juvenilecourt4

BY MR. FRIEDMAN:

Q. Doctor, why do you oppose, even during the period where you have isolated this child from his parents, removed the child from his parents, why did you oppose them and their attorney having access to the medical charts of this child? Can you explain that to the Court?

A. The reason for not discussing this with Mrs. Patrick was that it was felt at that time the only information that she needed while the State had custody was whether or not Phillip was getting better or whether or not he was getting worse.

Q. I guess what I'm getting at is that was on your decision. You were the decision maker from then on out, and it was your --

A. No, I was not the decision maker from then on out. I did not have custody of this patient.

Q. Who made the decisions about the availability of medical records and charts?

A. I was involved in that decision.

Q. Who? Who all else was?

MS, LUSTER: Your Honor, I'm going to have to object to this since counsel clearly yesterday had provided records to his own expert up until yesterday. I mean, there's -- other than the fact that they were -- the contract clearly indicates they're not going to discuss it, access has been given.

THE COURT: Let me inquire, The question is relevant to the Court.

THE WITNESS: The only relevance that I can give is that when Mr. and Mrs. Patrick would telephone, they would speak to the nurses and ask them if they would be willing to come and be a character witness for them, and part of the limitation in the discussion was to give some guidelines so that the nursing staff would not become engaged in protracted conversations about the custody issue or the Munchausen's issue, It was to give specific guidelines about how the child was doing, but, in part, to protect the nurses from being called and questioned at work and, in fact, some residents who were called at their home and told that they would be subpoenaed.

THE COURT: If you'll let me ask the only thing that's relevant to me is whether or not the restriction on Mrs. Patrick and Mr. Patrick having access to the medical records is related to your care of this child?

THE WITNESS: No.

THE COURT: So it really, in terms of -- no?

THE WITNESS: I don't think I'm understanding --

THE COURT: Let me restate the question. You have diagnosed, based on all the information you've given me, that the mother in your opinion has Munchausen Syndrome by Proxy. Is there a relationship between that diagnosis and your reasonable belief at this point, to a degree of medical certainty, that access to the medical records is an issue, her access to the medical records?

THE WITNESS: Yes, that is,

THE COURT: So if you will tell me why that is so that I know whether or not the counsel for the mother -- the point he's asking is why should she not see the medical records. I'm not worried about the lawyers, but in terms of the mother --

THE WITNESS: In the day-to-day management, Your Honor, she would repeatedly, after the staff had taken custody, instructed nurses in how to care for him, how to provide medication for him, what medications he should or should not receive. She informed me on the phone more than one occasion that he should not receive chloral hydrate, that he had a terrible reaction to that which she did not elaborate on, but should never receive chloral hydrate. She was very emphatic about that. And when I told her that I did not want to discuss his medications with her, she said, You do not understand my past experience with my other child. I can help you make those decisions about what medication to use for him. And I said, Ms, Patrick, I do not need your help in determining the medications to use for Phillip at this point, And I might add he's been on his medication that she described he would have horrible reactions to multiple times in the past, according to the medical record, with no documentation of significant reaction and is currently on them with very adequate sedation.

THE COURT: Do you see a problem with that?

THE WITNESS: only in the context of -typical in the diagnosis of Munchausen's Syndrome by Proxy there is a very strong alliance by the perpetrator of Munchausen's by Proxy with some health care providers and making certain that she did not still have the ability to control the medication that was administered.

THE COURT: And I understand that and that's why I was asking the first question

THE WITNESS: That's the only reason.

THE COURT: -- as to whether or not there was a reason, a medical reason in the management of Phillip that she should not have that detailed information, And I think that that is appropriate. I think my question is how can we try to manage so that she can have either something that you type out each day and that something is provided that gives a little more information. Do you think that's a problem?

THE WITNESS: No, I think that can be done, Your Honor.

THE COURT: That's what we'll do about that.

BY MR. FRIEDMAN:

Q. Why has her visitation been limited to a visit of 15 minutes? What's the magic of 15 minutes?

A. The 15 minutes was determined that that was the only length of time that the pediatric intensive care unit would be able to devote a nurse who could go nowhere else but stand at the patient's bedside and observe the interactions with the family while she also maintained the responsibility of watching the ventilator, watching his heart monitors, his tube feedings and his TPN.

