Tiredretiredlawyer wrote: ↑Thu Oct 19, 2023 8:24 pm
RV- I didn’t mean to pressure you!! Your posts are so well done I wanted to convey how interesting they are! Your mom’s care comes first, of course. Mea culpa!
you don't owe me any apology whatsoever. I did not take it badly or anything like that. No worries!! I know I had said that entry ws coming like right away. I had it mostly typed up, then things went south around here.
I'm nearly done with the next one. fingers crossed. Mom has been put to bed, so let's hope!
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Ok this is funny. I have a camera in Mom's room. When she is put to bed I turn on the sound on my phone, so if something hapens I can hear.
She is explaining to someone how to make a peanut butter and jelly sandwich. After she told them how to make it there is a few seconds of silence then she says in an irritated voice "Don't just glob it on. Spread it!" Then she mutters under her breath "dumb ass"
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
"Choose your leaders with wisdom and forethought. To be led by a coward is to be controlled by all that the coward fears… To be led by a liar is to ask to be told lies." -Octavia E. Butler
Ok this is funny. I have a camera in Mom's room. When she is put to bed I turn on the sound on my phone, so if something hapens I can hear.
She is explaining to someone how to make a peanut butter and jelly sandwich. After she told them how to make it there is a few seconds of silence then she says in an irritated voice "Don't just glob it on. Spread it!" Then she mutters under her breath "dumb ass"
Another “dumb ass” hot mic moment! Second one this week!
Based on the jury questioning, the defense wants to submit a statement to the jury regarding Beata’s suicide. There was summary judgement that the hospital has no responsibility in this, but the jury clearly is concerned about this, as evidenced by the question from the jury.
The judge decides no need for a jury instruction at this time.
Plaintiff learned that the defense plans on calling detective Graham tomorrow, we have an objection to his being called as a witness. And we have a curative instruction we want read to the jury. The judge stops him and asks him if this has anything to do with any witness for this afternoon. He says no. The judge says “sit down” (I think he used nicer words, but that is basically what he said)
They ae talking exhibits again. These are all exhibits the plaintiff objects to on relevance. This is also a huge waste of time. They are normal medical records made during the time in question, judge has already said these kind of thing are relevant. Mr Anderson objects to each and every one ad nauseum. Judge is over it.
Bring in the jury
Defense witness – Johanna Klink, Nurse Practitioner
BS Biology, BS Nurse, Nurse Practitioner
Explains the difference between a Registered Nurse and ARNP.
Prior to ARNP were you a Pediatric Intensive Care Nurse? Yes – Describes what that kind of work, and gives her history. Seems well qualified, well spoken, started at JHACH at 2010.
PICU is Pediatric Intensive Care Unit – she describes the daily duties of a nurse in PICU. Monitor vital signs, patient status changes, report changes in patient status, administer specialized drugs, therapies, ventilators, etc. Take care of patient, skin, turn them, give meds,
She became involved in the care of Maya K starting Oct 7 in PICU as a bedside nurse. She also served as a charge nurse in that same department at times.
She had 16 years of experience as a ICU nurse at the time she encountered Maya. On the afternoon of Oct 7th, she was bedside PICU. She remembers that afternoon because it was an unusual and stressful situation. The admission was challenging. Many things happened that have continued to stay in her mind. She got the report from the ER nurse, received a brief history, what she needed, the pain situation, and that she would be coming to the ICU.
She performed an admission assessment. It’s a profile of the potential needs she might have while she’s in ICU. Spiritual needs, pain history, diet, safety issues, who lives with them at home, profile, medical history. Mrs K gave the history, she was standing right next to the computer. There were no language barriers, she knew medical terminology, no problem in communication.
She was involved in monitoring vital signs, height, weight, Mrs K would not allow a blood pressure, said it would cause her pain. She wanted Maya pre-medicated for blood pressure. She’s treated many kids with pain and able to get their’s before. She decided to wait a bit for that. But she had to get some information initially. She observed her quite a bit. Mrs K told her Maya can’t walk because of her CRPS. She took her at her word. But she saw Maya was on her knees on the bed and moving around in the hospital bed. It takes a lot of strength to move on a hospital bed, it’s an air mattress. So, she was confused that Maya couldn’t use her legs, but had the strength in her legs to basically walk on top of the mattress on her knees. So her upper legs clearly had strength. You sink in the air mattress, but yet Maya had no issue walking on the bed. It’s like walking in one of those bounce houses.
Maya appeared agitated at times, upset at times, withdrawn at times. Other times she seemed perfectly normal. It changed when she was alone as opposed to when her mother was there. This happened with all the other staff as well. She would be age appropriate, nice, easy to work with when Maya was alone with the staff with no family there. But when family came she was withdrawn, cranky, agitated, yelling, upset, all these behaviors would come out. It was consistent. She observed this behavior on the 7th several times as her mother left a few times and then would come back. This happened on other days as well.
Beata’s behavior that day in PICU from the beginning she was very agitated. The staff was walking on eggshells when she was around. She was hovering and controlling, demanding. She recalls a lot of “F” bombs that happened that day. Both Maya and her mother used that language. She was charge nurse on this particular day. In ICU they have morning rounds. The residents, pharmacy, nursing, the whole team is there on the rounds. When they walked into Maya’s room Dr Teppa was attending that day. They walked into the room. (The witness asked the judge if she’s allowed to use the word). When the group walked into Maya’s room she said “I want my f’ing sedation, I want my F’ ing sedation”. Then, she called Dr Teppa an F’ing A….H….”. (ass hole I think). She doesn’t know why that happened. But Maya said the whole words. Dr Teppa seemed shocked. The whole group was uncomfortable.
She is shown some notes. Under Patient Behavior she had put an entry “tht the patient said “I want my sedation. I want to eat. I feel like I’m having a heart attack”. Mom replied “Well honey, if you have a heart attack at least the doctors will treat you”.
She is asked why she made that entry. There were a couple of reasons. First, she said it, that’s why it’s in quotes. I thought it was unusual for a 10 year old to say “I want my sedation”. She didn’t say “I’m in pain, I hurt, I have an owie”. It’s not typical for a 10 year old to specifically ask for “my sedation”.
There is a second note that indicates that Maya said “I am tired of all these lies, my life is a lie”. The nurse was alone with Maya when this happened. She was saying she was hungry and she wanted a donut. She asked where her mother was and the nurse told her that your mother and father are in a meeting with the doctors. Then she asked for sedation and then made the statement about the “lies”. The nurse asked her what she meant by that, what do you mean all the lies. She said Maya was about to answer her when her mother came into the room and she abruptly stopped talking and began acting the way she normally did when Mom was around. This all happened within an hour of her being admitted to ICU. The nurse didn’t have any idea what she was talking about. The nurse documented it because of how unusual this was.
Maya became withdrawn and shut down when her mother came in. She never had a child say anything like this. She was concerned about this statement, but couldn’t get Maya to open up again after this.
(I have a suspicion that I know what she is talking about. It is my belief she could be talking about how she herself had always said she had muscle pain. Her mother did research after meeting someone whose daughter has CRPS, and all the sudden the whole story of Maya’s pain changed completely. This online research is the basis of the whole Maya has CRPS claim. I have a suspicion that Maya was carrying on a lie started by her mother and that it was overwhelming her. She was having to mimic the symptoms her mother was associating with CRPS even after those symptoms went away when the real cause went away. Steroid myopathy was her real pain. But now that her mother has committed suicide for the sake of this very lie I don’t think Maya can let go of it at this point, the guilt would be overwhelming, she probably would blame herself because she was in on the whole pretense. At age 10. What a damn shame.)
Whenever Maya asked for sedation she always used the “F” word, she was upset, yelling. She never had any child of any age say “I want my sedation”.
She was the charge nurse for several days after the 7th. She had other interactions with the K family and Maya. A family care conference is when you get the whole team with the family together and go over things to get a care plan together. She was there for observation as a charge nurse. She remembered the ICU team talking to the parents about Maya’s care. They were working toward trying to get Maya into a stable regimen where she wasn’t on some of these ICU type meds and get her into therapy. Mr K ws very amenable to it and was trying o talk his wife into agreeing. He said it sounded reasonable and he wanted to go along with it. Beata did not want to entertain any other plan other than continuing with ketamine, propofol and other heavy drugs. Eventually she remembers they decided to stay.
At no time did she ever hear any person threaten the family with arrest if they refused to stay at the hospital. (Mr K claims they were threatened with arrest if they left the hospital. He claims that happened during this meeting. I have to say I thought Mr K was not very bright. He did well on direct, but was utterly destroyed on cross exam. He didn’t seem to understand even simple things. He had to admit to things that contradicted his direct testimony.)
