Taking Care of Maya - FL CPS/Munchausen case

Maclilly · #1

I'm starting this thread for discussion of the trial which is available on line. Don't know if anyone is watching but hoped to start a discussion on the legal merits of the case against JHAC for withholding Maya prior to a court order as well as alleged collusion between the hospital docs and CPS. Netflix has a documentary on this case which involves a 10 y/o girl at the time diagnosed with CRPS and was taken by her parents to Mexico for a 5 day Ketamine coma. She was taken to JHAC for severe pain, possibly from the high doses of Ketamine, and CPS was called. Maya was treated for CRPS in hospital while she was there and her mother committed suicide when she learned her husband was going to file for separation in order to be able to get Maya back from custody. It is a very sad case and as a person who has lived with chronic pain since puberty, I understand that Maya's mother, who is a nurse, wanted to do anything to help her daughter. I also feel like her mother might have had a psychological part in Maya's presentation to medical staff and there are some issues I find concerning.

I do not find intelligent discussion of this case on other forums so was hoping to start one here. The case does not seem to me that it is going well for the plaintiffs. I know they settled with the consulting child abuse evaluator but can't understand why they have so badly managed this case against JHAC. They have made new allegations against he hospital that were not noticed previously and have to answer today if they want a mistrial. Thoughts?

#2

RVInit posted on the “Can anyone hear me?” thread about her personal experience with CRPS and her thoughts about Maya.

Ok, so I finished feeding mom and hopefully she will settle in long enough for me to post why I have suspicions that Maya doesn't have CRPS. She may have pain, but I don't see what i expect to see with any kind of severe pain. Not all pain is the same level. And not all nerve pain is the same level. If you check this link you will see that CRPS is the worst pain so far ever discovered. After shingles nerve pain comes in at half the level. Even though it is pretty darn uncomfortable for the person who has it. But even that person cannot possibly comprehend CRPS. Which plays into why I seriously doubt that Maya has CRPS.

CRPS has two types. One type is caused by soft tissue injury. And example would be you sprain your ankle and as it's healing for some reason you can't understand your pain is getting worse and not better. Type II is when the injury involves nerve tissue. Either way, it starts with injury of some type.

Maya's parents describe asthma, stomach ailment, sinus infection....then eventually she's diagnosed with CRPS. Whut? Unless they are just forgetting to mention that oh yeah, she sprained her ankle, I'm puzzled how she could end up with a CRPS condition. Because it starts with INJURY of some type. Not just "sickness" or "infection". Injury. And they make no mention of any injury.

More than anything is her disposition in two different situations where she is not being treated for severe pain.

Pain originates from some part of your body, but you experience the pain in your brain. If you have severe pain, but somehow your brain is put "on hold" you will not EXPERIENCE the pain. The pain signal may be present, but you will not EXPERIENCE it. That is basically how pain medication works. It does some magic in your brain to prevent your brain from TELLING YOU that you are having pain. Or at least telling you that you have only a small amount of pain.

Because it's your brain that experiences the pain, anything that is done to cause the brain to do "other things' will automatically divide the attention between the pain you are experiencing and the other thing that your brain is having to do. This is why I have mentioned at other times that I keep myself very busy all the time. It is precisely because the more OTHER activity my brain is having to do, the less I EXPERIENCE the sensation of pain. It's still there. And as soon as I stop the other activity, I become VERY AWARE it's still there. The whole key to it is keep the brain as occupied as possible with anything other than the pain.

This is why when people are experiencing severe pain they will shift around, roll around, sway back and forth, or simply WALK. Even just walking uses brain activity. Your brain has to send a signal to your nerves to make your muscle contract to move your legs. As soon as you stop, the level of pain you were experiencing goes back up.

A person who is experiencing any level of pain will shift, move, etc. Take a gander at the McGill chart again and convince me that some with CRPS level of pain can simply sit in a wheelchair and mope and say "I have pain" but there is absolutely no movement in the body even though they are having the worst pain known to medical science. No. Way. Even in her hospital bed, while NOT receiving treatment for the level of pain of CRPS, she is not grimacing, rolling back and forth, rocking herself, Shifting around, etc. She is laying there gently playing with dolls.

So, if you haven't seen the documentary or watched the trial, the hospital sent a psychologist around and they basically determined that given all the factors, including the mother's behavior, the likely thing going on is Munchausen's by proxy. I failed to mention that, and wanted to mention it because I wasn't just trying to do my own diagnosis. I simply think that between the two, based on my experience and knowledge of CRPS and having been forced into having a pretty good understanding of how pain works, I think MBP is the more likely of the two. I don't believe she has CRPS. She may have some pain, she may have some real medical issues. But she is not exhibiting anywhere near the level of pain someone with CRPS would have.

Just a side note to also understand the kind of toll that CRPS level of pain has. I had a hip replacement surgery at age 40. That is how I ended up with CRPS. During this time we hired a new Admin Assistant. Due to limited office space, and because I am able to focus and work regardless of what is going on around me, I volunteered that they could move the Admin Asst into my office. She met me AFTER I was stricken with this condition and BEFORE I received adequate pain management. About two months after she started working in my office was when I finally met the pain management doctor that ended up helping me.

On the first visit he told me "you are not leaving my office with a prescription for pain meds". I answered "I am OK with that. All I want is a solution to my pain problem, I don't care WHAT that solution is, I will do anything that works. All I want is something that works". This is why he was willing to continue with me. Turns out that he uses this tactic to just get rid of people who are seeking pain meds. So he told me he could try a sympathetic nerve block. I said I am game for that, can we do that right now. He said no. I nearly burst out in tears. I begged him can we do it tomorrow. When I burst out in tears he looked at me, looked down at the chart and said "you are 40 years old, is that right??" and I could tell he looked kinda puzzled as he said that. At the time it went right over my head why he was so puzzled that I was 40 years old. He agreed to do the procedure the next day.

So, I show up for the procedure. I am in the room, get on the gown, he comes in the room and has me lay face down on the table. So I can't see him while I'm laying face down. He starts to explain what he's going to do and as he's explaining he gently puts his hand on the area where I have the most severe pain. I was not prepared for that and I came off the table. I came off so fast and hard I ended up on the opposite end of the room about 40 feet away. He was absolutely gobsmacked and said "THAT hurt???????" Again, I burst into tears, partly at the frustration that NOBODY WAS LISTENING TO ME. How the fuck could he ask me if that hurt. I had been very specific about what the fuck was going on with me.

