Doctor says woman instructed in daughter’s care

By Matt Pordum (contact)

Friday, June 11, 2004 | 9:51 a.m.

A doctor testified on Thursday that he had thoroughly instructed a mother accused of murder in the Feb. 9 death of her diabetic 11-year-old girl on how to monitor her daughter's disease so it would never become life-threatening.

Dr. Allan Rice, a pediatric endocrinologist, said that if Cheryl Botzet would have more closely monitored her daughter's insulin levels and looked for symptoms he warned her about, Ariel Botzet might have never contracted the fatal condition of diabetic ketocidosis.

Police and prosecutors allege Cheryl Botzet neglected the monitoring of Ariel's insulin levels over a period of time, which led to her death. Under Nevada law a murder can be levied if a child dies as result of parental abuse or neglect.

The testimony was part of a preliminary hearing to determine whether Botzet will stand trial on the charges.

Diabetic ketocidosis is a condition involving an acidifying of the blood caused by a lack of insulin. Rice said the condition can be mistaken for a cold or flu, but as a parent of a diabetic daughter, Botzet was told how to respond if Ariel became ill.

Rice's testimony Thursday supported the findings of Ariel's autopsy. The coroner ruled that the girl's death was caused by chronic medical neglect.

"Parents are supposed to make sure the blood sugar levels are down," Rice said. "Adolescents become less responsible for their (insulin) shots and checking (blood sugar) levels for the same reason they can't vote, drive or join the Army. They (adolescents) are not responsible."

Rice said Botzet should have checked Ariel's insulin and ketones levels as his office had instructed her.

Ketones are chemical byproducts formed when the body is forced to convert fat into energy rather than carbohydrates. That happens when there is a shortage of insulin available to break down the carbohydrates. Ketones, ordinarily cleansed from the blood by insulin, build up and poison the body creating symptoms that are often compared to the flu.

Rice testified that Botzet never called to tell him about the flu-like symptoms Ariel was experiencing on Feb. 6, but instead called to ask for a refill of insulin. Rice said it wasn't until his assistant called to inform Botzet the prescription had been filled that his office was informed that Ariel had been taken to the emergency room at UMC.

Rice said juvenile diabetes is "normally not a fatal disease" and if "monitored correctly a juvenile diabetic can lead a normal life." He said out of the 1,000 juvenile diabetes patients he has cared for in his career, only two have died.

"It's fatal if they don't take insulin," Rice said. "(Juvenile diabetes) is fatal if (the child) doesn't monitor it properly."

Rice also said Botzet failed to have a hemoglobin A1c test performed on Ariel as requested. The test measures the amount of glucose that has stuck to red blood cells over a period of time, which can show how well blood sugar was controlled in the previous two to three months.

Rice said by performing this test every three months DKA can be prevented. Rice said that the results of Ariel's A1c test -- which wasn't administered until she was in the emergency room -- revealed Ariel was getting "less than two shots (of insulin) a day."

Botzet's attorney, Herb Sachs, pressed Rice on cross-examination as to what determined chronic neglect.

Rice admitted under Sachs' questioning that stress, fear and diet can all cause a person's blood sugar to be high. Rice testified it was possible for a person to receive insulin as prescribed and still have high blood sugar because of such factors.

Sachs asked Rice to define in his opinion what chronic neglect would be in the case of a parent of a child with juvenile diabetes. Rice said it would be "inappropriate and dangerous" if a parent in charge of a diabetic child didn't give the child insulin.

When Sachs asked Rice if he would say chronic neglect existed if a parent gave the child three shots of insulin instead of the recommended four, Rice said while not "ideal" doing so "doesn't put a child in danger."

Sachs also asked Rice if Ariel's school should be held partly responsible for Ariel's condition since they are required to monitor those children with juvenile diabetes.

Rice said schools aren't allowed to administer insulin shots, but instead are required to call the parent to pick the child up and perform treatment at home. If a school can't contact the parent it is supposed to contact the physician.

Robert Lynn, a nurse practioner in Rice's office, testified Ariel's school did make the proper calls to the office.

Lynn said he became concerned after getting phone calls from a nurse at Laura Dearing Elementary School, where Ariel was a student, indicating Ariel was getting "inconsistent" care from Botzet. He set up several follow-up appointments with Botzet but she allegedly canceled them.

Clark County school records show Ariel was absent from school 26 times between December 2002 and July 2003. She was absent 17 times in the 2003-2004 school year.

According to Botzet's arrest report Botzet told the school nurse that she was managing Ariel's illness at home and didn't want the girl's blood sugar levels to be tested, the report says. The nurse began having Ariel come to the nurse's office to test her blood sugar levels.

The logs from the nurse's office show that during the 2002-2003 school year, if Ariel's blood-sugar levels were too high, Botzet would come to school to give her a shot, the police report says.

But through that school year and into the next, the report says, Botzet stopped coming to the school altogether. By October 2003, each time Ariel called to tell her that her blood-sugar was too high, Botzet allegedly told her to drink water, do some exercises and return to class.

Testimony in Botzet's preliminary hearing is scheduled to continue today.