She remembers Beata asking for Propofol. It’s a deep sedation medication, it’s used in OR, sometimes in ICU. She doesn’t know why she wanted it, it’s used for sedation, and that is unusual for someone to want sedation. She always asked for sedatives for Maya whenever it was bedtime. At one point Maya was almost asleep, her eyes were closing, she was hardly able to stay awake and Beata went over and shook her awake to ask her if she was in pain. (You can’t sleep when you are in pain. If Maya was falling asleep and needed to be awakened, then she was not in pain at the time). Another time when nurse was in the room Beata said “Maya is in pain, she needs pain meds”. The nurse was looking at the monitor and Maya’s pulse rate was 70. That is at the very low end of a normal pulse rate for a 10 year old. The nurse pointed this out to Beata and said there is no indication of pain. Maya herself had not said she was in pain, she has anormal pulse rate and low end of normal blood pressure. If you give her pain meds and she’s not in pain and her vitals are on the low side it can drop her vitals even lower. (This is the first time I have heard anyone under testimony tell the jury about pulse rate. I have been screaming at the video wanting SOMEONE to testify as to pulse rate and pain)
She explains she is proactive with pain. She didn’t want to tell Beata that Maya wasn’t in pain, but Beata said “Don’t you see she’s in pain?” So that’s when she said “no, she’s not showing any sign of pain”. She’s resting comfortably. That kind of thing was distinctive to her.
She was concerns for Maya’s care and well-being
Plaintiff:
Now comes the sarcasm. She explains to the jury that she’s not going to chart every tiny little detail. The charts go on for pages and pages and pages. So, in between trying to chart all the necessary things, she tries to mention the kinds of things like Beata was doing and saying. But she was not able to put every single little thing there is not time for that. She is required to fill out all the necessary entries.
The incidedent with Dr Teppa where Maya called her a F’9ng Ass hold, every single person on the team was in the room She didn’t have to communicate that in the chart. Everyone that needed to know about Maya’s behavior was there and witnessed it. If she had been able to predict that there would be a court case she would have charted every single thing. That is not something you can predict.
Now he’s asking her why she didn’t use her cell phone to video and record everything like this. She says there are no cameras in the room. There are cameras in the halls. She doesn’t take photos of patients, that is not allowed. That is just unprofessional and not done.
So, I guess taking her into a room and stripping her down to her bra and taking photos, that would not be appropriate would it. She says there are times when photos are taken for medical purposes, but to just take photos and video on her personal phone in ICU, that is not appropriate.
If somebody were to take a child and videotape hem without their consent it would be against policy? She says that is not what she said. She’s saying that in ICU it is not appropriate for nurses to pull out their phone and take video or record them.
He’s continuing to badger her about “commode out of reach”, she has no idea what he’s talking about. Objection sustained.
Sahe asks if she worked with Cathy Bedy? She said yes, for a time Cathi Bey was a social worker in PICU. She only saw her if there was a patient that they had in common at the same time she might run into her. It didn’t happen very often. Would she mention this to Cathi Bedy? Not necessarily no, she would only tell Cathy bey about a patient that needed social services. She was not in the habit of talking about patients to other people. She explains that she wouldn’t be surprised if Maya’s behavior did not spread throughout everyone on the floor. She explains it did not and it should not. She can’t guarantee that nobody talked about it because Maya behaved that way with everyone on the team, and who knows if any of them mentioned it within earshot of others who were not assigned to the team that took care o of Maya. Each side does not communicate with each other. There are two teams. There are lots of patients, everyone is busy taking care of lots of patients. Some kids are on ventilators, some kids are dying, some are close to it. There is a lot going on. We don’t go around about everyone.
Mr Anderson is bringing up an exhibit and asking who is Elizabeth Sumner. Oh lordy. He’s asking about all these pain scale entries. She explains that these are likely when the patient is reporting pain at specific times between pain meds. He’s trying to say that the nurses “felt that Maya came in with a 10 on pain”. That is what Maya is saying not what the nurse thinks it is.
He’s asking her about holding Maya down and trying to force a gastric tube down her nose. She says she does not remember that they ever put a feeding tube on Maya. He keeps badgering her and she keeps saying she does not remember any feeding tube on Maya.
He brings an exhibit that she electronically signed. She explains this is not a documents that says a feeding tube was inserted or attempted. It says the physician ordered a tube, and her name is listed as the “reviewer” meaning that she saw the order. But that does not mean the tube went in or ever was attempted to go in. She does not remember that Maya had any feeding tube. (The previous witness already said that they did TPN instead of feeding tube.)
Redirect
When someone puts a number from the pain scale down where does that come from. She explains you ask “what is your pain on a scale of 1 to 10”. The person puts the number the patient reports, not what the nurse thinks it is.
She re-states that she has no memory that Maya ever had a feeding tube in ICU or that anyone attempted to put one in.
Jury questions:
1. Have you ever worked with CRPS? No
2. Do you know how to work with CRPS patients? As a bedside nurse out job is to follow the bedside orders, so it’s the doctor that is specifying the treatment
3. Was Maya in any pain when she was cussing? Maya did not say she was in pain when she was cussing. Usually a 10 year old will say “I hurt” or “I’m in pain”. She never said “I hurt, my arm hurts, my leg hurt, my head hurts”. She never said she was in pain.
4. She would calm down when she got her meds, but remembers she was on heavy serious meds, so they would knock her out. So yes, she was calm down
5. Some question from the snarky juror about the “lies” comment. The nurse said she was never alone in ICU with Maya after that comment. There was always someone in the room, so she never felt comfortable to ask her what she meant by that comment
6. Did you report that to a doctor.? Yes, I discussed it with a doctor. Things had statted to escalate around Maya’s case and so everyone kind of knew that something unusual was going on, so yes, I mentioned it to the doctor. RN’s don’t step out of our job, we report to a doctor. I put it in the chart so the whole team knows.
I don’t’ think there was much more. The video is acting up, but it’s near the end. I will move on to the next witness.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Defense – Dr Paul Bryan Kornburg by deposition (They are going to read it in, with the attorneys reading the part of question and answer. Mr Shapiro is reading for Kornburg he reads so fast can hardly keep up)
Physician, specializing in rehabilitation and physical medicine (at Tampa General)
Background and training. U Berkeley, U Miami, MD in 1994
Baylor college of medicine 5 year program. Then Master’s degree in physical medicine.
Board certified, used to be board certified in pediatrics, but allowed that to expire once I entered my present board certified profession
As a physiatrist I work with children and adults, helping people to become more functional. Work from infants to geriatrics. (he talks too fast)
CRPS? Yes, not common, but have seen several times, maybe 1 or 2 patients per year. I see it more with children because of the type of work I do.
I remember Maya K. It’s been four years since I’ve seen her. I do remember the time she was at Tampa General for inpatient rehabilitation. The rehab center is really geared toward adults, but we do the same for children where we have more of a children’s setting where their parents cam room in with them. There are a variety of people on the team, it’s a well rounded program. I coordinate it all. Sometimes I do the diagnostic testing. Bonnie Rice was my ARPN working closely with me.
She would be at the hospital all day. I am there for portions of the say but also going to other facilities to do other work.
I review all records before the child is admitted and make sure it appropriate to even bring them in for inpatient therapy. July 30, 2015 she brought in. She had an asthma exacerbation (the famous July 4th incident) She had multiple trips to ER’s and develops muscle weakness due to heavy steroids. This is a summary of lengthy hospital records. There was a history of steroid myopathy (muscle pain) and was continuing to have difficulty with the muscle pain and weakness) She was also treated at a hospital in Chicago.
The history indicates a normal CPK. How is that significant? CPK is an enzyme that is released from the muscles when they are inflamed or damaged. So, when you have an active myopathy you normally have an elevated CPK. Maya did not have this, hers was normal. I am not an expert in steroid myopathy specifically so I can’t comment on that. She was unable to perform any ADLs (activities of daily living – feeding herself, grooming herself, brushing teeth, things like that)
If we see an elevated CPK that raises suspicion there is something muscular going on with those muscles releasing those chemicals. She definitely had steroid myopathy in her recent past.
The general physical exam was unremarkable as to heart, lungs, abdomen, general appearance, but was completed with extreme difficulty due to constant crying and moaning during most of the exam. She was observed to be able to roll from her back to her stomach without assistance, stretching her legs out fully, she would wipe away her tears with her right hand. She became very upset when she was asked to sit at the edge of the bed. She required assistance to be able to sit up so that she could be helped to the edge of the bed. She complained of generalized pain and a headache. She was oriented to time, place, and person, but refused any activities that Bonnie suggested.
Her exam suggested inconsistencies that suggest a psychological component to her current disability. She was observed to be able to reach and pick up and eat cookies without any help, but when specifically asked to grasp an object she could not gather the strength, would cry and turn her head away.
An exhibit is entered that contains the notes for the initial examination. Dr Kornburg says that is an accurate reflection of the exam.
Was there any indication of differences in skin temperature on one part of the body as opposed to others? I don’t think that was documented, so can’t comment on that.
Differences in color? I don’t recall noticing any of that, there is nothing documented in her exam about that. Temperature and color differences would have been documented because that is an abnormal finding.
No alopecia or hair loss.
Did you arrive at some impression of a possible diagnsos? Gait disorder, weaknes in all extremities, abnormal ability to ambulate, impairment in ADLs. I didn’t have anything to say she had muscle inflammation like abnormal CPKs and things like that. And the possible adrenaline insufficiency. That was some information that was provided to us, and that she had been treated for. And then pain and anxiety. And I also noted at least some psychological issue going on, some impairment in that respect, there would be inconsistencies in her ability to perform activities depending on who was doing it and who ws present in the room. She could clearly do things on her own and yet could not do those same exact things when specifically asked to do them. Any time it was a conscious effort, she was unable to do things.
