Kowalski, Ketamine, and Matthew Perry
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Experience amazing at your Lexus dealer. I'm Andrea Dunlop, and this is Nobody Should Believe Me Case Files.

Welcome back. I am so happy to be with you today. We are working hard to bring you season five of the show that'll be coming this January. But in the meantime, I am very excited to debut the first episode of our new in-between series format, which we are calling Case Files. So we are still going to be bringing you the long form, deep dive documentary style seasons where we tackle all the

one case at a time, we go out into the field and talk to folks, etc. But there is truthfully just so much else for us to look at around this topic. Other cases, updates on stories we've covered in the past, and also just a broader look at how society is dealing with Munchausen by proxy abuse, and to some extent, cases of child abuse in general.

The thing about me is I have a lot to say and this is my full-time job now, so no one can stop me. So please let me know what you think of this new format and tell me if there are any specific cases or topics that you'd like to see us cover here. The best way to reach me is on email at hello at nobody should believe me.com. That's hello at nobody should believe me.com. On with the show. We are here with

friend of the show, originally the secret Florida doctor friend from season three who helped us cover the Kowalski case, who has become our not-so-secret Florida doctor friend, Dr. Bex. So those of you who are subscribers will know her as my co-host for all of the Nobody Should Believe Me After Hours episodes that we do, but she is here with us on

Welcome, Dr. Becks.

Here in Florida, I first got involved in this subject because of some pretty amazing or kind of life-changing cases that I worked with. And I reached out to Andrea and then basically the Kowalski versus Johns Hopkins All Children's Trial took place

literally a couple hours down the road and it really hit home for me and definitely has changed a lot of what we do in terms of mandatory reporting and taking care of children who are sheltered in the hospital or it's really kind of changed some people's perspective on all of that.

And so that's, I think, really where we connected and we started covering and following the trial beyond anything anyone else did. And this has really become, I hate to say passion because it's a tough topic, but it's really become, I think, yeah, like a passion project or something I'm very...

interested in advocating for the victims. And so I've actually been giving talks around the country as well to different conferences on medical child abuse to different providers everywhere with Ethan Shapiro's joined me, Jordan from season four has joined me in a presentation and then with some of my colleagues from work. And so

it's really become something, I guess, yes, I am truly passionate about, and I'm just really glad to be here. Well, we're glad to have you. And yes, I was going to say that if you didn't, that you have been doing a lot of off-air stuff to really advocate for victims and survivors and really help just fill some of those knowledge gaps. I've loved having you on the team. And yes, if you were not following the show at the time, Bex and I watched

Every single second of the seven-week-long trial that happened a year ago, roughly. And we've been following it ever since we read these many thousands of pages of court documents. And yeah, to my knowledge, we're the only people who did anything like that. So if you do want to go check out that coverage, that's all on our Patreon. And of course, all of season three, which you make several appearances in, is also available on the main feed.

So today we are going to dig into something that is a very popular request. I would say anytime there is news about the Matthew Perry case, and he very tragically died from ketamine about a year ago. So really like while this case was in court, I mean, these really happened simultaneously. So he died tragically in October of 2023. The reason or the cause of death, listen, his autopsy was acute cancer.

effects of ketamine. And so this is something that I've heard from a lot of people about. I just get a ton of messages every time this is in the news. And I think increasingly as this case has developed, which we're going to talk about today, the cognitive dissonance of watching

Five people now be arrested in conjunction with his death over ketamine. These are ketamine related charges. And then watching Johns Hopkins All Children's essentially be sued. And of course, there are other charges in there, but be sued for a quarter billion dollars over not administering a high dose ketamine treatment to a 10 year old.

It's really been breaking my brain. And so I think that that is also lots of people who followed both stories are feeling similarly. So I thought we would just hop on today and really, first of all, give a case update about where the Kowalski case stands and then...

Dr. Bex is just going to help us break some of this down on the medical side to sort of really zero in on what we know about ketamine and how it played a role in these two cases. And then also just kind of the broader, you know, ketamine becoming really popular with these off-label usages and kind of just what to know about it because it certainly has been exploding. I see clinics all over Seattle, especially for friends that live in LA. It's extraordinary.

extremely popular there. And there's just a lot to watch out for. So I think that this is also just like a little bit of a PSA about what to know about ketamine as it really gets so popular. So Bex, I wanted to start with just recapping quickly, if we can, the Kowalski case.

So for folks that are not familiar, if you are just joining us, this is the case. This is a Maya Kowalski case. It was a little girl who was separated from her family by the courts in Florida while she was hospitalized at Johns Hopkins All Children's. What started the whole thing was she had come in with a diagnosis of a rare pain disorder for which she was receiving extremely high-dose ketamine treatments that her mother insisted on.

in the ICU or the ER, I can't remember which one it was. And they refused because it was not, you know, it's not something they did. It's not within the standard of care. And that sort of escalated to this really tragic situation where the mother died by suicide and then the family went back and sued the hospital for a variety of things. So Bex, anything quick to sort of add to that recap and then we can talk about where the case stands.

I think the biggest thing is that then that obviously Johns Hopkins filed with the Department of Children and Families on the grounds of medical child abuse or munchausen by proxy. And then that's what set that all in motion. So I think the biggest question at the trial was if Johns Hopkins was treating Maya for CRPS or complex regional pain syndrome, then they were kind of saying she had it versus if they were treating her trying to kind of

get her off of the medications that she was on and try to get her back to kind of normal, healthy child as much as possible and considered that she was a victim of Munchausen by proxy, then can those two things be coexisting or do they have to be two separate entities? And is it

if they were treating for, you know, for Munchausen by proxy or helping her to get back to normal and not quote unquote treating her for the CRPS. But I think end of the day, just so everybody knows, they actually did give her ketamine at the beginning of the treatment.

treatment, but it was just to wean her off and get her to medications that they felt more comfortable with and were more in the standard of care. Yeah. And so it's really a case that illustrates, I mean, many things. And it could not be a more important case in terms of not just Munchausen by proxy cases and how they're investigated and the ramifications for the doctors involved, but really child abuse as a whole, because the big

linchpin of this is that if this verdict stands, which it's just gone to, Johns Hopkins has just filed their appeal and we'll go over that extremely briefly. But if that verdict stands, then it really puts mandatory reporters and their legal protections in an impossible position and it's going to have effects just really on a variety of things nationwide. So it really is a huge deal. And I think that that piece of it has largely flown under the radar. And yeah, it really is a case that illustrates the

That false binary that people put on munchausen by proxy cases, which is either a child has a health condition or they are a victim of this abuse. And there are plenty of cases where it's both. I don't think this is one of those cases, but it can, especially in the beginning when you're trying to unravel that.

all. It certainly can be both. So again, this appeal has just been filed. This verdict went in the Kowalski's favor originally. They won a quarter billion dollar verdict in court, really a landmark court decision. So that has recently been appealed by Johns Hopkins team. We did an extensive breakdown of that appeal and what's in it in a

Patreon episode. We had Ethan Shapiro, who is the lead attorney for Johns Hopkins, join us for that to break that all down. So if you want to listen to that, all you have to do is actually join our Patreon as a free member. I made that episode free because I wanted people to have access to that information if they could. So if you just go on to Patreon and join as a free member, you can get that. I'll put a link in the show notes. And there are some other episodes that you can get for free on Patreon also.

And hopefully you'll like them and subscribe. It's a great way to support the show. So with that plug out of the way, so just to sort of like give a very brief rundown of the appeal and how it kind of brings us around to what we're talking about today. One of the biggest things in the appeal, they appealed on a number of grounds, right? And they had, as Ethan was talking through, a lot to choose from because this was an insane trial.

