1 IN THE CIRCUIT COURT, TWELFTH JUDICIAL CIRCUIT 1 IN AND FOR SARASOTA COUNTY, FLORIDA JUVENILE DIVISION 2 3 IN THE INTEREST OF: 4 MAYA KOWALSKI and 5 KYLE KOWALSKI, CASE NO.: 2016-DP-000601-NC 6 DOB: 12/16/2008, 06/07/2007, 7 Minor Children. 8 _______________________________/ 9 10 TRANSCRIPT OF DIGITAL RECORDING OF 11 SHELTER REVIEW EVIDENTIARY HEARING 12 13 DATE TAKEN: Thursday, December 29, 2016 14 TIME: Unknown 15 PLACE: Sarasota Judicial Center 16 2002 Ringling Boulevard Sarasota, Florida 17 BEFORE: The Honorable Lee E. Haworth 18 19 Transcribed by: 20 Susan B. Wilson, RPR, CRR, CRC, FPR 21 22 23 ____________________________________________________________ SUSAN B. WILSON, INC. 24 14015 Ivylgail Drive North Jacksonville, Florida 32225 25 (904) 994-6133 swlsn1@yahoo.com 2 A P P E A R A N C E S 1 2 SARAH RUNEVITCH, Esquire 3 Children's Legal Services 4 1864 17th Street Sarasota, Florida 34234 5 -and- 6 DAVID N. SILVERSTEIN, Esquire 7 Children's Legal Services 8 1301 6th Avenue West, Suite 101 Bradenton, Florida 34205-7403 9 appearing on behalf of the Department. 10 11 JARED M. MONAHAN, Esquire 12 Guardian Ad Litem Program 13 2071 Ringling Boulevard, Suite 625 Sarasota, Florida 34237 14 appearing on behalf of the Guardian Ad Litem. 15 16 DEBRA M. SALISBURY, Esquire 17 Law Office of Debra M. Salisbury, P.A. 18 3293 Fruitville Road, Suite 101 Sarasota, Florida 34237-6453 19 appearing on behalf of the Father. 20 21 VARINIA VAN NESS, Esquire 22 Van Ness Law Group, P.A. 46 North Washington Boulevard, Suite 9 23 Sarasota, Florida 34236-5932 24 appearing on behalf of the Mother. 25 3 A P P E A R A N C E S (C O N T I N U E D) 1 2 MARK R. ZIMMERMAN, Esquire 3 Zimmerman & Zimmerman, P.A. 4 434 South Washington Boulevard, Suite 250 Sarasota, Florida 34236-7100 5 appearing on behalf of Maya Kowalski. 6 7 C. HOWARD HUNTER, Esquire 8 Hill Ward Henderson 101 East Kennedy Boulevard, Suite 3700 9 Tampa, Florida 33602 10 appearing on behalf of Johns Hopkins All Children's Hospital. 11 12 ALSO PRESENT: 13 JACK KOWALSKI, Father 14 BEATA KOWALSKI, Mother 15 16 - - - 17 18 19 20 21 22 23 24 25 4 I N D E X 1 2 Discussion re proposed orders for 118 3 modification of placement 4 Beata Kowalski sworn for the purpose of 131 answering questions by the Court 5 Order directing hospital to release and then 170 6 readmit child on Friday, January 6, 2017 7 E X A M I N A T I O N S 8 Witness Page 9 CATHERINE ALEXIS MAJOR, M.D. 10 Direct Examination By Mr. Silverstein 15 11 Cross Examination By Ms. Salisbury 24 12 Cross Examination By Ms. Van Ness 35 13 Cross Examination By Mr. Zimmerman 40 14 Further Cross Examination By Ms. Salisbury 49 15 Further Cross Examination By Ms. Van Ness 55 16 Redirect Examination By Mr. Silverstein 61 17 Recross Examination By Ms. Van Ness 65 18 Recross Examination By Ms. Salisbury 70 19 Recross Examination By Mr. Zimmerman 72 20 Further Redirect Examination By Mr. Silverstein 77 21 Further Recross Examination By Ms. Van Ness 81 22 23 24 25 5 E X A M I N A T I O N S (C O N T I N U E D) 1 Witness Page 2 ASHRAF HANNA, M.D. 3 Direct Examination By Ms. Salisbury 90 4 Cross Examination By Ms. Van Ness 94 5 Cross Examination By Mr. Silverstein 100 6 Redirect Examination By Ms. Salisbury 104 7 8 9 EXHIBITS INDEX 10 ***** N O N E ***** 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 6 (Begin transcription of digital recording file 1 2016-12-29(1).mp4.) 2 THE COURT: All right. Be seated. 3 We're here on the Maya Kowalski case, 4 No. 2016-DP-601. 5 Let's have everybody identify themselves. 6 We'll start with the department. 7 MR. SILVERSTEIN: David Silverstein with the 8 department. 9 MS. RUNEVITCH: Sarah Runevitch on behalf of 10 the State. 11 MR. HUNTER: Howard Hunter for Johns Hopkins 12 All Children's Hospital. 13 MS. SALISBURY: Attorney Debbie Salisbury 14 representing the father. 15 MS. VAN NESS: Varinia Van Ness representing 16 the mother. 17 MRS. KOWALSKI: Beata Kowalski, Maya's mom. 18 MR. KOWALSKI: Jack Kowalski, Maya's father 19 and Kyle's father. 20 MR. ZIMMERMAN: Mark Zimmerman for Maya 21 Kowalski. 22 MR. MONAHAN: Jared Monahan for the guardian 23 ad litem program. 24 THE COURT: All right. 25 7 MR. VAN NESS: Your Honor, forgive me. Before 1 we begin, we're having difficulty with the hospital 2 getting Maya on the phone. They won't agree to 3 call Mom's iPad, which is ready to go. They're 4 saying they will only call an email in the 5 courtroom, the judge or the clerk, but not one of 6 us. 7 So perhaps you can instruct the nurse that 8 it's okay to call the iPad. 9 UNIDENTIFIED SPEAKER ON TELEPHONE: We have a 10 regular phone in the room, and I was told by our 11 risk manager that the Court usually has a person 12 with an iPad so we can get their phone number if 13 you want her to be FaceTimed. 14 MS. VAN NESS: That is incorrect. There is no 15 person in the courtroom with an iPad besides the 16 lawyers and the mother. So -- 17 THE COURT: Let's do the telephone. Is the 18 telephone available? Do you have a phone number? 