? 13 A: I did. 14 Q: And this is a two (2) page addendum? 15 A: That's correct. 16 Q: I'd like to make the addendum to the 17 report of Dr. McCallum the next exhibit please. 18 THE REGISTRAR: P-395, Your Honour. 19 COMMISSIONER SIDNEY LINDEN: P-395. 20 21 --- EXHIBIT NO. P-395: Two (2) page Addendum to 22 Document Number 5000004, page 23 391 by Dr. Andrew McCallum 24 25 CONTINUED BY MS. SUSAN VELLA:

1 Q: In conclusion, Dr. McCallum, assuming 2 that even under the optimal circumstances you have 3 described, that is arrival at a full trauma centre within 4 fifteen (15) minutes from point of injury, whether or not 5 pre-hospital medical intervention occurred, had all the 6 emergency procedures been followed, including an 7 emergency thoracotomy, Dudley George would likely have 8 not survived his gunshot wound based on the statistics 9 that you have reviewed today; is that right? 10 A: That's correct. 11 Q: Now, Dr. McCallum, part of the 12 mandate of the Commission is to make recommendations 13 aimed at ensuring such casualties as Dr. -- as Mr. Dudley 14 George, do not happen in the future; based on your expert 15 review of the delivery of emergency medical services to 16 Dudley George, do you have any recommendations which 17 might assist the Commission? 18 A: I have -- I do. 19 Q: Could you advise us? 20 A: Certainly. The first is that this -- 21 the events that are being examined here occurred nearly 22 ten (10) years ago. And the importance of transport has 23 been emphasized I think in -- in my testimony this 24 morning, transport time or minimizing transport time. 25 And therefore one recommendation I would

1 make is that the -- there be a better link with pre- 2 hospital care providers and in particular air ambulance 3 providers, because since the time of Mr. George's death, 4 the air ambulance system in Ontario has evolved 5 significantly. 6 There are now I'm told, some fourteen (14) 7 air ambulances available. At that time there was one 8 (1). And furthermore, these air ambulances are capable 9 of doing what are scene calls. 10 In other words landing near the -- the 11 scene of an injury, picking up the person, en route 12 providing advance life support and taking them directly 13 to a trauma centre. 14 And that is something that has been shown 15 in several studies to be beneficial -- beneficial 16 intervention. So, that's one (1) recommendation I would 17 make. 18 Q: And -- and just for our further 19 information, are you aware as to whether any of these air 20 ambulances are stationed anywhere close to -- to the 21 London General Hospital for example? 22 A: There is one (1) stationed in London, 23 to my understanding. 24 Q: Right in London? 25 A: Yes.

1 Q: Is there one (1) also in Windsor? 2 A: I'm not 100 per cent certain about 3 that. I -- I don't know that for sure. 4 Q: All right, thank you. 5 A: But I do know there's one (1) in 6 London. And the flying time from London to Ipperwash 7 would be twenty (20) minutes at most. 8 Q: Now would it be feasible to pre- 9 assign an air ambulance given the number of resources 10 that we have in the Province, to pre -- to have 11 preassigned an air ambulance to a scene of potential 12 multiple casualties? 13 A: It probably would -- it would be 14 conceivable but probably not advisable. 15 Q: Why is that? 16 A: And the reason is that the ambulances 17 have many tasks and -- and duties and they're flying 18 critically ill patients around the province constantly. 19 So, it would be I think not reasonable to remove one (1) 20 of those ambulances from somebody in -- in -- for an -- a 21 foreseeable but not yet seen eventuality. 22 Q: All right. 23 A: However, the system is such now that 24 I believe that the availability of the ambulances is -- 25 is -- is much better, and therefore one could obtain one

1 much more easily than at that time. 2 Q: All right. Thank you. And what is 3 your second recommendation? 4 A: My second recommendation is that it 5 probably, despite my testimony regarding the lack of 6 clear benefit of having advanced life support 7 interventions, it would be useful to have that available 8 because, for example, airway interventions early on, 9 opening the airway providing effective ventilation to the 10 patient, effective respirations, are associated with 11 better neurologic outcomes. 12 And furthermore, as -- and I think I gave 13 a rationale for this in earlier testimony, starting an 14 intravenous earlier, even though it's not clearly 15 beneficial, at least provides a conduit for the later 16 installation of IV fluids. 17 Q: So, in other words, the availability 18 of advanced care, paramedics and ambulances obviously -- 19 A: Correct, and that -- 20 Q: -- to -- 21 A: -- that's something that can be pre- 22 arranged in my view, ground ambulances. 23 There are now, in Windsor and in Sarnia, 24 advanced care paramedics. This is a phased-in 25 implementation that's gone on over the last five (5) to

