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i-Mammo Part III: Mammographic Serfdom

i Mammo: The Mammogram You Never Had

An article in several parts

Part III and Conclusion: Mammographic Serfdom

Tofu, Turkey, and Planet X

In the mid 1980's, an arcane new technology transformed the music and recording industry. Music CD's, with digital music pressed onto their silvery surfaces, emerged from avant garde record stores like UFO's from Planet X. The public was asked to abandon its long love affair with vinyl LP's; and worse...to forgo that sweet, unstable, quirky player-box: the turntable. In its place, astonishingly soulless and siliconized, was the CD player, a computerized device as far removed from the record turntable as tofu is from a Thanksgiving turkey.

Despite aesthetic shortcomings and poorly understood technology, digital music and CD's quickly and thoroughly transformed the recording, delivery, and storage of music. It was a revolution spurred by those twin engines of the market system: consumer demand and feedback. Convenience, portability, and reproducibility were honed to consumer preference in a marketplace where competition also took care of prices. CD players -- like all new technological products -- started at prices over $1,000, but quickly were available for less than $300. These same forces drove innovation, resulting in today's market gigaton bombs: the iPod and iTunes.

Divergent Paths, Asymmetrical Outcomes

In Part I of this series I drew a parallel between the advent of industry-changing technologies in music recording and breast imaging: the music CD and Full Field Digital Mammography (FFDM).

In this example, however, the parallels diverge after introduction of the technology. FFDM stands as a technology, now five years post introduction, that boasts all of the advantages of the digital format, with very few drawbacks. Yet FFDM has neither become widespread, nor has it evolved rapidly in the years since it broke into the FDA's universe of approved devices. This, despite the fact that routine use of FFDM will mean:

• Fewer images and less radiation overall
• No lost, damaged, or mislabeled films
• Portability
• Reproducibility
• New ways to detect cancer (manipulating the digital image); and
• "Double-reads" by Computer Aided Detection (CAD) software

As I wrote about in Part II of this series, "double-reading" is a highly desirable method to improve cancer detection, but it is not feasible currently. However, with digital mammography, CAD is effortlessly available* with the push of a button. After the digital mammogram is recorded, the radiologist makes a decision about the study (mainly: are there areas of suspicion?), then, with a keystroke, the image is "re-read" by the computer. The CAD software marks out, on the film, areas of question. The radiologist then observes the computer's markings to make sure there are no areas that were missed in the original interpretation. A large study recently confirmed the efficaciousness and value of these CAD over-reads. The conclusion? CAD increases the total number of breast cancers identified over a lone interpretation by a radiologist.

What power did digital music and recording have that digital mammography lacks? Why did one breakthrough technology snare the public's imagination while the other plods along, it's advantages and potentials relatively ignored? 

Is it too Expensive and Less Good?

The digital mammography machine is a lot more expensive than the format it seeks to supplant. An X-ray mammogram unit can be purchased for somewhere around $70-100,000. Digital mammography units are closer to $500,000, and adding on additional workstations to view and manipulate the images further increases the cost.

There are some imaging concerns, also. Many radiologists feel that although detection of calcifications (one of the ways one finds breast cancer) with digital mammography is improved over x-rays, the perception of masses and small opacities is not as good. Also, the resolution (how well two tiny areas can be seen as separate things) of film systems is slightly better than digital systems.

Could these two factors be holding back the imammo revolution? Hardly.

Issues with new technology are not uncommon, as the example of digital music demonstrates. Neither are high prices. Usually, these market deficiencies are dealt with rapidly and efficiently by consumer demand and feedback along with manufacturer competition. Currently, the benefits of FFDM outweigh the problems standing in the way of its widespread adoption, and the issues of price and image resolution surely would quickly be resolved if digital mammography were presented to the marketplace for absorption. It reminds me of the famous Spartan threat to Laconia that went something like this: "If we breech your walls we will capture your city and enslave your people." The Laconians -- being laconic -- answered:

If.