NOW, he started listening to me. He asked me all kinds of questions and it was very clear that he was actually listening to me because every time I answered him he asked a completely logical new question that made me see... FINALLY I was in front of a doctor that actually was now listening to me. He was very puzzled about why I am having this kind of severe nerve pain after what seemed a successful hip surgery. But he believed me. And was willing to try his best to figure it out. I went home with a prescription for what turned out to the first of a series of pain meds that he was willing to try to see if he could bring it under control while he figured out what the hell was going on.

I got home with the pain meds in the afternoon. I did not go back to work that day. I took a second dose before I went to bed. My prescription was for 3 doses per day. I took a dose when I woke up in the morning. Then I went to work.

When I walked into the office, my coworker, who had worked in an office with me for two months at this point, said "May I help you?". I laughed and walked over to my desk. She came around, told me that actually this is "______'s" office, can I help you? She did not recognize me. She went to get my boss because she was flustered that "someone" was just helping themselves to someone else's computer. My boss came into the office and I will never forget the odd way he looked at me. And he was really really smiling.

When I got home that night I was in the bathroom and after washing my hands I looked up and saw myself in the mirror. Again, burst out in tears. For the first time in eight months as I looked into the mirror instead of an 85 year old looking back at me, there was my previous 40 year old self. And that was with a medication that was so-so. Eventually we hit on a better one, but that first one initially saved my life.

I have now seen video of Maya in several situations, untreated, simply not having any appearance of having gone through, or being in, the hell of CRPS.

#3

I decided to start watching the case, not sure if I will get through it, or if it might be too triggering, but I will try. I will try not to write a novel on each post.

I am not a lawyer, so I can't speak to any legal issues. I could give my impression as a typical person who might be on a jury, but since I have CRPS I may not be an unbiased as a normal juror. My insights to her alleged CRPS might be interesting. I'm really torn on whether I think it's possible she has that diagnosis, for many reasons. But I'm going to open my mind back up on that and see what I think based on testimony.

I'll start by explaining briefly what is CRPS. There are 2 types, with mostly the same symptoms, but differ in severity. Type 1, which is what Maya allegedly has, is the most common. Neither is very common at all, it is classified as a rare condition. It's not even mentioned as a possible side effect for surgery, even though type II is almost always a result of surgery. But that is because it is exceedingly rare. Thank goodness.

Type I - starts with an injury to soft tissue, not nerve tissue. The pain can range from moderate to severe, but it can also be intermittent, i.e. you can have good days and bad days. It can go into periods of complete remission. So far nobody has been cured of it. Ketamine infusions are often used to treat CRPS Type I. 90% of CRPS is Type I. Since type I is most common, many sources of information about CRPS only describe this type and completely ignore Type II, even sources that you would expect to have excellent information, such as Mayo Clinic (last time I looked).

Type II - always initiated by some type of injury or damage to nerve tissue, most commonly it occurs after a surgery. The pain is severe, after a short period of the pain rising to the highest level it stays at that level. It is not intermittent, there is no remission, the symptoms are permanent, no good days and bad days, every day is the same day. It isn't better in the morning or evening, it's just the same all day every day until you pass away. So far nobody has been known to have been cured. 10% of CRPS patients have Type II.

In both Type I and Type II you can have other symptoms - the area that is affected swells, temperature difference in that area of the body (when you touch it often feels hot), dystonia, other symptoms.

I highlighted that both Type I and Type II are precipitated by some kind of injury because when Maya's parents give their story of her condition, they mention various illnesses but no actual injury. This was the beginning of my puzzlement about how she could end up with a CRPS diagnosis. Upon reflection, a possible explanation might be that sources, like Netflix documentary, are edited, and I suppose it's possible that the editors just really don't know enough about the condition that they could have edited out the part where the parents described a sprained ankle or something else. Her parents mentioned so many things - stomach ache, sinus infection, I can't remember what else, but either they never mentioned an actual soft tissue injury or it was edited out.

sugar magnolia · #4

Or perhaps they never made the connection between an injury and an illness. I don't think it would occur to me to tell the doc I broke my arm or took a blow to my thigh muscle when I'm seeing him for stomach pain.

#5

Wowee.

So far I have listened to opening statements by both the plaintiff and defense. If both sides are able to present what they say they will present I think a couple of things are true.

I still have suspicion of the diagnosis of CRPS in the first place. Lack of an initial injury, pain being all over the body as opposed to being "regional". CRPS is Complex REGIONAL Pain Syndrome. She describes pain as all over including the stomach. It night be confusing to some, but even though type I CRPS involves a NON NERVE injury, the pain is nerve related. The stomach does contain a surprising amount of nerve tissue, but CRPS pain is normally in the limbs - arms or legs, not stomach, headache, etc. She simply describes way too many symptoms that you don't see with CRPS, I haven't seen video where her pain is "convincing" and she says it's in areas where CRPS pain just doesn't really occur. CRPS of either type is rare at all, but especially rare in children. Most cases are women, and most are between 40 and 60 years of age at onset. If you are older than that, congratulations, you are pretty much out of the woods.

Assuming she does have CRPS - I am not sure how long it took for the Dr that initially recommended the ketamine, but I believe I'm hearing that he recommended ketamine right off the bat. That is unusual, it seems like other treatments should be sought first, especially for a child. Never heard of ketamine being the first thing a doctor tries for getting CRPS under control.

Also, the amount of ketamine she was given after the initial ketamine coma is way way way off the charts. I would be very suspicious that she's really having the symptoms if a smaller amount wasn't effective. I'm aware of a paper that analyzes 14 studies of ketamine treatment for CRPS showing that 13 of those studies showed it to be definitely effective treatment for people who were not responsive to more conservative treatments. However, the amount given was in the range of 7 mg/kg of patient weight. For a 100 lb person that would be 315 mg. She was around 10 years old being given 1400 mg at a time. Yikes.

Also, she is doing way too fine for way too prolonged period without any treatment. Actually seems to have gotten much better, again, for way to long a period of time. CRPS type I can go into remission but not typically for the length of time she apparently has been "in remission".

Just as an aside, I saw a brief interview with one of the doctors, I think that on the Netflix documentary, where he mentioned he's treated 1000's of CRPS patients with ketamine. 1000's of patients. CRPS is a very rare condition. Maybe he has patients that fly in from all over the place or something. I guess I can believe that. It still seems like an awful lot of people being diagnosed by a single doctor for what is a pretty darn rare condition.

I will start listening to testimony and see what I think...Sorry about the novel.....again.

