Mothers Against MSBP Allegations
A.
Causing chronic irritation, stimulating bleeding and the fact that
there is no evidence that there's indication for using a rectal tube in this
patient. It's one more procedure
for him to have undergone that does not appear to be necessary.
THE
COURT: Doctor, is she free at the hospital if she wants to use a rectal tube
ten times that she has been free just to manage, I guess, that tube?
THE
WITNESS: She was -- the rectal tube was predominantly used while in the
private room, so she was actually free to use it whenever she wanted to use
it.
THE
COURT: Had you talked with her, or other doctors in your practice, talked with
THE
WITNESS: Dr. Barnard had spoken with her about the tube and, in fact,
suggested discontinuation of the tube. I
don't have the exact date of that. I'm
sorry.
THE
COURT: Okay.
THE
WITNESS: And at the time of discussing with Mrs. Patrick the suspicion of
Munchausen's by Proxy Syndrome, she immediately informed me and the group that
she had been accused of this before at Oschner's.
She said, in fact, "I have been through this before," and I
asked her "Has someone accused you of Munchausen's by Proxy
Syndrome?" and she said, yes, she had been through this entirely at
Oschner Medical Clinic. And when
I spoke with the attending physician there, again, he denied that she had ever
been accused of Munchausen's by Proxy Syndrome.
BY
MS. LUSTER:
Q.
And who was the attending physician?
A.
Dr. Vikram Khoshoo.
Q
. Okay.
A.
And Point Number 15 is when I told Mrs. Patrick that every physician
who had received their fax and responded by calling to our office came to the
conclusion that this was Munchausen's by Proxy Syndrome, she stated that this
was probably Dr. Hyman because she knew he was an expert on the Munchausen's
by Proxy Syndrome from her reading of the literature.
In
the final portion of this on -- in her note that was left at the bedside at
the same time as the potential for eminent need of blood, this was written, or
at least posted at the bedside on September the 6th.
This says "What was the result of the urine culture done?
Has there ever," underlined many times, three times, "been a
fungal growth from a urine culture?" As it turns out, the urine culture
that was obtained the day prior to that is now growing a yeast infection and
it's not the typical yeast infection. It's
most likely the same yeast infection that he had in his bloodstream, and he
has had urine cultures prior to that which did not show evidence of that.
So it, again, points to the fact that there's an uncanny ability to
predict preeminent medical changes in this patient prior to there being
evidence of their occurrence.
Q.
Doctor, I'd just like to briefly run through some stated guidelines of
Munchausen's and ask you if you
MR.
FRIEDMAN: Your Honor, if I may, counsel asked for the qualification of this
doctor as an expert in gastroenterology -THE COURT: I agree. I don't need anymore. The
doctor's been very clear and has provided me with his expert opinion.
I think at this point I may need to hear from your expert and see
whether or not I can make a decision. I
don't need to -- I'm not trying this case.
He's been a very well qualified expert who has gone through very
specifically his basis for making that determination.
This is a preliminary hearing and what I need to do is find is there a
reasonable belief this mother has that diagnosis and, if so, is there
reasonable belief that the child will be in eminent harm if custody remains
with her.
MS.
LUSTER: Then, Your Honor, at this point, then, that is my next area.
BY
MS. LUSTER:
Q.
Doctor, what is it that is required in your medical opinion at this
point to keep Phillip Patrick safe
MR.
FRIEDMAN: Your Honor, I --
MS.
LUSTER: -- given your diagnosis.
THE
WITNESS: Given the diagnosis -THE COURT: Excuse me just one minute. What's the objection?
MR.
FRIEDMAN: Your Honor please, his opinion of safety is not what he's been
qualified as an expert on.
THE
COURT: Ms. Luster, I know what you're asking.
It's admissible if you'll ask him in a clearer way.
MR.
FRIEDMAN: Thank you.
BY
MS. LUSTER:
Q.
Doctor, in your expert medical opinion, what is required to properly
treat Phillip Patrick given the diagnosis of Munchausen's Syndrome by Proxy?
A.
Absolute separation of the patient from the parent, from Mrs. Patrick,
so that there would be no physical contact or the ability to administer any of
these therapies that have occurred in the past and given a period in which he
may recover from his illnesses to determine to what extent he will recover.
Q.
Doctor, has there been -- was visitation arranged for Mr. and Mrs.
Patrick following the removal?
A.
Yes. Your Honor, Phillip
was intubated because of the pulmonary edema that I mentioned earlier and his
overwhelming yeast infection that was in his bloodstream and presumed to be in
his lungs. He was intubated and
we became concerned that Mrs. Patrick was not allowed to see the child when
his condition was deteriorating from this infection.
We contacted DCS or DHS and set about with them the possibility of
arranging a limited visitation. After
consultation, they were in agreement with this and called me back and we
discussed specific guidelines for that.
Q.
What were those guidelines?
A.
The guidelines were that all the equipment was to be on one side of the
bed, all of the tubing and everything that would provide access to Phillip was
on one side of the bed and that Mr. and Mrs. Patrick would be allowed on the
opposite side of the bed. They
would be allowed for 15-minute visits. The
nurse was not allowed to leave the bedside during that time so that they would
be under constant observation and the DCS worker was also to be in constant
attendance during this 15 minutes. Mrs.
Patrick was specifically allowed to hold Phillip's hand and those are -- I
think are the full guidelines.
Q.
Did you explain these conditions to the
Patricks?
A.
I did. I called Mrs.
Patrick, presented her with the opportunity to come and visit him, be it
limited for the 15 minutes, with the guidelines that she would be able to hold
his hand.
THE
COURT: Can you get a date on that? Is
it the last few days?
THE
WITNESS: Yes. It was on September
the 10th, and I can read to you the guidelines as I read them to Mrs. Patrick.
THE
COURT: Just if there's anything different from what you've told me.
THE
WITNESS: The nurses -- the one thing I didn't tell you is the nurses were to
discuss his general status and condition but would not discuss his medication,
management or lab values, and that if the visits became disruptive, then DCS
would have to reconsider them. I
told her the time of the following visit at eleven o'clock and that they would
meet the DCS worker and that the time for each subsequent visit would be
arranged the day of that visit.
THE
COURT: Did that visit occur?
THE
WITNESS: Yes, it did.
THE
COURT: Were there any problems?
THE
WITNESS: The father requested being able to take
photographs of Phillip and
the nurse complied with that. And
before she was aware, the parents were on both sides of the bed completely
obstructing her view of the patient so that there were several minutes that
elapsed. She said she kept
directing them back from the bedside but was uncomfortable that she had not
been able to observe the entire visit and the entire extent of contact.