One of the biggest issues is the erroneous interpretation of Chapter 39, which is the statute that protects mandated reporters in the state of Florida from being sued, basically, if they are reporting in good faith. And this also, according to this appellate brief, covers other actions taken in conjunction with that, right? So they're arguing that the court

did not have, like basically that this sort of never should have ended up in court to begin with. There's also some pieces about the wrongful death

charges in the inflictions of emotional distress that really have a lot to do with how entities or other people could be held liable for someone's suicide. Those are really important as well. And then importantly, for what we're talking about today, it also is appealing the medical negligence claim. And that claim is specifically for not administering high dose ketamine. And the family received $143 million.

for that piece of the verdict. So yeah, so ketamine really plays a huge role in this case. And not only, you know, we're going to get into, you know,

Maya, the child's history with ketamine, but also it played a possible role in Beata's death. And I think that this is something that also has sort of just flown under the radar. And I'm not even sure actually that I got a chance to cover this on the show. Maya had, again, she was receiving these high dose ketamine treatments and she was also getting ketamine for administering at home, which again is like something that really ties into the situation with Matthew Perry. One of those prescriptions was filled with ketamine.

Maya was in shelter care. So Beata picked up the ketamine that was for Maya, but it obviously did not go to Maya because she was at Johns Hopkins at the time. Now, Beata, when she was discovered by her brother in her garage after her death, she was hooked up to an IV and

They did test the body for a number of things. Ketamine was not one of them. The fluids were never tested, I believe also, but there was never any test done for whether or not she had ketamine in her system. And I don't sort of know what to make of this. If anything, it could just be that I don't know that ketamine is something that's sort of like on the regular toxicology list.

screen that they do post, you know, in the postmortem. However, it's obviously notable in this case and Johns Hopkins did, their attorneys did follow up and ask for that. That is still, some of that is still in evidence. They asked for that to be tested for ketamine and Judge Carroll refused that request. That makes it a more notable piece. So again, ketamine is just a huge part of

this case. So Dr. Becks, could you kind of give us a review of how ketamine was being used in Maya Kowalski's treatment? If you could just give us a definition of, and again, this is

something we've covered in detail. I do not believe this is a legitimate diagnosis, but the diagnosis her mother was saying she had was CRPS. Can you just recap for us what CRPS is and what treatment was she being given in the year sort of leading up to this fateful Johns Hopkins stay?

So for those of you who are not as familiar with the case as we are, so she was diagnosed in September of 2015 by a doctor named Dr. Kirkpatrick, who practices in Tampa, has a clinic that is basically fully based on patients with complex regional pain syndrome. So classically, complex regional pain syndrome, just like the name suggests, is it's regional. It usually starts in

in one location. In adults, more often arms. In children, more often legs, just because of the way, you know, kids are running around and playing and adults are doing a lot more kind of with their hands. And so it starts with an injury or some insult, and it does not have to be that significant of an injury. It can be a simple twisting of the ankle, slipping off a curb, et cetera. And then that pain from the original injury is replaced by

by what we call a neuropathic pain. So it's a nerve pain. I know Andrea has experienced it in her own life and I have a lot of patients who do for different reasons. So nerve pain is a different kind of pain. We think of it as kind of being generated more in the spinal cord or kind of in the other areas and being transmitted to that area. And so they develop a severe, very debilitating pain, but often in the area of the location and beyond it.

In very rare cases, it can spread up the extremity that is involved. And then in even rarer cases, it will spread to the other extremity. And then in only the most significant and rare cases does it become full body. And there are still some physicians out there who believe that that may not in and of itself be CRPS, but that the original insult was CRPS.

And the unique pieces of Maya's case were when she presented, she had already presented with full body symptoms of pain, full body weakness. There were varying stories of kind of where this came from, a fall on a trampoline, an asthma attack, a sinus infection. There were multiple stories that came up, but not one consistent story where it started in one extremity and spread. According to the specialist who took the stand for Johns Hopkins All Children's,

These are very like world renowned pain doctors. This is Dr. Crane from Stanford. Dr. Crane is the one that I went back actually and listened to today, but this is not how CRPS would present. And the story changed very much over the course of the treatment.

And then standard of care treatment for CRPS is physical therapy, occupational therapy, cognitive behavioral therapy, plus minus medications. Usually they tend to avoid opiates at all costs if they can because these patients are very prone to become addicted because of the nature of the pain.

And then there are some very small studies in very few locations around the country, Stanford being one where Dr. Crane works, that they will do very low dose ketamine infusions as kind of for refractory CRPS pain. But the fact that Maya was diagnosed on September 23rd and she had her first treatment with ketamine on October 6th, there is a lot of question as to how she possibly could have gone through every other potential treatment or that this would truly have been

a refractory case if it had been a case at all. Yeah, I'm trying not to get us down a rabbit hole of just recapping the entire case, but we will talk a little bit more about Dr. Kirkpatrick later in the show because there are, as I was digging into this Matthew Perry case, there are just so...

many parallels. And I think there's sort of this case as a medical child abuse case, which I believe very strongly that it was. And then there's the element of using these kind of treatments that are

quite extreme as sort of a tool. And I think like there's a reason that this was such an accessible tool for Beata Kowalski because this has grown in so much popularity and their ketamine has and does not appear to be a ton of regulation on it. I think one of the things relevant also to the Matthew Perry case, and I've done a little bit of digging into this, but you

You know, ketamine is, it's a drug that's been around for a long time. It's been used by anesthesiologists for a long time. And Dr. Kirkpatrick, in so far as he has credentials that have to do with it, now he is importantly not board certified in anything, but he has worked as an anesthesiologist, which is likely why he has such a familiarity with these drugs. And he's very passionate about it. And very, very, again, you know, he's a self-proclaimed

expert on CRPS. This is not something you can get like a technical specialty in, but he's very focused on it, obviously. So with ketamine, you know, and there's a lot of talk in both cases, right, in Matthew Perry's death and in the Myakolsky case of this use of sort of like ketamine as an off-label drug.

And there's a lot of this in medicine, right? Where people use, if you have the right credentials, you can use a drug in a way that that hasn't been FDA approved for because you found that it has some other secondary benefit or there's something else that it's really useful for. And a lot of that, that's not necessarily on its face, a sketchy thing, right? To say that it's like, that'd be a bad faith argument to say, well, it wasn't FDA approved for this usage. Like,

There's plenty of that that goes on that is still good medicine. Can you just give us a little bit of the history of like, what's it been used for? What's it being used for now? Why are all these ketamine clinics popping up all of a sudden? The most common use at the beginning was actually as a battlefield medicine.

anesthetic during the Vietnam War. And the reason is it is a very what we call quick on quick off. So it gets its peak effect with a one time dose. It gets its peak within minutes and it wears off within about an hour. The oral doses last a little bit longer in your system, but that's quite a benefit.

for kind of those in the moment situations, emergencies to be able to give someone some pain control, some sleepiness and a little bit of amnesia as well to the incident or short-term memory loss. So that if you do have to do some procedure in the field in the moment,

you're giving them all of those benefits. So that's really where it started. And then I would say, you know, in my career, the most common time I've seen ketamine be used is in the emergency room for similar things. So you're setting a broken arm

or you need to do stitches or something that's in the moment, kind of an emergency, but you really want something that's gonna be quick on and quick off so the child can go home potentially after that. And so that's really when ketamine had been used the most. And I don't work in the ER, but I actually looked into my hospital's policies on using ketamine, and that is still the most common use for ketamine.

In recent years, as most of you probably know or maybe have heard of, is it actually is FDA approved now to treat, again, treatment resistant or refractory depression. In those cases, it's an intranasal spray. So you actually spray it in the nose and at least the first couple of treatments when you do it actually still need to be monitored by a physician.

So it's still not given just kind of willy nilly, like where you just can take it home and take it whenever you want to. You don't just like pop it in your purse and like. Right, exactly. It has to be monitored at first because there are other things that come along with it. And right now, those are the things that it is approved for. Everything else becomes what we call off-labeled.

