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Exhibit ‘‘A’’

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Gary M Vilke, MD., FACEP, FAAEM
11279 Breckenridge Way
San Diego, California 92131
(619) 666-8643

November 15, 2011
Bruce E. Disenhouse
Kinkle, Rodiger and Spriggs
3333 Fourteenth Street
Riverside, CA 92501

RE :

Carole Krechman, et al v. County of Riverside, et al
Case No. CV 10-08705 ODW(DTBx)

Dear Mr. Disenhouse:

Introduction
I am a board-certified emergency department physician with substantial experience in sudden
cardiac arrest and sudden cardiac death, including my service as the Medical Director of the
American Heart Association Training Center at the University of California, San Diego Center for
Resuscitation Science since 2007. I am also an independent researcher on the effects of body
positioning and restraint techniques and the impact they have on-human-physiology. I am also
knowledgeable of the state of the medical and scientific research of restraints and the impact on
humans as well as in-custody deaths. I have been retained to review relevant materials and provide
expert opinion on the cause of Mr. Robert Appel's death. After careful review, it is my opinion that
Mr. Appel suffered a cardiac arrest after being handcuffed by deputies. The actions of the deputies
did not cause the death. Mr. Appel was exhlbiting signs of excited delirium syndrome, which can
be lethal in and of itself, but also had cardiomyopathy and severe hyperkalemia associated with
renal failure, both of which can cause sudden cardiac arrest. These opinions and related opinions
are set forth in this expert report.

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Materials Reviewed
Riverside County Sheriff Department Special Investigations Bureau Central Homicide Unit
Investigation ofln Custody Death of Robert Appel on 5/14/10
Medical Examiner's Report and Toxicology Testing
Incident Report 1/29/10 involving Robert Appel
Investigative Report of 5/12/10 DUI involving Robert Appel
Computer Automated Dispatch Records
Standing Order Regarding Newly Assigned Cases in Krechrnan v. County of Riverside
Autopsy photos
Scene and emergency department photos
Interview oflnv Alfaro
Interview oflnv Dusek
Interview of Inv Garcia
Interview offieputyehacon-Deposition of Deputy Edward James Chacon
Deposition oflnvestigator Sean Michael Dusek
Deposition oflnvestigator Martin Alfaro
Deposition Investigator Robert Garcia
Deposition of Rachel Baker
Deposition of Carole Sumner Kretchrnan
Deposition ofM. Scott McCormick
Medical records from Eisenhower Medical Center from 5/15/10.
After reviewing these materials, there are several issues that are clear given this information. My
review of the above noted materials support the basis of my opinions with the regards to the
restraint and subsequent cardiac arrest of Mr. Robert Appel. All opinions given are to a reasonable,
or higher, degree of medical or scientific certainty or probability based on this information.

Overview of case
On May 14, 2010 at approximately 2230, Mr. Robert Appel, who was 48 years old at the time, was
approached by a Sheriff's deputy who was responding to a 911-call hang up. Mr. Appel was noted
to be talking to himself outside, was not wearing a shirt, and was sweating profusely. He did not
have shoes on and had cuts to his feet and was bleeding. At one point, unprovoked, he jumped into
the bushes. Officers subsequently tried to restrain him for safety purposes and he became agitated
and required four officers to get him handcuffed. Witlnn a minute of cuffing, he became
unresponsive, but was noted by officers to still have a pulse and rise and fall of his chest, indicative
of breathing. Upon arrival of Emergency Medical Services (EMS), Mr. Appel was noted to be in
cardiac arrest, was treated by paramedics, and was initially resuscitated. He was transported to the
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emergency department where he was noted to have both life-threatening elevated serum potassium
and magnesium levels as well as renal failure, and subsequently went back into cardiac arrest and
could not be resuscitated and was then pronounced dead. The medical examiner reported the cause
of death was sudden cardiac arrest following physical confrontation with law enforcement, with
alcoholic cardiomyopathy listed as another significant condition.