She did describe Mrs. Patrick putting her hands under Phillip's head
and then under his legs, sort of cradling him and that she had to remove the
gastrostomy tube from Mrs. Patrick's hand.
BY
MS. LUSTER:
Q.
Now, Doctor, subsequently to that -- let me ask you, were you aware
that a contract, as it were, was drawn up or a set of guidelines was drawn up
and presented to Mr. and Mrs. Patrick?
A.
I was not aware before the
fact. I
saw them after the fact.
Q.
Have you had a chance to review those
A.
I have. I don't have a
copy with me.
Q.
I'm going to just hand this to you briefly and ask you to take a second
and review that.
MR.
FRIEDMAN: Your Honor please, I'll be glad to have that admitted without
objection, DHS' requirements for further visitation.
No objection.
BY
MS. LUSTER:
Q.
Doctor, let me ask. in your expert medical opinion, are those
guidelines necessary for proper treatment, medical treatment, of Phillip
Patrick?
A.
Absolutely.
Q.
Doctor, if I may, just very briefly wanted to take you back, and I
apologize. Your discussion with
Dr. Khoshoo that you had and did you ask him to send records?
A.
I did.
Q.
What was his response to you?
A.
His response was that he had typewritten himself a summary of three
pages of Phillip's condition. informed him that I had not seen that
typewritten summary, could not find it in the medical records and he told me
he would fax that to me the following day.
I also informed him that we had no progress notes available to us for
any
Q.
What was his response to that?
A.
He said he thought that would be difficult but that he would do it by
Monday. My discussion with him,
again, was on Friday night when he called to speak to Mrs. Patrick in the
intensive care unit.
Q.
And that was September 6th?
A.
Yes.
Q.
Did he make any comments with regard to the helpfulness or any
information in the records?
A.
He did tell me that there would be nothing in the medical
records that would help me either way.
Q.
When you talked with him and discussed with him whether or not Mrs.
Patrick had ever been accused of Munchausen's Syndrome by Proxy, did he
indicate whether or not that had occurred by anyone other than himself?
A.
He said that, in fact, that it had, that there was concern among many
of the nurses that this represented Munchausen's by Proxy and -- by Proxy
Syndrome and his response to me was "I squashed it because he was getting
better, end quote.
Q.
Doctor, I also hand you a chart and, if you could, do you know the
source of that chart?
A.
This was a chart that was prepared by Dr. Barnard who is my division
chief in pediatric gastroenterology that outlines specific problems of
Phillip's. It was prepared for a
case care conference in which Phillip's management was discussed, and then at
the end of that case conference, when the physicians and nurses and physical
therapists, et cetera, were in attendance the mother was invited in to join
the case conference at that point. And she had this, a copy of this, as well.
Q.
Does that chart, in your opinion, accurately reflect Phillip's
condition today, or are there differences?
A.
It adequately reflects it with the additional caveat of his current
infectious state that he has with the multiple organisms that I described.
MS.
LUSTER: Your Honor, we would offer this again as a summary to the Court, the
medical condition.
BY
MS. LUSTER:
Q.
Doctor, one last thing. Could
you describe Phillip Patrick, his appearance for the Court.
A.
Phillip is a seven and-a-half kilogram, which is about fifteen pound
young man who is almost one year of age.
He is currently on a ventilator associated -because of his respiratory
condition. When he is not on
Q.
How about in terms of any bloating, swelling?
A.
He has edema, which is body fluids, excess body fluid associated with
multiple infections like this all over his legs, his arms, his abdomen.
His liver is enlarged and has been enlarged, as is noted in the initial
handout that I gave you.
Q.
Does he have prominent veins on his body?
A.
Yes, he does have prominent veins on his abdomen.
Q.
Doctor, have you noted a difference between -- any difference between
Phillip now and when his mother was with him constantly?
A.
The only difference that I've noted personally, as well as has been
commented to me, is the decreasing irritability that he constantly displayed
before as documented throughout the charts his tendency to be always irritable
and fussy.
Q.
Just one final question, Doctor. In
terms of the prognosis for Phillip, even following the guidelines that have
been presented to the Court what would be the
A.
This will take months for his intestine and lungs to heal.
The level of damage that's occurred in his intestine is not going to
heal anytime soon and will take four to six months for that to occur.
THE
COURT: Doctor, in terms of the damage to the intestine, can you point to any
of the congenital problems that Phillip had that would contribute to that
damage or are you concluding that the damage to the intestine originates with
some of the interferences that you've described?
THE
WITNESS; The concern is that it has resulted from the interferences. There's nothing else with his congenital condition that would
have indicated that he would have these sorts of intestinal problems.
THE
COURT: In other words, if you look through each of the things that he was born
with or that he was predisposed, I guess, because of his condition at birth,
nothing leads you to conclude that his intestine
THE
WITNESS: He has been tested for
THE
COURT: Are there any other tests that you're planning to do?
Is there something else that you feel is out there and that you'll
continue to look at?
THE
WITNESS: Not at this point. There
are -- I apologize for being late to this hearing, but the reason I was late
was I was still in the intensive care unit as the toxicology service, which
has been consulted to try to help piece together how he could have the lung
and pulmonary disease received back a lab result about twelve-forty this
afternoon that said that he had very elevated chromium levels in his
bloodstream that were ten times -- in his urine that were ten times the
expected normal values. Among
things that can cause this, and there are a long list of things that can cause
this sort of inflammatory bowel disease,
THE
COURT: The fact that you say months, I assume that's more than a couple of
months?
THE
WITNESS: Yes.
THE
COURT: And your proposal in terms of your plan of treatment for this child is
to continue these guidelines in effect until you determine they're no longer
necessary. Is that correct?
THE
WITNESS: Yes.
THE
COURT: In other words, you may find there's something else and continue to
look at other things. Is that
correct?
THE
WITNESS: Yes.
THE
COURT: Thank you, Ms. Luster.
MS.
LUSTER: That's all I have at this
MR.
FRIEDMAN: Your Honor please, I would like to take a recess to consult with my
expert prior to cross-examination, also to be able to review these documents.
THE
COURT: Let's see. What we're
going to do. We are going to have
to stop at four. The parties may
want to determine whether or not -- that's what I told everyone when we were
here originally to schedule this. I
do not need any more proof from the State.
Certainly, the State -- I know Dr. Sterling's here and I don't want to
inconvenience anyone. On the
other hand, we have the expert for the defense who I now have a basis that is
very helpful to me. I understand
what the diagnosis is in this doctor's opinion.