And to be fair in pediatrics, we use things off label more often, I would say, because there are things that have been tested in adults and we know are very successful in studies and have few side effects. And so because it's harder to do randomized controlled trials in children, there are times and it's always with parental consent and discussing all the pluses and minuses. But for things like ulcerative colitis, Crohn's disease, when we know something has had extremely good outcomes in the adult population,

We will use it in the pediatric population before it is truly FDA approved because the benefits outweigh the risks. And within that, there is still a standard of care. I think that's important to talk about that.

we still wouldn't give three times the adult dose of these medications to a kid with Crohn's disease. It still is within a standard, even though it's not quote FDA approved, there is still kind of a nationwide standard as to what you would use them for. Yeah, I think that's a really good point. And so I want to talk a few specifics about Maya's case and her dosage, because I think it is one of those, the poisons in the dose like stories here. But I mean, it

Matthew Perry, according to the... This is all from other news sources. It's mostly from ABC News and Daily Beast. I just want to clarify that I did not do original reporting on the Matthew Perry case. But he died in October of 2023. So after a couple months after he'd started using ketamine, now he has a long history of addiction, which we'll get to a little bit. But

you know, it's so jarring to have these two things happening really simultaneously because they were in court in October of 2023. You know, this was being litigated in court and when his death happened. And it's so jarring to sort of have, you know, the Kowalski's attorneys saying,

And their witnesses really making this case of like this treatment that she was getting, you know, she received 55. It started when she was nine years old. She was 10 by the time she came into Johns Hopkins. Myakwaski read 55 high dose ketamine infusions. Wow.

under sort of substandard monitoring, which was another thing that came up and came up in also the Matthew Perry cases, sort of just like there's a difference between using ketamine in the, like anything, right? There's a difference between using it in this set of circumstances where you have close medical supervision and not. So, you know, she was receiving these high dose ketamine treatments. We know Beata Kowalski, she had a port in her chest for that she could receive medications intravenously. We know her mother who was an

infusion nurse was giving her ketamine and other drugs via that port. So there was at home use, but this was really being played. And, you know, also famously she was flown to Mexico for this five day ketamine coma. The doctor, Dr. Cantu, who testified said that he told the parents there was a 50, 50% chance of death with this procedure. And,

And so we're hearing these details and we're hearing these doses. I want to go through with you, just zero in on the doses a little bit more so we can kind of have a framework for it. But we're hearing all of this and then simultaneously hearing the plaintiff's argument say like, this was no big deal. This was what she needed. She was never at risk from these treatments. This was what they should have done. They should have complied with this request when she was in the hospital. And in fact, that goes to the medical negligence claim. So it's extremely jarring.

So can you give us an idea of what are some dosages that you would see in some of these legitimate uses that we were just talking about? So like what's a dose you would see if someone's going in for an infusion? Because I believe they do use that same procedure, right? If someone is going in for treatment-resistant depression and an adult, presumably I don't think they use that.

for this, for that in children. That's intranasal, which the dosages like don't convert over. So I think the one that would be the most relevant is one either anesthesia for surgery, because that's like the highest you would ever do, like to where they are intubated. And then there are these

places that will do like an infusion for chronic pain that is becoming more and more studied. So those would be the two. Just because the intranasal, the doses aren't going to convert over. But with like the clinics that you see popping up, my understanding is those are clinics where people go in and get infusions, right? Right. Either just like a one-time dose, which I have those doses, or they sit for like the two to four hour infusion. Okay. Give us a range here. Yes. Of like all the way to like

anesthesia that is going to knock you out for or like infusion or like one time dose or like what kind of dosages are we looking at with those things?

So in most of the cases I can find in the pediatric literature, but also up to adults, they actually do everything in a per kilogram. So that's kind of how our world works in pediatrics is dosing things per kilogram of body weight. For instance, most places that I found that have a protocol for chronic pain, they start at

0.1, so 0.1 milligrams per kilogram per hour. So we were assuming kind of Maya at that time was about 30 kilograms. So that would be three milligrams per hour because it's 0.1 per kilo. And so that's kind of the starting point.

Most of the places I found will not go above one milligram per kilogram per hour. So again, that would be 30 milligrams per hour max for Maya's body weight. And even in adults, they usually max out at that 30 milligrams per hour. That's kind of the comfort in most of these clinics, I think. And then when we talk about anesthesia, so this is a kid who's undergoing surgery, needs to be not just

but completely out for the surgery. So this is intubation. So tube in the throat and all of it goes up to in pediatrics. I saw three milligrams per kilogram per hour. So that would be like 90 milligrams per hour for someone Maya size and,

In the very rarest of studies, six milligrams per kilogram per hour, but I did not find anything above that for pediatrics. And even in the adult studies, that's the recommended range. So 0.1 milligrams per kilogram per hour when you're looking for kind of those chronic pain infusions up to one milligram per kilogram per hour, and then all the way up to three to six for true anesthesia. But that's talking, you're not breathing on your own. You're not all of it.

So that like would basically put you in a coma. In Mexico, they were doing three to five milligrams per kilogram per hour. Okay. They start at three and go up to five. Okay. And that is 24 hours a day for those five days. Wow. What kind of doses was Maya getting when she was doing these infusions? So this is what is also interesting. And Dr. Crane pointed out very well. So diagnosed September 23rd, 2020.

Two weeks later, October 6th, her very first infusion was already higher than the max that the children's hospitals like Stanford will use. So her first dose was 1.4, 1.5 milligrams per kilogram per hour. So it was already...

like 42, 45 per hour, and she got it for three to four hours. So it was about 140 milligrams on that very first day. So they did not titrate up or start at the smaller dose. They already were above what most of the chronic pain places would use. I mean, that's 10x where...

Right. You would usually start. Because 0.15 to 1.5, right. And this is like two weeks after diagnosis. Diagnosis. And just as a reminder about how that diagnosis came to be is that three world-class hospitals had diagnosed Maya Kowalski with conversion disorder. Beata Kowalski, her mother, then found Dr. Kirkpatrick's name on a message board and

from another parent who allegedly has a child that has CRPS. And they said, go to Dr. Kirkpatrick. He will give you the diagnosis. And he did. And also Beata Kowalski reported to another physician, the pulmonologist in the case, that she had this diagnosis before they ever saw Dr. Kirkpatrick. Like right out the gate, she's getting, she's starting really high. ♪

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Eventually she moves to this other doctor, Dr. Hanna. And then like, where does the amounts of ketamine go from there? So between those two is when she ends up in Mexico. And that was the other thing. I was kind of looking back at the timeline and I think it gets me every time. She was in Mexico within like a month of diagnosis, a month and a half. And even if you want to go back to her first symptoms, which was July, so two months before that. So let's say three months since symptoms started. Since alleged onset of symptoms.

Right, alleged. She was in Mexico undergoing this coma with a 50% chance of death. So that one is the one that's up to five milligrams per kilogram per hour. And that's 24 hours a day. So that's even more extensive. But then she comes back and...

And as Dr. Crane says, the patient population that Maya is in, so a preteen female, are actually their most successful CRPS patients when there are. They're actually the most receptive to treatment and actually usually do very well. He said in his practice, he's actually never had a girl in that age group relapse after a first episode of CRPS. Yeah.

