The emergency room doctor who treated Maliyha Hope Garcia when she was rolled into St. Charles Redmond on the day she died immediately noticed signs of post-mortem conditions — rigor mortis and lividity.

“I would say she died sometime before I saw her,” Dr. Michael Bouska testified Wednesday in the murder trial of Maliyha’s parents, Estevan Garcia and Sacora Horn-Garcia.

“Her level of nourishment was striking. She appeared cachexic,” he said, using the term for the level of emaciation associated with late-stage cancer.

Maliyha’s parents are facing aggravated murder charges for allegedly depriving her of basic nutrition and medical care and singling her out for mistreatment among their five children.

Prosecutors have called the case a puzzle. Wednesday’s piece: Maliyha’s time in the St. Charles Redmond emergency room.

At 10:58 a.m. on Dec. 21, 2016, Horn-Garcia called 911, saying her daughter had been sick with flu-like symptoms and just lost consciousness. Estevan Garcia was at work at the time, having left the home a little after 5 a.m.

The dispatcher coached Horn-Garcia through chest compressions and clearing the girl’s airway.

At 11:07 a.m., the first emergency professionals made contact with Maliyha in her home and started basic lifesaving care.

At 11:23 a.m., paramedics left with Maliyha, bound for the hospital. Throughout the entire time they worked on Maliyha in the Garcia home, paramedics saw no signs of life in the girl, they testified in court.

At 11:32 a.m., she arrived at St. Charles Redmond.

Between 15 and 20 professionals were ready in the trauma bay, everyone with an assigned role, Bouska testified. A line of people was readied to give chest compressions.

But nothing they did that day brought Maliyha back. She was given 16 shots of adrenaline, and numerous medications, tests and interventions were employed intended to kick-start her into life again.

About about 40 minutes after Maliyha arrived, a pulse showed up on the heart-rate monitor. It lasted about a minute before it disappeared. But, as Bouska testified, a pulse can sometimes be a sign of electrical activity in the heart and nothing more.

“I think heart activity is not the same thing as saying someone’s alive,” Bouska said. “The heart is very resilient, especially in children.”

Attorneys questioned Bouska about death — when it occurs and what it entails.

“Death doesn’t take place in an instant,” Bouska said. “It’s a process.”

They asked Bouska why so much time and energy was spent attempting to revive Maliyha if she was dead the entire time she was there. A similar question was asked Tuesday to the first responders who worked on Maliyha and transported her to the hospital.

Bouska’s answer was similar to what the first responders said.

“Nobody wants to go to bed thinking they didn’t do everything,” Bouska said. “So we do everything as long as we think there’s even a chance.”

At 12:31 p.m., Maliyha was pronounced dead — “We’re calling it,” were the words a nurse said to Estevan Garcia, who was in the room at the time, according to testimony.

Horn-Garcia entered later and inquired about her daughter. Emergency room nurse Daphne Olmos told her the news and sat with her on the ground of the ER, offering her a shoulder to cry on, Olmos testified Wednesday.

Moments after Maliyha was pronounced dead, Redmond Police contacted the Oregon medical examiner’s office to begin a criminal investigation. A Redmond Police lieutenant sat with the body until deputy medical examiner Victoria Gawlowski arrived at 2:24 p.m.

Gawlowski testified she was taken aback when she first saw Maliyha.

“I was shocked at how skinny she was,” she said. “In all my years of being a nurse I haven’t seen someone quite this thin.”

She went home that night and read all of Maliyha’s medical records and filed a report the next day expressing serious concerns to fellow medical examiner Cliff Nelson, who would conduct Maliyha’s autopsy.

Photos of Maliyha’s body taken by Gawlowski during her investigation were shown to the jury Wednesday. They showed black sores in the girl’s mouth and the holes in her legs drilled by nurses and EMTs after they failed at finding a vein to start an IV. Pictures from the family’s home were also presented, showing a stocked refrigerator and cupboards full of food. Maliyha’s autopsy found she weighed 24 pounds at death.

Attorneys for Horn-Garcia have suggested Maliyha’s death was the case of a girl, who was already skinny, losing more weight due to a prolonged, undiagnosed illness.

Expected to testify Thursday are the last doctor to examine Maliyha alive as well as child welfare authorities involved in her case.

— Reporter: 541-383-0325,