Lindsay Clancy Trial: Day 5 Top Moments — The Children's Injuries and Her Own Journal (Duxbury Mom)

[00:00:00] Speaker 1: Thank you. You may have a seat, sir. Watch yourself, please. [00:00:14] Speaker 2: All right. Good morning, Don. Good morning. All right. [00:00:18] Speaker 3: May I inquire? [00:00:18] Michael Snyder: Tony Buckham, please. [00:00:19] Speaker 3: Thank you. Good morning, sir. Could you please tell the jurors your first and last name? [00:00:24] Michael Snyder: Yep. Michael Snyder. [00:00:25] Speaker 3: Do you mind spelling your last name for the record, please? [00:00:27] Michael Snyder: S-N-Y-D-E-R. [00:00:29] Speaker 3: And how are you employed? [00:00:31] Michael Snyder: I'm a physician at Beth Israel. [00:00:34] Speaker 3: And how long have you been a physician? [00:00:37] Michael Snyder: Since 1998. [00:00:39] Speaker 3: Can you tell us a little bit about your educational background? [00:00:42] Michael Snyder: So undergrad at UMass Amherst, I did medical school at Tufts University, and then I did my residency in emergency medicine at Boston University. [00:00:52] Speaker 3: And how long have you worked at Beth Israel? [00:00:56] Michael Snyder: Since 2014, 12 years. [00:00:59] Speaker 3: And do you primarily work in the emergency department? [00:01:03] Michael Snyder: Yes. [00:01:04] Speaker 3: I'm going to draw your attention to January 24th of the year 2023. Do you recall working in the emergency department on that day? Yes. And in the evening, were you made aware of multiple pediatric traumas that were coming into the emergency department? [00:01:19] Michael Snyder: Yes. [00:01:19] Speaker 3: And when you are made aware of people coming in, how does that occur? [00:01:25] Michael Snyder: So we'll typically get a call on the EMS phone that something's coming in that they want us to know about up front. [00:01:35] Speaker 3: And do they provide you with some basic background information about what's occurring or what occurred on scene and what's occurring during the transport? [00:01:42] Michael Snyder: When possible, yeah. [00:01:45] Speaker 3: And when the emergency personnel, the EMTs or paramedics arrived at Beth Israel, there were three patients, correct? Correct. And you were assigned to treat one patient? [00:01:57] Speaker ?: Correct. [00:01:58] Speaker 3: Do you recall which patient that was? [00:02:00] Michael Snyder: Cora. [00:02:00] Speaker 3: And prior to EMS arriving, did you learn more about Cora's presentation and what was occurring? [00:02:11] Michael Snyder: Yeah. So we had heard that all three were in cardiac arrest. And Cora in particular, they were still working on doing CPR and doing what we call pediatric advanced life support. So medications to try and restart the heart. And they also mentioned that they had used what we call a defibrillator to shock the heart to try to restart it. And they were still doing CPR when they were arriving. [00:02:39] Speaker 3: And is this information important to you as you're assessing a patient coming into the emergency department? [00:02:46] Michael Snyder: Yeah. Yeah. It's important to know what things look like in the field, how long the patient might have been without a pulse, or how long they may not have been breathing for. So we can kind of expect or know what injuries to look out for, what we can potentially reverse. [00:03:02] Speaker 3: And were you aware of the age of Cora? [00:03:06] Michael Snyder: Yes. [00:03:07] Speaker 3: And she was five, correct? Yes. And as far as the medications that you were aware of, what medications had been provided? [00:03:15] Michael Snyder: So prior to coming to us, she had been given epinephrine, which is the primary medication we use in a cardiac arrest. [00:03:24] Speaker 3: And do you know how they had administered that medicine to her? [00:03:28] Michael Snyder: Yeah. So she had what we call an intraosseous device in her right tibia. Sometimes it's very difficult to get an IV in, so we can go directly into the bone or the bone marrow. [00:03:40] Speaker 3: And were you aware of whether she had been intubated en route? [00:03:44] Michael Snyder: So she was not intubated en route. [00:03:47] Speaker 3: When she arrived at the emergency department, were you there to greet the ambulance? Yes. And what happens when a patient comes in through the emergency department via ambulance? [00:03:58] Michael Snyder: So when the patient first comes in, we immediately have our team start to sort of take over care so there's no gap. And then we also get a sign out from the paramedics and EMTs and any other staff that had been involved in the case. [00:04:13] Speaker 3: And do you and your emergency room staff then perform your own initial assessment of the patient? [00:04:19] Michael Snyder: Yes. [00:04:19] Speaker 3: So what do you do for that? [00:04:20] Michael Snyder: So initially we sort of go through our ABCs, airway breathing circulation, so initially focusing on the primary things such as making sure we're getting air and oxygen into the patient, keeping the heart going, so continuing CPR at that point. [00:04:37] Speaker 3: And as far as Cora went, did you observe that she was breathing? [00:04:42] Michael Snyder: So she was not breathing on her own. [00:04:43] Speaker 3: How about the heart? Did you observe that her heart was beating? [00:04:47] Michael Snyder: There was no heartbeat. [00:04:49] Speaker 3: How about her physical appearance? What observations did you make of her physical appearance? [00:04:54] Michael Snyder: So initially when she had come in, you know, some of the things we noticed is sort of a blue tint to the skin, which typically, you know, we can see when there's less oxygen or lack of oxygen. And then the other things on a quick survey is there was some areas of bruising on the neck and around the eyes. It's called petechia, kind of little bleeding, episodes of bleeding under the skin, and I believe a small amount of blood coming from the nose. [00:05:25] Speaker 3: Were you able to make observations of her hands or other parts of her body? [00:05:30] Michael Snyder: So the hands definitely had that, what we call cyanosis or blue cue. [00:05:37] Speaker 3: Now, as far as the eyes, you mentioned petechiae around the face and the eyes as well as the neck. Did you notice anything else about her eyes? [00:05:46] Michael Snyder: So the pupils were fixed and enlarged. [00:05:50] Speaker 3: What is, why is that significant to you? [00:05:52] Michael Snyder: So oftentimes it can, when we see it coming in, it can indicate two different things. Some of the medications like epinephrine can cause the pupils to dilate. But also if the brain is starting to become damaged or not functioning, then you start to lose initially some of the signals that would make the pupils smaller. So they'll tend to start to get enlarged or dilated if there's brain injury starting or has occurred. [00:06:22] Speaker 3: Now, you indicated that when Cora arrived, she did not, she was not intubated, meaning she did not have a breathing tube in. Did you and your team attempt to intubate her? [00:06:31] Michael Snyder: Yes. [00:06:32] Speaker 3: And did you do that on your own or with the assistance of other parts of the emergency department or the