Camp Verde, Arizona - Defense attorney Truc Do wrote out two lists on a white easel for jurors in the self-help author's manslaughter case - one with symptoms of heat exhaustion and the other with symptoms of heat stroke.
As she questioned the state's first medical expert on the witness stand Tuesday, she put a check mark next to the symptoms that could be indicative of poisoning as well as exposure to heat during a sweat lodge ceremony.
Defense attorneys for James Arthur Ray have said that investigators ignored other possible causes - such as toxins -for the deaths of three people that medical examiners attributed to heat stroke and multi-system organ failure.
Prosecutors say the evidence pointed to criminal liability on the part of Ray. They contend he conditioned dozens of people to trust him and to remain in the sweltering structure he led in October 2009 despite signs that things were going wrong.
Ray's name never came up in testimony Tuesday, as it did with more than a dozen participants who testified in the prior four weeks. Instead, attorneys queried Dr. Brent Cutshall on the medical conditions of three people who were critically injured and another person who died following the sweat lodge ceremony.
Do suggested that authorities failed to provide Cutshall and his colleagues with information they could have used to direct treatment of the patients and that pointed to possible poisoning - foaming at the mouth, gurgling and statements about treated wood and chemical agents.
Cutshall testified that the information would have been "nice to know," but it wouldn't have changed what he did. The conditions that included vomiting, nausea, acute renal failure, dizziness and dehydration were difficult to categorize because they are not specific to one diagnosis, he said.
"The problem with all these questions is there are just a lot of variables going on with all these things," he said.
Doctors at the Flagstaff Medical Center where Liz Neuman, Sidney Spencer, Stephen Ray and Tess Wong were taken also didn't have a complete picture on what caused the participants to be taken to the hospital or what treatment emergency responders administered before they got there, he said.
Doctors suspected carbon monoxide poisoning early on but Cutshall said that was ruled out through testing and consultations with poison control. But when asked whether he could rule out organophosphates - a chemical substance sometimes found in pesticides that can be ingested, inhaled or absorbed through the skin - Cutshall say he couldn't.
"I can't say I can rule it out with certainty, no," he said.
Prosecutors have asked a judge to allow them to present information on the type of pesticides or poisons used at the Arizona retreat where Ray held his weeklong "Spiritual Warrior" event. The judge hasn't ruled on the request that also extends to the wood that was burned to heat the rocks inside the sweat lodge.
Prosecutors have said the victims progressed on a continuum of heat-related illnesses that range from heat exhaustion to heat stroke. They say Ray ignored pleas for help from inside the sweat lodge and chided participants for wanting to leave.
Neuman, 49, of Prior Lake, Minn., arrived at the hospital with a rapid heart rate, low blood pressure and a 101-degree Fahrenheit temperature. Cutshall said she had to be put on dialyses due to kidney failure, remained on a ventilator, developed a blood clotting disorder, had severe brain injury and her lung functioned worsened.
Neuman's cousin sat in the front row and dabbed at her eyes with tissue as Cutshall described her complications. Neuman's family ultimately chose to take her off life support, and she died nine days after the sweat lodge ceremony, never regaining consciousness.
Kirby Brown, 38, of Westtown, N.Y., and James Shore, 40, of Milwaukee, also died.
Ray has pleaded not guilty to three counts of manslaughter.