If Dr. Khoshoo, I believe, who is here is going to testify B
MR.
FRIEDMAN: That's correct.
THE
COURT: -- his opinion that it's not a possibility, then I'll be glad to hear
that. I don't see any point in
the State continuing to build on top of this witness unless there is something
you have not
MR.
FRIEDMAN: Thank you, Your Honor. (WHEREUPON, there was a brief recess at this
time.)
CROSS-EXAMINATION
QUESTIONS
BY MR. FRIEDMAN:
Q.
Doctor, my name is Robert Friedman --
MR.
FRIEDMAN: And Your Honor please, I'm not going to attempt to make any opening
statement, and I am going to try to limit my questioning, for the most part,
not to direct examination but rather to the issues concerning Your Honor.
BY
MR. FRIEDMAN:
Q.
Doctor, let me ask you this. It's
my understanding that you are the physician who has made a diagnosis and you
stated your diagnosis in this case of Munchausen's Syndrome by Proxy.
Is that correct?
A.
Yes.
Q.
That is your diagnosis, you're the one who reached it.
Is that correct?
A.
Not alone, no; I did not reach it alone. it was in conjunction with the
group of physicians at Vanderbilt as well as other care givers known as the
abuse
Q.
Other than yourself, which of these other parts of your
interdisciplinary team had seen and observed Ms. Patrick around her child?
Which ones, if you'll tell Her Honor?
A.
I'll need to see a list of the people who were there so that I can
verify that.
Q.
Sir, I don't have the list because my client and I weren't there.
A.
Do we have a list?
THE
COURT: Doctor, go ahead and try to recall what you can.
THE
WITNESS: Dr. Barnard, myself, Dr. -
THE
COURT: Dr. Barnard -- Barnard is your --
THE
WITNESS: The attending -- he's the director of the pediatric GI division;
myself; Dr. Acra, who is a fellow that's on service; Dr. Crissinger, who is an
attending pediatric --
THE
COURT: Can you spell both of those
THE
WITNESS: Acra is A-C-R-A;
Crissinger
is C-R-I-S-S-I-N-G-E-R.
THE
COURT: And what is his position?
THE
WITNESS: I'm sorry?
THE
COURT: What is his position at Vanderbilt?
THE
WITNESS: She is a pediatric gastroenterologist and attending.
So three of the physicians that I'm aware that had direct, repeated
interaction with the patient and the mother on multiple, multiple occasions,
each of those over more than a one-month period. So that those are the ones that I have direct knowledge of,
sir.
BY
MR. FRIEDMAN:
Q.
You've stated to the Court heretofore all the reasoning that went into
your decision that was made, or at least advised to my client on September 6th
of this year. Is that correct?
A.
I did not state all of it. There
are more examples, but I stated the ones I felt that were most significant,
yes.
Q.
Had your interdisciplinary team met prior to
September
6th, 1996, and discussed the allegations of
A.
Yes.
Q.
How many times had you met, if you know?
A.
Once.
Q.
When was that, sir?
A.
It was on the Wednesday afternoon.
That would have been the 4th of September.
Q.
And that was the first time you met; correct?
A.
Yes.
Q.
So you met twice with these other physicians?
A.
No. I met once with these other physicians.
Q.
Well, excuse me. You met twice and then removed the child or had DHS remove
the child; correct?
A.
We met once.
Q.
I think you met once on Wednesday and once on Friday, if I understood
your testimony.
A.
We did not meet on Friday.
Q.
Oh, you didn't meet on Friday?
A.
Right.
Q.
So you reached your conclusion on Wednesday.
Is that correct? Wednesday,
September 4th, sir.
A.
The Friday meeting was with DHS to discuss the events that I've
described.
Q.
But you made your decision -- did you understand my question?
A.
I made my decision at one o'clock on Friday afternoon the 6th of
September.
Q.
Who was present when you made the decision at one o'clock?
Or did you make it on your own. I
don't mean to presume there was someone there.
A.
I made it on my own, yes.
Q.
So you are the doctor who has diagnosed Munchausen Syndrome by Proxy.
That is your diagnosis; you made it, and you made it on Friday at one
o'clock on your own. Is that
correct?
A.
Following consultation with many other physicians as described.
Q.
But you made it and it's your diagnosis.
A.
Yes.
Q.
That's my question. Thank
you. Let me ask you this.
Why did you decide to wait until 6:00 p.m. on Friday, September 6th, to
advise the Patricks of your decision? Why
did you do that? Was timing an
element?
A.
No, timing was not an element. The
reason that it occurred at six o'clock was at -- when I spoke with the other
physicians after the evidence came from Philadelphia, the mother's note was
left at the bedside and the note by the nurse stating that the mother would
only
Q.
Let's take some things you've discussed and see if we can put it into
context. You just said that one
of the things that precipitated your action was a note and a statement by Ms.
Patrick about her baby being dead. You
elaborated at length to the Judge about that; okay?
When did that note occur? Do
you know?
A.
The --
Q.
The date, sir.
A.
Which note? There are two notes you just mentioned. Which of those two notes?
Q.
When did each of them occur? Tell
me that.
A.
One occurred on
September the 5th; the other occurred
on September the 6th.
Q.
Let's talk about what else happened and what occurred just before the
note and the statements that you told Her Honor about on September the 5th.
Do you recall the background of that?
What was being said to Ms. Patrick in the context that that statement
was made? Do you recall and can
you tell Her Honor?
A.
No, but I could refer to the record.
Q.
Let me see if I can help you, Doctor-.
Wasn't the context of her discussion where she emitted these -- this
statement that you've told the Court, wasn't the context of that that she had
been told that her baby was -- the diagnosis and prognosis was extremely grave
or words to that effect and that there was a substantial likelihood that her
baby was going to die -- or might die. That
was the context, wasn't it? Think
about it, sir.
A.
She had been told that her child was gravely ill and that he might not
live.
Q.
After being told that, after facing that, she was very upset, wasn't
she? Is that a fair statement?
A.
She asked me if she could use a rectal tube after she was told that.
Q.
My question, sir, was not what she said, it was rather what you saw and
observed.
A.
She was not upset in the least.
Q.
She wasn't upset in the least, according to your testimony?
A. Absolutely.
Q.
And she simply said that "My baby's going to die.
That's the only way I'll get control of him and I'll carry him out of
this hospital." I think those were the statements you said she made.
A.
That's three days after she was told that he was gravely ill and may
not live.
Q.
What was the -- excuse me. You
said September 5th and 6th were when the two statements were made.