19 Is there a phone number we can call? 20 UNIDENTIFIED SPEAKER ON TELEPHONE: If the 21 judge wants to tell me to do that, I certainly can. 22 But we have a regular phone in the room where she 23 can join in the conversation. 24 MS. VAN NESS: Judge, we want her to be able 25 8 to observe the proceedings. 1 THE COURT: I understand that. 2 UNIDENTIFIED SPEAKER ON TELEPHONE: Does the 3 judge want that? 4 MS. VAN NESS: And we have the iPad ready and 5 they have an iPad in the hospital. They just don't 6 want to do it. 7 UNIDENTIFIED SPEAKER ON TELEPHONE: That's not 8 true. 9 THE COURT: Hold on. Hold on. 10 UNIDENTIFIED SPEAKER ON TELEPHONE: I'm asking 11 if the judge is in agreement to it -- 12 THE COURT: Just a moment. 13 UNIDENTIFIED SPEAKER ON TELEPHONE: -- to 14 using the mom's iPad. 15 THE COURT: Ask the person on the phone just 16 to stand by for a minute. 17 MS. VAN NESS: Stand by, the judge said. 18 THE COURT: All right. Now, Mr. Silverstein. 19 MR. SILVERSTEIN: Thank you, Your Honor. 20 Judge, at this time the State -- 21 [Interruption in audio.] 22 MS. SALISBURY: So it's kind of inequitable 23 for the parents to be able to, you know, defend 24 themselves and for the child to be able to defend 25 9 herself when we're being given this just stand up 1 in court and make a motion and without notice. 2 Yesterday I was able to spend an hour and a 3 half at CLS scanning over 2,000 pages from All 4 Children's Hospital, which I believe ended as of 5 December 10th, and I only began to read some of 6 them last night. And it is very apparent from the 7 records that the child is very angry at the 8 hospital for being separated from her parents and 9 being kept there in the notes that have been 10 recorded. She's been very sad and depressed by the 11 separation from her family. It is very apparent to 12 me that her anger is not because she's participated 13 in this proceeding, but -- 14 MR. SILVERSTEIN: Objection, calls for 15 speculation and counsel testifying. 16 THE COURT: This is an attorney giving her 17 impressions. 18 MS. SALISBURY: But I've had no opportunity to 19 prepare to put that evidence on. I would have to 20 have the records custodian here or some of those 21 witnesses that accurately reported what was going 22 on with the child. You just keep getting 23 presentations by another doctor that rotates on the 24 case every two weeks that this is the hospital and 25 10 the treatment team's position and that the child 1 becomes unmanageable. 2 I would also ask the Court to take into 3 consideration that the hospital has had this child 4 now two and a half months. The accusation of 5 Munchausen by proxy remains in place. The mother 6 has been removed from the picture and has only had 7 very limited contact with the child. And, you 8 know, if you read most of the literature about 9 Munchausen by proxy, once you remove the mother 10 who's causing the problem, supposedly, the child 11 usually gets very quickly better. They haven't 12 been able to fix this child. 13 The records also clearly indicated to me 14 yesterday that they have continued to treat this 15 child for CRPS and that that is a working diagnosis 16 that's continuing on in the medical records. 17 I did not have time to prepare for an 18 evidentiary hearing. I believed we were coming 19 here today to give you our proposed discharge plans 20 and that we were supposed to have it researched and 21 have sufficient detail in the order and that you 22 would choose an order. And that's what I have for 23 the Court today, a detailed order. 24 THE COURT: All right. Your position? 25 11 MS. VAN NESS: Judge, I echo the same 1 sentiments. There was no notice given to us that 2 some doctor's now saying that it would not be good 3 for her to appear. 4 We've already had Dr. Duncan testify. We 5 already had the other doctor testify. You already 6 told her she was able to testify. She's entitled 7 to be present, and she's not asking to be excused. 8 Her lawyer is here, and her lawyer is not asking 9 for her to be excused. So I would object to this 10 last-minute effort to keep Maya out of her 11 proceedings. 12 THE COURT: Mr. Zimmerman, anything you'd like 13 to add? 14 MR. ZIMMERMAN: Judge, I agree with counsel 15 for the parents. I mean, the child should be able 16 to be present. 17 I've spoken with her. She does express, you 18 know, displeasure in the way she's been cut off. 19 It seems that the hospital is, you know, making 20 efforts to make these processes more difficult. 21 She likes to have as much privacy as possible, but 22 other than that, I just agree with counsel for the 23 parents. 24 THE COURT: Mr. Monahan, any position on this? 25 12 MR. MONAHAN: Your Honor, I believe you 1 previously ruled that Maya is allowed to be present 2 for this. Without hearing from the doctor, I don't 3 know what's changed, but I'm sure we're going to 4 hear about that, so I would withhold my thoughts 5 until I hear from the doctor. 