by Helen Garner
Ms Forrester, re-examining, drew from these same case studies the fact that most of the subjects had identified themselves as heavy smokers. The American chopper pilot had recently been subjected to G-force in the course of his aviation training. Dr King shrugged calmly. He knew nothing about the effect of G-force on cough syncope. But he pointed out that most people who reported incidents of cough syncope were in their forties and fifties, so that thirty-six, Farquharson’s age at the time of the crash, was perhaps at the lower end of the range. The twitching seen during cough syncope, he repeated, was ‘involuntary and purposeless’. A person in such a state would not be capable of the purposeful steering of a car.
At this, the journalists en masse leaned forward to their notebooks, and the ABC television reporter sprang up and darted out of the court.
…
Professor Matthew Naughton, the Crown’s main expert medical witness, was the only man I had ever seen wear a pink tie with a tweed jacket. Rimless spectacles hung round his neck on a black cord. His turned-up nose made him look young, but he had a real mouthful of a title: Head of the General Respiratory and Sleep Medicine Service in the Department of Allergy and Respiratory Medicine at Melbourne’s Alfred Hospital. Mr Rapke led him through a CV of such vast scope and lavish detail that the journalists could hardly keep straight faces. The reporter beside me, stifling laughter, printed on my notebook, ‘Are you clever?’ But, as soon as Rapke’s examination began, Naughton showed himself to be soberingly quiet and modest.
Cough syncope, he said, is a recognised medical syndrome—a very brief loss of consciousness that follows an episode of intense coughing. The medical literature has described it for half a century in middle-aged, overweight males who are usually heavy smokers with underlying heart or lung disease. The mechanism most people accept as its cause is repetitive coughing that causes pressure within the chest. This pressure impairs the flow of blood on its way back to the heart from the lungs, so that the heart, when it contracts, has less blood to pump on its forward way.
‘I have trouble getting my head around this condition,’ said Naughton, ‘because it’s so nebulous. When I look through the literature on cough syncope, I find an absence of good quality scientific rationale to back up the validity of the condition. In twenty-five years as a medical practitioner I have never personally seen it.’
He had asked his respiratory colleagues at the Alfred Hospital ‘in a casual manner’ whether they had experience of cough syncope. They all knew of it as a condition, but there was only one case that any of them were personally acquainted with—a young man who suffered from the severe and chronic pulmonary condition cystic fibrosis and a neurological condition that impaired blood supply to his brain. The nurses on the respiratory ward were aware of his vulnerability to cough syncope and had to try to manage it.
Naughton had also consulted the physiotherapy staff at the Alfred. Part of their work is to test for the presence of a germ called pneumocystis that is common in the HIV population—people who, apart from their HIV-positive status and some breathlessness, are healthy. These patients are asked to inhale a hypotonic saline solution, which causes them to cough vigorously for up to thirty minutes. A physiotherapist who had administered this disagreeable-sounding treatment about once a week for ten years told Naughton she had not seen a single case of cough syncope in all that time.
‘Do people with normal lungs, hearts and brains,’ asked Rapke, ‘suffer cough syncope?’
‘I have never seen a case in which that has occurred,’ said Naughton. ‘Nor have I seen, in the modern medical literature, objective descriptions in which people have actually witnessed and monitored a person having cough syncope in which there has been normal heart, lung or neurological function.’
Now Rapke sharpened the focus. He asked Professor Naughton to imagine himself clinically faced with a man aged about thirty-seven, moderately overweight, a smoker who said he went through a packet roughly every three days. He was generally in robust health, but had been suffering for about three weeks from an infection which commenced in the upper respiratory tract, then developed lower down, and was being treated with antibiotics. An ECG taken ‘after a certain incident’ revealed no heart abnormality, a systolic reading of 140, and a rapid pulse. Seen immediately after the incident by paramedics and doctors at a hospital, he was not observed to be coughing. He had taken fluids within two hours of the incident. At the time of the incident, which he said occurred while he was driving, he was in a seated position. After the incident he was generally coherent and seemed to be lucid. He had been immersed in cold water, but had got himself out of the water, waved down a car and conversed with its occupants.
Morrissey jumped to his feet. To say that the man was coherent and lucid, but not that he was also delirious and a babbling mess, was misrepresenting the true situation!
‘I won’t intervene,’ said the judge. ‘Go on.’
No underlying medical illness was known or detected, Rapke continued smoothly. Blood tests showed no alcohol or drugs in his system. The patient claimed that as he was driving on a cool, even cold night, he had a coughing fit at the wheel of his car, and blacked out. Based on these facts, what was Professor Naughton’s professional opinion of the likelihood that the driver of that car had suffered an episode of cough syncope?