If that was three days later, that was after you had removed the child
and she wasn't even there, Doctor.
A.
No, that was on Tuesday.
THE
COURT: He said earlier she was told three days before the notes were written.
MR.
FRIEDMAN: Wait. Maybe I
misunderstood.
BY
MR. FRIEDMAN:
Q.
I asked you in the context of your statement, had she been told her
baby was gravely ill and might likely die and you answered yes.
Now, you've changed the timing of the context of the conversation.
Did I misunderstand you?
A.
I don't think I've changed the timing, no.
Q.
When was she told by you that her baby's diagnosis was grave and that
the child was likely to die? When
did that occur?
A.
On Tuesday, September the 3rd.
Q.
Tuesday, September 3rd. In
response to that, all she said is "Can I use a rectal tube,"
according to your testimony?
A. Yes.
Q. And she wasn't upset at all?
A. Yes, she was not upset at all.
Q. Then the day later is when she made the first of these statements; correct?
A. I was so bothered by the fact that she was not upset that I made a note in the chart to that effect.
Q. Under
what circumstances did you give her
A. At Phillip's
bedside.
Q.
Let me ask you this about this lady.
During the period of time of this child's hospitalization in your
hospital, how often has the mother been at the bedside of the child?
Do you know?
A. She has been at the bedside constantly throughout the entire hospitalization.
Q. Almost 24 --
A.
Except when she was at the library doing literature searches.
Q.
Almost 24 hours a day, 7 days a week is your answer?
A.
Yes.
Q.
During --
A.
In spite of being suggested that she needed to go home and spend some time with her family and to spend time away from this child and
being constantly managing his care. During
that time, she was continually administering therapy that was not recommended
and not always made -- the physicians and nurses were not always aware of.
Q.
Doctor, let me ask you this and maybe we can cut through parts of this.
I want you to state everything you saw this woman do, not what she
said, not what she popped off, not what she meant, everything that you saw
that would justify the diagnosis and prognosis that you arrived at of
Munchausen's Syndrome by Proxy. I
want you to tell us every objective thing that you saw and observed -- not
what was said to you, not what others said to you, but you saw and observed.
Tell the Judge everything.
MS.
McCLURE: Your Honor, I going to make an objection.
He's already answered that question in his direct examination.
THE
COURT: I'll sustain that to a
THE
WITNESS: No.
BY
MR. FRIEDMAN:
Q.
Have you ever seen -- I heard you make some conjectures.
Let me ask you to -- how much -- you are not a psychologist.
That's not what you were qualified as.
I presume you're not one. Is
that correct? A psychologist?
A.
That's correct.
Q.
What is your background or education regarding Munchausen's Syndrome by
Proxy?
A.
The majority of Munchausen's Syndrome by Proxy patients present to one
of two pediatric subspecialties. That's
one --
Q.
What --
A.
This is my background.
THE
COURT: Let him answer.
MR.
FRIEDMAN: Thank you.
THE
WITNESS: Is pediatric gastroenterologist and pediatric neurologist,
principally because the ability to falsify seizures and the ability to have
access to the gastrointestinal tract to create injury.
As part of that, we're
BY
MR. FRIEDMAN:
Q.
Let me ask you this, sir. You
have already testified that the first time you convened your interdisciplinary
team to discuss the problem, or the accusation or the consideration of
Munchausen's Syndrome by Proxy was on September 4. Is that correct?
Do you need to make a call?
A.
Unh-unh. I don't know.
Can I hand this over to someone else?
THE
COURT: Yes.
THE
WITNESS: Sorry.
THE
COURT: Mr. Friedman, let me say something.
I want you to have as much time as you need with this witness. I know you've flown an expert here. I want to be able to hear him.
MR.
FRIEDMAN: And I do too, Your Honor please.
THE
COURT: So you need to focus in. I
don't want argument. You'll do
that in your
MR.
FRIEDMAN: I'm going to try to do that, Judge.
BY
MR. FRIEDMAN:
Q.
I'll ask you, please, sir, are you familiar with the American
Psychiatric Association's diagnostic criteria in regard to a diagnosis of
Munchausen's by Proxy which you made?
A.
Yes.
Q.
Let me ask you this, sir. Are
you familiar with the nine criteria that they say one should consider before
beginning a diagnosis?
A.
Yes.
Q.
Did you follow those?
A.
I'll need to see a copy of them.
THE
COURT: Do you have one to hand to him?
MR.
FRIEDMAN: Well, Your Honor please, I say most respectfully, I'm asking him
what he did and did he follow them. He
says he's familiar with them. I
don't have a copy -THE COURT: Do you want him to recite them to you?
What do you want him to do?
MR.
FRIEDMAN: I want him to tell me what
he followed -- yes, ma'am.
THE
COURT: Would you --
MR.
FRIEDMAN: What did you follow?
THE
WITNESS: Let me find my articles on Munchausen's Syndrome by Proxy which I
followed.
MS.
LUSTER: Your Honor, if I may just enter an objection.
I attempted on direct to go through guidelines and there was an
objection from counsel to doing that.
THE
COURT: I understand that you tried to assist with this.
THE
WITNESS: The two principal sources I used were the first one from the
pediatric gastroenterology textbook which in my discussions with Dr. Khoshoo
he told me that Mrs. Patrick was concerned about the Munchausen's Syndrome by
Proxy diagnosis based on this article which is two pages out of a 2000-page
textbook on pediatric gastroenterology that were brought up because he wanted
to videotape the child and she asked him, "Do you want to videotape me
because you suspect this is Munchausen's Syndrome by Proxy?" There is
specific
The
Journal of Pediatrics, Volume 125, 1994, lists guidelines for suspecting and
identifying Munchausen's by Proxy Syndrome. There are one -
BY
MR. FRIEDMAN:
Q.
I don't want you to read from the article, sir.
A.
Well --
Q.
I appreciate that. I asked
you --
A.
-- she met 10 of the 12.
Q.
Well, let me see if I can ask you a couple of specific questions based
on the diagnostic criteria set out by the American Psychiatric Association in
194, as I understand them. A, sir, did you contact other family members to discuss this
allegation with them and, if so, what family members did you contact?
A.
I did not contact any family members.
And, in fact, in the pediatric literature you're suggested not to
contact the family members to alert anyone to a suspicion of Munchausen's by
Proxy.
Q.
Did you ensure that the hospital laboratory stored samples from the
child for future screening? Did
you do that?
A.
Yes.
Q.
So those are stored and accessible; correct?
A.
Some of the samples. The
ones that we were able to store, yes.
Q.
