An Almost Perfect Murder (17 page)

“And Mr. Higgs stuck it out,” Houston said. “He didn’t leave. In fact, you will hear from one of the nurses when they asked, ‘Well, why don’t you just leave?’ ‘I can’t leave her right now,’” Houston quoted Higgs as saying. “And that would be during the course of time that the impeachment was occurring.”

Houston drove home the point about context being so important in this case, and asked the jury not to be misled by the “cherry-picking” of statements, ideas, or occasions. He urged that the entire picture be evaluated prior to making a decision in the case, and explained the importance of the medical testimony that they would hear.

“The state’s case will not survive beyond the defense pathologist, as well as the other information and facts that will be provided you throughout,” Houston said. “Ladies and gentlemen, the idea of looking for justice is such an easy phrase. It’s a catchphrase to some. But, truly, it is not because this is a murder case or because it’s a high-profile case that we apply that rule in this room. This room has been here . . . way longer than most of us. The idea of it is it’s truly meaningful. And I can only ask you on behalf of Mr. Higgs to do everything within your power and honor your promise and to realize the importance of every word you said when you became a juror. Thank you very much.”

Following a brief recess after the opening statements were given, Kim Ramey was called as the state’s first witness. After being sworn in, Ramey explained her position as a traveling critical care nurse, an open-heart surgery recovery position that she had held since 1999. She explained that she had made the decision to be a “traveler,” a nurse who does not work on staff for a hospital. Due to her specialty in open-heart recovery and the overall nursing shortage in the United States, Ramey said, she had always been able to choose the geographical regions where she wanted to work. Because of poor acoustics inside Judge Kosach’s courtroom, Ramey was asked several times to speak up as she testified so that jurors on the far end of the jury box could hear her.

Ramey told of how she and her boyfriend had arrived in Carson City to work at the new Carson-Tahoe Hospital’s open-heart center in January 2006. Since the hospital did not yet do open-heart surgery at that time, Ramey and her boyfriend, because of their specialties, had been invited to help the medical center open such a unit and to help them train their nurses in that medical area. In response to Christopher Hicks’s questioning for the state, Ramey acknowledged that she had been working the day shift at the Carson-Tahoe Hospital on July 7, 2006. Just as she had told Detective Jenkins, she explained to the jury how she had met Chaz Higgs that day due to the fact that she had been asked to help out in the hospital’s intensive care unit, where Chaz had recently been hired. Because she was required to wear gloves and a gown when attending a patient in the ICU, and didn’t want to take the time to change each and every time the need to enter or exit the ICU arose, she asked Chaz to assist her by bringing her the things she needed from other areas in the hospital. That, she said, was how they had become acquainted and began talking that day. One of her patients had bacterial spinal meningitis, and the other had “all kinds of bugs” and was on a ventilator, and having Chaz there to get the things she needed helped her remain as sterile as possible for her patients and saved time by eliminating the need for her to frequently change in and out of a gown.

Because she had immediately perceived Chaz as a “player,” Ramey said, she had decided to engage him in conversation by telling him that she had a boyfriend and that the two of them were relocating soon to Virginia. She wanted to make it crystal clear to Chaz that she was not available. She also perceived that “he had this . . . aura . . . of anger,” she testified. She said that the anger came out mostly when he was talking about his wife and the fact that he wanted to divorce her.

“Now, did he tell you who his wife was?” Hicks asked.

“Yes,” Ramey responded.

“And who did he say that was?”

“High-profile, Kathy Augustine,” Ramey said. “I said, ‘Chaz, I’m not from around here. That means nothing to me.’ ‘Yeah, but you know high-profile. She’s the state controller, ’” she quoted Chaz as having said. “I said, ‘I don’t live around here. That means nothing to me.’ ‘Well, she’s running for treasurer.’ I said, ‘It still doesn’t mean anything to me.’”

“Now, you had indicated that he referred to her in some other unpleasant terms,” Hicks said. “I’m going to ask you. I know it’s embarrassing on the stand, but please just tell the jury how he referred to his wife.”

“‘She’s a fucking stalker,’” Ramey responded. “‘I’m looking for an apartment ’cause she’s a fucking stalker. She’s a bitch. She’s psycho.’”

Ramey explained that the derogatory remarks that Chaz had made about Kathy hadn’t been said all at the same time, but that Chaz had said these things to her at different times throughout the day.

“Aside from the obviously unpleasant terms, did he ever indicate that he loved his wife in any way?” Hicks asked.

“Not at all. There weren’t any terms of endearment at all.”

“Were there any terms of hatred?”

“That’s the only emotion I saw. Anger . . . rage.”