The professor hardly allowed a pause. ‘Extremely unlikely.’ From Rapke’s description, the man’s heart and lungs were in reasonably good health. He did not appear to be disabled by breathlessness. He was plainly not dehydrated. A dehydrated person who coughs would be more likely to experience changes in the pressure inside his chest—maybe not a blackout, but a dizziness that doctors call pre-syncopal.
Naughton was quiet and lucid. Rapke stood still and let him go on uninterrupted.
The interior of the car, said Naughton, where the hypothetical man said the coughing fit had overwhelmed him, would have been much warmer than the air outside. Cold can often trigger coughing, but this man did not cough after the event, although he was exposed to cold air and wearing wet clothing. Also, at the time he claimed he had started to cough, he was seated. A lot of our blood volume is in our abdomen and legs: cough syncope is more likely to occur if someone is fully upright.
Certainly he had a common-or-garden variety respiratory-tract infection. These happen every day in society, yet people with colds are not having cough syncope on a day-to-day basis. A single episode of cough syncope in a relatively warm environment, and one that was not replicated, struck the professor as highly unusual.
What if this hypothetical man, two days before the crash, asked Rapke, had been observed to have a severe coughing fit while on his feet? If he had gone red in the face, but had recovered once he was invited to sit down?
The fact that man had not passed out only consolidated the professor’s opinion. All of us in this room, he said, could cough to the point at which the colour of our facial skin changed.
He would expect a person with cough syncope to recover consciousness within seconds. He might feel confused for a few moments. Naughton had read reports of people becoming ‘flaccid’ when they lose consciousness: he let his head and shoulders droop forward, and flopped his hands apart, palms up, on the rail of the witness stand.
‘In that period,’ asked Rapke, ‘would the person be capable of any purposeful movement?’
What did it mean to say that the diagnosis—even a provisional one—of cough syncope is done ‘on history’?
‘We’re dealing,’ said Naughton, ‘with an extremely rare condition. Ideally we like to have a collateral history—at least one observer who witnessed the person cough and black out. But there is no definitive test that confirms or refutes cough syncope, apart from a classic description.’
‘The accuracy of the diagnosis is, then, solely dependent on the history?’
‘A hundred per cent,’ said Naughton.
‘But,’ said Rapke, ‘if you’ve got only the patient saying it happened, how does one test the diagnosis?’
‘It’s impossible to test. It relies on the individual providing an accurate history of what went on.’
…
Mr Morrissey himself was still struggling with spasms of harsh, dry barking that threatened to overwhelm him, but he was soon roughing up Professor Naughton with skill and gusto.
‘You’re not an expert in cough syncope? Did you tell the prosecutors, when they came to you for an opinion, that you’ve never seen it, never written about it, never diagnosed it, and didn’t know the way an episode would unfold if it happened? Yet they still called you as a witness?’
Naughton protested. ‘I’ve completed a training in respiratory disease where these conditions are discussed.’
But Morrissey made him out to have swotted up on cough syncope very recently and shallowly. Had he not read only one textbook and one article on the condition? Did he even know how to take a history of a cough syncope episode?
Naughton bristled. ‘I am educated about cough syncope,’ he snapped. ‘I do take a history of cough syncope when it’s presented to me. Because of its rarity, I don’t profess to be an expert in it.’
Well, had he read the list of cough syncope case studies that the defence had provided him with?
‘I did my best,’ said Naughton, ‘but they’re often not electronically available, and they take some time to locate. A lot of that data is many, many years old.’
Even so, said Morrissey, didn’t the data contain case histories of people without chronic airways disease who had been diagnosed with cough syncope while driving cars? Didn’t Naughton read the study of the four heavy-goods-vehicle drivers who had been involved in fatal crashes? They didn’t have chronic airways disease, but doctors were prepared to diagnose cough syncope on the histories they had provided. Didn’t this show that it was possible for a man without such a disease to have a coughing fit while driving and black out?
Naughton was beginning to gnaw and purse his lips, but he maintained steady eye contact with Morrissey. ‘I would rephrase that,’ he said. ‘I would say it is possible for someone to provide a history of having had cough syncope in the absence of chronic lung disease.’
What about the provisional diagnosis of cough syncope made by the Emergency Staff Specialist at Geelong hospital on the night of the crash? Wasn’t Dr Bartley, who unlike Professor Naughton had the benefit of being on the spot and taking a history from Farquharson face to face, fully entitled to make that diagnosis?
‘That’s his call,’ said Naughton.
What if a bloke came to Naughton and said, ‘Look, I’m twenty-eight. I don’t smoke. I play football. I’m a legend. But I’ve had an attack of coughing and blacked out’?
Naughton shrugged. He couldn’t exclude the possibility, but he would be very surprised indeed to hear of such an unlikely thing.