hospital? [00:06:40] Michael Snyder: So we had anesthesia there. After we got the phone calls of multiple patients coming in, typically we'll have all the help that we could possibly need there to be able to take care of all the patients. So I had an anesthesiologist in the room with me who put the breathing tube in. [00:06:58] Speaker 3: In instances where an individual might have suffered some sort of injury to their neck, does that complicate the insertion of a breathing tube? [00:07:06] Michael Snyder: It can, yeah, because normally you might need to move or tilt the head to get a direct view where you can put a breathing tube in. But when there's a concern for neck injury, we stabilize it, typically with a collar or manually. So you don't have the ability to move the head and the neck around to try and get a better view. [00:07:27] Speaker 3: Once a breathing tube was put in, were you and your team able to manually give breath to Cora? [00:07:33] Michael Snyder: Yes. [00:07:34] Speaker 3: Now, did you then perform an assessment, a cardiac assessment of her? [00:07:38] Michael Snyder: So in addition to listening to the heart, feeling for a pulse, we'll also tend to use an ultrasound machine in the room where we can kind of get a direct view of heart function. [00:07:52] Speaker 3: And you were aware that they had defibrillated her twice in the ambulance. Why is that significant when you're treating a patient that's been cardiac? [00:08:00] Michael Snyder: We had intensive care physicians from children that were on the phone with us, kind of working through any things that may have come up in the case, also expecting that they would be receiving the patients from us. [00:08:13] Speaker 3: Is your hospital at the Beth Israel equipped to handle this type of pediatric trauma? [00:08:19] Michael Snyder: So we can do the initial stabilization, but then we need to ship the patients out to either get a specialty care or continued inpatient care. [00:08:29] Speaker 3: And how long did efforts in treating Cora continue? [00:08:34] Michael Snyder: So in the emergency room, roughly 30 minutes. [00:08:39] Speaker 3: And fair to say that all of the efforts that you made were not successful? [00:08:47] Michael Snyder: Correct. [00:08:47] Speaker 3: And at approximately 1928 or 728, did you finally declare Cora deceased? [00:08:55] Michael Snyder: Yes. [00:08:56] Speaker 3: Thank you. I have nothing further. [00:08:59] Speaker 2: I have no questions. Thank you, director. [00:09:01] Speaker ?: Thank you. Thank you, doctor. [00:09:02] Michael Snyder: Thanks. [00:09:08] Speaker 5: Tom Law calls Dr. Andrew Capraro. [00:09:29] Speaker 2: All right, good morning, doctor. [00:09:53] Speaker ?: Good morning. [00:09:55] Speaker 6: Yes, please. [00:09:56] Speaker 5: Thank you. Good morning. Good morning. Can you please state and spell your name for the record? [00:09:59] Speaker 6: My name's Dr. Andrew Capraro, last name C-A-P-R-A-R-O. [00:10:05] Speaker 5: And your date of birth, please? [00:10:06] Speaker 6: July 9th, 1970. [00:10:08] Speaker 5: What do you do for a living? [00:10:10] Speaker 6: I'm an attending physician in the emergency department at Boston Children's Hospital. [00:10:13] Speaker 5: And how long have you done that? [00:10:15] Speaker 6: For the last 26 years. [00:10:17] Speaker 5: Can you just briefly describe for us the training and education you had to qualify for that role? [00:10:22] Speaker 6: I went to Providence College undergrad and then went to Brown Medical School. Subsequently, I went to Connecticut Children's Medical Center for my pediatric residency and then did fellowship training in pediatric emergency medicine at Boston Children's Hospital from 2000 to 2003 and have been in attending there ever since. [00:10:41] Speaker 5: And what's involved with being an attending at Boston Children's Hospital? [00:10:44] Speaker 6: It means that I am guiding the care and treatment for the patients that I am seeing during my particular shift. [00:10:52] Speaker 5: And are you assigned to a specific location or area of the hospital? [00:10:57] Speaker 6: I'm always in the emergency department and the emergency department is broken up into different zones of which I am sort of the primary attending for one set of rooms. [00:11:05] Speaker 5: I want to direct your attention to January 24th, 2023. Were you working that evening? [00:11:11] Speaker 6: I was. [00:11:12] Speaker 5: And at some point in time, did you learn that a patient named Callan Clancy was going to be transported to your hospital? [00:11:18] Speaker 6: I did. [00:11:19] Speaker 5: And do you recall where he was being brought from? [00:11:23] Speaker 6: From Beth Israel, Plymouth, I believe. [00:11:25] Speaker 5: And was he being med-flighted to your facility? [00:11:27] Speaker 6: Correct. [00:11:28] Speaker 5: And were you provided with some information about the patient in order to prepare for his arrival? [00:11:34] Speaker 6: I was. [00:11:34] Speaker 5: And what did you learn? [00:11:36] Speaker 6: We have a communication center where facilities that are transferring patients to us call to let us know that the patient is coming. And so that comm center had been notified about this patient, who then got in touch with me as the attending who would be caring for the patient, to let me know what had happened there and the condition of the patient when he was arriving. [00:11:56] Speaker 5: And what did you learn about the condition of the patient, Callan Clancy, as he was being flown to your hospital? [00:12:02] Speaker 6: What I was told was that it was believed that the patient had been strangled and when he arrived at Plymouth, he was in cardiac arrest, that they had intubated him and initiated CPR and they had gotten return of spontaneous circulation and that they were then going to transfer him to us for further evaluation and care. [00:12:20] Speaker 5: And at some point in time, did Callan arrive at your hospital? [00:12:23] Speaker 6: That is correct. [00:12:24] Speaker 5: And were you able to observe him physically? [00:12:26] Speaker 6: Yes. [00:12:27] Speaker 5: What observations did you make about his physical condition? [00:12:31] Speaker 6: He was cold on arrival and he was quite limp, was not making any purposeful movements on his own. His pupils were fixed and dilated and he had ligature marks about his neck with some swelling of the neck. [00:12:46] Speaker 5: And his pupils being fixed and dilated, is that medically significant for you? [00:12:51] Speaker 6: Yes, it is. [00:12:52] Speaker 5: And why is that? [00:12:53] Speaker 6: It typically means that significant injury has happened to the brain such that there is brain swelling that has sort of over... what do I want to say? It has overwhelmed the capacity of the skull such that the swelling has made the brain sort of herniate through the base of the skull. [00:13:14] Speaker 5: Does that mean the brain's swelling so much it's pushing through the skull? Correct. And what observations did you make of his heart rate? [00:13:22] Speaker 6: His heart was beating and we did have to provide him with an epinephrine direct to keep his heart rate and his blood pressure within normal limits but it was beating on its