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- [00:00]
Andrea Dunlop
Foreign.
- [00:12]
Dr. Bex
Today we are sharing part two in our series on the lawsuit against.
- [00:17]
Unknown Host
Ratty Children's in San Diego. If you have not listened to part one yet, please go back and start there as you will otherwise be quite lost.
- [00:26]
Dr. Bex
This this case is so complex and.
- [00:28]
Unknown Host
I am so thankful to Dr. Bex, our resident Pediatric Hospitalist and frequent co host for all of her work researching this.
- [00:36]
Dr. Bex
I am currently up to my eyeballs.
- [00:38]
Unknown Host
In my reporting for season six which will be coming to your ears on June 19th. And just a reminder that if you are a subscriber on Apple or Patreon.
- [00:48]
Dr. Bex
You will get all eight episodes in.
- [00:50]
Unknown Host
Your feed on the day it launches.
- [00:52]
Dr. Bex
You also get two bonus episodes a month of our subscriber show Nobody Should Believe Me.
- [00:56]
Unknown Host
After Hours with me, me and Dr. Bex, we talk about a lot of.
- [01:00]
Dr. Bex
Pop culture crossover on that show. Right now we are covering the Elizabeth Finch case which was featured in the.
- [01:07]
Unknown Host
Peacock documentary the Anatomy of Lies.
- [01:09]
Dr. Bex
You can also join our Patreon as a free member and sample some of.
- [01:13]
Unknown Host
Our bonus content there before you commit.
- [01:15]
Dr. Bex
We are so grateful for your support.
- [01:17]
Unknown Host
There truly is no show without you. And with that, on with the episode.
- [01:23]
Dr. Bex
Just a quick reminder that my new book, the Mother Next Medicine, Deception and Munchausen by Proxy is on sale right now wherever books are sold. The book was an Amazon Editor's Pick for nonfiction and the Seattle Times called.
- [01:37]
Unknown Host
It a riveting deep dive into mvp.
- [01:40]
Dr. Bex
And if you are an audiobook lover and you like hearing my voice, which.
- [01:43]
Unknown Host
I'm assuming you do since you're listening here, you should know that I narrate.
- [01:47]
Dr. Bex
The audiobook as well. If you have already read the book.
- [01:49]
Unknown Host
Which I know so many of you.
- [01:51]
Dr. Bex
Have, thank you so much. Please let me know your thoughts and.
- [01:54]
Unknown Host
Questions at hello and nobody should believe me.com and we will bring my co author Detective Mike Weber on for a.
- [02:01]
Dr. Bex
Little book Q and A and post retirement. Tell all special thanks for your support fellas.
- [02:07]
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- [02:37]
Dr. Bex
Hello Dr. Becks, so thank you as much for being here to walk us through the rest of what we know right now about the lawsuit involving the Mayer family and Ratty Children's in San Diego. So, Bex, can you just, can you just catch us up on where we left off in the last episode and just get us back into what we know about the series of events that led up to this lawsuit?
- [03:05]
Dr. Shailene Nienow
So those of you who were with us on the first episode will remember. So Madison is the patient that we're talking about this time, Madison Meyer. And where we left off was she had been suffering mainly from shoulder dislocations, then admitted to the hospital in pain, began to have kind of different and changing symptoms throughout that course. And then where we left off was she was about to be taken to New York to see a specialist or a neurosurgeon who specializes in Ehlers Danlos syndrome, which, if you remember, she was diagnosed with hypermobile Ehlers Danlos syndrome. And she had now been at Kaiser San Diego, Kaiser la, and back to Kaiser San Diego. And at this point, she's going to be transferred to a hospital in New York where this neurosurgeon, Dr. Paolo Bolognese, practices and where he sees patients.
- [04:00]
Dr. Bex
Got it. And I did want to just flag that we have heard from some listeners who have Ehlers Danlos syndrome after the airing of our first episode. And so we just wanted to recognize that and say, anybody, feel free to always send us your feedback. But nothing about this conversation is meant to indicate that Ehlers Danlos syndrome in and of itself is a questionable condition. It is very much a real thing and can lead to quite a bit of medical complexity. So we just wanted to recognize that up top.
- [04:34]
Dr. Shailene Nienow
And I agree, and I think what happened during other cases we've covered is that patients who truly suffer from these conditions and have some of the long term consequences and complications of these are actually getting a little bit lost in the shuffle because there are all these places and all these doctors that are diagnosing these things kind of in different ways and maybe using different criteria. And in a way, it's, it's kind of what happened with COVID with ADHD diagnoses, right? Where things are getting diagnosed now even on the Internet by other people. And the people who are truly suffering from these things at times are now facing drug shortages, inability to get care from providers because of all of this. So I think that's more. I think what Andrea was trying to say is that these conditions exist and they can be debilitating, and there's concerns with it, it's just. It's more that how do we kind of find a place where everybody's getting the care they need, but the appropriate care, you know, in the appropriate places?