Out of the Loop 

The reason that digital mammography remains in the starting gate, along with, in some aspects, another powerful high-tech procedure, MRI of the breast, is because of the market place distortions in medicine.

Unlike other markets, in medicine the consumer is unhooked from the formative and evolutionary processes. Consumers don't purchase the technology directly, nor are their preferences and desires fed back to the manufacturers and vendors. Instead, third party payers (insurance companies, HMO's, and the like) lead consumers by the nose to the mammography centers that have cut the best deal, or have the best relationship with the patient's insurance company or doctor. There is little of that essential market component: choice.

It goes further than that. Because consumers have no informed idea as to what constitutes a good mammogram, and appropriate interpretation, they cannot judge the product of this process. Is there a woman anywhere who can answer of her women's center:

Who is interpeting your mammogram?

What is the interpreter's qualifications?

Is that interpreter competent?

What type of machinery is in use?

Who is the technologist performing the study?

Is every mammogram satisfactory, or are there glitches in the process?

What degree of certainty is there as regards any particular diagnosis in any particular patient?

And most saliently: what is the track record of this facility and how is that track record documented?

If no one ever knew what good or appealing music sounded like, or the basic parameters of that decision, digital music and CD's would have gone nowhere. Likewise, with little notion of the determinents and results of quality in mammography, consumers cannot intelligently express their opinions and desires.

This is how backwards the consumer in medicine is. Not only can one not make an intelligent and rational decision between x-ray and digital mammography, most women don't even know if the mammogram they got, last year, was done competently or interpreted appropriately.

The government is aware of this gross information deficit. Their interpretation?  It is the government's opinion that women are not sophisticated enough to grasp these issues and to make their own choices. That's why legislators allowed Mammactivists (disease-specific lobbyists) to foist myriad laws onto the system, mandating thousands of pages of standards and complex, byzantine rules and regulations that attempt to legislate women's centers and mammographers into quality -- a task that most economists willl tell you, is inefficient, costly, and fraught with perils.

These laws had a predictable outcome: Compliance required raising the cost of running a women's center. To offset this (un)anticipated result of do-good legislation, the government -- through Medicare, which sets reimbursement standards -- instituted price controls limiting the amount a center can collect. Add to price controls the government's later conclusion that less expensive mammography would be more widely accessible (so they lowered reimbursement even more), and the result? A product that is produced as cheaply as possible, if at all.

The final nail being driven into the coffin of FFDM is liability lawsuits. Mammography is, by most estimates, second only to childbirth as a source of litigation. Every mammographer lives in fear -- each and every moment -- of receiving THE registered letter from Torter, Sorter, and Distorter, the lawsuit lions who perform retrograde scavenging of mammograms in breast cancer cases looking to find images they believe are confusing enough to befuddle juries and bludgeon insurers into settlements.

If people were informed and had choices, new technology would spread like wildfire, and breast cancer detection would get better. Fewer women would die from breast cancer. All the groups who lobby so hard and work so fervently against this cancer plague could do more by advocating simple market reforms than is done with all the walkathons, pink ribbons, and think tank group seminars together.

Worse Than Serfdom

It is profoundly cynical to conclude that the public's intelligence and ability are insufficient to evaluate and choose in matters of health care and medical technology. This cynicism prohibits any talk of such reform; That and the entrenched lobbyists on all sides -- including physicians.

It is also sad that on the horizon -- only one politician away -- lies the pernicious spectre of nationalized health insurance. This type of reform leads in the other direction, to less choice, fewer options, and more ignorance. Read my post regarding the British mammography program whose monolithic socialist health care system, until just recently, refused to accept even the rudiments of breast cancer screening. Many, many lives surely were lost as a result.

There is only one direction less choice and less information leads. Someone once called it serfdom.

But in the case of medical technology, and mammography, it's a road to death.

*Plain film x-ray mammograms can be digitalized with the use of an analog-to-digital converter, and these images can then be subject to CAD analysis by a computer. However, the converters are expensive, involve several extra steps and additional manpower, and have not entered into widespread  mainstream use.