own. [00:13:32] Speaker 5: And how did you know that you had to provide the epinephrine for him to stabilize that heart rate? [00:13:36] Speaker 6: It was initiated at BI because they had noticed that his blood pressure was low and you need to have normal blood pressure for the blood to perfuse your organs and keep them healthy. And so we were looking for certain parameters to sort of maintain that which we did on that epinephrine drip. [00:13:52] Speaker 5: And when you say BI, you're referring to Beth Israel? [00:13:54] Speaker 6: Yes, I'm sorry about that. That's okay. [00:13:57] Speaker 5: And so as far as his breathing how was, was he breathing on his own? [00:14:01] Speaker 6: He had been intubated at the outside hospital and he was needing a ventilator to breathe for him. Occasionally he would have sort of a breath on his own we would notice. We were able to see that because when he attempted to take a breath on his own he would trigger the ventilator to continue that breath but it was rare. For sure he needed the ventilator to maintain his ventilation. [00:14:24] Speaker 5: Would it be fair to say that the majority of his breathing was being done by the ventilator? [00:14:29] Speaker 6: Yes, the vast majority of his breathing. [00:14:32] Speaker 5: Now, once you have received this information while he's coming in and then you've made your own physical observations of Callan are there certain tests that you have run on him? [00:14:45] Speaker 6: Yeah, our job once we received him was to perform further evaluation and stabilization to help determine what the next steps of his medical care would be. So prior to him arriving we had contacted our trauma team and our ICU doctors to let them know that he was coming and that we would need their assistance. And then under my care we performed some routine blood work a head CT, a neck CT and a chest x-ray to sort of help us guide the next steps. [00:15:12] Speaker 5: And from the head CT and the other testing that you did what were you able to learn from the results of those tests? [00:15:20] Speaker 6: The head CT in particular showed significant brain swelling consistent with hypoxic ischemic injury which was most likely or which was the most significant finding that we found. [00:15:30] Speaker 5: So could you please explain for us what is hypoxic ischemic injury? [00:15:35] Speaker 6: Hypoxic is just a fancy word for not getting enough oxygen and ischemic is just a fancy word for not getting enough blood flow. And so when your organs don't get enough oxygen and blood they sort of suffer injury and therefore get to swelling. And so his brain was showing evidence of that. [00:15:56] Speaker 5: So would it be fair to say that his brain wasn't getting enough oxygen? [00:16:00] Speaker 1: Not that I'm aware. [00:16:03] Speaker 3: Did you observe any cuts, abrasions, or blood on the area of her head? [00:16:08] Speaker 1: No. [00:16:10] Speaker 3: And based on your review of those findings on the CT scans was there any noted injury from the head CTs that you could tell? [00:16:19] Speaker 1: No. [00:16:21] Speaker 3: And were you able after using that bear hugger device able to get her blood excuse me her body her core body temperature back up to normal? [00:16:30] Speaker 1: I don't recall. [00:16:33] Speaker 3: Did you ever observe those wounds that you observed on her neck or her wrists ever start bleeding actively again? [00:16:42] Speaker ?: No. [00:16:44] Speaker 3: I have nothing further. I have nothing further. [00:16:47] Speaker 2: Ms. Reddington. Morning. Morning. So would you agree with me that when Lindsay was brought into the South Shore Hospital that she was unconscious? [00:17:02] Speaker 1: I recall her eyes being open but she was non-verbal. [00:17:06] Speaker 2: Okay. So as an experienced emergency room doctor can you tell me when someone's unconscious what is that what are the symptomology of it? What does that mean? [00:17:18] Speaker 1: It usually means they're completely unresponsive with eyes closed. [00:17:21] Speaker 2: Okay. Was she responsive? [00:17:24] Speaker 1: Not verbally. [00:17:26] Speaker 2: Was she responsive at all? [00:17:28] Speaker 1: She was responsive to pain. [00:17:30] Speaker 2: So that means that you would do something to cause pain perhaps the bottom of the foot or whatever it is to see if they have a reaction? Correct. And would you agree with me that when people even have very very serious brain injuries that they can respond to pain stimuli? [00:17:50] Speaker 1: Sometimes. [00:17:51] Speaker 2: Sometimes. So her eyes were open. Were her pupils equal and reactive to light? [00:17:59] Speaker 1: I don't recall. [00:18:00] Speaker 2: You don't recall. What does it mean with P-E-R-L pupils equal reactive to light? What does that mean? [00:18:07] Speaker 1: Exactly what you just said. It means her pupils are equal and reactive to light. [00:18:10] Speaker 2: And as a doctor what does that tell you? [00:18:13] Speaker 1: It tells me that there's no significant neurologic injury. [00:18:16] Speaker 2: And in this case you don't recall if her pupils were equal or reactive to light? [00:18:22] Speaker 1: I don't. [00:18:23] Speaker 2: Okay. And that's when you take the little flashlight sometimes and you put it over the eye and see if there's constriction of the pupil. [00:18:31] Speaker 1: Correct. [00:18:33] Speaker 2: Did you do additional evaluations of her to see what her neurological function was? [00:18:42] Speaker 1: She was pretty quickly intubated from what I recall so after that it would be difficult to assess her neurologically. [00:18:48] Speaker 2: Sure. Was she on any pain medication if you remember? [00:18:52] Speaker 1: I don't remember. [00:18:54] Speaker 2: Do you recall did she have difficulty being intubated? I mean would you agree with me that if you're not under some type of medication or sedation or unconscious it hurts to be intubated doesn't it? [00:19:09] Speaker 1: We wouldn't intubate somebody without first giving them some induction medicines. [00:19:13] Speaker 2: Okay. So what would the induction medicines be? [00:19:17] Speaker 1: They're not universal. [00:19:19] Speaker 2: Well what would depend on the case. What are the induction medicines that you used on Lindsay Clancy? [00:19:23] Speaker 1: I don't know I'd have to refer to my record and also I wasn't the one who did the intubation. [00:19:27] Speaker 2: So she was intubated had the tube coming out of her mouth she's laying on the table and you are continuing an assessment. You were the lead doctor in the emergency route for Lindsay Clancy right? [00:19:39] Speaker 1: I wouldn't say I was the lead I think the trauma surgeon and I worked together. [00:19:42] Speaker 2: Right. Her temperature her core body temperature was 82 degrees is that right? [00:19:48] Speaker 1: If that's what the record states then yes. [00:19:50] Speaker 2: I'm sorry? [00:19:51] Speaker 1: If that's what her medical record states then yes. [00:19:53] Speaker 2: As you sit here you don't know what her core body temperature was? [00:19:56] Speaker 1: I saw her three years ago I see about 200 patients I'm sure you're [00:20:00] Speaker 2: very busy but this is a murder trial doctor. Did you review did you review your