Case : Jack Kowalski, Maya Kowalski and Kyle Kowalski v. Johns Hopkins All Children’s Hospital, et al. Reviewer: Robert J. Fortuna, MD, MPH Summary Assessment 1.1 – Ambulatory Care of Maya The overall primary care of Maya was profoundly lacking and superficial. It was lacking based on Dr. Wassenaar’s (1) lack of any documented medical assessment in his documentation beyond a simple list of diagnoses, (2) lack of oversight of multiple controlled medications prescribed (opioids, benzodia ze pines, hypnotics, and ketamine) by himself and others; (3) lack of coordination of multiple procedures (PICC line, PORT placement, medically induced coma, m icrolaryngoscopy bronchoscopy (MLB) ; (4) lack of coordination of multiple subspecialists, and (5) lack of addressing conflicting and concerning statements made by other pediatrician s and subspecialists. Many of the assertions made by Dr. Wassenaar in this affidavit are not adequately support ed in his documented chart notes. His chart notes are superficial and lack any true medical assessments. Although he lists diagnoses under t he impression, these appear to be carried forward from previous notes or checked from a problem list of diagnoses. There is not a thoughtful medical as sessment documented in any of the se e ncounters In his Affidavit, Dr. Wassenaar reported that he “co nsidered multiple causes of Maya’s symptoms,” yet there was never a documented assessment beyond listing diagnoses under the impression (point 6 in Affidavit ). Dr. Wassenar reports that he did not believe that Maya was under the psychological control of her mo ther” (Point 7 in Affidavit ) and that Maya is not the type of child who responds to “suggestive or bullying behavior ” (point 15). It is important to note that Dr. Wassenar references Maya at the age of 9 years old. At 9 years of age, and in early adolescence, a parent is the most influential figure in a child’s life. Beata, as any parent of a child at this age, had substantial influence over Maya conscious and subconscious behaviors. 1 .2 – Multiple Providers Raising Concerns regarding Maya Thr ough the course of her treatment, multiple independent physicians at multiple different hospitals expressed concern s and documented discrepancies between reported symptoms and objective findings. • The documentation from multiple independent physicians who expressed discrepancies and concerns is a red flag and should be have been noted by her PCP / longitudinal providers • It should also raise concerns when patients are bouncing between multiple different providers. Physician/Nurse/Provider Hospital Findings Short Stay Providers All Childrens Short Stay Unit Admitted for Short - Stay after being air - lifted. Exam and objective asthma score was not consistent with reported symptoms Pulmonologist Physician ACH pulmonology Discrepancies between objective findings and reports. Beatta reported that Maya required positive airway pressure during short stay treatment – which did not occur. Dr. Elizabeth Byrne (Attending Physician) Lurie Children’s Hospital Noted discrepancies in history and objective findings upon admission to Lurie Dr. Emily Lund Lurie Children’s Hospital Noted discrepancies in history and objective findings upon admission to Lurie Lynn Chen - Molina RN (Pediatric Nurse) Lurie Children’s Hospital Documented d iscrepancies in reports and objective findings. Unable to determine how Maya rolled out of bed over side rails Dr. Kathryn Smythe (Residents Physician) Lurie Children’s Hospital Documented discrepancies in reports and objective findings. Dr. Selina Varma (Resident Physician) Lurie Children’s Hospital Discrepancies noted between physical exam and reported symptoms. Mother frustrated that CT and MRI not performed Dr s Whaley and Elizabeth Byrne Lurie Children’s Hospital Met with mother and reported that t he y will not do “further diagnostic work - up” and that they do not believe “that further escalation of pharmacological therapy will assist Maya in long - term management of her pain ” per notes. Dr. Elvin Mendez (Allergist/Immunologist) Lee Mem orial Health System Noted discrepancies between objective lab findings, history, physical exam, and subjective statements by Beatta. Recommended consideration of Munchausen by proxy 1 .3 – Controlled substances prescribed to Maya Throughout the notes provided, Maya was prescribed multiple controlled substances – including ketamine, oxycodone , D ilaudid, valium, and Ambien. The multiple controlled substances prescribed are highly concerning for multiple reasons: 1) The doses of ketamine where very high , beyond common ranges for children. 2) Travel out of country to be placed in a coma with ketamine is highly concerning. 3) The lack of clear coordination and oversight of the multiple controlled substances in concerning. 4) Prescribing of controlled medications by Dr. Wassenaar without any documented assessment of risks is outside of recommended practice. 5) Prescribing of concurrent opioids and benzodiazepines by Dr. Wassenaar, especially without assessing and discussing risks, is outside of recommended practice. 1 .4 – Reporting to Department of Children and Families The case was and should have been reported to the Department of Children and Families (DCF). Physicians and healthcare p roviders are mandatory reporters for any case of suspected abuse, neglect, or endangerment of a child’s welfare. The basic threshold for mandatory reporting is that reasonable suspicion exists that a child’s welfare is endangered. Through the course of Maya’s care, more than enough evi dence accumulated to raise suspicion regarding Maya’s welfare. The concerns documented by multiple different physicians in different systems, the discrepancies between objective finding and subjective reports, the invasive procedures performed, the multi ple controlled medications, and the multiple requests for additional controlled medications all posed significant risks and raise d red flags. Reporting concerns to DC F was absolutely appropriate and mandatory in most , perhaps all, states. 1 .5 – Ambulat ory Care of Beata Similar to the ambulatory care of Maya, the documented primary care provided to Beata was limited. Beata was seen multiple times and dia gnosed with “situational stress,” yet there was no medical a ssessment beyond an impression of “situational stress ” Despite the lack of documented assessment, she was treated with Celexa, Nortriptyline, Xanax, and Ambien. There were no documented discussion s in the records available about counseling, therapy, or consultation with a psychiatrist. Overall, the care provided was rather superficial and lacked any documentation thorough medical assessment s This is concerning, especially given that controlled medications were prescribed. The above assessments are based on review of medical recor ds. The opinions are subject to amendment if additional records or evidence becomes available. Robert J. Fortuna, MD, MP H