And that's not even doing the whole ketamine infusion. That's just doing all of the other things. So it makes a point to all of this talk during the trial about how this was a disease for life and all of that. And I don't want to downplay some patients with CRPS do suffer for the rest of their lives. But in this specific patient population, it actually has a really good chance of not coming back. Obviously, there's the fear it could, but

These patients usually do very, very well. And so again, she was kind of the one who everything needed to be escalated very quickly and very rapidly, at least per her mother in terms of dosing. So she comes back and within...

two months, a month, a couple of weeks, she was already having pain again. And so that also is very atypical for these cases that usually get more relief from the treatment. And so when she started with Dr. Hannah, she was already starting on four milligrams per kilogram per hour. So four times the max dose that other, you know, children's hospitals would be doing and already into the anesthetic dosing. Wow. So that's already...

beyond the level at which we at our hospital would consider it anesthesia, meaning you should have to be intubated and monitored and all of that. Now, it's interesting to say that this really speaks to the dependence that people develop to ketamine. So,

there's dependence, there's addiction, and then there's kind of withdrawal symptoms. But dependence is really your body's dependence on the drug. And the way it manifests that sometimes is it needs higher doses of the drug to get the same effect. Right. You develop a tolerance just like with any... Correct. And ketamine classically can actually have that dependence develop and need the higher doses. So the fact that...

Already, she can tolerate doses that another child would need to be intubated for, makes you realize that her body was already developing these signs of dependence. And at the same time, she was still continuing to report 8 to 10 out of 10 pain already.

all through these treatments. So all the way up till October when she ended up at All Children's, which I'm thinking I figured out where the discrepancy is, but I had 10 milligrams per kilogram per hour at the point that she came to Johns Hopkins, but that would be assuming she got it for a four-hour treatment. Dr. Crane actually says...

20 milligrams per kilogram per hour, even up to 30. But I think it's because they were shortening the treatment. So she was getting that whole treatment in a shorter period of time. So again, it meant she was getting more, not the same amount, but just over a faster amount of time. And to make a point with ketamine, the other thing is the quicker it is given, the more likelihood of having a bad effect. So for instance,

called laryngospasm, where your larynx or your voice kind of around your voice box will spasm. It's the most common reason that they go into respiratory symptoms or respiratory distress with ketamine is that laryngospasm. And so the fact that she was getting more over a shorter period of time did put her at higher risk. Yeah. And just to sort of emphasize, because I think this gets us...

is sort of segue into like the sort of strip mall ketamine clinic of it all. She was at that point seeing Dr. Hannah and the reason that she left, which again, really strong parallel with the Matthew Perry case. He, who,

seems also very dubious in terms of like, you know, he's got his billboards, the no pain Hannah of it all, you know, and was also like one of the things that came out in the records was really this like substandard monitoring that was happening in this clinic where he was letting family members watch the vitals and it just did not sound like it was a super safe place to be getting these infusions. It even maxed out him like he wouldn't go any higher and Beato was trying to push him to go higher and that

is how she ended up getting referred to Johns Hopkins was through Dr. Hanna. She said, I can't do anything for it. And I think it speaks to what you were talking about, Bex, where it's such a, again, the argument, if you look at all closely at it, just really breaks your brain because it's like, okay, she was getting so many of these treatments, so much of this drug,

you know, 55 of these high dose ketamine infusions in the year leading up to this day, plus this five day ketamine coma where she was intubated and getting these really high doses. She was, they were fundraising to send her on another one of those. So every reason to believe that the plan was to send her back in the near future. And throughout this time, she's, her mother is talking about her impending death.

She's writing this blog in her voice where she said she wants to die. She's reporting 9, 10 out of 10 pain, 0 out of 10 quality of life. So it's like the only thing that works is this massive amount of ketamine, but also this isn't working and she's going to – I mean, it's just like the narratives don't make any sense together. You were kind of talking about how this can be – there can be issues of dependence. What are sort of just like the basic rules?

risks. And again, there's risks with every drug, right? And there's a lot of this has to do with dosage and monitoring and how to do it safely. And like, but what are some of the risks of ketamine? Now, ketamine is actually known. I mean, if you do look it up in the literature, one of the reasons it came about is it is

relatively safe when used in the appropriate doses. Again, that means in the battlefield, they did not have to put a tube down their throat in order to do these procedures, right? So again, there's a reason it is used for what it is used for, because the risk is

at safe doses of losing your airway or losing, you know, stopping breathing or having cardiac issues or heart issues are rare. Now it can make your blood pressure go up. It can make your heart rate go up. The big one is that laryngospasm. And what happens is it actually makes you have more saliva and more secretions. And so you almost choke on your own secretions, which is what, or your own saliva, your own spit, if that is what happens. Now, again, that's within those

reasonable dosage ranges. The thing is, we don't really even know at those highest doses because the studies haven't been done in those numbers. So there's something called in all pharmacology or all of anything having to do with medications, there's something called the lethal dose and it's called LD50. So that means in animals, unfortunately, when they do studies on these drugs,

If 50% of the animals die at that dose, then that is considered the lethal dose, LD50. And so what they have found, and again, this is in animal studies, but that that lethal dose is about 11 milligrams per kilogram. So putting that kind of in the realm of what we're talking about,

For a 30-kilogram girl, a lethal dose, all given at once in one big push, would be about 350 milligrams. So we know she got more than that in the course of days. She even got more than that in the course of an hour. However, her body had developed some form of dependence. So had she gotten one big slug of 350 milligrams on the very first day with, you know, not over time, it could have been a lot more.

it could have been lethal. And again, this is all how pharmaceuticals work, but there's a reason that data is out there. And I mean, I think because it has to do with how much you weigh, obviously a lethal dose for Matthew Perry, who I saw in one thing, I think it said he weighed about 220 pounds. So about a hundred kilograms, obviously that's triple what it would be for someone like Maya. But to be honest, there were days where Maya even got the total amount that would bypass Matthew Perry's

lethal dose. So that's kind of to put it all in perspective. And I think end of the day, like her doses from the day she started,

were higher than anything a pediatric hospital within its standard of care would use and already getting into the doses that they would use more for surgical anesthesia. And that's, I mean, again, it's the rapid escalation. It's how fast those doses went up and how it just, it's frightening how high that, you know, these doctors were willing to go in a child. And it sounds like they weren't

willing to go even in Matthew Perry's case from what some of it said, he stopped going to the one doctor because he wasn't, you know, there wasn't that ability to go higher. So that's some really good context about just putting sort of ketamine in perspective and where we sort of are with it and how it was used in this case. To just talk a little bit more about the Matthew Perry case. So again, Matthew Perry bought

beloved actor from Friends and many other things, had a long, long, very tragic struggle with addiction that he was incredibly open about. He talked about this in his memoir, Friends, Lovers, and the Big Terrible Thing. In reading about this case, I learned that his history with addiction started when he was a teenager, which made me really, really sad. He was from a Hollywood family. It sounds like he just had a strange and possibly traumatic childhood.

And that he went through detox 65 times. So obviously this is someone who just struggled mightily with addiction. The stuff around ketamine and sort of – I believe he started taking it originally for depression because he was struggling with depression. And I would assume that –

You know, I think there's a lot more awareness than there used to be because of the opioid epidemic. And opioids are something that people understand that you can't give that to someone. You know, you have to be really careful about giving that to people for pain or giving them any kind of long-term thing. And obviously, I think that would be something that would right away stand out to people if someone had a history of addiction. Like, you wouldn't put them on that.

And so I think ketamine seems to be seen a little bit differently. You know, in a lot of this press coverage about Matthew Perry's death, they've talked about how it's become so popular, especially in like wealthy, you know, in Hollywood circles. There have been a couple of celebrities that have been really vocal about, Sharon Osbourne was one about using it, I believe for, you know, treatment resistant depression. Also Lamar Odom has talked about his success with using it for treatment resistant depression. And actually that was interesting to me because he, you know,

He is also someone who has struggled with substance abuse disorder and said that for him, this was very helpful. And I guess there is some preliminary research that it could actually be a good option for people who have had past substance abuse disorder issues. So there has been some, it sounds like some preliminary research. And again, I did not do a super deep dive on this, but about using ketamine for folks who have struggled with

with substance use disorders. But the doctor, at least who opined on this for the Nightline special, said that he would be very, very cautious about prescribing something like ketamine to someone who struggled with addiction. And probably for all those reasons you mentioned, Bex, right? This can have dependence issues, that it can be addictive. I mean, I think that's the other thing that

really was sort of hammered on like, oh, this is not addictive. This is so safe. This is blah, blah, blah. I mean, it is a... What is it? A category three controlled substance, right? Right. So it's a controlled substance. So for a reason, right? I would guess just as a lay person, like that this is like many other things, you know, where you can have something that's super...

useful, but something like Klonopin, right, which can be really helpful for acute panic attacks. But like, if you start to take it regularly, which I've taken it in the past, and you know, there's a lot of warning about like, oh, you have to be really, really careful. And I know a lot of doctors actually don't like to prescribe it for that reason. So it sounds like maybe ketamine sort of falls in one of these categories of like, yes, this can have really great and helpful uses. It's not like taking a Tylenol, you know, it's like there should be a lot of caution and sort of best practices around it.

