Discussions prior to jury
The judge is leaning towards a ruling that pulls the rug entirely out from under the defense. In the very beginning I thought his rulings seemed very fair, I would not have said he was putting his finger on the case in any way. As it progressed I thought he made a couple of puzzling rulings as to denying the defense to put on certain exhibits, and that it harms their case and seemed unfair. Especially the email that proves without a doubt WHO interrupted the phone call. The witness (CPS Case Manage, Charolotte LaPorte) who interrupted the call says she’s the one who interrupted the phone call. Maya (who was 10 at the time and clearly HATES a certain person is saying the person she hates is the one who made the interruption. One member of the jury demanded from the witness “why should we believe you?”. The email was written on the day of the call, immediately after the call, addressed to Beata, explaining WHY the interruptions was made, the fact that she’s sorry she had to do that, and giving Beata lots of suggestions on how to keep the conversations on track so that she could have a quality phone call with her daughter. It clears everything up. The judge will not allow it in, saying the jury will have to just decide who they believe. That seems fucked up.
Now, this morning, the plaintiff wants to claim that the defense diagnosed Maya with Munchausen by proxy. The JUDGE is trying to claim that the hospital DIAGNOSED Muchausen by proxy. I have not one time heard any doctor or other witness claim to have diagnosed anybody in that family with Muchausen by proxy. What I have heard, and what the defense argued this morning, was that several doctors at ACH suspected that there was something psychological going on. And one doctor had experience personally with Munchausen by proxy. The plaintiff is good at red herrings and the defense is good at allowing themselves to get trapped in these red herrings and misrepresentations. And they don’t fight beack at all and correct the judge when he says that the hospital “said that Beata HAD Muchausen by proxy.
So, the defense wants to be able to put in evidence to give the jury a clear picture that the hospital had reasonable suspicion that something psychological was going on. And the judge is indicating he is probably going to not allow them to put on the evidence they need to put on to clearly show that there are HUGE discrepancies between what Maya and her mother were saying and everything that could objectively be seen in multiple types of testing and observation.
This is definitely headed for appeal in my opinion. Prior to today I thought the judge was putting his finger on it just enough to give the plaintiff an edge with the jury but probably not enough for the hospital to win any kind of appeal. But if he cuts the legs entirely out from under the hospital I’m not sure that might give the hospital more chance on appeal. But IANAL, just giving my layman’s take on it.
Taking Care of Maya - FL CPS/Munchausen case
Taking Care of Maya - FL CPS/Munchausen case
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
First defense witness was Dr Mendez. His understanding when Beata made the appointment was that she was coming in for a second opinion on an immune deficiency diagnosis. When she came in it seemed more like she wanted to "understand" her daughter's immune deficiency.
He noted that Maya appeared to be uncomfortable or have some kind of pain. He got a history from Beata. Said she had lots of details. He ordered lab testing and set up a follow up appointment. He was able to do an exam of Maya without causing her any complaint of pain.
He was asked if Beata told him that Maya had spent 4 weeks in Tampa General, no Beata had not told him that. He was asked if she mentioned the trip she made to Chicago and no, he was not told about any of that. Those were the other two places (so far) that ended up believing that there was something psychological going on maybe instead of, or in addition to, anything else. So, Beata had left them out and so he had no records from them because he didn't know to reach out and ask for them.
At this initial appointment he noted that Beata had specifically told him that Maya had "severe" asthma. He was asked about the steroids and he told the jury those are a double edged sword. They can definitely help when they are indicated, but they can also cause a lot of problems. He was surprised at the amount and dosage of steroids and noted that on his initial impressions, but didn't yet have all the records from other physicians.
End of initial visit.
He gathered actual records from doctors that Beata admitted to taking her to. He noted that Maya had been to an unusually high number of different doctors and hospitals. He mainly had records regarding her asthma and allergies.
All of the other doctors had noted in the section where the patients tells the history that the asthma was "severe". He noted what he considered to be very large amounts of steroids reported in the history section that the mother gave within these other records as well.
During this visit Maya was still in her wheelchair as she had been on first visit. She was busy on her laptop computer which was laying in her lap and was in a good mood. She showed no signs of distress or pain and was not really paying much attention to the doctor and her mother as they were initially talking.
At some point, he brought out the objective findings and brought out all the records from other doctors who had done any kind of objective testing regarding Maya's lung condition and her immune system lab testing. Every objective test showed perfectly healthy lungs, and he saw no sign of wheezing. The most recent person who saw Maya regarding any suspected asthma was a doctor at JHACH who had noted normal lung function, he was unable to confirm asthma and his notes on discharge were nor Maya to be weaned off the steroids. Dr Mendez told Beata that all of Maya's lab testing also indicated perfectly normal immune system functioning and he was of the opinion that there was no objective finding of immune deficiency and that he did not see evidence of asthma. He noted she definitely had allergies, and there were objective skin testing to show that. But none of her scans showed any scarring of the lungs, there were none of the actual objectively observable signs of asthma.
As soon as he told the mother that he saw no sign of immune deficiency and asthma condition was not indicated, Maya began screaming and crying and moaning and complaining about pain. Dr Mendez attempted to figure out what was going on with her, but only got vague responses. He thought this was odd behavior and as we find out later he had further suspicions, so ne made a point to observe Maya as she was leaving.
As soon as Maya was out (or though she was out) of Dr Mendez presence she went back to being happy,. playing on her laptop and acting like nothing was wrong. He thought it was notable that she had been fine until she heard that he didn't think there was an immune disorder or asthma, then she was fine again within a very short time after leaving his office.
He was concerned about what he thought were excessive use of steroids for a condition that he saw no objective findings for. He also noted that she had supposedly gone to him for a second opinion about immune deficiency but it was more like a fifth or sixth attempt to get a diagnosis of immune deficiency, which no previous doctor had diagnosed, but several mentioned that Beata brought it up.
Dr Mendez has never spoken to, or met, Mr. Hunter (defense attorney)
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Plaintiff
Plaintiff quickly changed the subject to CRPS, which this doctor had nothing to do with. It is clear to me that they want the jury to be distracted from the fact that here are yet TWO MORE conditions for which Beata is claiming Maya has, is getting extreme treatments for, and there are not only no objective findings for those conditions, but Maya's behavior completely changes according to his findings that there is no immune deficiency.
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No recross. I am stunned. IMO the defense needed to bring it back to the fact that Beata is seeking treatment for TWO conditions, asthma and immune deficiency, for which there is no evidence Maya has either of these.
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And true to my suspicions, the plaintiff distracting the jury from the real damage of this testimony worked like a charm. Every. single. question by the jury was about CRPS and pain.
So, kudos for the plaintiff attorney, I guess. They seemed to completely erase from the jury's mind what was IMO blockbuster evidence in this case. Beata was not only seeing extreme treatment for CRPS, which Maya doesn't have....she was seeking extreme treatment for asthma (and had successfully gotten her hands on such medication in the past) and also seeking an immune deficiency disorder diagnosis, going to several doctors, claiming she wanted a "second opinion" when nobody even diagnosed a "first opinion" of immune deficiency.
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She was more sick than I thought. And wow, yeah, I was iffy on actual Munchausen, thinking it may not have been that far down the spectrum of possibilities, but now I'm starting to wonder. To me this was blockbuster evidence, but I fear it went right over the jury's head thanks to brilliant lawyering by the plaintiff. In general have not been at all impressed with Mr Anderson, but I have to say he was able to throw a red herring into this and the jury fell for it. I fear that the most important testimony - showing Beata was SEEKING a ds of Immune Deficiency , went right over the jury's heads.
He noted that Maya appeared to be uncomfortable or have some kind of pain. He got a history from Beata. Said she had lots of details. He ordered lab testing and set up a follow up appointment. He was able to do an exam of Maya without causing her any complaint of pain.
He was asked if Beata told him that Maya had spent 4 weeks in Tampa General, no Beata had not told him that. He was asked if she mentioned the trip she made to Chicago and no, he was not told about any of that. Those were the other two places (so far) that ended up believing that there was something psychological going on maybe instead of, or in addition to, anything else. So, Beata had left them out and so he had no records from them because he didn't know to reach out and ask for them.
At this initial appointment he noted that Beata had specifically told him that Maya had "severe" asthma. He was asked about the steroids and he told the jury those are a double edged sword. They can definitely help when they are indicated, but they can also cause a lot of problems. He was surprised at the amount and dosage of steroids and noted that on his initial impressions, but didn't yet have all the records from other physicians.
End of initial visit.
He gathered actual records from doctors that Beata admitted to taking her to. He noted that Maya had been to an unusually high number of different doctors and hospitals. He mainly had records regarding her asthma and allergies.
All of the other doctors had noted in the section where the patients tells the history that the asthma was "severe". He noted what he considered to be very large amounts of steroids reported in the history section that the mother gave within these other records as well.
During this visit Maya was still in her wheelchair as she had been on first visit. She was busy on her laptop computer which was laying in her lap and was in a good mood. She showed no signs of distress or pain and was not really paying much attention to the doctor and her mother as they were initially talking.
At some point, he brought out the objective findings and brought out all the records from other doctors who had done any kind of objective testing regarding Maya's lung condition and her immune system lab testing. Every objective test showed perfectly healthy lungs, and he saw no sign of wheezing. The most recent person who saw Maya regarding any suspected asthma was a doctor at JHACH who had noted normal lung function, he was unable to confirm asthma and his notes on discharge were nor Maya to be weaned off the steroids. Dr Mendez told Beata that all of Maya's lab testing also indicated perfectly normal immune system functioning and he was of the opinion that there was no objective finding of immune deficiency and that he did not see evidence of asthma. He noted she definitely had allergies, and there were objective skin testing to show that. But none of her scans showed any scarring of the lungs, there were none of the actual objectively observable signs of asthma.
As soon as he told the mother that he saw no sign of immune deficiency and asthma condition was not indicated, Maya began screaming and crying and moaning and complaining about pain. Dr Mendez attempted to figure out what was going on with her, but only got vague responses. He thought this was odd behavior and as we find out later he had further suspicions, so ne made a point to observe Maya as she was leaving.
As soon as Maya was out (or though she was out) of Dr Mendez presence she went back to being happy,. playing on her laptop and acting like nothing was wrong. He thought it was notable that she had been fine until she heard that he didn't think there was an immune disorder or asthma, then she was fine again within a very short time after leaving his office.
He was concerned about what he thought were excessive use of steroids for a condition that he saw no objective findings for. He also noted that she had supposedly gone to him for a second opinion about immune deficiency but it was more like a fifth or sixth attempt to get a diagnosis of immune deficiency, which no previous doctor had diagnosed, but several mentioned that Beata brought it up.
Dr Mendez has never spoken to, or met, Mr. Hunter (defense attorney)
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Plaintiff
Plaintiff quickly changed the subject to CRPS, which this doctor had nothing to do with. It is clear to me that they want the jury to be distracted from the fact that here are yet TWO MORE conditions for which Beata is claiming Maya has, is getting extreme treatments for, and there are not only no objective findings for those conditions, but Maya's behavior completely changes according to his findings that there is no immune deficiency.
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No recross. I am stunned. IMO the defense needed to bring it back to the fact that Beata is seeking treatment for TWO conditions, asthma and immune deficiency, for which there is no evidence Maya has either of these.
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And true to my suspicions, the plaintiff distracting the jury from the real damage of this testimony worked like a charm. Every. single. question by the jury was about CRPS and pain.
So, kudos for the plaintiff attorney, I guess. They seemed to completely erase from the jury's mind what was IMO blockbuster evidence in this case. Beata was not only seeing extreme treatment for CRPS, which Maya doesn't have....she was seeking extreme treatment for asthma (and had successfully gotten her hands on such medication in the past) and also seeking an immune deficiency disorder diagnosis, going to several doctors, claiming she wanted a "second opinion" when nobody even diagnosed a "first opinion" of immune deficiency.
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She was more sick than I thought. And wow, yeah, I was iffy on actual Munchausen, thinking it may not have been that far down the spectrum of possibilities, but now I'm starting to wonder. To me this was blockbuster evidence, but I fear it went right over the jury's head thanks to brilliant lawyering by the plaintiff. In general have not been at all impressed with Mr Anderson, but I have to say he was able to throw a red herring into this and the jury fell for it. I fear that the most important testimony - showing Beata was SEEKING a ds of Immune Deficiency , went right over the jury's heads.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Count 5 dealing with EEG room/transport including punitive damages, defense granted a directed verdict.
“hugs and kisses” granted directed verdict including punitive damages
False imprisonment is going to the jury. (This is for the time period prior to DCF getting involved. The testimony by doctors (defense witnesses) indicated that leaving the hospital was AMA due to the hospital having relented and giving Maya various pain meds as well as she was dehydrated and in need of IV hydration. However, the doctor was clear that had the family insisted on taking Maya out at that point they would not have been stopped from doing that (Jack K insists that he was “threatened with arrest”, but no evidence beyond this claim from him was offered). The doctor said that because DCF had already been contacted she would have been required to notify them that Maya was no longer in the hospital but that the family could have taken Maya at any point prior to court intervention, even if AMA. But I think the directed verdict decision is made prior to defense witnesses, so it’s based on if there was any evidence put in by the plaintiff during their case in chief.
Proposed instructions regarding time frame of dependency hearing – judge is going to give attorneys some things to include and what he needs to help make decisions. He doesn’t remember everything he needs to rule on
Ms Crowells says on the Malik deposition there are some objections to some parts of it (this is the one they started one say, stopped, and now she is ready)
She needs plaintiff objections and she needs their counters so they can play that deposition (I missed the name of the person on this one)
Need rulings on exhibits - the defense is waiting on a number rulings for exhibits
A big arguments came up regarding entering evidence of a supposed instance of sexual abuse that Maya is now claiming happened at this hospital during this stay. I thought the judge was going to allow it, but in the end, after he left the room then came back he denied it again. After the jury was selected and evidence was beginning to come before the jury, Maya told her attorneys that a man at the hospital had come into her room, pulled down her pants, looked at her, and then left. It made her uncomfortable.
Dr Kassenstine has a note for one of the times that she saw Maya regarding Maya mentioning that someone looked at her private parts. The plaintiff wanted a proffer to try to get this in front of the jury as something that happened at JHACH, just one more bad thing that happened to Maya at this hospital. The judge took a proffer from Maya a couple weeks ago and denied that it could come in. he told her she could report to the police and sue separately for that, but it’s not coming in this case. So, today during Dr Kassenstein testimony the plaintiff wanted a sidebar to try to get this in again.
The note Dr Kassenstein made was a summary of a conversation, not a quote. She proffered that the reason she used the word “previous” was because it didn’t happen at JHACH, but Maya did not tell where WHICH hospital, clinic, or doctor office it happened at, just that it was somewhere else. She had the impression based on everything Maya said that it was in relation to a normal examination where a doctor wanted to determine what her puberty status is. It is normal at that age for a doctor to do such a thing, and it is also normal for a young girl to be uncomfortable with it. It doesn’t signify abuse, she didn’t get the impression it was abuse, and she couldn’t report it because Maya was not clear about where it happened just that it was before she entered this hospital.
The arguments became quite heated and I actually thought the judge was going to allow it in. In the end he said it’s not coming in this case because Maya never mentioned it until after the jury had been selected, and the jury was not vetted as to any sexual abuse question they may have to consider, so it’s too late to bring it in.
“hugs and kisses” granted directed verdict including punitive damages
False imprisonment is going to the jury. (This is for the time period prior to DCF getting involved. The testimony by doctors (defense witnesses) indicated that leaving the hospital was AMA due to the hospital having relented and giving Maya various pain meds as well as she was dehydrated and in need of IV hydration. However, the doctor was clear that had the family insisted on taking Maya out at that point they would not have been stopped from doing that (Jack K insists that he was “threatened with arrest”, but no evidence beyond this claim from him was offered). The doctor said that because DCF had already been contacted she would have been required to notify them that Maya was no longer in the hospital but that the family could have taken Maya at any point prior to court intervention, even if AMA. But I think the directed verdict decision is made prior to defense witnesses, so it’s based on if there was any evidence put in by the plaintiff during their case in chief.
Proposed instructions regarding time frame of dependency hearing – judge is going to give attorneys some things to include and what he needs to help make decisions. He doesn’t remember everything he needs to rule on
Ms Crowells says on the Malik deposition there are some objections to some parts of it (this is the one they started one say, stopped, and now she is ready)
She needs plaintiff objections and she needs their counters so they can play that deposition (I missed the name of the person on this one)
Need rulings on exhibits - the defense is waiting on a number rulings for exhibits
A big arguments came up regarding entering evidence of a supposed instance of sexual abuse that Maya is now claiming happened at this hospital during this stay. I thought the judge was going to allow it, but in the end, after he left the room then came back he denied it again. After the jury was selected and evidence was beginning to come before the jury, Maya told her attorneys that a man at the hospital had come into her room, pulled down her pants, looked at her, and then left. It made her uncomfortable.
Dr Kassenstine has a note for one of the times that she saw Maya regarding Maya mentioning that someone looked at her private parts. The plaintiff wanted a proffer to try to get this in front of the jury as something that happened at JHACH, just one more bad thing that happened to Maya at this hospital. The judge took a proffer from Maya a couple weeks ago and denied that it could come in. he told her she could report to the police and sue separately for that, but it’s not coming in this case. So, today during Dr Kassenstein testimony the plaintiff wanted a sidebar to try to get this in again.
The note Dr Kassenstein made was a summary of a conversation, not a quote. She proffered that the reason she used the word “previous” was because it didn’t happen at JHACH, but Maya did not tell where WHICH hospital, clinic, or doctor office it happened at, just that it was somewhere else. She had the impression based on everything Maya said that it was in relation to a normal examination where a doctor wanted to determine what her puberty status is. It is normal at that age for a doctor to do such a thing, and it is also normal for a young girl to be uncomfortable with it. It doesn’t signify abuse, she didn’t get the impression it was abuse, and she couldn’t report it because Maya was not clear about where it happened just that it was before she entered this hospital.
The arguments became quite heated and I actually thought the judge was going to allow it in. In the end he said it’s not coming in this case because Maya never mentioned it until after the jury had been selected, and the jury was not vetted as to any sexual abuse question they may have to consider, so it’s too late to bring it in.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
He's allowing the plaintiff to accuse the hospital of accusing Beata of MBP, but he'll be goddamed if they get to defend themselves.Kriselda Gray wrote: ↑Sat Oct 21, 2023 10:22 pm It's too bad he didn't let the jury hear that. I think it would be very relevent for the defense's case if the husband was actually concerned about MBP when no one at the hospital had brought it up (at least as I'm understanding from what you've said.) Was the judge concerned it would be too prejudicial?
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Defense witness Dr Elliot,
Anesthesiologist, JHACH. From Ohio completed a 6 year program at Kent State which combined BS and MD in an accelerated program.
Additional pediatric anesthesiology fellowship. He is board certified in anesthesiology, pediatric anesthesiology, and medical acupuncture.
He is anesthesiology/pain management at JHACH after several years in those specialties.
Currently he is the Director of Pain Management and was in that position in 2016. They did not have the outpatient pain clinic at that time, but just inpatient, but he had the same position with the addition of outpatient when they opened that clinic.
His daily duties include anesthetizing patients for surgery and managing inpatient chronic pain patients.
Outpatient chronic pain clinic is for helping patients manage pain when they are not admitted to the hospital. They involve the children, parents, family members.
The outpatient clinic was not in operation until 2018 or 2019, so it was not available during Maya’s stay at JHACH. He did inpatient chronic pain consulting within the inpatient setting. He has seen CRPS patients in his career, particularly at Kettering and has seen several patients. They now have an actual CRPS program
He was very familiar with CRPS at the time Maya was in the hospital. The treatment standard at the time revolves around functional restoration – PT/OT/cognitive behavioral therapy. That is still standard treatment for pediatric CRPS to this day
He also had experience with conversion disorder. It is not uncommon to have comorbidity with conversion disorder. Returning patients to function, regardless. The treatment is the same because even with conversion of FND, the pain is still real, it’s just coming from a different pathway. So, they are treated the same. We believe they have pain, we do not say “it’s in your head”, the pain is real, and we move forward with the same treatment so they can become functional and return to normal life of a child.
It’s important to understand that the way the brain is firing it perceives pain that might not be there, so to turn the “off” switch, you get them slowly and progressively working with the extremity. They need to use the extremity, and not allow it to atrophy, or it will never turn off as far as the pain goes. We do see that with PT/OT/ and dealing with stress, it’s very effective and can bring them to remission.
Function – it’s very important to get them back to normal social and school activity and often that alone helps reduce their perception of pain. Regarding ketamine – medications can be used to facilitate PT, in particular ketamine isn’t routinely used, but when used we use low dose – i.e. lower than what would be used for anesthesia
His first involvement, he was on vacation and received a phone call from a colleague to ask about the high doses of ketamine that Maya had ben given. Dr Dolan had called him because he had the most experience with pain management specifically and was working to set up their pain clinic.
The doses she was receiving as an outpatient at Dr Hanna’s office were shared with him by his colleague. His reaction was surprised and shocked. The doses were way higher than any doses he’s ever seen given to a child. Subanesthetic doses are typically used for pain.
The doses were over 50 times higher than anything JHACH would ever give. Ketamine is FDA as a general anesthetic. It can be used for a child going into surgery. Everything is based on weight. Dr Hanna were giving doses in the range of up to 25 mg/kg per hour. A normal dose would be .7 to 2 mg/kg
He became the primary pain management anesthesiologist for Maya when he returned from vacation on 10/10, he was on the same schedule as Dr Michelle Smith. He reviewed the charts and looked at her records. In the afternoon of his first day back he saw Maya and met Mr K. and got a rundown of what was going on with her.
What was the treatment plan that was in place. To five her several days of a small infusion of ketamine and clonidine and begin to come down on those in ICU watching for any issues, managing her pain and making sure she didn’t suffer from withdrawal. They were being very cautious about managing her pain and not having withdrawal. They used medications to help with any anxiety/agitation that might be involved with withdrawal. Dr Elliot was able to get a hold of Dr Hanna by cell phone and he confirmed the doses that she was being given. He felt that they were not working, was becoming uncomfortable with continuing to give her higher and higher doses.
At this point they did not have records from any outside CRPS pain management. He was attempting to gather that information. Typically would get information from referring patients, what studies, meds, conditions, etc. That info is vital. Dr Hanna had referred her to ACH. He passed along his treatment. He had administered large dozes of ketamine, benzos. other sedatives, clonidine. Dr Elliot wanted to try to get her safely through weaning her from any of these drugs.
Multiple times the treatment team presented multidisciplinary means of treating Maya with the family, he likes to collaborate with the family and make sure they understand. On the 10th it was Mr K, he met Mrs K on 11th. Mrs K was demanding more aggressive and higher doses of ketamine, potentially amounts that needed intubation and other invasive protections. Also implantable pain pumps. He tried to share with Mrs K the evidence and literature on CRPS and chronic pain, she was not interested, only wanted the ketamine.
Beata wanting her to the “put to sleep” with the ketamine, and to support that she would have to be intubated. It’s not appropriate to put the patient into a medical coma for CRPS. We did not recommend nor are we going to offer that. There is no evidence to support this, it’s not standard of care and it isn’t safe. Any pain medications are used to facilitate the other therapies, not a replacement for all other therapies. Some of the risks of putting her into a ketamine coma are that intubation carries a risk of pneumonia, there are additional medications that have to be given if you are going to intubate a patient, blood pressure, heart rate. Sometimes need high doses of sedatives and muscle relaxers.
Intrathecal pain pump – device usually placed in adults where they are in such high doses of medicines that they can be given lower doses directly in the spine. But these are not for children. Mrs K was asking specifically for clonidine (she was “doing her own research”, keep that in mind.) Pain pumps involve risks like infections. Maya was undernourished and having an intrathecal pain pump is definitely not indicated for a malnourished child. They require a needle, need to be filled periodically. It’s not something to take lightly.
Had these discussion with Mr K on the 10th and Mrs K on 11th. They agreed to proceed with the plan to wean her off the meds and proceed with the PT/OT/cognitive behavioral therapy. He doesn’t specifically recall them wanting to leave the hospital AMA. But he was aware of the discussion to transfer her to the outpatient Nemours clinic. He was not involved in any AMA discussion. He was not directly involved in the Nemours transfer. He had the diagnosis of CRPS at the time, this was given by the family and he didn’t have enough information at the time to question that.
At some point he began to question the diagnosis. There were lots of inconsistencies in reported symptoms and what was observed in Maya. In particular times where Maya complained of allodynia and couldn’t tolerate anything on her legs. But she would wear skinny jeans, very tight on her legs (OMG!!! I cannot wear pants at all. If I do, they are very, very, very loose. One of the things I missed the most in my younger days as a CRPS patient was that I could no longer wear jeans unless they were “dad jeans” super loose, which I had no jeans like that. I typically wear dresses, often shift type, loose. If I put on a pair of skinny jeans I would be crawling the walls within a few seconds.)
Other examples there would be times where she would wear anklets, but yet she would scream if you touched her in that area
During the first engagement, would have been off service on Friday, 14th. She was weaned off at that time or shortly after. He was back on service periodically and also on call at night. During the initial period, he successfully got agreement with the family on the plan and she was weaned.
Plaintiff (Anderson)
At the time first saw Maya had records from Dr Kirkpatrick, shown document – he says he has never seen this document. Wants to know if he went back to all the records from JHACH all the way back to July 7th? Preceeding Oct visit. He says he looked at whatever was available in the system at the time.
He repeats that he has not seen this record. He looks at a record from some other hospital and says he has not seen this document wither. Loyola medical center – he has not seen this before.
He saw notes from Dr Criseman two months prior to going to Mexico, he is familiar with those. Records from May of 2016, he is familiar with those. Dr Jackman’s endocrinology records – he saw those. Records were ports were put in – he is familiar with those. (I hope he talks about the lesions. CRPS lesions are not linear like scratches. They are patches of discolored skin. Maya’s quacks are calling her scratches “CRPS lesions”. The word lesion is misleading and not sure why they call the patches “lesions”)
His priority was Maya’s safety. Ketamine can be associated with withdrawal, but she wasn’t just on ketamine, she had clonidine benzodiazepenes and other medications. Those have withdrawal symptoms. Her quacks (he didn’t say that word) were never using ketamine by itself.
Even ketamine by itself can cause issues. He reviewed blood work that other doctors ordered. He is aware that she had received over 50 treatments of ketamine from Dr Hanna. She presented with agitation, anorexia, motor disturbances, agitation, all of which absolutely are consistent with withdrawal. She had severe constipation, probably from all the opioids. (this doctor is starting to get into the swing of effective combat with Anderson, who is an asshole)
Anderson challenges Dr Elliot that Maya had gastroparesis. He says he did not see that documented anywhere. Elliot says gastroparesis is when the motility of your stomach decreases. It has nothing to do with constipation. There is no association with CRPS and gastroparesis. Anderson gives up trying to school this doctor on medicine at this point, he’s getting his ass kicked by Dr Elliot who is not even breaking a sweat.
Haldol was given early at the hospital, agitation is why she was given this. Anderson says it’s an antipsychotic and trying to insinuate that she was taken off her ketamine and put on antipsychotics. Dr Elliot says the notes as to why she was given Haldol were that she was extremely agitated and Haldol is good for calming agitation when other things don’t work. Tramadol was continued for a short time, that was one of the meds she was being given. Atavan is also a sedative which was on her list of meds that were previously prescribed. (at the time she entered the hospital she was on 21 different prescribed medications. The hospital was not going to just cold turkey every single one of those. Anderson is trying to say the hospital was giving her these drugs because they thought she should have them. In truth, they weaned her off all 21 of those and replaced them with a total of 3 very modest conservative drugs to replace the massive cocktail mom had talked doctors into giving her. She clearly doctor shopped until she got massive steroids when a doctor that wouldn’t play ball did testing and found she doesn’t have asthma much less “severe” asthma)
He gives the jury a good description of why she was given sedatives while she was in ICU. Elliot is able to sneak in that the family refused all psychiatric treatment.
What is bolus? It’s given faster than an infusion. Through a syringe. Infusion is much slower. Now challenging him on medical terms again and Dr Elliot owns him again. Explains that dosage is determined by weight of the patient.
Now he’s challenging him as to why he’s more qualified than Kirkpatrick. He has not given lectures on CRPS. He hasn’t given lectures on using ketamine for CRPS. He says he’s not giving any opinion on any other doctor. He is telling the jury how they treated CRPS and that they were not comfortable with the amount that Beata was demanding. He actually gives the actual mg per kg that is recommended for CRPS today.
He spoke with Dr Hanna and Dr Hanna said the treatments of ketamine were not working. Anderson tries to say Dr Hanna said he went as high as he could go without intubation. Dr Elliot stands firm that Dr Hamma told him flat out that the ketamine was not working for Maya. (and really that should be all it takes to know that Maya’s pain was psychological in nature. Those doses are massively more than an adult would get. An adult with pain not caused by psych would get relief with those massive doses Maya was getting)
Dr Elliot is not backing down on this at all. Dr Elliot is being challenged as to whether Maya has CRPS. Dr Elliot says he did not rule out completely that Maya does or doesn’t have CRPS. He believes it is less likely that she has it because of the inconsistent presentation of symptoms. (I don’t think he’s expert enough to convince the jury, to be honest. He’s saying some things that are true, but I could do a better job of explaining the long list of reasons her presentation does not add up to CRPS)
He’s now asking Dr Elliot if he was billing for CRPS. He says that is the diagnosis code that is on the paperwork.
Redirecct
He points out there is a long list of diagnostic codes because they couldn’t rule anything out and the CRPS is what the family said her diagnosis was. He reiterates that he is not aware that level of ketamine is safe for a child. He has published on pediatric chronic pain and treating it. The incidence of pediatric CRPS is less than 1 in 100,000. There is no way for a doctor to specialize in pediatric CRPS along because there are not enough cases. (You would be sending most of your time playing solitaire on the computer than seeing patients.)
Why would a patient be given Haldol. They were trying to balance her comfort with agitation while weaning her off some of the meds she was on.
She did not present with a chronic pain crisis. She was referred to ACH by her treating CRPS doctor for stomach pain. Tramadol was prescribed by outpatient physicians. Ketamine can impact multiple receptors including gut receptors, so it could effect stomach motility.
Were any of the records available to you from any source, Tampa General, Luries or any other place/. No
Dr Elliot talks about why ketamine is not recommended for children to be used regularly. Its safe to be used for anesthesia in children, but children don’t have surgery 50 times per year. That kind of use puts a child at risk for losing brain cells during the time they are still developing.
She had a history of elevated liver enzymes in the past.