- [05:31]
Dr. Bex
So, yeah, and, you know, we still have much more to unpack about this particular case, but whenever we are talking about, you know, illnesses that happen to come up a lot in Munchausen by proxy cases or unsuspected Munchausen by proxy cases, you know, the reason for flagging those is not to say that anybody who has that diagnosis is a red flag. We are trying to point out, you know, what the questionable patterns are that surround those diagnoses, because we have very much seen that. You know, the example I'm thinking at the top of my head is with, like, the AHC community that we covered in season five of the show, right. That we've. We've seen perpetrators take a lot of resources from those communities, mess the data up, especially if it's something that is super rare. And so we see a lot of harm to those communities of people that legitimately have these diseases and. Or people whose. Who are parents of children that have these diseases. We see a lot of harm being caused to those communities by perpetrators. And again, that's not to say that specifically in this case, because we don't know enough to say either way at this point. But that's just it. That's just a really important caveat that I wanted to point out as we get into these questions surrounding Madison's treatment and this doctor that she saw in New York. Okay, so Madison goes to New York to see this specialist, Dr. Bolingnaisi. So what is his. He's a specialist in Ehlers Danlos. Like, what does he specialize in?
- [06:58]
Dr. Shailene Nienow
So he is a neurosurgeon by training. And it sounds like over time, he's kind of gotten into this niche of Ehlers Danlos syndrome. And his specific. What he is specifically looking at is the connection between Ehlers Danlos and what's called a Chiari malformation, which is where part of your brain, the cerebellum, actually hangs a little bit lower into your spinal canal. And at some point, based on measurements, it can start to have symptoms or things associated with it. And then there's the tether cord syndrome that he questions or thinks about in this case, which is where your spinal cord is actually attached to the tissues surrounding it in the canal. And it can cause symptoms basically from your waist down. And then the other one is something called craniocervical instability. Where basically your skull and your cervical spine, there's kind of instability, and that can have its own set of symptoms. So it seems like those three diagnoses that he works most specifically on and then their links to Ehlers Danlos syndrome. And he works with a neurologist, Dr. Kula, who I believe since has retired, according to the website. But at that time, when Madison went, it was Dr. Bolognese and Dr. Kula. And it's not extremely clear in the court documents what testing was done or how much was done when she was there. But they do give us a list of diagnoses that came out of that visit. So to start with, they do say they agree with the Ehlers Danlos diagnosis. The other one that we had already spoken about was the diagnosis of pots, or postural orthostatic Tachycardia syndrome. And at least from the documents, it seems like a tilt table test was done in New York that did, according to them, confirm the POTS diagnosis. And the one thing that was mentioned, which again, is what Dr. Bolognese seems to specialize in, is that there were concerns she may have what's called a tethered cord. And that really seems to be the focus of his research, is this connection between Ehlers Danlos and these different other conditions.
- [09:05]
Dr. Bex
So, Bex, I know we're going to, you know, once we kind of get through the timeline of what led us up to that, we are going to take a closer look at a number of these doctors that were involved in these cases and kind of what we know about them and their procedures. But for now. So Madison gets these additional diagnoses and then returns to San Diego.
- [09:25]
Dr. Shailene Nienow
Correct. And at this point, Kaiser Permanente San Diego has been in communication with Rady Childrens. And the decision was made that, based on Madison's complexity, that when she returned to San Diego, she would be admitted to Rady Children's as opposed to back to Kaiser Permanente. And as I was saying on the first episode, that did occur even when I practiced in Southern California, where if there are specialists or if there are things that a child needs that are not available at Kaiser Permanente, they will reach out to whatever the local children's hospital is and potentially transfer patients. So at this point, Madison is transferred back from New York to Rady Children's, and we again meet Dr. Shailene Nie, now, who is a child abuse pediatrician associated with Rady Children's. So we're now in January, and Madison is back at. In San Diego, but now at Rady Children's and we're gonna go into a little bit of what happens now during this stay at Rady.
- [10:24]
Dr. Bex
So we're going to. We're going to talk a little bit more about Dr. Shailene Nienow and exactly how her association with this hospital and the child abuse team works, because this is very different from state to state and hospital to hospital how these sort of teams interact. So we will. We will break that down a little bit more in a future episode. But for now, what do we know about this admission to Rady Children's?
- [10:46]
Dr. Shailene Nienow
This is where the question of COVID video surveillance comes into play. And I speculate or kind of assume that this is going to be a big part of the court process going forward because it has shown multiple times in the complaints filed by the parents as to this timeframe during which Madison and her family were under this covert video surveillance within the room. So when they arrived back to Rady Children's, they were placed in a room that has the capability for video surveillance.
- [11:12]
Dr. Bex
So by the time they get to radies, it sounds like we're to assume that there is some suspicion of abuse by the time they get to radies.