records and your notes? [00:20:04] Speaker 1: I'm happy to look at my record if you bring it here. [00:20:06] Speaker 2: Did you review your records and notes before you came in here today to testify on this case? [00:20:12] Speaker 1: Sorry I did but I don't have a photographic memory. [00:20:17] Speaker 2: Did she regain consciousness at all while she was in your emergency room? [00:20:23] Speaker 1: No. [00:20:24] Speaker 2: Can you tell me what CSF is? [00:20:29] Speaker 1: Cerebrospinal fluid? [00:20:31] Speaker 2: Yeah. Is that what that is? CSF? [00:20:34] Speaker 1: It could be. I'm not sure in what context you're referring to it. [00:20:36] Speaker 2: Well how about if there's a massive leakage of CSF from her nose? What does that tell you as a doctor? It could mean that there's a skull fracture. Did you notice any clear fluid coming from her nose? [00:20:50] Speaker 1: I did not. [00:20:51] Speaker 2: Is that something you would look for? [00:20:53] Speaker 1: Yes. [00:20:55] Speaker 2: How quickly do you get the results of the x-rays when you're in the emergency room? [00:21:01] Speaker 1: Well these were CT scans but fairly quickly in a trauma. [00:21:05] Speaker 2: I'm sorry. CT scans, x-rays. So you had CT scans that were able to show you the damage to her neck and upper chest. Is that right? [00:21:18] Speaker 1: Yes. [00:21:19] Speaker 2: And what did those CT scans show you? [00:21:23] Speaker 1: Well what I remember is a thoracic spine injury. [00:21:27] Speaker 2: And when you say a thoracic spine injury, would you agree that the top part of your neck, your throat area would be cervical, right? Correct. And that's when the numbers go C1, 2, or whatever they are. That would be the actual vertebrae in the cervical area of the upper body, correct? [00:21:47] Speaker 1: Yes, the cervical spine. [00:21:49] Speaker 2: Okay. And then below the cervical spine would be the thoracic spine. Is that correct? [00:21:55] Speaker 1: Correct. [00:21:56] Speaker 2: And the thoracic spine would be, and sometimes they're delineated as T1, T2, meaning thoracic 1, thoracic 2, all the way down to what? 5 or 6? [00:22:05] Speaker 1: 12. [00:22:06] Speaker 2: I'm sorry? [00:22:07] Speaker 1: 12. [00:22:07] Speaker 2: 12. So when you looked at, and the lower portion would be the lumbar. Is that right? Correct. Now, when you looked at the CAT scans, did you determine the extent of the injury to the spinal cord? [00:22:23] Speaker 1: I could determine the extent of the injury to the bony thoracic spine. Okay, what was that? I don't recall exactly the level. I would have to look at the report. [00:22:32] Speaker 2: What does that mean, the level of the T? Correct. Was her cervical spine injured? [00:22:38] Speaker 1: I don't recall. I'd have to look at the report. [00:22:40] Speaker 2: Were you aware that her thyroid was crushed? [00:22:43] Speaker 1: I don't recall. [00:22:44] Speaker 2: Do you know that her cervical spine vertebrae was fractured, destroyed? [00:22:54] Speaker 1: I don't recall. [00:22:55] Speaker 2: Doesn't that control a person's breathing? Does that have anything to do with breathing? [00:23:00] Speaker 1: It can. [00:23:03] Speaker 2: What do you remember about looking at the damage to the spinal cord depicted on the CAT scan? [00:23:10] Speaker 1: What sticks out most in my mind is her thoracic injury. [00:23:13] Speaker 2: Okay, and what was the thoracic injury? [00:23:15] Speaker 1: I don't recall the exact level. [00:23:17] Speaker 2: What does it mean by effect level? The exact level. I'm sorry. Were you aware that there was a complete transection of the spinal cord on T5 and T6? [00:23:30] Speaker 1: I'm sure I was aware at the time, yes. [00:23:32] Speaker 2: Okay, and just can you tell me what does it mean when it says a complete transection of the spinal cord at a particular, apparently that would be at thoracic 5 and thoracic 6, right? What does that mean with a complete transection? [00:23:47] Speaker 1: It means the bones are no longer one on top of the other. They're moved apart. [00:23:52] Speaker 2: Were you aware that there was a significant edema noted in her chest? If that that was the last that they asked you about. And correct me if I'm wrong on any of these dates or facts. She was admitted on the 24th of January. Is that correct? Yes. Do you have a memory as to approximately what time was it in the evening? [00:24:19] Speaker 7: Well, she got to the ICU around 3. [00:24:23] Speaker 2: You're very soft-spoken. Sorry? You can just keep your voice up so all the juries can hear [00:24:28] Speaker 7: you. She got to the ICU around 3 a.m. [00:24:31] Speaker 2: Thank you. And she came by med flight? [00:24:34] Speaker 7: She came to me from MRI. [00:24:36] Speaker 2: And MRI obviously would be when you're taking the pictures. And that would be on the 24th of January in the early morning hours. Correct? [00:24:46] Speaker 7: I think it went into the 25th. Into the 25th? I think so. [00:24:52] Speaker 2: Council asked you about the white board that she would write on and I think it was again if I'm wrong correct me was it January 28th that she used for the first time the white board to communicate. [00:25:08] Speaker 7: Yes. [00:25:09] Speaker 2: And the white board basically is just a white board and you write on it. And she was not able to speak because she was intubated right? [00:25:18] Speaker 7: Yes. [00:25:18] Speaker 2: And she moving forward January 28th 29th 30th into February 1st February 2nd it was on February 2nd that counsel asked you about her asking to reach out to her lawyer correct? [00:25:40] Speaker 7: Yes. [00:25:40] Speaker 2: And do you know who her lawyer was at that time? No. Had you seen him before? [00:25:47] Speaker 7: No. [00:25:48] Speaker 2: Did you know is his name attorney Gelb? No. make any reference to you? No. Do you know that whether or not she had conversation with attorney Gelb regarding her status as being under arrest by the numerous police that were guiding the room? [00:26:05] Speaker 7: I don't. [00:26:06] Speaker 2: Do you know whether or not she was ever able to talk to attorney Gelb or did you refer her to the social worker people? [00:26:14] Speaker 7: I put in a consult for the social worker. Okay thank you. [00:26:20] Speaker 2: When she was admitted on the 24th would you agree that she was in the state of cardiac arrest shortly thereafter? [00:26:33] Speaker 7: Shortly after arriving to me. [00:26:35] Speaker 2: So I'm looking at the medical records that have been introduced for the jurors and I'm referencing on page 18 if I may. Now this is one page of 400 pages of medical records. [00:27:13] Speaker 6: Can you see that? [00:27:14] Speaker 2: But looking at this does it indicate the it's an SICU course? [00:27:27] Speaker 7: Surgical ICU. [00:27:29] Speaker 2: I'm sorry? [00:27:29] Speaker 7: Surgical ICU. Okay [00:27:31] Speaker 2: and that makes reference to the fact that shortly after arriving in the ICU the patient had a cardiac arrest. Is that there? [00:27:41] Speaker 7: Yes. [00:27:41] Speaker 2: Were you there then? [00:27:43] Speaker 7: I was. [00:27:44] Speaker 2: And when it says the etiology of the arrest she got two rounds of CPR before obtaining ROSC. Can you tell