In response to questioning, she described how Chaz had been on the telephone in her presence and she had heard part of a heated conversation that he was engaged in.

“What did you hear him saying into the phone?” Hicks asked.

“‘I will fuckin’ talk to you when I get home.... I said I will fuckin’ talk to you when I get home,’” Ramey responded. “And this is in the middle of a unit, which . . . to me . . . was inappropriate. Especially with an employee that had just started. He wasn’t even off orientation.”

She explained that she hadn’t known who Chaz had been talking to at first, but she figured that it must have been his wife. She later asked him point-blank what the telephone conversation had been all about, and she said that he told her that his wife had found out that he had opened a separate bank account.

As the questions continued, Ramey’s testimony eventually turned toward the talk that she and Chaz had engaged in about the Darren Mack case in Reno. It had been the discussion of the Mack case that had led up to Chaz telling Ramey that Mack should have used succinylcholine.

“He said, ‘That guy did it wrong,’” Ramey testified, quoting Chaz. “‘If you want to get rid of someone, you just hit them with a little succs because they can’t trace it postmortem.’”

That statement, she said, had been the one that had made her “skin crawl” and had caused her hair to raise up. It had also been the statement that had interested Detective Jenkins at the probe’s outset.

“Now, you say your hair raised up,” Hicks said. “What do you mean by that?”

“I don’t know if you guys ever get a physical response to something horrible,” Ramey replied. “That’s what I get, that physical response. Like goose bumps . . .”

Ramey described how she had felt two days later when she had seen the newspaper headline that had read:
KATHY AUGUSTINE FOUND DOWN.
Although she said that she couldn’t believe it, her gut feeling was that Chaz had done something to his wife. She immediately thought that he had killed her. She said that she waited until July 11 to call the police.

“Now, ma’am, I’ve got to ask you this,” Hicks said. “It seems a little odd that you had this reaction, and you didn’t call the police right away. Can you please explain to the jury why that is.”

“I had four shifts left,” Ramey explained, “and I was going back to Richmond, Virginia, to settle a two-and-a-half-year divorce. I had lawyers up to here. I had everything physically taken away from me. I’m not a millionaire, but I worked very hard over twenty-one-and-a-half years. I—you have no idea how much I despised lawyers. And I didn’t want . . . to deal with any more lawyers. I was praying I would watch the TV and watch the newspaper, that they would just arrest him and . . . I would be off the hook.”

She said that her boyfriend and a coworker had urged her to go to the police about Chaz’s statement. At one point, one of her coworkers had spoken to Dr. Richard Seher, a cardiologist, about the situation. Seher, in turn, had come to Ramey to talk about it. She had become acquainted with Seher due to his specialty and hers having some overlap. They had conversed in the past, sometimes about personal issues, and she had felt comfortable talking with him. After she had explained to him what had been said, Seher told her that she needed to call the police. That was when she phoned Detective Jenkins.

Ramey also provided some basic information about succinylcholine for the jury, basically what it was, what it is used for, when to use it, its immediate effect when administered intravenously, and how it affects a patient. She also said that it was readily available in the hospital for medical personnel to use. She pointed out a bottle of the drug in a photo that was shown to her of the interior of a rapid-intubation kit. She also pointed out a bottle of the drug, etomidate, in one of the photos of the inside of a rapid-intubation kit. She described where the kit was kept, who had access to it, and how it could only be accessed by someone who knew the code of the key padlock that secured the door of the refrigerator where it was kept. Everyone, she said, used the same code.

“Are you familiar with the drug etomidate?” Hicks asked.

“Yes.”

“As a critical care nurse with your experience, would there ever be a reason to have a vial of etomidate at your house?”

“No,” Ramey responded. “That would be grounds for losing your license.”

 

 

Following Alan Baum’s cross-examination of Kim Ramey, which had amounted to little more than clarifying a few small details about her testimony, and had not brought any new and significant information for the jury to consider, the state called Dr. Richard Seher.

Seher, board-certified in internal medicine, general cardiology, and interventional cardiology, had been practicing in the Reno–Lake Tahoe area for more than twenty-one years. He had been working at Carson-Tahoe Hospital for about nine months, and had come to know Ramey by having worked with her. He described her as a “great” nurse who was “really on the ball,” and said that he would “be happy to have her take care of me or any of my family members.”

On the morning that he had spoken to Ramey about the comment that Chaz Higgs had purportedly made, Seher had been making rounds in the cardiovascular intensive care unit. Ramey, he said, appeared upset and visibly shaken. He said that he took her to a “side room” that is used for dictation and they, along with another doctor, sat down and talked.