6 THE COURT: Mr. Hunter, the objections that 7 the parents have made obviously are based on their 8 knowledge of the child's condition when we've heard 9 from other physicians and folks, but it's a moving 10 target. I mean, the position is all the time 11 changing. And I think I need to know about the 12 status currently. 13 And also I think to get into the issue of the 14 placement is certainly appropriate here. Short 15 notice is not something we can control, given the 16 nature of the case and the child's condition. 17 The objections will be overruled. You can 18 tell Dr. Major that we will entertain her phone 19 call. And if you get her on the phone, let us know 20 when that happens. 21 MR. HUNTER: I have a cell phone number for 22 her, Judge. 23 MS. VAN NESS: Your Honor, we're also going to 24 ask that Maya be allowed to present evidence and we 25 13 would call her as a witness, so we would still want 1 to present our own evidence in that regard. 2 THE COURT: You want to have the child rebut 3 what the physicians say? 4 MS. VAN NESS: Yes. 5 THE COURT: Okay. Well, I'll make that 6 decision after I hear from the doctor. 7 Let's go ahead and call. 8 MS. SALISBURY: Do you want our proposed 9 orders? 10 THE COURT: Yes. Do you have those with you? 11 MS. VAN NESS: What would you like me to do 12 with the nurse on the phone? 13 THE COURT: Tell her that we're going to talk 14 to the doctor and that she can be excused. 15 MS. VAN NESS: (Addressing party on telephone) 16 Okay. We're going to deal with this through the 17 doctor, so I'm going to go ahead and hang up now. 18 Thank you for your time. 19 THE COURT: Go ahead. 20 Have you shared these proposed orders with 21 each other? 22 MS. SALISBURY: Absolutely. 23 THE COURT: Okay. Good. 24 Counsel, if you want to approach here so that 25 14 you can ask the questions. 1 MR. SILVERSTEIN: Yes, thank you. 2 THE COURT: Approach the bench so that we 3 can ... 4 (Sound of telephone call being placed.) 5 DR. MAJOR: This is Dr. Major. 6 THE COURT: Dr. Major, this is Judge Haworth. 7 We're in open court in Sarasota. 8 DR. MAJOR: Hi. Yeah, uh-huh. 9 THE COURT: Okay. What we're going to do 10 here, we're going to have some questions to ask of 11 you. Mr. Silverstein from the department is going 12 to be -- 13 DR. MAJOR: Yes. 14 THE COURT: -- asking you first. And if you 15 would, wait -- 16 DR. MAJOR: Okay. 17 THE COURT: The way this works, because it's a 18 little bit awkward, if you haven't done this before 19 on the phone, please wait for the questions to be 20 finished, listen for objections in case a lawyer 21 has an objection to a question, and then I'll -- 22 DR. MAJOR: Okay. 23 THE COURT: -- I'll rule on that and then we 24 can get a decision whether or not to have you 25 15 answer or not. 1 We have present -- 2 DR. MAJOR: Okay. 3 THE COURT: We have present Mr. Hunter, who's 4 with the hospital attorneys. We have Ms. Van Ness, 5 who's an attorney representing one of the parents, 6 and Ms. Salisbury, who also represents a parent. 7 And then we have some questions for you also 8 perhaps from the guardian and the attorney for the 9 child. 10 So we'll start with Mr. Silverstein. Before I 11 do, I need to administer an oath. 12 (Witness sworn by the Court.) 13 THE COURT: All right. Now, Mr. Silverstein, 14 you're up. 15 MR. SILVERSTEIN: Thank you, Your Honor. 16 - - - 17 CATHERINE ALEXIS MAJOR, M.D., 18 having been produced and first duly sworn as a witness, 19 and after responding "Yes, I do" to the oath, testified 20 as follows: 21 DIRECT EXAMINATION 22 BY MR. SILVERSTEIN: 23 Dr. Major, could you please give your full 24 Q name for the record. 25 16 Yes. My name is Catherine Alexis Major. 1 A And, Doctor, are you employed? 2 Q Yes, I am. 3 A Where are you employed? 4 Q I'm employed at Johns Hopkins All Children's 5 A Hospital in St. Petersburg, Florida. 6 And how long have you been employed there? 7 Q Recently for about four months. 8 A And are you a licensed medical doctor? 9 Q Yes, I am. 10 A And how long have you been licensed for? 11 Q 12 years. 12 A Do you have a specialty? 13 Q Pediatric hospitalist. 14 A THE COURT: Pediatric what? 15 THE WITNESS: Hospitalist. 16 BY MR. SILVERSTEIN: 17 And what is a pediatric hospitalist? 18 Q We take care of patients specifically in the 19 A hospital, usually acute patients. In my particular 20 setting, it would be acute illnesses and not necessarily 21 directed to a staff specialist per se but a varied array 22 of diseases. 23 And how long have you had this specialty? 24 Q I actually worked nine years prior and then 25 A 17 worked -- I worked nine years as a pediatric hospitalist 1 here at Johns Hopkins All Children's and then worked two 2 years in private practice and then just came back 3 approximately four months ago to pediatric hospitalist 4 medicine. 5 And what was your private practice? 6 Q It was general pediatrics. 7 A And, Doctor, are you board certified? 8 Q Yes, I am. 9 A In what? 10 Q General pediatrics. 