When some medical experts look at the choppy, grainy video of Freddie Gray's arrest, they see that he has a spinal cord injury. Others are not so sure.
"He can't use his legs," said Dr. Mary Anne Whelan, a retired neurologist from Cooperstown, N.Y. "It's entirely consistent with a spinal cord injury."
"It's so hard to tell" from a video whether there's damage to a neck and spine or the extent of it, said Dr. Robert E. Harbaugh, president of the American Association of Neurological Surgeons.
Neither one is involved in the investigation into Gray's death in police custody about a week after the 25-year-old West Baltimore man was chased, wrestled to the ground and put in a police transport van April 12. But medical experts say the video is likely only one piece of evidence officials will examine as they try to determine what happened.
The question is when and how Gray was injured — during Gray's arrest before he got into the van or during the trip to a police station, or if there was a progressive injury worsened by the trip or complicated by a pre-existing condition.
The Baltimore Police Department turned over a report on the events Thursday to the Baltimore state's attorney's office, which is conducting an independent review and will decide whether to file criminal charges. The state medical examiner said Thursday it will complete its autopsy soon and turn it over to prosecutors. Meanwhile, a separate federal investigation is also underway.
Officials likely will look at all the evidence, from the video and the autopsy to testimony from officers and doctors at the University of Maryland Shock Trauma Center, where Gray was taken and died seven days later, according to medical and forensic experts who have handled similar cases
The video shows the 5-foot-8, 145-pound Gray screaming on the ground with police kneeling beside him before he's dragged to the police van, where he appears to stand briefly. Witnesses have said Gray's legs looked broken and suggested the injury may have occurred during his arrest.
Police acknowledged Gray was having trouble breathing and asking for an inhaler for asthma. Police now say he should have received medical treatment before being loaded in the van, where they also say they failed to buckle him in.
It may prove impossible to tell when Gray's spine was mostly severed, said Dr. Gregory McDonald, director of forensic medicine at the Philadelphia College of Osteopathic Medicine.
Medical examiners will pay particular attention to injuries on the outside of his body, such as patterns of bruising on his face, said McDonald, who is also the chief deputy coroner of Montgomery County, Pa.
He said it would be difficult to sustain a severe spinal injury inside a police van without other marks on the cheeks or the chin, or on the knees and elbows, which would indicate banging around. Other bodily bruising could indicate a beating by boots or batons, McDonald said.
The police investigation found that Gray suffered a head injury in the van, likely from a protruding bolt in the van's interior. Police have contended Gray was arrested with no force or incident and was walking and talking and even climbed into the van on his own power.
A witness has said a police officer had a knee on Gray's neck during the arrest.
Details of what happened in the next 45 minutes on the way to the Western District police station remain unclear, with Gray being removed and shackled at one point and unresponsive and not breathing by the end when officials said he was in "serious medical distress."
Police have said only that medical assistance was called and Gray was taken to the Shock Trauma Center.
City officials said a preliminary autopsy showed he had no broken bones and no injuries except to his spinal cord, as well as a crushed voice box.
McDonald said if examiners find no patterns of bruising, as indicated by the preliminary report, that would suggest most of the injury occurred with a knee or blow to the neck.
"Banging around in a van would get you a bunch of injuries not just isolated to the neck," he said. "Without them it indicates more of a non-accidental injury, but a direct blow to the neck. Since he was walking and talking, the injury may have been aggravated, but still probably did not occur, in the van."
McDonald added that, in his experience, "that kind of injury doesn't occur in the back of a van."
Others agree the crucial piece — exactly when the spine was harmed — may be difficult to determine.
If Gray's neck was fractured during the arrest and unstable, the spine could have been damaged without much thrashing around, said Harbaugh, also chair of the Penn State University Department of Neurosurgery.
Since Gray was not properly restrained by a seat belt, Harbaugh said someone with cuffed hands could fall or even throw himself on his head.
He also said someone with a spinal cord injury still could move their legs some depending on the location and severity of the damage, so Gray's spine could have been harmed before the ride.
Another doctor cautioned people not to read too much into a video that really cannot show how or even if an injury occurred.
Dr. Timothy Witham, an associate professor of neurosurgery at the Johns Hopkins School of Medicine and director of the Hopkins Bayview Spine Program, said images are necessary to see damage to the spine, and other factors could contribute to such an injury.
Some patients have pre-existing spine conditions such as spinal stenosis, or narrowing of the spinal column, with which trauma doesn't have to be that great to cause problems, he said. With a death, a medical examiner would look for that, as well as the damage and other evidence to piece together the nature of the injury, he said.
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While Gray's trouble breathing could be a symptom of asthma, it also could indicate a spinal cord injury in the neck because it is above the diaphragm, which regulates breathing, Witham said. In that case, first responders must offer artificial respiration immediately for a person's survival.
"We just don't know all the details of this case," Witham said. "I caution people from making a judgment. Until there is a full investigation of the medical facts, it really is speculation."
Because the spinal cord is so at risk from a neck injury, and damage hard to detect without diagnostic images, car accident and sports injury victims typically are placed in neck braces at the scene as a precaution.
"Inevitably, a fracture would cause neck pain, and it's often the biggest complaint," Harbaugh said. "That's a clue to the neurosurgeon evaluating that person. That's when they get a radiological assessment to make sure there isn't an injury that can lead to a spinal cord injury down the road."
Gray's screaming was apparent in the video, but Dr. Barbara Scherokman, a retired neurologist from Northern Virginia, just can't get past the images themselves.
"He should have been moving his legs," she said. "They may not have completely severed his spine before he got in the van, but his legs are dragging."