Plan of therapy at that point – Comprehensive rehabilitation including cognitive rehab, neuropsychology, integrative medicine, physical and occupational therapy, monitoring and making sure she was medically stable, nursing involvement for safety precautions, and medication administration and education. Social services and case management to help with discharge planning and any equipment needed. A Dietician to optimize her nutritional status, and a hospital homebound teacher to help with school integration, and having a neuropsychologist to work with her. She needed assessment y all these disciplines to assess where she is currently. Once we establish where she is, then establish goals and try to work towards those.
RSD or CRPS was not on his list of possible diagnosis or on his radar at that time. (it wouldn’t have been on anyone’s radar at that time. There is no mention whatsoever of burning pain like she is on fire.)
Why would that be that it wasn’t on your radar? I did not identify any history or symptoms that were consistent with that. I know it can present in a variety of different ways, but that was not something that was consistent with her history or her physical exam. (again, most of all her own description of vague pain “all over” but can’t really define it at all. Believe me, you can absolutely define that you feel like someone set you on fire. That is just unmistakable.
What was this person’s hospital course (this person?) I examined the hospital discharge notes yesterday. I do remember without looking at the notes that her performance had been variable throughout her stay at the hospital, so you know, again, inconsistencies. That was the most notable thing about her hospital course. Every child is different, every problem is different. It’s a little easier for me to predict how someone will respond if they have an identifiable injury like a hip fracture, spinal chord injury, or even a brain injury. Not everyone “reads the book” and some are atypical. But as I recall, Mayas performance varied from day to day, depending on the therapist, depending on her mood, and whether family members were present or not.
In the discharge summary I notice it says the patient should stop taking certain medications, including acetaminophen, clonidine, diazepam, hydrocortisone, and oxycodone. Is that correct? Yes, my approach is to minimize medications that clearly are of no benefit. We also had her off the steroids. He lists all the meds and amounts she was on when she entered the hospital and what was discontinued.
We continued baclofen, Pepcid, Prozac, ibuprofen, nsaids. She had been weaned off all the narcotics and most of the others.
What was the purpose of inpatient psychiatric treatment? It seemed to me that Maya’s mental health was a primary issue impeding her progress and functional recovery. She was not responding to any normal physical or occupational therapy and I felt that she would not be able to make progress without psychiatric treatment. Her mother indicated there was no facility anywhere nearly so this was out of the question.
She still needed a significant amount of assistance. She was unable to walk, needed a great deal of assistance with everything, even moving around in bed, unless she wanted to do it or wasn’t asked to do it.
I was unable to find any organic, physiologic explanation for her inability to function.
Did you recommend outpatient psychological treatment? Certainly. How often? Intensive, prefereabley inpatient, but if outpatient it needed to be frequent.
Did you consider referring her to a CRPS specialist? No, she had no symptoms consistent with that.
Turn to page three of Budapest criteria. Are yu familiar with this? No. How about the Orlando Criteria? Not with the name itself, but I am familiar with the symptoms. How many patients have you had with CRPS. Probably 15 to 20 total.
It can be diffuse pain or local, right? I have never seen a generalized one, all cases I am familiar with the pain was localized.
Do you treat CRPS patients different than other? Yes, but some things are the same. For instance functional issues are treated the same. It’s the pain that is different.
Two hospitals had already given their thoughts as to what it could possibly be, right? A working diagnosis of steroid induced myopathy, right. And CRPS takes time to evolve, right? Yes.
(Well, the pain does not take time to evolve, that part comes very quickly, during the early part of the immune system trying to heal the injury. It’s the OTHER symptoms that come along sometimes a couple of years later. So, technically, yes. But given that for most patient it’s the pain that is the most debilitating part of the condition, it doesn’t evolve over time.)
Did she had decreased range of motion? One of the most difficult things about Maya is the inconsistency of her symptoms. Allodynia is consistent and we simply didn’t see that. There was nothing consistent about any of Maya’s symptoms. Th documentation reflects that sometimes she would posture her feet inward, but this also was inconsistent and seemed to occur when she was thinking about it rather than when she was engaged in a fun activity all on her own. I can’t really include or exclude that she had dystonia.
There is a photo that does show her feet pointed inwards. But this is a static photo. There is no way to look at a photograph and say that she was consistently in this position. I can’t say this isn’t a resting posture. I can’t tell if she’s relaxed or not by a photograph.
(He goes on to describe lots of situations and how the muscle acts in those situations. Here is the most interesting thing he said. So, when she was in Mexico they show a photo of her in bed while she’s anesthetized and her feet are turned in. The plaintiff is using that to prove that she’s not doing it on purpose. Dr Kornburg said that when anesthetized your muscles automatically relax, and gravity will hold your feet in whatever position they were in before you went under. So, just because her feet are turned in when she was in a coma in Mexico does not prove the dystonia as the plaintiffs are saying. )
But dystonia doesn’t prove CRPS anyway. It can occur with CRPS, but normally takes a couple of years to “evolve” if it’s the CRPS that is causing it. Many of the symptoms of CRPS take time to show up. But supposedly she has this dystonia in July and the sprain in July. So, somehow the dystonia happened before the “burning pain”. Not how it works. At all.
(I am just floored at the plaintiffs trying to say that all these unrelated doctors at unrelated hospitals, clinics, and private practice are all lying about all her symptoms. So if they all disbelieved the pain but agreed on all the other symptoms that would be consistent with what happens with any chronic pain patient. But these doctors are all saying the same thing about ALL of her symptoms. And also, back to the same old…..her OWN description of the pain does not match CRPS pain. Even after her mother started using the “burning” pain description she herself never said it burned. Until the witness stand 7 years after these events.)
If someone has limited range of motion, then holding the feet pointing in can be there “normal” position. Dr Kornburg is not going to give this to the plaintiff. He is standing firm that she may or may not have had dystonia, he can’t tell because it was inconsistent. He says lots of things play into it, the range of motion of her ankles, torsion of her tibia.
Normally dystonia is consistent because it’s the lower leg muscles that will not relax. So, it tends not to “come and go”. Of course. CRPS also tends not to “come and go” and Maya insists that hers does, so, I guess everything about Maya is super duper special.
On direct again - Kornburg’s final position is that the turning in of her feet is more likely volitional because of the inconsistency and because whenever she needed to reposition her feet in her wheelchair, she could turn her feet back outward, reposition her feet, then she would turn them in again. He is all but certain it was being done on purpose. It was happening on and off. And that is a concern. To try to come up with a great understanding of what was going on.
He is being confronted with an statement that Mr K was upset because Kornburg allegedly told Maya “look, I’m going to have to break your ankles if you don’t hold them right”. He states that he is not in the habit of telling things like that to children. He goes on to say that even if he believed they needed to be “fixed”, it wouldn’t involve breaking anything, usually it’s a muscle surgery or tendon surgery. So no. I would not have said anything about breaking bones, that would not have come out of my mouth.
(This is starting to remind me of the Johnny Depp/Amber Heard trial. At some point Heard was just piling on the most ridiculous allegations, such as accusing Depp of trying to KILL her and trying to push her sister down the stairs, that the jury just could not believe it. If she had stuck ot he slapped me once or twice they may have bought her story. But it was so over the top. Maya and Mr K have, on the witness stand, accused multiple hospitals and doctors besides JHACH of doing and saying malicious things to Maya. It’s at the point of absurdity at this point, IMO)
You would agree with me that under the Budapest criteria Maya had some of the trophic symptoms? Kornberg says besides the dystonia, which was undetermined and likely volitional, there were no others under that criteria that he saw in Maya. If they show weakness then they are consistently weak and Maya was variable. She could easily do things that she wanted to do during “down times’ when she believed she was not being evaluated.
And then #4 is that no other diagnosis can describe her symptoms. Kornburg mentions yes, the psychological issues, possible conversion/factitious disorder fit Maya’s presentation. I do not believe CRPS is that inconsistent as Maya’s does. But the psychological diagnosis does.
Thee’s a lot that is possible. Regional means regional. She said it was global. I do not think her presentation is consistent with CRPS.
He says he did not note any child abuse. (They keep saying child abuse rather than medical abuse because everyone thinks of child abuse as someone physically hitting their child)
Marissa Higgins on a specific date noted general observations indicate that mother was present during second half of PT and presented improved motivation.
Input from various interdisciplinary team members, many of whom are medical doctors, not one of them ever suspected CRPS.
He talks about the incident where the mother mentioned she though she saw Maya’s eye twitch and then Maya said she’d been having blurry vision. This was after they had asked Beata to stay away for a few days. It was noted by many of the team members that Maya’s performance was improved during that time. When Mom returned, she said “Maya I saw your eye twitch just now”. And Maya said her vision had been blurry. She had never told anyone about that, she only said it when Mom said she thought she saw Maya’s eye twitch. This prompted all kinds of neurologic, ophthalmologist exams. None of them showed any issue, nobody aside from the mother was ever able to see Maya’s eye twitch, Maya’s eye exams all came back normal. The final determination was that whatever it had been was now resolved. When Maya was discharged well after it was determined that no issue could be found , the mother insisted that she be given a referral for CT scans and other expensive diagnostic tests for Maya’s eye problem.