“Dr. Seher, when Miss Ramey approached you, visibly upset as you’ve stated, what was it that she told you?” Hicks asked.

Hicks’s question generated a near-automatic objection from Baum on the grounds that the response would be hearsay. The issue was argued out of the jury’s presence, after which Judge Kosach overruled the objection and allowed the question to stand.

“She said, ‘I know—I know that Chaz Higgs killed her. I know what he did,’” Seher testified.

“And what did you say when she said that?”

“I said, ‘What was it?’ And she recounted that . . . when they worked together, she had heard him arguing with his wife on the phone, and he said something to the effect of ‘I’m going to leave my wife, take the money out of the account. ’ Then he said, ‘You know, Darren Mack was stupid. He should never have been caught. He should have used succinylcholine. He wouldn’t have been caught.’”

“And did you know what she meant when she said ‘succinylcholine’? What is succinylcholine to you?”

“Oh, absolutely,” Seher responded. “Succinylcholine is a paralytic drug. It’s a type of curare. There are several drugs in that category that we use in the hospital as a paralytic agent.”

Seher said that when he indicated to her that she needed to call the police, Ramey had been reluctant to do so at first. Seher recounted what Ramey had testified to about not wanting to go to the police because “she had just gone through a divorce, and I think she sort of had it with the legal system.” He said that he continued to urge her to contact the police.

“I said, ‘You know, this isn’t like a traffic violation.... This is a real crime. You have to report it. You have to call.’”

“Did you take any steps yourself once you heard what she had spoken with Mr. Higgs about and then after she had told you everything?” Hicks asked. “What did you do?”

“I called my partner, Dr. Richard Ganchan,” Seher said. “And there’s two large cardiology groups in town, and we take care of the sickest of the sick people. So, if somebody is ill, there’s a fifty-fifty chance we’re taking care of them. So I called my partner . . . and I said, ‘Are we taking care of Kathy Augustine?’”

“And did you find out if you were, in fact, taking care of her?”

“He confirmed the fact that we were indeed physicians consulting on her case.”

“Did you give any specific instructions to . . . Dr. Ganchan?”

“We had a very brief conversation,” Seher responded. “I said, ‘Get a succinylcholine level now.’ And he said—after a pause—‘Got it,’ and hung up the phone.”

“The state calls Dr. Paul Mailander,” Washoe County Deputy District Attorney Christopher Hicks said.

After being sworn in, Dr. Mailander took the witness stand and attempted to get comfortable. In response to questions from Hicks, Mailander explained that he worked as an anesthesiologist for Sierra Anesthesia in Reno and nearby Sparks, where he performed surgical anesthesiology.

“If you could please explain for the jury what schooling you had that led you to where you are today,” Hicks asked.

Mailander explained that he earned a bachelor’s degree in medical engineering from the University of California at Berkeley, and a master’s degree in biomedical engineering from the same university. He went to medical school at Case Western Reserve University in Cleveland, Ohio, after which he did two years of general surgical residency at Cleveland’s Lutheran Medical Center, three years of general anesthesia residency at the Cleveland Clinic, and a year of postanesthesia fellowship in cardiothoracic anesthesia and pain management, also at Cleveland Clinic. He had been practicing in Reno since that time. He also had served as chair of the Department of Anesthesia at Washoe Medical Center from 1994 to 1996.

“Your Honor, I would offer Dr. Mailander as an expert in anesthesia,” Hicks proclaimed.

The defense team stipulated and made no objection.

In response to a question from Hicks about the role of the anesthesiologist, Mailander explained that it was his job to take patients who are about to undergo surgery and render them comfortable and safe so that they could tolerate the stress and duress of surgery. Of course, he said, this was accomplished through the use of a variety of medications that place the patients in a hypnotic, or unconscious, state in which they would not be aware of what was happening to them. He said that the patients were carefully monitored during the surgery for any changes in their vital signs, and to ensure that they remained unconscious. When the procedure had been completed, he said, his job involved bringing them back to a conscious state and monitoring them through their recovery as they woke up.

“We have a variety of tools,” Mailander explained, “but, basically, on any given general anesthetic, for example, where a patient is going to sleep, we use a rock-bottom minimum of about seven different medications. And that’s for someone who is having a simple procedure, who is essentially healthy and doesn’t have any outstanding medical conditions.”

He said that an anesthesiologist will typically sedate patients preoperatively to alleviate any anxiety that they might be experiencing. To keep patients safe, their blood pressure is checked frequently, as is their pulse rate, oxygen saturation levels, and carbon dioxide levels. The patients’ EKGs are monitored closely throughout their operations, and their motor responses are checked.