Clean Your Blood With This Week's Carnival

Conservative Dialysis, is the quizzical name of this week's blog host for the Carnival of the Vanities.

If you haven't been following the controversy surrounding the COTV, and last week's carnival host, you've missed a sure part of blogosphere history as this -- the first and leading web-wide "Carnival" -- reaches a crossroad in its life.

Check it all out. Read this week's COTV, then go see what Kevin at Wizbang had to say about the imbroglio; and, finally, go to the source, COTV founder Bigwig at Silflay Hraka.

GRAND ROUNDS AND SICK PARROTS

GRAND ROUNDS AND SICK PARROTS

Girl Scientist, at Living the Scientific Life, hosts Grand Rounds this week -- a compilation of medical blog posts.

Ironically, in the midst of proliferating medical knowledge and advice, Girl Scientist fell ill while preparing the compendium...and so our first Grand Rounds from the sick bed!

Don't worry though, one cannot see the footprints of illness on the host's trail through this week's medical blogosphere, speaking to the fortitude and will of a:

"postdoctoral fellow who has been living in New York City since September 2002, working in my "dream job", researching the evolution of parrots from the south Pacific Ocean."

So go to the site and check out the links.

One question: If one were studying parrots from the south Pacific Ocean, in which part of Manhattan would one spend the most time working? Soho? The Upper East Side? Hell's Kitchen? Interesting...

i-Mammo Part II: Breasts, Lies and Videotapes

iMammo: The Mammogram You Never Had

An article in several parts

Yesterday, in Part I:

The Music of Digital Mammography

• What is digital (computerized) mammography?
• How does digital mammography compare with traditional (x-ray film) mammography?
• What are the advantages of digital; mammography?

Today, in Part II:

Breasts, Lies, and Videotapes:

The Iron Triumvirate and the Dirty Secret of Mammography

I've Got A Secret

Shhhh…What is the dirty little secret of mammography? Double reading picks up 15% more cancers.

A double reading means that a mammogram is looked at twice, by two different radiologists.

This “secret” is well known in the imaging community, and was established in the early 1990’s when a study of 11,000 mammograms confirmed that: Double reading detected 15% more cancer cases. The author's conclusion to that study?

"Independent double reading does significantly increase sensitivity of mammography screening."

If having a mammogram interpreted twice prevents 15 more women -- on top of every 100 found -- from having their breast cancer remain undiagnosed, why aren't all mammograms double-read?

Answer: It's impossible.

Have you heard of the "crisis" in mammography? What is this crisis? Well, since every woman over the age of forty needs a mammogram every year, there is a never ending -- and right now constantly enlarging -- pool of women needing mammography. There are tens of millions of mammograms that need to be done every year. However, increasingly, doctors, hospitals, and clinics are dropping the procedure from their repertoire of imaging studies. It is getting harder and harder to get routine mammograms scheduled, done, interpreted and acted upon in a timely fashion. Eh? How can that be?

The Confederacy of Dunces

There are three large, important, forces of influence that shape the face of mammography in the United States. Ten seconds to guess them.

Did you say the millions of women over age 40? Wrong.

Did you say physicians, scientists, or mammographers? Wrong.

The ruling Iron Troika of mammography consists of: The government, Mammactivists, and Torters. These are the groups that, in reality, have the most influence over how mammography gets done -- or not done -- in the United States. The "crisis" in mammography is directly related to the perverse influence of these three groups on that procedure.

In a previous post I wrote about Mammactivists Killing the Mammogram. Burdensome, expensive, superfluous and redundant anti-market legislation promulgated by "disease-specific" breast cancer lobbyists and approved by weak-kneed legislators has created thousands of pages of regulations controlling the entire process of mammography, from the building the machine is in, to the developing fluid used in the photographic process.

To comply with these regulations (the laws, that is) is expensive and time-consuming. These costs -- added to all the other fixed overhead of a women's center -- make mammography a money loser.

Medicare -- run by the federal government -- has, over the years, slashed the reimbursement for obtaining and interpreting mammograms under the claim that if the examination is too expensive, fewer women will obtain it.