1 seven (7) years and so that now is -- is -- would be 2 available. It wasn't at the time. 3 Q: Do you know whether or not there were 4 any advanced ambulance care paramedics in Sarnia in 1995? 5 A: I don't believe so, and the reason I 6 say that is there was a study done called the Ontario 7 Pre-hospital Advanced Life Support Study, or OPALS, which 8 resulted in a gradual introduction in communities like 9 Sarnia and Windsor of advanced care paramedics. 10 And I don't believe that it had been 11 implemented at that time there, but I might be wrong. I 12 can't be 100 percent certain. 13 Q: All right. Thank you. And do you 14 have any third recommendation? 15 A: I do. Based on the information that 16 I received, and on review of the transcripts of Dr. Marr 17 and Saettler I gather that there wasn't clear 18 communication between the officers who were involved in 19 the incident and the -- and the hospital staff. 20 And that's something I believe should be 21 emphasized for any future incident, that it's important 22 that the -- that the personnel at the scene or -- and 23 that would include the relatives who came with Mr. 24 George, be allowed to or -- and in fact encouraged to 25 give their information to the hospital staff so it's

1 clear what happened, when. 2 Now, that's quite important, and it's one 3 (1) of the things I stress when I used -- I did stress 4 when I was teaching residents and -- and -- and 5 paramedics is that that communication can be missed and 6 it's -- can give -- there can be very valuable 7 information relayed. 8 Q: Hmm hmm? 9 A: So, that's something that's -- that 10 should be emphasized to police and to paramedics, and to 11 hospital staff. 12 Q: And to family members? 13 A: And -- and to family members who 14 accompany a person. 15 Q: All right. And they should be 16 encouraged by whatever professionals have accompanied 17 them? 18 A: Correct. 19 Q: Do you have any further 20 recommendations for the Commission? 21 A: I think those would constitute my 22 recommendations. 23 Q: Dr. McCallum, thank you very much, 24 that concludes my examination-in-chief. 25 Perhaps we can canvas Counsel for possible

1 cross-examination, Commissioner? 2 COMMISSIONER SIDNEY LINDEN: Let's do 3 that now. Does anybody wish to ask Dr. McCallum any 4 questions? 5 Yes, Mr. Orkin...? 6 MR. ANDREW ORKIN: Ten (10) minutes. 7 COMMISSIONER SIDNEY LINDEN: Mr. 8 Rosenthal...? 9 MR. PETER ROSENTHAL: Twenty (20) minutes 10 to a half an hour, sir. 11 COMMISSIONER SIDNEY LINDEN: Mr. 12 Henderson...? 13 MR. WILLIAM HENDERSON: Perhaps five (5) 14 minutes. 15 COMMISSIONER SIDNEY LINDEN: Ms. 16 Jones...? 17 MS. KAREN JONES: Fifteen (15) minutes. 18 COMMISSIONER SIDNEY LINDEN: Mr. 19 O'Marra...? 20 MR. AL O'MARRA: Reserve five (5) to ten 21 (10) minutes, sir. 22 COMMISSIONER SIDNEY LINDEN: Mr. 23 Falconer...? 24 MR. JULIAN FALCONER: Ten (10) to fifteen 25 (15) minutes.

1 COMMISSIONER SIDNEY LINDEN: We will take 2 a morning break now, and we'll do cross-examination right 3 after. 4 THE REGISTRAR: This Inquiry will recess 5 for fifteen (15) minutes. 6 7 --- Upon recessing at 10:25 a.m. 8 --- Upon resuming at 10:45 a.m. 9 10 COMMISSIONER SIDNEY LINDEN: Yes, Mr. 11 Orkin? 12 13 (BRIEF PAUSE) 14 15 MR. ANDREW ORKIN: Good morning, 16 Commissioner. 17 COMMISSIONER SIDNEY LINDEN: Good 18 morning. 19 20 CROSS-EXAMINATION BY MR. ANDREW ORKIN: 21 Q: Good morning, Dr. McCallum. 22 A: Good morning. 23 Q: My name is Andrew Orkin, I'm co- 24 counsel to the estate of the late Dudley George and of 25 the Sam George group of family members.

1 A: Good morning. 2 Q: And I have just a few questions from 3 you, as you saw from the grow -- the go-around. 4 You indicated a moment ago in your 5 testimony concerning the -- the report that you prepared 6 at the request of the -- the commission -- of the -- of 7 the Coroner, that your report was February 17, 2003; is 8 that correct? 9 A: That's correct. 10 Q: Could you tell us, please, when you 11 were requested or when you were commissioned to undertake 12 that report? 13 A: My recollection is that it was 14 several weeks before that. Usually it would take me two 15 (2) to three (3) weeks, but I don't have a precise date. 16 Q: So, it's accurate to say that early 17 in 2003 -- 18 A: Correct. 19 Q: -- you were approached by the Coroner 20 to undertake this review of the various reports that had 21 -- and -- and documents that you referred us to? 22 A: Correct. 23 Q: Now, Dudley George was shot and 24 killed in 1995, so this would be some seven (7) years or 25 more after the shooting in September --

1 A: That's right. 2 Q: -- of 1995? 3 Is there any significance to you in being 4 requested some years after an event like this, which is 5 something or was something at the time, something of a 6 cause celebre, to be reviewing the various factors that 7 you were asked to review so many years after that event? 8 A: It's unusual to be asked that long 9 afterwards, yes. 10 Q: Could you elaborate as to why you 11 find that unusual? 12 A: Well, my experience having prepared 13 other expert reports is that one (1) to two (2) years 14 wo