#6

Not sure what day of testimony this is, but it's part of the plaintiff case.

Maya definitely doesn't have Type II CRPS, meaning she does not have actual damage to nerve tissue. In spite of this, the video is showing she can barely put one foot in front of the other. Normally if a CRPS patient has this type of problem, it's because of PAIN, not because of something else. In spite of this, Maya is pounding each leg trying to get it to move. This is absolutely inconsistent with CRPS. If her legs can't move because of CRPS, she would be experiencing also very severe sensitivity. The kind of sensitivity that if you tried to touch her legs with a feather, she would be coming out of her skin. Similar to what I describe on my second visit with the doctor that eventually diagnosed my CRPS.

Not saying she's faking the inability to move her legs. Simply that in CRPS inability to move a limb is always because the nerves are "frying", they are sending burning pain signal and are extremely sensitive, you can't touch the affected area at all. A fan blowing air at her legs would be causing her extreme pain if her legs were this bad due to CRPS.

Fiascoist · #7

This may be a little off topic, but I represented a young teen whose mother was diagnosed with MBP. But it took a really long time for the diagnosis. So, up to a state's intervention, the child was seen by doctors all over the country and treated for a myriad of "rare" conditions, hospitalized constantly. Treatments upon treatments, drugs upon drugs. This mom fooled a multitude of specialists. It was only because the father was chasing after her and compiling binders of treatments and finally getting those binders to a CSD worker that something finally happened to benefit the childwhile the child was instate. I got involved representing the child and she was, putting it nicely, like a potato, just a lump of protoplasm. (Too many years in a bed in a sterile type situation with no control plus really serious kinda drugs on top of each other). The child had lost a chunk of her childhood to treatment and drugs. I knew her for several years and while she got better, she was never really normal. Too much damage and no connections with any peer groups for too long of time. .

So, I won't watch this, too sad for me.

The dad ended up with custody and I don't know what happened to mom.

#8

The cross examination of the therapist in the video above (last 15 - 20 minutes) was quite bad for the plaintiff, I think. This therapist worked with Maya at a different hospital 2 years earlier than the visit to Johns Hopkins in the time frame related to the lawsuit.

Although the therapist wasn't aware that this other hospital ended up banning Maya's mother from entering the hospital, the fact that they asked her if she was aware of it makes me think the defense will put on evidence that Beata's attitude and interference were a problem as far back as this hospital visit, which was at the very beginning of Maya's apparent illness/condition.

Multiple times on multiple days the therapist noted under "Barriers to Release" were "attitude of family; attitude of self".

Other notes indicated that when Maya was fully aware that she was supposed to use certain muscles she was unable to do so. But when she was only subconsciously aware, she was able to move and use those muscles.

Another note the therapist made was that Maya did not complain of any pain during an entire physical therapy session but when her mother entered the room she began complaining of pain with increasing frequency. (When I watched the Netflix video I saw what I believed were instances of this kind of thing - I could not help but have the impression that at least some of Maya's complaints seemed strangely to be something she thought was making her mother happy. I know this sounds weird, but maybe that is part of the Munchausen thing. It was disturbing to me).

#9

I forgot to mention, in case some of you are listening to the trial, the ketamine thing might confuse you. I believe that ketamine may not have been widely in use for CRPS at the time Maya was in the hospital. It has since become accepted for patients that do not respond to more conventional or conservative treatments. It isn't considered dangerous, but typically administered at around 7 mg per kg of body weight. Maya was getting ketamine at a time when it wasn't universally accepted, and also getting what is definitely considered a huge dosage for a grown adult.

#10

Hooboy. Now know what Smallily meant by it not necessarily going great for the plaintiff (the Kowalski family). It took me a while to find the best place to find the YouTube videos to watch the trial in order.

My impression of the testimony of Maya's teacher is I have to say she was a better witness for the hospital than for the Kowalski's. She is describing Maya as bright, good attitude, everything great, yada yada yada. On both direct and cross. I don't think the direct understands how bad this is and how the hospital attorneys will use this as more evidence that as long as Maya wasn't being egged on by her mother, she was absolutely fine. With CRPS, even type I which the pain can be, but not necessarily, less severe, it's still going to be severe enough to be distracting. If she was truly symptomatic with CRPS symptoms while in the hospital, she should have been having difficulty concentrating, should have been fidgety from trying to get comfortable, should have had real difficulty being a bubbly, vibrant, yay, everything is great student. I'm sure the Kowalski attorneys must be thinking the jury is going to see what a wonderful, bright, intelligent (she was in gifted classes) Maya is, but it just isn't likely she could perform at this level in the middle of untreated CRPS as severe as her and her family are claiming.

#11

Before I found the day to day testimony, I found a video showing only the direct exam of one of the CRPS doctors. He wasn't bad, but the camera kept going back between him and Maya. I doubt that the jury will pick up on this, but I sure picked up on it. I guess maybe my notes on this will be useless in terms of seeing how this witness will impact the jury. Especially since I haven't seen the cross - yet. When I see the cross I will talk more about him.

But here is what struck me as someone who has CRPS. There were times when this doctor was testifying that he was saying things that triggered ME. And I was not ever his patient. CRPS is a traumatizing experience partly because you typically go for quite a long time experiencing severe pain beyond imagining and nobody is helping you because they don't believe it. He talked about that. Being a person who went through that experience, hearing this doctor describe it, even though he didn't dwell on it, was difficult for me because any time you are reminded of what you went through it is very triggering and painful to remember.

Maya's face didn't register anything at all during this discussion by her doctor. She is intelligent enough to understand that she needs to sit at the table looking like a Sad Sack. But she doesn't change her expression at all. Ever. Even during testimony that should have triggered her she has that sad look like some boy she dated for less than a week has just broken up with her. She certainly wasn't triggered by testimony that should have reminded her of the worst experience a person can imagine. Just sat looking like her dinner got cold.

I have to feed Mom now, but I will try to find the cross exam and see what I think about the doctor's overall testimony.

#12

Is that her, is she supposed to still be unable to move, and is she still in pain? She’s not fidgeting at all.

#13

pipistrelle wrote: ↑Thu Oct 05, 2023 7:02 pm Is that her, is she supposed to still be unable to move, and is she still in pain? She’s not fidgeting at all.

You got that right. She was in the hospital for approximately 3 months. She got to go home after her mother committed suicide. Her father was under court order that she cannot receive ketamine or analgesics of any kind. She was required to be weaned off of all meds and to get physical therapy to strengthen her legs, which she had not been using.