Did you consider a search of the mother or her possessions to see if
there was possible poisons or substances?
Did you consider that? Did
you do that?
A.
I don't feel that I have the authority to search another person.
I think that's the police
Q.
So you didn't consider a search of the mother or --
A.
Again, I'm not aware that I had the authority to
search the mother.
Q.
Let me ask this, most important. I think one of the suggestions is to
exclude the mother for a day or two and observe whether symptoms disappear.
That's something you effectively did, correct, by the DHS announcing,
based on your diagnosis at Friday at six o'clock, that the child was under DHS
care. You accomplished that;
right?
A.
Yes.
Q.
Now, you have partial records from various hospitals; correct?
A.
We have full records from Vanderbilt and the records
provided by the parents from Children's Hospital of Philadelphia --
Q.
Those --
A.
-- with the addition of the records that Philadelphia sent in response
to the -- that were not present in the records the family provided.
We have no progress notes or any written record from Ocshner's Medical
Center and we have partial records from LeBonheur Medical Center.
Q.
Let me ask you this in regard to some specific things you talked about
as your basis for deciding this was Munchausen's by Proxy; okay?
You said that you found that you kept growing cultures and you found
gross, if you will, you found infections that you felt came from fecal matter.
Is that correct?
A.
Yes.
Q.
That's part of your diagnosis?
A.
Yes.
Q.
I want you tell this Court (a) at or about this time was this child
having repeated episodes of explosive diarrhea?
Yes or no, sir?
A.
It depends on which infection you're talking about.
No at the time that his head infection occurred with fecal soiling and
fecal wounding on either side of his head.
Q.
You didn't treat that at all, did you?
A.
No, but I thought that was why I had the medical record was to be able
to determine how to treat him.
THE
COURT: Doctor -- I know this is stressful.
I just really -- I mean, you did treat him, but that you read that in
Philadelphia Hospital, I recall. Next
question.
BY
MR. FRIEDMAN:
Q.
When you found these -- let me say this.
Since the child has been at Vanderbilt Hospital, has the child had
repeated episodes of explosive diarrhea.
Is that true?
A.
Yes.
Q.
Is the child today, since -- well, let me rephrase that. Since you took
over custody at Friday at six o'clock about I think it's 12 -- 11 or 12 days
ago, has that child continued to have explosive diarrhea?
A.
No, he has not.
Q.
He hasn't?
A.
He has not.
Q.
When was --
A.
He has not had
explosive diarrhea since Vanderbilt took custody.
He has continued to have loose
Q.
Let me ask you this. Prior
to Vanderbilt Hospital taking over, as you call it, had this child ever in
it's 11 months of life been put on a respirator, based upon your review of all
of these records?
A.
He was on a respirator at the time that he had surgery, and he's not
been on the ventilator since that time as far as I can tell.
Q.
That's all right. I'll
agree when a patient has surgery and when they're anesthetized, they have to
be on a respirator. I understand
that. I appreciate that.
A.
Not necessarily.
Q.
Other than that, has
that ever been part of the child's treatment or regimen, sir, until --
A.
No.
Q.
-- you took custody of him?
A.
No.
Q.
When did you put the child on the respirator? How long after you took
custody of him?
A.
Two days.
Q.
And let me ask you this, sir. At
the time that you treated him when you say you found these infections, the
child was having explosive diarrhea. Is
that true? Think about it, sir.
A.
Yes, he was having diarrhea. I'm
not sure that
it is documented anywhere it was explosive at that point.
Q.
Let me ask you this, sir. Is
there a realistic chance -- within the best of your medical opinion that this
diarrhea could have led to contamination of the central line that's in the
baby's belly? Yes or no.
A.
Would you ask the question again.
Q.
If you will tell me what part you didn't understand, I'll try to re --
THE
COURT: Would you repeat the question, Counsel.
Excuse me.
BY
MR. FRIEDMAN:
Q.
I said is there a chance, is there a reasonable possibility, based upon
your medical expertise, that this diarrhea condition could have led to
contamination of the central line? Yes
or no.
A.
No.
Q.
Explain why.
A.
Because of the multiple organisms that are present, including the
degree in which those organisms were present on the 21st of August at which
time bacterial cultures were grown out within a matter of hours and the
description when the blood sample was received in the laboratory and first
processed for blood culture was grossly contaminated sample.
Q.
And this was when, sir; what day?
A.
August the 21st.
Q.
So August the 21st is when you decided this was Munchausen's by Proxy
Syndrome?
MS.
LUSTER: Objection, Your Honor, he has already testified.
THE
COURT Sustained. Ask another
question.
BY
MR. FRIEDMAN:
Q.
Have you attempted to confirm the exact type of organism in Phillip's
stool and correlate that with the exact organisms in the blood by using any
serotyping or DNA fingerprinting technique, Doctor?
A.
No.
Q.
Why not?
A.
He does --
Q.
Why?
A.
The stool, the urine culture is not growing candida albicans which is
the normal type of organism that's present in the stool.
He's growing a candida that' other than albicans, which is the type
that is growing in his bloodstream. But,
no we have not done that sort of testing.
Q.
Haven't done it at all?
MS. LUSTER: That has been --
BY
MR. FRIEDMAN:
Q.
Then how do you know that it is his stool causing the contamination of
the blood without doing serotyping, DNA fingerprinting to identify the exact
organisms, sir? Explain that to me.
A.
Because the organisms are not present on the head or scalp in relation
to the studies that were done at Children's Hospital of Philadelphia, and
those organisms would not be present on a central line.
Q.
You are basing everything you say about something that you didn't treat
or didn't see that being Philadelphia, and what you did treat and what you do
have before you based on the tests you've run at Vanderbilt Hospital, you've
declined to identify or attempt to confirm the exact type of organism.
Is that true, sir?
A.
I have not declined.
Q.
You just haven't done it?
A.
Yes.
Q.
You talked about chromium very briefly; okay?
Does TPN -- did TPN have
any chromium in it?
A.
Yes, it does.
Q.
Is it possible that the high level of chromium could reflect the high
level -- the level of chromium he is receiving via the TPN?
A.
That was one of the reasons I was late in
trying
to find out, and the answer from the laboratory was no.
Q.
The answer from the laboratory was no based on what?
A.
Based on their laboratory experience.
Q.
Well, was the chromium level done in random urine sample or was it a
24-hour urine collection?
A.
It was a 24-hour collection.
Q.
Do you know what the variation was over the period of time in which you
took samples? Or was there any
variation?
A.
I'm not certain.
Q.
Was the --
A.
I'm not certain of the question.
Q.
-- chromium level drawn even?