- [11:21]
Dr. Shailene Nienow
Cause there was the report made prior that had been closed for. It sounds like the investigator, it was closed after an evaluation for not having enough evidence at that time to proceed. So now that she's at Radi and they have the ability to do video surveillance in the rooms, a discussion was had. Again, that's that depending on which side, we're hearing kind of different stories. But whatever it's worth, video surveillance began in the patient's room at that time when she was placed at Rady's and carried on for over 30 days. There's times where it says 36 and times where it says 38. But it was 24 hours a day, seven days a week for at least 30 days or over 30 days. Andrea and I have talked about this a little bit about using video surveillance in these cases. And maybe you can speak a little bit to your experience with video surveillance being used.
- [12:13]
Dr. Bex
Absolutely. And Bjorker, who is a friend of the show and a frequent contributor and a very well regarded expert in Munchausen by Proxy, has actually written about the sort of legal implications of using covert video surveillance. And it can be an extremely helpful tool, especially in cases of, you know, that are serious and life threatening. Actually, the case that we're covering for season six involves covert video surveillance. There was some covert video surveillance in my sister's case. You know, these can capture anything from Instances of suffocation to instances of illness induction via a child's line, you know, improper use of medications, like that kind of thing. So it's really important to understand when you're looking at these cases that you're not looking for a single incident. It is very unlike something like a broken bone or abuse of head trauma, where those also might be sort of patterns of abuse over time. But you are looking at a single incident and trying to unpack what happened around a single moment in time or a single period of time. So for Munchausen by proxy abuse, you know, you're looking for this pattern. And so covert video surveillance can provide a piece of abuse. It is not the only thing. And importantly, I think it's not exculpatory if there's nothing that happens under that. You know, we've seen that. I'm thinking of the Brittany Phillips case, actually, where she was put under video surveillance that did not capture anything. But she pointed out, like the video camera and said, you're watching me. It's not a sort of black and white thing. But certainly if something is captured, that is a very strong piece of evidence. There are other pieces of evidence, you know, in Brittany Phillips case that I was mentioning, obviously the medical record review is a huge piece of it, as well as, you know, other sort of instances of fabrication that when you cross reference with social media and, you know, in that case, her Internet search played a big role. So it is. It is a. It is a tool.
- [14:08]
Dr. Shailene Nienow
And I think it's. It's important to say too, that doing video surveillance is not to falsify evidence of medical child abuse or Munchausen by proxy. So just placing the camera in and of itself is not forcing evidence to occur. Right. It's. The idea is you have an eye in the room and you can see behaviors and patterns and things that may stand out. It doesn't mean you're gonna find any. It means it's a tool like you said to use because it's often varying versions of the same story. Right. There's the medical record, there's social media, there's what the parents are reporting, there's what the child is reporting. And you may have two doctors who got two different stories as well. So part of it is, I think in the world we live in, people want to see evidence. People want to see clear, concise evidence that is going to say, this is what is happening. And I have no doubt it's a hundred percent. And that just doesn't exist in this, you know, in this world. But the idea of COVID video surveillance, if you do capture something, it may mean you're able to save or help the child if you have this piece of evidence so you're not making something happen, you're doing it as another piece of your, I think, investigation. And what's most important is every state has their own laws as to how covert video surveillance can be used. Every probably county, DCF or child protective services branch has their own kind of methods for using that. And then each hospital has their own set of consents that come into play in these cases. So it really, without knowing very specifically this hospital, this county, this state, this HHSA or their child protective services, that's going to be where all the litigation comes into play, I think, is kind of how that all does play out. But as of now, this is the parents do not know that the video is in the room until much later, at which point, you know, they realize they had been watched for 24 hours a day for seven days a week. And so that does come in a lot into the court documents. When it comes to concern for invasion of privacy, violation of constitutional rights to privacy, search and seizure, all of these other things, the COVID video surveillance comes up time and again.
- [16:25]
Dr. Bex
Yeah, just to kind of put a button on that I think we sort of talked about in the last episode while we are trying to be, yes. As open minded as possible looking at this case, I think there are sort of things we will entertain and things that we won't entertain. And the idea again of like child abuse pediatricians being looking for cases or, you know, sort of creating cases, that's something that comes up a lot in these lawsuits. That came up in Sophie Hartman lawsuit that came up in my sister's lawsuits. That came up obviously in the Maya Kowalski case. You know, their job is to evaluate abuse in a medical context. So this is a tool to evaluate. And I think it's worth saying that they use video surveillance in other capacities in hospitals. Right. Monitor for seizure activity, to monitor for other things, that it is a medical tool and that is how it is used by hospitals, by child abuse pediatricians.
- [17:20]
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Dr. Bex
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- [20:00]
Dr. Bex
Great way to support the show.