Q. Doctor, if I understand your answer, then that's for the convenience of the hospital, There are other people who could be present so a nurse didn't have to stand by who could watch each and every action of the mother, aren't there?

A. Yes, In fact, I think that's most appropriate that a medical care giver has to be present because we did not have specific diagnoses of what could have been happening that she could have been doing and which areas we needed to be watching, and so someone who medically knew what was appropriate and not appropriate medical intervention or attention paid by the mother to the child had to be present. In general, parents are completely separated in these cases and not allowed any interaction, and I think -- I want to reemphasize the point that we contacted Mrs. Patrick, we contacted DCS and said because this child is more ill and may not live through this last round of infections that we wanted the family to be able to come and visit, And that was the situation which we felt like the child would remain safe.

Q. You called Ms. Patrick in Memphis, Tennessee, knowing that she was in Nashville, Tennessee, didn't you, sir? That's what --

A. I did not.

Q. -- you logged in your chart.

A. The intensive care physician did call and the intensive care --

Q. In Memphis, Tennessee --

THE COURT: Wait a minute, Counselor, and let him answer your question.

THE WITNESS: The intensive care physician who called did not have other phone numbers to reach the mother at that point, She did call, left a message on the machine, When I came in that morning, I found the cellular phone number. I tried calling on the cellular phone number, as I told Mrs. Patrick, several times to tell her that he had been put on the ventilator, and each time I got a recording that said this phone is not working at this time, And then at approximately 10:00 she called into the unit where I had instructed them if she called in to page me immediately so that I could talk to her and explain to her what had happened,

BY MR. FRIEDMAN:

Q. I have one further line of inquiry and it's going to be short. You told the Court that although the child in many respects in separation of the mother his condition, his medical condition has worsened, you said there was one way it had bettered, You said that was his irritability -- he wasn't as irritable. I think that was your term, Is that correct, sir?

A. There were two ways, the irritability and the lack of explosive diarrhea.

Q. Let's talk about the irritability as to the irritability factor, Doctor, Does the sedation or changes in sedation affect the irritability factor, yes or no, sir?

A. Yes.

Q. Are you not aware, sir, that pursuant to your orders the sedation was increased during the period of time since separation from the mother, yes or no, sir?

A. I didn't understand the first part of the question.

Q. You increased the amount of sedation this child was getting, yes or no, sir?

A. The intensive care unit, yes.

Q. In fact, you also included a further form of sedation that was not being used, a new form -- it's not new by any means. It was new to the medical treatment of this child -- after separation of the mother to keep him sedated, did you not?

A. On the ventilator, To be able to maintain him on the ventilator, yes, Not prior to his being placed on the ventilator.

Q. If one utilizes Morphine, which was the choice, correct, Doctor? That was used -- do you want to look at your charts? Maybe I'm mistaken.

A. I do not have the orders with me, Your Honor, so I'm not certain that Morphine was ordered. The predominant sedative that has been used for him has been Ativan and chloral hydrate,

Q. Let me see if I don't have the medical records for you, sir, and you can take a look.

THE COURT: Counselor, and the relevance of this is that you believe the doctor's statement that irritability had decreased is related to the fact the sedation was increased. Is that the point?

MR. FRIEDMAN: Yes, ma'am, and there's such --

THE COURT: Doctor, can you comment on that?

THE WITNESS: The irritability decreased immediately before we began sedation for his -- following his intubation. And, as I had told the parents on the telephone before, Phillip is not so sedated that he cannot respond appropriately, he wakes up, he smiles, he looks around at the care givers. Last night I was at his bedside after leaving here. He was awake enough from his sedation to look at me, to hold my hand, to smile at me at that point, So he is not snowed, or completely sedated where he's unresponsive.

MR. FRIEDMAN: I think my question was, Judge, if utilizing more sedation and, in fact, introducing a new type of sedation would have any effect, positive or negative, on what the doctor called his irritability, which is one improvement he says the child made. That was my question, I don't understand the answer, if there has been one.

THE COURT: Does the increase -- I understand he is not overly sedated and is responding. Does, in fact, if the amount of sedative was increased, does that have any impact, positive or negative, on irritability?

THE WITNESS: It would have a positive effect on decreasing irritability, yes, Your Honor,

THE COURT: So there's some thought that that may also have helped him in the decreased irritability?

THE WITNESS: Yes.

THE COURT: And the answer originally was that his irritability decreased immediately before you had increased the sedative.