me please what is CPR two rounds and what is ROSC? [00:27:55] Speaker 7: Meaning we did chest compression. She was already intubated so she was getting oxygen. [00:27:59] Speaker 2: Okay and then bilateral chest tubes were placed in her body? [00:28:06] Speaker 7: Yes. [00:28:07] Speaker 2: Does that mean from both sides? Both sides. Okay and that punctures through the chest into what the lungs? The lungs. and when they placed the chest tubes at this point shortly after admission there was 100 to 300 cc's of blood from each chest tube? What does that mean? [00:28:27] Speaker 7: That's the output they got once they put the chest tube in. [00:28:31] Speaker 2: That's [00:28:31] Speaker 7: the output they got once they put the chest tube in. [00:28:34] Speaker 2: Okay so when they put the chest tube in it drained 100 to 300 cc's of blood is that correct? [00:28:40] Speaker 7: Correct. [00:28:41] Speaker 2: And then after that again shortly after admission to the hospital coming from South Shore Hospital she then got a massive transfusion protocol which you told us about right? [00:28:53] Speaker 7: Yes. [00:28:54] Speaker 2: What does that mean? [00:28:56] Speaker 7: It means she gets we have a protocol that blood depending blood products [00:29:02] Speaker 2: she [00:29:03] Speaker 7: gets infused rapidly. [00:29:06] Speaker 2: And was there a notice shortly after arrival she was being turned and had 30 cc's of clear fluid that came out of her nose is that right? [00:29:18] Speaker 7: Yes. [00:29:19] Speaker 2: And what is that was there a suspicion that that was what's called CSF? [00:29:25] Speaker 7: Yes. [00:29:26] Speaker 2: And what is CSF? [00:29:28] Speaker 7: It's spinal fluid. [00:29:30] Speaker 2: Okay. Going to the next page which would be 19 does it indicate again on there if I can just bring this up a little bit better. So she now has noted acute blood loss anemia right? What does that mean? [00:29:51] Speaker 7: She has a low blood count. [00:29:53] Speaker 2: And do you know what happened to the blood or any idea? [00:29:56] Speaker 7: I do not. [00:29:57] Speaker 2: So she had very low lost a lot of blood right? [00:30:01] Speaker 7: Yes. [00:30:04] Speaker 2: And she had anemia that would be what low blood or something? [00:30:07] Speaker 7: Yes. [00:30:08] Speaker 2: And she required multiple transfusions immediately following her arrest right? [00:30:14] Speaker 7: Yes. [00:30:15] Speaker 2: And when it says arrest does that mean arrest by the police does that mean the cardiac arrest? I want to make sure that's clear. It's cardiac arrest nothing to do with the police. And she had massive required multiple transfusions. And you were there for that, correct? [00:30:30] Speaker 7: Yes. [00:30:45] Speaker 2: Were you aware the extent of the after you had the MRIs and the CAT scans were you aware as her the lead nurse or treating nurse as to what the extent of her injuries were? [00:31:01] Speaker 7: At that point I don't believe so. [00:31:04] Speaker 2: At some point did you become aware of that? Yes. Okay. So again I've got the records you don't so let me do it this way just to make it easy do you remember that she had a burst fracture of C1 [00:31:14] Speaker 7: Yes. [00:31:15] Speaker 2: What does that mean? [00:31:16] Speaker 7: It means a cerebral fracture [00:31:18] Speaker 2: It'll be up here so this is the cervical spine up here and then T5 and T6 there was a transection what does that mean? Thoracic Okay so down here and when it says transection what does that mean? [00:31:35] Speaker 7: It's severed [00:31:36] Speaker 2: And then T1 2 3 4 also were injured as well right? What is neurogenic shock what does that mean? If you know [00:31:51] Speaker 7: Neurogenic shock [00:31:53] Speaker 2: Sorry yeah neurogenic shock [00:31:54] Speaker 7: It just [00:31:56] Speaker ?: makes [00:31:56] Speaker 7: reference on These are not my notes so I can't really [00:32:00] Speaker 8: For patients with depression they're often lacking kind of that ability to have enough serotonin in those spaces and so a selective serotonin reuptake inhibitor prevents serotonin being kind of sucked back into the cell so it allows for serotonin to be more available And [00:32:16] Speaker 2: what is an SSA I what does that mean an antagonist selective serotonin antagonist [00:32:23] Speaker 8: So those are medications that kind of do the opposite [00:32:26] Speaker 2: Okay And you knew as a psychiatrist at least looking at her history you knew that she had been seeing psychiatrists immediately prior to her suicide attempt correct Correct And you knew that she had been prescribed a number of drugs by these various psychiatrists Correct Correct And to your knowledge was she prescribed diazepam Yes Was she prescribed buspirone otherwise known as Vanspar Yes About Wellbutrin Yes And what is Wellbutrin Is that an antidepressant It is an antidepressant Hydroxazine What is hydroxazine [00:33:05] Speaker 8: It can be used for a number of reasons but for psychiatric purposes it's often used as an anti anxiety medication [00:33:11] Speaker 2: And Klonopin [00:33:12] Speaker 8: Yes [00:33:13] Speaker 2: Is hydroxazine is Klonopin That's a benzodiazepam right That's correct And then Lamotrigine Yep Lamotrigine Lamotrigine Sorry Yes What type of medication is that is that a mood stabilizer It [00:33:31] Speaker 8: is yeah it's also an anti seizure medication but in the psychiatric realm it's used as a mood stabilizer And [00:33:37] Speaker 2: then we talked about Prozac that's an SSRI correct Correct And what's Remeron [00:33:41] Speaker 8: Also [00:33:42] Speaker 2: an antidepressant So in addition to all of the drugs that I had mentioned she was also prescribed Remeron correct Correct She was also prescribed Seroquil or Quetipine [00:33:54] Speaker 8: Quetipine Yes [00:33:56] Speaker 2: Quetipine Okay And what is Seroquil [00:33:58] Speaker 8: So Seroquil is an antipsychotic medication [00:34:00] Speaker 2: And she was prescribed as we already talked Trazodone Was she also prescribed Amitriptyline Yes What is Amitriptyline [00:34:09] Speaker 8: Amitriptyline Amitriptyline is one of the older antidepressants It's a tricyclic antidepressant that can often be used to help with sleep but also mood [00:34:18] Speaker 2: And Ambien correct Correct And Zolpidem Yep [00:34:25] Speaker 8: Zolpidem is the generic name of Ambien [00:34:27] Speaker 2: Oh okay Some of these drugs they also have what's called a suicide warning or a black box warning isn't that right Yes Can you tell me what that means [00:34:37] Speaker 8: Yeah So in studies that have been done some of them show that especially after starting an antidepressant it can increase someone's risk of suicidality Many of those studies showed that it was mostly in adolescents and young adults but it can happen in adults as well [00:34:56] Speaker 2: And Celexa was also a drug Is that an SSRI too It is And all of these drugs that we just went through were all prescribed from September end of September till January [00:35:16] Speaker 8: Yes September 2022 [00:35:18] Speaker 2: Yes It's an awful lot of drugs to be prescribed in four months isn't it Sustained Thank you [00:35:27] Speaker 8: Thank you [00:35:29] Speaker 2: Call almost