He took her complaints of pain seriously. It doesn’t matter whether pain has a basis in a psych condition or other medical condition, it’s still really being felt by the patient. He would never had said her pain was “in her head”. He is not aware of anyone telling Maya that her mother was putting her in a coma at home or that her mother was “in a psych ward”.
Plaintiff
Agree or disagree that the K family knew what was best for their own daughter’s medical treatment. After reviewing the medical records and given that multiple other hospitals and a plethora of doctors observed the same inconsistencies and came to the same conclusions, Dr Elliot is confident that the treatment plan set out for Maya by her treatment team at ACH was a reasonable plan. The family continuing to seek aggressive treatments was concerning to him.
Is it true that the K family had the right to reject their treatment? They certainly could have.
(Jack K is smiling up a storm and laughing in front of the jury. I don’t know why, all the doctors said they could have taken Maya home up until the time that the court stepped in. That doesn’t help the plaintiff case at all, except for the possibility that the jury will make an emotional decision. And of course, the judge is putting his finger on the case.)
Jury questions.
1. You testified your protocol is pre-anesthesia level, we have heard that Maya had 5 mg/kg at ACH. Why would they go above that level. He says the pain protocol is .7 to 2 mg/kg. Prior to Dr Elliot coming on duty on Monday 10th, the doctors made a compromise with the family with the agreement that they would stabilize her pain and then wean her off the ketamine and some of the other drugs completely over time and then use more conventional medications along with the PT/OT/cognitive behavioral therapy.
2. What was the dose of Haldol and how often given. I believe 1 mg probably every 6 yo 8 hours as needed. I believe intravenous.
3. How was it possible that Maya could be given such large doses of ketamine and still be awake. I know there were times she was not awake. I did not see her after those doses she was given by Dr Hanna, I was never thee.
4. If these are known to be dangerous, how were doctors able to give her those doses? This is a topic of controversy right now, these ketamine clinics are not currently regulated, people use things off label, and so there is no regulation of this although there is talk of this happening.
5. You mentioned that you were able to wean her off the medication s over time. Were the parents cooperative with that plan? With me, most of the time I believe I had a reasonable relationship with them at the time. I tried to work with them and engender their trust. I treat their children as if they were my own children.
6. Ketamine was being weaned, but one medication you added was Haldol, an antipsychotic with sedative qualities. What are the side effects of Haldol? It can potentially impact heartbeat, abnormal movements, those are the main side effects
7. Did she have withdrawal? Hard to say, because we put her on medications to ease withdrawal symptoms, we did not want her to suffer withdrawal so that is why we gave her those meds to prevent those uncomfortable symptoms.
8. Was the ACH staff trained in CRPS before 2016 when you took over? I’m not sure what is meant by that question per se. At that time we were working on putting together a CRPS and an outpatient clinic. They were generally familiar with it. All the anesthesiologisst are also pain management and they were all familiar with it.
9. Dr Elliot, in 2016, it seems ketamine is not your preferred treatment and you had other preferred treatments. Is this a correct understanding of your position? Yes, the standard across the country for pediatric CRPS was PT/OT/and cognitive behavioral therapy. Some of the pediatric facilities used those three things alone, but some did as we did and used small amounts of standard pain medications as needed to help facilitate the patients comfort as they are getting into the PT/OT/CBT therapies.
10. Are you more open to using larger amounts of ketamine now that some studies have shown efficacy? His response is that there are still no high quality studies to show ketamine’s effectiveness in pediatrics. There simply are not enough patients, particularly pediatric, to even be able to conduct high quality studies, even if those studies are attempted by so-called CRPS experts. The data shows even in these studies there is no benefit to ketamine beyond three months
11. Have you ever been involved in studies for treating illnesses with new drugs? Yes, I have been involved in medication trials, vaccine trials
12. Are you a doctor that uses only “set” treatments for a condition or illness? I think all of us use those as a foundation for treatment. Do we look beyond that, yes, but always keeping safety in mind in that regard. Especially in pediatrics we have to be much more mindful of things because young patients are going through changes in body chemistry. Adult body chemistry is generally stable and so it’s much easier with an adult to go outside of the scope of generally accepted treatment. For a child it’s a much bigger risk. Also, working in a hospital setting some of that is protected on a state level. (I think he may have nailed it here)
13. Are you saying that diagnostic codes don’t need to match billing codes for payment? (guess which juror asked this question.) I don’t claim to be an expert on billing. There are two codes involved in billing, an ICD code and a CBP code. It’s typically other people that are more expert on how exactly billing is done. We will assign a diagnosis code either if we have been able to make a complete diagnosis or if the patient came with the parents reporting an existing diagnosis. (She came in with stomach pains as her main complaint, but it quickly became chaotic because her mother would not allow them to try to figure out what was going on with her stomach pain unless they treated her CRPS with amounts of ketamine higher than any of her treating doctors ever gave her). We try to be all inclusive and include whatever previous diagnosis given by the parents, and also include any differential or suspected diagnosis so that any further treating facility will be aware of any possible diagnosis that could be appropriate.
Anderson
You have no data showing systematic harmful effects of treating CRPS with ketamine, true? There is data on ketamine and potential harm to children, including the FDA warning that the brain continues to develop until upper teen years. Maya was not 5 and under at the time.
Anesthesiologist, JHACH. From Ohio completed a 6 year program at Kent State which combined BS and MD in an accelerated program.
Additional pediatric anesthesiology fellowship. He is board certified in anesthesiology, pediatric anesthesiology, and medical acupuncture.
He is anesthesiology/pain management at JHACH after several years in those specialties.
Currently he is the Director of Pain Management and was in that position in 2016. They did not have the outpatient pain clinic at that time, but just inpatient, but he had the same position with the addition of outpatient when they opened that clinic.
His daily duties include anesthetizing patients for surgery and managing inpatient chronic pain patients.
Outpatient chronic pain clinic is for helping patients manage pain when they are not admitted to the hospital. They involve the children, parents, family members.
The outpatient clinic was not in operation until 2018 or 2019, so it was not available during Maya’s stay at JHACH. He did inpatient chronic pain consulting within the inpatient setting. He has seen CRPS patients in his career, particularly at Kettering and has seen several patients. They now have an actual CRPS program
He was very familiar with CRPS at the time Maya was in the hospital. The treatment standard at the time revolves around functional restoration – PT/OT/cognitive behavioral therapy. That is still standard treatment for pediatric CRPS to this day
He also had experience with conversion disorder. It is not uncommon to have comorbidity with conversion disorder. Returning patients to function, regardless. The treatment is the same because even with conversion of FND, the pain is still real, it’s just coming from a different pathway. So, they are treated the same. We believe they have pain, we do not say “it’s in your head”, the pain is real, and we move forward with the same treatment so they can become functional and return to normal life of a child.
It’s important to understand that the way the brain is firing it perceives pain that might not be there, so to turn the “off” switch, you get them slowly and progressively working with the extremity. They need to use the extremity, and not allow it to atrophy, or it will never turn off as far as the pain goes. We do see that with PT/OT/ and dealing with stress, it’s very effective and can bring them to remission.
Function – it’s very important to get them back to normal social and school activity and often that alone helps reduce their perception of pain. Regarding ketamine – medications can be used to facilitate PT, in particular ketamine isn’t routinely used, but when used we use low dose – i.e. lower than what would be used for anesthesia
His first involvement, he was on vacation and received a phone call from a colleague to ask about the high doses of ketamine that Maya had ben given. Dr Dolan had called him because he had the most experience with pain management specifically and was working to set up their pain clinic.
The doses she was receiving as an outpatient at Dr Hanna’s office were shared with him by his colleague. His reaction was surprised and shocked. The doses were way higher than any doses he’s ever seen given to a child. Subanesthetic doses are typically used for pain.
The doses were over 50 times higher than anything JHACH would ever give. Ketamine is FDA as a general anesthetic. It can be used for a child going into surgery. Everything is based on weight. Dr Hanna were giving doses in the range of up to 25 mg/kg per hour. A normal dose would be .7 to 2 mg/kg
He became the primary pain management anesthesiologist for Maya when he returned from vacation on 10/10, he was on the same schedule as Dr Michelle Smith. He reviewed the charts and looked at her records. In the afternoon of his first day back he saw Maya and met Mr K. and got a rundown of what was going on with her.
What was the treatment plan that was in place. To five her several days of a small infusion of ketamine and clonidine and begin to come down on those in ICU watching for any issues, managing her pain and making sure she didn’t suffer from withdrawal. They were being very cautious about managing her pain and not having withdrawal. They used medications to help with any anxiety/agitation that might be involved with withdrawal. Dr Elliot was able to get a hold of Dr Hanna by cell phone and he confirmed the doses that she was being given. He felt that they were not working, was becoming uncomfortable with continuing to give her higher and higher doses.
At this point they did not have records from any outside CRPS pain management. He was attempting to gather that information. Typically would get information from referring patients, what studies, meds, conditions, etc. That info is vital. Dr Hanna had referred her to ACH. He passed along his treatment. He had administered large dozes of ketamine, benzos. other sedatives, clonidine. Dr Elliot wanted to try to get her safely through weaning her from any of these drugs.
Multiple times the treatment team presented multidisciplinary means of treating Maya with the family, he likes to collaborate with the family and make sure they understand. On the 10th it was Mr K, he met Mrs K on 11th. Mrs K was demanding more aggressive and higher doses of ketamine, potentially amounts that needed intubation and other invasive protections. Also implantable pain pumps. He tried to share with Mrs K the evidence and literature on CRPS and chronic pain, she was not interested, only wanted the ketamine.
Beata wanting her to the “put to sleep” with the ketamine, and to support that she would have to be intubated. It’s not appropriate to put the patient into a medical coma for CRPS. We did not recommend nor are we going to offer that. There is no evidence to support this, it’s not standard of care and it isn’t safe. Any pain medications are used to facilitate the other therapies, not a replacement for all other therapies. Some of the risks of putting her into a ketamine coma are that intubation carries a risk of pneumonia, there are additional medications that have to be given if you are going to intubate a patient, blood pressure, heart rate. Sometimes need high doses of sedatives and muscle relaxers.
Intrathecal pain pump – device usually placed in adults where they are in such high doses of medicines that they can be given lower doses directly in the spine. But these are not for children. Mrs K was asking specifically for clonidine (she was “doing her own research”, keep that in mind.) Pain pumps involve risks like infections. Maya was undernourished and having an intrathecal pain pump is definitely not indicated for a malnourished child. They require a needle, need to be filled periodically. It’s not something to take lightly.
Had these discussion with Mr K on the 10th and Mrs K on 11th. They agreed to proceed with the plan to wean her off the meds and proceed with the PT/OT/cognitive behavioral therapy. He doesn’t specifically recall them wanting to leave the hospital AMA. But he was aware of the discussion to transfer her to the outpatient Nemours clinic. He was not involved in any AMA discussion. He was not directly involved in the Nemours transfer. He had the diagnosis of CRPS at the time, this was given by the family and he didn’t have enough information at the time to question that.
At some point he began to question the diagnosis. There were lots of inconsistencies in reported symptoms and what was observed in Maya. In particular times where Maya complained of allodynia and couldn’t tolerate anything on her legs. But she would wear skinny jeans, very tight on her legs (OMG!!! I cannot wear pants at all. If I do, they are very, very, very loose. One of the things I missed the most in my younger days as a CRPS patient was that I could no longer wear jeans unless they were “dad jeans” super loose, which I had no jeans like that. I typically wear dresses, often shift type, loose. If I put on a pair of skinny jeans I would be crawling the walls within a few seconds.)
Other examples there would be times where she would wear anklets, but yet she would scream if you touched her in that area
During the first engagement, would have been off service on Friday, 14th. She was weaned off at that time or shortly after. He was back on service periodically and also on call at night. During the initial period, he successfully got agreement with the family on the plan and she was weaned.
Plaintiff (Anderson)
At the time first saw Maya had records from Dr Kirkpatrick, shown document – he says he has never seen this document. Wants to know if he went back to all the records from JHACH all the way back to July 7th? Preceeding Oct visit. He says he looked at whatever was available in the system at the time.
He repeats that he has not seen this record. He looks at a record from some other hospital and says he has not seen this document wither. Loyola medical center – he has not seen this before.
He saw notes from Dr Criseman two months prior to going to Mexico, he is familiar with those. Records from May of 2016, he is familiar with those. Dr Jackman’s endocrinology records – he saw those. Records were ports were put in – he is familiar with those. (I hope he talks about the lesions. CRPS lesions are not linear like scratches. They are patches of discolored skin. Maya’s quacks are calling her scratches “CRPS lesions”. The word lesion is misleading and not sure why they call the patches “lesions”)
His priority was Maya’s safety. Ketamine can be associated with withdrawal, but she wasn’t just on ketamine, she had clonidine benzodiazepenes and other medications. Those have withdrawal symptoms. Her quacks (he didn’t say that word) were never using ketamine by itself.
Even ketamine by itself can cause issues. He reviewed blood work that other doctors ordered. He is aware that she had received over 50 treatments of ketamine from Dr Hanna. She presented with agitation, anorexia, motor disturbances, agitation, all of which absolutely are consistent with withdrawal. She had severe constipation, probably from all the opioids. (this doctor is starting to get into the swing of effective combat with Anderson, who is an asshole)
Anderson challenges Dr Elliot that Maya had gastroparesis. He says he did not see that documented anywhere. Elliot says gastroparesis is when the motility of your stomach decreases. It has nothing to do with constipation. There is no association with CRPS and gastroparesis. Anderson gives up trying to school this doctor on medicine at this point, he’s getting his ass kicked by Dr Elliot who is not even breaking a sweat.
Haldol was given early at the hospital, agitation is why she was given this. Anderson says it’s an antipsychotic and trying to insinuate that she was taken off her ketamine and put on antipsychotics. Dr Elliot says the notes as to why she was given Haldol were that she was extremely agitated and Haldol is good for calming agitation when other things don’t work. Tramadol was continued for a short time, that was one of the meds she was being given. Atavan is also a sedative which was on her list of meds that were previously prescribed. (at the time she entered the hospital she was on 21 different prescribed medications. The hospital was not going to just cold turkey every single one of those. Anderson is trying to say the hospital was giving her these drugs because they thought she should have them. In truth, they weaned her off all 21 of those and replaced them with a total of 3 very modest conservative drugs to replace the massive cocktail mom had talked doctors into giving her. She clearly doctor shopped until she got massive steroids when a doctor that wouldn’t play ball did testing and found she doesn’t have asthma much less “severe” asthma)
He gives the jury a good description of why she was given sedatives while she was in ICU. Elliot is able to sneak in that the family refused all psychiatric treatment.
What is bolus? It’s given faster than an infusion. Through a syringe. Infusion is much slower. Now challenging him on medical terms again and Dr Elliot owns him again. Explains that dosage is determined by weight of the patient.
Now he’s challenging him as to why he’s more qualified than Kirkpatrick. He has not given lectures on CRPS. He hasn’t given lectures on using ketamine for CRPS. He says he’s not giving any opinion on any other doctor. He is telling the jury how they treated CRPS and that they were not comfortable with the amount that Beata was demanding. He actually gives the actual mg per kg that is recommended for CRPS today.
He spoke with Dr Hanna and Dr Hanna said the treatments of ketamine were not working. Anderson tries to say Dr Hanna said he went as high as he could go without intubation. Dr Elliot stands firm that Dr Hamma told him flat out that the ketamine was not working for Maya. (and really that should be all it takes to know that Maya’s pain was psychological in nature. Those doses are massively more than an adult would get. An adult with pain not caused by psych would get relief with those massive doses Maya was getting)
Dr Elliot is not backing down on this at all. Dr Elliot is being challenged as to whether Maya has CRPS. Dr Elliot says he did not rule out completely that Maya does or doesn’t have CRPS. He believes it is less likely that she has it because of the inconsistent presentation of symptoms. (I don’t think he’s expert enough to convince the jury, to be honest. He’s saying some things that are true, but I could do a better job of explaining the long list of reasons her presentation does not add up to CRPS)
He’s now asking Dr Elliot if he was billing for CRPS. He says that is the diagnosis code that is on the paperwork.
Redirecct
He points out there is a long list of diagnostic codes because they couldn’t rule anything out and the CRPS is what the family said her diagnosis was. He reiterates that he is not aware that level of ketamine is safe for a child. He has published on pediatric chronic pain and treating it. The incidence of pediatric CRPS is less than 1 in 100,000. There is no way for a doctor to specialize in pediatric CRPS along because there are not enough cases. (You would be sending most of your time playing solitaire on the computer than seeing patients.)
Why would a patient be given Haldol. They were trying to balance her comfort with agitation while weaning her off some of the meds she was on.
She did not present with a chronic pain crisis. She was referred to ACH by her treating CRPS doctor for stomach pain. Tramadol was prescribed by outpatient physicians. Ketamine can impact multiple receptors including gut receptors, so it could effect stomach motility.
Were any of the records available to you from any source, Tampa General, Luries or any other place/. No
Dr Elliot talks about why ketamine is not recommended for children to be used regularly. Its safe to be used for anesthesia in children, but children don’t have surgery 50 times per year. That kind of use puts a child at risk for losing brain cells during the time they are still developing.
She had a history of elevated liver enzymes in the past.
He took her complaints of pain seriously. It doesn’t matter whether pain has a basis in a psych condition or other medical condition, it’s still really being felt by the patient. He would never had said her pain was “in her head”. He is not aware of anyone telling Maya that her mother was putting her in a coma at home or that her mother was “in a psych ward”.
Plaintiff
Agree or disagree that the K family knew what was best for their own daughter’s medical treatment. After reviewing the medical records and given that multiple other hospitals and a plethora of doctors observed the same inconsistencies and came to the same conclusions, Dr Elliot is confident that the treatment plan set out for Maya by her treatment team at ACH was a reasonable plan. The family continuing to seek aggressive treatments was concerning to him.
Is it true that the K family had the right to reject their treatment? They certainly could have.
(Jack K is smiling up a storm and laughing in front of the jury. I don’t know why, all the doctors said they could have taken Maya home up until the time that the court stepped in. That doesn’t help the plaintiff case at all, except for the possibility that the jury will make an emotional decision. And of course, the judge is putting his finger on the case.)
Jury questions.
1. You testified your protocol is pre-anesthesia level, we have heard that Maya had 5 mg/kg at ACH. Why would they go above that level. He says the pain protocol is .7 to 2 mg/kg. Prior to Dr Elliot coming on duty on Monday 10th, the doctors made a compromise with the family with the agreement that they would stabilize her pain and then wean her off the ketamine and some of the other drugs completely over time and then use more conventional medications along with the PT/OT/cognitive behavioral therapy.
2. What was the dose of Haldol and how often given. I believe 1 mg probably every 6 yo 8 hours as needed. I believe intravenous.
3. How was it possible that Maya could be given such large doses of ketamine and still be awake. I know there were times she was not awake. I did not see her after those doses she was given by Dr Hanna, I was never thee.
4. If these are known to be dangerous, how were doctors able to give her those doses? This is a topic of controversy right now, these ketamine clinics are not currently regulated, people use things off label, and so there is no regulation of this although there is talk of this happening.
5. You mentioned that you were able to wean her off the medication s over time. Were the parents cooperative with that plan? With me, most of the time I believe I had a reasonable relationship with them at the time. I tried to work with them and engender their trust. I treat their children as if they were my own children.
6. Ketamine was being weaned, but one medication you added was Haldol, an antipsychotic with sedative qualities. What are the side effects of Haldol? It can potentially impact heartbeat, abnormal movements, those are the main side effects
7. Did she have withdrawal? Hard to say, because we put her on medications to ease withdrawal symptoms, we did not want her to suffer withdrawal so that is why we gave her those meds to prevent those uncomfortable symptoms.
8. Was the ACH staff trained in CRPS before 2016 when you took over? I’m not sure what is meant by that question per se. At that time we were working on putting together a CRPS and an outpatient clinic. They were generally familiar with it. All the anesthesiologisst are also pain management and they were all familiar with it.
9. Dr Elliot, in 2016, it seems ketamine is not your preferred treatment and you had other preferred treatments. Is this a correct understanding of your position? Yes, the standard across the country for pediatric CRPS was PT/OT/and cognitive behavioral therapy. Some of the pediatric facilities used those three things alone, but some did as we did and used small amounts of standard pain medications as needed to help facilitate the patients comfort as they are getting into the PT/OT/CBT therapies.
10. Are you more open to using larger amounts of ketamine now that some studies have shown efficacy? His response is that there are still no high quality studies to show ketamine’s effectiveness in pediatrics. There simply are not enough patients, particularly pediatric, to even be able to conduct high quality studies, even if those studies are attempted by so-called CRPS experts. The data shows even in these studies there is no benefit to ketamine beyond three months
11. Have you ever been involved in studies for treating illnesses with new drugs? Yes, I have been involved in medication trials, vaccine trials
12. Are you a doctor that uses only “set” treatments for a condition or illness? I think all of us use those as a foundation for treatment. Do we look beyond that, yes, but always keeping safety in mind in that regard. Especially in pediatrics we have to be much more mindful of things because young patients are going through changes in body chemistry. Adult body chemistry is generally stable and so it’s much easier with an adult to go outside of the scope of generally accepted treatment. For a child it’s a much bigger risk. Also, working in a hospital setting some of that is protected on a state level. (I think he may have nailed it here)
13. Are you saying that diagnostic codes don’t need to match billing codes for payment? (guess which juror asked this question.) I don’t claim to be an expert on billing. There are two codes involved in billing, an ICD code and a CBP code. It’s typically other people that are more expert on how exactly billing is done. We will assign a diagnosis code either if we have been able to make a complete diagnosis or if the patient came with the parents reporting an existing diagnosis. (She came in with stomach pains as her main complaint, but it quickly became chaotic because her mother would not allow them to try to figure out what was going on with her stomach pain unless they treated her CRPS with amounts of ketamine higher than any of her treating doctors ever gave her). We try to be all inclusive and include whatever previous diagnosis given by the parents, and also include any differential or suspected diagnosis so that any further treating facility will be aware of any possible diagnosis that could be appropriate.
Anderson
You have no data showing systematic harmful effects of treating CRPS with ketamine, true? There is data on ketamine and potential harm to children, including the FDA warning that the brain continues to develop until upper teen years. Maya was not 5 and under at the time.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Defense witness – Dr Elizabeth Terry Walford (deposition)
Pediatric surgeon, Guld Coast Pediatric General Surgery, Gulf Coast Medical Centerm, Panama City FL
Used to work at ACH, for 8 years, Internship in General Surgery, Pediatric Surgery fellowship 2010, then went to ACH
Board certified in both General and Pediatric surgery.
She saw Maya K. does not have independent memory of her. She reviewed her records. She was a patient where she saw in the office after she had a referral. The purpose of the referral was to get a port placed. The procedure is that when a board certified doctor orders a port, ACH agrees to place them, but the asking physician is expected in good faith to maintain the port in good condition with appropriate maintenance procedures
What history were you given on presentation? She had a diagnosis of RSD and needed the port for medication and blood draws. It is typical that she would not personally know the doctor that is ordering the port. She never consulted with Dr Hanna, the consulting physician. It is not practice to comment on or confirm the diagnosis. It is not customary to comment, confirm or deny whatever the diagnosis or treatment the referring physician makes.
She gives an example. If a cancer patient comes in for a port, she doesn’t say “I don’t believe you have this type of cancer, so I’m not going to put in the port”. There is a trust factor there. She is a surgeon and not a cancer or RSD expert. And she doesn’t tell a doctor how to treat cancer or RSD.
She was successful in placing the port. She never saw Maya again. Sometimes they do post-op to remove the port. She can’t say 100% but she doesn’t see any note or record that she ever saw Maya again.
We don’t really discuss full history just anything related to anesthesia, i.e. allergies to medications, etc. But not history of her general medical history.
Her office staff writes down the reason for the placement, but we don’t confirm or question a diagnosis from a board certified doctor ordering a port.
History of RSD is listed on the paperwork. She has a note that it’s the same as CRPS, she would have gotten that from someone else, like the parent. Needs port, frequent ketamine treatments, IV, blood draw. There is no “typical” reason for a port. Usually it’s for an infusion. Maybe most common would dbe for chemo therapy.
If people are chronically in and out of the hospital for various reasons may have a port, or if there are difficult blood draw.
For port placement it wouldn’t be necessary for her to review previous treatment at JHACH. HIPAA allows doctors to discuss or see what other doctors have done if the treatment if the prior treatment details are necessary for what they are doing, or if the patient/guardian specifically gives permission. But they don’t just go looking into a patient’s history for no reason or if they are doing something like placing a port. She doesn’t need to know about a patient’s broken leg from 4 years ago when she’s placing a port.
She only looks at what a referring physician sent. Unless she said she had lots of central lines placed before and there was scarring or something like that. That would be legitimate reason to look at that specific information.
Maya and her mother are very specific about where they want the port placed for cosmetic reasons. They were very specific about where it should be placed. She noted that because it’s not the best place to put the port and she would not have chosen to put it there. So, she wanted the note to explain why it was put in that location. It’s a longer tunnel for the catheter to make and that can cause problems. Her note indicates that both mother and child were very demanding. She felt it was required to explain to them why a port would not normally be placed where they were asking because it can be problematic to use. Her notes indicate they were very demanding.
It’s very unusual for a patient to specify where they want a port. Would this be available for another doctor to access these records. No, this note would not be available. The surgery records would dbe there, but not notes. It’s a separate record system.
An ACH physician would have had access to patients age, op note, anesthesia record. Not sure what would be available now, as opposed to then, systems update from time to time.
Pediatric surgeon, Guld Coast Pediatric General Surgery, Gulf Coast Medical Centerm, Panama City FL
Used to work at ACH, for 8 years, Internship in General Surgery, Pediatric Surgery fellowship 2010, then went to ACH
Board certified in both General and Pediatric surgery.
She saw Maya K. does not have independent memory of her. She reviewed her records. She was a patient where she saw in the office after she had a referral. The purpose of the referral was to get a port placed. The procedure is that when a board certified doctor orders a port, ACH agrees to place them, but the asking physician is expected in good faith to maintain the port in good condition with appropriate maintenance procedures
What history were you given on presentation? She had a diagnosis of RSD and needed the port for medication and blood draws. It is typical that she would not personally know the doctor that is ordering the port. She never consulted with Dr Hanna, the consulting physician. It is not practice to comment on or confirm the diagnosis. It is not customary to comment, confirm or deny whatever the diagnosis or treatment the referring physician makes.
She gives an example. If a cancer patient comes in for a port, she doesn’t say “I don’t believe you have this type of cancer, so I’m not going to put in the port”. There is a trust factor there. She is a surgeon and not a cancer or RSD expert. And she doesn’t tell a doctor how to treat cancer or RSD.
She was successful in placing the port. She never saw Maya again. Sometimes they do post-op to remove the port. She can’t say 100% but she doesn’t see any note or record that she ever saw Maya again.
We don’t really discuss full history just anything related to anesthesia, i.e. allergies to medications, etc. But not history of her general medical history.
Her office staff writes down the reason for the placement, but we don’t confirm or question a diagnosis from a board certified doctor ordering a port.
History of RSD is listed on the paperwork. She has a note that it’s the same as CRPS, she would have gotten that from someone else, like the parent. Needs port, frequent ketamine treatments, IV, blood draw. There is no “typical” reason for a port. Usually it’s for an infusion. Maybe most common would dbe for chemo therapy.
If people are chronically in and out of the hospital for various reasons may have a port, or if there are difficult blood draw.
For port placement it wouldn’t be necessary for her to review previous treatment at JHACH. HIPAA allows doctors to discuss or see what other doctors have done if the treatment if the prior treatment details are necessary for what they are doing, or if the patient/guardian specifically gives permission. But they don’t just go looking into a patient’s history for no reason or if they are doing something like placing a port. She doesn’t need to know about a patient’s broken leg from 4 years ago when she’s placing a port.
She only looks at what a referring physician sent. Unless she said she had lots of central lines placed before and there was scarring or something like that. That would be legitimate reason to look at that specific information.
Maya and her mother are very specific about where they want the port placed for cosmetic reasons. They were very specific about where it should be placed. She noted that because it’s not the best place to put the port and she would not have chosen to put it there. So, she wanted the note to explain why it was put in that location. It’s a longer tunnel for the catheter to make and that can cause problems. Her note indicates that both mother and child were very demanding. She felt it was required to explain to them why a port would not normally be placed where they were asking because it can be problematic to use. Her notes indicate they were very demanding.
It’s very unusual for a patient to specify where they want a port. Would this be available for another doctor to access these records. No, this note would not be available. The surgery records would dbe there, but not notes. It’s a separate record system.
An ACH physician would have had access to patients age, op note, anesthesia record. Not sure what would be available now, as opposed to then, systems update from time to time.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
There was another witness that was first in the morning. I was able to begin taking notes, then had to stop and then when I came back it wa on cross exam. So, I missed most of her direct, so I have to go back and finish that. I am dead tired, so I won't do that right now. Depending on how much I sleep tonight I may get it done before morning, but have no idea. From what I could tell, that is going to be a good witness.
That is Dr Kassenstein, and part of her notes were not allowed to be entered into evidence. Specifically the part where Maya admitted to her that Mom did her diagnosis based on online research, then took her to Dr Kirkpatrick after looking up CRPS online. Her visit to Dr Kirkpatrick was the first time mom ever described Maya's symptoms as being consistent with CRPS. So, the jury is not going to get all of that, they will be left with the impression that she was diagnosed based on truthful telling of symptoms by Maya's mother to Dr Kirkpatrick even though all the symptoms from previous doctor visits had a different description.
Also being kept from the jury - Beata was blogging every detail of Maya's medical problems "severe" asthma, the whole bit, every doctor and clinic she visited, which were numerous. She was getting lots of attention and sympathy, "mother of the year" type commentary, etc. When you add this to the myriad of other concerning issues, it helps paint a picture.
That is Dr Kassenstein, and part of her notes were not allowed to be entered into evidence. Specifically the part where Maya admitted to her that Mom did her diagnosis based on online research, then took her to Dr Kirkpatrick after looking up CRPS online. Her visit to Dr Kirkpatrick was the first time mom ever described Maya's symptoms as being consistent with CRPS. So, the jury is not going to get all of that, they will be left with the impression that she was diagnosed based on truthful telling of symptoms by Maya's mother to Dr Kirkpatrick even though all the symptoms from previous doctor visits had a different description.