In brief, my opinions are as follows with more description of each below:
1. The use of the handcuffs and having Mr. Appel on his stomach in a prone position with
passive restraints did not cause or contribute to his death.
2. The use of the weight on his back during the handcuffing process did not cause or contribute
to the death of Mr. Appel.
3. The attempted placement of a lateral vascular neck restraint (LVNR) did not cause or
contribute to the death of Mr. Appel.
4. The three reported fist strikes to Mr. Appel's head did not cause or contribute to his death.
5. Mr. Appel was suffering signs and symptoms consistent with excited delirium syndrome,
which in and of itself can cause sudden cardiac arrest.
6. Mr. Appel had reported alcoholic cardiomyopathy, which places him at risk for sudden
cardiac arrest.
7. The life-threatening level ofhyperkalemia (elevated potassium levels) and
hypermagnesemia (elevated magnesium levels) due to renal failure were the most likely
cause of his cardiac arrest and death.
8. The actions of the deputies in handcuffing Mr. Appel did not cause his death.
9. Under the circumstances presented, there was nothing that the sheriffs officers should have
done differently in restraining Mr. Appel to prevent his cardiac arrest, as it was an
unpredictable event.

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Detailed review of opinions

1. The use of the handcziffs and having Mr. Appel on his stomach in a prone position with
passive restraints did not cause or contribute to his death.
There are no studies, clinical findings in this case or previous case reports that support that any
variation of restraining a handcuffed individual with hands behind his back will impede one's
ability to ventilate and cause positional asphyxia or a respiratory arrest. Leaving the subject on his
stomach in the prone position is considered physiologically neutral. The Mr. Appel was breathing
and could move side-to-side if desired and not having the ventilatory movement of his lungs
impeded. Mr. Appel did not suffer from positional asphyxia nor did the restraint have any
contributing component to his demise.

2. The use of the weight on his back during the handcuffing process did not cause or contribute
to the death oflvfr. Appel.
During the period that _Mr. Appel was being handcuffed, he was restrained in a prone position with a
certain amount of weight force was being placed on his back by the officers to secure the handcuffs.
Mr. Appel was making noises and struggling and even verbalizing without any evidence of
respiratory or ventilatory difficulty during this time period. He was reported to be moving and
resisting during this period and was not noted to complain of shortness of breath or difficulty
breathing. Given that Mr. Appel was clearly alive and struggling during the short period of restraint
and minimal weight force, and that the cardiac arrest was sudden, as well as there were no findings
or changes consistent with asphyxiation on autopsy, the weight force on the back did not cause Mr.
Appel' death.

3. The attempted placemen/ of a lateral vascular neck restraint (L VNR) did not cause or
contribute to the death oflvfr. Appel.
The pathophysiology and safety, of the lateral vascular neck restraint (LVNR), also known as a
carotid restraint, are relatively straightforward and well delineated in many texts. The purpose is to
place the arm around the neck of the subject to be controlled. The crook of the elbow is placed at
the anterior (front) region of the neck and the forearm and upper arm come around the sides and are
used to place pressure on the lateral aspects of the neck where the carotid arteries are located.
Pressure placed on the arteries diminishes blood flow to the brain, quickly rendering the subject

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unconsc10us. The reports reflect that there was an unsuccessful attempt to place Mr. Appel into an
L VNR. However, correct placement could not be obtained and the attempt was abandoned. The
findings in the autopsy report support that there was no negative impact from this attempt as the
hyoid bone was intact as were the laryngeal cartilages. Additionally, there was no soft tissue injury
reported of the neck muscles. The attempted placement of the L VNR did not contribute to the death
of Mr. Appel.

4. The three reported fist strikes to Mr. Appel 's head did not cause or contribute to his death.
Although Mr. Appel reportedly received a strike with a fist three times to his head with he was
reportedly trying to bite one of the officers, there were no clinical changes reported at the time of
the strike, including-no-loss of-eonsciousness-from the.stFikec Additionally, there were no autopsy
findings that indicate that these strikes had any contributing effects to Mr. Appel's death.

5. Mr. Appel was suffering signs and symptoms consistent with excited delirium syndrome,
which in and of itself can cause sudden cardiac arrest.