A.
The blood chromium level?
Q.
Blood chromium level.
A.
Not to my knowledge.
Q.
What other toxicological --
A.
It is --
Q.
I'm sorry. I didn't --
A.
I actually think that
it has been drawn. I'm sorry. I can't be certain to that.
Q.
You don't know --
A.
The toxicologists
maybe have assayed that.
Q.
What are the guidelines, toxicological guidelines for determining
chromium toxicity? Do you know?
A.
All I know is his is ten times normal when she called the lab and asked
them could this be TPN, they said no, and they did not feel this was
contamination.
Q.
Do you know how many days or months out of this child's 11-month life
that it's been in the hospital since it was delivered?
A.
Not exactly.
Q.
I didn't hear you.
A.
Not exactly. Very few.
Q.
Very few? Very few days
that it's been in the hospital --
A.
Out of the -- I thought you said out of the hospital.
I'm sorry.
Q.
I'm sorry. I think I did. I
just didn't hear your answer, Doctor. During
that period of time, are you aware that Ms. Patrick has spent day for day,
virtually every day of this child's life, with the child.
Are you aware of that?
A.
Yes.
Q.
Have you ever seen the child respond favorably to the mother?
A.
No.
Q.
You never have. Doctor, is it fair to say that you and Ms. Patrick have a
severe personality clash? Is that
a fair statement before the Court?
A.
I don't think so; no.
Q.
Has Ms. Patrick challenged your decisions about the medical care of her
child from time to time during his stay in Vanderbilt Hospital?
A.
The only thing that I'm aware of that she challenged was the level of
antibiotic that he was having administered for the fungal infection.
Q.
That's the only thing, according to your sworn testimony, that she's
ever challenged while she was there at Vanderbilt Hospital?
A.
You asked --
MS.
LUSTER: Your Honor, I think he's changed the question.
The first question was of the doctor, specifically, Dr. Polk.
THE
WITNESS: That's the only thing she has challenged from me was his Amphotericin
dose.
BY
MR. FRIEDMAN:
Q.
Has she challenged with other doctors that you are aware of the course
of medical treatment and care that's being administered?
A.
Not that I'm personally aware of.
There is the
documentation in a -- the conference that the mother attended that she
expressed concern about physicians not doing everything, but not to me, no.
Q.
Not to you, no. Would you describe the intensive care unit where this child
was being -- was present, where it was being medically maintained on September
6th,
1996. Would you describe
very briefly to the Court what it looks like.
A.
It's a ward area with individual bays where each patient is located.
There's monitoring equipment, the patient's bed, the patient, of
course, and there's a nurse in attendance either at every bed or at a
combination of two beds in the unit.
Q.
Is it a place set up so that the patients can be carefully monitored?
Is that a fair statement of the ICU?
A.
Yes.
Q.
At the time that you made the prognosis of Munchausen's disease by --
or Munchausen's Syndrome by Proxy, it is clear that this lady had not
attempted to take the child, remove the child in any manner, shape or form.
That's true; correct?
A.
Yes.
Q.
It is also true that you have never personally witnessed her do
anything adverse to this child.
A.
Yes.
Q.
Is it true, please, sir, that if you had wished to you could have
requested the parents' permission, the mother's permission, to put up a
monitoring system, a video camera in the ICU?
You could have done that, couldn't you?
A.
Yes.
Q.
You could have set it up in a manner in which it recorded everything
that was said and done, or whatever, in that unit, if you wanted to.
Is that true?
A.
Not exactly.
Q.
When I say "the unit," I should have said in a bay, in the
individual bay.
A.
The structure in there, it's not possible to record videotape-wise
everything that happens to a small patient.
Q.
Did you attempt to do
that? Did you ask the parents'
consent to do that --
A.
No.
Q.
-- since you had considerations that this might be a Munchausen case?
A.
No.
Q.
Did you ask that?
A.
No.
Q.
There certainly could have been considerations of having someone there
with the mother when she was there with the baby.
Is that correct? Another person from the church or a friend or, for that
matter, maybe a professional nurse. Those
were all possibilities, weren't they?
A.
Yes.
Q.
Did you ever consider that before you seized -- considered and
discussed it with Ms. Patrick or Mr. Patrick or the grandparents before you
seized custody of this child at approximately 6:00 p.m. on September 6th,
1996? Did you ever consider that
or ask them to do that?
A.
No, I did not.
Q.
You didn't?
A.
As I said, all of the pediatric literature states that you should not
discuss this with the families before proceeding with a diagnosis of
Munchausen's by Proxy. And
because of the concern about the letters that she had left at the bedside and
her uncanny ability to predict the onset of illnesses, I was concerned that we
would not be able to adequately observe him, nor as I testified earlier, the
degree of illness he has would not simply go away in a matter of days.
Q.
The fact is you didn't consider it and you didn't talk about it --
A.
Oh, I did consider it.
Q.
So you did consider it?
A.
Yes. In fact, beginning on
the meeting on September the 4th we discussed whether or not that was a viable
option to try to videotape and record the observations with Mrs. Patrick and
the child.
Q.
But you decided not to do that?
A.
Yes.
Q.
Why?
A.
As I stated, I did not do it because I became concerned that Mrs.
Patrick may be doing -eminently doing something to Phillip in a very short
period. The question about why
did he need an eminent transfusion of the blood, the statement to the nurse
that only when this child was dead would she have full control over him.
Those are reasons why I did not feel we had time to wait to arrange a
videotaping, which we did not feel was adequate where we would be able to
actually observe the child.
Q.
Then why did you wait from September 4th to September 6th if it was so
eminent before you ceased this child, Doctor?
What was your reasoning there?
A.
On September the 5th is the day after
Q.
Do you know how many times you've transfused the child since you took
custody of it? Tell the Court. How
many times.
MS.
LUSTER: Objection to relevance, Your Honor.
THE
COURT: I'll allow it.
MR.
FRIEDMAN: Thank you, Your Honor.
THE
WITNESS: Four.
BY
MR. FRIEDMAN:
Q.
Four times you've transfused the child.
The mother was opposed to using shelf blood, wasn't she?
She made you -- she let you know that early on when she came to
Vanderbilt.
A.
She did let the service know, yes.
Q.
And, in fact, shelf blood, based on the literature, Doctor, can be less
predictable, if you will, I don't know that that's a proper medical term, than
the recently donated blood. Is
that true?
A.
Yes.
Q.
That's why she wanted to give blood for a
possibility
that the child would have to be transfused and, in fact, the child has had to
be transfused four times since you took custody; right?
A.