She got better and better until finally no sign of anything being wrong with her. Her family is saying she has good days and bad days, but they have not presented any evidence of anyone outside the family, such as physical therapist, that has witnessed the bad days.

#14

RVInit wrote: ↑Thu Oct 05, 2023 1:31 pm In spite of this, Maya is pounding each leg trying to get it to move. This is absolutely inconsistent with CRPS. If her legs can't move because of CRPS, she would be experiencing also very severe sensitivity. The kind of sensitivity that if you tried to touch her legs with a feather, she would be coming out of her skin. Similar to what I describe on my second visit with the doctor that eventually diagnosed my CRPS.

One analogy might be if you've ever had a deep burn or wound or peel off of skin layers. Anything touching it sends you through the roof.

#15

OK. so I watched a physical therapist, which I alluded to in the response to pipistrelle.

She was great on direct, but again, cross exam is once again revealing problems for the plaintiffs. I believe there are actually four plaintiffs. Maya, her father, her brother, and her mother's estate.

She was weaned off all meds and sent home under court order to have nothing but physical therapy. Of course, she came home "in bad condition" according to everyone. But over time with physical therapy the testimony shows that she got better, no sign of any issues. The defense very effectively went over the physical therapists reports which showed steady progress, no mention of pain, and each month the reports showed she could do more and more activity. All without any CRPS treatment, except it is common for CRPS type I patients to receive some physical therapy, so I guess technically she's getting some treatment that a CRPS patient might get. But certainly not getting anything for pain, which is the worst symptom, and there is no sign that she's experiencing the type of severe pain that allows for a normal life without pain management of some type.

She is now in college, has a boyfriend, is doing well in school and has all the appearance of living a fulsome life. Again, without any CRPS treatment.

I'm about to see the full testimony of one of the CRPS doctor's so that might be interesting.

Edit - I made a mistake, she's not yet in college. She is in high school.

#16

sugar magnolia wrote: ↑Thu Oct 05, 2023 11:31 am Or perhaps they never made the connection between an injury and an illness. I don't think it would occur to me to tell the doc I broke my arm or took a blow to my thigh muscle when I'm seeing him for stomach pain.

But a doctor who treats this condition should know to ask. Because regardless of type i or type ii there is always some kind of injury that starts the whole thing. Initially, the patient is not in remission. So on an initial diagnosis there is no way to determine a specific diagnosis, type I or type II without knowing if the injury was soft tissue or nerve damage. If you don't know that, you can only say suspected CRPS and then wait and see if they ever go into remission, then OK, probably type I. But normally a diagnosis should be specific as to type because the treatment is not the same. Also, a type II diagnosis might be missed because type II typically doesn't have some of the other symptoms and is mainly just the severe pain. You don't always feel temperature difference in the affected limb, or skin changes, etc.

#17

pipistrelle wrote: ↑Thu Oct 05, 2023 7:29 pm
RVInit wrote: ↑Thu Oct 05, 2023 1:31 pm In spite of this, Maya is pounding each leg trying to get it to move. This is absolutely inconsistent with CRPS. If her legs can't move because of CRPS, she would be experiencing also very severe sensitivity. The kind of sensitivity that if you tried to touch her legs with a feather, she would be coming out of her skin. Similar to what I describe on my second visit with the doctor that eventually diagnosed my CRPS.
One analogy might be if you've ever had a deep burn or wound or peel off of skin layers. Anything touching it sends you through the roof.

Or imagine yourself being dunked into a vat of boiling oil.

#18

Oh Lordy.

If the case is going this bad for the plaintiffs and we've barely gotten into their witnesses, I'm not sure it's worth their time to keep slogging on.

Dr Chopra is the doctor I mentioned earlier whose direct exam I watched. Turns out that it had been edited and I had not seen it all. So now I've seen it all. Dr Chopra seemed to be doing a great job for the Kowalski's on. On cross, it's a disaster for them.

After the obligatory "how much are you getting paid" question, he asks the question that pretty much (IMO) ends the Kowalski's case. "During 2017, when Maya was being treated with ketamine, ketamine wasn't approved for the treatment of CRPS, was it"? So, I was aware that it wasn't approved as far back as 2015 when she went to Mexico for the ketamine coma. I wasn't sure when it was approved. But this doctor confirmed, it was not approved as early as 2017. So, there was no way the hospital was going to do what Beata Kowalski was demanding.

Other stuff came out that was not good for the plaintiff. The jury has questions, which I have not seen as of yet. They seem to like Dr Chopra, he is charismatic and had a good rapport with the jury.

1, Do you have an opinion on how the CRPS started? His answer is no. (Interesting, maybe someone on the jury knows something about CRPS? Hmmm.

2. Is ketamine addictive? No*
3. Does it cause constipation or obstination? No
4. How do you know it's rare, but still know the treatment will have a certain outcome"? He doesn't understand the question. Answer: officially it's considered rare. He believes it's more common, just misdiagnosed. He says Maya's example is common for a child with CRPS type I.

5. (oh lordy) What is your basis for the belief, is it opinion or science? He says it's his belief that it's not a rare condition. He says there is not enough data to know how rare or common, and thinks that patients want it to be rare because the FDA will approve treatments for easily. (He's the same doctor that I said earlier treated 1000's of patients. But actually I was mistaken, he claims to have treated over 100,000 patients. I suspect he is over diagnosing. If it's really as common as he says, then doctors would be more familiar with people coming in with the symptoms. My pain management doctor works in an office with 4 full time pain management doctors. Out of all the patients for all the doctors I am the only one diagnosed with CRPS. So, not sure it's really as common as this doctor is saying it is. Officially, it is considered a rare condition, that's the part of his answer that matches my experience with it)

6. Are there withdrawal symptoms after long term ketamine treatments? No, not at all.

7. Is it common for the disease to come on suddenly or slowly progress? He doesn't answer this question, but he says the condition just gets worse and it doesn't get better. That's a weird answer for most of them to understand because Type I can go into remission, so they seem better. But it can always come back and when it does, it's with the same vengeance as usual.