Also being kept from the jury - Beata was blogging every detail of Maya's medical problems "severe" asthma, the whole bit, every doctor and clinic she visited, which were numerous. She was getting lots of attention and sympathy, "mother of the year" type commentary, etc. When you add this to the myriad of other concerning issues, it helps paint a picture.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
-
Sam the Centipede
- Posts: 1986
- Joined: Thu Feb 25, 2021 12:19 pm
Taking Care of Maya - FL CPS/Munchausen case
Off Topic
I don't know anything about this case but I noticed that the contributors have been discussing CRPS. In relation to that, I thought this CRPS sufferer's story in The Guardian might be of interest:
I have spent years in such pain that I begged for someone to cut my arm off. This is how I survived.
I have spent years in such pain that I begged for someone to cut my arm off. This is how I survived.
Taking Care of Maya - FL CPS/Munchausen case
Sam the Centipede wrote: ↑Tue Oct 24, 2023 4:17 amOff TopicI don't know anything about this case but I noticed that the contributors have been discussing CRPS. In relation to that, I thought this CRPS sufferer's story in The Guardian might be of interest:
I have spent years in such pain that I begged for someone to cut my arm off. This is how I survived.
Off Topic
That is a great story. it's really only been in the last couple of years that I ever was able to even find halfway decent information on the internet. And a surprising amount of it is sketchy, even from sources that you would think would know better.
Pohl has found the same thing I have found - immersing yourself in something else is the only way to "get away" from the constant pain taking over your life and becoming your life. She mentions the cruelty of reading all about how a huge percentage of people who have it commit suicide to the point where doctors themselves called it "suicide disease". They don't say it directly to their patients of course, but you read about that all the time, especially when you are desperately searching for answers. Pohl got it the same way I did, and the same way most of us get it. Walk into the hospital perfectly normal and leave with something you can never get away from. She has other immune system issues as well, but most of us have nothing else that in any way could predict something like this could happen
Pohl has found the same thing I have found - immersing yourself in something else is the only way to "get away" from the constant pain taking over your life and becoming your life. She mentions the cruelty of reading all about how a huge percentage of people who have it commit suicide to the point where doctors themselves called it "suicide disease". They don't say it directly to their patients of course, but you read about that all the time, especially when you are desperately searching for answers. Pohl got it the same way I did, and the same way most of us get it. Walk into the hospital perfectly normal and leave with something you can never get away from. She has other immune system issues as well, but most of us have nothing else that in any way could predict something like this could happen
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Big day.
Mom has been super agitated for the last several days, and I'm not able to sit and take notes while listening like I try to do. But I am listening. I was under the impression that the defense would not be putting on a doctor knowledgeable in CRPS.
Well, turns out they DO have a doctor that I'm crossing my fingers on. He seems to have more knowledge than anyone else I've heard on that witness stand. I will write it up when I can. Not finished listening to it yet, I'm behind in time. But he seems like the real deal more than anyone else.
He definitely is puttin' the whoopin' on the plaintiff case.
Mom has been super agitated for the last several days, and I'm not able to sit and take notes while listening like I try to do. But I am listening. I was under the impression that the defense would not be putting on a doctor knowledgeable in CRPS.
Well, turns out they DO have a doctor that I'm crossing my fingers on. He seems to have more knowledge than anyone else I've heard on that witness stand. I will write it up when I can. Not finished listening to it yet, I'm behind in time. But he seems like the real deal more than anyone else.
He definitely is puttin' the whoopin' on the plaintiff case.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Glad to hear this. Thought the defense doctor earlier was really good at pointing out how pushy mom was demanding ketamine and explaining the CRPS diagnosis was from mom but he had noticed inconsistencies. I am appalled at the Judge's decisions not to enter exabits into evidence allowing the to show documentation of testimony. It's odd to me. BTW, I just read Mr. K previously sued his employer in IL as well as the school district for not allowing Maya to do school at home. He is a professional litigant. This is not his first rodeo.RVInit wrote: ↑Tue Oct 24, 2023 11:38 am Big day.
Mom has been super agitated for the last several days, and I'm not able to sit and take notes while listening like I try to do. But I am listening. I was under the impression that the defense would not be putting on a doctor knowledgeable in CRPS.
Well, turns out they DO have a doctor that I'm crossing my fingers on. He seems to have more knowledge than anyone else I've heard on that witness stand. I will write it up when I can. Not finished listening to it yet, I'm behind in time. But he seems like the real deal more than anyone else.
He definitely is puttin' the whoopin' on the plaintiff case.
Taking Care of Maya - FL CPS/Munchausen case
Here are the jury questions for Dr Crane. I have to write up his direct and rebut testimony.
Jury questions
(really curious as to how the jury responds to this witness. He was exceptional for the defense, answered fully and really left no doubt that his opinions were well founded based on the records, and he flat out does not believe Maya has CRPS. He was most definitive about this. He did not mention everything that I have put in my comments about why I do not believe she has it, but he made many of those same points to this jury)
1. How is Maya doing after her discharge from JHACH? She’s doing very very well. Looking at PT notes she went in 6 months from wheelchair bound to fully walking around, no pain complaints, I understand today she is doing well, in athletics, she’s doing wll
2. What are withdrawal symptoms from ketamine? Talks about tolerance, why someone needs more and more like Maya did. The withdrawal symptoms are the opposite of what you get with using the drug = so, they feel pain, they get diarrhea, they get wired, the opposite of sedation. Same is true of withdrawal for every drug. They will beg for ketamine after they have had it for a while, they are anxious, etc. There is no question they get addicted, you can tell by how they act
3. Is it possible that the “symptoms” of CRPS (LOL) that Maya had were actually withdrawal symptoms? Good question, that was one of my hypothesis. She was agitated, screaming for ketamine, and it is quite possible she was addicted and wanted that drug (that’s the same thing I was wondering myself)
4. What is the half life of ketamine? He would dhave to look it up, probably the same as morphine, 2-3 hours
5. We have heard from physicians that all assessed Maya did not note always temperature changes, color changes, or asses her skin or other things on the Budapest criteria. Can you make an assessment that Maya did not have CRPS (He DID make that assessment) without seeing her yourself? He talks about how temperature and color changes are checked. He did not see any of these or have any idea how Dr Kirkpatrick and Dr Hanna checked various things but he highly suspects that wasn’t done. (I think he doesn’t want to say that Dr K is running a whole clinic for what would be a true population of about 2 people, meaning he has to diagnose a shitload of people who don’t have it to keep a specialty CRPS clinic open in Sarasota Florida. He kind of alluded to that somewhat during direct, but I think he’s trying to stay away from saying they are quacks, which is what they are)
6. You said many times that Maya doesn’t have CRPS, but also you didn’t examine her. How can you come to this conclusion? I’ve seen 1,000 to 2,000 cases of CRPS. You know it when you see it. When you don’t see the symptoms you know those symptoms are there. It’s like if you told me someone was an amputee but I looked at them and they have all of their limbs, they aren’t an amputee. It didn’t look like CRPS in videos and photos, it didn’t sound like CRPS by description, there were emails that Maya’s mother wrote to herself but in Maya’s voice similar to the blog that she was putting out, I don’t know if that is something that you’ve seen, but she’s saying “she’s the youngest patient in the world ever to have total body CRPS” then she said “she’s the youngest person ever to get a ketamine coma”. There are no records of whole body CRPS. Wha are the odds that she is the only person in the world to ever get this “whole body” CRPS. It’s a regional pain syndrome, (I wish he would remind them of something he said during direct, which is that she didn’t have as many symptoms as were attributed, no dystonia, and also if it was dystonia it takes years to develop. Also, it would take years for the pain to transfer to a different limb from the one it started in, much less the whole body)
7. Is there any medical oversight to ketamine dosing? I’m not sure what is meant by medical oversight, except that most hospitals specify an acceptable range, insurance won’t authorize doses above a certain amount (which is why Maya had the GoFundMe to pay for her treatments). I am on a Listserv and sometimes people ask for advice on using ketamine. At Stanford we have some of the most liberal standards for ketamine that I’ve seen, and we wouldn’t give anywhere close to what Maya was getting. Hospitals have policies and procedures. If I was to write an order for more, the nurse wouldn’t do it, and they would pull out the policy and would not do it.
8. Is it common for a diagnosis of CRPS to be questioned by physicians. We honor patients and people, but a diagnosis is an “idea”. And it can be wrong. Especially in a situation where another doctor is suggesting that the only treatment should be huge amounts of a potentially dangerous drug. (people get second opinions all the time) In Maya’s case, the pain specialists were saying this just does not look like CRPS. So then you have to take a step back and ask what else could that be.
9. Does the diagnosis of CRPS automatically raise questions of psychiatric condition? No, not at all.
10. Do you require IQ tests to accept enrollment in your pain clinic? No, not at all (I guarantee you the real reason Nemours refused to take Maya inpatient was because they saw this freaking lawsuit coming a mile away and didn’t want anything to do with it. The hospital sent their records. Their records talked about Beata and Maya’s behavior. Nemours wasn’t going to touch that with a 10 foot pole. That’s why they said “outpatient only” for Maya. The flat out refused to take her inpatient)
11. What part does IQ play in pain treatment. None, we treat children who are congnitively impaired. It can be challenging, but we do it and we don’t treat them different.
12. If it was whole body CRPS would they experience pain from a charm bracelet, anklet, pulling hair back in a pony tail, makeup application? Yes, they would. Adult women with CRPS don’t shave their leg if they have it on a leg, it hurts to drag a sock over it, they don’t wear jeans, they wear shorts or a dress 365 days a year
13. Has any CRPS case reoccurred at your center? Yes
14. At what age? It’s never reoccurred in a child at Maya’s age. Those are our favorite to treat because if they are treated appropriately by that age it does not come back. Complete remission. Teenagers reoccur much more frequently. Adults rarely ever go into remission. (I hope he talks about what remission really is. Not one good day, two bad days, 4 good days, one bad day, etc. That is what Maya claims.
15. What was the length of occurrence between symptoms? He is answering about how long it takes for onset of symptoms after injury. He says it’s days, sometimes possibly a couple of weeks if it’s an injury that takes a very long time to heal. It onsets during healing, not after. He describes the ankle scenario exactly the way I described it in a previous post. He says 5 days at the most for an ankle injury to turn to CRPS pain. In terms of recurrence it can be 6 months to a couple of years (again, not good ay bad day kind of thing)
16. Has it ever been a standard of care for 25 mg/kg. He says not even for use as a general anesthetic would you use a dose that high. (we saw a photo of Maya inr Hanna’s office, she was “out cold” with mouth open and he commented that she would probably have not responded at all if you tried to talk to her. She was actually under anesthesia during her ketamine treatments.
17. In CRPS the final requirement to rule out other things, are these directives in conflict here? They were in conflict with what Dr Hanna or Dr Kirkpatrick did. He states that he saw not evidence that either of these physicians were given any records from any previous doctors that had seen Maya. If they had, they should have been able to see her onset of symptoms doesn’t match CRPS (ha ha just like I’ve been saying). The notes from previous doctors are very telling. The symptoms came and went, CRPS doesn’t, what they wrote in their charts was different than what was being reported. When the child is in the bathroom fixing her hair, putting on makeup and then sits on the bed and when the nurse comes in she can’t even lift her arms to put a pill into her own mouth 15 minutes after applying makeup there is something wrong there. It raises red flags. That is not how CRPS works, and that should raise questions about the diagnosis.
18. Hanna says the stay at JHACH was an “interruption in treatment”. What was the presumed conclusion of the dosage of ketamine? It was too high by at least 10-fold. In the ER at JHACH they gave her 3 mg/kg which is a high dose and that did not stop her from screaming and thrashing. Nobody could feel comfortable going higher than that, reasonably. He agrees that it was an “interruption in her therapy” and says “and that is a GOOD THING!”. (LOL) If you look at the overall trajectory of where she was by the following summer she went from huge doses of ketamine that had no visible effect in her functionality to cutting down all those meds and she started doing great. Why>? Because she wasn’t constantly going through ketamine withdrawal, she was getting Physical therapy, occupational therapy. The point is JHACH put a stop to the drastic ketamine treatments clearly doing no good.
19. Can the CRPS pain starting in a limb radioate to other areas as well>? Yes, it can spread eventually
20. Are most medical treatments temporary if effective? Some are lucky enough to never experience symptoms again, if they are young enough and get proper treatment.
21. CRPS doesn’t usually reoccur if adolescent girls are treated? Isn’t it a lifelong condition although fluctuating in severity over time? In 9,10,11 year olds it doesn’t usually reoccur. Older teenagers will have reoccurance. Almost all adolescents who have CRPS in childhood go on to live normal lives. Adults are the most common to get CRPS and they do not go into remission so for most patients, it’s lifelong. That’s where the “uncurable” comes from. Because most people who get it are adults.
22. You testified Maya was in athletics what was she involved in? He made notes, doesn’t remember off hand. Looking for notes. He can’t find it. Either gymnastics or cheerleading
23. (Oh god. I’m not going to try to write this out. This question is a juror trying to blame the hospital for giving Maya drugs that made her behave the way she behaved. I have noticed that the juror that seems to be gunning for the plaintiff gets more and more offensive as the evidence gets more and more favorable to the defense. The look on the doctor’s face is priceless) He starts talking about the drugs and saying these should sedate most kids. It would be very unusual for these drugs to cause her to thrash about, it would have the opposite affect. He says the amounts they gave her would not have made her “pass out” she would be responsive, but just not acting out. She needed to be calmed down, she was disrupting the entire environment by screaming
24. You said that intrathecal pump is too dangerous a procedure. Who should make that decision, you or the patient? Not the patient, for sure. We don’t let a patient come in and say “take out my appendix or I need you to cut out half my lung”. Intrathecal pumps are often used for cancer patients and we don’t have to worry about what the effect is 2 years from now because by the time they get this, they are likely going to be gone in 6 months. Maya did not have any condition that was terminal. Spinal meningitis is a real possibility with an intrathecal pump. It is not taken lightly.
25. Is CRPS or the Budapest criteria call for once CRPS appear they are continuous for life or until cured or can they come and go? The physical observation diminished during therapy over time. All those symptoms go away and once they go away they can get some residual color changes that might stay for a while. The rest of the symptoms go away unless there is a recurrence, then they come back. (I guess he came close to saying it’s not good day/bad day kind of thing. Maya drives me nuts when she claims that. She is using that so she can have a great life, but still get $220 million bucks. I hope the defense asks “good day bad day” question)
26. I am not aware that she had any difference in any leg for color or temperature
27. It seems very drastic to me to meet the Budapest criteria. (No shit, Sherlock. It’s RARE) The criteria inolve several categories. You don’t have to have them all, you can have one and ot the other, but usually have both because the vascular symptoms are all because of blood flow. So, they usually go hand in hand. The Budapest are very useful, they are not carved in stone, sometimes very early they do not yet have full symptoms, but you can tell early on sometimes anyway
28. Is the government standard the only “allowed” or “right” treatment? Almost nothing we do is FDA approved in children. Most have not been approved for children so we do use them off label
29. Titration term – with many drugs more may be needed to have the same benefit over time? Is ketamine the same? That’s different than titration. Tolerance is when you use a drug over time you get tolerance so more is needed to get the same effect. Neurontin, Gabapentin you can’t give 1800 mg right away because of terrible side effects, so you titrate up from smaller doses until you get to the dosage that works for that patient.
30. Is ketamine coma not FDA approved? It’s not FDA approved, but that is NOT why it is not used
31. Per other medical witnesses it is approved in other countries, is that correct? Mexico doesn’t have an agency like FDA, there is no such thing as approved or not approved. Europe has a body like the FDA, don’t know what te status of ketamine is and how it’s use is approved or not. There is no law against doing it here, you don’t get arrested or fined for using drugs off label in the USA. We don’t do it because it’s not effective and it’s dangerous. That’s why Dr Cantu told Maya’s family there is a 50% chance she could die during treatment
32. You stated that you at times use ketamine in low doses is that true? Yes
33. Is it like chlorine treatment keeping the pool clean, so wouldn’t a high dose be like a shock treatment for a pool and have it’s uses as well? As a general rule, more is not better. If you give 200 mg of penicillin to someone isn’t 2000 mg better, the answer is no. The higher you go, the more toxicity you have, the more danger you have. Shock treatments to the body, no, it’s not better and doesn’t make sense.
34. In 2016 was CRPS a well understood ailment? Yes
35. In 2016 was CRPS a curable illness? We don’t know the exact cause of it. We know changes in spinal chord, changes in body, we don’t know why it happens, why it’s 8 times more common in females. WE see it we know it, we know how to treat it, var from perfect. It’s not curable. It’ can go into remission, hopefully for a long time in some patients. Except for in very young, like Maya’s age I have never seen it recur in someone that age once it goes into remission.
36. In 2023 is CRPS now a well understood ailment? Not any more than in 2016, it’s a confusing syndrome
37. In 2023 is there a medication or drug to cure it? No, I wish there were.
Plaintiff follow up
You said JHACH had weaned her off most of the drugs? No, I said many of them
Discharge summary – She’s obviously going to remain on her allergy medications because she came in with allergies, she will always probably take those. The rest are multivitamins not medications and it will be up to her pediatrician to determine when or if she would stop taking those. What she was on for pain or “CRPS” was pregabalin instead of the ketamine and opioids. And that’s it.
No,no what you told the jury that her allergies were better. No I did not. Looks like thre are 14 different substances listed. He says some are drugs and most are vitamins and none of the pain medications she was taking are on that list.
You were telling us the ketamine coma is highly dangerous. Did you know that in 10 years not a single injury or death has occurred? Well, he’s doing this in Monterrey, Mexico, there is no records for us to know anything about how many have been treated, or what the outcome is. Record keeping is very ppor in this respect. Mr Anderson says “he’s just throwing bodies away” judge didn’t like that.
As to Dr Hanna are you aware he has treated 18,000 CRPS patients with ketamine. Dr Crane says he flat out doesn’t believe him. He worked in a worldwide pain clinic with people coming from all over he world and they did not see 18,000 CRPS patients in 40 years. This is a rare condition.
Let’s just say if he comes in and testifies and says that, wouldn’t with that many patients there would be one or two bad results. What bad results have you seen from either Dr Cantu or Dr Hanna’s infusions? In Dr Cantu’s hands, Maya developed a multi-microbial pneumonia requiring antibiotics and that type of pneumonia can be life threatening. Notes indicate she may have aspirated, one time she vomited with the indotracheal tube in and there is a notation as well as Beata’s emails indicate the nurses had to jump in and suction it all out, suction out her tracheal tube, this may even have been the source of her pneumonia for all I know. But a multi-microbial means several types of microbes – this is not trivial it is very dangerous. I can’t say she cam to no harm. As far as Dr Hanna he was giving her humongous doses of ketamine, she was LOSING weight, (a 10 year old losing weight like a drug addict) she had abdominal pain, again, I can’t say there was no harm from that.
No, I was asking you about statistics! Whether you had any statistics or reports. Let’s leave your view of Maya aside, do you have any statistics or reported cases indicating the treatment they were using caused injury or death? (LOL, he only has info about Maya and he said they caused her harm) Are you asking me if Dr Cantu or Dr Hanna reported their problems? Did anyone come forward with any reports? I did not go after them I am not a detective, how would I know the answer to that question, I haven’t checked court records to see if anyone has sued them, I haven’t checked police reports or anything like that. (Mr Anderson should have remembered this is the witness that left Anderson’s mouth gaping open like a puffer fish earlier) I have no idea if anyone made a claim to a medical board.
He never heard the term “suicide disease”. One patient, 30 year old, died many months after treatment in the clinic where Dr Crane works. She overdosed on ocycontin, we did not write that prescription and it was not established for certain that she overdosed on purpose. He asks “didn’t you have three other suicides?” Dr Crane says unequivocally absolutely not.
Ketamine is FDA approved and there is no upper limit to it’s used. It’s approved as an anesthetic. Can be titrated to what is needed for anesthesia. During surgery the goal is to have the patient lose consciousness.
Anderson is arguing that ketamine was not responsible for pneumonia. Dr Crane says that the ketamine is why she had to be intubated. The ketamine rendered her unable to breathe correctly to protect her airway from aspiration, therefore the tube was put in for that. The ketamine, she wouldn’t have needed the tube, she wouldn’t have aspirated because her airway would have been under her normal control. How many patients have you intubated? Many thousand. Bacterial infections can happen when patients are on ventilators because they cannot cough effectively and clear secretions. Intubation in and of itself is an accepted medical procedure. He doesn’t have clear enough records to say how long the infection took to clear. Insufficient information to answer that.
Withdrawal symptoms from ketamine. Does not directly affect opioid receptors in the brain. Ketamine withdrawal can cause person to be anxious and agitated (exactly like Maya was acting) Elevated blood pressure or heart rate might be possible. Children don’t usually tell you they are agitated, you can see it. They don’t say they feel agitated, they may act agitated. They kept her on Haldol for four weeks to help with agitation.
Excused.
Jury questions
(really curious as to how the jury responds to this witness. He was exceptional for the defense, answered fully and really left no doubt that his opinions were well founded based on the records, and he flat out does not believe Maya has CRPS. He was most definitive about this. He did not mention everything that I have put in my comments about why I do not believe she has it, but he made many of those same points to this jury)
1. How is Maya doing after her discharge from JHACH? She’s doing very very well. Looking at PT notes she went in 6 months from wheelchair bound to fully walking around, no pain complaints, I understand today she is doing well, in athletics, she’s doing wll
2. What are withdrawal symptoms from ketamine? Talks about tolerance, why someone needs more and more like Maya did. The withdrawal symptoms are the opposite of what you get with using the drug = so, they feel pain, they get diarrhea, they get wired, the opposite of sedation. Same is true of withdrawal for every drug. They will beg for ketamine after they have had it for a while, they are anxious, etc. There is no question they get addicted, you can tell by how they act
3. Is it possible that the “symptoms” of CRPS (LOL) that Maya had were actually withdrawal symptoms? Good question, that was one of my hypothesis. She was agitated, screaming for ketamine, and it is quite possible she was addicted and wanted that drug (that’s the same thing I was wondering myself)
4. What is the half life of ketamine? He would dhave to look it up, probably the same as morphine, 2-3 hours
5. We have heard from physicians that all assessed Maya did not note always temperature changes, color changes, or asses her skin or other things on the Budapest criteria. Can you make an assessment that Maya did not have CRPS (He DID make that assessment) without seeing her yourself? He talks about how temperature and color changes are checked. He did not see any of these or have any idea how Dr Kirkpatrick and Dr Hanna checked various things but he highly suspects that wasn’t done. (I think he doesn’t want to say that Dr K is running a whole clinic for what would be a true population of about 2 people, meaning he has to diagnose a shitload of people who don’t have it to keep a specialty CRPS clinic open in Sarasota Florida. He kind of alluded to that somewhat during direct, but I think he’s trying to stay away from saying they are quacks, which is what they are)
6. You said many times that Maya doesn’t have CRPS, but also you didn’t examine her. How can you come to this conclusion? I’ve seen 1,000 to 2,000 cases of CRPS. You know it when you see it. When you don’t see the symptoms you know those symptoms are there. It’s like if you told me someone was an amputee but I looked at them and they have all of their limbs, they aren’t an amputee. It didn’t look like CRPS in videos and photos, it didn’t sound like CRPS by description, there were emails that Maya’s mother wrote to herself but in Maya’s voice similar to the blog that she was putting out, I don’t know if that is something that you’ve seen, but she’s saying “she’s the youngest patient in the world ever to have total body CRPS” then she said “she’s the youngest person ever to get a ketamine coma”. There are no records of whole body CRPS. Wha are the odds that she is the only person in the world to ever get this “whole body” CRPS. It’s a regional pain syndrome, (I wish he would remind them of something he said during direct, which is that she didn’t have as many symptoms as were attributed, no dystonia, and also if it was dystonia it takes years to develop. Also, it would take years for the pain to transfer to a different limb from the one it started in, much less the whole body)
7. Is there any medical oversight to ketamine dosing? I’m not sure what is meant by medical oversight, except that most hospitals specify an acceptable range, insurance won’t authorize doses above a certain amount (which is why Maya had the GoFundMe to pay for her treatments). I am on a Listserv and sometimes people ask for advice on using ketamine. At Stanford we have some of the most liberal standards for ketamine that I’ve seen, and we wouldn’t give anywhere close to what Maya was getting. Hospitals have policies and procedures. If I was to write an order for more, the nurse wouldn’t do it, and they would pull out the policy and would not do it.
8. Is it common for a diagnosis of CRPS to be questioned by physicians. We honor patients and people, but a diagnosis is an “idea”. And it can be wrong. Especially in a situation where another doctor is suggesting that the only treatment should be huge amounts of a potentially dangerous drug. (people get second opinions all the time) In Maya’s case, the pain specialists were saying this just does not look like CRPS. So then you have to take a step back and ask what else could that be.
9. Does the diagnosis of CRPS automatically raise questions of psychiatric condition? No, not at all.
10. Do you require IQ tests to accept enrollment in your pain clinic? No, not at all (I guarantee you the real reason Nemours refused to take Maya inpatient was because they saw this freaking lawsuit coming a mile away and didn’t want anything to do with it. The hospital sent their records. Their records talked about Beata and Maya’s behavior. Nemours wasn’t going to touch that with a 10 foot pole. That’s why they said “outpatient only” for Maya. The flat out refused to take her inpatient)
11. What part does IQ play in pain treatment. None, we treat children who are congnitively impaired. It can be challenging, but we do it and we don’t treat them different.
12. If it was whole body CRPS would they experience pain from a charm bracelet, anklet, pulling hair back in a pony tail, makeup application? Yes, they would. Adult women with CRPS don’t shave their leg if they have it on a leg, it hurts to drag a sock over it, they don’t wear jeans, they wear shorts or a dress 365 days a year
13. Has any CRPS case reoccurred at your center? Yes
14. At what age? It’s never reoccurred in a child at Maya’s age. Those are our favorite to treat because if they are treated appropriately by that age it does not come back. Complete remission. Teenagers reoccur much more frequently. Adults rarely ever go into remission. (I hope he talks about what remission really is. Not one good day, two bad days, 4 good days, one bad day, etc. That is what Maya claims.
15. What was the length of occurrence between symptoms? He is answering about how long it takes for onset of symptoms after injury. He says it’s days, sometimes possibly a couple of weeks if it’s an injury that takes a very long time to heal. It onsets during healing, not after. He describes the ankle scenario exactly the way I described it in a previous post. He says 5 days at the most for an ankle injury to turn to CRPS pain. In terms of recurrence it can be 6 months to a couple of years (again, not good ay bad day kind of thing)
16. Has it ever been a standard of care for 25 mg/kg. He says not even for use as a general anesthetic would you use a dose that high. (we saw a photo of Maya inr Hanna’s office, she was “out cold” with mouth open and he commented that she would probably have not responded at all if you tried to talk to her. She was actually under anesthesia during her ketamine treatments.
17. In CRPS the final requirement to rule out other things, are these directives in conflict here? They were in conflict with what Dr Hanna or Dr Kirkpatrick did. He states that he saw not evidence that either of these physicians were given any records from any previous doctors that had seen Maya. If they had, they should have been able to see her onset of symptoms doesn’t match CRPS (ha ha just like I’ve been saying). The notes from previous doctors are very telling. The symptoms came and went, CRPS doesn’t, what they wrote in their charts was different than what was being reported. When the child is in the bathroom fixing her hair, putting on makeup and then sits on the bed and when the nurse comes in she can’t even lift her arms to put a pill into her own mouth 15 minutes after applying makeup there is something wrong there. It raises red flags. That is not how CRPS works, and that should raise questions about the diagnosis.
18. Hanna says the stay at JHACH was an “interruption in treatment”. What was the presumed conclusion of the dosage of ketamine? It was too high by at least 10-fold. In the ER at JHACH they gave her 3 mg/kg which is a high dose and that did not stop her from screaming and thrashing. Nobody could feel comfortable going higher than that, reasonably. He agrees that it was an “interruption in her therapy” and says “and that is a GOOD THING!”. (LOL) If you look at the overall trajectory of where she was by the following summer she went from huge doses of ketamine that had no visible effect in her functionality to cutting down all those meds and she started doing great. Why>? Because she wasn’t constantly going through ketamine withdrawal, she was getting Physical therapy, occupational therapy. The point is JHACH put a stop to the drastic ketamine treatments clearly doing no good.
19. Can the CRPS pain starting in a limb radioate to other areas as well>? Yes, it can spread eventually
20. Are most medical treatments temporary if effective? Some are lucky enough to never experience symptoms again, if they are young enough and get proper treatment.
21. CRPS doesn’t usually reoccur if adolescent girls are treated? Isn’t it a lifelong condition although fluctuating in severity over time? In 9,10,11 year olds it doesn’t usually reoccur. Older teenagers will have reoccurance. Almost all adolescents who have CRPS in childhood go on to live normal lives. Adults are the most common to get CRPS and they do not go into remission so for most patients, it’s lifelong. That’s where the “uncurable” comes from. Because most people who get it are adults.
22. You testified Maya was in athletics what was she involved in? He made notes, doesn’t remember off hand. Looking for notes. He can’t find it. Either gymnastics or cheerleading
23. (Oh god. I’m not going to try to write this out. This question is a juror trying to blame the hospital for giving Maya drugs that made her behave the way she behaved. I have noticed that the juror that seems to be gunning for the plaintiff gets more and more offensive as the evidence gets more and more favorable to the defense. The look on the doctor’s face is priceless) He starts talking about the drugs and saying these should sedate most kids. It would be very unusual for these drugs to cause her to thrash about, it would have the opposite affect. He says the amounts they gave her would not have made her “pass out” she would be responsive, but just not acting out. She needed to be calmed down, she was disrupting the entire environment by screaming
24. You said that intrathecal pump is too dangerous a procedure. Who should make that decision, you or the patient? Not the patient, for sure. We don’t let a patient come in and say “take out my appendix or I need you to cut out half my lung”. Intrathecal pumps are often used for cancer patients and we don’t have to worry about what the effect is 2 years from now because by the time they get this, they are likely going to be gone in 6 months. Maya did not have any condition that was terminal. Spinal meningitis is a real possibility with an intrathecal pump. It is not taken lightly.
25. Is CRPS or the Budapest criteria call for once CRPS appear they are continuous for life or until cured or can they come and go? The physical observation diminished during therapy over time. All those symptoms go away and once they go away they can get some residual color changes that might stay for a while. The rest of the symptoms go away unless there is a recurrence, then they come back. (I guess he came close to saying it’s not good day/bad day kind of thing. Maya drives me nuts when she claims that. She is using that so she can have a great life, but still get $220 million bucks. I hope the defense asks “good day bad day” question)
26. I am not aware that she had any difference in any leg for color or temperature
27. It seems very drastic to me to meet the Budapest criteria. (No shit, Sherlock. It’s RARE) The criteria inolve several categories. You don’t have to have them all, you can have one and ot the other, but usually have both because the vascular symptoms are all because of blood flow. So, they usually go hand in hand. The Budapest are very useful, they are not carved in stone, sometimes very early they do not yet have full symptoms, but you can tell early on sometimes anyway
28. Is the government standard the only “allowed” or “right” treatment? Almost nothing we do is FDA approved in children. Most have not been approved for children so we do use them off label
29. Titration term – with many drugs more may be needed to have the same benefit over time? Is ketamine the same? That’s different than titration. Tolerance is when you use a drug over time you get tolerance so more is needed to get the same effect. Neurontin, Gabapentin you can’t give 1800 mg right away because of terrible side effects, so you titrate up from smaller doses until you get to the dosage that works for that patient.