Yes.
Q.
Let me move along. You
talk about this letter that she sent out and you passed that forward to the
Court. You talk about this
letter, and that's part of the basis for your diagnosis of Munchausen's
syndrome by Proxy. Let me ask you
this. That letter was submitted
to your partner for his approval before being sent and he gave his full
approval, didn't he? That's true,
isn't it, Doctor?
A.
I know that he reviewed it. I
do not know that he gave his full approval.
Q.
Well, he reviewed it, but you don't know
whether
he approved of it or not. You
didn't tell the Judge that your firm, your group had reviewed that letter that
the mother --
MS.
LUSTER: Objection to relevance, Your Honor.
I mean, whether Vanderbilt knew that the letter was going out and saw
it ahead of time is irrelevant as to the response that the letter got.
THE
COURT: I understand that. I'll
allow him to ask. Basically the
question is that I understand your answer, your partner
THE
WITNESS: I don't know what he was aware of about the letter.
I do know that he did review the letter before it went out. That is all
I know about it.
BY
MR. FRIEDMAN:
Q.
May I ask you this, please, sir. You
say you talked to Dr. Khoshoo on Friday, September 6th, the day that you took,
based on your diagnosis, that you took the child.
Is that true?
A.
The day that DCS took the child, yes.
Q.
Had you talked to Dr. Khoshoo before approximately 14 days before that,
sir?
A.
No.
Q.
Had any of your group, your multi- disciplinary team talked to him, or
do you know?
A.
My understanding is that, yes, they had talked to him on more than one
occasion.
Q.
As a matter of fact, although you say that the first time you
considered this Munchausen by Syndrome - - Munchausen's Syndrome by Proxy diagnosis was September 4th.
Better than two weeks before, or approximately two
A.
I'm not aware of that conversation ever occurring.
Q.
Well, what did you think they talked to him about?
You're aware of a conversation about two weeks before you took the kid. What are you aware that they talked about?
A.
I have no idea. My assumption was that they talked about what his diagnosis
was. He was having a blood sample
done to check for what's called anti-interacite antibodies to see if he had
antibodies to his own intestine, and that was sent off, and my understanding
of the level of conversations was that the physician called to discuss with
him those results that we had received about that time. I do know that Dr. Khoshoo told me on the phone that he had
spoken with my partner that day, that very afternoon, that he called to talk
to Mrs. Patrick and that my partner told him at that point of our concern
about Munchausen's Syndrome by Proxy, but I'm not aware of the details of any
conversation prior to that.
MR.
FRIEDMAN: Judge I'd like to say most respectfully I have a ton of more
questions that I'd like to ask that I think
THE
COURT: All right.
(WHEREUPON,
there was a brief recess at this time.)
MR.
FRIEDMAN: Due to the time concerns, we have an expert witness in from New
Orleans, and given that this is a preliminary hearing, I can't say that I've
completed my cross-examination.
THE
COURT: It's your choice, Counsel. You
certainly have the right to complete it and I think we've know the time for
some time, so do you want to call Dr. Khoshoo at this point?
MR.
FRIEDMAN: I do, Your Honor please.
MS.
LUSTER: Your Honor, the State would have some redirect for Dr. Polk.
MS.
MILLER: I believe I should be allowed to ask a few questions.
I won't take long, Your Honor.
THE
COURT: You know, as I recall, when we discussed this a week ago, everyone
MR.
FRIEDMAN: Well, Your Honor please, you know --
THE
COURT: You certainly have a right to have it heard immediately, which we're
trying to accommodate, and nine to eleven in the morning is a time that's
scheduled for something else, but I'll make it available.
MR.
FRIEDMAN: Well, Your Honor, I wonder if we could continue the
cross-examination -- the cross-examination, the redirect of this doctor who
happens to be
THE
COURT: Dr. Polk, I don't know if you can come back in the morning at nine.
If it's possible for you to do that, it would be relatively short.
I'm going to limit the cross. We're
not going to do what we do at trial. Your
one set of questions are very directed in a preliminary hearing. I appreciated that. You
talked about what he did or didn't do.
THE
WITNESS: Your Honor, I had a clinic full of patients this afternoon. One of my partners was asked to cover and I'm not certain,
but I will try and see if they can cover -- I have a clinic full tomorrow
morning as well.
THE
COURT: Let us do this. If you
would try to be on call and I suspect Dr. Khoshoo will take more than 20
minutes.
THE
WITNESS: Okay.
THE
COURT: And we may be going with him and if you will just -- we'll appreciate
you working with us. Thank you.
THE
WITNESS: Thank you.
THE
COURT: Dr. Khoshoo.
VIKRAM
KHOSHOO
was
called as a witness, and after having been first duly sworn, testified as
follows:
THE
COURT: Ms. Luster, do you already have his resume?
MS.
LUSTER: No, I do not, Your Honor.
MR.
FRIEDMAN: Your Honor please, I'll take him briefly through his qualifications.
I think counsel is familiar and the predicate has already been laid.
DIRECT
EXAMINATION
QUESTIONS
BY MR. FRIEDMAN:
Q.
But, Dr. Khoshoo, would you state your full name, please, sir.
A.
My first name is V-I-K-R-A-M, Vikram, last name is Khoshoo,
K-H-0-S-H-0-0.
Q.
How long have you been a physician, please, sir?
A.
I graduated from medical school in 1978; about 18 years.
Q.
Where do you reside, please, sir?
A.
I reside in 4944
Alphonse, A-L-P-H-0-N-S-E,
Q.
Would your briefly give your educational background and your field of
specialty.
A.
Graduated from the Armed Forces Medical College in India in 1978 and I
did my pediatric residency in India for three years.
Subsequently, I did a Ph.D. in diarrheal disease for five years, then I
further trained at Cornell in pediatrics and pediatrics gastroenterology.
Then I trained in nutrition at the Hospital for Sick Children in
Toronto, Canada, and subsequently have been working in New Orleans for the
past five years. I also got
training in diarrheal disease in London at Child Health and Queen Elizabeth
Hospital.
THE
COURT: Have you board certification?
THE
WITNESS: In nutrition.
THE
COURT: Pediatrician?
THE
WITNESS: In nutrition.
BY
MR. FRIEDMAN:
Q.
Doctor, will you agree, please, sir, to forward a CV, a curriculum
vitae, which you omitted to bring as a later filed exhibit to this record?
A.
Yes, sir.
Q.
Will you do that? Thank
you, sir. I'll ask you, please, sir, if you have had occasion to treat
Phillip
A.
Yes, sir.
Q.