Plaintiff additional - if it was an opioid type of withdrawal, what would you see? Tremors, bugs under your skin, all of those symptoms, severe nausea (that's his answer)

Defense - have you seen asthma attacks cause CRPS? No, there is no direct correlation in that, maybe an indirect correlation, but not a direct correlation. (If the defense presents a CRPS expert, it's likely that expert will dig out all the literature and studies done on CRPS and show that it always starts with an injury. This is going to be a problem for the plaintiff if defense has a good CRPS expert, which I suspect they will. Their opening statement indicated they expect to present multiple witnesses that will shed serious doubt on the CRPS diagnosis. I was already suspecting that diagnosis before I even heard the defense opening argument, so I am really intrigued as to what they are going to present. I have been far more impressed with the defense than the plaintiff lawyers so far)

Dr Chopra asks the judge if there is a STOP button he can push. He's clearly ready to go home. He has enough charisma and rapport with the jury to get away with asking this, everyone is laughing, including the defense attorney

Defense has a killer follow up question: He lists a number of symptoms and asks if those are side effects of ketamine. Dr Chopra had to answer yes. The significance of this is that Maya received 5 large infusions of ketamine prior to her father taking her to Johns Hopkins. That whole list of side effects were the same as the symptoms that caused her father to bring her to Johns Hopkins. Not good for the plaintiff.

Here is the video for the testimony. Chopra was the last witness on this day, but he took up a good portion of the morning and all afternoon.

#19

Day 7:

Investigative Detective, retired:

Bottles of medications found for Beata:

Ambien - 30 doses issued, 5 remaining. Filled Oct 10, 2016
Zanax - filled Nov 21, 2016 - 16 doses issued, 16 remaining
Oxycodone - Nov 21, 2014, 15 doses issued, 13 remaining

Usually someone with an addiction problem will not have pills remaining in the bottle. found no evidence that Beata misused prescription drugs. No empty bottles found, no recently filled prescptions with empty or mostly used bottles.

In garage found Beata's pink cell phone

scene of suicide: entered garage and victim suspended using belts hung from garage door.

She used a ladder, she had a bag with some kind of solution going into her left arm

Small plastic pan with items a nurse might use

(Beata was an infusion nurse, she had worked in a cancer treatment center)

Alcohol pads, syringe, gloves found in the bin

Means of strangulation - used a wide belt, the medical examiner determines the cause of death

Beata appeared to have used the ladder to step up and possibly stepped off the ladder to put the pressure on her neck.

Had investigated many deaths by hanging.

Listened to 911 call and spoke to Mr Kowalkski.

What do you look for in motives? Is that part of investigation? First, looks at scene, if nothing suspicios starts interviewing. Learned there had been stressful situation with daughter at hospital.

Always want to know why. Jack told him that in Oct 2016 went to Johns Hopkins with severe stomach pains. Hospital accused his wife of Munchausen by proxy and would not allow her to see Maya. Caused psychological stress.

Did you find any indication that Beata or Jack had been using any drugs of any type in illegal or unauthorized way.

What was on outside of IV bag? Sodium chloride.

What was significance to you of this bag? She was an infusion nurse, and he doesn't know why she used that ,couldn't fingure it out. Could have had a meaning to her.

Delivered all to medical examiner. All items went to med examiner, he doesn't know what was done with each item.

Any history of child abuse or domestic violence in the family? No

She left a suicide note. The note explained why she committed suicide. Her state of mind - first thing she says is take care of Maya and she loves Kyle (her son). Says she no longer can take the pain of being separated and accused of being a criminal. It was 3 months to the day of Maya being in the hospital.

She gave her parental rights to her sister and brother in the Chicago area.

She wrote a note to the family court judge , blaming him for allowing the hospital to destroy Maya and destroy their family, her marriage, put them into bankruptcy, etc.

From his experience and training the death apprared to be suicide by hanging

2nd page of letter to judge - wanted to make sure the doctor would lose her medical license and never harm another child again.

Cross Exam:
Asks him about the IV bag and the syringe. He gave them to the medical examier, never got test results back from the IV or the syringe.

2 additional syringes found underneath her sweatshirt. Those went to the medical examiner. Never got the test results.

Re-Direct:
Toxicology report on the body - tested for a number of drugs, Zanax and opioids both were not detected.

In the toxicology report any narcotics or other drugs that could have contributed to her death? No

Any signs of any other cause of death? No

Jury questions? No

#20

Day 7:

Deborah Hanson, social worker, on duty at Johns Hopkins at intake

Met all kinds and all races of people

1991 after wall fell, any parents from Eastern Europe? yes, more than one occassion before she met the Kowalkski's. Different cultures have different needs. She spent a month in Greece, understanding a culture might help because it can impact the way the parents understand symptoms, the medical system, and other things.

In general, certain ideas or concepts are unknown. Depression is unknown in some cultures,

At Johns Hopkins she worked on oncology floor. She would stay on oncology floor, but if a patient went to PICU she would go down to "hand off" to the social worker in PICU.

Patient/Family rights and responsibilities - she is familiar with these, has to consider them at all times while working with families and patients.

Privacy and Respect - Right to refuse treatment, except that written by law, and to be told effects of your shoice. Right to talk to another doctor or transfer to another health care provider. From time to time parents want a second opinion is not uncommon.

Parent has a right to reject a treatment or leave against medical advice.

Families can practice their cultural and spiritual beliefs as long as it doesn't interfere with other patients.

There is a chapel open to all faiths, Muslim families can bring their prayer rugs and also respect that a male can't enter a room with a female if that is part of religious or cultural belief of patient and family.

She was required to do a psychosocial evaluation of the families and was asigned to the floor with the Kowalkski's

The Kowalkski's seemed to have appropriate concern that is typical in parents. They were concerned about their child.

She felt like Maya's parents seemed reasonable to work with. She has had experience with Munchausen by proxy, did not see evidence of that. They were stressed, at times she thought they would benefit from being deescalated a bit.

She wasn't clear about the causes of their distress. Wasn't sure what was going on. She had not done a full assessment of her evaluation. There were many conversations going on in the room and that is what prevented her from completing her evaluation.

Looking at her social worker note: There was a need for a safety assessment because she was told Maya "wanted to die".

She was called back to the floor for suspected child medical neglect which requires more assessment and paperwork. At that time she asked about the report of Maya talking about wanting to die.

Her understanding of the diagnosis that Maya came in with was pain. She wasn't familiar with CRPS.

(This questioning is so confusing. The witness is having a hard time expressing herself, the questions are being stricken on objection. Sorry if it's not making sense. she's halfway answering questions and then bringing up other things before she completes an answer. She's a train wreck.)

She called Eagle's Wings, a counseling center the family told her about. Where Maya sought counseling. She made a call and nobody answered the phone on Friday. They called her back on Monday but she was no longer on the case. She passed the number on to the PICU social worker

The Kowalkski's were declining psychological evaluation of Maya and I gather the attorney is trying to establish that they declined because Maya had her own counselor she was working with.