“Then we give them medications [that] will put the patient into a state of what we call hypnosis,” he said. “Most people . . . call it going to sleep. Most people are familiar with sodium pentothal . . . a sleeping medication that makes you basically fall into a state of unconsciousness.”

Once a patient is asleep, he explained, the anesthetic needs to be maintained so that the patient will not wake up on the operating table. Sodium pentothal, which has no pain-relieving properties, works clinically for only approximately two to three minutes.

“We have to give the patient other medications to keep them comfortable for the duration of the procedure,” he testified. “And, if needed, we give them medication to keep them immobile so they can’t move. Surprisingly, if you’re asleep, but not very deeply asleep, if someone does something painful to you, you’re going to twitch or move. So by giving you some medications [that] either make you more comfortable, or in some case simply prevent you from moving, it makes things safer and faster for the surgeon and for the patient.”

“Now, are one of those drugs that will prevent a patient from moving called succinylcholine?” Hicks asked.

“Yes,” Mailander replied.

“If you would, please explain to the jury what, in a nutshell, succinylcholine is and what it is used for.”

“It is a clear, colorless liquid that we inject almost exclusively intravenously into our patients,” the doctor responded. “Virtually all of the anesthetic agents we use work on your nerves and your brain primarily. The muscle relaxants, including succinylcholine, work at the level of the muscle. It’s the one medication, or one of very few, that actually works at the level of the muscle itself.

“Whenever you move a muscle purposefully,” he continued, “making a fist, moving your hand . . . your brain sends a nerve impulse to your muscles, and there’s a chemical released at the nerves on to the muscle [that] triggers the muscle to twitch. So I tell my hand to make a fist, the nerves stimulate the muscle fibers with chemical reaction, and I make a fist.... The muscle fibers all pull together.

“Succinylcholine is a medication [that] looks very much like the chemical that is the neurotransmitter, from the nerve to the muscle. And it is very avidly bound on to the receptors of the muscle. And by binding to the receptors of the muscle it blocks the neurotransmitter from working. As a result, the muscle fibers do not work. And that medication will stay in effect clinically on the muscle, making the muscle unable to respond to nerve stimulus until it is metabolized. And then it goes away and . . . regains normal function.”

Mailander explained that succinylcholine is used in numerous types of surgery situations, and is commonly used in the intubation of a patient. He explained that succinylcholine wasn’t the only medication used for that purpose, but that it was one of the earliest discovered. Because it has certain side effects that are not beneficial for the patient, its clinical use is avoided whenever possible.

“But in a circumstance where we need to place a breathing tube into a patient relatively quickly,” Mailander explained, “succinylcholine is still the fastest-acting muscle relaxant that we use clinically. By giving it to the patient, they can be rendered motionless within about a minute of its injection, and then we can open their mouths and place a breathing tube basically into the top of their windpipe at that point.”

“I just want to make sure I understand correctly,” Hicks said. “If a person is administered succinylcholine, they are paralyzed, correct?”

“That is correct.”

“Can they move anything?”

“Any muscle you can voluntarily control, your breathing, your eyelids, shrugging your shoulders, anything you voluntarily control, will be paralyzed and unable to move. Your heart will work. Your intestines will work. Other muscles that you don’t normally control voluntarily will continue to work. But the skeletal muscles are what we call them, all will stop functioning, and the patient will be unable to move.”

“So I assume your brain is not a voluntary muscle,” Hicks said, generating mild laughter from the gallery. “It’s always working. Is that right?”

“Well, your brain is not a muscle. In most cases.”

“In some of us, it is,” Hicks said, taking another stab at creating levity. “So it doesn’t affect your brain?”

“No, it does not.”

“And you said it doesn’t affect your heart.”

“No, it does not, either.”

“So, if someone was administered solely succinylcholine, would they be totally awake during that state of paralysis?” Hicks asked.

“Yes, they would.”

“Again, sir, assuming someone is administered succinylcholine. . . if there was no airway intervention, something to help them breathe, what would happen?”

“They basically would lose the capacity to breathe voluntarily, and it would be incumbent upon us to maintain an airway and either lift the patient’s chin, make sure there’s no obstruction, and then using a bag and a mask, which we use in surgery paramount to forcefully ventilate the patient for him or herself. So we would be driving oxygen and other anesthetic acid into the patient’s lungs for their benefit and on their behalf until they can regain their own muscle tone.”

“And if that didn’t happen?”

“The patient would not breathe,” Mailander responded. “And then it’s a matter of how much oxygen they have in their system and how long a wait before they amass enough carbon dioxide. Their blood is still circulating, so there is CO
₂
, carbon dioxide, accumulation in the lungs as well during a period of paralysis. So it’s a matter of how long you want to wait before the patient starts suffering the ill effects of too much carbon dioxide and too little oxygen.”