Under what circumstances did you treat Phillip Patrick?
Tell the Court.
A.
He was referred to me from LeBonheur at Memphis with intractable
diarrhea and G.I. bleed.
Q.
How long did you serve as a physician for Mr. Patrick, young Mr.
Patrick, and for his parents?
A.
About three months.
Q.
During that period of time, how often did you have occasion to see
interaction between Mrs. Patrick and her son?
A.
All but two days.
Q.
All but two days of three months you saw that?
A.
That is correct.
Q.
Would you give the dates, if you're able to, of your treatment of
Phillip Patrick, please. Tell the Court what dates.
A.
I cannot really recall the exact dates, but
Q.
To the best of your ability, what three month period?
THE
COURT: Was it in June of this year or December of last year or this summer -
THE
WITNESS: It was sometime, I think, between February and June of this year.
THE
COURT: Of this year?
THE
WITNESS: That is correct.
THE
COURT: '96; okay.
BY
MR. FRIEDMAN:
Q.
I want you to, if you will, describe the interaction that you saw
between Mrs. Patrick and her son Phillip.
Tell the Court what you saw and observed.
A.
I think the interaction between the two was very fostering.
The child neurodevelopmentally did very well.
He would neurodevelopmentally do things for mom which he did not do for
me or any of the other nurses with lots of experience.
And that's why we encouraged the mom to hold the child as much as
possible.
THE
COURT: Doctor, if you'll tell me what things.
THE
WITNESS: He would specifically smile for the mom and he would not smile for
me. He would cry whenever I came in. Maybe
it's my personality. He would not
do the interaction he would do for the mom, he would not do that for any of
the other
BY
MR. FRIEDMAN:
Q.
Let me ask you this, please, sir.
Based upon your observations of the interaction between the mother and
child, what is your opinion, your best medical opinion, based upon your
knowledge of this case and your knowledge of this child and mother, of the
necessity of having the mother close to the child during his stay in a
hospital?
MS.
LUSTER: Your Honor, objection. His field of expertise that he's been offered
in, as far as I can tell, is nutrition, and I'm not sure that based on the
testimony of the -- that's been presented in terms of the problems that he's
qualified to give an opinion for that.
THE
COURT: I'll agree with that unless you have some other qualification or some
other -- he certainly can say what he's observed, that the mother and the
child interact very well, and I understand that.
I also know that children do better to have their mothers and fathers
around, and I
MR.
FRIEDMAN: I agree, and what I was really calling upon was first, based upon
his medical treatment, and, second of all, based upon his personal observation
what his opinion was. And I'm not
sure --
THE
COURT: So you're not asking an expert opinion?
You're asking a -- he's a fact witness.
MR.
FRIEDMAN: I'll ask it as a fact witness.
That's fine.
BY
MR. FRIEDMAN:
Q.
What is your opinion, sir?
A.
Could you repeat the question, please.
Q.
I'm not sure I can. I
think I asked you about based upon your experience of seeing and observing Ms.
Julie Patrick and her child, seen observing their relationship that you
described, what is your opinion as to the necessity of having the mother close
by while this child is in the hospital?
A.
I think I relied very heavily on the mom to give me information about
the child's day-to-day happenings, and I based a lot of my decisions based on
information the mom gave me and for the simple reason that I did not have
one-on-one nursing, did not have a nurse monitor
the child every single minute, so I had to have eyes and ears, and I chose to
have the mother's eyes and ears to inform me of what was happening with the
child on a minute-to minute basis, and she did keep impeccable records which
helped me manage the child, I think, a little better.
Q.
Was the mother a faithful reporter?
A.
Yes.
Q.
Was she a reliable reporter?
A.
Yes.
Q.
I'll ask you if you believe the mother assisted in the care that you
provided?
A.
Yes.
Q.
Tell me the condition, situation that the
A.
He was moderately malnourished and
BY MS. LUSTER: Your Honor, I can't hear.
THE COURT: Moderately malnourished and dehydrated.
BY MR. FRIEDMAN:
Q.
What, if anything -- you heard the description of Dr. Polk of the
various problems that this
A.
Those are well documented.
THE
COURT: Doctor, if I could be sure I understand.
Did this child come to you directly from Children's Hospital in
Philadelphia?
THE
WITNESS: No, ma'am. From
LeBonheur.
MR.
FRIEDMAN: From LeBonheur Children's Hospital.
THE
COURT: From LeBonheur and that was sometime afterwards?
THE
WITNESS: That is correct.
BY
MR. FRIEDMAN:
Q.
As you rendered care and treatment to this child in your area of
expertise, did you find a symptomatology that you found difficult to explain
such as infections, such as various things that Dr. Polk has described?
A.
No.
Q.
Did you ever
have occasion to consider that Ms. Patrick should be considered for -- of
Munchausen's Syndrome by Proxy?
MS.
LUSTER: Again, Your Honor,
THE
COURT: Your response.
MR.
FRIEDMAN: Your Honor please, I think that quite frankly, I'll ask him the
predicate questions if counsel wishes -
THE
COURT: I don't have any way to know other than you were very vigorous with
challenging Dr. Polk in terms of where had he been trained in Munchausen's and
the same -- I don't know if this witness knows anything about Munchausen or
not.
MR.
FRIEDMAN: I'll lay the predicate, Your Honor.
BY
MR. FRIEDMAN:
Q.
What is your background knowledge or training in regard to Munchausen's
Syndrome by Proxy?
A.
Same as any other gastroenterologist, because, as Dr. Polk earlier
said, that is part of the G.I. training, you are trained in Munchausen's by
Proxy because most of the children with Munchausen's by Proxy will present
with G.I. symptoms.
Q.
Please, sir, you have some specific training, specific background in
this; correct?
A.
That is correct.
THE
COURT: I may have misunderstood. Are you a pediatric gastroenterologist?
THE
WITNESS: That is correct.
MR.
FRIEDMAN: I'm sorry. I -
THE
COURT: That's all right. Ms.
Luster, any objection?
MS.
LUSTER: If I may just briefly.
VOIR
DIRE
QUESTIONS
BY MS. LUSTER:
Q.
Doctor, are you board certified in pediatric gastroenterology?
A.
No, ma'am.
Q.
Did you take the test
for board certification?
A.
No.
Q.
Is there a reason you haven't taken the test to become certified in that?
A.
No.
MS.
LUSTER: Yes, Your Honor. It's a
certified subspecialty and he is not board certified and we object to his
expertise in that area.
THE
COURT: How do you respond to that?
MR. FRIEDMAN: Your Honor please, I don't think board certification has ever
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