Add to these factors the ever present Torters (go here if you are unfamiliar with this beast) who have turned mammography interpretation into one of the greatest liability risks in all of health care, and...voila! A crisis exists.

Low reimbursement, burdensome federal regulations and the constant threat of lawsuits make mammography an undesirable task for any radiologist. As a result, only a small percentage of radiologists will interpret mammography. In many communities it is hard enough to find one radiologist who will interpret mammography, let alone another radiologist to reread the thousands of mammograms done in any given center each year.

Ineluctable Cell Logic

This is a breast cancer cell. Some of these cells double every 120 days. So a cancer that is barely visible and highly curable -- say 3mm -- today, could have a dramatically worse prognosis in a year, at over 2 cm.

The Iron Troikites all claim that what they do is for the "good" of women.

• Mammactivists claim that their legislation helps protect women from substandard equipment, facilities and doctors
• The government claims that by forcing lower reimbursements, they are allowing more women access to mammography
• Torters snap away about how liability lawsuits protect women from bad doctors

What, actually, are the consequences of their good intentions? The "Iron" in their title stands for irony because, the consequences of these good intentions are:

• Radiologists are being driven away from women's imaging
• Clinics are closing their doors
• Mammograms are not double-read which would detect 15 more cancers in addition to every hundred breast cancers found...meaning, if these women are lucky their missed cancers (that could have been detected this year) will only grow "a little" before next year's mammogram
• New, more expensive technology-- such as digital mammography and MRI of the breast -- is adopted slowly and limitedly

In the next installment I'll discuss how digital mammography and the breast MRI fall victim to the final irony of the Troika.

i-Mammo: The Mammogram You Never Had

iMammo: The Mammogram You Never Had

This is an article in two parts. Today, in Part I:

The Music of Digital Mammography

• What is digital (computerized) mammography?
• How does digital mammography compare with traditional (x-ray film) mammography?
• What are the advantages of digital; mammography?

Tomorrow, in Part II:

The Fellowship of the Ring: Digital Mammography, Cancer Detection and Consumer Choice

• The dirty little secret of mammography: We could find 15% more cancers every year.
• If digital mammography is so great why don't you know more about it?
• Why don't you have it?
• Consumer choice in medicine: The role of feedback and consumer choice in the adoption of expensive, beneficial new technology

From Part I:

"As a radiologist who has read mammograms for fifteen years, I cannot tell you how many times I have had to deal with a woman’s entire twenty year folder of mammograms that has been completely lost.

Not to mention the uncountable times I’ve opened a patient’s mammogram x-ray folder to find someone else’s mammograms mixed in with the folder, or the wrong name flashed onto the patient’s film, or films degraded by age, humidity or insects!"

Part I:

The Music of Digital Mammography

Make It New

In the mid 1980’s, a small display of weird and untamed jewel boxes began to crop up in an obscure corner of Manhattan’s Tower Records.

There were always people standing around the odd kiosk. Curious shoppers opened and closed the hard plastic cases (this was before the world was catastrophically altered forever by the advent of shrink-wrapped merchandise); and, occasionally, someone would stick an index finger down, bringing back a small shiny silver disc: the CD.

The whisperers in the corners were saying something bizarre and unfathomable: One day CD's would replace the beloved vinyl LP record album. To most, this seemed patent nonsense. After all, vinyl reproduced a sound that was warm and complex. The CD screeched music that was tinny, cold, shallow, and bright. Worse, the Paleolithic disc players were more like toasters than turntables: no cartridges or needles or platters…the entire system totally without character or class.The CD was ridiculed and dismissed along with the digital music it so outrageously produced from the zeroes and ones pressed into its sectors.

In just a few years the marketplace had spoken. Manufactures heeded criticisms and beefed up the sound. Hundreds of competitors -- high and low end -- vied to establish themselves all along the chain of production and sales as the entire audio industry rushed to backfit the convenience and portability of CD's with consumer taste, preference and choice. In an historic flash, the vinyl LP was a memory as quaint as the fedora.

