The report from the EMS crew is shown here. En route, his dopamine drip was shut off due to hypertension. Shortly before arrival, he had an episode of bradycardia and was given 1mg atropine. As they were taking him into the ED, he lost pulses again and CPR was started.

Several cardiac tracings are shown below to illustrate the variability in the patient’s rhythm. These were taken at various points throughout his care, and the exact chronological order is not clear from the court exhibits.

His cardiac rhythm eventually progressed to alternating PEA and asystole (not pictured). The ED code sheet is shown below.

The documentation states “Pt was having cervical fusion done @outpt surgical center. Went into PEA and then V tach – shocked x 2 – pulse back. Given amiodarone, epi, dopamine. While EMS was pulling into hospital pt bradycardic and gave epi x 1.”

The code continues for about 20 minutes. Given complete lack of return of pulses, resuscitation was terminated and the time of death was 9:41am.

The case was referred to the medical examiner and an autopsy was performed. To see the results and the cause of death, continue to the next page.