What is the import of the last line? Well, this was another problem with treating Maya. She often told her mother she was having lots of different symptoms that she never brought up to anyone else, even though she was asked all the time if she had any new problem or difficulty or symptom. The report of symptoms was always changing depending on who she was talking to.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Ok this is funny. I have a camera in Mom's room. When she is put to bed I turn on the sound on my phone, so if something hapens I can hear.
She is explaining to someone how to make a peanut butter and jelly sandwich. After she told them how to make it there is a few seconds of silence then she says in an irritated voice "Don't just glob it on. Spread it!" Then she mutters under her breath "dumb ass"
Another “dumb ass” hot mic moment! Second one this week!
Off Topic
Sometimes these conversations she is having from her past are so funny. But other times the dementia can be seriously taxing and awful to deal with. I was laughing out loud listening to her talk to whoever she was making PBJs with. It was pretty funny.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Today was like yesterday, I was able to listen but not type. I am going to start with the second witness today and then go back to the first one during the jury lunch time.
Holy crap.
The first witness I will discuss is the detective from the Sheriff's department that met with Jack K and recorded the conversation. There are areas they can't get into, but some of the conversation is coming in. It's a doozy. Stay tuned.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Judge wants to give the case to the jury on November 7th. He’s telling this to the jury.
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Defense witness – Stephanie Graham, Detective, Sarasota Sheriff’s office
Goes over her credentials, impressive
She worked in several areas, court deputy, criminal investigation detective, special unit detective, she’s talking too fast, but several areas of work she was involved with over the years. Currently retired.
Jack is taking a huge drink of water, he kows what is coming. She looks uncomfortable. I think Maya is not in the courtroom today. Neither is Kyle. They are probably being sheltered from the defense case.
We are going to talk about her involvement in a case involving the K family in October of 2016. Special victims unit from June 2012, crimes involved in child abuse and elderly adults. She was in this role in October 2016.
They go to sidebar on first question. From there Mr. Shapiro will be asking leading questions because certain areas cannot be discussed in this case. LOL Mr Anderson is going to cross I guess. His younger colleague is much better and doesn’t waste time.
Once the call is made, the law enforcement is assigned from the Sargeant to an investigator. She wanted to meet with Jack K in pursuant to this investigation. She met with Mr K at the hospital. M. She wore casual slacks, badge, gun. Introduced herself and identified herself as a detective with sheriff’s department. She told him he was free to leave several times during the interview which lasted well over an hour. She recorded the conversation because this is the most accurate way to document the conversation. She puts the iPhone on the table in full view of Mr K.
Mr K told her about a meeting where he had expressed his consent to the treatment recommended by the hospital. Mrs K was not happy about it. They play a short clip from the recording
“When we were in a meeting with the Dr, Beata wanted to sign Maya out and I said wait a minute, I don’t know what she was mad about, but I asked her to just listen. I asked the doctors what is the time frame. I thought it was doable. “
“I don’t know why Beata was so resistant”. Did he make other statements about his agreement to the treatment by ACH? Yes.
Detective “Why would someone go to such extremes”
Jack “She told me this was the last resort”
Detctive “But you know it’s not. And all it would have taken is a question from you somewhere along the line that are we doing the right thing, maybe we should talk to another doctor and do something more conventional, not something that could possible kill your daughter. “
Jack (I couldn’t understand exactly what he said, I believe something about deferring to Beata, that’s what I told you. “I’m supportive of keeping her here and getting the treatment they are recommending”
Did Mr K indicate any concerns with Mrs K? yes She wasn’t being cooperative with some of the things that were being recommended and he stated that he was appalled by some of her behavior (if you watch the Netflix special you will hear him screaming at her in frustration asking her to just stop her crap)
Going to play more of the tape
Detective “It’s just, your wife is (I can’t tell what she says here)
Jack “Sure, and it’s getting worse right now because, you know, she doesn’t want to cooperate”
Detective tells the jury that Mr K indicated that Beata was interfering with Mr K’s attempts to communicate with Maya.
More recording
Jack “I only got to talk to her once and that was supervised. I told Beata ‘you can’t do that , don’t talk to her about medical stuff. Why do you have to do that?’”
Etective “If her daughter is her main priority, why can’t she follow the rules and do what she’s being told”
Jack “Exactly”
Detective tells the jury that Jack told her there would be times that he would be home alone with Maya and there would dbe no complaints of pain or other issues and when the mother came home the child would immediately be in pain.
Play another clip:
Detective “When nobody else was in the room but Maya and the staff she would be normal. When mom would walk in the room she would complain of pain ”
Jack “ I heard that too. “
Detective “There is no other explanation”
Jack “I noted that too, when I was home alone she would be fine…”
Detective “she would be fine, no complaints of pain”
Jack “yeah, no complaints at all. But then when mom came home, there would be the pain again.”
Detective tells jury that Jack told her if Maya comes home I will have Beata move out of the house.
Play another clip:
Jack (unintelligible) ….”if Maya was released from here and I could bring her back hom, I would have my wife move out”
Detective “That’s my next question”
Jack “Absolutely. My honor (something)
Plaintiff cross exam
Oof, he is hot, hot, hot. He tells her there is a technique when trying to get a confession out it’s called flipping the accomplice, is that true? She says she hasn’t heard that term. She calls it doing an interview. I’m not sure I understand your question.
He says she would use threats of prosecution to get someone to talk. She says she told him about a person can be put away for 10 years as part of a conversation where she was explaining to him that sometimes a parent loves their child and does not intend to do any harm, but if there are unintended consequences, there is a punishment for that.
Mr Anderson tries to reframe it to make it look like a threat. She says no, that she wanted to make sure he understood that if a parent thought they were doing the right thing and there was a bad outcome for the child, that is possibly something that parent could be punished for their actions.
He’s trying to make something sinister about the fact that she used the word “opportunity”. Then he says that is not exactly how it went down. She says she asked if she could speak privately and they were given a private room. The room was arranged by Cathy Bedy (the social worker) and she met the detective at the hospital lobby and took her to the room.
The detective had medical information that was provided by Sally Smith. (These are the two people that have been made to be the evil ones)
Sidebar
She had information provided by Dr Sally Smith and DCF. She had a Sig Sauer. She says it’s possible that the first time Jack and Maya had seen her Ms Bedy may have been with her as they had rode up the elevator together so Ms Bedy could show her which room she could meet with Mr K. Mr Adnderson is trying to say “you worked with Ms Bedy and you worked with Sally Smith”. Objection, sidebar.
Someone provided a room. She sat on one side of a table, it was a small table, a family waiting room. Did you sit down between Mr K and the door? She doesn’t recall. She had a badge and a gun sitting with Mr K in a visitor room. And she asked if we could talk. She did not say “I am going to record you”. The phone was on your purse – she says no, she puts it on the table, you can tell how clear the recording is. She does not recall if she specifically told him it’s recording, but there is no right to privacy when you speak to the police they can record you any time you speak to the police. But she was not hiding that she turned on the record button and set the phone on the table.
She was not aware he was represented by a criminal attorney. He never asked to speak with an attorney, he said he had an attorney representing him in family court. She is not specifically required to tell him he has a right to have an attorney present, she did tell him multiple times he was free to leave at any time. He was not in custody. She had a DCF report and a medical report voicing concerns about the health and well being of the child with the focus on the mother and her inappropriate behavior and yes, I did have a reasonable suspicion to go and speak to him to find out what his opinion was on this matter. That is why I requested to speak to him.
She says she did ask him leading questions but he was very forthcoming in offering his own information that I did not ask for. She states that there was a time later in the conversation when she was pressing him for why wasn’t he asking more questions and why was he allowing certain things to happen with Maya’s treatment. Mr Anderson says “you told him in the question the answer that you wanted”. She says that is incorrect. She says you would have to refer to the entire recording to get a full picture of the demeanor of both of them throughout. She told him right at the beginning that if he was not comfortable answering any question that he did not have to answer it, she told him if she had spoken anything incorrectly that he should correct her and in fact he did correct her on a couple of things and she thanked him for that. It was not a conversation where she was throwing questions at him really fast, he was able to ask questions, they were having a conversation back and forth. I thanked him for sharing information with me,
Cooperation is not unusual. I worked child abuse investigations for five years and parents are always involved. This was a very complicated investigation not the same as a typical one we think of where the child has bruises from physical abuse.
He tries to get into asking her questions about Mrs K’s psychological problems and the judge asks attorneys to come up to the bench before the defense can even object. ( Probably another spanking and reminder that he’s using up time on something that will not get him anything. The recording is what it is.)
They come back and he’s shuffling through papers. Now wants to see the judge again.
She does not interview the child, that is generally not done by the investigative team. She never met Mrs K.
Redirect
She told Mr K several times he could leave at any time.
She told Mr K she was “out of her jurisdiction” and tells the jury she only has arrest powers within Sarasota County and the hospital was outside that county so even if she had any idea whatsoever to arrest him, she was not legally able to do so. She says they talked about the fact that he had been a fireman and they also work under the concept of jurisdiction and he would know the full meaning of that term. She reminds the jury of things that he offered without her asking leading questions, and stated there are many things he volunteered on that interview that they had not heard.
At the end of their interview Mr K gave her his cell phone number and he told her she was welcome to come to his home if she wanted to talk to him further.