11 A And, Doctor, approximately how many children 12 Q have you provided treatment to? 13 That would be hard to say. It would have to 14 A be a couple of thousand patients. That would be really 15 hard to say. 16 And, Doctor, do you know a child by the name 17 Q of Maya Kowalski? 18 Yes, I do. 19 A And how do you know her? 20 Q I am presently the attending physician taking 21 A care of her presently at Johns Hopkins All Children's 22 Hospital. 23 And when have you been the attending physician 24 Q for her? 25 18 I am -- I'm presently now for this week. And 1 A I was her attending physician two weeks ago as well for 2 a week. 3 And, Doctor, how often during the week do you 4 Q see Maya? 5 Approximately 30 to 40 -- oh, a week? I'm 6 A sorry. 7 Yes. 8 Q Approximately 30 to 40 minutes a day, so 9 A probably about three, three and a half -- three and a 10 half hours to four hours a week. 11 And do you see her every day? 12 Q Yes, I do see her every day. 13 A Including weekends? 14 Q Yes, I do. 15 A And, Doctor, do you have a recommendation 16 Q whether Maya Kowalski appear in these court proceedings? 17 MS. VAN NESS: Objection, improper foundation. 18 THE COURT: Overruled. 19 THE WITNESS: Can you clarify what you're 20 asking? 21 BY MR. SILVERSTEIN: 22 Doctor, do you have any feelings as to -- 23 Q well, in your opinion -- 24 Uh-huh. 25 A 19 -- do you feel that Maya's participation -- 1 Q MS. VAN NESS: Objection, leading question. 2 THE COURT: Overruled. 3 BY MR. SILVERSTEIN: 4 Doctor, in your opinion, do you have -- well, 5 Q do you have an opinion whether Maya Kowalski 6 participating in these court proceedings impacts her 7 medical treatment at All Children's Hospital? 8 Yes, I do. 9 A And what is your opinion? 10 Q My opinion is that I have some significant 11 A reservations about her actually participating and 12 hearing what is discussed during these sessions, 13 secondary to the fact that I feel that, one, I don't 14 think that she fully understands all of the terminology, 15 what the ramifications mean; and then also with the 16 concern of this being partly psychosomatic, some of the 17 things that we will discuss may actually sway her 18 clinical presentation, and that is concerning; and also 19 the fact that I will continue to need to take care of 20 this patient and I am concerned that it may cause some 21 regression given the past history of every time she goes 22 to court, we seem to have regression of -- 23 MS. SALISBURY: Objection. 24 THE WITNESS: -- wanting to participate -- 25 20 THE COURT: Hold on. 1 THE WITNESS: -- in [unintelligible]. 2 MS. SALISBURY: Objection, lack of foundation, 3 hearsay. 4 THE COURT: Overruled. 5 I didn't hear your last answer, ma'am. 6 THE WITNESS: I'm just concerned about the 7 fact that every time she goes to court, we have 8 regression where she does not want to participate 9 in physical therapy, occupational therapy. She 10 also tends to be very defiant with vital signs, the 11 physical exam. And in her demeanor overall she 12 seems to be quite unhappy. 13 MS. SALISBURY: Quite what? 14 MR. SILVERSTEIN: Quite what? 15 MS. SALISBURY: Quite happy? 16 THE WITNESS: Unhappy. 17 BY MR. SILVERSTEIN: 18 And, Doctor, have you observed this yourself? 19 Q Yes, I have. 20 A Now, you mentioned a word, "psychosomatic." 21 Q What is that? 22 Another way to describe that is a conversion 23 A disorder, which is a disorder in which the patient will 24 present with some specific symptoms which to them, for 25 21 the majority of them, they feel that these symptoms are 1 real, but there's no true organic justification for 2 them. So they -- for example, you can have something 3 like a pseudoseizure where the patient presents looking 4 like a seizure, but if you did -- 5 MS. SALISBURY: I would object as to 6 relevancy. 7 THE COURT: Just a moment. We have an 8 objection. 9 It's overruled. 10 Continue, Doctor. 11 THE WITNESS: Okay. 12 If you were to place, for example, electrodes 13 looking at their brain activity, it would be 14 completely normal. 15 And the patients are often -- they can be very 16 much weighted or influenced by other individuals 17 discussing symptoms of what they should have, and 18 then sometimes they will present with that. But a 19 lot of this just requires psychotherapy, and 20 there's often psychological stressors that induce 21 these particular manifestations. 22 BY MR. SILVERSTEIN: 23 And, Doctor, have you seen these psychosomatic 24 Q issues with Maya? 25 22 In my opinion, yes, because of the diagnosis 1 A that she was carrying of chronic [sic] regional pain 2 syndrome. A lot of what she should manifest, she is not 3 manifesting. 4 For example, she should have unilateral pain, 5 but she has global pain which is really unusual. She's 6 had no preceding trauma, which is almost always in all 7 cases. And she should have things like temperature 8 changes, color changes in her extremities, which she 9 doesn't have. 10 And then she -- on days that she's in a lot of 11 pain, she participates in a lot of activities, which 12 don't -- it just doesn't make any sense to me. So 13 clinically what she should be experiencing and what 14 she's telling me don't go together. 