Parallel Collision

Much the same story has played out, on a parallel course, in the history of breast imaging and mammography. Digital mammography, once a freakish technology relegated to pre-biopsy localization, has emerged on the imaging scene with full-field technology, boasting all the power of the digital technique and format. Only this time the technology has penetrated the market with less ferocity, an important catalyst to the adoption process missing: the consumer. Standing on the third-party-payer sideline, removed from the all-important feedback loop, the consumer power of the end-user is divorced from the marketplace evolution of a medical technology whose time has come.

Last month, in the American Journal of Roentgenology (abstract), researchers from the George Washington University published a powerful study demonstrating one of the great benefits of Full Field Digital Mammography (FFDM); namely, the opportunity, with the click of a mouse button, to have a computer recheck the mammogram and alert the radiologist to areas of mass or abnormal calcium that may have been overlooked. These are areas under suspicion for cancer. This technology, Computer Aided Detection (CAD) serves as a “second look” at the mammogram. “Second-looks” have long been highly recommended by the literature as a way to improve cancer detection. However, before digital imaging, a second-look required a second radiologist to read the mammogram. The high liability risk, burdensome Federal regulations, and low reimbursement that saddle mammography make it hard enough to find any radiologist to read a mammogram once. Twice is almost out of the question. But with FFDM, a second read is a mouse click away.

What are the other advantages of FFDM?

Buggy Whips and Cameras

Standard mammograms are x-rays and they are analogous to the old style cameras you used to take photographs with, only replace LIGHT with X-RAYS. An x-ray is generated and it passes through the breast taking a “picture” on a piece of photographic film on the other side of the breast. If you take a bad photo (or a bad mammogram, which is a common occurrence) you can either live with the obscured image or you can repeat the photo.

Digital images also use x-rays (and the dose is low – about the same as a mammogram) but a bad image does not have to be repeated. Think of your digital camera at home, and what you can do with the images on the computer. It’s the same case with FFDM. The radiologist simply adjusts the settings on a computer and fixes the problem. So, the first benefit is:

• Fewer repeat mammograms

therefore less radiation exposure to the breast

Being able to manipulate the image (changing contrast, density, magnification and orientation), also lets one study the breast more thoroughly, changing parameters to try and better detect a cancer that may be hiding, or nested, in a confusing array of breast opacities. So digital mammography affords the radiologist

• New ways to detect hiding cancers

therefore potentially improving survival rates

Just as a PC’s iTunes folder – with thousands of songs – has replaced the giant shelves needed to hold and store LP records, digital mammograms can be kept and backed-up on secure computer servers: No more lost, mislabeled, mixed-up, and unretrieveable x-ray mammograms.

As a radiologist who has read mammograms for fifteen years, I cannot tell you how many times I have had to deal with a woman’s entire twenty-year folder of mammograms that has been completely lost.

Not to mention the uncountable times I’ve opened a patient’s mammogram x-ray folder to find someone else’s mammograms mixed in with the folder, or the wrong name flashed onto the patient’s film, or films physically degraded by age, humidity or insects! Digital mammography offers:

• Storage and retrieval is safe, secure, accurate and ample

Tomorrow: Part II and the conclusion of iMammo: The Mammogram You Never Had

Includes:

• The dirty little secret of mammography: we could find 15% more cancers on mammograms every year…but we don’t. Why?
• If digital mammography is so great why doesn’t everyone offer it?
• If digital mammography is so great why don’t you know anything about it?

Terri Schiavo R.I.P. Part III: The Brain Speaks

Terri Schiavo R.I.P.

The CodeBlueBlog Papers

Part III

This is a summation in three parts.

Part I is here.

Part II is here.

The Third Revelation

After looking at the medical records of TS late in the game (the feeding tube was to be withdrawn any day), last month, I was emailed a link at the The EmpireJournal that gave a chronology of TS's hospitalization, purportedly written by caregivers on the scene. Three CT scans of the brain were listed thus:

2/25: Normal

2/27: Normal

3/30:  noncommunicating hydrocephalus, changes occurred since 2/27 exam

One must remember that a cornerstone of the "dead cortex/dead brain" rhetoric was that there had occurred, before hospital admission, a massive event of hypoxia-anoxia. What does this mean?