The family was talking about CRPS to the doctor and discussing transferring Maya to Nemours. She was not aware of any other diagnosis.

It is a chore to listen to this witness.

She keeps saying she assumes that the case worker now on duty knows various things. Most of the questioning isn't going anywhere because of this.

I think the gist of it is that the paperwork for the transfer to Nemours mentioned Munchausen by proxy. So, if the parents had signed the transfer they would have been admitting to this diagnosis. So the transfer never happened because the parents wouldn't sign the transfer paperwork.

Did she ever learn what the doctors thought Maya actually had (diagnosis). No.

she made notes that there should be a discussion with Dr Hanna (the doctor that was giving Maya the ketamine treatments)

She said the team and parents made a temporary agreement about pain treatment for Maya.

Patient wouldn't cooperate with blood pressure reading because she said it was too painful to put the cuff on.

Her notes indicate Beata told her that psychiatric help was not desired because "they don't help us".

She doesn't seem to know if Maya was getting counseling or only had evaluation at Eagle's Wings.

No doctor ever asked her about her opinion of the family.

Cross Exam:

she had an opportunity to speak with plaintiff team before tstifying

From her deposition she had contact for a total of 2 to 3 hours total, in and out

Her last note was signed at 16:44. Her first note was started at 14:04 PM.

Looking at the start and end times of each note

she never spoke with dr Hamma but notes indicate the health care team did speak with him.

She was covering PICU for Kathy Beatty because of the hurricane. Otherwise she doesn't work that floor

she did not have any understanding of what services they received from Eagle's Wings.

Did not have any understanding of whether Maya had been seen at Tampa General Hospital.

She recalls the patient woke up and started yelling, throwing things, and demanding to have her medication. she was very agitated. This was adding to confusion in the room.

She only witnessed some of the conversation regarding trandfer to Nemours and has no knowledge of what happened after that. She believed Nemours couldn't accept her that day because of the hurricane.

Was not aware of how dr Hanna was treatimg Maya

Jury questions:

1. Who was the case manager at this time? I was the case manager on Friday, should have been Joyce Sheere.

2. Judge said he could not ask the second question.

#21

I am getting into the testimony of Maya's father, and that is going to bring up actual diagnoses and symptoms. Before I finish listening to his testimony I found this interesting article.

While Maya has many of the same symptoms of CRPS Type I, there are elements of her experience that really don't fit a typical case of either type of CRPS. While Johns Hopkins Children's Hospital did originally mention RSD (the old name for CRPS type I), eventually they started suspecting conversion disorder. The symptoms of CRPS and conversion disorder are the same, and the medical history of Maya seems to me (I am not a doctor) more in line with conversion disorder. They are both real, both debilitating, both have similar symptoms, but treatment is different. I think Maya's mother became unreasonably angry at the suggestion of conversion disorder because of the psychological nature of it. She is confusing it with the idea of "it's all in her head" kind of thing. In the article below, they use the newer terminology which is FND (Functional Neurologic Disorder) which I think is more palatable.

Similar to what happened in the case study I am linking below, Maya has seemed to have gotten better when her treatment changed from CRPS treatment to a treatment more in line with conversion disorder. At least three different pediatric hospitals diagnosed Maya with conversion disorder, I haven't written up all the testimony yet, but that has been testified to.

Case Study: The Overlap of Complex Regional Pain Syndrome and Functional Neurologic Disorder in Pediatrics

Two complex conditions with clinical and diagnostic similarities

A 13-year-old female presented to the Pediatric Pain Rehabilitation Program at Cleveland Clinic Children’s Hospital for Rehabilitation (CCCHR) with a diagnosis of complex regional pain syndrome (CRPS) of her left leg. Along with her leg greatly inhibiting her normal daily functioning, she had a history of depression, conversion disorder (known today as functional neurologic disorder), panic attacks and generalized anxiety disorder, as well as peroneal tendonitis and frequent sprains due to dance.

The patient participated in the intensive interdisciplinary pain rehabilitation program for four weeks with day hospital and inpatient elements. She received daily physical and occupational therapy, individual and group psychotherapy, recreation therapy, educational services, and medical services.

Untangling symptoms
As the patient’s CRPS treatment in the program progressed and assistive devices were weaned, “her presentation was much more functional in the way that her symptoms were limiting her,” says Heidi Kempert, physical therapy assistant at CCCHR and author of a case study published in the Journal of Pediatric Rehabilitation Medicine. With CRPS, the typical symptoms that hinder progress are pain, swelling, decreased range of motion, allodynia and weakness. Instead, the patient’s balance, mobility and tremors worsened.

The interdisciplinary team began searching for answers. “We were all seeing that it was looking like functional neurological disorder (FND aka conversion disorder), but we were also very cautious about giving her that diagnosis because once you have it, unfortunately, many providers assume that all future medical issues you have could be related to FND,” Ms. Kempert says.

Once the patient was treated according to her FND diagnosis, her participation and response to treatment increased. On discharge, she showed improvement in her functional strength and mobility. She was sent home with a 10-week exercise program and went back to school and dance classes with fully resolved mobility (Maya is completely out of her wheelchair and appears to be living a normal life within several months of being released from JHCH with court orders to replace CRPS treatment with treatment consistent with conversion/FND)

https://consultqd.clevelandclinic.org/c ... ediatrics/

#22

This case is such a mess. I feel bad for Maya and I also can see things from the hospital point of view. However, the social worker seems like a real monster. And Beata's reaction made it all worse. I have a feeling Mr Kowalski would have handled the situation without it getting to this had it not been for his wife.

In direct exam of Mr Kowalski he's admitting that Beata has a strong personality and can be direct and seem pushy. I think he's trying to paint it in a more delicate light, but she was pushing the hospital to give her daughter a treatment that was not approved for a diagnosis of CRPS (at that date and time, it's approved now). And she was being really demanding about it.