30. Is ketamine coma not FDA approved? It’s not FDA approved, but that is NOT why it is not used
31. Per other medical witnesses it is approved in other countries, is that correct? Mexico doesn’t have an agency like FDA, there is no such thing as approved or not approved. Europe has a body like the FDA, don’t know what te status of ketamine is and how it’s use is approved or not. There is no law against doing it here, you don’t get arrested or fined for using drugs off label in the USA. We don’t do it because it’s not effective and it’s dangerous. That’s why Dr Cantu told Maya’s family there is a 50% chance she could die during treatment
32. You stated that you at times use ketamine in low doses is that true? Yes
33. Is it like chlorine treatment keeping the pool clean, so wouldn’t a high dose be like a shock treatment for a pool and have it’s uses as well? As a general rule, more is not better. If you give 200 mg of penicillin to someone isn’t 2000 mg better, the answer is no. The higher you go, the more toxicity you have, the more danger you have. Shock treatments to the body, no, it’s not better and doesn’t make sense.
34. In 2016 was CRPS a well understood ailment? Yes
35. In 2016 was CRPS a curable illness? We don’t know the exact cause of it. We know changes in spinal chord, changes in body, we don’t know why it happens, why it’s 8 times more common in females. WE see it we know it, we know how to treat it, var from perfect. It’s not curable. It’ can go into remission, hopefully for a long time in some patients. Except for in very young, like Maya’s age I have never seen it recur in someone that age once it goes into remission.
36. In 2023 is CRPS now a well understood ailment? Not any more than in 2016, it’s a confusing syndrome
37. In 2023 is there a medication or drug to cure it? No, I wish there were.
Plaintiff follow up
You said JHACH had weaned her off most of the drugs? No, I said many of them
Discharge summary – She’s obviously going to remain on her allergy medications because she came in with allergies, she will always probably take those. The rest are multivitamins not medications and it will be up to her pediatrician to determine when or if she would stop taking those. What she was on for pain or “CRPS” was pregabalin instead of the ketamine and opioids. And that’s it.
No,no what you told the jury that her allergies were better. No I did not. Looks like thre are 14 different substances listed. He says some are drugs and most are vitamins and none of the pain medications she was taking are on that list.
You were telling us the ketamine coma is highly dangerous. Did you know that in 10 years not a single injury or death has occurred? Well, he’s doing this in Monterrey, Mexico, there is no records for us to know anything about how many have been treated, or what the outcome is. Record keeping is very ppor in this respect. Mr Anderson says “he’s just throwing bodies away” judge didn’t like that.
As to Dr Hanna are you aware he has treated 18,000 CRPS patients with ketamine. Dr Crane says he flat out doesn’t believe him. He worked in a worldwide pain clinic with people coming from all over he world and they did not see 18,000 CRPS patients in 40 years. This is a rare condition.
Let’s just say if he comes in and testifies and says that, wouldn’t with that many patients there would be one or two bad results. What bad results have you seen from either Dr Cantu or Dr Hanna’s infusions? In Dr Cantu’s hands, Maya developed a multi-microbial pneumonia requiring antibiotics and that type of pneumonia can be life threatening. Notes indicate she may have aspirated, one time she vomited with the indotracheal tube in and there is a notation as well as Beata’s emails indicate the nurses had to jump in and suction it all out, suction out her tracheal tube, this may even have been the source of her pneumonia for all I know. But a multi-microbial means several types of microbes – this is not trivial it is very dangerous. I can’t say she cam to no harm. As far as Dr Hanna he was giving her humongous doses of ketamine, she was LOSING weight, (a 10 year old losing weight like a drug addict) she had abdominal pain, again, I can’t say there was no harm from that.
No, I was asking you about statistics! Whether you had any statistics or reports. Let’s leave your view of Maya aside, do you have any statistics or reported cases indicating the treatment they were using caused injury or death? (LOL, he only has info about Maya and he said they caused her harm) Are you asking me if Dr Cantu or Dr Hanna reported their problems? Did anyone come forward with any reports? I did not go after them I am not a detective, how would I know the answer to that question, I haven’t checked court records to see if anyone has sued them, I haven’t checked police reports or anything like that. (Mr Anderson should have remembered this is the witness that left Anderson’s mouth gaping open like a puffer fish earlier) I have no idea if anyone made a claim to a medical board.
He never heard the term “suicide disease”. One patient, 30 year old, died many months after treatment in the clinic where Dr Crane works. She overdosed on ocycontin, we did not write that prescription and it was not established for certain that she overdosed on purpose. He asks “didn’t you have three other suicides?” Dr Crane says unequivocally absolutely not.
Ketamine is FDA approved and there is no upper limit to it’s used. It’s approved as an anesthetic. Can be titrated to what is needed for anesthesia. During surgery the goal is to have the patient lose consciousness.
Anderson is arguing that ketamine was not responsible for pneumonia. Dr Crane says that the ketamine is why she had to be intubated. The ketamine rendered her unable to breathe correctly to protect her airway from aspiration, therefore the tube was put in for that. The ketamine, she wouldn’t have needed the tube, she wouldn’t have aspirated because her airway would have been under her normal control. How many patients have you intubated? Many thousand. Bacterial infections can happen when patients are on ventilators because they cannot cough effectively and clear secretions. Intubation in and of itself is an accepted medical procedure. He doesn’t have clear enough records to say how long the infection took to clear. Insufficient information to answer that.
Withdrawal symptoms from ketamine. Does not directly affect opioid receptors in the brain. Ketamine withdrawal can cause person to be anxious and agitated (exactly like Maya was acting) Elevated blood pressure or heart rate might be possible. Children don’t usually tell you they are agitated, you can see it. They don’t say they feel agitated, they may act agitated. They kept her on Haldol for four weeks to help with agitation.
Excused.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Yes, I found that out today, too! This is at least the third time they have sued someone.Maclilly wrote: ↑Tue Oct 24, 2023 12:12 pmGlad to hear this. Thought the defense doctor earlier was really good at pointing out how pushy mom was demanding ketamine and explaining the CRPS diagnosis was from mom but he had noticed inconsistencies. I am appalled at the Judge's decisions not to enter exabits into evidence allowing the to show documentation of testimony. It's odd to me. BTW, I just read Mr. K previously sued his employer in IL as well as the school district for not allowing Maya to do school at home. He is a professional litigant. This is not his first rodeo.RVInit wrote: ↑Tue Oct 24, 2023 11:38 am Big day.
Mom has been super agitated for the last several days, and I'm not able to sit and take notes while listening like I try to do. But I am listening. I was under the impression that the defense would not be putting on a doctor knowledgeable in CRPS.
Well, turns out they DO have a doctor that I'm crossing my fingers on. He seems to have more knowledge than anyone else I've heard on that witness stand. I will write it up when I can. Not finished listening to it yet, I'm behind in time. But he seems like the real deal more than anyone else.
He definitely is puttin' the whoopin' on the plaintiff case.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
-
pipistrelle
- Posts: 6922
- Joined: Mon Feb 22, 2021 11:27 am
Taking Care of Maya - FL CPS/Munchausen case
That’s what you said yourself earlier. This guy knows his stuff.Adult women with CRPS don’t shave their leg if they have it on a leg, it hurts to drag a sock over it, they don’t wear jeans, they wear shorts or a dress 365 days a year
Taking Care of Maya - FL CPS/Munchausen case
yes. I am trying to get all his testimony together, I think you will recognize lots of stuff he says that I have already commented on. And look at all the jury questions! He definitely made an impact. He really hurt the plaintiff case. But I did think he really does know more about CRPS than any of the other doctors. Some of them seem to really just know "textbook" type things, but this guy is the real deal.pipistrelle wrote: ↑Tue Oct 24, 2023 7:37 pmThat’s what you said yourself earlier. This guy knows his stuff.Adult women with CRPS don’t shave their leg if they have it on a leg, it hurts to drag a sock over it, they don’t wear jeans, they wear shorts or a dress 365 days a year
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Defense witness, Dr Paula Dees, Pediatrician Hospitalist
Pediatrician that takes care of hospitalized children in general medical services (outside the ICU)
Goes over qualifications. Board certified in two pediatric areas
Attending physician since 2011 at JHACG
Works with other specialists, they are usually in charge of the case, and they put together a team wo work with the patient. She would be the main attending physician during the hospital stay
She took care of Maya during her stay
Two names are listed, hers and a resident (they are a teaching hospital). Dr DelSanto is a resident.
Residents usually present the case, ultimately it is her responsibility to supervise the care. The resident generates the note, it’s her responsibility to review the note and add additional comments if necessary. She sees the patient every day, sometimes with or without the resident. As a rule, she saw Maya every day. One day Maya was in PT and she wasn’t able to see her on that one day.
Daily progress notes, update anything new, lab tests, synthesize any specialist recommendations. Any acute events over night, decompensation event, unstable vital signs, new symptoms or complaints
Her note says Maya has a complex medical history, possible diagnosis of CRPS, mild asthma, allergies, history of adrenal suppression related to high steroid use, possible immunodeficiency (reported by mom), generalized pain, transferred from PICU where she was weaned from pain meds/ketamine, now working on nutrition and rehab therapies. SW/CPI involved for suspected Munchausen by proxy
(this is the only actual mention of MBP, this is one of two doctors at ACH that had prior experience with MBP and they both had suspicion specifically of this. Others had suspicion of some kind of psychological issue being at the root of Maya’s pain, but the two that had seen MBP as confirmed cases both suspected this was at issue. The other doctor that had MBP experience brought it up in her deposition, she passed away from cancer, but she didn’t put it in writing. The judge is mulling over how much the defense is allowed to bring this up because they don’t want to get into Chapter 39 issues, but the plaintiff is accusing the defense of accusing Beata of this, and somehow they are allowed to bring it up, but the defense’s hands are tied so they can’t explain their side of the MBP issue. It seems screwed up)
No acute events overnight, patient stating she has pain “all over” but was able to get some sleep. Her per oral (eating or drinking by mouth) intake seems to be improving.
By the end of her time taking care of Maya I did not believe she had CRPS. Had reviewed lots of records from other doctors. She reviewed all previous medical records from other providers, put together all her own observations, other team members observations. She does a good job of explaining what CRPS is, and how Maya’s symptoms differ from cases of CRPS she has seen. It’s rare, challenging, not a blood test or study or biopsy to definitely rule in or out. Usually a peripheral nerve pain disorder. By definition it’s regional, so it will involve an extremity like a hand a foot or lower or upper part of leg. It’s not global, it’s regional. She has treated many CRPS patients. They also will see discoloration, temperature differences, different hair or nail growth in that same region as the pain, again, not all over the body or here and there on the body. There are also significant pain in that region, also allodynia in that same area. It is never a global overall pain disorder. Maya’s case just doesn’t match anything like CRPS - she had not even one feature that is typical symptom of CRPS. Several factors specific to Maya’s case that caused her to question the diagnosis.
The resident wrote part of the note, and noted that she was receiving huge doses of ketamine and likely she had physical addiction to ketamine, so the whole team was involved in a decision to wean her off the meds she had been getting from Dr Hanna. They added some medications that would help alleviate any symptoms of withdrawal, but it’s possible she may have experienced some withdrawal as they wened her off.
The parents wanted an intrathecal clonidine? That request was passed along to her.
Maya had a port which is a reservoir under the skin that is used to access the patient’s vascular system. It has a risk of infection or blood clots. We noticed there was a small red area, the soft tissues looked inflamed, so we were drawing attention to the fact the port could become infected, so we needed to monitor this closely. If a port becomes infected it can cause a range of symptoms including sepsis, which can be life threatening. Not trivial.
An order was placed to move Maya to a room that had closed circuit video capability. The team was having a hard time getting a handle on what Maya’s physical capabilities were because she would be unable to do things when asked, but she was observed in her room or in the activity room or other times when she was playing with other kids and not directly being asked to do things, she could use her arms, legs, hands, and feet in ways she claimed not to be able. So, we needed to get a true evaluation of what she was able to do or not do. It was for diagnostic reasons. Her previous room did not have cameras. Patient rooms generally do not have video capabilities.
Photo of room is being shown, this is the same as room 709 which was the room Maya was moved into. They look like all the other rooms, but have video No difference for the patient. There are 8-10 rooms with video.
Specific consent is not required because the use of video monitoring is including in the hospital treatment consent form. Dr Sally Smith also needed video for her investigation. Dr Dees became aware of that and was concerned that since she was not on the treatment team wasn’t sure it would be OK for the one instance of video monitoring to be used by the treatment team as well as Dr Smith’s forensic investigation. She reached out to Risk Management to make sure they could both use the same video surveillance time frame for each of their separate needs.
Sidebar (Jack K is smirking at Dr Dees while staring at her. It’s creepy.
She’s being shown text messages. She explains she wanted Dr Smith to know she was taking over as physician and letting her know that she was aware of an investigation and would cooperate with anything she needed.
The next time she saw Maya was Oct 19. They worked shift work, but they tried to schedule for consistency in patient treatment. No acute incidents, transferred to room 709, oral intake slowly improving.
Showing video of a nurse putting a blood pressure cuff on Maya (from video monitoring room). Maya presents her arm without any visible hesitation and the blood pressure cuff is placed. (As noted by multiple providers, when Beata was present, Maya would scream in pain at everything anyone tried to do. Beata and Maya would not allow blood pressure cuffs to be put on Maya because it hurt too much. This video shows Maya having no problem at all, when the nurse approaches her with the cuff, she rolls up her sleeve immediately and presents her arm for the cuff to be put on.
Another video shows a nurse brushing Maya’s hair, they are talking calmly, Maya is not claiming to hurt when her hair is brushed. Another video shows Maya using her left hand to hold her phone to her left hear and her right hand is painting .
Another video shows a nurse helping Maya to transfer onto the commode. She explains the placement of the commode, has to be far enough so the feet can clear and not hit the commode when getting out. Then you have to have room for two people to stand between the bed and the commode so they can pivot Maya onto the commode. Since someone has to help there has to be extra room for that person to help Maya onto the commode. (Mr Anderson asks every single witness “is it normal to put a commode so far away that a patient can’t reach it jus tso they can try to catch them walking when they are in a wheelchair?”
(I have the impression that the Kowolski family are the family from hell. JHACH is at least the fifth person or organization that I know of that they have sued. Most families go all the way through life without suing people, but they have filed lawsuits against at least five people/organizations that I know of including Maya’s school when they briefly denied her Hospital Homeschool status)
Progress note from after Maya spent a night in the observation room. These come from a review of the overnight nursing notes, speaking with nurses and other caregivers. No issues noted that night
Attending physician note: She reads to herself. Explain to jury a certain part. After the highlighted portion are my additional comments. When asked to move her legs, Maya could not move her legs,she did not have voluntary control of her legs at all. But I saw her being pushed in her wheelchair and she was not using the footrests, so she was using her leg muscles to hold her feet up off the ground. If she had just let them hang, they would have dragged and got caught under her wheelchair, so she had to hold them up herself since the footrests were not being used. She also had her feet crossed and touching each other, even though she would scream if anyone tried to touch her feet. She also put stuffy toys all around herself, touching all over her body (if you tried to put a fuzzy toy on my left leg I would slap the heck out of your hand, there is no way I could stand something fuzzy touching my left leg above the knee)
Maya had chronic malnutrition and poor weight gain history, so it is important to note her eating habits and if she had any discomfort while eating
Oct 21, 2016 Progress note – no acute events over night. Complained of pain all over, wanted the table moved closer to the bed to eat in bed. She would not drink the pediasure which was recommended to help with the malnutrition.
The next note is very interesting in light of Dr Mendez’ testimony. He is the doctor that figured out the Beata had been claiming Maya had “severe asthma” and had successfully conned doctors into prescribing large amounts of steroids before he dug into the actual doctor records and discovered there was no actual diagnosis of asthma ever made. Dr Mendez is the doctor Beeata went to for a “second opinion” on immune deficiency “diagnosis” that turned out to be another one that no previous doctor had ever diagnosed.
The note in question is an addendum to Dr Dees progress notes made after having a discussion by phone with Dr Sally Smith and Dr Hart. The note indicates that Dr Sally Smith had gathered all of Maya’s medical records from as many providers as she could find that ever treated Maya. She had mentioned to Dr Dees that the immune deficiency that was reported in the ACH medical history was a bogus diagnosis that Dr Mendez had discovered had never been made. Dr Smith noted that Dr Mendez indicated that Beata came to him for a second opinion, but that Beata had actually taken Maya to three different immunologists and told them the same story about having already been diagnosed with immune deficiency disorder and looking for “more information”.
There is a sidebar, not sure if the jury read this note, I stopped the video so I could read the whole thing. Dr Dees is being given the note to read and apparently the jury is not going to hear the above information, although they heard the basic gist of it from Dr Mendez. I think the reason the jury is not going to hear it in relation to the port removal is that it is very clear that Dr Dees decision to remove the port was initiated by her realization that not only had Beata sought a likely bogus CRPS diagnosis, but she had gotten doctors to prescribe large amounts of steroids based on her self reporting that Maya had been diagnosed with severe asthma (turned out no evidence of asthma) and was also seeking an immune deficiency diagnosis from three different immunologists, telling the operator who made the appointment that she was seeking a “second opinion” but then telling the doctor during the appointment that she wanted to understand her daughter’s immune deficiency condition, which had actually not ever been diagnosed. (and who knows if she would have then eventually tried to seek actual treatment for that)
In the end Dr Dees is allowed to explain only that she made a decision to remove Maya’s port because she didn’t see any indication for why someone like Maya would need this kind of port. (I bet she was terrified of what Beata might actually use it for). She talks about weighing the risks and benefits, she already is seeing the early signs of possible infection.
Next note – Maya was seen earlier in the morning, still complaining about all over pain, but playing happily with her stuffed animals. Still refusing any nutritional supplements.
Dr Dees reads a note to herself and waiting for a question. She had a conversation with Mrs K about removing the port. Mrs K asked her about medications, specifically a compounded medication that Dr Dees saw no indication for whatsoever. She also asked about naltrexone which can be used for lots of different things, some are helping with addiction. Dr Dees did not think Maya indicated for this. Another medication that is used for traumatic brain injuries, and she was not willing to give Maya this medication either. Another drug that Dr Dees has never heard of or used and Dr Dees declined to give this to Maya as well.
Another sidebar before asking next question. No more questions.
Plaintiff questions
She was previously deposed in this case. She is not an expert in CRPS. She believes Maya does not have this. She can’t give an exact date that she decided, by the end of the time of her last interaction she had come to that conclusion. She is part of the treatment team. He’s asking about the damn billing again because they used CRPS as one of the diagnosis codes
She did not just use crossing legs, or Maya’s leg conditions as her only reason for not believing she had CRPS. The video was for diagnostic purposes. Part of her overall assessment - she made notes and observations while she was in the room.
Looking at the fourth text message in a series. Oct 19 text to Dr Sally Smith. She says staff has been making notes from the videos. Wants to know why the notes are not in the medical records. They are incorporated into the progress notes. Sally Smith is NOT part of the treatment team. Whitney (attorney) is badgering her about Dr Smith and whether she’s part of the treatment team. Judge calls them up to bench. (this lawyer is even worse asshole than Anderson. They are both jerks. When the defense questions plaintiff witnesses, they have never been rude or loud or angry about it. The plaintiff team can’t cross a single witness without being rude, loud, angry, badgering)
Says we are going to come back to this (saving face, he isn’t coming back to this, the judge tore hima new anus)
He is looking at a note that came from the Risk Management file (he says). She has no idea who wrote this note. It’s a bunch of out of context partial sentences on a sheet of paper, The defense tried to keep this out because nobody knows who wrote this note. She is not letting him put words into her mouth or accuse her of anything regarding this note. She is sticking to her testimony . He tries to say she was trying to “catch” Maya doing things. She said no, she wasn’t trying to catch her doing things, she wanted to get a good assessment of what Maya was able to do. They needed a good assessment of what she could do. All of the notes about what she observed are in her progress notes.
Looking at a text from Dr Sally Smith to Dr Dees. She is making a suggestion of “removing medications”. That is a treatment and care decision, she is texting you so she is involved. Dr Dees says no, Dr Smith can make as many suggestions or opinions as she wanted but the decision to wean Maya from medications was made on day one in PICU before Maya was ever put into a room.
She did keep Dr Smith informed of what they were doing. Dr Smith was involved in forensic investigation and Dr Dees was required to cooperate.
The questioning is hard to follow, he’s just rambling through notes making insinuations, she’s not allowing him to get her flustered.
Puts up patient bill of rights. She had a right to have her pain managed, right? Dees says yes.
Asking about Dr Major, another hospitalist. She made a note about the treatment team and she included Dr Sally Smith. (It was already established that she was a new hospitalist, and she had confused Dr Michelle Smith with Dr Sally Smith, I guess the jury is supposed to be stupid or something. sidebar)
Should the jury ignore dr Major’s testimony if she testifies? Argumentative, Sustained. (What an ass)
No more questions.
Re Direct
Why are you reducing medications? There were inconsistencies between what she reported as pain 10 out of 10 and she’s reporting this for weeks in a row every single day, and yet she is smiling, playing, going to the activity room, etc. She did not need heavy medications. She gives an example, you don’t get morphine for a scratch. There was no outward demonstration that she was in any significant pain
The decision to start and stop pain meds was made in collaboration with the pain specialists. Did Dr Sally Smith make a single order for Maya or any other patient? No
She is the only child protection expert and I would be committing medical malpractice if I did not communicate with her. Also I have a legal obligation to communicate with her.
It was significant for me to see that Maya could tolerate blood pressure cuff, touch, playing, transfer to and from wheelchair and bed.
Maya’s name was on on the door, it could have been because of the shelter status
Patients move rooms for lots of reasons -change in service, cleaning room after patient has been there a long time, isolation, reverse isolation, deep cleaning of room
Do yu remember an incident on 11/5 of Maya using her legs in a certain way? Yes. I was conducting rounds and Maya’s door was propped open. Maya was in wheelchair at the foot of her bed. A toddler started to run into Maya’s room, so I reached for the door. I saw Maya use her feet to “walk” the wheelchair closer so she could see what was going on
Plaintiff
(FFS) Whitney trying to insinuate that Maya was desperately trying to reach the door because she was deprived of all social contact. Why was Maya being cut off from all social contact?
She was not cut off from social contact. If she wanted to interact with that child, she could do that at any time. The point was that Maya had no problem with propelling her wheelchair using her feet and legs even though she claimed to not have the use of her legs at all.
You ignored her pain because you didn’t see her pain. Not true. She was reporting the worst pain ever, but she was happy , smiling, playing with other kids less than 2 minutes after claiming she was 10/10 pain.
Jury questions
1. Did you testify it was your idea to place Maya under video surveillance. Yes, it was my decision to move forward with being able to objectively determine what Maya could and couldn’t do in order to accurately assess her capabilities, develop a treatment plan, and ability to assess progress
2. Why did you ask Dr Smith how long she wanted to keep Maya in the video room? Dr Smith also needed to be able to observe Maya for other reasons and may, or may not, have needed surveillance for her purposes for the same amount of time we needed it for our assessment of her capabilities. Dr Dees had checked with Risk Management about it, and it was also determined that if they had her in that room for long enough for both reasons, Maya wouldn’t have to be moved back and forth more than once.
3. You also texted Dr Smith to ask if she wanted to review footage from that room. Why? Because she needed to gather information for her forensic evaluation.
4. Who was on the care team with you? Internal providers. Physicians, interns, residents, phys therapy, occupational therapy, pain team, all internal providers
5. Does CRPS pain change daily? Presumably it can, sure (that may be true for someone Maya’s age, but not for an adult, who are actually the majority of patients. Unless you are talking about during times pain management is being adjusted)
6. Maya complained about having pain all over. How does she dress herself? Good question, I can’t answer that
7. Why is the note for pain the words “all over” in quotes? When we are teaching residents about involvement in cases of possible child abuse or anything else where there is a likelihood of court proceedings, we try to teach them it’s important not to interpret what the patient is saying, so quotes are used when the note is quoting exactly what the patient says. We aren’t changing what the patient reports
8. Where you presupposed to doubting Maya? No
9. How many CRPS pediatric patients have you treated? I don’t have an exact number. Over the years at least a handful if not two handfuls, maybe five to ten, more than just Maya
10. How many CRPS pediatric patients had been treated at JHACH prior to Maya? I don’t know I’m sorry
11. Would you be willing to admit that sometimes staff in high stress service jobs develop relationships beyond just coworkers when the work is arduous and prolonged? Yes, that is certainly a possibility
12. ACH has had a large number of employees with “deep roots” aka, Sally Smith how would you describe these relationships as almost familial (grammar provided by juror) Not sure I understand the question. He repeats the question. Judge says maybe lawyers can follow up. She says maybe she can answer that in her own personal case some of her best friends are colleagues. One of the things she’s most proud of at ACH is the high caliber of staff and how compassionate and caring they are. They support each other as they support patients. She has not ever been concerned about friendly relationship between coworkers as compromising integrity or compromising our ability to be objective in treating challenging cases
13. Did you ever see about Maya being denied religious ceremony? No
14. Did you ever hear about Maya being denied anything relating to religious ceremony? No, not that I can recollect (This juror may be thinking of the single time when DCF Case Manager said she asked that communion wafers not be given to Maya on one specific occasion. That was after there was concern about the possibility of ketamine being put on the wafers. It was suspected (and I think later confirmed) that Dr Hanna was giving Beata ketamine that she could treat Maya with at home. I don’t know if there was ever an investigation, but when defense asked for records related to Maya they received an order for “at home” ketamine undated, with no name on it. My impression was it was in her file because Hanna was ordering ketamine to give to Beata for use at home. At the very end of his treatment of her, he seemed to kind of “freak out” and sent her to JHACH because he had delivered as much ketamine as he was comfortable with and didn’t know what else to do. I think there is something going on there involving his providing Beata with large amount of ketamine. When her body was found she had an IV bag attached to her leg, had infused herself with something. I suspect she dosed herself with ketamine so she could just fall asleep and “let go”, She was strangled rather than actually hung, her feet were able to touch the floor. There was all kinds of questioning of the detective because he said he delivered all of that stuff that was found on and attached to Beata to the medical examiner, but there is no record of any testing being done on any of it to determine what was in that IV bag she dosed herself with during her suicide.)
15. Was it normal expectation that most kids struggle to eat hospital food? She laughs. Well, in theory hospital food is thought to be unpalatable, but we are geared toward children, we have cake, cookies, pizza, things that kids generally like to eat. Hard to make a global statement about that.
16. Did Maya struggle to gain weight and eat desserts? I don’t remember everything she ate, I know she loved graham crackers and ate those quite a bit, there was a history of struggling to gain weight, but she did have improvement in gaining weight.
17. What kind of oversight did the hospital have over Cathi Bedy? The social worker area had their own evaluation and reporting structure separate from the hospital and we don’t have any authority over their standards of care or performance, professionalism, conduct, or proficiencies. (Uh oh, this is not going to be good for the plaintiff on one of their claims against the hospital. I guarantee whatever money they get from this lawsuit Mr K will likely go after DCF. Hell, he might go after Dr Kirkpatrick and Dr Hanna before he’s done – he probably has good reason to do that)
18. As the coordinating hospitalist does your work require you to work with Cathi Bedy? Yes
19. Does a child’s overall treatment in the hospital have an effect on their overall recovery and length of treatment in your experience? Hard to say, there are so many different things we treat – asthma, cerebral palsy, so I can’t think of them all as one. Some kids have conditions were they absolutely cannot get better without treatment at a hospital. There are certainly some cases where a prolonged hospitalization being away from family and support network I can see where that could impact their overall path to recovery, but our goal is always to get them medically stabilized so they can get back to normal life.
20. What floor did you work on? 7th and 8th floor. Occasionally I worked on 2nd floor
21. Who was the Cathy Bedy of those floors? I don’t know that I can remember names that far back, I think Yvonne Walton was during that time period, but I don’t remember
22. Do social workers usually stick to a patient if they move to a different floor? Yes, I believe they typically do. (Explains why Cathi Bedy stayed on Maya’s case. (Plaintiff is trying to insinuate that Bedy was following Maya around for some nefarious reason)
23. When you switch a patient from room to room do you just move them with no explanation? I would assume when we are moving them for a clean and the family is asking, we would share that information. In Maya’s case it was a little different because we needed an accurate assessment of what she could do, and we were unable to get that from asking her. So, we didn’t want to give away why we were moving her to the room with video. We needed to be able to get accurate information for care plan and evaluation of whether she’s making real gains. Alerting her to why we were moving her was not good
24. Do nurses not use gait belts for fall prevention? I have seen them using them but I don’t know if there is actually policy about when to use them.
25. We have heard testimony that CRPS is rare, how many have you treated before Maya. I don’t know exactly probably five to ten.
26. We heard staff had nicknames for Maya, what was your nickname? I do not recall every using any nickname for Maya
27. Is Ketamine Girl an appropriate nickname for Maya? I certainly think that is probably not ideal, however knowing the physician that was treating her prior I don’t have any concern about any treatment not being appropriate because of the use of a nickname. (That nickname wasn’t actually used by a physician, it was used by Cathi Bedy who was writing a text message to the physician) It doesn’t sound like Dr Dees has complete information about that but probably heard about it through the grapevine kind of thing.
28. How often did you communicate with Cathi Bedy about Maya’s care and needs? I don’t know exactly how many times I would have talked to her, but I do know there were times when I needed to communicate things to her. Of the total of 14 days that I took care of Maya probably a couple of times each of the two weeks. I needed to make sure I was up to date on everything, so I had to ask her questions
29. How was Risk Management involved in Maya’s care? They were not involved in any care of Maya. The only time I ever had any interaction with Risk Management was when I wanted to put Maya into the room with video and became aware that Dr Sally Smith also wanted video for her investigation I did not know if there were problems with us both having different goals for why we wanted to be able to surveil Maya if it was OK for us to arrange to do it at the same time or if we would have to move her in and out of that room more than once so it would be completely separate. She is external and not part of the treatment team and I was concerned about possibly how it would appear if we both were surveiling at the same time, even though for different reasons.