THE WITNESS: Yes.

MR. FRIEDMAN: Let me ask this -

MS. LUSTER: Your Honor, again noting the time B

Q. I'll ask you, please, sir, is it not true that after separation, a brief separation from the mother, if there is not marked improvement in the child, much less if there is deterioration in a child, the literature says to put the mother back with the child, It shows that that's a negative consideration for Munchausen's Syndrome by Proxy, doesn't it, yes or no, sir?

A. Yes.

MR. FRIEDMAN: I have no further questions.

THE COURT: Ms. Miller.

CROSS-EXAMINATION

QUESTIONS BY MS. MILLER:

Q. To follow up on counsel's last question, does the literature not also say, though, Doctor, that if the child has become permanently impaired that even with the separation the child may not recover?

A. Yes.

Q. What was Phillip Patrick's condition on 9-6-96?

A. He was on -- getting nasal oxygen and getting oxygen under a hood, His oxygen requirements had been increasing over the three days prior to the 6th of September, and he was placed under an oxygen hood to increase the concentration of oxygen that was available in the air that he was breathing, He was febrile, or had a fever, intermittently and was -- had a very -- in fact, had high fevers off and on and was still being treated for infection, for the multiple organism infection.

Q. He's still in pediatric ICU?

A. He's still in the pediatric intensive care unit.

Q. Is his condition still grave at this point?

A. Yes.

Q. What is his prognosis?

A. Currently or what was --

Q. What was his prognosis on 9-6 and what is his prognosis today, sir?

A. It is still grave. I thought that the one aspect of improvement with him was that we weren't, at that point, any longer growing out the yeast infection in his bloodstream. That was the first sort of sign of positive improvement, that the bacterial organisms were not growing any longer,

THE COURT: Doctor, let me stop you. I want to be sure I understand. Between September 6th when the contact was stopped and September the 18th, today and last night when you saw the child, the one positive change was he was no longer growing a yeast infection out of his blood, Is that correct?

THE WITNESS: Or any of the other bacteria that had contaminated -- when he had the four organisms growing out of his bloodstream.

THE COURT: So that the last lab test testing for those two factors showed that was no long occurring?

THE WITNESS: Yes,

THE COURT: Anything else?

THE WITNESS: As for his improvement or

THE COURT: Yes,

THE WITNESS: Again, only --

THE COURT: A change, any change.

THE WITNESS: He was placed on the ventilator, as we talked about before, the deterioration in his breathing condition as part of his overall infection and lung disease and intestinal disease that he had or has, continues. He has, over the past two days, developed some blood in his urine indicating that there's some renal involvement or kidney involvement with this, which could either have been from the infection itself or from toxicity to the kidneys,

BY MS. MILLER:

Q. Phillip Patrick's condition is still very tenuous at this point, Would you agree with that?

A. Yes.

Q. If the mother were to have access to the child, what specific risks would she pose to the child?

A. It would depend upon the amount of access that she had, If she was not to have physical contact, then she would not pose any physical -- any risk to him, If -- and I can't say beyond that, There -- it totally would depend on whether or not someone was able to control the central lines and prevent her from having access to those, to prevent her from having access to the gastrostomy tube site, which are the two sources of entry to him from the outside.

Q. The visitation contract, agreement, whatever, is this still your recommendation to the Court for visitation?

THE COURT: I don't think we've

established that he's even aware of it. This is the Department's evaluation. Why don't you hand that to him, which he doesn't have. The question, Doctor, I want you to address is that this says visits will last 15 minutes. How many times a day were you - I know the problem with the nursing staff. I don't know if Mr. and Mrs. Patrick provided the funds to hire another nurse to be available. At this point, the proof has been presented and there's a reasonable belief that your diagnosis is correct and a reasonable belief that there must be great care taking to have no contact. So I also know this child is attached to his mother. I don't think there's any question about that and that he benefits from seeing her if she can have no physical contact. But I'm trying to think of a way that we can do that between now and four weeks from now when we have the trial.

BY MS. MILLER:

Q, May I ask you, too, the other issue is the father, too, So I think if we can let the Doctor address whether the father can visit separately. My question is what specific risk does the father present and would these guidelines be for both parents?

MR. FRIEDMAN: Your Honor, I must interpose an objection. The purpose of cross-examination is to explore matters that were raised on direct examination, not to go beyond.