redirect [00:35:31] Speaker 5: Yes Doctor all those drugs that defense counsel just listed you're aware she wasn't on all of those drugs at the same time correct Correct And did you know that many of those drugs she took a very small amount of some she didn't take any pills at all I was not aware of that For Buspar which is one of the ones he mentioned were you aware the first prescription she only took two pills out of that bottle I was not aware were you aware the second prescription a month or so later for Buspar she took zero pills out of that bottle I was not aware so you're just where are you getting this information about what she was on and when [00:36:06] Speaker 8: yeah so one of the things that we do is try to collect as much information as we can during our assessments and so we look through the record in terms of what was prescribed we also talk with other providers as to what they prescribe but in the context of the assessments that we were doing it did not require us to determine what exactly she had been on before because we were using a different set of medications to treat something different symptoms that she was experiencing [00:36:31] Speaker 5: so you really have no [00:36:41] Speaker 8: getting reports of what was being taken what wasn't being taken but from the defendant correct [00:36:45] Speaker 5: okay so she's reporting to you that she took those medications but you'd be surprised to know that at least one of them zero pills were taken um I don't think I'm surprised no okay and you talked about well talked about prescription and what she was taking were you aware that in the time frame just prior to her being admitted to the hospital she was only prescribed trazodone valium and imitriptyline just three medications yes I was aware and you were asked about you know mania and and you know exercising and cleaning out your garage and selling your belongings could be signs of mania correct correct but there are people who just exercise every day and they're not manic correct correct and there are people who have a messy garage and have accumulated a lot of junk and decide to clean out the garage that aren't manic correct correct and in fact if someone is manic and attempts to do one of those tasks like cleaning out a garage it's usually in a disorganized way and oftentimes they don't finish the task correct sometimes so if someone approaches a task like cleaning out the garage by organizing out that's pretty organized behavior correct correct and if someone sells belongings that they no longer need that's not necessarily a sign of mania correct correct that's more if they're selling their stove and then they have nothing to cook with correct correct so if they're selling junk in their garage that they no longer need that's not necessarily manic correct not necessarily thank you [00:38:26] Speaker 2: person as counsel said they're exercising every day and they have a messy garage that obviously would not be indicative of hypomania probably normal person could have as counsel said it how about a person that at the same time can't sleep because the insomnia is so bad they go 48 hours without sleep is that something to be considered in the whole evaluation yes how about the fact of person saying that my brain is broken and that they can't concentrate they can't think is that something that the person you would consider in conjunction with the messy garage and the exercise yes thoughts of hurting themselves suicidal ideation that's something that's important to evaluate yes homicidal ideation telling your husband that you're having thoughts about hurting your children that's something you'd consider isn't it [00:39:17] Speaker 8: yes [00:39:17] Speaker 2: in reference to counsel's going to commit suicide you're not aware of the doctors telling her to discontinue this medication start a new medication go on to a different medication depending on the doctor you're not aware of that right no and finally if you know did she sign a DNR do not resuscitate [00:39:44] Speaker 8: she asked to the day after the first evaluation that I did of her which was the capacity assessment to change her health care proxy but in the context of her reporting a serious suicide attempt we did not change her code status we continued to chat with her about that and she ultimately came to the conclusion that it made sense to make sure that her mental health was stable before she considered her code status [00:40:08] Speaker 2: okay but her initial reaction or her conversations with you all was that she wanted to have a do not resuscitate status correct thank you [00:40:19] Speaker 8: all right [00:40:21] Speaker 2: thank you doctor [00:40:21] Speaker 8: thank you your honor [00:40:22] Speaker 2: almost ready to call your next witness [00:40:28] Speaker 5: yes your honor the call calls dr this was good [00:40:45] Speaker ?: afternoon ma'am good afternoon [00:40:46] Speaker 9: i do thank you you may have a seat ma'am thank you all right [00:41:03] Speaker 7: good afternoon doctor [00:41:04] Speaker 5: good afternoon [00:41:05] Speaker 7: all right call please [00:41:06] Speaker 5: thank you your honor good afternoon can you please state and spell your first and last name [00:41:10] Speaker 9: yes my name is jillam biswas my first name is spelled j-h-i-l-a-m last name spelled b-i-s-w-a-s [00:41:21] Speaker 5: and your and your [00:41:22] Speaker ?: and your [00:41:22] Speaker 5: date date [00:41:23] Speaker 9: date of birth is 9-12 1982 what do [00:41:26] Speaker 5: you do for a living [00:41:27] Speaker 9: i'm a forensic psychiatrist and i work on uh at brigham and women's hospital [00:41:32] Speaker 5: and what is a forensic psychologist or psychiatrist pardon [00:41:36] Speaker 9: well i'm a forensic psychiatrist by specialty training and we work in the courts often doing forensic evaluations of individuals but i'm also an adult psychiatrist and i work at brigham and women's hospital as an adult psychiatrist on the consult liaison unit [00:41:57] Speaker 5: and what can you just briefly describe your education and training background that qualifies you for this work [00:42:03] Speaker 9: sure i grew up in the south shore i went to dartmouth college and then i went to medical school at umass chan medical school i then did my psychiatry residency at harvard longwood which consists of brigham and women's beth israel boston children's at the time and after that i did subspecialty training after my psychiatry residency in forensic psychiatry again at umass chan medical school [00:42:34] Speaker 5: and focusing in on january of 2023 were you working at the brigham and women's hospital i was and specifically on january 25th 2023 did you interact with a woman a patient there named lindsey clancy [00:42:51] Speaker 9: i did on january [00:42:54] Speaker 5: 26th 26th okay and um in what capacity did you interact with her as a forensic psychiatrist or as a member of the staff at brigham and women's [00:43:05] Speaker 9: i interacted with her as a member of the staff the psychiatry staff at brigham and women's hospital [00:43:11] Speaker 5: and did you have a particular role that day on january 26th 2023 [00:43:16] Speaker 9: yes i was on the consulate liaison service which is