30. Was Risk Management kept up to date about Maya’s ongoing care? I’m not sure, I don’t know how or how much they would have been monitoring anything about her care.
31. Are you aware if upper management was aware of what was happening with Maya? I know I had one interaction with someone that I would probably say is upper management during the 2 weeks I was involved with Maya, but I don’t know about anyone else or if they were following her case
32. How long did Maya receive Haldol while at ACH? I don’t know I would have to check the records
33. Could Dr Sally Smith make suggestions to the team? Yes, but it would be up to the team providers to decide whether any of her suggestions, if she made them, would be appropriate.
34. You testified you did not make mention to the parents about the video room because it’s part of the agreement that parents sign when agreeing to hospitalization. Is that correct? Yes that is correct. Sometimes as a courtesy we will tell a parent why we are moving a patient, but it is not required and in this case could have defeated the purpose
35.
Pediatrician that takes care of hospitalized children in general medical services (outside the ICU)
Goes over qualifications. Board certified in two pediatric areas
Attending physician since 2011 at JHACG
Works with other specialists, they are usually in charge of the case, and they put together a team wo work with the patient. She would be the main attending physician during the hospital stay
She took care of Maya during her stay
Two names are listed, hers and a resident (they are a teaching hospital). Dr DelSanto is a resident.
Residents usually present the case, ultimately it is her responsibility to supervise the care. The resident generates the note, it’s her responsibility to review the note and add additional comments if necessary. She sees the patient every day, sometimes with or without the resident. As a rule, she saw Maya every day. One day Maya was in PT and she wasn’t able to see her on that one day.
Daily progress notes, update anything new, lab tests, synthesize any specialist recommendations. Any acute events over night, decompensation event, unstable vital signs, new symptoms or complaints
Her note says Maya has a complex medical history, possible diagnosis of CRPS, mild asthma, allergies, history of adrenal suppression related to high steroid use, possible immunodeficiency (reported by mom), generalized pain, transferred from PICU where she was weaned from pain meds/ketamine, now working on nutrition and rehab therapies. SW/CPI involved for suspected Munchausen by proxy
(this is the only actual mention of MBP, this is one of two doctors at ACH that had prior experience with MBP and they both had suspicion specifically of this. Others had suspicion of some kind of psychological issue being at the root of Maya’s pain, but the two that had seen MBP as confirmed cases both suspected this was at issue. The other doctor that had MBP experience brought it up in her deposition, she passed away from cancer, but she didn’t put it in writing. The judge is mulling over how much the defense is allowed to bring this up because they don’t want to get into Chapter 39 issues, but the plaintiff is accusing the defense of accusing Beata of this, and somehow they are allowed to bring it up, but the defense’s hands are tied so they can’t explain their side of the MBP issue. It seems screwed up)
No acute events overnight, patient stating she has pain “all over” but was able to get some sleep. Her per oral (eating or drinking by mouth) intake seems to be improving.
By the end of her time taking care of Maya I did not believe she had CRPS. Had reviewed lots of records from other doctors. She reviewed all previous medical records from other providers, put together all her own observations, other team members observations. She does a good job of explaining what CRPS is, and how Maya’s symptoms differ from cases of CRPS she has seen. It’s rare, challenging, not a blood test or study or biopsy to definitely rule in or out. Usually a peripheral nerve pain disorder. By definition it’s regional, so it will involve an extremity like a hand a foot or lower or upper part of leg. It’s not global, it’s regional. She has treated many CRPS patients. They also will see discoloration, temperature differences, different hair or nail growth in that same region as the pain, again, not all over the body or here and there on the body. There are also significant pain in that region, also allodynia in that same area. It is never a global overall pain disorder. Maya’s case just doesn’t match anything like CRPS - she had not even one feature that is typical symptom of CRPS. Several factors specific to Maya’s case that caused her to question the diagnosis.
The resident wrote part of the note, and noted that she was receiving huge doses of ketamine and likely she had physical addiction to ketamine, so the whole team was involved in a decision to wean her off the meds she had been getting from Dr Hanna. They added some medications that would help alleviate any symptoms of withdrawal, but it’s possible she may have experienced some withdrawal as they wened her off.
The parents wanted an intrathecal clonidine? That request was passed along to her.
Maya had a port which is a reservoir under the skin that is used to access the patient’s vascular system. It has a risk of infection or blood clots. We noticed there was a small red area, the soft tissues looked inflamed, so we were drawing attention to the fact the port could become infected, so we needed to monitor this closely. If a port becomes infected it can cause a range of symptoms including sepsis, which can be life threatening. Not trivial.
An order was placed to move Maya to a room that had closed circuit video capability. The team was having a hard time getting a handle on what Maya’s physical capabilities were because she would be unable to do things when asked, but she was observed in her room or in the activity room or other times when she was playing with other kids and not directly being asked to do things, she could use her arms, legs, hands, and feet in ways she claimed not to be able. So, we needed to get a true evaluation of what she was able to do or not do. It was for diagnostic reasons. Her previous room did not have cameras. Patient rooms generally do not have video capabilities.
Photo of room is being shown, this is the same as room 709 which was the room Maya was moved into. They look like all the other rooms, but have video No difference for the patient. There are 8-10 rooms with video.
Specific consent is not required because the use of video monitoring is including in the hospital treatment consent form. Dr Sally Smith also needed video for her investigation. Dr Dees became aware of that and was concerned that since she was not on the treatment team wasn’t sure it would be OK for the one instance of video monitoring to be used by the treatment team as well as Dr Smith’s forensic investigation. She reached out to Risk Management to make sure they could both use the same video surveillance time frame for each of their separate needs.
Sidebar (Jack K is smirking at Dr Dees while staring at her. It’s creepy.
She’s being shown text messages. She explains she wanted Dr Smith to know she was taking over as physician and letting her know that she was aware of an investigation and would cooperate with anything she needed.
The next time she saw Maya was Oct 19. They worked shift work, but they tried to schedule for consistency in patient treatment. No acute incidents, transferred to room 709, oral intake slowly improving.
Showing video of a nurse putting a blood pressure cuff on Maya (from video monitoring room). Maya presents her arm without any visible hesitation and the blood pressure cuff is placed. (As noted by multiple providers, when Beata was present, Maya would scream in pain at everything anyone tried to do. Beata and Maya would not allow blood pressure cuffs to be put on Maya because it hurt too much. This video shows Maya having no problem at all, when the nurse approaches her with the cuff, she rolls up her sleeve immediately and presents her arm for the cuff to be put on.
Another video shows a nurse brushing Maya’s hair, they are talking calmly, Maya is not claiming to hurt when her hair is brushed. Another video shows Maya using her left hand to hold her phone to her left hear and her right hand is painting .
Another video shows a nurse helping Maya to transfer onto the commode. She explains the placement of the commode, has to be far enough so the feet can clear and not hit the commode when getting out. Then you have to have room for two people to stand between the bed and the commode so they can pivot Maya onto the commode. Since someone has to help there has to be extra room for that person to help Maya onto the commode. (Mr Anderson asks every single witness “is it normal to put a commode so far away that a patient can’t reach it jus tso they can try to catch them walking when they are in a wheelchair?”
(I have the impression that the Kowolski family are the family from hell. JHACH is at least the fifth person or organization that I know of that they have sued. Most families go all the way through life without suing people, but they have filed lawsuits against at least five people/organizations that I know of including Maya’s school when they briefly denied her Hospital Homeschool status)
Progress note from after Maya spent a night in the observation room. These come from a review of the overnight nursing notes, speaking with nurses and other caregivers. No issues noted that night
Attending physician note: She reads to herself. Explain to jury a certain part. After the highlighted portion are my additional comments. When asked to move her legs, Maya could not move her legs,she did not have voluntary control of her legs at all. But I saw her being pushed in her wheelchair and she was not using the footrests, so she was using her leg muscles to hold her feet up off the ground. If she had just let them hang, they would have dragged and got caught under her wheelchair, so she had to hold them up herself since the footrests were not being used. She also had her feet crossed and touching each other, even though she would scream if anyone tried to touch her feet. She also put stuffy toys all around herself, touching all over her body (if you tried to put a fuzzy toy on my left leg I would slap the heck out of your hand, there is no way I could stand something fuzzy touching my left leg above the knee)
Maya had chronic malnutrition and poor weight gain history, so it is important to note her eating habits and if she had any discomfort while eating
Oct 21, 2016 Progress note – no acute events over night. Complained of pain all over, wanted the table moved closer to the bed to eat in bed. She would not drink the pediasure which was recommended to help with the malnutrition.
The next note is very interesting in light of Dr Mendez’ testimony. He is the doctor that figured out the Beata had been claiming Maya had “severe asthma” and had successfully conned doctors into prescribing large amounts of steroids before he dug into the actual doctor records and discovered there was no actual diagnosis of asthma ever made. Dr Mendez is the doctor Beeata went to for a “second opinion” on immune deficiency “diagnosis” that turned out to be another one that no previous doctor had ever diagnosed.
The note in question is an addendum to Dr Dees progress notes made after having a discussion by phone with Dr Sally Smith and Dr Hart. The note indicates that Dr Sally Smith had gathered all of Maya’s medical records from as many providers as she could find that ever treated Maya. She had mentioned to Dr Dees that the immune deficiency that was reported in the ACH medical history was a bogus diagnosis that Dr Mendez had discovered had never been made. Dr Smith noted that Dr Mendez indicated that Beata came to him for a second opinion, but that Beata had actually taken Maya to three different immunologists and told them the same story about having already been diagnosed with immune deficiency disorder and looking for “more information”.
There is a sidebar, not sure if the jury read this note, I stopped the video so I could read the whole thing. Dr Dees is being given the note to read and apparently the jury is not going to hear the above information, although they heard the basic gist of it from Dr Mendez. I think the reason the jury is not going to hear it in relation to the port removal is that it is very clear that Dr Dees decision to remove the port was initiated by her realization that not only had Beata sought a likely bogus CRPS diagnosis, but she had gotten doctors to prescribe large amounts of steroids based on her self reporting that Maya had been diagnosed with severe asthma (turned out no evidence of asthma) and was also seeking an immune deficiency diagnosis from three different immunologists, telling the operator who made the appointment that she was seeking a “second opinion” but then telling the doctor during the appointment that she wanted to understand her daughter’s immune deficiency condition, which had actually not ever been diagnosed. (and who knows if she would have then eventually tried to seek actual treatment for that)
In the end Dr Dees is allowed to explain only that she made a decision to remove Maya’s port because she didn’t see any indication for why someone like Maya would need this kind of port. (I bet she was terrified of what Beata might actually use it for). She talks about weighing the risks and benefits, she already is seeing the early signs of possible infection.
Next note – Maya was seen earlier in the morning, still complaining about all over pain, but playing happily with her stuffed animals. Still refusing any nutritional supplements.
Dr Dees reads a note to herself and waiting for a question. She had a conversation with Mrs K about removing the port. Mrs K asked her about medications, specifically a compounded medication that Dr Dees saw no indication for whatsoever. She also asked about naltrexone which can be used for lots of different things, some are helping with addiction. Dr Dees did not think Maya indicated for this. Another medication that is used for traumatic brain injuries, and she was not willing to give Maya this medication either. Another drug that Dr Dees has never heard of or used and Dr Dees declined to give this to Maya as well.
Another sidebar before asking next question. No more questions.
Plaintiff questions
She was previously deposed in this case. She is not an expert in CRPS. She believes Maya does not have this. She can’t give an exact date that she decided, by the end of the time of her last interaction she had come to that conclusion. She is part of the treatment team. He’s asking about the damn billing again because they used CRPS as one of the diagnosis codes
She did not just use crossing legs, or Maya’s leg conditions as her only reason for not believing she had CRPS. The video was for diagnostic purposes. Part of her overall assessment - she made notes and observations while she was in the room.
Looking at the fourth text message in a series. Oct 19 text to Dr Sally Smith. She says staff has been making notes from the videos. Wants to know why the notes are not in the medical records. They are incorporated into the progress notes. Sally Smith is NOT part of the treatment team. Whitney (attorney) is badgering her about Dr Smith and whether she’s part of the treatment team. Judge calls them up to bench. (this lawyer is even worse asshole than Anderson. They are both jerks. When the defense questions plaintiff witnesses, they have never been rude or loud or angry about it. The plaintiff team can’t cross a single witness without being rude, loud, angry, badgering)
Says we are going to come back to this (saving face, he isn’t coming back to this, the judge tore hima new anus)
He is looking at a note that came from the Risk Management file (he says). She has no idea who wrote this note. It’s a bunch of out of context partial sentences on a sheet of paper, The defense tried to keep this out because nobody knows who wrote this note. She is not letting him put words into her mouth or accuse her of anything regarding this note. She is sticking to her testimony . He tries to say she was trying to “catch” Maya doing things. She said no, she wasn’t trying to catch her doing things, she wanted to get a good assessment of what Maya was able to do. They needed a good assessment of what she could do. All of the notes about what she observed are in her progress notes.
Looking at a text from Dr Sally Smith to Dr Dees. She is making a suggestion of “removing medications”. That is a treatment and care decision, she is texting you so she is involved. Dr Dees says no, Dr Smith can make as many suggestions or opinions as she wanted but the decision to wean Maya from medications was made on day one in PICU before Maya was ever put into a room.
She did keep Dr Smith informed of what they were doing. Dr Smith was involved in forensic investigation and Dr Dees was required to cooperate.
The questioning is hard to follow, he’s just rambling through notes making insinuations, she’s not allowing him to get her flustered.
Puts up patient bill of rights. She had a right to have her pain managed, right? Dees says yes.
Asking about Dr Major, another hospitalist. She made a note about the treatment team and she included Dr Sally Smith. (It was already established that she was a new hospitalist, and she had confused Dr Michelle Smith with Dr Sally Smith, I guess the jury is supposed to be stupid or something. sidebar)
Should the jury ignore dr Major’s testimony if she testifies? Argumentative, Sustained. (What an ass)
No more questions.
Re Direct
Why are you reducing medications? There were inconsistencies between what she reported as pain 10 out of 10 and she’s reporting this for weeks in a row every single day, and yet she is smiling, playing, going to the activity room, etc. She did not need heavy medications. She gives an example, you don’t get morphine for a scratch. There was no outward demonstration that she was in any significant pain
The decision to start and stop pain meds was made in collaboration with the pain specialists. Did Dr Sally Smith make a single order for Maya or any other patient? No
She is the only child protection expert and I would be committing medical malpractice if I did not communicate with her. Also I have a legal obligation to communicate with her.
It was significant for me to see that Maya could tolerate blood pressure cuff, touch, playing, transfer to and from wheelchair and bed.
Maya’s name was on on the door, it could have been because of the shelter status
Patients move rooms for lots of reasons -change in service, cleaning room after patient has been there a long time, isolation, reverse isolation, deep cleaning of room
Do yu remember an incident on 11/5 of Maya using her legs in a certain way? Yes. I was conducting rounds and Maya’s door was propped open. Maya was in wheelchair at the foot of her bed. A toddler started to run into Maya’s room, so I reached for the door. I saw Maya use her feet to “walk” the wheelchair closer so she could see what was going on
Plaintiff
(FFS) Whitney trying to insinuate that Maya was desperately trying to reach the door because she was deprived of all social contact. Why was Maya being cut off from all social contact?
She was not cut off from social contact. If she wanted to interact with that child, she could do that at any time. The point was that Maya had no problem with propelling her wheelchair using her feet and legs even though she claimed to not have the use of her legs at all.
You ignored her pain because you didn’t see her pain. Not true. She was reporting the worst pain ever, but she was happy , smiling, playing with other kids less than 2 minutes after claiming she was 10/10 pain.
Jury questions
1. Did you testify it was your idea to place Maya under video surveillance. Yes, it was my decision to move forward with being able to objectively determine what Maya could and couldn’t do in order to accurately assess her capabilities, develop a treatment plan, and ability to assess progress
2. Why did you ask Dr Smith how long she wanted to keep Maya in the video room? Dr Smith also needed to be able to observe Maya for other reasons and may, or may not, have needed surveillance for her purposes for the same amount of time we needed it for our assessment of her capabilities. Dr Dees had checked with Risk Management about it, and it was also determined that if they had her in that room for long enough for both reasons, Maya wouldn’t have to be moved back and forth more than once.
3. You also texted Dr Smith to ask if she wanted to review footage from that room. Why? Because she needed to gather information for her forensic evaluation.
4. Who was on the care team with you? Internal providers. Physicians, interns, residents, phys therapy, occupational therapy, pain team, all internal providers
5. Does CRPS pain change daily? Presumably it can, sure (that may be true for someone Maya’s age, but not for an adult, who are actually the majority of patients. Unless you are talking about during times pain management is being adjusted)
6. Maya complained about having pain all over. How does she dress herself? Good question, I can’t answer that
7. Why is the note for pain the words “all over” in quotes? When we are teaching residents about involvement in cases of possible child abuse or anything else where there is a likelihood of court proceedings, we try to teach them it’s important not to interpret what the patient is saying, so quotes are used when the note is quoting exactly what the patient says. We aren’t changing what the patient reports
8. Where you presupposed to doubting Maya? No
9. How many CRPS pediatric patients have you treated? I don’t have an exact number. Over the years at least a handful if not two handfuls, maybe five to ten, more than just Maya
10. How many CRPS pediatric patients had been treated at JHACH prior to Maya? I don’t know I’m sorry
11. Would you be willing to admit that sometimes staff in high stress service jobs develop relationships beyond just coworkers when the work is arduous and prolonged? Yes, that is certainly a possibility
12. ACH has had a large number of employees with “deep roots” aka, Sally Smith how would you describe these relationships as almost familial (grammar provided by juror) Not sure I understand the question. He repeats the question. Judge says maybe lawyers can follow up. She says maybe she can answer that in her own personal case some of her best friends are colleagues. One of the things she’s most proud of at ACH is the high caliber of staff and how compassionate and caring they are. They support each other as they support patients. She has not ever been concerned about friendly relationship between coworkers as compromising integrity or compromising our ability to be objective in treating challenging cases
13. Did you ever see about Maya being denied religious ceremony? No
14. Did you ever hear about Maya being denied anything relating to religious ceremony? No, not that I can recollect (This juror may be thinking of the single time when DCF Case Manager said she asked that communion wafers not be given to Maya on one specific occasion. That was after there was concern about the possibility of ketamine being put on the wafers. It was suspected (and I think later confirmed) that Dr Hanna was giving Beata ketamine that she could treat Maya with at home. I don’t know if there was ever an investigation, but when defense asked for records related to Maya they received an order for “at home” ketamine undated, with no name on it. My impression was it was in her file because Hanna was ordering ketamine to give to Beata for use at home. At the very end of his treatment of her, he seemed to kind of “freak out” and sent her to JHACH because he had delivered as much ketamine as he was comfortable with and didn’t know what else to do. I think there is something going on there involving his providing Beata with large amount of ketamine. When her body was found she had an IV bag attached to her leg, had infused herself with something. I suspect she dosed herself with ketamine so she could just fall asleep and “let go”, She was strangled rather than actually hung, her feet were able to touch the floor. There was all kinds of questioning of the detective because he said he delivered all of that stuff that was found on and attached to Beata to the medical examiner, but there is no record of any testing being done on any of it to determine what was in that IV bag she dosed herself with during her suicide.)
15. Was it normal expectation that most kids struggle to eat hospital food? She laughs. Well, in theory hospital food is thought to be unpalatable, but we are geared toward children, we have cake, cookies, pizza, things that kids generally like to eat. Hard to make a global statement about that.
16. Did Maya struggle to gain weight and eat desserts? I don’t remember everything she ate, I know she loved graham crackers and ate those quite a bit, there was a history of struggling to gain weight, but she did have improvement in gaining weight.
17. What kind of oversight did the hospital have over Cathi Bedy? The social worker area had their own evaluation and reporting structure separate from the hospital and we don’t have any authority over their standards of care or performance, professionalism, conduct, or proficiencies. (Uh oh, this is not going to be good for the plaintiff on one of their claims against the hospital. I guarantee whatever money they get from this lawsuit Mr K will likely go after DCF. Hell, he might go after Dr Kirkpatrick and Dr Hanna before he’s done – he probably has good reason to do that)
18. As the coordinating hospitalist does your work require you to work with Cathi Bedy? Yes
19. Does a child’s overall treatment in the hospital have an effect on their overall recovery and length of treatment in your experience? Hard to say, there are so many different things we treat – asthma, cerebral palsy, so I can’t think of them all as one. Some kids have conditions were they absolutely cannot get better without treatment at a hospital. There are certainly some cases where a prolonged hospitalization being away from family and support network I can see where that could impact their overall path to recovery, but our goal is always to get them medically stabilized so they can get back to normal life.
20. What floor did you work on? 7th and 8th floor. Occasionally I worked on 2nd floor
21. Who was the Cathy Bedy of those floors? I don’t know that I can remember names that far back, I think Yvonne Walton was during that time period, but I don’t remember
22. Do social workers usually stick to a patient if they move to a different floor? Yes, I believe they typically do. (Explains why Cathi Bedy stayed on Maya’s case. (Plaintiff is trying to insinuate that Bedy was following Maya around for some nefarious reason)
23. When you switch a patient from room to room do you just move them with no explanation? I would assume when we are moving them for a clean and the family is asking, we would share that information. In Maya’s case it was a little different because we needed an accurate assessment of what she could do, and we were unable to get that from asking her. So, we didn’t want to give away why we were moving her to the room with video. We needed to be able to get accurate information for care plan and evaluation of whether she’s making real gains. Alerting her to why we were moving her was not good
24. Do nurses not use gait belts for fall prevention? I have seen them using them but I don’t know if there is actually policy about when to use them.
25. We have heard testimony that CRPS is rare, how many have you treated before Maya. I don’t know exactly probably five to ten.
26. We heard staff had nicknames for Maya, what was your nickname? I do not recall every using any nickname for Maya
27. Is Ketamine Girl an appropriate nickname for Maya? I certainly think that is probably not ideal, however knowing the physician that was treating her prior I don’t have any concern about any treatment not being appropriate because of the use of a nickname. (That nickname wasn’t actually used by a physician, it was used by Cathi Bedy who was writing a text message to the physician) It doesn’t sound like Dr Dees has complete information about that but probably heard about it through the grapevine kind of thing.
28. How often did you communicate with Cathi Bedy about Maya’s care and needs? I don’t know exactly how many times I would have talked to her, but I do know there were times when I needed to communicate things to her. Of the total of 14 days that I took care of Maya probably a couple of times each of the two weeks. I needed to make sure I was up to date on everything, so I had to ask her questions
29. How was Risk Management involved in Maya’s care? They were not involved in any care of Maya. The only time I ever had any interaction with Risk Management was when I wanted to put Maya into the room with video and became aware that Dr Sally Smith also wanted video for her investigation I did not know if there were problems with us both having different goals for why we wanted to be able to surveil Maya if it was OK for us to arrange to do it at the same time or if we would have to move her in and out of that room more than once so it would be completely separate. She is external and not part of the treatment team and I was concerned about possibly how it would appear if we both were surveiling at the same time, even though for different reasons.
30. Was Risk Management kept up to date about Maya’s ongoing care? I’m not sure, I don’t know how or how much they would have been monitoring anything about her care.
31. Are you aware if upper management was aware of what was happening with Maya? I know I had one interaction with someone that I would probably say is upper management during the 2 weeks I was involved with Maya, but I don’t know about anyone else or if they were following her case
32. How long did Maya receive Haldol while at ACH? I don’t know I would have to check the records
33. Could Dr Sally Smith make suggestions to the team? Yes, but it would be up to the team providers to decide whether any of her suggestions, if she made them, would be appropriate.
34. You testified you did not make mention to the parents about the video room because it’s part of the agreement that parents sign when agreeing to hospitalization. Is that correct? Yes that is correct. Sometimes as a courtesy we will tell a parent why we are moving a patient, but it is not required and in this case could have defeated the purpose
35.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Defense witness Dr Elliot Crane, Physician, Stanford university school of Medicine.
Impressive credentials, appropriate for anesthesia pain management and specifically pediatrics, pediatric critical care, focused practice on pediatric pain management more than 20 years
I was hoping the defense would have someone who looked at ALL Maya’s medical records. This man was probably paid a fortune, and he earned it. He had all of Maya’s medical records and was well prepared to discuss in details what he thought of Maya’s various treatments, how she responded (or didn’t ) to those treatments and whether they conformed to standard of care IF she had CRPS and also opined that she did NOT have CRPS in his opinion and he detailed why not. A very impressive witness who blew a truck through the plaintiff’s case, IMO.
During the time Maya was treated he was working exclusively in pediatric pain management. Very familiar with CRPS, diagnosing and treatment. They treat mostly chronic pain, but sometime post op acute pain. Wide spectrum of different pain problems, cancer, CRPS is one of the most common, fibromyalgia, congenital birth defects, all kinds of pain. FND is something that he sees from time to time, functional abdominal pain, pain is not “in their heads” but it may be amplified by psychological factors
He has contributed significantly to chronic pediatric pain literature. Lectures, lectured on CRPS somewhere around 200 times, made a number of video lectures on CRPS, pain management, over 79 peer reviewed articles on pediatric pain management, explains what peer reviewed means.
He reviewed medical records from virtually every doctor and hospital Maya visited from 2015 – 2017, Mr Hunter lists each of them, he responds yes to all of them, except unsure about the school board records, includes physicians and psychiatrist. He says he also reviewed log entries, emails, and blogs by Beata. Reviewed photos and videos from various times in Maya’s life
CRPS – cause is unknown, involves typically a leg or an arm. In kids it’s typically a leg, in adults it’s often an arm. It follows surgery or a seemingly trivial injury. It occurs very soon after the injury. The pain morphs from the “normal” pain from that injury to a burning neurological pain. The skin becomes very sensitive, can’t stand air from a fan touching the skin. Other symptoms evolve over time, it can take up to 2 years for some of the symptoms to appear. Usually a person will end up going to a neurologist or pain management doctor as the pain is the first symptom to appear.
We get patients from all over the world so we see more CRPS than most clinics.
There is no such thing as all over CRPS. Never has there been recorded such a case. It starts in a limb.It can spread, but not right away, after months or even years it can spread to another limb. But it doesn’t spread to other parts of the body.
The foundation of treatment is PT/OT/CBT, psychotherapy. Everything else we do is only useful s much as it supports the PT and OT. If they can’t tolerate PT then we use pain medications to allow them to tolerate the therapy. We might also do a nerve block to help reduce the pain so they can tolerate the therapy. It’s effective only for a short period of time (nerve block for CRPS case).
Ketamine can be used in low dose amounts. At Stanford we use this only for cases that don’t respond to normal therapy. So, normal therapy takes at least 10-12 weeks, so we would not use ketamine before a full course of 12 week therapy and the patient cannot get relief. In that case they will be hospitalized and given a 4-5 day low dose ketamine treatment. Our max is 1 mg/kg per hour. That is a high dose. We start in the range of .3 mg/kg per hour.
An anesthetic dose would be about 1-2 mg/kg (27 mg for someone the size of Maya) will anesthetize someone enough to do surgery. Asking him about Kirkpatrick and Hanna gets a sidebar.
He gives the numbers, Hanna was using up to 30 mg/kg per hour. Significantly more than Stanford would use.
Maya reported significant pain, inability to use her legs, arms, behavior often screaming – attributed to pain, periods that her pain seemed to be less, then severe pain again, then less. But from summer of 2015 to fall of 2016 she was not better and significantly worse. By the time Oct 2016 came around she said she could not lift her limbs, screaming, could not be touched
At Kirkpatrick’s initial involvement was his treatment within standard of care for pediatric CRPS. No, not within standard of care. Ketamine is normally reserved for refractory pain, that will not respond to other treatment. Pt/OT.Psychotherapy. His very first treatment was ketamine, it was very premature. Also, it was significant doses, in violation of standard of care in terms of record keeping.
He was giving anesthetic doses, not keeping proper records, skeletal record keeping, no notation of vital signs. It violated standard of care for any anesthesiologist utilizing ketamine in the dosage range he was using. She as essentially being put into a light stage of anesthesia by Kirkpatrick right from his initial treatment.
Was there any harm as a result? There was no direct harm to Maya, she didn’t have any side effects. And her pain was diminished for short periods of time. The main harm that was done, was instead of getting her the standard of care treatment for pediatric CRPS, he was giving ketamine. Someone Maya’s age typically gets a single round of 12 week treatment and never has any symptoms ever again. So, she wasn’t directly harmed by his dosage of ketamine, but deprived her of what would have been a relatively short period of treatment for what is almost always for a 10 year old girl the full amount of treatment they will ever need, IF she had CRPS.
There was no adequate trial of any other treatment. Girls Maya’s age are the easiest to treat for CRPS. They never recur in a child that age if you treat them with the specified standard of care for 10-12 week period. Once they reach teen years it becomes harder, but not as hard as adult onset CRPS. A teenager will often have decent results in treating CRPS and in getting to remission. But they will be more likely to have a recurrence at some point, where a 10 year old child never will have a recurrence after initial treatment. An adult pretty much never will go into remission, so that is the worst case, we can only manage the symptoms for an adult.
Because it didn’t work, he referred her to Mexico. He called this ketamine coma. It’s not a real coma, it’s general anesthesia. So, the patient is unresponsive during the whole treatment. It’s not actually what would be properly called a medical coma.
He starts the treatment at 3 mg/kg/hr and then goes up to 5 or 6 mg/kg/hr which results in complete anesthesia. For that reason, he has to treat the patient just like we treat someone under general anesthesia for surgery. They have a breathing tube placed, they have vital signs monitored, mechanical ventilator is used, nutition has to be administered by tube. They are under a prolonged general anethetic for 5 days.
This does not meet the standard of care for treating pediatric CRPS in the united States, not done anywhere in the USA.
Did the treatment rendered in Mexico successful? No, there was no sustained benefit. Within 3 or 4 weeks she was needing another treatment, her pain returned. In contrast, even low dose ketamine has a better outcome that these higher doses and will keep a patient pain free for longer
After seeing Dr Cantu, she saw Dr Hanna? Yes. His treatment started Dec 2015 until Oct 2016, nearly a year. His treatment involved infusions over several days in ever increasing doses. He started around 3 mg/kg/hr and because Maya was reporting continuation of her symptoms he had to continue giving these treatments frequently. Because of the excessive doses of ketamine, she had actually lost weight, she had no appetite, she was in the 1 percentile for weight for her age, meaning 99% of kids her age weighed more than she did. It’s significant that she actually lost weight, she should have been gaining weight. She had terrible abdominal pain. And she had had episodes of abdominal pain throughout his treatments, based on his records. His records also showed virtually no improvement whatsoever from those treatments. He was reporting she had the same symptoms every time she came to see him and in less than a years time she visited him for 55 four day infusions.