I mean, anything that becomes a street drug, right? You have to know there are some positive effects that people are seeking to get by taking it, right? And so ketamine, just to make a point, I mean, it is a dissociative agent. So it's actually the drug it is most closely connected to or closely, like when you look at the physical structure of it, is actually PCP, which

It's supposed to be like one-tenth the potency of PCP, but basically it looks the closest to PCP, just like a lesser potent derivative. But I mean, think about that. That means that people are using it for that dissociation, that euphoria feeling, or even to the point of true full-blown hallucinations, which I actually was interested to see most people

hospitals that have some protocol for ketamine, actually they find that it's usually somewhere around half a milligram per kilogram per hour. That 0.5 is about when hallucinations and things actually start to become more pronounced. And that's often the point they need to hold the infusion or not go above that is really for that side effect. So when you think of how much

how much Maya was getting and probably how much, you know, again, we don't know exact doses, but I can tell from the level that was in his blood on the autopsy, like he was getting higher levels than, than that. And do you just bypass the hallucinations all the way through? But in some of Beata's blogs where she was, you know, acting again as Maya, she talked about floating, floating, flying like an angel, you know, being up in the whatever and all of that. And so it was happening. One of the things that,

haunts me the most in terms of clips of audio that they used in the film was some audio from something that Beata recorded when Maya was getting ready to go into her ketamine coma. And she sounds terrified.

And, I mean, I'm not a person that wants to take anything that will make me hallucinate because that, to me, like, I am not, never experimented with, like, shrooms or, like, absolutely not. My imagination all on its own is terrifying enough. I can't imagine a worse idea. I do not understand the appeal, not to whatever yuck anybody's, you know, adult consensual yum here, but, like, just do not understand the appeal of anything that would make me hallucinate. That sounds horrible.

terrifying. I'm the person that smoked too much weed and was hallucinating in college. It's not a good vibe for me personally. It does sound like a super intense experience. And yet to your point about it being a street drunk, I mean, this was where I knew ketamine from before this whole journey into this case was just like, oh yeah, special K. People would talk about going into a K-hole, right? Where they would have a bad high and just be like,

you know, tripping balls in the corner, just like afraid for their life, right? It's not just like a lighthearted drug, right? It's not something that you should be taking willy nilly. It sounds like kind of one of these things where these new uses are exciting and new research is exciting. And that makes sense to why it's popular, right? That also might explain why it's helpful for treatment resistant depression, because it does have that sort of like, I don't know, reset your

brain a little bit. Maybe that's why it sort of breaks through that. And I'm really glad that people have it for that if they need it for that. No, but it's interesting because I'm listening to a book right now too. They're also talking about how ketamine is going around like these high school parties and stuff like that. It is everywhere. And I think it's funny because my phone obviously knows the things that I

rabbit hole about. And so it sends me like the news alerts. And I mean, it's every single time there's something new about the Matthew Perry case or anything related to it, it's popping up. And I think, again, just like the take care of Maya thing, I wish it didn't happen. I was a huge Matthew Perry fan. I am a huge Matthew Perry fan. At the same time, I'm glad people are talking about it. I want people to realize like, and this is, I think why we're really doing this is we're

We're questioning all these people out in California who were giving these doses or potentially supplying, you know, an adult male at 54 years old versus what was happening right here in Florida down my street, you know, which is giving these doses to a 10 year old child who was not

able to consent to them on her own and whose parents were consenting to things that had a 50% risk of death. I mean, how dramatically different that is in and of itself. And as a pediatrician bothers me even, you know, more to my core is that this was a child. And I think I've told Andrea this and probably said it on the Patreon feed, but

It really took me a while to see things a little clearer. It was when some of the PICU doctors and PICU nurses from Johns Hopkins actually testified and talked about Maya's behavior at the beginning. And to be fair, I was like, sure.

she's a preteen girl. She's being difficult, but they were talking about her saying, I mean, dropping F-bombs and yelling at them and saying, just give me my, you know, whatever medicine and things like that. I believe in my heart. She was as addicted as you can be to ketamine. But when you look at these numbers, she was dependent at the least. And,

And, you know, some of these pain doctors got up and said, this is these patients that show up like yelling and begging for medication because they want their next, you know, whatever, or their body is actually dependent and feels like it needs it. And it wasn't really until I was hearing all of that and then looking into ketamine kind of on the side and realizing, I mean, that was probably a sign of how dependent she truly was. And she was 10%.

She was 10. You know, I mean, that's setting up. I worry because, you know, addictive personalities, there's addiction in families, obviously all of that. But the sooner, the earlier these kids are getting addicted, the earlier these kids are getting exposed to these things. I worry. And in this case, it was the medical institution, you know, his doctors.

doing it along with the mom who was, again, you know our feelings if you've listened to us, but that Beata was really pushing for higher and higher doses and she was a nurse. So she would have known

Yeah. And again, you know, we know about that home use and we know about what she was advised not to do, but did and admitted to doing. And then, you know, there was this fixation about her daughter's high tolerance, right? She wrote this extraordinarily creepy blog in Maya's voice. And during the trip to Mexico was talking about, yeah, I have enough ketamine in me that would kill a horse, but I'm like a special girl or what, you know, it was just, it was so strange. Yeah.

Max Bankman, I'm the new doctor. Welcome aboard the Odyssey. ABC Thursdays. This ship is heaven. We're tending to our passengers. I'm in. From 911 executive producer Ryan Murphy comes a splashy new drama on a luxury cruise ship with Joshua Jackson and Don Johnson. It's your job to keep everyone alive. She's in V-fit. One, two, three. Clear. Clear.

I have a pulse. You're going to be okay. Doctor Odyssey, Thursdays, 9, 8 central on ABC and stream on Hulu. Streaming only on Peacock. Being with Finch felt like I was in some fairy tale. I write for Grey's Anatomy. I was like, what? Her writing was so highly regarded because Finch had been through so much. A Hollywood writer's life. When you love somebody, you ignore red flags that are hitting you in the head. Filled with fiction.

She would do whatever it takes to get ahead. She saw her life like a TV series. I don't know who my wife is. Anatomy of Lies. Streaming now. Only on Peacock. It was all a lie.

So the outcomes of these two paths could not be more stark. Five people recently have been arrested in conjunction with Matthew Perry's death, which again, these are related to ketamine specifically. So basically the breakdown is there's two doctors, there's a middleman, and then Matthew Perry's personal assistant who gave him the shot. So he was taking it, it sounds like,

like he was taking it intravenously at home. So the assistant gave him the shot that ended up- I was thinking maybe intramuscularly, which is another way. Honestly, that I can't speak to because some places said orally, some places said intramuscular. Yeah, they referred to it as a shot, that he was taking shots, like six to nine shots of ketamine. I'm assuming that's like a shot-

with a syringe syringe um yeah so they they arrested two doctors there was a middleman who we'll talk a little bit about and then the assistant so one of the doctors the middleman and the assistant pled guilty right away and they turned on the other two so the two that um are pleading innocent or at least that's their sounds like that's what's happening currently are um dr salvador

Placencia, also known as Dr. P, who works for, according to ABC News, a strip mall urgent care, which I was like, wow, that sounds familiar. You know, it really sounds very, very analogous to Dr. Kirkpatrick and Dr. Hannah's setups, right? Not within a hospital system, not within like, you know, just, again, nothing wrong with having doctor's offices in strip malls, but like

This speaks to sort of the, yeah, like what he was specializing in. And then this other woman, Yasvin Sangha, who was just a drug dealer, but there's found like a ton of ketamine and other drugs in her home. And so it sounds like there was sort of this,

like a little network of people that were getting him. So some of it he was getting by prescription, at least originally. And then it started getting pretty quickly. Again, this was only a period of like two months that this addiction really escalated and became lethal, that he was getting it originally from doctor's office. And according to the indictment, you know, they said when doctors refused to increase the dosage, he turned to unscrupulous doctors. And I was like, what?