15 So, Doctor, so can you explain to the Court 16 Q how participating in the court proceeding can impact 17 this psychosomatic issue? 18 Well, I feel that if we discuss all these 19 A specific symptoms of what she should be experiencing, 20 what she shouldn't be experiencing, are things that she 21 could actually incorporate into her clinical findings, 22 her daily findings. 23 Or she could say it. She's very smart. So 24 she could say, "Well, I'm experiencing this," because a 25 23 lot of this is subjective. Especially pain can be very 1 subjective on what one person rates versus another. And 2 then it becomes much more difficult to figure out 3 exactly what's going on and it will completely muddy the 4 waters. 5 So -- and I think that's my biggest concern. 6 And then I think also because we are actually taking 7 care of the patient, that it may really impede care 8 because she won't want to participate and she will 9 become defiant. 10 MR. SILVERSTEIN: And, Judge, did you want me 11 to address the placement issue now or later? 12 THE COURT: Let's hold on that. 13 Dr. Major, we're also concerned about options 14 for placement of the child, which is a subject 15 we'll return to in a moment. 16 THE WITNESS: Okay. 17 THE COURT: But in the meantime I'm going to 18 have the attorneys representing the parents have a 19 chance to question you. So please, if you would, 20 wait until they finish their question before you 21 answer. 22 And who wants to go first? 23 MS. SALISBURY: I will. 24 THE COURT: All right. This is Ms. Salisbury. 25 24 CROSS EXAMINATION 1 BY MS. SALISBURY: 2 Hi, Doctor. 3 Q Hi. 4 A You indicated that you are the physician 5 Q treating the child for this week? 6 Yes. 7 A And that you treated her two weeks ago. Are 8 Q those the only two weeks that you've been the attending 9 physician for her? 10 Yes, that's correct. 11 A And she's been there how long? 12 Q She has been here approximately two and a half 13 A months. 14 So out of two and a half months, you've 15 Q treated her for two weeks? 16 Yes, that is correct. 17 A And how many patients do you have on your 18 Q patient load right now? 19 Twelve. 20 A Okay. And what do you do with her for 30 to 21 Q 40 minutes every day when you meet with her? 22 Basically I just talk with her very briefly. 23 A I don't do a lot of -- I don't ask her a lot about her 24 pain because of the fact that it's always ten out of 25 25 ten. And then I examine her the best I can. Sometimes 1 she is defiant with some of the exam. 2 And then the other part is spent with -- 3 between meeting, discussing with other team members, and 4 then also discussing with the residents. 5 Okay. So when you said you spend 30 to 40 6 Q minutes with her a day, you don't actually spend 30 to 7 40 minutes with her at the bedside; is that correct? 8 That is correct. 9 A Okay. About how many minutes do you spend at 10 Q the bedside with her? 11 Probably about 15 minutes. And that's give or 12 A take, depending on the day. 13 Okay. 14 Q You said that you had a reservation about her 15 participating in the proceedings. And can you tell me 16 the last time that you saw her immediately after she 17 participated in a proceeding? 18 That was two weeks ago, after one of our 19 A hospitalists actually went -- or participated in one of 20 the [unintelligible]. I actually examined her later 21 that day. 22 What day was that? 23 Q I cannot remember offhand. I want to say it 24 A was a Thursday, but I don't -- honestly, I can't 25 26 remember. 1 Okay. And you said that every time she goes 2 Q to court, you had concerns that she may regress; is that 3 correct? 4 Yes. 5 A Okay. Have you reviewed her whole records at 6 Q All Children's Hospital? 7 I have to the best of my ability. It's pretty 8 A extensive -- 9 Okay. So -- 10 Q -- so I can't say that I've read every single 11 A note. 12 Okay. So you're not maybe familiar with how 13 Q angry she's been at the hospital and those documented 14 notes that she feels that the hospital is lying to her 15 and she's angry about being separated from her family? 16 I have actually read that. And I've read that 17 A with -- a lot of that is from her psychology notes and 18 her -- you know, they do cognitive behavioral therapy 19 with her as much as they can. It's usually about once a 20 week. And I do read those notes. Those are fairly well 21 documented on how she feels. 22 Okay. And -- 23 Q So -- 24 A -- did you read any of the child's -- 25 Q 27 MR. HUNTER: Excuse me. Can we let the 1 witness finish her answer? 2 THE COURT: Yes. 3 Go ahead and answer, ma'am. Complete your 4 answer. 5 THE WITNESS: I was just going to say, so I 6 understand and I do get that feeling that she -- 7 you know, she is angry, and that's hopefully 8 understandable. 