- [20:06]
Dr. Shailene Nienow
So I think more to know about the specifics of this case but you'll just see that this is something that has come up in previous cases and probably will continue to and I'm you know, so we will see how this part plays out when she does return to Rady Children's. There is another report made to HHSA or called into the abuse hotline at that time. We do not have access to those reports. We know that a report was made and there is documentation of Dr. Ninao, again, being a part of this because she is the child abuse pediatrician. So she is the one who would be helping with the medical reporting of symptoms that are occurring that are concerning, you know, for medical child abuse or Munchausen by proxy or neglect or anything else that is coming up in this case by this point. It is stated in the court documents that Dr. Ninaow are somewhere in these reports that there was a potential risk of death if Madison remained in the care of her parents. We don't have all of those details, but I don't think that's said lightly in my experience or in my opinion. And Andrea, we've seen it in other cases, but there is a path of no return in some of these cases that there may be warning signs and it may be a review of the record and it may be all of the information you have in front of you. But at some point there is a concern for death, is there not?
- [21:28]
Dr. Bex
Yes. I mean, we've seen a lot of cases that were escalating in that direction. And unfortunately, I'm researching a number of cases right now where the parent followed through on that. And I think, certainly, like when you see a parent persistently talking about a child's death who has not been diagnosed with a terminal illness, when they are consulting things like palliative care, hospice care, you know, tpn, nutrition for a child that doesn't need it, when you're seeing those kinds of escalations, if you have concerns about induct of illness through contamination of a child's line that could lead to, you know, sepsis and, you know, those kind of things should be taken really seriously. And I think that that's always where kind of the tension in child protection comes in. Right. Like, where does. Where does a parent's rights right to make medical decisions for their child and. Or, you know, where does the right parent's right to privacy and if a child's life is in danger and you are making different decisions with a different sense of urgency, if you feel that the child's life is genuinely at risk because you do not know when that will escalate. Right. You don't know where along the progression you are at any given moment. And particularly if a child has something like a feeding tube or a port that could be, you know, that could lead to death instantly, then that certainly is going to elevate that concern.
- [22:49]
Dr. Shailene Nienow
And the record review that, you know, Dr. Nienow or any child abuse pediatrician would do is I just want to clarify that their specialty is child abuse pediatrics. So Dr. Nienow actually did the fellowship in child abuse pediatrics, is board certified in child abuse pediatrics. I mean, there's other child abuse pediatricians that have a different backstory, but that is hers and has maintained, you know, continuing medical education in the field, all of that. That being said, the record review is the kind of heart of these cases, at least from that side, there are all the medical records. There are the doctors, the parents, you know, feel have information that would be important. There's neighbors, there's friends. Right? I mean, like, all these cases have a lot of people. But this is one piece of the puzzle is the report from the child abuse pediatrician. So just to be clear that a child abuse pediatrician's role is in diagnosing or finding evidence that there is no concern for abuse. So their report is going to be a review of the records and what they are finding in those records that is concerning enough to potentially show signs of child abuse. That report is part of the entire, you know, case and information that is put in front of the judge, and then it's the judge making the determination based on that information whether you shelter or detain the child from the parents.
- [24:11]
Dr. Bex
Right. And their job is to evaluate the medical piece. And, you know, something that is not mentioned contextually a lot of times in the media coverage of these cases is that child abuse pediatricians, number one, the data shows us that they find, you know, find have findings of abuse in less than 50% of the cases that they evaluate and also that they are less likely to come up with findings of abuse than their less well trained colleagues. So again, I think I said it in the last episode, but I will say if I am a parent who is not abusing my child, I want a child abuse pediatrician making that evaluation. They are less likely to make mistakes, which makes sense, right? They're more trained.
- [24:46]
Dr. Shailene Nienow
And that's. I think that's where maybe there's a little bit of dissension in how people feel about them. But again, I think when you put it in that context of they are a specialist in this field, it doesn't mean they're going to find it. And like you said, it actually data shows that maybe they find it less. I think that's an important, just an important piece to kind of set this up before we go forward. But as with a lot of the cases we've followed, it is going to come into question whether this report, whether the initial call to HHSA was falsified or this idea of a false accusation or false elements of these reports. And that also it's this word false that I think gets to me personally. Is, is it false or is it what they saw at that time or their again, reasonable suspicion of whatever it is that they're calling in or reporting, which is what we're were taught to do, is that you call in when there's a reasonable suspicion. So saying these accusations or these reports are false. I think that word is just. Is interesting not to say there couldn't be something that is just blatantly wrong in a report. Of course there is. But at the same time, that word false accusation or false reporting to me could mean a variety of things.
- [26:04]
Dr. Bex
Yeah, it's. It's pretty loaded. And I think, yeah, again with the standard being reasonable suspicion. So I gather if you are talking about a false allegation, you know, if an evaluation said that a parent falsified test documents or lied about, you know, a test result and they just didn't. That's not what the medical record shows. Then that doesn't match up with the medical record then. Yeah, I mean that would be. But it sort of. There's a lot of room for speculation. So this family is saying than that the second report. Then we're at the second report that was made when, when Madison enters Rady Children's. So yeah, take us back to the timeline. So there's a period of. We know there's a period of COVID video surveillance and then how long into her stay there is this second report entered.