What could that also describe word for word, right? With different pronouns, obviously. But like, yeah, it's like Beata was trying and trying and then found the doctor that would do it. And I think unfortunately, you know, we get asked a lot about these cases. Well, why aren't they going after the doctors? Well, not every doctor is culpable in one of these cases, depending on the circumstances. But certainly there are doctors who are a real problem. The doctors that will give parents advice.

anything they want, especially if that's their business model, is to just be a cash-only clinic to administer ketamine, which I didn't say specifically about Dr. Plasencia, but I'm sort of assuming that is also his model. That is a real problem when you have... Then I think the doctors are culpable. I do actually think that Dr. Kropotkin and Dr. Hanna should be investigated. I think it's outrageous that no one has sort of looked at them, and instead they're blaming the doctors that did not want to give her these outrageously high doses of ketamine.

So, yeah, just a couple kind of interesting things about how this is all playing out. There was another death of a man called Cody McClory, who actually lived here in Seattle, and they interviewed some of his family members in conjunction of this, and he died recently.

from, you know, and I believe actually Matthew Perry also had some other substances, though acute effects of ketamine was listed as the cause of death. So very similar with this guy, Cody McClory died from ketamine, also had like heroin and meth and cocaine in his system. And Yasmeen Sangha and also this guy, Eric Fleming were both involved in his death as well. So Eric Fleming is sort of a middleman and it sounds like he worked for a treatment center or

and was sort of then involved in this black market ketamine. And there was a whole bunch of text messages that were discovered in both cases between the two of them. So he was a sort of

middleman. I assume there's kind of probably a lot of these people surrounding. Unfortunately, this is one of the reasons where you see these addiction deaths in rich and powerful people is they kind of can get whatever they want and they can get people to sort of bend the rules. So it sounds like maybe he was, that was kind of the role that he played in this. This is a case where you're sort of, the framing is very clearly, these are unscrupulous doctors and drug dealers. And like, this is, you know, they sort of emphasize the importance of like,

holding people accountable for that death. And one of the prosecutors who was talking to ABC was saying, we're really trying to move away in these deaths from blaming the victim, right? They're classifying Matthew Perry as a victim of the people who were giving him this medication when they shouldn't. And I think that is definitely a shift, right? I do think like deaths of addiction, especially probably

post the opioid epidemic where there's so many people that have lost family members and friends. This is just absolutely devastated entire communities. And you could say like, well, that was that person's choice to take that. They should have been better. That just doesn't ring true for a lot of us where you're like, no, this, the doctor that wrote the original prescription like plays a part in this too. The drug reps that lied about the side effects so that they could make a profit, you know, like they are responsible too. Like there's sort of a whole chain of people that,

that failed that person who ended up dying from an overdose. And I think that that's sort of, they're making similar connections here. And this is really the first high profile death, at least that I've seen that has to do with ketamine. So I really wonder if we're heading for, given how popular it is, given how prevalent it is, like, I wonder if we're heading for another sort of epidemic with this drug. It's really scary. Yeah.

And I think there's a lot of links. I think it has come up when it has because of the opioid crisis. So specifically in Florida,

Now there are such restrictions on prescribing opiates. If I even prescribe a couple pills for a patient who underwent a big surgery or has significant pain related to an underlying condition, you have to check boxes and you have to query a system to make sure that they're not getting it elsewhere. And there's all these checks and balances to it where it literally makes my blood pressure go up every time I prescribe even a few because it's

You're like, you know, you're being tracked. And I mean, it's a good thing. Don't get me wrong. I mean, it's very important, but I just find it interesting that I remember the first day I looked up Dr. Hannah, I think I texted you and I said, he comes up as like the number 10 on the list of physicians in the state of Florida for a number of opiate prescriptions. So he was already on the list for being one of the worst in during the opioid epidemic.

And then what does he do once that starts being regulated and watched over is he kind of becomes more focused now on ketamine, where that's what his billboards are, etc. And he's not just giving ketamine according to what this is saying. He was giving extremely high doses, doses that even Dr. Kirkpatrick, think what you want of him, was not willing to give. So-

This man who was at the top of the problem for opiates is now just shifting to a different drug. And it does worry me because again, it's,

because of the safety profile of ketamine or the reasons it really came up, I think there's less fear among doctors about this. And especially as you kind of build up your tolerance or your dependence or whatever. But the thing is, they were also sending it home with the mother. And I mean, the thing is, Maya had a port that for those who don't know, that means she had permanent IV access straight into her bloodstream. So it's

Anything can be given. I mean, we hesitate very much to send kids home with those. Obviously, with chronic illness, you are forced to. But we actually do a full like social psychosocial assessment because there is always fear. We are giving them an open access port for anything. So someone who has a history of addiction to other substances, even if you're sending them home with a port for, say, antibiotics, you are still sending them home with access.

access to put anything in that port. You're opening it up to anything and everything. And a mom who is an IV infusion nurse giving things to other patients, again, this is speculation, but I mean, she has a supply of medications just from being an IV nurse. And it's crazy to me how much this has bothered you and I since the very beginning, like how much access and how this story is getting so much publicity, which I'm excited about. But when you really compare it

I think Maya's case is more appalling in the sense of it being a child and a mom and these doctors willing to do it. Yeah, 100%. You know, when you come to the mention of her report, you know, when we interviewed Dr. Sally Smith, I think there was sort of all of these different sort of sets of questions that people had. I think the reason that, you know, there is such like the film and the plaintiff's case in court, it had such like a strong emotional narrative. Like, look at these parents. They were just trying to protect.

you know, care for their sick daughter and then, you know, Beata ends up losing her life. But when you actually look at the facts in the case,

You know, and sort of one of the things that people were like, okay, well, do they have to do the removal that way? Like that was so severe. Do they have to put those kind of restrictions on Beata not being able to see her in person, et cetera? And I think it's really important to bring people back to that port because that's a huge element. And you see ports in so many of these cases because there are these escalations in treatment and they're presenting their child as chronically ill or terminally ill. And that gives a perpetrator an immediate way to kill their child, right?

And that is very scary. And that was one of the things that Dr. Sally Smith talked about, which is like why you have to intervene. And again, it's the courts. It's not Dr. Sally Smith herself. It's not the hospital. They have to make a case to the court to get an emergency removal like that, to get a shelter order. And that was what she pointed to was like, you're seeing the sasquation in treatment and this parent is an infusion nurse and they have a port. Like that means she could take her home and,

give her too much ketamine and kill her like today. And sure enough, what was Beata saying she was going to do? Like, I feel like such a broken record on this, but I come back around to it every time. She was saying, if you don't give her this ketamine, I might as well take her and put her in hospice so that she can finally die. She doesn't want to live this way anymore. And there's every reason to believe those interventions save that kid's life.

And these doctors have been taken to court over it and their lives have been ruined over it. Their reputations have been ruined for it. And I'm like, there are doctors who should have lost their livelihoods and reputation and maybe be in prison for this. Not those doctors. Wrong doctors. And again, would love to see someone who made these editorial decisions in the film to feature Dr. Kirkpatrick as the good doctor, as the helpful doctor.