Prior to and during the time of his being placed into handcuffs, Mr. Appel was exhibiting signs and
symptoms consistent with excited delirium syndrome (ExDS). In his case, the ExDS appeared to be
caused by and underlying and undertreated paranoid psychosis. ExDS is a syndrome most
commonly caused by use of stimulant drugs like cocaine, methamphetamine or PCP and presents
typically with aggressive and often paranoid behavior, but can also be caused by uncontrolled
behavioral or psychiatric illnesses. Classically, people suffering from ExDS are delusional,
hyperactive, and may be violent. They are often breathing fast, sweating and under clothed for
ambient conditions. They are often destructive, do not yield to overwhelming force, and have
reported to have a propensity to break glass.

Excited delirium syndrome places the individual at increased risk for sudden death, felt by most
experts to be caused by an irregular heartbeat from the increased stress and work on the heart by the
excited, over-stimulated, agitated physical state. Once the heart goes into an irregular beat, blood
flow through the body ceases and shortly thereafter, the subject will lose consciousness due to lack
of blood flow to the brain and then stop breathing. Often, law enforcement officers will notice that
the subject has finally quieted down, no longer yelling and struggling, thinking that he has finally
calmed down and given up the fight. Then a short time later is when someone will identify that the
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subject is suddenly in cardiac arrest. In this case, the change in status was promptly noted and
appropriately addressed by the deputies at scene.

Sudden death from ExDS has been documented to occur with subjects in restrained, prone, supine
and even sitting positions. The position does not appear to be tl1e causative factor for the cardiac
arrest, but rather the ExDS state itself. Once a person goes into cardiac arrest from excited delirium
syndrome, they are almost impossible to successfully resuscitate.

Mr. Appel, though all of his medical records are not available to me, has a history of noted bizarre
and paranoid behavior. He was reported in January of2010 in an incident report to exhibit paranoid
behavior,-including accusing a-security guard of allowing his computer to get hacked and reporting
that he was raped, but had no specific complaints or details of tl1e incident. He was noted by the
community guard, as well as a neighbor, to be acting bizarre and "unstable" for quite some time.
His mom also reported that on the day of his death, he was crawling around house and acting
"crazy" "like an animal." She reported that he had a cut foot and bleeding all over the carpet and
repeating that someone had given him something or made him take something and that they were
out to get him.

Medications found at his house included Zyprexa and Depakote, both of which are mood stabilizers
used to treat psychosis, including paranoid schizophrenia and excited moods. The urine toxicology
screen by the medical examiner did not find either of these medications in Mr. Appel's blood or
urine samples, indicating that he was not apparently taking them. IfMr. Appel, was indeed a
patient with underlying psychosis, who was intermittently on medications, that would certainly
explain some of his functionality in the past months as noted by the community guard, who reported
periods of normal behavior as well a "unstable" behavior. And stopping the medications would
explain the decompensation and increased paranoid and bizarre behavior and place at risk for
excited delirium syndrome and sudden death.

Clinically, Mr. Appel was suffering the signs and symptoms consistent with a diagnosis of excited
delirium syndrome. He was profusely sweaty and only partially clothed. He was delusional,
thinking he was poisoned and that there were people after him tliat were not really there. Broken
glass was found in his house. He was not complaint witl1 officers' commands and was struggling
against overwhelming force and did not appear impacted by pain, as evidenced by tl1e continued
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struggle even with an arm bar hold. His sudden cardiac arrest is also consistent with sudden death
by excited delirium syndrome.
6.

lvfr. Appel had reported alcoholic cardiomyopathy, which places him at risk/or sudden
cardiac arrest.

Mr. Appel had alcoholic cardiomyopathy noted on autopsy, which was described as concentric left
ventricular hypertrophy. The medical examiner described it as a "large dilate, almost balloon like
heart ... " This physical enlargement of the heart in and of itself can place an individual at increased
risk for sudden cardiac arrest and death from a spontaneous irregular heart beat. Given the excited
state and agitation of Mr. Appel, along with his enlarged heart, he was at risk to go into cardiac
arrest.

7. The life-threatening level ofhyperkalemia (elevated potassium levels) and hypermagnesemia
(elevated magnesium levels) due to renal failure were the likely cause of his cardiac arrest
and death.