THE COURT: You're not asking for any visits? Do you want Mr. and Ms. Patrick treated the same?

MR. FRIEDMAN: No. ma'am. In fact, the question about the father goes to the heart of the initial petition filed before and pending before this court.

THE COURT: It hasn't been raised yet by counsel, I appreciate the guardian raising it. You may answer the question.

THE WITNESS: In general the literature says that the father is usually a very passive participant in Munchausen's Syndrome by Proxy, either not directly involved or passively aware that something is wrong but does not explore to find out what it is that is wrong, I don't know what specific threat that he would pose in visitation.

BY MS. MILLER:

Q. Based upon your knowledge of Munchausen's Syndrome by Proxy and the literature, what would be your recommendation to this Court regarding visitation by the father?

A. Again, that he would have no physical contact.

THE COURT: Doctor, back to my question of the 15 minutes, was that intended or was that discussed with you whether or not that would be once a day or whether that would be more than once a day?

THE WITNESS: The pediatric intensive care nurses, again, indicated that they could do that once a day and provide attendance, so that the specific number of times a day were predicated on the ability to have a constant medical observant,

THE COURT: Do the pediatric ICU nurses stay on for a 24-hour shift now, or how does that work?

THE WITNESS: No. They are there between eight and twelve hours. Some of them work 8-hour shifts; some of them work 12-hour shifts,

THE COURT: Do you have a time of the day that you feel you have more qualified staff or more able staff to provide the supervision based on the operation of the ICU?

THE WITNESS: I think that the DCS workers were discussing that with the nursing supervisors and came -- that's why the initial visits were scheduled for late morning. It's after the change of shift and the majority of the medications that are on time schedules are given.

THE COURT: Is that at 11:00?

THE WITNESS: Between 10:00 and 11:00.

THE COURT: That's all I need, Ms. Miller?

MS. MILLER: There's just one final question on visitation.

BY MS, MILLER:

Q. It has been offered that friends of the family or other family members would supervise these visits, Is that something that you would -- can you make a statement about -- or take a position about that?

A. I don't know the friends of the family. I would assume they would be very supportive in not believing this diagnosis of Munchausen's Syndrome by Proxy, so I do not feel that they would be adequate supervisors.

Q. Does the literature speak to that issue as to whether --

A. The literature speaks to the issue of specifically removing the child from the parent with no visitation, and it talks about the poor success rate of reintroducing a child into the family but it does not address issues of whether or not friends of families can supervise.

MR. FRIEDMAN: Your Honor, just for the record, can we know what literature he's talking about so he can be cross-examined at the trial? I would ask that the Court ask him to provide specifically for his literature,

THE COURT: You can do any sort of discovery you want to do. He's been qualified as an expert, He's the only expert I have that's been presented to deal with these issues, and I -- no, the answer. Go ahead,

MS. MILLER: That's all my questions, Thank you.

THE COURT: Any redirect? Just what has to be asked.

REDIRECT EXAMINATION

QUESTIONS BY MS, LUSTER:

Q. Just very briefly, Doctor, You talked yesterday and you were cross-examined by counsel a little bit about this chromium that you found in, I believe, the urine. Is that correct?

A. Yes.

Q. Could you tell the Court, I believe you've had a chance now to review that a little more thoroughly?

A. Yes,

Q. What have you found and what opinions can you draw with regard to that?

A. I had the opportunity after leaving to go back to my office and reread about chromium and to go to the library and then too we've had a little bit more reporting on the chromium levels. Maybe I should start with that, The normal levels of chromium expressed in the urine are about two micrograms per liter of urine. His levels are 21 micrograms per liter of urine, So they're 10 times the normal level expressed n the urine. I pursued whether or not total parenteral nutrition when the trace elements are given is a source of elevated chromium in the urine, It is not.

I then began to investigate where the trace elements come from that are administered to patients at Vanderbilt, All of the formulas, the total parenteral nutrition formulas, again, this is what he receives through the central line, are prepared by an outside facility using a computerized system that's quality assured every day to ensure it's delivering the correct amount of chromium. As a consequence, that means every patient in Vanderbilt Hospital is receiving -- that's receiving TPN is receiving the same TPN and there have been no other reported cases of chromium toxicity in the hospital.