Like, you explain to me how you're arresting this doctor in the Manny Berry case and then making Dr. Kirkpatrick the hero of this story. I mean, it's truly wild. And it's not different. Like, there's a lot of nuance in this case. For example, giving someone a ton of ketamine with substandard monitoring against medical advice, doing it at home, not a good idea, could result in death. That is true in both cases. Yeah.

I think there are all these ways that sort of like the people telling the story on that side made it something else. And it wasn't. It wasn't something else. It was a parent who was pushing for increasingly –

high doses. And it's like, they talked about this in the Matthew Perry case, right? Where he's just escalating and escalating, escalating. And to sort of like tie it together, we've talked about how munchausen by proxy behaviors on the, you know, the psychopathology of it really functions like addiction. Like you have to escalate and escalate. It's like doing, you know, a little bit in the beginning, like that sort of gets the need met and to keep the

story going, that's why you see these really scary escalations where it starts with this thing and then you pile on this thing and you have to get this more extreme treatment and you keep escalating. It's like just as Matthew Perry's addiction was escalating

So was Beata's. And the difference is that there was a child suffering, and that's not to take away from anything. It's horribly tragic what happened to Matthew Perry. And these doctors should be held accountable. These other folks should be held accountable. But I would really love to see people really reframe this as also a story about ketamine. It did come up quite a bit, I think, in the trial for those that did follow it at all. But there was really a mixed...

testimony about it, I guess. I mean, we all sat through, or we didn't know, who am I kidding? You and I sat through the testimony of a Dr. Chopra or a Dr. Kirkpatrick that did talk about ketamine on such a, oh, ketamine, it's FDA approved now for depression. We use it all the time, just very much. Very no big deal. Yeah. Yes. Very much

no big deal. And then you have the people come after to testify on behalf of the defense. And of course we know it kind of probably fell on deaf ears, but not mine. Like my ears were open and it really, you know, some of that did really stick with me and I am kind of a math nerd. I taught math for a while. So like the dosages when Dr. Crane was talking about them, I mean, I remember my jaw just kind of dropping, you know, for those listening that are in the medical field, you can appreciate like

I knew she was getting a lot of ketamine. I mean, I had my calendar drawn out with all the doses, but hearing it in that perspective of multiples of the normal is,

is mind-boggling because in pediatrics, I always tell people like pediatrics is in some ways like a finer science than adult medicine. There's a lot more going on maybe in adult medicine as far as comorbidities, but in kids, you mess up a decimal point. Like you give one per kilo of something instead of 0.1 per kilo of something. You can potentially overdose a child or cause significant side effects. And so those numbers are so pertinent to my everyday life that hearing that

was just, you know, mind blowing to me how much these doctors were giving and how significant that meant that Dr. Creighton said when all children's was trying to stay within their standard of care, they even had to extend that for, you know, the doses at the beginning because she was wide awake and like imperfectly, you know, screaming, et cetera, on these doses that most children would be intubated for. And that just speaks to-

her body's dependence. There are certain things in medicine that it's kind of hard to tell somebody who's maybe not in medicine, but the thing is the amount she could tolerate in and of itself is proof of how dependent her body was on it because it would definitely get me to the point of needing to be intubated as an adult. And that's frightening to think how quickly she got there. And that's

I mean, I'm glad it sounds like at least from what we've heard or what we know, at least up until the trial time, she had gotten no more ketamine and she was doing significantly better than she had been. And even very, you know, within the year out of Johns Hopkins was walking and back in school and doing all of that. And that was without ketamine. And so I think that also speaks for itself. Yeah. I did dig a little bit into the side effects of ketamine and the whole abdominal pain, nausea, vomiting being a pretty significant side effect.

I think we've talked about this too, is that her presenting symptom to all children was actually abdominal pain. And so that very well may have been a side effect. You know, some will argue, I think they went through it being gastroparesis from the CRPS in and of itself. But I think more people were favoring that it was actually related to the ketamine. And so again, this side effect is actually what potentially brought her into the hospital, her poor appetite, her weight loss, her abdominal pain. And so-

really getting her off the ketamine what had to be the first priority of Johns Hopkins when they felt that it could be a contributing factor and they needed to take it out of the equation. Yeah. And I mean, I know we could never could get to the bottom of Dr. Cantu saying there was a 50% chance of death for that procedure. I know it came up during the trial, but they didn't

He didn't really dig into it. I mean, what we do know is that he did say it. He did say it. So I think it is important in terms of it being an abuse dynamic, what the parents were consenting to on their child's behalf, what they believed they were consenting to, whether or not, like why there was such a high, I mean, obviously there's always a risk of death when you're being, you know, when you're being put under anesthesia, especially for five days.

days. And I don't know if that's accurate, a 50% chance of death, but he certainly did say that. So yeah, it just scrambles your brain. So we will keep you updated on how this appeal plays out. Fingers crossed, I guess. I think this is just, the longer I sit with this, the further I get out from being so in it. It just is such a miscarriage of justice. And I really hope it's not

allowed to stand. And listening to Dr. Crane again, I'm going to give him another shout out, but I watched his testimony again today and I was like, gosh, darn it. My medical brain, my medical heart, like it just really, it really struck a chord with me. And I think you remember when we first read his first letter kind of deposition that was filed, it was a real moment for me because again, he put it in such, to me,

clear-cut, organized kind of the way my brain works as far as his documentation, it really, really hit me. And that was when I realized this was not unintentional in the terms of what was being sought for Maya was well beyond what a reasonable parent I think would do for their child. And again, that doesn't mean you wouldn't find one or two willing to do it. Obviously they do.

But I keep trying to tell my students and my residents that the concept is, and again, this comes from being way too into this trial and the law and all of that, but that concept of reasonable. It's like the standard of care as physicians. Yes, there will always be physicians willing to push the standard of care. You can always find a physician who will diagnose you. You can always find a physician who would be willing to give that medication if you look hard enough.

At the same time, you can always find a parent who maybe is that outlier. But if you put a room of 100 parents of 10-year-old children who have some kind of chronic pain and said, how far would you be willing to go? How many of them would really have gone that far? And I think that reasonable part of it, that word is so important, I think, in law or in the courts is that

It doesn't have to mean everybody wouldn't or it doesn't have to mean nobody would. It means that a reasonable parent in the same situation would not. And I still feel like in a room of 100 parents, you know, most would not. And that was really the turning point for me was the ketamine and the amount and the dosages and the seeking it.

really convinced me, you know, that this was a case of, of Munchausen by proxy. And again, that takes out whether it was CRPS or not, which we have our thoughts on, but either way, it was medical child abuse because those levels and what they were seeking was well above. This is another case where it's very easy to get, I think in these cases, and they did use this to their advantage, the plaintiffs use this to their advantage, this idea of like, oh,

oh, you know, Munchausen by proxy is a mental illness and you either have it or you don't. You can have somebody give you an evaluation and be like, thumbs up, thumbs down. And I think what's really important when you talk about sort of like the reasonable or like, it's also like the decision that they're trying to make. And again, this was not on trial, right? She was sort of on trial by proxy, I guess, which they did say at one point. But it's really like what the courts are there to determine. And

and what mandatory reporters, the reason they're supposed to report and have that invocation, the reason that child protective systems exist at all is not to determine what's in a parent's heart and what's in a parent's head, what's in their heart. It's are they a safe parent? Are they a person who is able to provide a safe and nurturing home for a child or not? Doesn't need to be a judgment on their mental state, their character, their history, whatever.

obviously those things come up, but it's like, are you a safe person for your child? No, not if you're subjecting them to this. That's sort of the beginning and end of the story, which is I think why we have to focus on like the harm being done to the child. Like I think there's really strong evidence that this was, you know, straightforwardly a Munchausen by proxy case. There's a lot of intentional deception. There was a lot of attention getting behavior. There were all those hallmarks, but at the end of the day,

It's what the child was being put through that matters. It was the risks being taken with that child's life that matter. It was the harm that had been done to her already and the potential harm that would be done to her if she was allowed to leave the hospital, up to and including death. But also, you know, that she was not in school. She was being separated from her peers. She was being ushered into a dependence on others.