9 BY MS. SALISBURY: 10 And did you consider the fact that by 11 Q isolating her further from her family in these 12 proceedings she may become more angry at you and the 13 staff and not want to cooperate more in her treatment 14 there? 15 Yes. I think that's completely 16 A understandable, that she would be angry. 17 Okay. 18 Q But can I just -- can I just interject? I 19 A think that's even more reason why we need to -- 20 MS. SALISBURY: I would move to strike as 21 being nonresponsive. 22 THE COURT: Hold on. 23 Go ahead and complete your answer, Doctor. 24 THE WITNESS: I think that's even more reason 25 28 why we need to get her to a facility where she can 1 have intensive therapy -- 2 MS. SALISBURY: That's outside the scope. 3 THE COURT: Overruled. 4 Go ahead, Doctor. 5 THE WITNESS: -- to get intensive therapy both 6 for physical therapy and for cognitive behavioral 7 therapy. 8 BY MS. SALISBURY: 9 How many times a week are you providing 10 Q physical therapy to her at All Children's Hospital? 11 They are trying to do it every day. 12 A So she's having physical therapy every day for 13 Q two and a half months and you haven't been able to fix 14 her feet, have you? 15 Well, that -- I cannot say I could answer that 16 A with a good educational answer, given the fact that I'm 17 not a physical therapist. But I will state that she 18 does not always participate in the physical therapy 19 either. 20 Okay. And you're not a CRPS expert either, 21 Q are you? 22 Excuse me? I'm not a what? 23 A An expert in treating patients with CRPS, are 24 Q you? 25 29 No. 1 A Okay. 2 Q No, I'm not an expert on that. 3 A So if her legs had reached a second stage of 4 Q CRPS where she would no longer have the temperature 5 changes in her extremities because she has bilateral 6 changes that may not be apparent, you wouldn't know 7 that? 8 MR. SILVERSTEIN: Objection. Objection, 9 Your Honor, relevance. 10 MS. SALISBURY: She testified to -- 11 THE COURT: Hold on. 12 Overruled. 13 THE WITNESS: I wouldn't say -- yeah, I'm not 14 an expert on that. I'm the first to say that I'm 15 not an expert on those -- on that specifically. 16 That would be -- I would defer that to somebody 17 who's an expert with that. 18 BY MS. SALISBURY: 19 All right. And you were testifying earlier 20 Q about her possibly having a conversion disorder, that 21 there's no true organic basis. Is it your testimony 22 that this child does not suffer from CRPS and there's no 23 organic basis to her feet and her lower extremities 24 being atrophied and pronated? 25 30 Frankly, I'm basing this more on the fact 1 A that -- one is the clinical signs, and two is the 2 history. And also the history of her therapy and why 3 she did not get any better during therapy. 4 And what is the history of the therapies 5 Q before she came to All Children's that you're aware of? 6 The big ones are the ketamine drip and 7 A infusions that she's had. I know she's been -- she also 8 had IgG infusions because of an immunodeficiency. But 9 the big ones were the ketamine infusions that she was 10 getting in fairly large infusions -- 11 And what do you know about -- 12 Q -- [unintelligible]. 13 A What do you know about her treatment for 14 Q conversion disorder in the past? 15 MR. SILVERSTEIN: Objection, Your Honor. 16 Asked and answered. 17 THE COURT: Overruled. 18 THE WITNESS: I don't actually know a lot 19 about her treatment for conversion disorder in the 20 past. 21 BY MS. SALISBURY: 22 So you weren't aware that she spent a month at 23 Q Tampa General Hospital being treated for that on a rehab 24 unit prior to coming to All Children's? 25 31 I did know that she was being treated -- I do 1 A know she did go to Tampa General Hospital, and I know 2 she did not have a good experience there from a 3 psychological standpoint. Now, granted, I thought she 4 was being treated for pain and -- 5 So would it be -- 6 Q MR. HUNTER: She didn't finish. 7 BY MS. SALISBURY: 8 Would it be fair to say you haven't reviewed 9 Q those records? 10 MR. HUNTER: Excuse me. Excuse me. 11 THE COURT: Hold on. 12 Go ahead and finish your answer, Doctor. 13 THE WITNESS: I was just going to say that my 14 big thing that I -- just what I knew about that was 15 that the -- that, Judge, she did not have a good 16 experience there from a psychological standpoint. 17 So -- 18 BY MS. SALISBURY: 19 Okay. So you haven't read those records, 20 Q then, have you? 21 I have not seen those records. 22 A And have you reviewed her records where she 23 Q was having physical therapy as an outpatient when she 24 was living at home with her parents? 25 32 No, I did not review that. 1 A Okay. Were you aware that she was having 2 Q physical therapy before she was admitted to All 3 Children's Hospital, as an outpatient? 4 I do -- I did read that in the -- either one 5 A of the physical therapy notes or it was in her last 6 history and physical from the ICU. Because that one was 7 fairly explicit. 8 Okay. And do you remember who she was having 9 Q physical therapy with? 10 No, I do not. 11 A Do you remember how long she was having 12 Q outpatient physical therapy? 