This was not in any way successful treatment. I believe he knew that he could not give her more ketamine, he had maxed out, she was not getting better, and out of desperation he sent her to JHACH. He basically bailed out of treating her.
It did not comply with standard of care for treating pediatric CRPS. And there were several factors. The glaring problems, including the massive doses, just like Kirkpatrick there was insufficient monitoring of her vital signs, inadequate record keeping, which violated the standard of care for an anesthesiologist. She was receiving actual general anesthesia doses from Dr Hanna. The reason for monitoring vital signs is for patient safety.
Was there injury or harm as a result of the course of therapy from Dr Hanna? Yes, there was harm. She was developing complications, weight loss, loss of appetite , there was no other obvious possible cause of the weight loss and appetite loss in her records. Also because he denied her the opportunity for effective treatment IF that is what she had.
Patient admission to JHACH – have you reviewed the entire record? Yes. The care that was rendered during that admission complied with the standard of care. There were so many things that were done for Maya in the hospital.
First she came with a complaint of abdominal pain. The ER physician noticed immediately that her symptoms did not correspond to her physical examination, so there was a discrepancy there. They realized that some of the symptoms they were seeing were complications of those large doses of ketamine, and she needed to be hospitalized to care for those.
In the intensive care unit they needed to put her back on the ketamine because she was essentially having withdrawal from each of the treatments as soon as he finished those treatments. And she had just had the largest treatment from him, so she needed to be put back on the ketamine in order to them wean her slowly down from it and ease her symptoms.
The fact that she could still be awake on those amounts, means that she had developed a tolerance for those high doses. This is why he had to keep giving her more and more. This violates what I call the rule of holes, which is when you are in a hole, stop digging.
He was actually making her more and more dependent, major physical dependency in a controlled fashion. At that point they still needed to evaluate for exactly what was causing the abdominal pain. And then while she was still in ICU, they had to deal with her mother who was telling them she was going to take her back to Dr Hanna for more high dose ketamine treatments.
Sidebar. That was well documented in the records that Beata was threatening to take Maya for more of those treatments. Jury instructed to disregard the last comment (not a comment, it’s a fact)
Was it reasonable for the staff to attempt to wean Maya off? Yes, she had come from Dr Hanna’s office, she was showing signs of dependency, weaning was to prevent her from having withdrawal symptoms.
It was reasonable for them to attempt to transfer Maya to Nemours treatment facility as long as they got her stabililzed first. The priority at the time was to take care of the acute problem, weaning her from dependency
What would have been the appropriate treatment at the time? Can’t treat without a diagnosis. I believe it was becoming increasingly clear to them that she did not actually have CRPS, so they really needed to try to diagnose her properly.
Sidebar. The diagnosis indicated that CRPS was reported as the diagnosis, that is not the same as saying that ACH diagnosed her with CRPS. Dr Crane says he does not believe she had CRPS.
I didn’t see anything consistent with a diagnosis of CRPS. Except just the report of pain, but lots of conditions have pain. By itself it does not denote CRPS.
Looking at her history, she did not present as a patient that has CRPS. She did not meet the criteria for this diagnosis. He talks about the Budapest Criteria. There ae a number of symptoms that are divided into different areas. It’s a very difficult diagnosis to make and the same combination of symptoms can be something entirely different from CRPS. So only if there is a constellation of these symptoms and there is no other diagnosis that fits, can you say it is CRP
Features of the affected limb such as the color and temperature of the affected limb as opposed to the opposite limb. In the very earliest phases of the condition, the area is red, but it can morph into blue/purple or almost a bruise like skin appearance covering a large area. There are secondary changed to the skin in terms of hair or nail growth. So, the fingernails on an affected arm or hand may grow very fast or stop growing.
There are motor abnormalities such as tremors and dystonia. There are a list of symptoms that the patient should be experiencing, and a list of observable conditions a physician should see. And, if there is another possible diagnosis, it Is not CRPS.
There was no effort in any of Maya’s medical records to rule out any other possibility. She had been seem with this cluster of supposed symptoms at Tampa General Hospital, at Lurie Children’s hospital, and at JHACH, all during 2015, prior to her 2016 visit to JHACH and all three institutions independently recorded not one but multiple treating team members who all noted very significant discrepancies in what Maya and her mother reported and what they were able to observe. These discrepancies included every category and every individual symptom reported by Maya and her mother.
Coming to a diagnosis when faced with this situation takes a long period of observation in trying to come to an actual diagnosis of the exact cause of Maya’s symptoms. We know that there is no organic reason for what is going on and certainly it’s not CRPS. But to say what exactly is the absolute cause, would take time to determine.
There is no note whatsoever in Kirkpatrick or Hanna’s records to indicate they were even aware of the opinions of the other institutions. If they had, I believe they would have begun to question their diagnosis of CRPS. It is clear that something else is going on. No, they did not pursue any other ideas, at least according to their notes.
Between October 2016 and Jan 2017 there was improvement in Maya’s condition from her stay at JHACH. First, her symptoms didn’t get any worse in spite of her drug therapy being pruned down considerably. She was more functional on discharge than on admission, able to propel her wheelchair, able to support her weight standing with assistance, she was able to do things with her arms such as reaching for things, which she was not doing prior to admission.
I did not see any area or symptom that was made worse, and no areas where loss of functionality happened. No injury caused whatsoever.
Looking at photos. These all go to Maya’s supposed symptoms.
First is the photo of something the family (and Dr K and Dr H!!) insists is called a “CRPS lesion” (try looking this up on the internet, there is no such thing) Dr Crane says this is a scratch. It’s on her forehead.
There is no such thing as CRPS lesions. There are skin problems that occur with CRPS. When there is a skin injury the injury can become larger because the blood supply to the skin is so poor. So, it can take a long time for skin injuries to heal. But these are not called “lesions” and it can be any kind of injury to the skin. Nutrients are not arriving at the part of the skin that is damaged. There are also patches of abnormally colored skin.
CRPS does not occur on the face. You can see this scratch is red/pink it has good blood flow, which is obvious. This is not CRPS. It’s a linear thing, looks exactly like a scratch.
Next exhibit. Photo of Maya with Santa Claus – Before her symtpms began. She’s happy, the position of the feet. She’s holding the left foot up at 90 degrees. Her right foot is dropped down with gravity. The point of the photo is that just because a foot is pointed down does not mean it’s an abnormality. This is prior to any complaint of symptoms and her foot is pointing down.
Next exhibit -This is dated July 30, 2015. She supposedly had a broken ankle prior to July 4th, several weeks before that. In the photo she is being picked up by an adult maile. Supposedly both arms and both legs have CRPS pain including allodynia. But he’s carrying her, she’s smiling in spite of the fact that he’s touching all the areas that supposedly hurt so bad. She is wearing socks, which she would not be doing if she had CRPS pain in her feet or ankles. She is smiling widely. His fingers are even pressing into her skin, which in the hospital she would scream at anyone touching her lightly. Her feet are pointed down a little bit, because of gravity not because of dystonia.
Exhibit – July 6, 2016. She’s in a wheelchair. She is holding her arm up against gravity, meaning she had strength in her arm. According to Hanna’s notes she had dystonia so badly her feet were in a fixed position. (There are several photos of Maya when she’s turning her feet in severely. This is the one symptom that is hard for me to believe that she’s not faking it on purpose. When she is distracted she forgets to point her feet in).
Exhibit – Aug 28, 2016. Once again this is during the time Maya is being treated by Dr Hanna. She is in a wheelchair, but she has her legs completely folded underneath her and she’s sitting on her legs. She looks happy,. If she had dystonia as Dr Hanna claims she has, she would not be able to fold her legs into that position with dystonia.
Exhibit – Aug 31, 2016 Her right hand is holding a flower and it’s being help up, against gravity. So, she is able to use the muscles of the right hand. Her feet are perfectly straight, not turned in at all perfectly normal position. Hanna’s notes during this time period is that Beata is reporting that Maya’s feet are in “fixed dystonic position” but clearly they are not.
Exhibit – Aug 16, 2016. This is a photo of Maya during a treatment at Dr Hanna’s office. You can se the monitoring stickers, tubing, she has a teddy bear lying close enough to her to be touching her body that supposedly is so sensitive it can’t be touched. Her right arm is bent at the elbow and all the way up, her hand is near her shoulder. Her mouth is open, she is clearly under unconscious. Breathing on her own. Likely on a ketamine infusion, more than “sedated”. It seems clear that she is not going to respond to sound or movement.
He has seen Dr Wassenauer’s (her primary care doctor) records since discharge from ACH. She has recovered full function since discharge. He does not believe she had CRPS to begin with, but even if she did, considering that she was recovered prior to reaching age 11 he has never seen anyone at that age ever have any recurrence of CRPS once they have remission, which, IF it was CRPS, she definitely went into remission. He believes the only medical needs she has are a need for a mental health professional.
Mr K seems also to have found that same juror that Maya has been smiling at, he looks over and does that same thing. I did not listen to anything about jury selection but I understand there were 12 seated. So half of them are going away, in Florida civil trials have 6 jurors that deliberate.
Plaintiff questions
Tried to bully Dr Crane, he was having none of it
Tried to put words into Dr Crane’s mouth, he was having none of it
Those were pretty much the two things Mr Anderson tried. This witness ate him for lunch and Anderson gave up and sat down.
No points made by plaintiff on this witness, just reinforced the points he made on direct
Jury questions
(really curious as to how the jury responds to this witness. He was exceptional for the defense, answered fully and really left no doubt that his opinions were well founded based on the records, and he flat out does not believe Maya has CRPS. He was most definitive about this. He did not mention everything that I have put in my comments about why I do not believe she has it, but he made many of those same points to this jury)
1. How is Maya doing after her discharge from JHACH? She’s doing very very well. Looking at PT notes she went in 6 months from wheelchair bound to fully walking around, no pain complaints, I understand today she is doing well, in athletics, she’s doing wll
2. What are withdrawal symptoms from ketamine? Talks about tolerance, why someone needs more and more like Maya did. The withdrawal symptoms are the opposite of what you get with using the drug = so, they feel pain, they get diarrhea, they get wired, the opposite of sedation. Same is true of withdrawal for every drug. They will beg for ketamine after they have had it for a while, they are anxious, etc. There is no question they get addicted, you can tell by how they act
3. Is it possible that the “symptoms” of CRPS (LOL) that Maya had were actually withdrawal symptoms? Good question, that was one of my hypothesis. She was agitated, screaming for ketamine, and it is quite possible she was addicted and wanted that drug (that’s the same thing I was wondering myself)
4. What is the half life of ketamine? He would dhave to look it up, probably the same as morphine, 2-3 hours
5. We have heard from physicians that all assessed Maya did not note always temperature changes, color changes, or asses her skin or other things on the Budapest criteria. Can you make an assessment that Maya did not have CRPS (He DID make that assessment) without seeing her yourself? He talks about how temperature and color changes are checked. He did not see any of these or have any idea how Dr Kirkpatrick and Dr Hanna checked various things but he highly suspects that wasn’t done. (I think he doesn’t want to say that Dr K is running a whole clinic for what would be a true population of about 2 people, meaning he has to diagnose a shitload of people who don’t have it to keep a specialty CRPS clinic open in Sarasota Florida. He kind of alluded to that somewhat during direct, but I think he’s trying to stay away from saying they are quacks, which is what they are)
6. You said many times that Maya doesn’t have CRPS, but also you didn’t examine her. How can you come to this conclusion? I’ve seen 1,000 to 2,000 cases of CRPS. You know it when you see it. When you don’t see the symptoms you know those symptoms are there. It’s like if you told me someone was an amputee but I looked at them and they have all of their limbs, they aren’t an amputee. It didn’t look like CRPS in videos and photos, it didn’t sound like CRPS by description, there were emails that Maya’s mother wrote to herself but in Maya’s voice similar to the blog that she was putting out, I don’t know if that is something that you’ve seen, but she’s saying “she’s the youngest patient in the world ever to have total body CRPS” then she said “she’s the youngest person ever to get a ketamine coma”. There are no records of whole body CRPS. Wha are the odds that she is the only person in the world to ever get this “whole body” CRPS. It’s a regional pain syndrome, (I wish he would remind them of something he said during direct, which is that she didn’t have as many symptoms as were attributed, no dystonia, and also if it was dystonia it takes years to develop. Also, it would take years for the pain to transfer to a different limb from the one it started in, much less the whole body)
7. Is there any medical oversight to ketamine dosing? I’m not sure what is meant by medical oversight, except that most hospitals specify an acceptable range, insurance won’t authorize doses above a certain amount (which is why Maya had the GoFundMe to pay for her treatments). I am on a Listserv and sometimes people ask for advice on using ketamine. At Stanford we have some of the most liberal standards for ketamine that I’ve seen, and we wouldn’t give anywhere close to what Maya was getting. Hospitals have policies and procedures. If I was to write an order for more, the nurse wouldn’t do it, and they would pull out the policy and would not do it.
8. Is it common for a diagnosis of CRPS to be questioned by physicians. We honor patients and people, but a diagnosis is an “idea”. And it can be wrong. Especially in a situation where another doctor is suggesting that the only treatment should be huge amounts of a potentially dangerous drug. (people get second opinions all the time) In Maya’s case, the pain specialists were saying this just does not look like CRPS. So then you have to take a step back and ask what else could that be.
9. Does the diagnosis of CRPS automatically raise questions of psychiatric condition? No, not at all.
10. Do you require IQ tests to accept enrollment in your pain clinic? No, not at all (I guarantee you the real reason Nemours refused to take Maya inpatient was because they saw this freaking lawsuit coming a mile away and didn’t want anything to do with it. The hospital sent their records. Their records talked about Beata and Maya’s behavior. Nemours wasn’t going to touch that with a 10 foot pole. That’s why they said “outpatient only” for Maya. The flat out refused to take her inpatient)
11. What part does IQ play in pain treatment. None, we treat children who are congnitively impaired. It can be challenging, but we do it and we don’t treat them different.
12. If it was whole body CRPS would they experience pain from a charm bracelet, anklet, pulling hair back in a pony tail, makeup application? Yes, they would. Adult women with CRPS don’t shave their leg if they have it on a leg, it hurts to drag a sock over it, they don’t wear jeans, they wear shorts or a dress 365 days a year
13. Has any CRPS case reoccurred at your center? Yes
14. At what age? It’s never reoccurred in a child at Maya’s age. Those are our favorite to treat because if they are treated appropriately by that age it does not come back. Complete remission. Teenagers reoccur much more frequently. Adults rarely ever go into remission. (I hope he talks about what remission really is. Not one good day, two bad days, 4 good days, one bad day, etc. That is what Maya claims.
15. What was the length of occurrence between symptoms? He is answering about how long it takes for onset of symptoms after injury. He says it’s days, sometimes possibly a couple of weeks if it’s an injury that takes a very long time to heal. It onsets during healing, not after. He describes the ankle scenario exactly the way I described it in a previous post. He says 5 days at the most for an ankle injury to turn to CRPS pain. In terms of recurrence it can be 6 months to a couple of years (again, not good ay bad day kind of thing)
16. Has it ever been a standard of care for 25 mg/kg. He says not even for use as a general anesthetic would you use a dose that high. (we saw a photo of Maya inr Hanna’s office, she was “out cold” with mouth open and he commented that she would probably have not responded at all if you tried to talk to her. She was actually under anesthesia during her ketamine treatments.
17. In CRPS the final requirement to rule out other things, are these directives in conflict here? They were in conflict with what Dr Hanna or Dr Kirkpatrick did. He states that he saw not evidence that either of these physicians were given any records from any previous doctors that had seen Maya. If they had, they should have been able to see her onset of symptoms doesn’t match CRPS (ha ha just like I’ve been saying). The notes from previous doctors are very telling. The symptoms came and went, CRPS doesn’t, what they wrote in their charts was different than what was being reported. When the child is in the bathroom fixing her hair, putting on makeup and then sits on the bed and when the nurse comes in she can’t even lift her arms to put a pill into her own mouth 15 minutes after applying makeup there is something wrong there. It raises red flags. That is not how CRPS works, and that should raise questions about the diagnosis.
18. Hanna says the stay at JHACH was an “interruption in treatment”. What was the presumed conclusion of the dosage of ketamine? It was too high by at least 10-fold. In the ER at JHACH they gave her 3 mg/kg which is a high dose and that did not stop her from screaming and thrashing. Nobody could feel comfortable going higher than that, reasonably. He agrees that it was an “interruption in her therapy” and says “and that is a GOOD THING!”. (LOL) If you look at the overall trajectory of where she was by the following summer she went from huge doses of ketamine that had no visible effect in her functionality to cutting down all those meds and she started doing great. Why>? Because she wasn’t constantly going through ketamine withdrawal, she was getting Physical therapy, occupational therapy. The point is JHACH put a stop to the drastic ketamine treatments clearly doing no good.
19. Can the CRPS pain starting in a limb radioate to other areas as well>? Yes, it can spread eventually
20. Are most medical treatments temporary if effective? Some are lucky enough to never experience symptoms again, if they are young enough and get proper treatment.
21. CRPS doesn’t usually reoccur if adolescent girls are treated? Isn’t it a lifelong condition although fluctuating in severity over time? In 9,10,11 year olds it doesn’t usually reoccur. Older teenagers will have reoccurance. Almost all adolescents who have CRPS in childhood go on to live normal lives. Adults are the most common to get CRPS and they do not go into remission so for most patients, it’s lifelong. That’s where the “uncurable” comes from. Because most people who get it are adults.
22. You testified Maya was in athletics what was she involved in? He made notes, doesn’t remember off hand. Looking for notes. He can’t find it. Either gymnastics or cheerleading
23. (Oh god. I’m not going to try to write this out. This question is a juror trying to blame the hospital for giving Maya drugs that made her behave the way she behaved. I have noticed that the juror that seems to be gunning for the plaintiff gets more and more offensive as the evidence gets more and more favorable to the defense. The look on the doctor’s face is priceless) He starts talking about the drugs and saying these should sedate most kids. It would be very unusual for these drugs to cause her to thrash about, it would have the opposite affect. He says the amounts they gave her would not have made her “pass out” she would be responsive, but just not acting out. She needed to be calmed down, she was disrupting the entire environment by screaming
24. You said that intrathecal pump is too dangerous a procedure. Who should make that decision, you or the patient? Not the patient, for sure. We don’t let a patient come in and say “take out my appendix or I need you to cut out half my lung”. Intrathecal pumps are often used for cancer patients and we don’t have to worry about what the effect is 2 years from now because by the time they get this, they are likely going to be gone in 6 months. Maya did not have any condition that was terminal. Spinal meningitis is a real possibility with an intrathecal pump. It is not taken lightly.
25. Is CRPS or the Budapest criteria call for once CRPS appear they are continuous for life or until cured or can they come and go? The physical observation diminished during therapy over time. All those symptoms go away and once they go away they can get some residual color changes that might stay for a while. The rest of the symptoms go away unless there is a recurrence, then they come back. (I guess he came close to saying it’s not good day/bad day kind of thing. Maya drives me nuts when she claims that. She is using that so she can have a great life, but still get $220 million bucks. I hope the defense asks “good day bad day” question)
26. I am not aware that she had any difference in any leg for color or temperature
27. It seems very drastic to me to meet the Budapest criteria. (No shit, Sherlock. It’s RARE) The criteria inolve several categories. You don’t have to have them all, you can have one and ot the other, but usually have both because the vascular symptoms are all because of blood flow. So, they usually go hand in hand. The Budapest are very useful, they are not carved in stone, sometimes very early they do not yet have full symptoms, but you can tell early on sometimes anyway
28. Is the government standard the only “allowed” or “right” treatment? Almost nothing we do is FDA approved in children. Most have not been approved for children so we do use them off label
29. Titration term – with many drugs more may be needed to have the same benefit over time? Is ketamine the same? That’s different than titration. Tolerance is when you use a drug over time you get tolerance so more is needed to get the same effect. Neurontin, Gabapentin you can’t give 1800 mg right away because of terrible side effects, so you titrate up from smaller doses until you get to the dosage that works for that patient.
30. Is ketamine coma not FDA approved? It’s not FDA approved, but that is NOT why it is not used
31. Per other medical witnesses it is approved in other countries, is that correct? Mexico doesn’t have an agency like FDA, there is no such thing as approved or not approved. Europe has a body like the FDA, don’t know what te status of ketamine is and how it’s use is approved or not. There is no law against doing it here, you don’t get arrested or fined for using drugs off label in the USA. We don’t do it because it’s not effective and it’s dangerous. That’s why Dr Cantu told Maya’s family there is a 50% chance she could die during treatment
32. You stated that you at times use ketamine in low doses is that true? Yes
33. Is it like chlorine treatment keeping the pool clean, so wouldn’t a high dose be like a shock treatment for a pool and have it’s uses as well? As a general rule, more is not better. If you give 200 mg of penicillin to someone isn’t 2000 mg better, the answer is no. The higher you go, the more toxicity you have, the more danger you have. Shock treatments to the body, no, it’s not better and doesn’t make sense.
34. In 2016 was CRPS a well understood ailment? Yes
35. In 2016 was CRPS a curable illness? We don’t know the exact cause of it. We know changes in spinal chord, changes in body, we don’t know why it happens, why it’s 8 times more common in females. WE see it we know it, we know how to treat it, var from perfect. It’s not curable. It’ can go into remission, hopefully for a long time in some patients. Except for in very young, like Maya’s age I have never seen it recur in someone that age once it goes into remission.
36. In 2023 is CRPS now a well understood ailment? Not any more than in 2016, it’s a confusing syndrome
37. In 2023 is there a medication or drug to cure it? No, I wish there were.
Plaintiff follow up
You said JHACH had weaned her off most of the drugs? No, I said many of them
Discharge summary – She’s obviously going to remain on her allergy medications because she came in with allergies, she will always probably take those. The rest are multivitamins not medications and it will be up to her pediatrician to determine when or if she would stop taking those. What she was on for pain or “CRPS” was pregabalin instead of the ketamine and opioids. And that’s it.
No,no what you told the jury that her allergies were better. No I did not. Looks like thre are 14 different substances listed. He says some are drugs and most are vitamins and none of the pain medications she was taking are on that list.
You were telling us the ketamine coma is highly dangerous. Did you know that in 10 years not a single injury or death has occurred? Well, he’s doing this in Monterrey, Mexico, there is no records for us to know anything about how many have been treated, or what the outcome is. Record keeping is very ppor in this respect. Mr Anderson says “he’s just throwing bodies away” judge didn’t like that.
As to Dr Hanna are you aware he has treated 18,000 CRPS patients with ketamine. Dr Crane says he flat out doesn’t believe him. He worked in a worldwide pain clinic with people coming from all over he world and they did not see 18,000 CRPS patients in 40 years. This is a rare condition.
Let’s just say if he comes in and testifies and says that, wouldn’t with that many patients there would be one or two bad results. What bad results have you seen from either Dr Cantu or Dr Hanna’s infusions? In Dr Cantu’s hands, Maya developed a multi-microbial pneumonia requiring antibiotics and that type of pneumonia can be life threatening. Notes indicate she may have aspirated, one time she vomited with the indotracheal tube in and there is a notation as well as Beata’s emails indicate the nurses had to jump in and suction it all out, suction out her tracheal tube, this may even have been the source of her pneumonia for all I know. But a multi-microbial means several types of microbes – this is not trivial it is very dangerous. I can’t say she cam to no harm. As far as Dr Hanna he was giving her humongous doses of ketamine, she was LOSING weight, (a 10 year old losing weight like a drug addict) she had abdominal pain, again, I can’t say there was no harm from that.
No, I was asking you about statistics! Whether you had any statistics or reports. Let’s leave your view of Maya aside, do you have any statistics or reported cases indicating the treatment they were using caused injury or death? (LOL, he only has info about Maya and he said they caused her harm) Are you asking me if Dr Cantu or Dr Hanna reported their problems? Did anyone come forward with any reports? I did not go after them I am not a detective, how would I know the answer to that question, I haven’t checked court records to see if anyone has sued them, I haven’t checked police reports or anything like that. (Mr Anderson should have remembered this is the witness that left Anderson’s mouth gaping open like a puffer fish earlier) I have no idea if anyone made a claim to a medical board.
He never heard the term “suicide disease”. One patient, 30 year old, died many months after treatment in the clinic where Dr Crane works. She overdosed on ocycontin, we did not write that prescription and it was not established for certain that she overdosed on purpose. He asks “didn’t you have three other suicides?” Dr Crane says unequivocally absolutely not.
Ketamine is FDA approved and there is no upper limit to it’s used. It’s approved as an anesthetic. Can be titrated to what is needed for anesthesia. During surgery the goal is to have the patient lose consciousness.
Anderson is arguing that ketamine was not responsible for pneumonia. Dr Crane says that the ketamine is why she had to be intubated. The ketamine rendered her unable to breathe correctly to protect her airway from aspiration, therefore the tube was put in for that. The ketamine, she wouldn’t have needed the tube, she wouldn’t have aspirated because her airway would have been under her normal control. How many patients have you intubated? Many thousand. Bacterial infections can happen when patients are on ventilators because they cannot cough effectively and clear secretions. Intubation in and of itself is an accepted medical procedure. He doesn’t have clear enough records to say how long the infection took to clear. Insufficient information to answer that.
Withdrawal symptoms from ketamine. Does not directly affect opioid receptors in the brain. Ketamine withdrawal can cause person to be anxious and agitated (exactly like Maya was acting) Elevated blood pressure or heart rate might be possible. Children don’t usually tell you they are agitated, you can see it. They don’t say they feel agitated, they may act agitated. They kept her on Haldol for four weeks to help with agitation.
Excused.
Impressive credentials, appropriate for anesthesia pain management and specifically pediatrics, pediatric critical care, focused practice on pediatric pain management more than 20 years
I was hoping the defense would have someone who looked at ALL Maya’s medical records. This man was probably paid a fortune, and he earned it. He had all of Maya’s medical records and was well prepared to discuss in details what he thought of Maya’s various treatments, how she responded (or didn’t ) to those treatments and whether they conformed to standard of care IF she had CRPS and also opined that she did NOT have CRPS in his opinion and he detailed why not. A very impressive witness who blew a truck through the plaintiff’s case, IMO.
During the time Maya was treated he was working exclusively in pediatric pain management. Very familiar with CRPS, diagnosing and treatment. They treat mostly chronic pain, but sometime post op acute pain. Wide spectrum of different pain problems, cancer, CRPS is one of the most common, fibromyalgia, congenital birth defects, all kinds of pain. FND is something that he sees from time to time, functional abdominal pain, pain is not “in their heads” but it may be amplified by psychological factors
He has contributed significantly to chronic pediatric pain literature. Lectures, lectured on CRPS somewhere around 200 times, made a number of video lectures on CRPS, pain management, over 79 peer reviewed articles on pediatric pain management, explains what peer reviewed means.
He reviewed medical records from virtually every doctor and hospital Maya visited from 2015 – 2017, Mr Hunter lists each of them, he responds yes to all of them, except unsure about the school board records, includes physicians and psychiatrist. He says he also reviewed log entries, emails, and blogs by Beata. Reviewed photos and videos from various times in Maya’s life
CRPS – cause is unknown, involves typically a leg or an arm. In kids it’s typically a leg, in adults it’s often an arm. It follows surgery or a seemingly trivial injury. It occurs very soon after the injury. The pain morphs from the “normal” pain from that injury to a burning neurological pain. The skin becomes very sensitive, can’t stand air from a fan touching the skin. Other symptoms evolve over time, it can take up to 2 years for some of the symptoms to appear. Usually a person will end up going to a neurologist or pain management doctor as the pain is the first symptom to appear.
We get patients from all over the world so we see more CRPS than most clinics.
There is no such thing as all over CRPS. Never has there been recorded such a case. It starts in a limb.It can spread, but not right away, after months or even years it can spread to another limb. But it doesn’t spread to other parts of the body.
The foundation of treatment is PT/OT/CBT, psychotherapy. Everything else we do is only useful s much as it supports the PT and OT. If they can’t tolerate PT then we use pain medications to allow them to tolerate the therapy. We might also do a nerve block to help reduce the pain so they can tolerate the therapy. It’s effective only for a short period of time (nerve block for CRPS case).
Ketamine can be used in low dose amounts. At Stanford we use this only for cases that don’t respond to normal therapy. So, normal therapy takes at least 10-12 weeks, so we would not use ketamine before a full course of 12 week therapy and the patient cannot get relief. In that case they will be hospitalized and given a 4-5 day low dose ketamine treatment. Our max is 1 mg/kg per hour. That is a high dose. We start in the range of .3 mg/kg per hour.
An anesthetic dose would be about 1-2 mg/kg (27 mg for someone the size of Maya) will anesthetize someone enough to do surgery. Asking him about Kirkpatrick and Hanna gets a sidebar.
He gives the numbers, Hanna was using up to 30 mg/kg per hour. Significantly more than Stanford would use.
Maya reported significant pain, inability to use her legs, arms, behavior often screaming – attributed to pain, periods that her pain seemed to be less, then severe pain again, then less. But from summer of 2015 to fall of 2016 she was not better and significantly worse. By the time Oct 2016 came around she said she could not lift her limbs, screaming, could not be touched
At Kirkpatrick’s initial involvement was his treatment within standard of care for pediatric CRPS. No, not within standard of care. Ketamine is normally reserved for refractory pain, that will not respond to other treatment. Pt/OT.Psychotherapy. His very first treatment was ketamine, it was very premature. Also, it was significant doses, in violation of standard of care in terms of record keeping.
He was giving anesthetic doses, not keeping proper records, skeletal record keeping, no notation of vital signs. It violated standard of care for any anesthesiologist utilizing ketamine in the dosage range he was using. She as essentially being put into a light stage of anesthesia by Kirkpatrick right from his initial treatment.
Was there any harm as a result? There was no direct harm to Maya, she didn’t have any side effects. And her pain was diminished for short periods of time. The main harm that was done, was instead of getting her the standard of care treatment for pediatric CRPS, he was giving ketamine. Someone Maya’s age typically gets a single round of 12 week treatment and never has any symptoms ever again. So, she wasn’t directly harmed by his dosage of ketamine, but deprived her of what would have been a relatively short period of treatment for what is almost always for a 10 year old girl the full amount of treatment they will ever need, IF she had CRPS.