Chromium toxicity specifically affects the intestine, It causes an intestinal and colon inflammation, hemorrhage, loss of the lining of the intestine, It also causes renal damage and can put a patient into shock, make them have difficulty maintaining their blood fluid levels and require ventilatory support as a consequence. Chromium is available as a liquid preparation over the counter from drug stores as well as from health food stores that can be provided by the gastrointestinal route.

They have checked his sample four times now because the level was so inordinately high, and they've checked it by the two gold standard methods, one of which is called atomic absorption spectroscopy. The other is called ICP, and I do not know what that stands for, Your Honor, I'm sorry. When the amount of chromium present in his urine was compared to his urine function, the normal range for that is from 0 to 4.9. There's a protein that's called creatinine that's followed in the urine, and his level related to his creatinine was 144. So it's more than 30 times the normal. So he clearly has chromium poisoning and chromium toxicity and meets the requirements for that additional medical diagnosis.

Q. Doctor, is that diagnosis -- oh, I'm sorry, Your Honor,

THE COURT: When did you first start doing -- when did you first suspect chromium poisoning?

THE WITNESS: The urine sample was obtained with a toxicology consult immediately after DCS took custody of the patient, of Phillip. A follow-up urine is being performed today to make sure that he is, in fact, now decreasing his levels expressed through his urine.

THE COURT: Is chromium poisoning or toxicity built up over a period of time or is it something that dissipates -THE WITNESS: It's predominantly excreted in the urine very rapidly.

BY MS. LUSTER:

Q. Is chromium something you can test for routinely in the blood work?

A. No.

Q. Doctor, is what you've talked about in terms of chromium toxicity and the effects of that, is that consistent with what you've observed in Phillip Patrick's condition?

A. It's consistent with his intestinal disease that he currently has as far as loss of the lining of his intestine and the bloody explosive stools that he has had in the past. It's also consistent with the potential renal damage that he has now and the source for developing the shock-like syndrome that he has gone through that ultimately put him on the ventilator.

Q. Doctor, are you aware of any items that have been found in the room that was occupied by Ms. Patrick that are being investigated that are possibly related to this?

A. There were --

MR. FRIEDMAN: Your Honor, I certainly on this, I hope this is what you saw and observed, not what he was told.

THE COURT: Ms. Luster, if you will ask a preliminary question as to his personal knowledge.

BY MS. LUSTER:

Q. Do you have personal knowledge of any items that have been found in the room that was occupied by Mrs. Patrick?

A. That I have personally seen?

Q. Yes,

THE COURT: Why don't you tell me how you're aware of the items that were found? Don't tell me what they were yet. Just tell me how you're aware.

THE WITNESS: One group of items I saw personally at his bedside.

THE COURT: Why don't you tell me those.

THE WITNESS: Okay. There was a medication called Mylicon. It's a medicine that is routinely used for gas bloating and it's used in children not very successfully and it's used in adults not very successfully in preparations such as Maalox or Mylanta. On the day that I came in to take care of Phillip, there was Mylicon in his gastrostomy tube. I then could not find where Mylicon had been ordered in the chart and went to the nurses that had been caring for him and asked them if the had put -- my first concern was that there was blood in the gastrostomy tube because Mylicon is red and pink and I asked the nurse to test his gastrostomy secretions for blood. And she tested it and said, no, there was not. I said, Well, what medicines is he on that are red? And we went through all of his medicines and he was not on any medication put through his gastrostomy tube that was red in color. And the nurse's comment to me, Well, it could be some of the medicines that his mother has at the head of his bed that I've been told she gives to him.

So I went and looked at the head of the bed and there was a plastic container, a hospital basin, in fact, that had several medications in it, most of which were topical medications either for a diaper rash or ophthalmic medications, eye drops that were present. And the final thing was the Mylicon bottle. I picked up the Mylicon bottle because I had not personally ever prescribed the use of Mylicon and to look and see if it was red. I opened the bottle. It was nearly full and it was, in fact, the same material that was in his gastrostomy tube.

MR. FRIEDMAN: What date was that? Did I hear the 8th of September?

THE COURT: The 8th.

MR. FRIEDMAN: Okay.

THE WITNESS: So the medicine had been removed from the unit, according to the nurse, by Mrs. Patrick and then has reappeared in the unit. And when I questioned the nurse, Was this here Saturday? She said, Yes, and I said, Was it still here from Friday? And she said, Yes, that it had been here at least through Friday the 6th of September, but it's not clear to anyone when it returned, and no nurse seems to be aware of the mother bringing it back, Mrs. Patrick bringing it back into the intensive care unit.