Jury questions:
1. Did you show Jack that you wre carrying a gun? It would be normal for me to wear it.
2. Was he aware that you had it on you? (oh brother) it is part of my uniform, it’s always carried, we don’t conceal it.
3. Do you remember if you gave him your business card before or after you met with him? At the very beginning of the conversation he requested it, I gave it to him and it’s all on the recording
4. When you say this conversation is voluntary, did you tell Jack there would be consequences if he did not speak to you? No, I would not tell someone that, it isn’t true. He was under no obligation whatsoever to talk to me.
5. If you were out of your jurisdiction why were you interviewing him? Because we were contacted by DCF for Sarasota County, the family lives in Sarasota county, and that is not unusual to interview someone wherever they currently are when a time for meeting can be arranged.
6. Did Jack inform you of his service? He told me he was retired, but he made a comment that he was a medic
7. Did he demonstrate from that service that he understood his rights and that he had a right to not participate? There was no discussion about that. He was willing to converse with me(I’m sure defense will clean up. She did tell him herself that he had no obligation to stay and he could leave at any time)
8. Did he mention his legal counsel? He mentioned hiring Deborah Salsbury and that was part of the family court process, which is a separate process from my criminal investigation.
9. In your experience do members of services such as firefighters usually have more knowledge of their civil rights than the average citizens? I would not have an answer to that
10. Did Jack exhibit any non verbal behaviors that indicated a discussion was not wanted? No
11. Were you there to “get to an anticipated conclusion” or to seek the truth? I was conducting an investigation to get to the truth
12. Did you inform Jack as to reason for the interview? I don’t recall the exact verbiage, but I explained to him that we got a report from DCF and that I was following up on those reports.
13. You said it was probably your iPhone that was used for the recording. Where was it placed? Based on the fact that there was a table in the room and the recording was very clear it would have been on the table. That is my practice if a table is available. It was probably sitting closer to me than to him.
14. Was Jack given the notice that the interrogation was being recorded or the ability to refuse? First it wasn’t an interrogation, it was an interview. There is no obligation to specifically inform anyone they are being recorded, there is no right to privacy if anyone is being interviewed by police. (She already said she took it out and turned it on and put on the table and he was sitting right there)
15. Yes or no, was there an opening statement on the recording that stated a date, time, names of attendees and statement it was being recorded? It did not. (Good lord, these jurors think that nurses now have to take out their iPhones while attending a patient and record everything or else they are lying., per the questions from the past few days. I wonder if they think Maya is lying because she didn’t record with her iPhone)
16. If not, is it your usual modus operandi to record in that manner? It would not be unusual , no. (so, he only has to tell the truth if he knows he’s being recorded?)
Defense Follow up:
A recording is the most accurate way to take down everything that is being said by both parties, both Mr K and myself, for both of our benefit.
Plaintiff follow up:
Wants sidebar first
Did you tell Jack K that you don’t care that you would put his wife in jail tomorrow if it means Maya gets better? If you are saying that is what is on the recording then yes, I don’t recall every word in perfect detail exactly as I said it from that long ago.
And did you remind him of what good it would do for both Kyle and Maya if both parents were put in jail? Objection, argumentative. Overruled
She asks him to repeat the question.
Now, he asks a different question – Did you ask Jack what good it would do Kyle and Maya if both their parents were put in jail? She gets a funny look on her face and says I would have to look, but if you are telling me that is what is on the transcript then I guess so, but I don’t recall that. (that wasn’t admitted into evidence, only the parts that were played. Not sure why this is allowed in) At the end she sees the quote.
Redirect
That conversation came at the very end after all the conversation when Jack was telling me he was trying to be protective, this was the context, that it was important for him to make sure he was protecting Maya from any medical treatment that might end up having negative consequences for her. She was encouraging him in that endeavor. Mr K was indicating that he would do anything to keep Maya safe and her statement was in the context of the entire paragraph of that part of the conversation.
At any time in your interview did you ever threaten to arrest him? No, and even during that conversation I made sure he understood that he was not at any risk of being arrested
Plaintiff
Mr Anderson says “didn’t he tell you that his wife would never harm the child?”
She says “he said that he believed that Beata was intending to take Maya back for the same potentially dangerous treatments that she had undergone already in Mexico.
Did he tell you at least twice that he didn’t believe she would do anything that would harm the child? Yes.
More jury questions
1. Did you talk to him again over the next few months? Yes
Excused, lunch break.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Ms Masecca and the attorney for DCF is sitting in with her.
She is a therapist. She worked for DCF as a CPI investigator and supervisor. Worked for them for 6 or 7 years. Not a JHACH employee
From 2013 – 2019
She had some involvement with the k family matter
In October of 2016 she was sheltered but physically in JHACH
Visitors were required to have background checks in order to visit Maya
She was involved in communicating with Mr K about this
Various people actually did the background check. Mr K had to give her the names. Regardless of what job they had, including priest, they had to have the background check and be vetted by DCF
Do you remember back on Oct 24, 2016 being involved in what items could be brought into the room by her father? Yes
Specifically did you deny the razors? Yes, the communion? Yes. Was thee concern there might be liquid ketamine on the communion? Yes
Lots of other items were allowed in.
Plaintiff
Email between herself and Cathi Bedy on Nov 29, 2016. Did Cathi Bedy listen in on phone calls. Yes
She excluded the razors, and communion wafers. Allowed chapstick, nail file, bath needs, etc.
Was there ever a time you disallowed shampoo, chocolate cake, a dress, prayer book, rosary beads? No
Redirect
The email of Nov 29 was that a phone call on that particular date? She doesn’t know
Was DCF monitoring outside food to be brought in? Yes, any items from outside
Judge is giving an instruction to the jury – the parties have agreed that the phone call being referenced by the Nov 29 email was a pone call that occurred on that date. (The defense was hoping to confuse the jury between this phone call and the famous one where Ms LaPorte had to interrupt and the defense, Maya herself, is trying to say it was Cathi Bedy who interrupted that phone call. There is an email that Ms LaPorte sent to Beata right after that phone call explaining why she had to interrupt, that she didn’t want to interrupt and if Beata sticks to a quality, positive phone call she wouldn’t have to interrupt. So far the judge is not allowing that email in, even though it is clear the jury needs clarification because of jury questions about it. Maya says one thing, Ms LaPorte says another and Ms LaPorte’s email confirms Ms LaPorte’s statement that it was her and not Cathi Bedy that interrupted that call.)
Jury questions:
( Maya is now in the courtroom and flirting with the jury. Smiling at them. She is her usual pouting self, only smiles when she’s making efforts to connect with specific jurors but otherwise she sits there with her sad face on the whole time)
1. Why did you let computer workbook in when you did not let her have her laptop? I don’t recall a specific reason between one and the other (she was only asked about a specific day and the laptop was a different day, I think the question is confusing to her)
2. Was the communion wine or crackers in a sealed package? I don’t know
3. Was she aware that there were some vials on one day that had oils or something in it that could have had ketamine in it? She was not aware of any of that
Defense follow up
No
Plaintiff follow up:
Are you in Sarasota? No
Where was your office in 2016? Sarasota
Did you ever go to JHACH personally? No
Is that why you don’t have any knowledge about whether the communion wafers were sealed? Yes
More juror questions
1. Did you have an assigned single contact at the hospital? It wasn’t assigned, but the majority of my contact was Cathi Bedy
2. Idd mor than one contact you, if so, who were they? She doesn’t recall, she could have spoken with nurses, but she doesn’t recall without seeing it on her notes
Defense follow up
You didn’t get over to the hospital. Do yu recall Ms Nehouse (Tory, her testimony was yesterday) Yes, I recall, she worked for the Safe Children’s Coalition and she was there in person several times
Was she the one on October visit regarding the communion wafer and what could be let in and what was left out? Yes (so, not Cathi Bedy)
Nothing further
Released from all subpoenas
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Defense witness – Jack Kowolski via video (recorded? He was in the courtroom earlier, I’m confused)
(Maya keeps looking over and smiling at one of the jurors, it seems to be the same one she’s looking at each time)
Is it your contention that everything you said to Detective Graham is untrue? Everything I said to her was true (he puts stress on the word “was”)
Nothing from plaintiff
( the comment section is going to start calling Mr. K a troll after today)
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Defense witness – Dr Revivo Works at Lurie in Chicago. This is where Beata took Maya after she didn’t get the answers she wanted in Tampa/Sarasota - by deposition.
He is board certified pediatric physician, with a specialty in pain management and spasticity management
He has fellowship training in pediatric physiatry. Physical medicine and rehab is a 4 year program after all the medical school and training
Did you treat CRPS? Yes
Expert? Yes
Approx how many cases up until the point he encountered Maya? Probably 30-40 cases, it’s rare
The other big component of the program is cognitive which is important in the pain management – he lists the kinds of stressors that affect pain.
Cognitive behavioral therapy./
Three main modalities for pediatric CRPS? Cognitive behavior therapy, occupational therapy, and physical therapy
Are there times when anesthesia is used as a “block”? If we are not making headway in treating allodynia and other pain I send them to see if a central nervous system block or peripheral nerve block can desensitize or anesthetize the pain
How often do you involve this tpe of block in pediatric patients? 5 or 6
Do you recall anyone using ketamine to treat a pediatric CRPS patient? No
In pediatric circles you do not consider ketamine to be standard of care? No. Why? It’s efficacy is not proven in pediatric patients or recommended for children.