Hypoxia means low oxygen concentration (in this case to the brain) and anoxia means no oxygen. The mechanism finally settled on that was blamed for the hypoxia/anoxia was dysrythmmia/arrhythmia of the heart (ineffective heart pumping due to "electrical" disturbance) secondary to potassium deficiency brought on by diet change.

Translated, this means that TS had severe dietary changes that lead to a decrease in blood potassium that disrupted the normal electrical activity that stimulates the heart to beat (contract and relax). The heart thus contracted abnormally, leading to severe decreased blood flow to the brain and resulting in oxygen deprivation. This lack of blood flow/oxygen severely injured the cerebral cortex.

There are plenty of medical arguments and issues that can be raised regarding the above paragraph and the proposed scenario. None of that is important in my analysis. I am starting from the assumption -- now taken as fact -- that TS suffered severe oxygen deprivation to the brain causing massive anoxic (oxygen deprivation) damage to the cortex before she ever reached the emergency room.

Brain cortex is extremely sensitive to oxygen levels in the blood, and certainly, when there is prolonged oxygen deprivation, widespread cortical injury and  destruction can occur. The experts who repeatedly showed TS's CT brain slice in the media were supporting a direct chain of events from:

irregular heart beat ---> oxygen deprivation ---> cortical injury ---> massive atrophy

In order to manifest that degree of cortical atrophy from the single assumed event of hypoxia/anoxia, before admission, the degree of cortical damage, at the time of oxygen deprivation, must have been great.

So how was the CT scan at 48 hours negative?

Mechanisms of Madness

Severe hypoxia/anoxia leads to rapid injury of the cells in the brain's cortex. When the cells are severely damaged, they leak fluid. This fluid rapidly accumulates in the closed space of the skull.

Damage to the brain, from oxygen loss, has been shown to occur within twenty minutes, and in severe cases, begins to show on CT scans within hours. In a case such as TS, where there is proposed massive damage, one would expect massive reaction to the damage. After 24 hours there usually is substantial brain swelling in a case such as this, evident on the CT scan.

My experience with the handful of cases I've seen is that the CT evidence of massive hypoxia/anoxia (of the extent being proposed by the experts who point to TS's CT) is evident soon after the event. By 24 hours, I'd be surprised not to see some evidence; and, if I did not see swelling and abnormalities by 48 hours after the event, I would be perplexed enough to seek alternative explanations or a reevaluation of the case.

Most research concerning massive hypoxia and anoxia is in newborns, and, obviously, a newborn brain is different from an adult brain. Nonetheless, here's a report from one study:

Hypoxic-ischemic insults to the central nervous system of infants may show a characteristic sequence of imaging findings. CT immediately after the insult may be normal or near normal in appearance. Over 24-48 hours, diffuse cerebral edema causes loss of the distinction between grey and white matter, obliteration of cortical sulci, and diffuse low density

Here's a case, reported in the Japanese literature of a woman who suffered massive cerebral anoxia/hypoxia and had immediate follow-up CT (after resuscitation). According to the authors:

CT revealed massive cerebral edema soon after resuscitation ...

And a repeat CT the next day showed:

on the following day (after anoxia/hypoxia) the CT demonstrated low attenuation area of white matter and gray matter in the cerebrum and brainstem

By 48 hours it is hard to imagine that the CT scan would not show some evidence of swelling and/or changes in the relative appearance of different parts of the brain.

The cases of massive hypoxia/anoxia I have seen, have been in adults, and have been grossly, markedly abnormal by 24-48 hours. The swelling can be so bad that a neurosurgeon has to remove a part of the skull so that the brain has an outlet to bulge.

Some have written me to explain that the CT used may have been an old model and not been as sensitive as newer models; however, as early as 1983 The American Journal of Radiology (AJR Am J Roentgenol. 1983 Dec;141(6):1227-32), reporting on a study of adults said:

Even with no clinical information, neuroradiologists can assess CT signs of cerebral infarction within the first 6 hours of symptom onset with moderate to substantial interobserver agreement.