the psychiatry service that's called by medical and surgical specialties to help evaluate and provide psychiatric recommendations and [00:43:31] Speaker 5: when you did you meet with miss clancy on that day on the 26th i did and was that around 2 14 p.m. that you had that interaction I [00:43:40] Speaker 9: think somewhere between 2 and 3 o'clock yes [00:43:43] Speaker 5: and when you met with lindsey clancy was that in her hospital room in the ICU it was and was she intubated at the time [00:43:51] Speaker 9: she was [00:43:52] Speaker 5: and was she awake she was awake and was she oriented [00:43:57] Speaker 9: so she was intubated so it was difficult for her to really answer a lot a range of questions and so she gestured to me and so we knew that she was really exhausted and anxious from the entire experience and the evaluation and so we didn't ask her all of the questions around orientation [00:44:24] Speaker 5: when she gestured that she wanted to write did you give her something to write with or something to write on [00:44:29] Speaker 9: I did [00:44:30] Speaker 5: and what did you give her paper and did you also give her a pen or something like that I did and was she able to when you asked her certain questions was she able to answer those questions by writing the answers on the paper she was and did you ask her about her mood that day I did ask her her mood and what did she write she wrote horrified and what was her affect during this interaction at [00:44:59] Speaker 9: the time that I saw her she was intubated and that in and of itself is very uncomfortable and so she seemed very anxious and [00:45:09] Speaker 5: did she write anything else on that paper that you saw [00:45:14] Speaker 9: yes the entire evaluation was done through writing because she couldn't speak [00:45:21] Speaker 5: so what types of questions were you asking her and what was she responding with so [00:45:26] Speaker 9: we asked her you know how how are you feeling horrified and then she wrote down do I have an attorney and I said with my team that at this time we're just getting to know you and getting to know the case and we're not sure exactly what is happening and we asked her do you have questions for us and she asked is my body broken are my legs straight and she then asked about can she have visitors and you know where her family is [00:46:14] Speaker 5: and when you are asking her questions what is the goal of the questions that you're asking her what are you trying to address or assess [00:46:26] Speaker 9: it depends psychiatrists are called for all kinds of issues that happen in the hospital in this situation we were asked around you know diagnostic clarity that there was a likely suicide event that occurred can you evaluate her for safety at this time before she goes into surgery [00:46:46] Speaker 5: and I know that she was intubated so she's writing her answers but based on the answers she wrote on the paper did she seem to understand the questions you were asking yes and her responses did you understand those [00:47:02] Speaker 9: yes she was anxious and she needed breaks and I said anytime you need a break we can leave but she did write to us those particular answers [00:47:15] Speaker 5: so what she was writing even when she asked if she had a lawyer those were things what she was writing made sense given the situation she wasn't writing is there a unicorn in the corner right correct [00:47:28] Speaker 2: if [00:47:31] Speaker 5: there was a unicorn in the so what she's asking do I have an attorney are my legs straight is my body broken those all made sense given the situation she was in correct [00:47:44] Speaker 9: they were relevant answers and questions she was asking [00:47:48] Speaker 5: and are you familiar with the characteristics of psychosis yes okay and what are the typical signs or symptoms of someone who is in psychosis [00:48:04] Speaker 9: it really depends and it ranges across a spectrum of symptoms so we have a whole category of different types of symptoms that we look at for psychosis and they are different for everyone but they can be what we call negative symptoms which are more internal isolating not responding not reacting very much and then we have symptoms like positive symptoms that's what we call them in psychiatry but they're a little bit more outward focused where objectively you can see what those symptoms are like being paranoid darting your eyes around responding to internal stimuli which means you're responding to voices and you know being within a delusion so there's all kinds of symptoms and they look different for each and every person [00:49:04] Speaker 5: in your conversation with Ms. Clancy did you notice any internal or external signs of psychosis at [00:49:14] Speaker 9: the time I documented that I did not note those [00:49:18] Speaker 5: and did you also note that you know she was her thinking was linear goal oriented thoughtful and she didn't appear to be responding to internal stimuli [00:49:31] Speaker 9: yes that is typical language in psychiatric mental statuses and I did document that [00:49:36] Speaker 5: what is internal stimuli [00:49:38] Speaker 9: oftentimes it's very difficult for our patients to be able to articulate what they're hearing they may have perceptual disturbances like hallucinations or auditory hallucinations and maybe hearing voices when it's really active we often see those individuals interacting with those voices I didn't see that in that particular moment [00:50:03] Speaker 5: so for example you could see someone engaging in a converse looks like they're engaging in a conversation with someone or looks like they're looking over at something thinking something or someone is there when they're not [00:50:15] Speaker 9: is that correct that's what responding to internal stimuli is and [00:50:21] Speaker 5: you didn't see any of that present with Ms. Clancy [00:50:23] Speaker 9: correct [00:50:24] Speaker 5: and would it be fair that some of the obvious signs of psychosis would be someone whose thoughts are disorganized that their thinking isn't linear that they're not making sense things like word salad where they're just throwing in words making sentences that don't make sense [00:50:47] Speaker 9: so you describe symptoms that we can see in people with serious mental illness who have a psychotic disorder with active symptoms and [00:50:57] Speaker 5: you didn't see any of that with Ms. Clancy is that correct not in that snapshot moment of time and to be clear you only saw her for a limited amount of time on that one day correct that [00:51:06] Speaker 9: is correct [00:51:07] Speaker 5: and this is January 26 2023 about a day and a half or so after she's admitted to Brigham and woman's that is correct one of the first questions she asked is do I have a lawyer yes and did you have any based on your training experience did you have any thoughts about her awareness or thoughtfulness about the questions she asked or the answer she gave [00:51:44] Speaker 7: did [00:51:48] Speaker 5: you have any assessment professionally of the responses and awareness that she had [00:51:56] Speaker 9: yes at that time I was trying to assess is she confused or oriented is she completely disorganized is she