You do not refer patients to providers for ketamine? No, we’ve never had that conversation.
Tell me a little about Rehab institute of Chicago. Freestanding rehab hospital providing services to adults and pediatric patients, inpatient services are provides as well, we get referral from other institutions, we have some intensive outpatient treatment for patients well enough to be in the home setting but still get intensive treatment. OT, speech therapy, in my specific work I see children with cerebral palsy, spina bifida and lots of other conditions involving pain, inpatient are mainly for traumatic injury
He reviewed his progress notes and emails. Is he familiar with a ketamine coma. Every heard of Anthony Kirkpatrick? No. Ashra Hanna? No,
Not familiar with any publications by Kirkpatric or Hanna
Ever hear of a pediatric patient receiving up to 23 mg/kg of ketamine for treatment of pediatric CRPS? No
Exhibit one he recognizes as a consultation for Maya K at Lucie Hospital in Chicago as an inpatient in 2015. 7/23/15
He personally interacted with Maya and so did Dr Rohas
After reviewing records, Maya seems to have low cortisol levels but not related to her symptoms. That was a note from previous doctor, he doesn’t know what that is about, has no insight as to why this note is here from previous institution
Any independent recollection of interaction without notes of Maya and Beata
Today Maya is having pain. She describes it as related to her entire body involving legs, arms, head, and back. Is that the typical type of pain condition you see with CRPS? No
Well the very definition, it complex and it regional, so typically it involves a single limb. But not all over and not back, head, trunk. He has seen a single patient with a limb and a trunk, that is a special case called hemiparesis. Not common at all.
Never seen a patient with “whole body” CRPS. He’s seen plenty of patients with whole body pain, but into CRPS.
Someone with widespread pain is not all over. Some patients may have more than one limb, sometimes it may start it one limb and move eventually to another rlim. But not all over the body.
Notes indicate Maya is unable to walk, can’t sit up independently, mom carries her to the bathroom? Correct
Notes say she is moaning and crying without tears. She stops moaning to answer questions, then goes back to moaning (this is at least the third doctor that has made this observation, it is not normal for someone with high level of pain)
Putting that information in the exam notes allows us to create a clear picture of the patient’s presentation. There is clearly a behavioral/psych component to her pain. This doesn’t happen with severe pain or pain that has physiological source.
Behavioral relates to movement, facial, in this case the behavior is moaning and crying, but with no tears.
Note says refuses exam due to pain. It looks like as we went through the exam under sensation she screams when she gets light touch (allodynia is not “pain pain” it has a quality that is very different and hard to describe. You don’t scream and cry. But you would slap someone’s hand away because it just irritates the skin so badly. But not as in “pain”. I believe that when Maya’s mother researched CRPS she probably asked Maya if she’s sensitive to touch. Maya being a 10 year old is complying with what her mother wants her symptoms to be and she’s reacting the way she THINKS extreme sensitivity should make her act. But that is not how anyone with allodynia actually acts. They will slap your hand away if you try to touch, or they will see your hand moving to touch and they will put their hand between your hand and the area they don’t want you to touch. The way Maya tries to act out allodynia is one of the dead giveaways that she doesn’t truly have it. She’s acting it out as if it has the same quality of pain. It’s completely separate from the constant burning pain of CRPS.)
During the assessment if providing a sensory input is providing too much pain then we stop at that point. When asked to wiggle toes she does this, but screams like she’s in pain. (CRPS pain is not related one tiny single bit to movement or activity. It is present all the time, does not get better if you stop doing something and does not get worse if you begin activity. It is completely unrelated to activity. This is another area that Maya’s pain doesn’t show characteristics of CRPS pain)
We are getting a sense of whether the patient has any ability to move any part of the body. What kind of neurologic function do they have to move any limb. Moves upper extremities against gravity, so she has that ability. Also she could move her lower extremities, however when we specifically asked her to do so, she couldn’t do it and would scream.
Needed assistance getting around. He came up with an assessment and recommendation for steps moving forward. She shows the behavior to pain sensitization, conversion disorder. Mood and anxiety needs to be alleviated. She would benefit from physical and occupational therapy and psychological treatment, and cognitive behavioral therapy. He says they have been “asked and asked” (Beata?) to consult this patient and possibly our program could help this patient.
What is conversion disorder. That is an older term used at the time. It’s described as functional neurological symptom disorder, they have a basis considerably overlayed with psychiatric disorder. So, she has a neural experience of pain, he’s not saying outright Munchausen in Maya based on this exam.
We’ve seen patients with more than one limb with CRPS, but not whole body pain. Her mobility issues are strange, she demonstrates the ability to do it, except when she’s asked to do it. In 2015-2016 the term is conversion, he is not critical about the use of this term, that was proper for the time.
Clearly she lives out of state, would she find something similar closer to home in Florida. What is the type of program you would recommend. These would be cognitive behaviorally based, physical, occupation therapy, psychiatric. She needs a return in function while reducing her pain perception. He did not recommend pain meds at this time.
Jennifer Rickart – she is the clinical manager at our clinic. Beata was asking about the services we offer, Mrs Rickart responded appropriately. Does he use an intrathecal clonidine pump? No, he does not recognize this as standard of care for pediatric CRPS.
What meds would you recommend in general for pediatric. Gabapentin, Lyrica, antidepressants to try to change the neuropathic signature. That’s as far as we will go. Not ketamine. I don’t have experience with it, not a normal treatment. PT, OT, cognitive behavioral – yes, that would be standard
The emails are unclear about where Beata stood on how she wanted to proceed (we know she shut it down as soon as she heard of any psych involvement)
Does not recall any contact from JHACH directly to him
Budapest criteria? It provides a construct to help diagnose CRPS. How to sift through the other possible diagnosis. If you can’t explain it, everyone has it kind of thing. He uses Budapest criteria. Provides for better accurate diagnosis for appropriate treatment.
He did not diagnose Maya with CRPS. Conversion disorder is a big part of what he saw. He did not put CRPS on her differential because the presentation had no specific injury followed by the appropriate symptoms, especially the kind of pain and location of pain. They got none of the symptoms of CRPS.
Now Mr Anderson’s voice laysplaining (lay = layperson) CRPS to Dr Revivo, a pain management specialist. LOL.
His cross exam on Plaintiff gets them nothing.
Back to defeinse:
He talks about CRPS lesions. CRPS lesions do not look anything like Maya’s lesins. CRPS lesions are more like patches of discolored skin, can look almost like a large bruise (I agree with this, I have never seen things that look like scratches called “CRPS lesions”. That is just outside anything you will find in any literature. Again, I think that Beata read an article and it didn’t have photos and she assumed Maya’s dermatologic scratch looking things are “lesions”) The photo taken of Maya from the famous before and after photos is clearly a scratch and he says so. It is not a CRPS lesion. It’s on the forehead, Thee is no edema, which is always present in a CRPS lesion. They are not discreet longish marks. They are areas of swelling that are discolored, almost bruise like in appearance. They are often purple or red, sometimes dark enough to look almost black. And they are patchy not lke a linear mark.
(There is lots more, he basically says the things I have ben saying, but with one huge problem. He is aloof, she talks over everyone’s head, uses medical terminology which they will in no way understand in the way that hopefully some of you might understand from my more “non medical” descriptions. He’s not friendly, seems full of himself, somewhat arrogant. This jury in no way is going to take his obvious (to me) expertise over the friendly, folksy banter of Maya’s CRPS quacks. Sadly, It’s a lot like how people love Trump because he’s “so honest”. That is how they responded to Maya’s quacks. They came across the way I wish this guy had come across. He probably moved nobody.)
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Defense. 2 hour deposition – Dr Farhan Malik – JHACH
Treated Maya K, goes over his credentials. Osteopathic medicine. Long Island. New York, 4 year program
Give differences between MD and DO. Very similar, but take additional courses in osteopathic manipulation. Osteopaths take a more holistic approach, the philosophy is treat the patient as a whole, not just the symptoms. Osteo’s tend to be more hands on.
Critical care with a focus on cardiac intensive care. Residency in New Jersy 2009-2012
Fellowship in Pediatric Critical Care in Houston Texas
2015 licensed to practice medicine in Florida. At the time he saw Maya October 7th had been licensed in Fflorida 17 months. Sounds right
Fairly young. Yes. Licensed also in New Jersey.
Describes what a pediatric critical care physician. Took additional courses in psychiatry as part of CEU. He has a large list of CME’s for psychology. Not specific to pediatric. (Plaintiff lawyer is minimizing his CEU’s by describing them as “quizzes” that he took.) They were not specific to CRPS.
I rely on my medical training when treating Maya as a patient. He doesn’t usually treat medical child abuse patients in cardiac critical care. Not an expert in medical child abuse. Not an expert in factitious disorder by proxy. Not expert in conversion disorder. He says that Mr Anderson is listing psychiatric disorders and that he is a medical doctor not a psychiatrist.
Has not personally met Dr Sally smith. He may have spoken to her by phone about this case, but doesn’t recall. He knew of her, but didn’t know her. She is our go to person to speak to if there were concerns of child abuse.