- [26:54]
Dr. Shailene Nienow
So the report is made very early, but it goes forward to March 7th of 2019. So she was in New York in January. So now we're in March. And this is when the petition is filed with the court for detention or for meaning like that Madison will be separated from her parents. And so at this point, the decision is made in the court to separate Madison from her parents. And the next day there will be the hearing to kind of discuss this when the parents can arrive in court and be a part of the hearing. It is told in the court documents that the father was the one that was present at the time and that he was brought into a meeting with the team and with security is what is said in the document. And it is explained to him that the court has made this decision. He is asked to leave the hospital. He needs to surrender his parental badge. It sounds like Dana came up to pick him up, had to surrender her parental badge. And from that moment of that meeting, it does not sound like they saw Madison again, at least you know, that day. And along with that is the whole report that what was done by the state workers or those who work in the HHS, a system, and then Dr. Nina's report and any other collateral information from both sides is brought to the judge. And based on what is placed before him, him, I mean, again, we don't know what that all entailed, but what went in front of him. The decision was made to separate Madison from her parents and to put her in the custody of the county of San Diego.
- [28:30]
Dr. Bex
So we can assume at this point that Dr. Nina's review and her evaluation process has had findings of abuse. We don't know what specifically was in her report. And we can also assume at this point that hhsa, which is their child protection state team in, in California, that that division has also done their. Completed their investigation and has had positive findings for abuse. So I think we can assume both of those things if a judge made this decision. So those two pieces of evidence, and again, like these investigations all look different. They're all kind of complimentary. You know, the child abuse pediatrician's job is to evaluate the medical piece of it, DCF or child, you know, cps, those entities. Their job is to decide whether or not those parents can provide a safe home for that child at that time. So they're going to talk to other collateral sources, teachers, friends and family member, that kind of thing. They will interview the parents. So, yeah, just to delineate these. So like child abuse pediatrician, they're looking at the medical piece of it. They're doing a medical evaluation, you know, Child Protective Services, whatever they call that in the state. Their job is to decide whether or not this family can provide a safe home for that child. So those obviously all have a lot of interplay, but they all are separate jobs. And then a judge's role in this is to make a ruling based on those findings of whether or not those parents can continue to have custody of that child.
- [29:55]
Dr. Shailene Nienow
Child. Correct. With all of the information provided to them. And I think this is a part of this, these stories that as a parent, as a human, you know, it sounds a certain way when you hear it, but I don't know.
- [30:09]
Dr. Bex
This is a parent's worst fear. I mean, for sure like, this is a parent's worst fear of someone telling you that you can't be with your children and not knowing sort of when that's gonna end. I think we can just fully acknowledge that that is a really heartbreaking thing. And I think most of the people involved in these cases absolutely acknowledge that that is. You know, I have never met a person that works in child protection or child abuse pediatrics or any of these roles that relishes separating a parent from their children. We all know and fully recognize that that in and of itself is going to cause trauma to the child and the family. So sometimes it needs to be done. But 100%, that is a really heartbreaking moment.
- [30:46]
Dr. Shailene Nienow
And I think children's hospitals, we. I mean, this is not a regular occurrence, but it has happened. And I think that's why we have all the teams that we do. You know, our job is with the child. That's the patient at our hospital. And so, you know, offering all the kinds of support, being present, you know, doing explaining to the child in child languages, kind of what, you know, what's happening as we're able to. And then also HHSA is somehow communicating with the child when they're in the hospital as well. And like you said, I don't. There's no perfect way to do this. I don't think there is. But we also know that the time of, you know, separation or when this is playing out is also a high risk time for children. I'm not saying, you know, in this case in particular, but in any case, you know, tempers, emotions, fear. Right. Are all at their highest. So we also have to understand that that's a time where we do have to protect the child because there is still a risk. Okay. So the next day. So now we're on March 8th, is the hearing before the judge where the parents are present. And what we know about it from the court documents is that the parents are going to be allowed one visit per week for one hour, and it's going to be a supervised visit. One of the things they do say in the document is that they were told they're not to talk about her medical condition, her symptoms, how she's feeling about things. And you and I both know that this is part of kind of the AppSec guidelines for what should be done in these cases if it gets to the separation point. So do you maybe want to explain that a little bit?