The family attorney tried to paint it all as if no previous visit to any hospital had been problematic, but on cross exam the JHCH attorney showed time after time there were issues going as far back as the July 4 asthma attack where Maya started saying she had all over muscle pain.(She was having huge coughing fits, had rode her bike all day in a parade, lots of physical activity on that day combined with coughing fits can make your body hurt). He pulled out discharge paperwork from all the different hospitals they took her and they all mention possible conversion/FND. Given Beata's behavior it is really hard to have a good sense of whether this was just the typical 'we don't know what it is so we will say it's in your head' or whether Beata's behavior made the hospital have some suspicions about what was going on. Partly because I've already said a million times, her symptoms may seem to someone who is only learning about CRPS to actually be CRPS, but there are nuances about her own description that would make a person familiar with CRPS suspect that is not an accurate diagnosis. I can absolutely understand a hospital, which likely does not have staff that has any expertise in CRPS might make a diagnosis of possible CRPS and then also suspect there may be conversion going on. That makes this case more complicated because there were times early in the process that various hospitals mentioned RSD as a possible diagnosis. But they all ended up ruling it out eventually.

Back to July 4, 2015. Beata's immediate response was to start filing for SSD for Maya and seeking a diagnosis. That was a big surprise when that came out in cross exam of Kowalski. Because as of that date the only thing Maya ever had was asthma and allergies. There is also going to be likely testimony that even her asthma treatments were over the top in terms of level of medication she was given. But that her mother would instantly decide to file for disability for Maya based on asthma and allergies is mind blowing. Was she so debilitated by asthma as to be truly disabled? Were the excessive steroid treatments causing her to have trouble fucntioning? All kinds of questions here. The only new thing Maya complained of was the over all muscle pain. that's it. That was all she had on that date.

The cross exam of Mr Kowalski was brutal to their case in my opinion. But when I glance at the rolling commentary while watching the testimony it is clear that the general public are all on the family side and thinks the hospital are monsters. I do think that the social worker at the hospital is a piece of work, I thought I heard that the family sued her personally and that there was a settlement but I'll have to search that again. But the cross of Mr K was just bad for their case. The jury is going to have to figure out who was the worst of the bad here. I think the hospital has the upper hand legally - IANAL, but this is my suspicion. They can't treat with unapproved medication, especially the extreme doses Beata was demanding.

Also, Western trained doctors just have a different attitude toward treatments for things that you can't see. Like pain. When I first presented with my symptoms, the doctor that finally believed me and started down the path of first getting the pain under somewhat control, then eventual diagnosis, then getting the pain under better control was not only trained in western medical techniques, but he also was certified in acupuncture and other non western methods. I think doctors who study more traditional (as in actual traditional if you know what I mean) are far better at having compassion and enough patience to give difficult cases the good old college try when it comes to figuring it out. My personal experience with typical western trained doctors is if you present with a difficult case, it's all in your head, you are making it up, you are trying to get drugs. That's part of why this case is so difficult, there are elements of all of this going on. So, there are problems on both sides of this case.

And a young girl stuck in the middle of it, in my opinion being victimized by the whole lot of them, including her mother even if it was done subconsciously.

What a damn mess.

Maclilly · #23

pipistrelle wrote: ↑Thu Oct 05, 2023 7:29 pm
RVInit wrote: ↑Thu Oct 05, 2023 1:31 pm In spite of this, Maya is pounding each leg trying to get it to move. This is absolutely inconsistent with CRPS. If her legs can't move because of CRPS, she would be experiencing also very severe sensitivity. The kind of sensitivity that if you tried to touch her legs with a feather, she would be coming out of her skin. Similar to what I describe on my second visit with the doctor that eventually diagnosed my CRPS.
One analogy might be if you've ever had a deep burn or wound or peel off of skin layers. Anything touching it sends you through the roof.

Ha I've gotten pensions for people with CRPS after a work injury and they would absolutely NOT be slapping their leg. They can't even stand to have a sock on.

Maclilly · #24

RVInit wrote: ↑Fri Oct 06, 2023 12:57 pm This case is such a mess. I feel bad for Maya and I also can see things from the hospital point of view. However, the social worker seems like a real monster. And Beata's reaction made it all worse. I have a feeling Mr Kowalski would have handled the situation without it getting to this had it not been for his wife.

In direct exam of Mr Kowalski he's admitting that Beata has a strong personality and can be direct and seem pushy. I think he's trying to paint it in a more delicate light, but she was pushing the hospital to give her daughter a treatment that was not approved for a diagnosis of CRPS (at that date and time, it's approved now). And she was being really demanding about it.

The family attorney tried to paint it all as if no previous visit to any hospital had been problematic, but on cross exam the JHCH attorney showed time after time there were issues going as far back as the July 4 asthma attack where Maya started saying she had all over muscle pain.(She was having huge coughing fits, had rode her bike all day in a parade, lots of physical activity on that day combined with coughing fits can make your body hurt). He pulled out discharge paperwork from all the different hospitals they took her and they all mention possible conversion/FND. Given Beata's behavior it is really hard to have a good sense of whether this was just the typical 'we don't know what it is so we will say it's in your head' or whether Beata's behavior made the hospital have some suspicions about what was going on. Partly because I've already said a million times, her symptoms may seem to someone who is only learning about CRPS to actually be CRPS, but there are nuances about her own description that would make a person familiar with CRPS suspect that is not an accurate diagnosis. I can absolutely understand a hospital, which likely does not have staff that has any expertise in CRPS might make a diagnosis of possible CRPS and then also suspect there may be conversion going on. That makes this case more complicated because there were times early in the process that various hospitals mentioned RSD as a possible diagnosis. But they all ended up ruling it out eventually.

Back to July 4, 2015. Beata's immediate response was to start filing for SSD for Maya and seeking a diagnosis. That was a big surprise when that came out in cross exam of Kowalski. Because as of that date the only thing Maya ever had was asthma and allergies. There is also going to be likely testimony that even her asthma treatments were over the top in terms of level of medication she was given. But that her mother would instantly decide to file for disability for Maya based on asthma and allergies is mind blowing. Was she so debilitated by asthma as to be truly disabled? Were the excessive steroid treatments causing her to have trouble fucntioning? All kinds of questions here. The only new thing Maya complained of was the over all muscle pain. that's it. That was all she had on that date.

The cross exam of Mr Kowalski was brutal to their case in my opinion. But when I glance at the rolling commentary while watching the testimony it is clear that the general public are all on the family side and thinks the hospital are monsters. I do think that the social worker at the hospital is a piece of work, I thought I heard that the family sued her personally and that there was a settlement but I'll have to search that again. But the cross of Mr K was just bad for their case. The jury is going to have to figure out who was the worst of the bad here. I think the hospital has the upper hand legally - IANAL, but this is my suspicion. They can't treat with unapproved medication, especially the extreme doses Beata was demanding.