If there are definite suspicions of child abuse JHACH policy is that Dr Sally Smith is the person who is contacted. She specifically handles those issues. He believes that she was supposed to have been called first, not just directly call the hotline. There is a contact number under all the specialist list.
Has he run into Maya any other time before Oct 7. He did not directly make a call to the child abuse hotline. He would have to review the records to see exactly who directly called. He knows Dr Teppa Sanchez. She is a colleague. Worked together for a couple of months at that point. Same specialty, pediatric critical care.
Protocol for child abuse suspicion – you contact Dr Sally Smith (sidebar). Tells jury they are going to try to shorten the video. They need to go to jury room.
(Apparently something went wrong with the editing of the video. For deposition, each side specifies the start and stop time for each section of deposition they want entered. Then someone has to edit if and produce a video of just these portions. They make one tape with all evidence for both sides presented in one video to the jury. Some of the issues regarding the dependency hearing and child abuse investigation stuff are not admissible in this case. I think someone made a boo boo)
I think the lawyers and judge are going to try to use some of this time to argue about exhibits. The jury is being told they can go home now, it’s going to take time to edit the video.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Dr Zachary Pitzenberger – Chicago – by deposition
Pediatric ER physician. Goes over credentials.
Lurie Children’s hospital in Chicago.
In 2016 he spoke at a conference, his paper was “Child abuse, overcoming the Disbelief”
The talk was about detecting child abuse in ER and hospital setting. Signs and symptoms that could be indicative of child abuse.
Reviewed his notes on a July 2015 visit by Mayak to Lurie Hospital in Chicago.
He also wrote a paper on “Trends in Pediatric Visits to ER Department For Psychiatric Illness”. 2014. Project he completed during fellowship.
Many patients come in with psych concerns, he has training in screening psych illness in ER.
After she left ER are you familiar with where she went from there. No. How did she arrive on July 21 2015, by ambulance. (Maya and Beata flew to Chicago to go to Lurie for 2nd opinion. Then I guess they called an ambulance)
How to the “Chief Complaints” get in the chart? The source would be the patient parent and the nurse would have charted it.
HPI information is provided by the patient or the patient’s parent or caregiver. At the time of this intake the hospital would have been provided with discharge summary from the hospital in Florida where they just left.
The HPI indicates multiple visits to healthcare for mystery illnesses related to asthma with a pain complication from the steroids. (Paperwork indicates she was weaned from the steroids during this stay)
Myopathy is the muscle pain from the corticosteroids used for patient’s asthma. Thre is listed possible neuropathic pain. He explains, that would be some type of irritation of the nerves that causes pain. Irritation of inflammation can cause that finding, but according to the paperwork it was not confirmed. It says patient became unable to walk.
He was diagnosed with adrenal deficiency. It’s a complication you can get from chronic corticosteroid use. The hospital indicated they had treated her reported pain with a cocktail of different pain meds including morphine. (That is one of the pain meds Maya was demanding when the nurses came in to give her Tramadol)
Neurology consult. Pain management. All these were done at JHACH. Mom requested discharge and transported Maya to Chicago to go to Lurie Hospital. Under medications several are listed with some of then having a “last given” date.
Past medical history indicated no history given. (this is typical in MBP and other situations where someone is seeking treatments not necessarily indicated)
The medications given part of the record was per patient report, not from them getting confirmation of from the hospital.
Beata reported pain and weakness beginning 15 days ago, steroid myopathy and myocytis. JHACH indicated possible neuropathy. His understanding was she wanted a second opinion regarding these diagnosis.
In ER we assess their physical state of being, and document that. Hands on assessment. He performed this assessment. Vital signs are noted. Pulse, respiration, temperature. 75 BPM is on the low side of normal for pediatric female 9 years old. Same for BP. Same for temperature. Weight seemed normal for her age at this point. She was awake and responsive, no dehydration noted, no signs of distress. Lungs and chest. No abnormal sounds. Any sign of asthmatic episode? No.
What does normal mean for skin? No rashes or changes in skin. No lesions, no rash,
Under neurologic the patient would not cooperate, but she was observed to be able to use muscles normally and demonstrated good upper arm strength when doing tasks not asked to do. (this is a pattern) What is this describing> Difficult to perform as she did not cooperate, but she appeared to have normal strength when doing things on her own without being asked specifically. She could lift her own body weight with her arms.
Generalized muscle weakness and myopathy. There was a concern for conversion disorder so lab testing and other testing was planned. Trying to get objective findings. What is conversion disorder? A psychiatric disorder where patients display physical findings that do not appear to have a physiological source. Often a manifestation of a psychiatric diagnosis. It was one consideration but not necessarily confirmed at this time. Psychiatric eval is not done in the ER so that would have had to be done after admitting to hospital.
CK was “reassuring”. It was in the normal range, meaning no muscle breakdown. So, the myocytos was puzzling, again, no physiologic reason for it, along with displaying muscle strength when doing things unconsciously.
We were planning on giving her a dose of morphine to help with pain.
Janis Zhianni – ARNP. She provided an assessment. She brings her findings to the doctor and they come up with a plan of treatment. The doctor will do his own assessment to confirm the ARNP findings.
On his exam her noted that patient would not cooperate with exam. She moaned and screamed in pain, but when he tried to talk to her she immediately stopped moaning and crying and had no problem talking without showing any signs of distress. As soon as the conversation would finish she would start moaning and crying. She had no cough and lungs sounded clear, but after prolonged screaming and moaning and crying she began coughing.
The information from ACH was that she presented with steroid myopathy which left her weak and unable to walk. After treatment at ACH, she made no progress in spite of being weaned off the steroids. Mom became frustrated after treatment for 3 weeks resulted in marginal gains and she left ACH and came to Lurie for 2nd opinion and treatment.
3rd paragraph says mother requesting further diagnostic workup. He touched the top of her foot and she screamed so mother requested no more assessment. She was able to easily distract when asked questions, she would act like no pain at all, then she would quickly go back to screaming and crying. This is significant to an ER physician because if she can be easily distracted away from noticing her pain it means it is not very severe. The term distractible appears in the medical chart. It means the patient can easily be distracted away from her pain by getting her to notice other things.
Not in any significant respiratory distress and her pain is less significant than she is reporting. Skin pale, no rash. No localized changes in skin, such as “lesions”. Assessment moving forward was that she may have residual steroid myopathy, she was behaving as if she had severe pain beyond what someone on her medications should have, but with signs that her actual pain was not as severe as reported since she was easily distracted away from it. Labs do not show signs of possible muscle injury. Her behaviors are concerning for psychiatric component of her pain, possible conversion disorder given distractible nature of the pain, atypical presentation of pain for the given condition, and reporting of significant pain in spite of being on significant pain medications. He says her examination was concerning for an underlying psych disorder. Can’t diagnose at this one exam, but needed to be examined further.
Conversion disorder was on the plan due to the nature of the pain as noted above. Admitted her to Gen Med. That Is where specialists would be able to assist for consultation Psych and pain management primarily. Rehab Institute of Chicago (the previous doctor testimony was from that institute)
Ketamine is not used as infusion in ER. Only bolus is used. ER is not set up for that. Has to be done in ICU for infusion. Close monitoring and administering provider must be present the whole time as well. Bolus dose of ketamine is 2 mg/kg. Ever had a patient come in asn ask for 1500 mg of ketamine/ no
Why does ER not administer more than 2 mg/kg? Abose the manufacturer dosing range. Propofol is not used in ER. Intrathecal pump is not done here either.
Plaintiff
Mr Adnderson is challenging him that the Mom was not acting in unusual or concerning manner. He say he didn’t see that at this visit. If a parent was acting in an abnormal or unusual manner would you incorporate that into the record. Depends, maybe maybe not.
He doesn’t know anything about Maya’s treatment outside of his meeting her at Lueie as noted. He is familiar with MBP. He did not make that diagnosis.
He did not note anything to indicate MBP from her ER visit at Lurie. Any experience with CRPS? Yes. Insofar as her extreme reaction to touch, could this be an indicator. No, I would defer to a specialist, I don’t make that diagnosis in ER.
The top of her feet is the only area that touching was causing her to scream. He agrees that Maya behaved atypically. Could that be CRPS? Defer to specialist I don’t make that diagnosis.
He is continuing to tell Mr Anderson that he does not diagnose CRPS in an ER setting, it is far more complex than what can be diagnosed in an ER visit. He’s asking him about these weird devices that Dr Kirkpatrick claims are able to detect pain level.
He is aware the diagnosis that are listed in intake were from JHACH. He is not an anesthsiologist. He doesn’t treat CRPS in ER. He did not do EEG, MRI, etc in the emergency room setting.
Have you ever treated patients with CRPS? Yes, a handful of CRPS patients have come through
Have you ever place CRPS as a differential diagnosis for pediatric patient? Yes
Was CRPS on differential for Maya? No, her reported pain involved almost her entire body and that is not what Is seen with CRPS.
Plaintiff
Anderson is trying to give this doctor a quiz on CRPS. He says he’s not an expert on CRPS, he has seen it, he as seen patients that presented with clear symptoms of it, we consider all reasonable differential diagnosis for all patients.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
I'm curious, what is her life like today? Is she still having all these problems, or is she closer to "normal"? I think I've seen that the's 17 now? Is there any plan for her to take care of herself or does she still require home care?