There was no adequate trial of any other treatment. Girls Maya’s age are the easiest to treat for CRPS. They never recur in a child that age if you treat them with the specified standard of care for 10-12 week period. Once they reach teen years it becomes harder, but not as hard as adult onset CRPS. A teenager will often have decent results in treating CRPS and in getting to remission. But they will be more likely to have a recurrence at some point, where a 10 year old child never will have a recurrence after initial treatment. An adult pretty much never will go into remission, so that is the worst case, we can only manage the symptoms for an adult.
Because it didn’t work, he referred her to Mexico. He called this ketamine coma. It’s not a real coma, it’s general anesthesia. So, the patient is unresponsive during the whole treatment. It’s not actually what would be properly called a medical coma.
He starts the treatment at 3 mg/kg/hr and then goes up to 5 or 6 mg/kg/hr which results in complete anesthesia. For that reason, he has to treat the patient just like we treat someone under general anesthesia for surgery. They have a breathing tube placed, they have vital signs monitored, mechanical ventilator is used, nutition has to be administered by tube. They are under a prolonged general anethetic for 5 days.
This does not meet the standard of care for treating pediatric CRPS in the united States, not done anywhere in the USA.
Did the treatment rendered in Mexico successful? No, there was no sustained benefit. Within 3 or 4 weeks she was needing another treatment, her pain returned. In contrast, even low dose ketamine has a better outcome that these higher doses and will keep a patient pain free for longer
After seeing Dr Cantu, she saw Dr Hanna? Yes. His treatment started Dec 2015 until Oct 2016, nearly a year. His treatment involved infusions over several days in ever increasing doses. He started around 3 mg/kg/hr and because Maya was reporting continuation of her symptoms he had to continue giving these treatments frequently. Because of the excessive doses of ketamine, she had actually lost weight, she had no appetite, she was in the 1 percentile for weight for her age, meaning 99% of kids her age weighed more than she did. It’s significant that she actually lost weight, she should have been gaining weight. She had terrible abdominal pain. And she had had episodes of abdominal pain throughout his treatments, based on his records. His records also showed virtually no improvement whatsoever from those treatments. He was reporting she had the same symptoms every time she came to see him and in less than a years time she visited him for 55 four day infusions.
This was not in any way successful treatment. I believe he knew that he could not give her more ketamine, he had maxed out, she was not getting better, and out of desperation he sent her to JHACH. He basically bailed out of treating her.
It did not comply with standard of care for treating pediatric CRPS. And there were several factors. The glaring problems, including the massive doses, just like Kirkpatrick there was insufficient monitoring of her vital signs, inadequate record keeping, which violated the standard of care for an anesthesiologist. She was receiving actual general anesthesia doses from Dr Hanna. The reason for monitoring vital signs is for patient safety.
Was there injury or harm as a result of the course of therapy from Dr Hanna? Yes, there was harm. She was developing complications, weight loss, loss of appetite , there was no other obvious possible cause of the weight loss and appetite loss in her records. Also because he denied her the opportunity for effective treatment IF that is what she had.
Patient admission to JHACH – have you reviewed the entire record? Yes. The care that was rendered during that admission complied with the standard of care. There were so many things that were done for Maya in the hospital.
First she came with a complaint of abdominal pain. The ER physician noticed immediately that her symptoms did not correspond to her physical examination, so there was a discrepancy there. They realized that some of the symptoms they were seeing were complications of those large doses of ketamine, and she needed to be hospitalized to care for those.
In the intensive care unit they needed to put her back on the ketamine because she was essentially having withdrawal from each of the treatments as soon as he finished those treatments. And she had just had the largest treatment from him, so she needed to be put back on the ketamine in order to them wean her slowly down from it and ease her symptoms.
The fact that she could still be awake on those amounts, means that she had developed a tolerance for those high doses. This is why he had to keep giving her more and more. This violates what I call the rule of holes, which is when you are in a hole, stop digging.
He was actually making her more and more dependent, major physical dependency in a controlled fashion. At that point they still needed to evaluate for exactly what was causing the abdominal pain. And then while she was still in ICU, they had to deal with her mother who was telling them she was going to take her back to Dr Hanna for more high dose ketamine treatments.
Sidebar. That was well documented in the records that Beata was threatening to take Maya for more of those treatments. Jury instructed to disregard the last comment (not a comment, it’s a fact)
Was it reasonable for the staff to attempt to wean Maya off? Yes, she had come from Dr Hanna’s office, she was showing signs of dependency, weaning was to prevent her from having withdrawal symptoms.
It was reasonable for them to attempt to transfer Maya to Nemours treatment facility as long as they got her stabililzed first. The priority at the time was to take care of the acute problem, weaning her from dependency
What would have been the appropriate treatment at the time? Can’t treat without a diagnosis. I believe it was becoming increasingly clear to them that she did not actually have CRPS, so they really needed to try to diagnose her properly.
Sidebar. The diagnosis indicated that CRPS was reported as the diagnosis, that is not the same as saying that ACH diagnosed her with CRPS. Dr Crane says he does not believe she had CRPS.
I didn’t see anything consistent with a diagnosis of CRPS. Except just the report of pain, but lots of conditions have pain. By itself it does not denote CRPS.
Looking at her history, she did not present as a patient that has CRPS. She did not meet the criteria for this diagnosis. He talks about the Budapest Criteria. There ae a number of symptoms that are divided into different areas. It’s a very difficult diagnosis to make and the same combination of symptoms can be something entirely different from CRPS. So only if there is a constellation of these symptoms and there is no other diagnosis that fits, can you say it is CRP
Features of the affected limb such as the color and temperature of the affected limb as opposed to the opposite limb. In the very earliest phases of the condition, the area is red, but it can morph into blue/purple or almost a bruise like skin appearance covering a large area. There are secondary changed to the skin in terms of hair or nail growth. So, the fingernails on an affected arm or hand may grow very fast or stop growing.
There are motor abnormalities such as tremors and dystonia. There are a list of symptoms that the patient should be experiencing, and a list of observable conditions a physician should see. And, if there is another possible diagnosis, it Is not CRPS.
There was no effort in any of Maya’s medical records to rule out any other possibility. She had been seem with this cluster of supposed symptoms at Tampa General Hospital, at Lurie Children’s hospital, and at JHACH, all during 2015, prior to her 2016 visit to JHACH and all three institutions independently recorded not one but multiple treating team members who all noted very significant discrepancies in what Maya and her mother reported and what they were able to observe. These discrepancies included every category and every individual symptom reported by Maya and her mother.
Coming to a diagnosis when faced with this situation takes a long period of observation in trying to come to an actual diagnosis of the exact cause of Maya’s symptoms. We know that there is no organic reason for what is going on and certainly it’s not CRPS. But to say what exactly is the absolute cause, would take time to determine.
There is no note whatsoever in Kirkpatrick or Hanna’s records to indicate they were even aware of the opinions of the other institutions. If they had, I believe they would have begun to question their diagnosis of CRPS. It is clear that something else is going on. No, they did not pursue any other ideas, at least according to their notes.
Between October 2016 and Jan 2017 there was improvement in Maya’s condition from her stay at JHACH. First, her symptoms didn’t get any worse in spite of her drug therapy being pruned down considerably. She was more functional on discharge than on admission, able to propel her wheelchair, able to support her weight standing with assistance, she was able to do things with her arms such as reaching for things, which she was not doing prior to admission.
I did not see any area or symptom that was made worse, and no areas where loss of functionality happened. No injury caused whatsoever.
Looking at photos. These all go to Maya’s supposed symptoms.
First is the photo of something the family (and Dr K and Dr H!!) insists is called a “CRPS lesion” (try looking this up on the internet, there is no such thing) Dr Crane says this is a scratch. It’s on her forehead.
There is no such thing as CRPS lesions. There are skin problems that occur with CRPS. When there is a skin injury the injury can become larger because the blood supply to the skin is so poor. So, it can take a long time for skin injuries to heal. But these are not called “lesions” and it can be any kind of injury to the skin. Nutrients are not arriving at the part of the skin that is damaged. There are also patches of abnormally colored skin.
CRPS does not occur on the face. You can see this scratch is red/pink it has good blood flow, which is obvious. This is not CRPS. It’s a linear thing, looks exactly like a scratch.
Next exhibit. Photo of Maya with Santa Claus – Before her symtpms began. She’s happy, the position of the feet. She’s holding the left foot up at 90 degrees. Her right foot is dropped down with gravity. The point of the photo is that just because a foot is pointed down does not mean it’s an abnormality. This is prior to any complaint of symptoms and her foot is pointing down.
Next exhibit -This is dated July 30, 2015. She supposedly had a broken ankle prior to July 4th, several weeks before that. In the photo she is being picked up by an adult maile. Supposedly both arms and both legs have CRPS pain including allodynia. But he’s carrying her, she’s smiling in spite of the fact that he’s touching all the areas that supposedly hurt so bad. She is wearing socks, which she would not be doing if she had CRPS pain in her feet or ankles. She is smiling widely. His fingers are even pressing into her skin, which in the hospital she would scream at anyone touching her lightly. Her feet are pointed down a little bit, because of gravity not because of dystonia.
Exhibit – July 6, 2016. She’s in a wheelchair. She is holding her arm up against gravity, meaning she had strength in her arm. According to Hanna’s notes she had dystonia so badly her feet were in a fixed position. (There are several photos of Maya when she’s turning her feet in severely. This is the one symptom that is hard for me to believe that she’s not faking it on purpose. When she is distracted she forgets to point her feet in).
Exhibit – Aug 28, 2016. Once again this is during the time Maya is being treated by Dr Hanna. She is in a wheelchair, but she has her legs completely folded underneath her and she’s sitting on her legs. She looks happy,. If she had dystonia as Dr Hanna claims she has, she would not be able to fold her legs into that position with dystonia.
Exhibit – Aug 31, 2016 Her right hand is holding a flower and it’s being help up, against gravity. So, she is able to use the muscles of the right hand. Her feet are perfectly straight, not turned in at all perfectly normal position. Hanna’s notes during this time period is that Beata is reporting that Maya’s feet are in “fixed dystonic position” but clearly they are not.
Exhibit – Aug 16, 2016. This is a photo of Maya during a treatment at Dr Hanna’s office. You can se the monitoring stickers, tubing, she has a teddy bear lying close enough to her to be touching her body that supposedly is so sensitive it can’t be touched. Her right arm is bent at the elbow and all the way up, her hand is near her shoulder. Her mouth is open, she is clearly under unconscious. Breathing on her own. Likely on a ketamine infusion, more than “sedated”. It seems clear that she is not going to respond to sound or movement.
He has seen Dr Wassenauer’s (her primary care doctor) records since discharge from ACH. She has recovered full function since discharge. He does not believe she had CRPS to begin with, but even if she did, considering that she was recovered prior to reaching age 11 he has never seen anyone at that age ever have any recurrence of CRPS once they have remission, which, IF it was CRPS, she definitely went into remission. He believes the only medical needs she has are a need for a mental health professional.
Mr K seems also to have found that same juror that Maya has been smiling at, he looks over and does that same thing. I did not listen to anything about jury selection but I understand there were 12 seated. So half of them are going away, in Florida civil trials have 6 jurors that deliberate.
Plaintiff questions
Tried to bully Dr Crane, he was having none of it
Tried to put words into Dr Crane’s mouth, he was having none of it
Those were pretty much the two things Mr Anderson tried. This witness ate him for lunch and Anderson gave up and sat down.
No points made by plaintiff on this witness, just reinforced the points he made on direct
Jury questions
(really curious as to how the jury responds to this witness. He was exceptional for the defense, answered fully and really left no doubt that his opinions were well founded based on the records, and he flat out does not believe Maya has CRPS. He was most definitive about this. He did not mention everything that I have put in my comments about why I do not believe she has it, but he made many of those same points to this jury)
1. How is Maya doing after her discharge from JHACH? She’s doing very very well. Looking at PT notes she went in 6 months from wheelchair bound to fully walking around, no pain complaints, I understand today she is doing well, in athletics, she’s doing wll
2. What are withdrawal symptoms from ketamine? Talks about tolerance, why someone needs more and more like Maya did. The withdrawal symptoms are the opposite of what you get with using the drug = so, they feel pain, they get diarrhea, they get wired, the opposite of sedation. Same is true of withdrawal for every drug. They will beg for ketamine after they have had it for a while, they are anxious, etc. There is no question they get addicted, you can tell by how they act
3. Is it possible that the “symptoms” of CRPS (LOL) that Maya had were actually withdrawal symptoms? Good question, that was one of my hypothesis. She was agitated, screaming for ketamine, and it is quite possible she was addicted and wanted that drug (that’s the same thing I was wondering myself)
4. What is the half life of ketamine? He would dhave to look it up, probably the same as morphine, 2-3 hours
5. We have heard from physicians that all assessed Maya did not note always temperature changes, color changes, or asses her skin or other things on the Budapest criteria. Can you make an assessment that Maya did not have CRPS (He DID make that assessment) without seeing her yourself? He talks about how temperature and color changes are checked. He did not see any of these or have any idea how Dr Kirkpatrick and Dr Hanna checked various things but he highly suspects that wasn’t done. (I think he doesn’t want to say that Dr K is running a whole clinic for what would be a true population of about 2 people, meaning he has to diagnose a shitload of people who don’t have it to keep a specialty CRPS clinic open in Sarasota Florida. He kind of alluded to that somewhat during direct, but I think he’s trying to stay away from saying they are quacks, which is what they are)
6. You said many times that Maya doesn’t have CRPS, but also you didn’t examine her. How can you come to this conclusion? I’ve seen 1,000 to 2,000 cases of CRPS. You know it when you see it. When you don’t see the symptoms you know those symptoms are there. It’s like if you told me someone was an amputee but I looked at them and they have all of their limbs, they aren’t an amputee. It didn’t look like CRPS in videos and photos, it didn’t sound like CRPS by description, there were emails that Maya’s mother wrote to herself but in Maya’s voice similar to the blog that she was putting out, I don’t know if that is something that you’ve seen, but she’s saying “she’s the youngest patient in the world ever to have total body CRPS” then she said “she’s the youngest person ever to get a ketamine coma”. There are no records of whole body CRPS. Wha are the odds that she is the only person in the world to ever get this “whole body” CRPS. It’s a regional pain syndrome, (I wish he would remind them of something he said during direct, which is that she didn’t have as many symptoms as were attributed, no dystonia, and also if it was dystonia it takes years to develop. Also, it would take years for the pain to transfer to a different limb from the one it started in, much less the whole body)
7. Is there any medical oversight to ketamine dosing? I’m not sure what is meant by medical oversight, except that most hospitals specify an acceptable range, insurance won’t authorize doses above a certain amount (which is why Maya had the GoFundMe to pay for her treatments). I am on a Listserv and sometimes people ask for advice on using ketamine. At Stanford we have some of the most liberal standards for ketamine that I’ve seen, and we wouldn’t give anywhere close to what Maya was getting. Hospitals have policies and procedures. If I was to write an order for more, the nurse wouldn’t do it, and they would pull out the policy and would not do it.
8. Is it common for a diagnosis of CRPS to be questioned by physicians. We honor patients and people, but a diagnosis is an “idea”. And it can be wrong. Especially in a situation where another doctor is suggesting that the only treatment should be huge amounts of a potentially dangerous drug. (people get second opinions all the time) In Maya’s case, the pain specialists were saying this just does not look like CRPS. So then you have to take a step back and ask what else could that be.
9. Does the diagnosis of CRPS automatically raise questions of psychiatric condition? No, not at all.
10. Do you require IQ tests to accept enrollment in your pain clinic? No, not at all (I guarantee you the real reason Nemours refused to take Maya inpatient was because they saw this freaking lawsuit coming a mile away and didn’t want anything to do with it. The hospital sent their records. Their records talked about Beata and Maya’s behavior. Nemours wasn’t going to touch that with a 10 foot pole. That’s why they said “outpatient only” for Maya. The flat out refused to take her inpatient)
11. What part does IQ play in pain treatment. None, we treat children who are congnitively impaired. It can be challenging, but we do it and we don’t treat them different.
12. If it was whole body CRPS would they experience pain from a charm bracelet, anklet, pulling hair back in a pony tail, makeup application? Yes, they would. Adult women with CRPS don’t shave their leg if they have it on a leg, it hurts to drag a sock over it, they don’t wear jeans, they wear shorts or a dress 365 days a year
13. Has any CRPS case reoccurred at your center? Yes
14. At what age? It’s never reoccurred in a child at Maya’s age. Those are our favorite to treat because if they are treated appropriately by that age it does not come back. Complete remission. Teenagers reoccur much more frequently. Adults rarely ever go into remission. (I hope he talks about what remission really is. Not one good day, two bad days, 4 good days, one bad day, etc. That is what Maya claims.
15. What was the length of occurrence between symptoms? He is answering about how long it takes for onset of symptoms after injury. He says it’s days, sometimes possibly a couple of weeks if it’s an injury that takes a very long time to heal. It onsets during healing, not after. He describes the ankle scenario exactly the way I described it in a previous post. He says 5 days at the most for an ankle injury to turn to CRPS pain. In terms of recurrence it can be 6 months to a couple of years (again, not good ay bad day kind of thing)
16. Has it ever been a standard of care for 25 mg/kg. He says not even for use as a general anesthetic would you use a dose that high. (we saw a photo of Maya inr Hanna’s office, she was “out cold” with mouth open and he commented that she would probably have not responded at all if you tried to talk to her. She was actually under anesthesia during her ketamine treatments.
17. In CRPS the final requirement to rule out other things, are these directives in conflict here? They were in conflict with what Dr Hanna or Dr Kirkpatrick did. He states that he saw not evidence that either of these physicians were given any records from any previous doctors that had seen Maya. If they had, they should have been able to see her onset of symptoms doesn’t match CRPS (ha ha just like I’ve been saying). The notes from previous doctors are very telling. The symptoms came and went, CRPS doesn’t, what they wrote in their charts was different than what was being reported. When the child is in the bathroom fixing her hair, putting on makeup and then sits on the bed and when the nurse comes in she can’t even lift her arms to put a pill into her own mouth 15 minutes after applying makeup there is something wrong there. It raises red flags. That is not how CRPS works, and that should raise questions about the diagnosis.
18. Hanna says the stay at JHACH was an “interruption in treatment”. What was the presumed conclusion of the dosage of ketamine? It was too high by at least 10-fold. In the ER at JHACH they gave her 3 mg/kg which is a high dose and that did not stop her from screaming and thrashing. Nobody could feel comfortable going higher than that, reasonably. He agrees that it was an “interruption in her therapy” and says “and that is a GOOD THING!”. (LOL) If you look at the overall trajectory of where she was by the following summer she went from huge doses of ketamine that had no visible effect in her functionality to cutting down all those meds and she started doing great. Why>? Because she wasn’t constantly going through ketamine withdrawal, she was getting Physical therapy, occupational therapy. The point is JHACH put a stop to the drastic ketamine treatments clearly doing no good.
19. Can the CRPS pain starting in a limb radioate to other areas as well>? Yes, it can spread eventually
20. Are most medical treatments temporary if effective? Some are lucky enough to never experience symptoms again, if they are young enough and get proper treatment.
21. CRPS doesn’t usually reoccur if adolescent girls are treated? Isn’t it a lifelong condition although fluctuating in severity over time? In 9,10,11 year olds it doesn’t usually reoccur. Older teenagers will have reoccurance. Almost all adolescents who have CRPS in childhood go on to live normal lives. Adults are the most common to get CRPS and they do not go into remission so for most patients, it’s lifelong. That’s where the “uncurable” comes from. Because most people who get it are adults.
22. You testified Maya was in athletics what was she involved in? He made notes, doesn’t remember off hand. Looking for notes. He can’t find it. Either gymnastics or cheerleading
23. (Oh god. I’m not going to try to write this out. This question is a juror trying to blame the hospital for giving Maya drugs that made her behave the way she behaved. I have noticed that the juror that seems to be gunning for the plaintiff gets more and more offensive as the evidence gets more and more favorable to the defense. The look on the doctor’s face is priceless) He starts talking about the drugs and saying these should sedate most kids. It would be very unusual for these drugs to cause her to thrash about, it would have the opposite affect. He says the amounts they gave her would not have made her “pass out” she would be responsive, but just not acting out. She needed to be calmed down, she was disrupting the entire environment by screaming
24. You said that intrathecal pump is too dangerous a procedure. Who should make that decision, you or the patient? Not the patient, for sure. We don’t let a patient come in and say “take out my appendix or I need you to cut out half my lung”. Intrathecal pumps are often used for cancer patients and we don’t have to worry about what the effect is 2 years from now because by the time they get this, they are likely going to be gone in 6 months. Maya did not have any condition that was terminal. Spinal meningitis is a real possibility with an intrathecal pump. It is not taken lightly.
25. Is CRPS or the Budapest criteria call for once CRPS appear they are continuous for life or until cured or can they come and go? The physical observation diminished during therapy over time. All those symptoms go away and once they go away they can get some residual color changes that might stay for a while. The rest of the symptoms go away unless there is a recurrence, then they come back. (I guess he came close to saying it’s not good day/bad day kind of thing. Maya drives me nuts when she claims that. She is using that so she can have a great life, but still get $220 million bucks. I hope the defense asks “good day bad day” question)
26. I am not aware that she had any difference in any leg for color or temperature
27. It seems very drastic to me to meet the Budapest criteria. (No shit, Sherlock. It’s RARE) The criteria inolve several categories. You don’t have to have them all, you can have one and ot the other, but usually have both because the vascular symptoms are all because of blood flow. So, they usually go hand in hand. The Budapest are very useful, they are not carved in stone, sometimes very early they do not yet have full symptoms, but you can tell early on sometimes anyway
28. Is the government standard the only “allowed” or “right” treatment? Almost nothing we do is FDA approved in children. Most have not been approved for children so we do use them off label
29. Titration term – with many drugs more may be needed to have the same benefit over time? Is ketamine the same? That’s different than titration. Tolerance is when you use a drug over time you get tolerance so more is needed to get the same effect. Neurontin, Gabapentin you can’t give 1800 mg right away because of terrible side effects, so you titrate up from smaller doses until you get to the dosage that works for that patient.
30. Is ketamine coma not FDA approved? It’s not FDA approved, but that is NOT why it is not used
31. Per other medical witnesses it is approved in other countries, is that correct? Mexico doesn’t have an agency like FDA, there is no such thing as approved or not approved. Europe has a body like the FDA, don’t know what te status of ketamine is and how it’s use is approved or not. There is no law against doing it here, you don’t get arrested or fined for using drugs off label in the USA. We don’t do it because it’s not effective and it’s dangerous. That’s why Dr Cantu told Maya’s family there is a 50% chance she could die during treatment
32. You stated that you at times use ketamine in low doses is that true? Yes
33. Is it like chlorine treatment keeping the pool clean, so wouldn’t a high dose be like a shock treatment for a pool and have it’s uses as well? As a general rule, more is not better. If you give 200 mg of penicillin to someone isn’t 2000 mg better, the answer is no. The higher you go, the more toxicity you have, the more danger you have. Shock treatments to the body, no, it’s not better and doesn’t make sense.
34. In 2016 was CRPS a well understood ailment? Yes
35. In 2016 was CRPS a curable illness? We don’t know the exact cause of it. We know changes in spinal chord, changes in body, we don’t know why it happens, why it’s 8 times more common in females. WE see it we know it, we know how to treat it, var from perfect. It’s not curable. It’ can go into remission, hopefully for a long time in some patients. Except for in very young, like Maya’s age I have never seen it recur in someone that age once it goes into remission.
36. In 2023 is CRPS now a well understood ailment? Not any more than in 2016, it’s a confusing syndrome
37. In 2023 is there a medication or drug to cure it? No, I wish there were.
Plaintiff follow up
You said JHACH had weaned her off most of the drugs? No, I said many of them
Discharge summary – She’s obviously going to remain on her allergy medications because she came in with allergies, she will always probably take those. The rest are multivitamins not medications and it will be up to her pediatrician to determine when or if she would stop taking those. What she was on for pain or “CRPS” was pregabalin instead of the ketamine and opioids. And that’s it.
No,no what you told the jury that her allergies were better. No I did not. Looks like thre are 14 different substances listed. He says some are drugs and most are vitamins and none of the pain medications she was taking are on that list.
You were telling us the ketamine coma is highly dangerous. Did you know that in 10 years not a single injury or death has occurred? Well, he’s doing this in Monterrey, Mexico, there is no records for us to know anything about how many have been treated, or what the outcome is. Record keeping is very ppor in this respect. Mr Anderson says “he’s just throwing bodies away” judge didn’t like that.
As to Dr Hanna are you aware he has treated 18,000 CRPS patients with ketamine. Dr Crane says he flat out doesn’t believe him. He worked in a worldwide pain clinic with people coming from all over he world and they did not see 18,000 CRPS patients in 40 years. This is a rare condition.
Let’s just say if he comes in and testifies and says that, wouldn’t with that many patients there would be one or two bad results. What bad results have you seen from either Dr Cantu or Dr Hanna’s infusions? In Dr Cantu’s hands, Maya developed a multi-microbial pneumonia requiring antibiotics and that type of pneumonia can be life threatening. Notes indicate she may have aspirated, one time she vomited with the indotracheal tube in and there is a notation as well as Beata’s emails indicate the nurses had to jump in and suction it all out, suction out her tracheal tube, this may even have been the source of her pneumonia for all I know. But a multi-microbial means several types of microbes – this is not trivial it is very dangerous. I can’t say she cam to no harm. As far as Dr Hanna he was giving her humongous doses of ketamine, she was LOSING weight, (a 10 year old losing weight like a drug addict) she had abdominal pain, again, I can’t say there was no harm from that.
No, I was asking you about statistics! Whether you had any statistics or reports. Let’s leave your view of Maya aside, do you have any statistics or reported cases indicating the treatment they were using caused injury or death? (LOL, he only has info about Maya and he said they caused her harm) Are you asking me if Dr Cantu or Dr Hanna reported their problems? Did anyone come forward with any reports? I did not go after them I am not a detective, how would I know the answer to that question, I haven’t checked court records to see if anyone has sued them, I haven’t checked police reports or anything like that. (Mr Anderson should have remembered this is the witness that left Anderson’s mouth gaping open like a puffer fish earlier) I have no idea if anyone made a claim to a medical board.
He never heard the term “suicide disease”. One patient, 30 year old, died many months after treatment in the clinic where Dr Crane works. She overdosed on ocycontin, we did not write that prescription and it was not established for certain that she overdosed on purpose. He asks “didn’t you have three other suicides?” Dr Crane says unequivocally absolutely not.
Ketamine is FDA approved and there is no upper limit to it’s used. It’s approved as an anesthetic. Can be titrated to what is needed for anesthesia. During surgery the goal is to have the patient lose consciousness.
Anderson is arguing that ketamine was not responsible for pneumonia. Dr Crane says that the ketamine is why she had to be intubated. The ketamine rendered her unable to breathe correctly to protect her airway from aspiration, therefore the tube was put in for that. The ketamine, she wouldn’t have needed the tube, she wouldn’t have aspirated because her airway would have been under her normal control. How many patients have you intubated? Many thousand. Bacterial infections can happen when patients are on ventilators because they cannot cough effectively and clear secretions. Intubation in and of itself is an accepted medical procedure. He doesn’t have clear enough records to say how long the infection took to clear. Insufficient information to answer that.
Withdrawal symptoms from ketamine. Does not directly affect opioid receptors in the brain. Ketamine withdrawal can cause person to be anxious and agitated (exactly like Maya was acting) Elevated blood pressure or heart rate might be possible. Children don’t usually tell you they are agitated, you can see it. They don’t say they feel agitated, they may act agitated. They kept her on Haldol for four weeks to help with agitation.
Excused.
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Taking Care of Maya - FL CPS/Munchausen case
Sorry to hear your mom is having so much troubleRVInit wrote: ↑Tue Oct 24, 2023 11:38 am Big day.
Mom has been super agitated for the last several days, and I'm not able to sit and take notes while listening like I try to do. But I am listening. I was under the impression that the defense would not be putting on a doctor knowledgeable in CRPS.
Well, turns out they DO have a doctor that I'm crossing my fingers on. He seems to have more knowledge than anyone else I've heard on that witness stand. I will write it up when I can. Not finished listening to it yet, I'm behind in time. But he seems like the real deal more than anyone else.
He definitely is puttin' the whoopin' on the plaintiff case.
I appreciate you keeping us up on the story, but don't worry about it when you can't. Your mom is far more important!
Taking Care of Maya - FL CPS/Munchausen case
Hugs for you & your mom.
You can't wait until life isn't hard anymore before you decide to be happy.Taking Care of Maya - FL CPS/Munchausen case
Defense witness – Lisa Breck, RN, pediatric nurse at ACH since spring 1991
Pediatric floor nurse. Coordinate care, provide help with daily care, ADLs, changes in status
I wanted to be a nurse since I was little, at clinicals she really felt like pediatrics would be most fulfilling
She was the floor nurse and also served as charge nurse several periods of Maya’s stay. Did she have good days and bad days? I would say definitely. No different than any other child. Some days are harder or busier than other days for everyone.
Maya complained of pain now and then. Pain is patient specific, if someone tells me they are in pain I am going to be compassionate and try to help with that. She definitely complained of pain on occasion. Nobody ever told Maya in my presence that she was faking it or making it up. That is something that we would never do. Something that might be painful for me might not be painful for you and we recognize that and we do not question the authenticity of pain
While Maya was with us we as a nursing staff tried to bring normalcy of daily routine in her life. Nursing is going to follow the care plan, but we also have the most one on one contact with the patients, so we interact with them more than anyone else. We tried to provide things she could do to make her life a little more normal.
She had a specific morning routine. We would get up in the morning. Get her into the bathroom, she would brush her teeth and hair. She could get back in bed and he would pick out the clothing she wanted to wear that day. We would lay out different options for which top to go with which bottoms. She was very modest. We would close the door and the blinds. Whatever nurse was assisting would move the clothes close to her. We would hold up a blanket and stand behind it to give Maya privacy as she dressed herself. Once she was done changing she would say “I’m done”. Then we would put the blanket down, open her door and blinds.
She had a specific routine she followed. Some mornings she would put on a little makeup. She had a makeup kit, we would move it close to her so she could apply the makeup.
All rooms are private, have their own bathroom. A large screen TV directly in front of her bed and she had control over whatever she wanted to watch. Then a smaller tv off to the side in a sitting area. They all have a large picture window. Varying views, for example the hospital is curved part of it faces the bay, some have city view, some have beach view, they are all open and bright, pastel colors, not stark white. She accumulated a lot of items in her room, lots of arts and crafts, stuffed animals, blankets. Bingo is every Thursday and they can choose a prize from the prize cart even if they didn’t win anything. Beecause of Maya’s length of stay, she had accumulated a very large number of items in her room
Why did the door have to remain slightly open even with the toileting routine? Maya at one point was in the bathroom by herself and she had a fall from the toilet to the floor. So, at that point she became a heightened risk for fall patient. So, following that incident any nurse assisting her would have to stand outside the door with the door slightly cracked so we could see just a small part of her legs or torso or head just to make sure she wasn’t about to fall. It was done for safety. There is a door for the bathroom and for the hallway. The hallway door also had to be cracked a little, in case she was alone in the room we needed to make sure she was safe.