13 No, I do not. 14 A And do you remember if she was having 15 Q outpatient psychotherapy prior to coming to All 16 Children's? 17 I do believe that I have read that. 18 A Okay. Do you know who was treating her for 19 Q outpatient psychotherapy? 20 I do not. 21 A And do you know how long she was treated for 22 Q outpatient psychotherapy? 23 No, I do not. 24 A And have you had an opportunity to review any 25 Q 33 of Dr. Hanna's notes about treating her for CRPS? 1 No, I have not. 2 A And have you had an opportunity to review 3 Q Dr. Kirkpatrick's notes about treating her for CRPS? 4 No, I have not. 5 A Okay. And can you tell me if you have done 6 Q any -- well, so you don't have any familiarity with 7 treating patients with CRPS once they pass through the 8 change in their extremities where they no longer have a 9 temperature change in their extremities; correct? 10 That is correct. I have not actually -- I've 11 A never had a patient that had chronic regional pain 12 syndrome. I've taken care of patients that have had 13 acute. 14 So you wouldn't be familiar with those 15 Q symptoms, then? 16 I can't say that I would, because I'm not an 17 A expert. 18 Okay. And so if we don't discuss any specific 19 Q symptoms in our hearing -- those are the issues that 20 you're concerned about Maya picking up on, specific 21 symptoms? 22 Yes. Yes. And my other concern is just the 23 A fact that we have to take care of her, so she's aware of 24 who's on the line. I'm just worried about how well 25 34 she's going to cooperate with us as far as treatment and 1 exam. 2 Okay. But you also acknowledge that she may 3 Q not cooperate with treatment just because she's angry at 4 the hospital and feels that she's being isolated from 5 everybody; correct? 6 Yeah. I can't say that a lot of this isn't 7 A from anger. I can't say that. 8 Okay. And -- 9 Q I do feel that she is angry. 10 A Okay. And do you have any concerns about her 11 Q being angry after she finds out that she may not be 12 allowed to participate today in this hearing because of 13 the hospital not wanting her to participate? 14 I do, but I just -- I think I'm a little more 15 A concerned that specifically it may be targeted to me 16 specifically, and then, I mean, I may not even be able 17 to go in the room and do anything. That's what I'm -- 18 that's what I'm concerned about. 19 Okay. But when you go in the room, you talk 20 Q to her and examine her for about ten minutes if she 21 allows you to? 22 Yes, for the most part. 23 A MR. SILVERSTEIN: Objection. Mischaracterizes 24 prior testimony. 25 35 THE COURT: Overruled. 1 BY MS. SALISBURY: 2 Okay. And some days she lets you examine her 3 Q and other days she doesn't; correct? 4 In general, she lets me examine her. It's 5 A just sometimes she'll say things that -- she won't let 6 me listen to her heart or she won't let me listen to her 7 abdomen, but she'll let me listen to her lungs. So it's 8 day to day. 9 Okay. When you testified earlier that her 10 Q symptoms don't make sense to you, you really have never 11 treated another patient that's passed through the 12 initial phases of CRPS and has had it chronically; 13 correct? 14 That is correct. 15 A MS. SALISBURY: Thank you. I don't have any 16 further questions. 17 THE COURT: All right. This will be Ms. Van 18 Ness, Dr. Major. 19 CROSS EXAMINATION 20 BY MS. VAN NESS: 21 Good morning, Doctor. 22 Q Hi. 23 A As a follow-up question, you also don't know 24 Q if Maya's not participating with treatment because of 25 36 pain, do you? 1 No. But I can tell you that, just looking 2 A through some of the notes, sometimes it is related to 3 pain, but sometimes it's things like "My lunch is 4 coming," "My dinner is coming," "Can I" -- you know, "I 5 would rather eat that." Those kind of things. So it's 6 sort of a combination of things as far as participation. 7 And this is just also as far as things like 8 trying to flush her port or to do blood work 9 periodically, and it's always a comment of "Why didn't 10 you ask me this last week because I was in less pain?" 11 So there's -- sometimes it's about pain but sometimes 12 it's not. 13 And speaking of flushing her port, that was 14 Q just recently done for the first time after two and a 15 half months; isn't that correct? 16 I don't know exactly if it was two and a half 17 A months, but it had been over a month. Per our protocol, 18 yes, it had been over the protocol. 19 And the reason that it got flushed is because 20 Q Mom inquired about when was the last time that her port 21 had been flushed, and that's what prompted you guys to 22 do it. Isn't that true? 23 That I don't know. I can't -- I can't answer. 24 A What happened for me was that was brought up to me by 25 37 the nurse. 1 Have you spoken to a psychologist about your 2 Q recommendation? 3 Yes. 4 A Who is that? 5 Q That's Dr. Katzenstein. 