- [32:13]
Dr. Bex
Yeah, so I would have to check the specifics, but, you know, I believe the AppSat guidelines say that actually visitation is not recommended in these cases. And that sounds extremely harsh, and I understand why that sounds upsetting to people. What I think people need to understand that in Munchausen by proxy abuse, specifically, the amount of psychological manipulation is so intense. This is something that we know from sort of. That we know from watching these cases play out. That child, and especially I think in a little bit of an older child that is able to, you know, be sort of a part of keeping up the. You know, if there is a ruse around an illness, sort of keeping that up. You know, this is something that Gypsy Rose Blanchard talked about with her experience that she would be in the room with her mom, and her mom would, like, put her, you know, hand on her shoulder, and she would know that that meant she was sort of straying from what she was supposed to do. And so I think given that that psychological manipulation is so intense, the recommendations are really to have a separation period where there isn't visitation and there just isn't interaction at all in order to see how that child behaves and what is really going on with that child without that influence. So that is actually the recommendation. And then in situations where we saw this in the Maya Kowalski case and the Justina Pelletier case, Justina Politier case, they absolutely did not follow this. This rule. But, you know, where if the parent is allowed some visit, some supervised visitation with the child, you know, that they absolutely do not discuss their health because of the fear that the parent will remind that child that they are supposed to be sick, that, you know, not to listen to the doctors that are surrounding them, that they will really, you know, that they will make it this very contentious relationship with the doctors who. Who are supposed to be treating and healing that child. So there. There are many reasons why there have to be strong parameters if visitation is allowed.
- [34:18]
Dr. Shailene Nienow
And I think at this point, the concern and the reasonable suspicion and what was found by the judge was that there were concerns specifically of this type of abuse. So, again, whether you. Whether the parents or whoever believes that or not to be true at this point, that is what the court had before them. And so following this pathway is what is recommended. But remember that if it is in fact found that there was abuse happening each of these times, that that is kind of replaying itself can be very traumatic to that child or even, you know, set them back. If there was, say, there was starting to be recovery seen, that could lead to another setback.
- [35:00]
Unknown Host
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- [36:38]
Dr. Bex
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Dr. Bex
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Dr. Bex
No exaggeration. I think probably half of my clothes are from this brand at this point. So it is finally warming up here.
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Dr. Bex
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- [38:01]
Dr. Shailene Nienow
Support the show during this time. I just want to point this out because again, once we get into the court process, this is going to come up again because it is one of the claims that is filed as to unwarranted medical procedures that were allegedly performed on Madison while she was at Radies and while this shelter order or this detention order was in place. And this we are relying solely on what was said in the court documents, which is that it seems there were specifics of what the court said the hospital could do and stuff that needed to be told to the parents before it was done. And then things that maybe specifically would need consent because the parents, that's important to point out. The parents are still the medical decision makers in these, these cases. So even though they may not be allowed to be present, they are still the ones who would say sign consent forms. And if not, then it would go to it would have to actually go to a court order. So I think a lot of things come up in terms of what constitutes kind of a normal medical procedure versus what is something that constitutes needing that extra, you know, guidance or extra consent from a parent. And this kind of actually made me think a little bit, to be honest, because there are times that a parent isn't directly at bedside. And if you're kind of following along with what the plan was, a lab test could be drawn while the mom isn't there. You know, an X ray could be ordered and done without the parent there. And it's kind of what is that limit? A lot of things may warrant or may kind of, as a physician, you feel like you should be notifying someone versus the act of consent. And I think that is an important point. And again, as we've said a couple times, it's very state specific. It may be in the hospital bylaws as to what procedures require consent. But I think there's some gray areas and that's one of the ones that comes up in this case is this swallow study. And just for those who are following along. I want to explain to you what it is and maybe we'll hear from you guys kind of what you think. But the idea is she was describing, or Madison was not eating by mouth. Not very clear exactly what symptoms she was describing. But the test that was ordered is what's called a swallow study. And a swallow study is you go down to the radiology suite, there's usually a speech therapist or an occupational therapist, and you drink liquids, eat foods that are tagged with a certain dye, D Y, E dye, so that you can watch it go down. And the idea is you wanna make sure the swallow mechanism is intact, that they're able to pass it from their mouth to their esophagus and then that it passes down through to the stomach. And there are pieces of this. Again, it's not just a routine abdominal X ray, but there is no anesthesia involved, no sedation involved, side effects, no risk, no pain. I mean, again, if she's having pain when swallowing, sure, but then the study would end, you know, it's not necessarily. You wouldn't push through significant symptoms, I don't think, at least in my experience. But the idea is she was swallowing contrast, and that was. There were pictures being taken. So I'd be interested, I think, to hear what people think or maybe since you're not in this field, what you think about that. But. But the point is, it depends really what the hospital, I think, what their policy is and then what the court order said and how those two things play into each other.
- [41:15]
Dr. Bex
So basically just the parents are alleging that they were not included in the medical decision making. But yeah, I mean, I think specific to the swallow study, I haven't undergone one. None of my children ever gone one. They certainly come up all the time in these cases because of the. Because GI issues are such a huge, pretty much ubiquitous part of Munchausen by proxy cases. But, yeah, I mean, it certainly when we talk about this child's particular medical history and the things that she underwent up until the point where she was. Where she was at radies, it doesn't stand out to me as something that would be particularly invasive. It sounds like there was another. A number of other procedures, lab tests, X rays. Yeah, yeah, yeah.