so anxious that she won't be able to sleep I was assessing suicidality mostly I was being called into the room for that and so there were a lot of things that I was assessing all at the same time before the surgical intervention that was going to happen and did I answer your question yes okay [00:52:30] Speaker 5: all right and so in doing that in evaluating all of those things did you have any concerns at that point in time that she couldn't make a decision to have the surgery or that there was some cause for concern there in her behavior I [00:52:48] Speaker 9: felt she had the capability to make the decision for surgery at that time and [00:53:07] Speaker 5: another [00:53:09] Speaker 3: just in relation to now what's been marked as exhibit 151 the brown journal and just noting that when you the journal opens to the first page there's no dates on it correct correct and in those first few pages just highlighting page one you reviewed this handwritten these handwritten entries and at some point in this paragraph it says obsessed with his sleep and nap schedule like to the minute says hearing him cry for one plus hours and not intervening just about killed me I even said the words I want to die to Pat while he was crying after that I became obsessed with his sleep and nap schedule like to the minute that's one of the entries you reviewed and noted page two says I also feel like I did it wrong because I did it when he was overtired so it made it harder now I have horrible insomnia and anxiety you recall reviewing that in the journal [00:54:13] Speaker 6: correct yes [00:54:14] Speaker 3: page four of the journal says why else I feel guilty he's not really hitting his milestones again that's a page that's not dated in this journal correct correct page eight I'm completely overwhelmed trying to take care of the three kids I feel like I'm drowning every day again another page that's not dated correct at some point there are some dated pages in this journal fair to say right [00:54:48] Speaker 2: yes [00:54:49] Speaker 3: and there's one on November 18th and November 18th that page reads it's like I'm so desperate to get a mental break from taking care of everyone that my mind is trying to make something physically wrong with me recall reviewing that in the journal [00:55:07] Speaker 2: yes [00:55:08] Speaker 3: now in addition to the brown journal when you were back at the office you also had the occasion to review some of the other journals collected right correct this journal I'm holding up exhibit number 147 is that familiar to you yes and again this is a journal that has handwritten notes in it very similar to the handwriting in the brown journal you reviewed [00:55:31] Speaker 2: yes [00:55:32] Speaker 3: and fair to say the entries in this notebook only span a few pages and only go from October 13th as the first entry and the last one being January 18th correct correct and this third journal that you reviewed after the search warrant exhibit number 50 the yellow journal with Callan Clancy's name on it you recall that [00:56:00] Speaker 6: yes I do [00:56:00] Speaker 3: and you are where Callan Clancy was one of the children [00:56:03] Speaker 2: yes okay [00:56:05] Speaker 3: and in this instance did you see similar handwriting from the other two journals that you reviewed [00:56:10] Speaker 2: yes I believe there was two separate [00:56:13] Speaker 3: okay at some point in this these entries you began to notice there were other handwriting correct at the time you were looking at this did you know who the other handwriting was at the time who it belonged to [00:56:29] Speaker ?: okay [00:56:29] Speaker 3: and fair to say reviewing the contents of it it's a pretty detailed list of a schedule for the baby correct nothing for this [00:56:48] Speaker 2: is ranking so one of the things that the district attorney did was read to you certain entries from what is referred to in your report as the tree of life artisan journal should [00:57:21] Speaker 3: have a tree on it yes [00:57:22] Speaker 2: set forth on a number of pages her feelings dealing with her children is that fair it's fair to say yes sir and you wrote in your report on page 19 of 63 counsel asked you first about her stating that she had horrible PTSD from sleep training Kellen hearing him cry for one hour plus and not intervening just about killed me I even said the words I want to die to Pat while he was crying he would be the baby right correct and this is her saying that not being able to go to her child because they were trying to do sleep training she indicated that it was just about killing her correct and after that I meaning Lindsay became obsessed with his sleep and nap schedule like to the minute I would tell Lainey and you know who Lainey is right yes who's Lainey the other child the what I'm sorry again Lainey Lainey Lainey Lainey Lainey Lainey don't recall this time do you recall that she had a young lady or they had a young lady that was in their home helping with the baby while she was supposed to recall this time okay that she would tell Lainey to put him down at 1036 I would also drive him around for car naps for hours every day feeling guilty for doing this to my baby do recall making that notation yes I also feel guilty we did it too young parenthesis one week shy of four months and parenthesis right correct you also noted in your report that I also quote I also feel like I did it wrong because I did it when he was overtired so I made it harder I now have horrible insomnia and anxiety which is causing depression I have no appetite I don't know what's wrong with me I want help I want to be well you saw that in there didn't yes and then she went on and said I think the anxiety started after sleep training doctor said it was okay to let him cry I need to get a good night sleep and take care of him rocking him to sleep every nap in bed in the middle of the night she noted that right yes noting further and separate occasion he's still a happy baby despite his sleep training why I stone she wrote that right correct she wrote I have crazy brain fog I feel like I can't make a plan I can't carry it out like I just live moment to moment waiting for the next nap time I'm terrified of Cal getting overtired now because I feel I can't help him she wrote that right correct she then wrote I'm really worried about going back to work and not being able to function with the brain fog I feel like I should start with a four hour shift and see how I do I can't tell if I am withdrawing from Ativan and Benadryl or is this my new baseline I feel completely disconnected with my baby I feel like I'm going through the motions every day she wrote that right correct and there were a number of other entries that you put in your police report about that one of which was that I feel horribly guilty about my marriage I want to connect with Pat again I know he needs it I need it I'm terrified because I'm terrified of the relationship she needs to get birth control first she made reference to her inability to have conjugal relations with her husband right I believe so she indicated further on into her travels I am completely overwhelmed trying to take care of the kids I'm drowning every day I feel guilty that I'm