Kriselda Gray wrote: ↑Sat Oct 21, 2023 10:08 am
I'm curious, what is her life like today? Is she still having all these problems, or is she closer to "normal"? I think I've seen that the's 17 now? Is there any plan for her to take care of herself or does she still require home care?
Thanks!
She left the hospital under court order that she cannot resume the ketamine or opioids. She was restricted to all the therapies that all the various doctors had suggested as being good therapies under the idea of conversion disorder. She got better within months, regained all strength in her legs. She doesn't use wheelchair, walker, cane or anything. To this day the family has sdmitted she has not had any type of "CRPS" treatment, no pain meds, aside from over the counter.
She is first in her class, President of every club she belongs to, has a boyfriend for over a year, her life is a dream life. However, she claims on the witness stand that is misleading, she has "good days and bad days", which is normal for peoople with psych issues, but not for CRPS.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
Kriselda Gray wrote: ↑Sat Oct 21, 2023 10:08 am
I'm curious, what is her life like today? Is she still having all these problems, or is she closer to "normal"? I think I've seen that the's 17 now? Is there any plan for her to take care of herself or does she still require home care?
Thanks!
She is doing just fine. Going to school, has a boyfriend and functioning normally. This girl is going to have lifelong trauma. If the jury awards this girl damages, it's only going to further psychologically reinforce her belief she has/had CRPS.
From Rivnit:
Note says refuses exam due to pain. It looks like as we went through the exam under sensation she screams when she gets light touch (allodynia is not “pain pain” it has a quality that is very different and hard to describe. You don’t scream and cry. But you would slap someone’s hand away because it just irritates the skin so badly. But not as in “pain”. I believe that when Maya’s mother researched CRPS she probably asked Maya if she’s sensitive to touch. Maya being a 10 year old is complying with what her mother wants her symptoms to be and she’s reacting the way she THINKS extreme sensitivity should make her act. But that is not how anyone with allodynia actually acts. They will slap your hand away if you try to touch, or they will see your hand moving to touch and they will put their hand between your hand and the area they don’t want you to touch. The way Maya tries to act out allodynia is one of the dead giveaways that she doesn’t truly have it. She’s acting it out as if it has the same quality of pain. It’s completely separate from the constant burning pain of CRPS.)
Rivnit is correct. I have a spot on my shin bone from a fracture where I have alladynia. I don't scream out in pain, but I always guard away any touch or pull away from accidental touch. It's a weird sensation. Like having a bloom of nerve endings and it's just really sensitive.
RVInit wrote: ↑Sat Oct 21, 2023 10:36 am
She left the hospital under court order that she cannot resume the ketamine or opioids. She was restricted to all the therapies that all the various doctors had suggested as being good therapies under the idea of conversion disorder. She got better within months, regained all strength in her legs. She doesn't use wheelchair, walker, cane or anything. To this day the family has sdmitted she has not had any type of "CRPS" treatment, no pain meds, aside from over the counter.
She is first in her class, President of every club she belongs to, has a boyfriend for over a year, her life is a dream life. However, she claims on the witness stand that is misleading, she has "good days and bad days", which is normal for peoople with psych issues, but not for CRPS.
Wow. That's quite a life she's got going there. Which is good, I suppose - better than if she were miserable. I do hope she gets the psych help she needs, though
I forgot to say that the court order for no ketamine expired a long time ago. So, even though her family is well within their rights to do whatever treatment they want, as long as it's legal, they can. And they haven't . She has not gone back to using prescription pain meds or anything like that. But she's also refused any psych treatment except for the minimal amount the court required in the beginning.
Once her muscles regained strength after being in a wheelchair for a couple of years, she hasn't required any treatment of any kind. Except I would say she needs psych treatment. She sits in court with flat affect and mopey look on her face for the entire day. Except she seems to have recognized a connection with someone who sits in the same place every day (I suspect it's the juror who asks questions as an extension to the plaintiff attorney). She will periodically look at that person and smile coyly for a few seconds, then go back to looking down or at a witness or her attorney acting like she's the saddest, biggest victim that ever lived. It's bizarre.
And her go-to whenever the defense asks her a question where the answer clearly would show that her life is great, she falls back on explaining to the jury that "it's just the nature of CRPS that you have good days sometimes, but I have lots of bad days". And this is why I keep saying the defense made a HUGE error in not putting on a CRPS expert that explains the onset mechanism, how long it takes for any secondary symptoms to come on, the very nature of the pain itself, allodynia is not "pain" per se and not normal for a person to act the same way upon touch, how long would it actually take if any dystonia would happen as a result of CRPS, what is the proper definition of remission (not good days and bad days).
I could go on and on. If the defense had bothered to do this, every person on that jury would be able to see that NONE of these things (and many more) match Maya's documented case PER HER OWN FAMILY as it was progressing through all the medical interventions. And if she doesn't have CRPS and the jury can clearly see that, it is easy to see that the hospital did not commit medical malpractice (one of the counts). They would easily see that the reason she is doing so well is because she didn't ever have it. And here's the thing. They are left with no choice but to believe Maya's quack doctors and believe HER that it is likely to come back, she will become seriously disabled, and she needs millions of dollars to treat it - because they know it is not curable. That is actually a fact. So, they believe she has bad days from CRPS, they can easily believe she will need further medical treatment for it and likely to get millions for that. The testimony by the person who came up with the dollar figure for what she will need is based on her diagnosis of CRPS, it's incurable, and likely to "come back". So yeah, the hospital is STUPID to not put on an expert and they are likely going to pay through the nose because of it. If you want to defend against this, then you have to put on witnesses to defend against what they are claiming. And they are not defending against her diagnosis, which is almost the whole ball of wax in terms of the damages they will end up paying.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
RVInit wrote: ↑Sat Oct 21, 2023 3:16 pm
Except she seems to have recognized a connection with someone who sits in the same place every day (I suspect it's the juror who asks questions as an extension to the plaintiff attorney). She will periodically look at that person and smile coyly for a few seconds, then go back to looking down or at a witness or her attorney acting like she's the saddest, biggest victim that ever lived.
I've been wondering if the looks have been toward the juror asking the plaintiff-friendly questions you've described. And wondering if there's a little tampering. Probably not.
If I were on the jury, I'd be hung up on how huge amounts of serious drugs were given to a 10-year-old. And, yeah, if she has so many "bad days," she wouldn't be doing better than most of her peers.
I was just listening to the lawyers argument about which audio clips from the detective and Jack K interview would come in or left. out.
The plaintiff has made a big deal of how the hospital were the big bad wolf by someone bringing up the possibility of Munchausen by proxy. I haven't seen actual evidence at this point of anyone at the hospital using that term except for the doctor from ER that has passed away and can't be put on the stand. She had a short deposition which was played, the plaintiff grilled her about Munchausen by proxy, which she had actual previous experience with. She gave a talk on it at a conference. She was the first to bring up that she had concerns about something going on with the mother wanting extreme doses of ketamine. But she did not say Munchausen. The plaintiff kept accusing her of it because that is part of their case that Beata was being accused of it. Her actual deposition testimony was that MBP is not something that can be determined by a 2 hour encounter in an ER setting. She was concerned about Beata, she noted her concern and she left it to the ICU staff who took over to do whatever was appropriate while she was in ICU.
That is the bckgrround of why MBP became in issue in this case.
Clips were played for the judge for purposes of him to determine which ones are in and which ones are out. In one clip Jack brought up Munchausen by proxy in the interview with detective Graham. He said he looked it up on the internet and started researching it and he became concerned that this is exactly what was going on with his wife. He felt like what he was reading fit the situation they were in. I am including the video clink below. The video starts out with this audio evidence and discussion of whether any of it can come in as evidence.
On the witness stand, the subject of Jack having discussions about divorcing Beata came up. He claims that this was a "ruse" that they were using to try to get Maya home. That if the court thought that Beata would not be in the house that they would let Maya come home. But this clip shows that there was a lot more to the Jack and Beata story than meets the eye. He is clearly admitting to the detective that when he read about MBP be thought things started to get clear for him about what was going on with his wife and that it seemed to fit the whole situation he was dealing with concerning Beata's insistence on these extreme treatments for Maya. The judge did not allow this clip to be played for the jury.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
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?
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?
The judge didn't really give an explanation of why he was not letting it in. The plaintiff has made a big deal accusing the hospital of accusing Beata of having MBP. Nobody at the hospital used that term, but one of the staff had a lot of experience with it, and she had noted concerning behavior in Beata. So, the hospital is trying to defend themselves and here is evidence that the hospital were concerned, her husband looked up this term, and he believed that MBP description matched what he has been witnessing between his wife and daughter for a almost 2 years. So, the defense thought that was relevant because they are being accused of using that term by Mr K and here we find out that HE thought it applied and offered to tell the detective that he thought it applied. He is a piece of work.
"It actually doesn't take much to be considered a difficult woman. That's why there are so many of us."
you don't owe me any apology whatsoever. I did not take it badly or anything like that. No worries!! I know I had said that entry ws coming like right away. I had it mostly typed up, then things went south around here. 
the comment section is going to start calling Mr. K a troll after today)