- [42:00]
Dr. Shailene Nienow
And I mean, again, this kind of reading, this did make me think a little bit more about the things we do and kind of what standard of care, what falls under that, you know, general medical consent that the parents sign at the beginning. And a lot of times in pediatrics, to be honest, parents are present or a family member Is there just because of the nature of a child being in the hospital, but there are times they can't be. And so just really thinking that out, I think especially when I'm talking to residents and the future kind of about notifying, keeping parents in the loop. And I think there are parents that can't be at the bedside for other reasons, you know, work, other children, life things that they can't necessarily be there and that we're sure we're kind of giving them the same, you know, involvement in the care as if they were within reason, too.
- [42:41]
Dr. Bex
Yeah, that's a good point. I mean, when I look at the things that are outlined in this lawsuit, you know, ekg, renal function panel test, plasma renin test test, which is a blood test, you know, X ray, medical, behavioral treatments, I mean, those are things that would make a lot of sense if you are treating a child with a lot of medical complexity and a lot of medical complexity that you're not sure is what the parents have said. It was like if you, if you are. If you are treating a child in the context of a medical child abuse suspicion. I mean, these things make a lot of sense if you're trying to figure out what is really going on with this child and what might. Might be a fabrication. Okay, so. Yeah, so take us back. Take us back to the timeline.
- [43:28]
Dr. Shailene Nienow
Okay, so this is the window of time where we really lose eyes on Madison, if you want to say it that way, or that there's not a lot in the court documents, probably because this is the parents that we're talking about now, and they're filing with the courts and they weren't at the bedside. Right. So I think there is some. Some information we don't have during this time. But just so we know, she is in radies after this shelter order goes into place in March of 2019 until February of 2020, when kind of the story picks back up. And again, there's a lot of reference back to times in there, but we don't know a lot in this time period until February 5, 2020, when Madison is returned to the custody of her parents. There's another hearing. It's in front of a judge, judge called Judge Imhoff in California in the county of San Diego, and he is now determining that Madison could be returned to the custody of the parents. But he. There's. There's some terminology, and, and just so everyone understands, it's the terminology that's in the court document. But then the court document occasionally puts things in quotes. So we are relying A little bit on what they're saying, somebody said so a little bit of he said, she said. But. But there was a term that was used at this time that I just. It really kind of stuck out to me. And I'm curious to hear what you think. But he uses the term Scarlet letter of Munchausen by proxy, or basically that this family had been branded with their own scarlet letter of Munchausen by proxy. And there's times, I think, like we just said that legal terms, opinions, adjectives, adverbs, all these things just get kind of interesting in medicine, in law, where you want it to be like, it's this because of this. And that's just not always how it works out. But this one, I don't know, it hit me a little bit.
- [45:17]
Dr. Bex
Scarlet letter. I mean, that certainly is. I would say that is a very emotionally evocative language. And I think it's very interesting in, like. Because there's this tension between the rights of the parents and the safety of the child that certainly puts, like, emphasis on the experience of the parents. Right. So not this sort of thought of, like, yes, we should always look at child abuse. You know, it's sort of like not focused on the child and what she may have experienced or what may have, you know, been a possibility, but really looking at that experience of that, parents dealing with that accusation. And now certainly I want to acknowledge that, like, that would be horrible. We recognize that it's horrible for a family to be accused of abuse. However, abuse is very much a part of our society, and it is. Child abuse is. Child abuse as a whole is common. Mentalism by proxy abuse is not rare. So, yeah, that's certainly striking and certainly mirrors many of the other lawsuits I've seen. Certainly came to play in the Kowalski lawsuit where, you know, in that instance, because of Biata's suicide, that the implication was that these accusations that she was a perpetrator of Munchausen by proxy abuse drove her to suicide because they were so emotionally distressing. And so I think that is. Yeah, that's certainly striking. Certainly striking language. And it's striking language to use as a judge. Right. And I think we have. Which I have been thoroughly disabused of this notion at this point, but I think we have this idea that judges are these. These sort of neutral parties that are going to, you know, make decisions, you know, based on legal precedent and the, you know, the facts in front of them. And that's just not what happens, I think in. Particularly in family court situations where you're not dealing with the same level of evidence that's being presented. I have seen quite a lot of opinion from judges in these decisions and quite a lot of extremely colorful language about the nature of that, which, of course, is, you know, a judge's prerogative, I suppose, but. But yeah, I think it is, you know, judges are human beings that bring all their biases and feelings to their. To the bench with them. And it certainly seems like this judge may have had some feelings about this case.