BY MS. LUSTER:

Q. Now, Doctor, how were you aware and, again, without yet saying what other items were found, how are you aware of other items being found in the room of Mrs. Patrick?

MR. FRIEDMAN: Your Honor does realize, and I think I know what the Court's going to rule, but this redirect examination is far beyond matters touched upon or considered in cross-examination of either counsel. That is -- I do object.

THE COURT: Ms, Luster, do you want to respond?

MS. LUSTER: Well, Your Honor, it goes to the issue of chromium which was gone into in great detail by opposing counsel, both with Dr. Polk and with Dr. Khoshoo, his own expert, in terms of its coming in through the TPN and what I believe the evidence will show is that there were items found in Ms, Patrick's room that could have been utilized to insert or inject the chromium into Phillip Patrick as an alternate method.

MR. FRIEDMAN: Your Honor, it certainly wasn't Ms. Patrick's room on September the l0th, which was four days after this child was taken and moved to another bay, and I think counsel's saying Ms. Patrick's room,

MS LUSTER: I said the room she had occupied, Your Honor.

MR. FRIEDMAN: She never occupied that bed.

THE COURT: Counselor, I understand.

THE WITNESS: Yes.

THE COURT: Thank you, Do you have any other questions?

MS. LUSTER: Just one final.

BY MS. LUSTER;

Q. Doctor, you were asked also about the mother's interactions and there's been some testimony about how she's behaved as an adoring, caring mother, very concerned for her child. Are you aware of incidents in which she's behaved in a way that would not be considered caring for the child?

MR. FRIEDMAN: Your Honor please, again, that would take a matter of interpretation. At the hearing this was not raised on --

THE COURT: Your objection is this witness is not qualified?

MR. FRIEDMAN: Yes, ma'am.

THE COURT: Overruled,

MR. FRIEDMAN: I only ask then you limit it to what he saw and observed, not his interpretation of records or somebody else told him.

THE COURT: I think that was the question. Let him answer. Go ahead, Doctor.

THE WITNESS: This is not based on an interpretation of the record but is based on direct reading of the record.

MR. FRIEDMAN: Your Honor, that's the

THE COURT: Counselor, I'll rule after he's answered whether or not I'll give it any weight,

THE WITNESS: On July the 9th, the resident in noting her conversations with Mrs. Patrick noted that there was a "rough" night and that she had to use the rectal tube 10 times during the night to place in his rectum. That would be considered very inappropriate.

THE COURT: Doctor, if you can help me understand this rectal tube that I understand she was allowed to use. I mean, you didn't prohibit her from using it. The doctors didn't prohibit it. Exactly why would you use a rectal tube and tell me how it works. I guess I think I know but I need you to tell me.

THE WITNESS: Again, I am not sure why it was instituted in this patient. When Dr. Khoshoo called to speak to Mrs. Patrick and I talked with him, he told me that he had instituted it because he felt like it might help the patient defecate and said that he had evidence that it had helped him defecate. Mrs. Patrick indicated to the resident that it was mostly air that was expelled from his rectum in each of those occasions, the 10 times that she had used it that night.

THE COURT: I know you don't know why she chose to use it, I understand that, Is there any reason that you would prescribe or approve of a mother, father, anyone other than nursing personnel using a rectal tube while the child was in the hospital?

THE WITNESS: No.

THE COURT: Have you ever done that?

THE WITNESS: I have had nurses use a rectal tube before in a patient that we were trying to what's called clean out prior to being able to do an endoscopy, a colonoscopy,

THE COURT: Is there anytime you've prescribe that that be done just as a routine way to have feces come out of the body?

THE WITNESS: Only in this setting of trying to clean out --

THE COURT: For that purpose if there's a medical procedure that's about to occur?

THE WITNESS: Yes. Or a patient who is severely constipated and that route is used to do an initial clean-out of that constipation.

THE COURT: Doctor, I may have missed something, but all I've heard about is diarrhea. Was this child ever constipated and that was a problem that Vanderbilt was dealing with? Not way in the past, not with Dr. Khoshoo. But July, August and September, are there any notes that indicate he was constipated?

THE WITNESS: No.

BY MS. LUSTER:

Q. And, specifically, Doctor, with regard to any instances with blood in the rectum, any problems in that way in the use of a rectal tube?