“And if that happens?”

“You start basically having a condition that we call ischemia, which is a lack of oxygen, and you start suffering organ damage.”

“To what organs?”

“Primarily to the most sensitive ones,” Mailander responded. “And the nerves and the brain are the most sensitive organs to oxygen deprivation. They will be the first ones to suffer irreversible damage.”

“After the nerves in the brain, are there any other organs that would suffer damage?”

“Well, all organs will eventually, but the actively metabolic organs. The liver, the kidneys are very sensitive as well. Not as sensitive as the nerves, but the kidneys and liver will start to show signs of ill effect. And eventually the muscles will, too.”

He explained that the heart is a highly metabolic organ, a muscle that is constantly working, but that in the absence of oxygen and nutrition from the blood, it will start to suffer ill effects as well and will begin to fail.

“You had indicated that this particular drug is primarily administered intravenously,” Hicks reminded the witness.

“Yes.”

“Are you aware if it can be administered intramuscularly?”

“It can,” Mailander affirmed. “And most of the anesthesia books [and] most . . . anesthesia instructors will tell you that in a pinch, if you have to get someone paralyzed and there is no intravenous access, you can give them a shot in a muscle. It will take a little longer to act, but it will act, and the patient will be paralyzed, and you have to move accordingly.”

Dr. Mailander said that he had not seen firsthand succinylcholine administered intramuscularly because, he explained, if a patient needed to be put to sleep emergently without an IV line, there were other anesthetic and sleeping medications, such as the hypnotics that he had discussed earlier, that could render the patient unconscious without paralyzing him or her. Paralyzing a patient without knowing that you can establish an airway is a major risk factor, he said. One of the circumstances in which a physician would not be able to administer succinylcholine intravenously would be when dealing with an uncooperative patient in an emergency situation.

“Now, if you were to administer succinylcholine intravenously, how quickly would it take effect?” Hicks asked.

“In a normal, healthy individual, normal circulation, in under a minute,” Mailander responded.

“And intramuscularly?”

“About three minutes.”

“Again, back to my hypothetical of a patient who is not being cooperative, and you have to administer it intramuscularly,” Hicks said. “Would that three-to-five-minute window speed up if the person was still fighting?”

“Well, the faster someone moves, the faster their blood circulates, the faster the medication is picked up in the muscle and circulated through their system, yes,” Mailander responded. “So, if someone is struggling, then medication takes effect faster.”

“Are you familiar with a drug called etomidate?” Hicks asked.

“Yes.”

“Is there any reason why a person would have etomidate at their home?”

“I can’t think of a good therapeutic reason, no. I can’t think of a reason.”

“What is etomidate?” Hicks asked.

“It’s a hypnotic medication,” Mailander said. “Back to inducing an anesthetic, putting someone from essentially awake to asleep, etomidate is another medication we have, to inject in someone, which will put them into a state of sleep. It creates amnesia, which is a good thing. And anesthesia, which means you’re unable to respond to stimulus. It does not . . . relieve any pain.”

Mailander explained that etomidate, a controlled drug, is not commonly used because it has a side effect that affects the adrenal glands in that it interferes with normal adrenal gland hormone production, a complication that is potentially hazardous to patients. However, it has the benefit of maintaining normal cardiovascular stability when injected into patients to put them to sleep.

“(For) patients who have unstable cardiovascular systems,” Mailander added, “whether they are anemic or have lost a lot of blood or simply have weak hearts, etomidate is a better choice than others because it maintains a normal blood pressure, normal pulse rate.”

Hicks led the expert witness through a series of questions in which he confirmed through Mailander’s answers that, among other things, etomidate is a drug that cannot be obtained through pharmacies because they don’t stock it, and that etomidate, as well as succinylcholine, is under controls, with limited access in a hospital setting.

“Dr. Mailander, I want to digress for a second to intramuscular injections,” Hicks said. “Again we’ll go back to the uncooperative patient in which you need to get paralyzed, for lack of a better term, and you need to administer intramuscularly. Would the buttocks be an appropriate spot to do that?”

“Yes.”

“And in your training and experience as an anesthesiologist, is there any pause you have as to say whether or not succinylcholine would work if administered in that manner?”

“It should work very well.”

“And why would that be?”

“It’s a large muscle. One of the reasons the buttocks is a general muscle of choice for shots is that it’s a very large muscle mass, so the odds of hitting the muscle are very, very good without going too deep in the bone or going too superficially. And has a very, very good, strong blood supply for rapid uptake.”