- [47:44]
Dr. Shailene Nienow
And I think it is interesting how. How some seem, like you said, some seem to have a little bit more to say. And you are right in the dependency court, this isn't a jury. This isn't. It's not that same, you know, kind of a feeling in the courtroom where he really was kind of laying down his final thoughts on this. And then also where. What is the state of the case? So he says, you know, or at least the court documents tell us that he, you know, spoke out and said, I think about the implementation of the COVID video surveillance as being an invasion of privacy. He does use some of this terminology or these words, at least according to the documents. And if there is, say, a police investigation or other things are going on, you know, these words could be very, you know, inflammatory or very kind of pushing in. In one direction.
- [48:30]
Dr. Bex
Yeah, it's. I mean, these things are really very much ongoing a lot of the time, you know, and certainly many cases that we've seen off the top of my head, my sisters, Sophie Hartman's Mary Welch, a police investigation was ongoing when the family court, because the family court is based on preponderance of evidence rather than beyond a reasonable doubt. It doesn't involve a jury. It's a much less robust process that often comes to a decision point before the criminal court is, you know, follows through. So where are we now? What time? When. When is this happening? The judge makes a decision that returns custody of Madison to her parents. How long has she been in ratties when this happens?
- [49:17]
Dr. Shailene Nienow
So this is almost a total of a year. So it's. It's less a month. So 11 months. March 7th. I mean, she has been in radies since January of 2019, but in the custody of the county of San Diego from March 2019. Now we're in February 2020. Oh, I'm thinking what February 2020 was like. See, there's more to come now that I think about it.
- [49:38]
Dr. Bex
It's a little while.
- [49:39]
Dr. Shailene Nienow
Yes, but I think. So that's where we are. And this is again, where we're filling in the blanks here and there. But February 5, 2020, she's returned to custody of parents and she goes home that day with parents. So she does remain at Rady Children's. And we'll talk about it, I think more next time about kind of what we do know about that timeframe. But this is where we kind of leave off after this is, yes, she was returned to her parents custody, but she is still a patient at Rady Children's for whatever reason, we don't completely know. And that now the parents are back in the room, back in the, you know, kind of process and present.
- [50:16]
Dr. Bex
And so, so at that point, yeah, so as you said, she, she remains in the hospital for whatever, whatever medical condition complexities is still ongoing with her. And but her parents now have custody back, so there would be presumably no restrictions. Of course there, there could be. I mean, we've seen court orders where there are, you know, the Sophie Hartman case is one where, you know, there were additional restrictions put on for like a period of time. So we don' we don't really know that to be the case, but likely they were then much more involved with her and with her medical decision making than they were previous to that decision.
- [50:54]
Dr. Shailene Nienow
Yep. And just so people understand, I think the dependency court process and now the process that we're kind of talking about going forward, where then there is a lawsuit by the parents against all of these defendants, that's two different courts and that's two different pieces. And often the dependency court process, a lot of those documents are sealed for other reasons. And so the court now going forward needs to determine whether those documents come into play or not. There has to be, you know, orders and motions to get all of that to happen. So we're relying on the court. When I say the court documents, I'm referring to the court process when the family brings lawsuit or the parents of the lawsuit.
- [51:33]
Dr. Bex
Right. Because this is always one of the huge challenges of covering these cases. And the reason we were able to cover the, so robustly in the Maya Kowalski case was because of the litigation that brought much of that into the public record that would not have otherwise been because again, this varies from state to state. But certainly anything involving child protection work, family court, dependency decisions, those are all sealed under ordinary circumstances, as is, of course, the medical records themselves, any reports that the child abuse pediatrician would have made, those would all be sealed because of, of, you know, because of HIPAA and, or because they're sensitive documents related to, you know, child protection. So, yeah, the, the tracking down of the source documents is, you know, and the availability of those can be very difficult in these cases.
- [52:23]
Dr. Shailene Nienow
Yep. And so I think next time we'll, we'll pick up and talk a little bit. There's, there's some interesting factors that come into play with the lawsuit that the parents file and kind of how they're the counts they're bringing against the defendants. And it's a little bit different than other cases we have covered on the podcast. And so we'll, we'll get a little bit more into all of that and the court process and where we stand now next time.
- [52:47]
Unknown Host
All right.
- [52:48]
Dr. Bex
Well, thank you so much, Bex, for your research on this case and for.
- [52:52]
Unknown Host
Walking us through it. And we will see you next week. This episode of Nobody Should Believe Me. Case Files was hosted and executive produced.
- [53:03]
Dr. Bex
By me, Andrea Dunlop.
- [53:05]
Unknown Host
Dr. Bex is my co host and the lead researcher for the ratty children's case. Mariah Gossett is our supervising producer. Greta Stromquist is our producer and editor.
- [53:16]
Dr. Bex
Aaron Ajayi is our fact checker.
- [53:18]
Unknown Host
And thanks also to Nola Carmouche for administrative support.
- [53:39]
Andrea Dunlop
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