But Morrissey ushered Naughton down a fire escape of unlikelihood, step by step. ‘Since it could be possible, though extremely unlikely, with a person who’s twenty-eight and has no health problems, you’d agree with me that it’s less unlikely if he were a smoker? Even less unlikely if he were thirty-seven rather than twenty-eight? Even less unlikely if he’d had an acute respiratory-tract illness for three weeks? Even less unlikely if he’d suffered from paroxysms of coughing during those three weeks? And less unlikely still if he’d been witnessed to have a bad gripping coughing attack where the watcher thought he was going to have a stroke and told him to sit down?’
Naughton assented in a wary, affectless tone to each step.
But then Morrissey got down to what he riskily called ‘an actual episode’. On the Thursday before the crash, Farquharson had reported to his friend Darren Bushell, a Winchelsea shearer known to everyone as DB, that he had had a coughing fit in his car a few days earlier. He told DB he had blacked out at the wheel of his car outside the Winchelsea roadhouse; when he came to, he found his car had driven twenty metres further towards some rocks.
Mr Rapke sprang to his feet. ‘That is based on an assertion, not a witnessed event!’
Morrissey pulled his horns in. Had Naughton not noticed this report of Mr Bushell’s in the documentation he had been provided with? No? Still, if this incident were accepted as a proved fact, wouldn’t it have a massive impact on Naughton’s opinion?
‘It would have an impact,’ said Naughton.
And had the prosecution told the professor that, three weeks after Farquharson’s car went into the dam, a man called Zane Lewis had come forward saying, ‘I had one of these’?
‘Bloke down our way,’ whispered the reporter from the Geelong Advertiser. ‘Ran his car into a fence and said he’d had a coughing fit.’
‘I object!’ said Rapke. ‘That’s not fact at all. There’s no evidentiary basis for that whatsoever.’
‘Had one of these?’ said Justice Cummins, picking up the words in tweezers. ‘It’s not something you get off the supermarket counter. Is he an expert in neurology? Or an expert like this professor? Or is he a layperson? Is he expressing a medical diagnosis? What are you talking about?’
‘Would it have been of interest to you, Professor,’ said Morrissey, corrected, ‘in your consideration of the nature and scope and existence of cough syncope, to meet someone who said he had a coughing fit and drove off the road after blacking out?’
‘Yes,’ said Naughton politely. ‘That would be of interest.’
…
Court rose for a short break. Some of us stayed in our places, updating our notes. Mr Morrissey’s junior, Con Mylonas, got out of his chair and wandered along the bar table towards the press box. He was a small, dark man with pouty lips, who wore his wig low on his forehead. The word among the journalists was that he had been a brain surgeon before he came to the law, and had been taken under Morrissey’s wing. He stopped in front of me. I looked up nervously.
‘What’s your take on this guy?’ he said in a confidential tone.
Did he mean Farquharson? Why the hell was he asking me? I stared at him in alarm. But he jerked his head at the witness stand that Professor Naughton had just vacated.
‘I don’t know.’ I blurted out the first thing that came into my head. ‘He’s biting his lips a lot. What do you think?’
He smiled genially, and strolled away. Baffled, I turned to Louise; but she and the young journalist from Geelong were doubled over like schoolgirls in a fit of silent hysterics.
…
For the rest of that afternoon Morrissey hammered away at N
aughton. Hadn’t he jumped too early? Offered his opinion before he had properly informed himself? Wasn’t he now too proud or vain to admit he had been wrong?
Naughton rolled with the punches, continuing to work his lips and teeth. Eventually he got a grip. For twenty years, he said, he had regularly attended conferences. Some of these were focused purely on cough. Cough syncope had not been included as a condition that respiratory physicians should be routinely aware of. He kept a close eye on the medical literature as it came through. In the last fifteen or twenty years he hadn’t seen anything on cough syncope. References he had found were from the 1980s. He was yet to be convinced that there were physiological reasons to explain cough syncope in an otherwise healthy person who does not have any chronic lung, heart or brain disorder.
He offered a brief, clear lecture on the four levels of evidence in medicine. ‘As I read the data here,’ he said, ‘we’re running on the lowest, most anecdotal level to support a diagnosis of cough syncope. I’m not saying it doesn’t exist. I’m just saying it’s rare, it’s poorly defined, and most of the time the episodes are not witnessed.’
‘So in short,’ said Morrissey with a light scorn, ‘you’ll believe it when you see it? You’re as good as the scenario you’re given?’
‘Absolutely.’
‘Rare conditions do happen, though? It’s not much use to a person when they get a rare form of cancer to be told, “It’s all right—it’s rare”? The fact that it’s rare doesn’t tell you it can’t happen? Just that it’s unlikely to happen?’
Louise, who had been studying the jurors with a pale concentration, leaned over and whispered, ‘Even when he wins a point, he does it in such a way that the jury doesn’t seem to notice.’