Mr. Appel was found to have a potassium level> I 0.0 and a magnesium level of 5.2 at the time of
his emergency department evaluation at 23 :27 on 5/14/10. The cause of these elevations is his
kidney failure as noted by his creatinine of3.7 at this visit. This elevation was not caused by or
worsened by the interaction with the officers. In my almost 20 years of being an emergency
department physician I have never seen a potassium level this high before. By way of comparison,
a normal potassium level is 3.5-5.0. Patients with chronic kidney failure on dialysis can get up to
levels of 6.0 to 7 .5 with little in the way of clinical findings, but patients with acute kidney failure
will have EKG changes at these levels and are already at risk to go into sudden cardiac arrest. The
highest level I have seen is in the 8+ range and was in a dialysis patient who did not go to his
dialysis and presented in cardiac arrest from the hyperkalemia. Mr. Appel, with a potassium of
greater than IO was at risk to go into cardiac arrest at any moment, with or without any involvement
by law enforcement. When the potassium level is greater than 8, significant EKG findings occur,
including widening of the normal electrical activity and significant slowing of the heart rate. This is
exactly what was reported in Mr. Appel in that his heart rate slowed prior to his cardiac arrest. A
potassium level of greater than IO is not compatible with sustaining life for very long. This severe
hyperkalemia is the probable cause of Mr. Appel's cardiac arrest.

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8. The actions of the deputies in handcuffing Jvlr. Appel did not cause his death
As noted above, the restraint, weight on the back, attempted LVNR and the strikes did not cause or
contribute to Mr. Appel's death.

9. Under the circumstances presented, there was nothing that the sheriff's officers should have
done differently in restraining Mr. Appel to prevent his cardiac arrest, as it was an
unpredictable evell/.
Mr. Appel had previously undiagnosed kidney failure with life threatening hyperkalemia coupled
with cardiomyopathy. He was a ticking time bomb ready to go into cardiac arrest at any time. The
officersrestrained Mr. Appel in an expeditious-manner-and-then-evaluated-his vitalsigns whileEMS was en route. There is no medical care that needed to be rendered prior to the arrival of EMS
as Mr. Appel was breathing and had a pulse. This evaluation and monitoring is what is warranted
by law enforcement under these circumstances to manage a combative subject.

Background and Qualifications

My background is that I am a full time faculty member in the department of emergency medicine at
the University of California, San Diego Medical Center. I am residency trained and board certified
in Emergency Medicine. I work full time as a practicing clinician in the Emergency Department of
a busy urban hospital. I also work for the medical center as the Director of Custody Services for the
San Diego County Sheriffs Department Jail Medical Service where I oversee direct patient care,
interface between the jail clinical staff and the hospital staff, and have been involved in the process
of utilization review. I have also served as the UCSD Medical Center's Chair of the Medical Risk
Management Committee as well as the Chair of the Patient Care and Peer Review Committee, both
of which are charged with the task ofreviewing medical records and making determinations of
standard of care, and I currently serve as Chief-of -Staff for the Medical Center.

As a physician working at both the jail and in the emergency department that is contracted to care
for incarcerated patients, I have managed many patients over the last 15 years who have been
incarcerated. I have worked at the jail as a clinic physician for over IO years and I have talcen care
of hundreds of patients at the time who have been arrested by police and thousands of patients who
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have been arrested and restrained. I have also been directly involved with numerous restraints and
extractions of individuals. I have also been involved in multiple evaluations and research on
humans involving restraint techniques and have restrained hundreds of human volunteers. A list of
my peer reviewed published articles can be found in my attached Curriculum Vitae.

Appendix A is a copy of my current Curriculum Vitae, which includes a list of all publications
authored by me over the previous ten years. Appendix B is a list of all cases in which I have
testified as an expert in trial or deposition within the preceding four years. I have not referred to
any other specific sources beyond my own research and those listed in this report. Appendix C
contains my and rate sheet. The knowledge base that I utilize has been developed over time from
my years of clinical practice, reading and research, including specifically those articles that I have
published myself in Appendix A.

Respectfully submitted,

Gary M. Vilke, M.D., FACEP, FAAEM
Professor of Clinical Medicine
Director, UCSD Custody Services
Director, Clinical Research for Emergency Medicine
University of California, San Diego Medical Center

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