6 A When is the first time that you saw Maya? 7 Q What is the date? 8 It would be in November. I'm sorry, I don't 9 A know exactly the date, but it was the week -- it was the 10 week after Thanksgiving. 11 Okay. And was Maya compliant with you that 12 Q week? 13 To some extent. She was a little bit defiant, 14 A but she would let me listen to her. 15 Okay. So you encountered defiance from Maya 16 Q prior to December 15th? 17 I had -- I'm sorry. I didn't hear you well. 18 A You encountered -- 19 Q Can you repeat that? 20 A Yes. 21 Q You encountered defiance from Maya prior to 22 December 15th? 23 I'm sorry. I still didn't hear. I'm sorry. 24 A Did you encounter defiance from Maya prior to 25 Q 38 December 15? 1 Yes, I did. 2 A Okay. And when's the first time -- what is 3 Q the date of the first time you saw Maya this week? 4 That would be December 26th. 5 A Okay. December 26th. 6 Q Do you know which date Maya appeared in court? 7 In between that time? 8 A Anytime. Tell me the dates that Maya has 9 Q appeared in court. 10 I'm trying to remember. 11 A I remember when I was on -- when I took care 12 of her, so actually just what -- that was actually in 13 December. It was just the week before Christmas. So it 14 was that Thursday of the week before Christmas. 15 But you didn't see her until the 26th? 16 Q No. Actually I'm just trying to remember my 17 A schedule. So I actually -- I took care of her the week 18 before, that full week before Christmas, and now I'm 19 taking care of her again. This is the week after 20 Christmas. So that -- whatever that Thursday was, I 21 think that was the day of her court appearance, or the 22 court date. 23 So that would have been -- that Thursday 24 Q before Christmas was the 22nd? 25 39 No, I did not take care of her during the 1 A 22nd. I took care of her from the -- the 19th was that 2 Monday, so that previous week, that whole previous week. 3 I don't have a calendar on me. I just can't 4 tell you offhand what the dates are. 5 So you took care of her the week of the 12th 6 Q and then this week starting what day? 7 The 26th. 8 A And you're encountering defiance from her this 9 Q week? 10 Yes. And a little bit the week -- that prior 11 A week as well. 12 So the very first day that I went to examine 13 her, she was very defiant. She was a little bit better 14 the next couple of days. And then towards the end of 15 the week and then the weekend, she was fairly -- you 16 know, "I don't want you to listen to my heart or my 17 stomach or" -- it was something, always something. 18 Do you know if she's encountered that same 19 Q kind of defiance from other -- if she's exhibited that 20 defiance to other doctors? Has this been pretty routine 21 for her since she's been there? 22 She -- so last week the hospitalist taking 23 A care of her told me that she was pretty defiant with 24 her. And -- but prior hospitalists have told me that 25 40 they actually -- she was fairly good for them. 1 MS. SALISBURY: Objection, hearsay. 2 THE WITNESS: This is a more recent 3 development. 4 THE COURT: Hold on. 5 MS. SALISBURY: Objection, hearsay. 6 THE COURT: Overruled. 7 Go ahead. 8 The objection is overruled. 9 MR. HUNTER: Go ahead, Doctor. 10 MS. VAN NESS: She finished. 11 BY MS. VAN NESS: 12 Does Maya have lesions on her body now? 13 Q Does what? I'm sorry. Excuse me? 14 A Does she have lesions? 15 Q No, not that I know of. 16 A MS. VAN NESS: Okay. I have no further 17 questions. 18 THE COURT: This is Mr. Zimmerman. He's the 19 attorney for Maya Kowalski. 20 CROSS EXAMINATION 21 BY MR. ZIMMERMAN: 22 Good morning, Doctor. 23 Q Doctor, what, if anything, have you personally 24 diagnosed Maya with? 25 41 What have we diagnosed her with? 1 A Yeah. I'm asking you personally. Have you 2 Q personally attributed any specific diagnoses to the 3 child? 4 My personal opinion is that I think that this 5 A is a conversion disorder. I do feel that she -- 6 definitely some of the pain that she perceives to her is 7 real. And then she has some of the other comorbidities, 8 so she does have asthma that the other -- 9 Okay. Have you consulted with Dr. Sally Smith 10 Q from the child protection team? 11 MR. ZIMMERMAN: Is she there? 12 I'm not sure she's there. 13 Are you there, Doctor? 14 MR. HUNTER: She's disconnected. 15 MR. ZIMMERMAN: Yeah. 16 THE COURT: Stand by. We'll re-call. 17 (Sound of telephone call being placed.) 18 THE WITNESS: I'm sorry about that. 19 THE COURT: Yeah, we dropped the call. This 20 is Mr. Zimmerman. He had a question for you. 21 Go ahead, sir. 22 BY MR. ZIMMERMAN: 23 Dr. Major, have you consulted with Dr. Sally 24 Q Smith with the child protection team? 25 42 Yes, I have spoken with her. 1 A Okay. How many times? 2 Q A couple of times. 3 A When was the most recent conversation you had 4 Q with Dr. Smith? 5 That would have been around like the 14th or 6 A 15th -- 7 Okay. 8 Q -- of December. 9 A Have you reviewed Dr. Smith's report on the 10 Q child? 11 I have, to my best ability. It's a -- it's a 12 A small novel. 13 Have you consulted with Dr. Elliott, the p