ADLs that she could do by herself – brush hair, brush teeth, wash face, put on makeup, dressed herself, sports bra, tshirt, short. We had to assist her with moving from bed to wheelchair to help her pivot and from wheelchair to toilet.
On the days when she wasn’t feeling well, what would staff try to do. Some of my best memories of that time were the little things we did for her. We had a couple of nurses who were good at braiding hair. If she was feeling down, we would braid her hair, have mini spa days, nurses brought nail polish from home or even bought nail polish for her and we would have her paint her nails. So, even nurses that were not specifically assigned to Maya would participate in giving her some special attention.
If I heard she got a new tshirt or painted her nails or had hair braided other nurses not assigned would come by and acknowledge her new hairdo, or her new t-short – tell her how cute it is, things like that. The nurses worked very collaboratively with each other always keeping all the nurses aware of which kids might need some little pick me ups or special attention.
Another example is if I’m walking down the hallway and I see her light on even if I’m not assigned I will stop in and ask what she needs. All the nursing staff were good about doing that.
Was Maya appreciative of the efforts – yes. Something that I talk about a lot is the Child Life therapists, they run programs every day of the week. There is open Activity Center and they have scheduled group activities and they also do one on one activities. Maya is one they definitely did one on one activities with. One thing that comes to mind, they had taken her to bake cupcakes. She picked out a cupcake to give to me specifically, then she ask me to send in the other nurses so they could pick out a cupcake. Little things like that I think Maya was appreciative.
Holiday events – she was there for Halloween. For any holiday we have talented nurses that paint the outside of the door and decorate. She wanted to dress as Harley Quinn, The family helped with part of the costume and the nurses helped with her hair and makeup. One of the days she was getting ready with her costume, she was trying to paint something on her face but it was backwards because she was looking in a mirror. So, I held a second mirror to put the orientation correct so she could put it on how she really wanted it.
Thanksgivivng meal we do special things, invite friends and family. For Christmas our unit always does a cookie exchange. Since Maya was there so long we allowed her to be the judge. The nurse brought her a dozen of the cookies that won just for Maya. That is not really the kind of thing we would do for just anyone, this is really a staff tradition, but since Maya had been there for so long we brought her into our staff tradition. We felt like we had a little more of a bond with Maya than with other kids that were not there as long.
Nobody is ever just stuck in their room for their stay. They are encouraged to participate in activities. The activity center was on a different floor so we made an effort to make sure Maya could get to that activity center every day, even on weekends. She really liked it. We were still having our team volunteers come, so that helped because Maya could go any time.
Music therapy, sometimes one on one music, pet therapy, dogs are cleared for their temperament. The only ask is for patients to clean their hands with alcohol to prevent germs, but they could pet the animals
We utilize our Child Life team members to help kids interact and have activities in their room or in the Activity center and usually both
Maya had lots of opportunity to engage in activities that have nothing to do with a normal experience of being in a hospital and getting therapy. There are lots of opportunity because tis is a children’s hospital, for kids to interact with other kids. There is a beautiful picture window with a seating area that the kids loke to sit in that area and play, talk, interact with each other. Child Life services are utilized to a great degree to encourage kids to have a good social lie experience.
Maya seemed to spend a lot of time in the Activity Center. She used her rosary and holy water often, Father Tom dressed in traditional Catholic garb and he would go around to the rooms where the patients are Catholic. One of the nurses brought Maya an Advent calendar so she could open the section for the day and have that experience.
Her father and brother visited frequently, she had an aunt and uncle who visited, a couple of her friends from school and their mothers visited, she remembers a school teacher that visited her
Maya would stay in the room when the teacher came, but when the other visitors came they went to the cafeteria or the activity center, I now they definitelyleft the room when the family were there
There is a program for food where the kids order ala carte. She could call a phone number any time and ask for anything on the menu. She remembers Maya being a picky eater and she would just want to order white rice by itself. But she had smoothies. The care team wanted her to have multi-vitamins and she remembers Maya had trouble swallowing pills. So they gave her pediasure, but she didn’t like it. We would try squirting the vitamin on a popsicle and she could get the vitamins that way.
She remembers Maya nominating one of her colleagues for exemplary nursing service. (Maya claimed she only did that because as a 10 year old I was desperate to get aout of there and I thought if I said the nurses and staff were good, they would let me go) That was Lindsey Aranas. It was the Daisy Award. It’s a nursing only award, created by a family that had a member who had cancer as a child. In his 30’s he developed a immune deficiency disorder and passed away from that. So, they created a foundation and it’s to honor nurses that have exemplary skills and create special bonds with a patient.
A patient can nominate a nurse a couple of ways. There is a paper format, the child can fill out a Daisy award nomination on paper or they can submit it online.
Exhibit. Do you recognize this. It’s two pages. This is on page one is a description of the what the Daisy award is, basically what I just said. Page two is where Maya filled out her nomination. Maya’s handwriting, she says the nurse is very fast, super nice, example when I have to use the bathroom or need anything she will come as fast as possible.
She also won a Daisy Award regarding her care of Maya. My nomination came from a fellow staff member (objection).
I took Maya’s laundry home on two occasions and washed her clothes for her and brought them back. She noticed that Maya didn’t have a lot of selection for clothing, so she wanted her to have as many of them clean so she had more choices on any given day. We could have just put her in a gown when she ran out of her personal clothing, but didn’t want that to happen, it’s a nicer experience if they can wear their own clothing. She was nominated for a Daisy Award for that
Plaintiff – Mr Anderson
According to JHACH regulations you are supposed to complete at least one nursing note, right? Well we chart, so yes.
He is sarcastic about how close her and Maya were. Nurse answers that she was close with a lot of the staff. (Maya told the jury she didn’t like any of them, but was pretending to like them so she could go home)
In fact there were a lot of staff who saw her a heck of a lot more than you did? She agrees
In fact you only saw Maya charting in, on five occasions. I would say that is accurate as far as how many times she charted. But I was also the charge nurse and as a charge nurse I’m not doing the charting even though I am participating in helping the other nurses doing things like helpng Maya dress, and other things. So I’m not charting ever detail of every interaction with every patient. I am overseeing the entire floor’s status, point person for transfer, discharge, etc. Even if I wsn’t charting I was helping oversee and interacting with her.
28 Max kids on the floor. He is sarcastic throughout questioning. He points out that her name is not on the page of Maya’s “My Care” journal.
She knows who Cathi Bedy is. She never discussed Maya with Cathy or with anyone in Risk Management. With anyone on the floor? To fellow nursing staff. She was in several different rooms while there. She works on 7th floor. Cathi Bedy worked on all floors like all social workers.
7th floor is the med surg floor. Why was Cathi Bedy on your floor? Because social workers go to all the units. They can be assigned to specific floors but they can fill in. I’m sure she was one of the social workers that may have seen Maya
Asking her abput Maya being “stripped down for photos to be taken”. I have no comment on that, I wasn’t there, wasn’t part of that at all.
He is challenging her about that. She repeats that she has no comment on that, she has no personal knowledge of that event.
He’s bringing out the exhibit. Sidebar. Jack K is looking his usual smug self and staring down the witness like he did yesterday.
He’s now asking her about the security cameras and she doesn’t know about those. He’s trying to insinuate that those security cameras could be used to for watching Maya for the diagnostic instead of putting her into a special room with the camera. I don’t know why he’s asking this witness, that count was thrown out by the judge yesterday, defense got a directed verdict on that. I guess they are going to try to weave her stay in that room into the false imprisonment count.
Were you involved in transporting Maya to a surveillance room? NO
Re-direct
On the 7th floor are there rooms called seizure monitoring rooms? Yes. Do they have video monitoring capability? Yes
Jury questions
1. It was kind of you to take home Maya’s laundry. Do you think you overstepped boundaries as a nurse? I think that is a tough call. Because I could have called it a day and put her in a gown. But I felt like letting Maya having a choice would make a difference for her
2. Did you reach out to her parents to ask permission to take home her laundry to wash or did you ask DCF if you could take home her laundry to wash? (oh good grief) I did not do either of those
3. Did you call her parents to tell them she needed clean clothes? We did let her dad know that she was running out of clothes, but I did not ask permission to wash her clothes
4. Is it protocol to use a gait belt for a fall risk patient at the hospital? It can be, depending on what you are doing
5. Did you ever observe Maya wearing “skinny jeans”? I don’t recall her wearing jeans at the hospital, I mostly remember her wearing shorts and athletic pants
6. If you received an order from a doctor that was above hospital rules, would you question that and document it in the medical records? I think I need a better example, not sure what that means. Judge prods her. If I was concerned about something, or something didn’t fit I would definitely make contact with the doctor before carrying it out but I’m not sure what I’m being asked, I would need a specific example
7. How often as the bedside or charge nurse did you communicate with Cathi Bedy about Maya’s care? I don’t recall having many conversations with her at all. The kinds of things Cathi would have kept us informed about would be like any changes related to DCF plan or if she could have different visitors, those are the kinds of things that social workers would inform nursing staff about. So, it would be more on an “as needed” basis than any kind of constant communication
8. Did Maya have bad days where she just stayed in bed? I don’t recall her staying in bed, if a child does that we reach out to Child Life so they can engage the child with some kind of pet therapy or something to bring her mood up.
9. Would you say Maya was a good patient or trouble? I didn’t have issues with her. She was a beautiful, smart little girl, in my interactions she was good patient.
10. When Maya was in video observation were you the floor nurse for Maya during those days? I was not
11. Did you or a different floor nurse keep the morning routine flowing or was in interrupted? I can’t speak for what someone else’s process was at that time
12. Same question but additional -= they should have been charting assessment and daily activities during that time as usual
13. After Maya was returned to regular room were you still Maya’s floor nurse? I definitely am the charge nurse, so I have an overview of everyone on the floor. Nursing doesn’t happen as you are the only one assigned to this patient and no other nurse is interactions. The one assigned is the one who does the charting for that day, but all the nurses step in and assist with patients every day. And a nurse might just pop in the room and say “hi”
14. Did you make any review of the observation room nurse’s notatins? No, I wouldn’t have had any reason to do that
15. Where you Maya’s floor nurse from the time she was discharged from ER to the time she was discharged from the hospital? I was one of the nurses. She went to ICU first, when they cleared her she was transferred to my unit
16. Was Maya from October to January was she on the same floor but different rooms? I believe that once she was out of PICU she was always on our unit, except for the brief stay in video room. We also have a policy that says every 30 days a patient has to move to a different room so the housekeeping staff can give the room a good deep cleaning to keep germs down
17. As a floor nurse was it part of your job to chart notes on a daily basis? If I was actually assigned to the patient, yes. Only the assigned nurse will do the charting and sign it.
18. When if ever did you last speak with counsel for your testimony today? At some point I think yesterday evening to make sure I knew when and where I was supposed to come today.
Where you involved in Jack K attempts to get a Christmas dress to Maya? I don’t recall anything about that
Did Cathi Bedy tell you that The K family kept (?) medical decision? Objection, hearsay, So I don’t recall having any conversation like that with Cathi
As a floor nurse were you responsible if there was going to be a procedure for surgery to get a signed consent form? Any procedure requires consent. The first step for a nurse would be to check the chart to see who can sign the consent, and that is who we would reach out to.
Were you involved in trying to get any consent for the port removal? I was not
Were you involved in getting consent for taking photographs of Maya without her clothing on? No
For Maya being place in the video room? I was not
You were prepped by defense counsel for how many hours in the last month? Like maybe one, maybe five emails
Did Cathi Bedy ever tell you there was a belief that Maya could actually walk? No
Jury additional questions
1. Did you observe Bedy siting on Maya’s bed? No
2. Did you observe Bedy listening to Maya’s phone calls No
3. Was not Maya told there were some kids she was not allowed to talk to? No, we would not have restricted her from talking to people, like fellow patients for sure
4. Clarifying when Maya returned to your care after the video room. Where you not curious about anything that happened while she was in that room or while she was gone? First, Maya never left our unit, she was just moved to a different room. So, outside of just moving from one room to another room nothing changed as far as her nursing care. It’s really not nursing’s place to make a diagnosis or order new testing, so at that point we would have been relying on the physician staff to relay any information that we would need if there were any changes required in nursing care. We had no changes in nursing care communicated to us, she was under the same nursing care same unit, just different
Pediatric floor nurse. Coordinate care, provide help with daily care, ADLs, changes in status
I wanted to be a nurse since I was little, at clinicals she really felt like pediatrics would be most fulfilling
She was the floor nurse and also served as charge nurse several periods of Maya’s stay. Did she have good days and bad days? I would say definitely. No different than any other child. Some days are harder or busier than other days for everyone.
Maya complained of pain now and then. Pain is patient specific, if someone tells me they are in pain I am going to be compassionate and try to help with that. She definitely complained of pain on occasion. Nobody ever told Maya in my presence that she was faking it or making it up. That is something that we would never do. Something that might be painful for me might not be painful for you and we recognize that and we do not question the authenticity of pain
While Maya was with us we as a nursing staff tried to bring normalcy of daily routine in her life. Nursing is going to follow the care plan, but we also have the most one on one contact with the patients, so we interact with them more than anyone else. We tried to provide things she could do to make her life a little more normal.
She had a specific morning routine. We would get up in the morning. Get her into the bathroom, she would brush her teeth and hair. She could get back in bed and he would pick out the clothing she wanted to wear that day. We would lay out different options for which top to go with which bottoms. She was very modest. We would close the door and the blinds. Whatever nurse was assisting would move the clothes close to her. We would hold up a blanket and stand behind it to give Maya privacy as she dressed herself. Once she was done changing she would say “I’m done”. Then we would put the blanket down, open her door and blinds.
She had a specific routine she followed. Some mornings she would put on a little makeup. She had a makeup kit, we would move it close to her so she could apply the makeup.
All rooms are private, have their own bathroom. A large screen TV directly in front of her bed and she had control over whatever she wanted to watch. Then a smaller tv off to the side in a sitting area. They all have a large picture window. Varying views, for example the hospital is curved part of it faces the bay, some have city view, some have beach view, they are all open and bright, pastel colors, not stark white. She accumulated a lot of items in her room, lots of arts and crafts, stuffed animals, blankets. Bingo is every Thursday and they can choose a prize from the prize cart even if they didn’t win anything. Beecause of Maya’s length of stay, she had accumulated a very large number of items in her room
Why did the door have to remain slightly open even with the toileting routine? Maya at one point was in the bathroom by herself and she had a fall from the toilet to the floor. So, at that point she became a heightened risk for fall patient. So, following that incident any nurse assisting her would have to stand outside the door with the door slightly cracked so we could see just a small part of her legs or torso or head just to make sure she wasn’t about to fall. It was done for safety. There is a door for the bathroom and for the hallway. The hallway door also had to be cracked a little, in case she was alone in the room we needed to make sure she was safe.
ADLs that she could do by herself – brush hair, brush teeth, wash face, put on makeup, dressed herself, sports bra, tshirt, short. We had to assist her with moving from bed to wheelchair to help her pivot and from wheelchair to toilet.
On the days when she wasn’t feeling well, what would staff try to do. Some of my best memories of that time were the little things we did for her. We had a couple of nurses who were good at braiding hair. If she was feeling down, we would braid her hair, have mini spa days, nurses brought nail polish from home or even bought nail polish for her and we would have her paint her nails. So, even nurses that were not specifically assigned to Maya would participate in giving her some special attention.
If I heard she got a new tshirt or painted her nails or had hair braided other nurses not assigned would come by and acknowledge her new hairdo, or her new t-short – tell her how cute it is, things like that. The nurses worked very collaboratively with each other always keeping all the nurses aware of which kids might need some little pick me ups or special attention.
Another example is if I’m walking down the hallway and I see her light on even if I’m not assigned I will stop in and ask what she needs. All the nursing staff were good about doing that.
Was Maya appreciative of the efforts – yes. Something that I talk about a lot is the Child Life therapists, they run programs every day of the week. There is open Activity Center and they have scheduled group activities and they also do one on one activities. Maya is one they definitely did one on one activities with. One thing that comes to mind, they had taken her to bake cupcakes. She picked out a cupcake to give to me specifically, then she ask me to send in the other nurses so they could pick out a cupcake. Little things like that I think Maya was appreciative.
Holiday events – she was there for Halloween. For any holiday we have talented nurses that paint the outside of the door and decorate. She wanted to dress as Harley Quinn, The family helped with part of the costume and the nurses helped with her hair and makeup. One of the days she was getting ready with her costume, she was trying to paint something on her face but it was backwards because she was looking in a mirror. So, I held a second mirror to put the orientation correct so she could put it on how she really wanted it.
Thanksgivivng meal we do special things, invite friends and family. For Christmas our unit always does a cookie exchange. Since Maya was there so long we allowed her to be the judge. The nurse brought her a dozen of the cookies that won just for Maya. That is not really the kind of thing we would do for just anyone, this is really a staff tradition, but since Maya had been there for so long we brought her into our staff tradition. We felt like we had a little more of a bond with Maya than with other kids that were not there as long.
Nobody is ever just stuck in their room for their stay. They are encouraged to participate in activities. The activity center was on a different floor so we made an effort to make sure Maya could get to that activity center every day, even on weekends. She really liked it. We were still having our team volunteers come, so that helped because Maya could go any time.
Music therapy, sometimes one on one music, pet therapy, dogs are cleared for their temperament. The only ask is for patients to clean their hands with alcohol to prevent germs, but they could pet the animals
We utilize our Child Life team members to help kids interact and have activities in their room or in the Activity center and usually both
Maya had lots of opportunity to engage in activities that have nothing to do with a normal experience of being in a hospital and getting therapy. There are lots of opportunity because tis is a children’s hospital, for kids to interact with other kids. There is a beautiful picture window with a seating area that the kids loke to sit in that area and play, talk, interact with each other. Child Life services are utilized to a great degree to encourage kids to have a good social lie experience.
Maya seemed to spend a lot of time in the Activity Center. She used her rosary and holy water often, Father Tom dressed in traditional Catholic garb and he would go around to the rooms where the patients are Catholic. One of the nurses brought Maya an Advent calendar so she could open the section for the day and have that experience.
Her father and brother visited frequently, she had an aunt and uncle who visited, a couple of her friends from school and their mothers visited, she remembers a school teacher that visited her
Maya would stay in the room when the teacher came, but when the other visitors came they went to the cafeteria or the activity center, I now they definitelyleft the room when the family were there
There is a program for food where the kids order ala carte. She could call a phone number any time and ask for anything on the menu. She remembers Maya being a picky eater and she would just want to order white rice by itself. But she had smoothies. The care team wanted her to have multi-vitamins and she remembers Maya had trouble swallowing pills. So they gave her pediasure, but she didn’t like it. We would try squirting the vitamin on a popsicle and she could get the vitamins that way.
She remembers Maya nominating one of her colleagues for exemplary nursing service. (Maya claimed she only did that because as a 10 year old I was desperate to get aout of there and I thought if I said the nurses and staff were good, they would let me go) That was Lindsey Aranas. It was the Daisy Award. It’s a nursing only award, created by a family that had a member who had cancer as a child. In his 30’s he developed a immune deficiency disorder and passed away from that. So, they created a foundation and it’s to honor nurses that have exemplary skills and create special bonds with a patient.
A patient can nominate a nurse a couple of ways. There is a paper format, the child can fill out a Daisy award nomination on paper or they can submit it online.
Exhibit. Do you recognize this. It’s two pages. This is on page one is a description of the what the Daisy award is, basically what I just said. Page two is where Maya filled out her nomination. Maya’s handwriting, she says the nurse is very fast, super nice, example when I have to use the bathroom or need anything she will come as fast as possible.
She also won a Daisy Award regarding her care of Maya. My nomination came from a fellow staff member (objection).
I took Maya’s laundry home on two occasions and washed her clothes for her and brought them back. She noticed that Maya didn’t have a lot of selection for clothing, so she wanted her to have as many of them clean so she had more choices on any given day. We could have just put her in a gown when she ran out of her personal clothing, but didn’t want that to happen, it’s a nicer experience if they can wear their own clothing. She was nominated for a Daisy Award for that
Plaintiff – Mr Anderson
According to JHACH regulations you are supposed to complete at least one nursing note, right? Well we chart, so yes.
He is sarcastic about how close her and Maya were. Nurse answers that she was close with a lot of the staff. (Maya told the jury she didn’t like any of them, but was pretending to like them so she could go home)
In fact there were a lot of staff who saw her a heck of a lot more than you did? She agrees
In fact you only saw Maya charting in, on five occasions. I would say that is accurate as far as how many times she charted. But I was also the charge nurse and as a charge nurse I’m not doing the charting even though I am participating in helping the other nurses doing things like helpng Maya dress, and other things. So I’m not charting ever detail of every interaction with every patient. I am overseeing the entire floor’s status, point person for transfer, discharge, etc. Even if I wsn’t charting I was helping oversee and interacting with her.
28 Max kids on the floor. He is sarcastic throughout questioning. He points out that her name is not on the page of Maya’s “My Care” journal.
She knows who Cathi Bedy is. She never discussed Maya with Cathy or with anyone in Risk Management. With anyone on the floor? To fellow nursing staff. She was in several different rooms while there. She works on 7th floor. Cathi Bedy worked on all floors like all social workers.
7th floor is the med surg floor. Why was Cathi Bedy on your floor? Because social workers go to all the units. They can be assigned to specific floors but they can fill in. I’m sure she was one of the social workers that may have seen Maya
Asking her abput Maya being “stripped down for photos to be taken”. I have no comment on that, I wasn’t there, wasn’t part of that at all.
He is challenging her about that. She repeats that she has no comment on that, she has no personal knowledge of that event.
He’s bringing out the exhibit. Sidebar. Jack K is looking his usual smug self and staring down the witness like he did yesterday.
He’s now asking her about the security cameras and she doesn’t know about those. He’s trying to insinuate that those security cameras could be used to for watching Maya for the diagnostic instead of putting her into a special room with the camera. I don’t know why he’s asking this witness, that count was thrown out by the judge yesterday, defense got a directed verdict on that. I guess they are going to try to weave her stay in that room into the false imprisonment count.
Were you involved in transporting Maya to a surveillance room? NO
Re-direct
On the 7th floor are there rooms called seizure monitoring rooms? Yes. Do they have video monitoring capability? Yes
Jury questions
1. It was kind of you to take home Maya’s laundry. Do you think you overstepped boundaries as a nurse? I think that is a tough call. Because I could have called it a day and put her in a gown. But I felt like letting Maya having a choice would make a difference for her
2. Did you reach out to her parents to ask permission to take home her laundry to wash or did you ask DCF if you could take home her laundry to wash? (oh good grief) I did not do either of those
3. Did you call her parents to tell them she needed clean clothes? We did let her dad know that she was running out of clothes, but I did not ask permission to wash her clothes
4. Is it protocol to use a gait belt for a fall risk patient at the hospital? It can be, depending on what you are doing
5. Did you ever observe Maya wearing “skinny jeans”? I don’t recall her wearing jeans at the hospital, I mostly remember her wearing shorts and athletic pants
6. If you received an order from a doctor that was above hospital rules, would you question that and document it in the medical records? I think I need a better example, not sure what that means. Judge prods her. If I was concerned about something, or something didn’t fit I would definitely make contact with the doctor before carrying it out but I’m not sure what I’m being asked, I would need a specific example
7. How often as the bedside or charge nurse did you communicate with Cathi Bedy about Maya’s care? I don’t recall having many conversations with her at all. The kinds of things Cathi would have kept us informed about would be like any changes related to DCF plan or if she could have different visitors, those are the kinds of things that social workers would inform nursing staff about. So, it would be more on an “as needed” basis than any kind of constant communication
8. Did Maya have bad days where she just stayed in bed? I don’t recall her staying in bed, if a child does that we reach out to Child Life so they can engage the child with some kind of pet therapy or something to bring her mood up.
9. Would you say Maya was a good patient or trouble? I didn’t have issues with her. She was a beautiful, smart little girl, in my interactions she was good patient.
10. When Maya was in video observation were you the floor nurse for Maya during those days? I was not
11. Did you or a different floor nurse keep the morning routine flowing or was in interrupted? I can’t speak for what someone else’s process was at that time
12. Same question but additional -= they should have been charting assessment and daily activities during that time as usual
13. After Maya was returned to regular room were you still Maya’s floor nurse? I definitely am the charge nurse, so I have an overview of everyone on the floor. Nursing doesn’t happen as you are the only one assigned to this patient and no other nurse is interactions. The one assigned is the one who does the charting for that day, but all the nurses step in and assist with patients every day. And a nurse might just pop in the room and say “hi”
14. Did you make any review of the observation room nurse’s notatins? No, I wouldn’t have had any reason to do that
15. Where you Maya’s floor nurse from the time she was discharged from ER to the time she was discharged from the hospital? I was one of the nurses. She went to ICU first, when they cleared her she was transferred to my unit
16. Was Maya from October to January was she on the same floor but different rooms? I believe that once she was out of PICU she was always on our unit, except for the brief stay in video room. We also have a policy that says every 30 days a patient has to move to a different room so the housekeeping staff can give the room a good deep cleaning to keep germs down
17. As a floor nurse was it part of your job to chart notes on a daily basis? If I was actually assigned to the patient, yes. Only the assigned nurse will do the charting and sign it.
18. When if ever did you last speak with counsel for your testimony today? At some point I think yesterday evening to make sure I knew when and where I was supposed to come today.
Where you involved in Jack K attempts to get a Christmas dress to Maya? I don’t recall anything about that
Did Cathi Bedy tell you that The K family kept (?) medical decision? Objection, hearsay, So I don’t recall having any conversation like that with Cathi
As a floor nurse were you responsible if there was going to be a procedure for surgery to get a signed consent form? Any procedure requires consent. The first step for a nurse would be to check the chart to see who can sign the consent, and that is who we would reach out to.
Were you involved in trying to get any consent for the port removal? I was not
Were you involved in getting consent for taking photographs of Maya without her clothing on? No
For Maya being place in the video room? I was not
You were prepped by defense counsel for how many hours in the last month? Like maybe one, maybe five emails
Did Cathi Bedy ever tell you there was a belief that Maya could actually walk? No
Jury additional questions
1. Did you observe Bedy siting on Maya’s bed? No
2. Did you observe Bedy listening to Maya’s phone calls No
3. Was not Maya told there were some kids she was not allowed to talk to? No, we would not have restricted her from talking to people, like fellow patients for sure
4. Clarifying when Maya returned to your care after the video room. Where you not curious about anything that happened while she was in that room or while she was gone? First, Maya never left our unit, she was just moved to a different room. So, outside of just moving from one room to another room nothing changed as far as her nursing care. It’s really not nursing’s place to make a diagnosis or order new testing, so at that point we would have been relying on the physician staff to relay any information that we would need if there were any changes required in nursing care. We had no changes in nursing care communicated to us, she was under the same nursing care same unit, just different
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Off Topic
Thanks for the well wishes
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
After jury leaves for a break defense attorney Ms Crowells is complaining to the judge that the plaintiff counsel specifically asked to be seated next to the jury. Mr K is always sitting right next to the jury box, almost touching it. They are constantly laughing, eye rolling, making snarky comments during defense witness testimony. In the future instead of waiting until the jury leaves, we will be standing up and objecting to that behavior when it happens.
the judge reminds counsel that the microphones ae all very sensitive and to be respectful when the other side are presenting witnesses.
the judge reminds counsel that the microphones ae all very sensitive and to be respectful when the other side are presenting witnesses.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
Taking Care of Maya - FL CPS/Munchausen case
Hopefully I will be posting some additional testimony later tonight.
Here is an interesting gossip about the case. Apparently the court has information from multiple sources that Beata was administering ketamine by IV at home. But the judge is shutting down any portion of emails, discussions, and even the lawyers talking about it in court, they talk almost in code. Today is not the first time there has been discussion about emails and redacting things, and a lawyer slipping about why they have to redact it being having to do with Beata administering ketamine via IV at home.
My suspicion is this explains one of the records from Dr Hanna that has no patient name on it, but it "lives" in Maya's records. It an order that Hanna sent to his ketamine supplier for a fairly large amount in total of ketamine, but packaged in smaller bottles. Yup. I think I have a suspicion why this order for ketamine is stuck in Maya's file.
Here is an interesting gossip about the case. Apparently the court has information from multiple sources that Beata was administering ketamine by IV at home. But the judge is shutting down any portion of emails, discussions, and even the lawyers talking about it in court, they talk almost in code. Today is not the first time there has been discussion about emails and redacting things, and a lawyer slipping about why they have to redact it being having to do with Beata administering ketamine via IV at home.
My suspicion is this explains one of the records from Dr Hanna that has no patient name on it, but it "lives" in Maya's records. It an order that Hanna sent to his ketamine supplier for a fairly large amount in total of ketamine, but packaged in smaller bottles. Yup. I think I have a suspicion why this order for ketamine is stuck in Maya's file.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick
-
pipistrelle
- Posts: 6922
- Joined: Mon Feb 22, 2021 11:27 am
Taking Care of Maya - FL CPS/Munchausen case
I refreshed my memory of MBP the other day, and the mother checked almost all the boxes. Not a parent, but i'd never want that cocktail of high dosage drugs in an underweight child unless it was for cancer and it was their only hope.
Asthma is not a mystery disease to diagnose, I don't think.
Asthma is not a mystery disease to diagnose, I don't think.
Taking Care of Maya - FL CPS/Munchausen case
yeah, it looks suspiciously like Beata was able to get an ENT or some other doctor to prescribe the steroids based on her being a nurse and describing symptoms. Both JHACH in 2015 (before the visit that got them sued) had determined that she did not have asthma and they got her off the steroids. I think Mom just went back to whoever was prescribing them and got her back on. Then Dr Mendez also determined that she did not have asthma or may have at most had a mild case of it, not the "severe" that he saw that Beata was reporting to every doctor including himself. He testified about it.pipistrelle wrote: ↑Wed Oct 25, 2023 6:43 pm I refreshed my memory of MBP the other day, and the mother checked almost all the boxes. Not a parent, but i'd never want that cocktail of high dosage drugs in an underweight child unless it was for cancer and it was their only hope.
Asthma is not a mystery disease to diagnose, I don't think.
There's a lot of things that need to change. One specifically? Police brutality.
--Colin Kaepernick
--Colin Kaepernick