A potent drug. There was horrible harm that was happening to her emotionally, psychologically, and physically in this situation. And that was, again, something that Sally Smith talked about, which is like when she makes those recommendations to the court, you know, the framing that she uses, these parents are not able to provide a safe home for this child at this time.

And like, that is the decision that those systems are meant to project. So it's like, you can get in on all the whys and the hows and the, you know, but that's what matters is that this child was being put at risk. And Beata had some collaborators in that, right? Jack was one. These doctors, I think Dr. Hannah, Dr. Cantu, and Dr. Kirkpatrick were all also collaborators in this abuse. I mean, I think they should all be held accountable, quite frankly, but like, you have to look at the harm

that happened to the child. And you have to look at, you know, like you could make all kinds of other arguments about Matthew Perry, right? Well, he was an addict and he was able to afford it. And if it wasn't that, it would have been something else. And, oh, alcohol is legal and you can drink yourself to death. And I think in the past, we did make a lot of those kinds of arguments about people who died, who were struggling with substance abuse.

And I'm glad people are not making that. I'm glad people are like, no, like you should be, people should be held accountable when they are giving people powerful drugs that they should not have. And like, you know, there's a lot of complicated things to get into here. It was sort of like the war on drugs and et cetera, but particularly doctors who, you know, again, they take that oath of do no harm, right? That's a violation of this oath. I think all the doctors that we talked about today violated that oath.

I think Dr. Kirkpatrick and Dr. Hanna violated that oath. And I think the doctors in the Matthew Perry case violated that oath and they've been rightly arrested. So...

Yeah. If someone would like to try and make an argument for why these two things are different, I am, as always, all ears. Open invitation. And I just want to say, as a doctor, I'm fully willing to say that. I've talked to Detective Weber about this too, but there are some people who feel it's so rarely the doctor because we are taught to believe the parents and we are taught to hear the story and we're taught to do all of that. I get all of that.

But at some point, I mean, I may stand alone among physicians, but I would argue that at some point a physician does become part of the problem and does actually become a perpetrator of the abuse at some point. I think there's like a negligence there. I mean, his whole business model just sounds extremely shady and sketchy, like just being able to like.

give children ketamine for cash seems like not a thing that should exist. Call me crazy. With not a lot of oversight. And I think that's it too, is that I do think most physicians in these cases, it was a matter of negligence. Like maybe they knew better. Maybe they had that gut feeling something wasn't right, but they did it anyway. You know, those kinds of things versus an intentionality. And I think that comes into a lot of this, that if these doctors

are giving diagnosis that they diagnose 100% of people that walk through their door with something, you know, that does not stand to reason. I mean, I'm sorry, anybody knows that does not stand to reason. Science stands in the way of that. Exactly. Or that you're pushing ketamine within two weeks of a diagnosis. Again, all of that starts to become intentional to me. And I think that's when I'm going to argue the other side or feel the other way is that the doctor actually was, you know, becoming an actual activist.

active participant, you know, in the abuse versus a innocent bystander or a, you know, like you said, just negligence, which in and of itself, um,

But I think these ones that we've talked about quite a bit on the podcast, some of these ones we dug into a little bit, these websites that are telling parents how to do all of this and things like that. And to be fair, you can also find websites that will tell you where to get ketamine in your state or where to go that they will treat kids. Right. And all of that is kind of enabling this stuff, which I then argue puts you more. Yeah, not kind of, it's straightforwardly enabling it.

Yeah. To your point. I mean, I think there's sort of a range of how doctors play into these cases, right? Dr. Wassner was a pediatrician who'd seen Maya, uh, and I believe Kyle also five times before this hospitalization. So not a super long term because they had moved from Chicago, but Dr. Wassner was really the only other than Kirkpatrick and Hannah, uh,

He was the only treating physician who was really on the plaintiff's side, right? He was the only one out of all the doctors that had seen her that testified on behalf of the Kowalskis.

and he's not someone, I think he was wrong. I don't think he's very knowledgeable about Munchausen by proxy, but I think he was genuinely fooled and he wasn't prescribing any of the dangerous stuff really. He's sort of in a different spot, right? I disagree with him, but I'm sort of like, well, there isn't anything that they did in his office specifically that was extreme enough. You know, he did have the warning from the other doctor that had seen them that

told him, hey, there were some red flags for Munchausen by proxy abuse, which he ignored. So I would argue he's maybe a little bit negligent, not well enough informed about Munchausen by proxy, maybe doesn't believe it's real given some of his comments about it. That is extremely problematic. But I don't think in this case was criminally implicated in the way that I think that Dr. Patrick and Dr. Hannah really

really should be held accountable for their role in this. So as you said, there's a range. But there's a reason that we have mandatory reporting laws. There's a reason why it's a federal offense for a doctor who's working in pediatrics not to report a reasonable suspicion of abuse because we are trusting doctors to be in between the

the parents and access to things like potent medications that you can't get over the counter, right? That's a trusted role. It's not your job. If you're a doctor that prescribes ketamine, it's not your job to just give it on demand, right? As in the Matthew Perry case, that's not your role that goes against your Hippocratic oath. If you're in pediatrics, it's not your job to treat the patient and

exactly according to the parents' demands when they come into the hospital. That would be negligent. That would be malpractice. So it truly, again, it is pretty black and white at the end of the day. So it's very frustrating. But hopefully we in this country are coming out of a number of our collective delusions in the near future. Fingers crossed. Yeah.

Yes. And I think I want to keep, you know, the conversation open. It frustrates me on some of these websites, you know, talking about how they're all like the doctors are already going to come in ready to accuse you, et cetera. That is never the case. There's no evidence for that, by the way, like no evidence, no data. I have searched online.

high, low, and sideways to find all of these false accusations of child abuse that are allegedly happening. Someone bring me one. Thank you. The people I've talked to in my arena that have been studying this for 30 years, they've either seen there was one that Dr. Mark Feldman saw that he felt like was not really a case of my child's myoproxy, but was something else. That's the only one. I've not talked to any of my other colleagues who've seen any evidence of this, any at all.

I mean, I do think it's more prevalent in certain cases because of everything in the media and because of everything that's at our fingertips right now, just because it's also accessible. And all of this, you know, the social media life, how we're portrayed online can be very different than what we're, you know, portrayed in the room or in our homes or whatever. And I think that that is making this a more difficult thing. And I do think the softer cases or the lesser cases are

are happening more and that's where it's going to be difficult because the ones that are drastic and very obvious, you get a whole room of doctors to agree on and it is not as conspiring. It is every single person sees the abuse of the child and there's not a question that, again, that's not us all sitting in a room colluding. It's literally, oh my gosh, did you see this? You know what I mean? And it's just that everybody can see it for what it is. It's those lesser cases or the earlier cases when the kids are younger and

that I worry about because they're happening. And that's what I want to understand. That's really what I want to get to at some point, hopefully in my career is kind of how to stop that train, seeing them so early on. Are there things we can do? Are there resources? Are there, you know, what can we do to make it better? And I think that's

where my career still has a long way to go as far as that is, but I'm just glad people are talking and asking questions. And I appreciate, you know, the physicians that are listening to this. And I hope that we are spreading the word around the country, which again, with these talks and things, because...

It is so important. You know, honestly, being able to save one or being able to stop the train on one is so important to me. And I just, I hope this all really, you know, is hitting home with people. Yeah. Well, keep up the good fight, Dr. Bex. Thank you so much for being with us today. Oh, thank you.

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