Also, Western trained doctors just have a different attitude toward treatments for things that you can't see. Like pain. When I first presented with my symptoms, the doctor that finally believed me and started down the path of first getting the pain under somewhat control, then eventual diagnosis, then getting the pain under better control was not only trained in western medical techniques, but he also was certified in acupuncture and other non western methods. I think doctors who study more traditional (as in actual traditional if you know what I mean) are far better at having compassion and enough patience to give difficult cases the good old college try when it comes to figuring it out. My personal experience with typical western trained doctors is if you present with a difficult case, it's all in your head, you are making it up, you are trying to get drugs. That's part of why this case is so difficult, there are elements of all of this going on. So, there are problems on both sides of this case.

And a young girl stuck in the middle of it, in my opinion being victimized by the whole lot of them, including her mother even if it was done subconsciously.

What a damn mess.

Yes I understand there was a settlement with Dr. Smith and some other person was dropped just before trial. This case is only against the hospital. I want to thank you for watching the trial and giving these summaries. I'm at work and can only catch up on weekends. Watching the documentary I was very sympathetic to Maya but had concerns about the mom. I also have concerns about the CPS investigator. As a former GAL, I don't think she acted appropriately. She might very well have been right, but her actions and words were cruel and inappropriate. She seemed tainted. It is a mess and I am so curious how this turns out. ergo Ketamine Infusions and use nasal sprain. But I would not to a Ketamine coma. I would have to be on death's door in pain before doing that.

#25

Mr Zimmerman - from Sarasota Fl via Zoom

He's an attorney licensed in Florida. he represented Maya in a dependency proceeding.

Handles dependency cases where criminality is suspected. Contacted by a friend attorney who was representing Beata. Maya had an attorney, but they thought it would help for her to have a private counsel. His duties were to her, he made that clear to the family and the other attorneys.

Familiarized himself with the case, the shelter action had already happened. Conferred with Maya's parents, went to hospital to meet with her.

Saw Maya 2 days at the hospital, may have gone a 3rd time, can't remember. Eventually she was permitted to come to court in January 2016 and he met her in person there.

General impression of her, the room, etc. She was brought out in a wheelchair in a waiting area. She was wearing a dress. Not given any real privacy at that time. He expressed that he needed to speak with her privately. Ultimately was allowed to go into her room and talk to her with the door open.

Problems having confidential conversations. maya expressed she wanted privacy. He was aware someone was outside the door possibly trying to listen.

What were her concerns - she did not want to be in the hospital said she was in a lot of pain, wanted to go home. There was a social worker assigned to her case and Maya expressed specifically that she disliked and distrusted that person. She blamed her for keeping her away from her parents. Kathy Beatty was the social worker. Social worker was keeping Maya from speaking freely during phone conversations. Maya seemed miserable. He's not easily surprised, didn't know what to expect, but the situation left him puzzled as to why the social worker was trying so hard to keep Maya from communicating with family and with him. Was limiting Maya's freedom, Maya felt captive.

He came a second time to see Maya. He waited until the misery level hit a high point and she was expressing a sense of urgency. (Weird answer)

Consistent in describing physical health. Pain was at level 10, emotional well being was deteriorating. She seemed in distressed. Emotionally withering. Loved her family. Maya was mature enough to express what was happening with her.She had the affect of a much older person in ability to articulate her feelings.Redundant. Constant statements of I miss my parents, being prevented from seeing them, in pain. She didn't think the hospital was helping her. He found taht surprising. His duty to determine what forces were affecting her.He thought the social worker was preoccupied with controlling access to Maya insteading of personally helping Maya. Micromanaging He felt she had an agenda. He didn't understand why.

He saw her in early December 2016. 2nd visit was 10 to 14 days later. Court hearing Jan 6, right before Beata committed suicide. Maya's relationship grew worse and worse, frustration to desperation.

Hospital staff treated him with distrust and tried to minotor him when he was there. They knew he was her attorney. Miss Beatty interrupted a call with Maya saying he needed specific approval. He was having to havigate his way around her just to speak to Maya. 9but he persisted)

He emailed the hospital about the problem. Ultimately he received a letter telling him not to have contact with any of their staff. Sidebar. There aee so many sidebars in this trial. That poor jury must be frustrated, truly.

At some point he was made aware that Beata took her own life. He is not aware of how Maya was notified of this.

She felt like she was a prisoner. Her focus shifted to "I want to see the judge" rather than "I want to see my parent". So that became the new battle. Her overall physical presentation seemed to be very consistent (I think the attorney was hoping he would say deteriorating over time). he says her descrption of her physical condition was consistent throughout.

He felt like there was some kind of agenda on the part of the hospital and social worker in terms of keeping Maya from her family.

--------------------------------------------------

Cross Examination:
Wants to make sure of time frames. A note on hospital chart mentions first date of Dec 6, the shelter order had already been entered (October 13 effective date)

By that time, she had been there well over a month. Would it be natural for a ten year old to be distressed about not seeing her family. The order specified no physical contact with Beata.

It's common for a child to put a face on someone to blame? He doesn't know. Was Maya blaming the hospital? Yes

The hospital is who she was dealing with day to day directly so that is who she blamed. The hospital was bound to follow the court orders. He says they were complying with orders based on their interpretation of the orders.

He was allowed to have conversations, but it was difficult. He advised her of what was happening during court proceedings.

--------------------------------------------

Cross exam

THere were multiple types of court orders, such that there was a great deal of interpretation as to what orders applied in what situation. He says there was a particular level of fervor in abiding by the orders

Did he express that the hospital had their own patient bill of rights, and there was some tension between the hospital bill of rights and the court orders.
---------------------------------------------

Jury questions:
1. Request to see the court orders - judge says he will give them all the info he needs about that

2. Did you observe Ms Beatty listening in - one time he knew that she was outside the room

3. Did she experss any religious needs? Yes, she wanted to see her priest, she wanted some particular symbol, like a corss, doesn't remember the exact symbol she wanted

4. He did not witness her receiving her religious items, he was aware she got them, but didn't focus on it. (the family says she was denied these requests)

--------------------------------------
redirect

Was he involved in a discussion of Jack and Beata having a "technial" separation in order to get Maya otu of there.

What advice about Kyle did you give to them? He expressed horror that they divorce to solve this problem because their other child would be affected and cause more issues. He was vehemently opposed. The suggestions had came fro one of the other counsel.

------------------------------------------------------

Mr Zimmerman may be called back.He's currently on a cruise and participating through Zoom. I can see his room, looks stark.