I was incredulous to read that TS's CT was interpreted as "normal" 48 hours after the proposed event of hypoxia/anoxia. Surely, given the amount of damage being proposed in the media -- with that famous CT slice -- there would be some sign of the brain's distress at 48 hours. But the CT report produced on The Empire Journal said that the 48 hour CT was "normal." And a CT report from a scan done one month later (3/30) reported "noncommunicating hydrocephalus, changes occurred since 2/27 exam." This report was given by a different radiologist than the report of 2/27, indicating that this different radiologist re-evaluated the CT of 2/27 to compare it with 3/30, so the CT of 2/27 was seen twice, by two experts.

Pictures at an Exhibition

Here are some CT images of brains -- taken at 24 hours -- that suffered massive hypoxia/anoxia:

                     

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These brains show diffuse swelling, with loss of the normal spaces between cortical folds, and abnormally different shades of "grayness" that are immediately evident to an interpreter. According to a prominent University's teaching file, here are the CT findings of massive cerebral hypoxia/anoxia after 24 hours:

CT immediately after the insult may be normal or near normal in appearance. Over 24-48 hours, diffuse cerebral edema causes loss of the distinction between grey and white matter, obliteration of cortical sulci, and diffuse low density. Frequently there is relative sparing of the cerebellum and or basal ganglia which appear hyperdense compared to the abnormally low density cerebral hemispheres.

Mirrored Spectacles

How could this be?

Here are the possibilities:

• I think that the least likely explanation is that the CT actually was negative.
• The CT may have been misinterpreted. Sometimes when there is uniform, massive abnormality -- and all things in the brain are equally abnormal -- there can be the phenomenon when the interpreter sees everything in a uniform state and calls it negative. This happens, and it is not necessarily malpractice or incompetence. Interpreting CT's is just that: interpreting. I look at a Rorschach image and call it a butterfly, you call it a wildebeest. However, given the history of a massive event of anoxia/ hypoxia, one is usually on the alert for the appropriate changes.

• The CT scanner may have been an old model that was less sensitive than newer models available at that time. Not everyone upgrades their equipment every time a new generation of equipment is available, same way you don't upgrade your computer every time there is a new memory chip. Older CT's in 1990, could produce pretty poor images, at times, and if you throw in a little motion artifact (patient moving her head, etc), the combination of these two factors might lead to misinterpretation.

• The CT was actually negative, or normal. If the CT was actually normal, it is hard to postulate massive hypoxic injury two days prior. So if the brain was really negative, then the inciting event (massive hypoxia/anoxia) did not occur before TS was admitted to the hospital, it occurred after she arrived at the ER on 2/25/90 occurred after that time.

My impression that this discrepancy needed -- at the very least -- to be reevaluated by a second look at those CT scans before the removal of TS's feeding tube, lead to my attempts to draw attention to my observations.

Once again, my only contention when I reported this finding was that it needs to be explained. That's all. Like the bone scan, it is difficult for me to understand how results like these could be left alone and not commented upon. This was the crux of my issue. If one does not explain why the bone scan was abnormal or why the CT scans did not fit the clinical history, then by everything I know and have learned, one is obligated to investigate and pursue.

Terri Schiavo R.I.P. Part II: The Story In The Bones

Terri Schiavo R.I.P.: The CodeBlueBlog Papers

Part II

Reconstructing the Dinosaur

Following-up a reader's link, I found the report of a bone scan done on Terri Schiavo in 4/91. This gave me the second real "jolt" in as many days looking at some of the medical details of the TS case.

First, the chronology is important here:

2/25/90  TS admitted to hospital

4/91  Bone Scan

I won't get into why the bone scan was ordered, but there are a lot of interesting avenues of exploration regarding that question. Note that the bone scan is done 14 months after admission.

Scanning Bones

A bone scan is a test wherein a minuscule amount of radioactive material is attached to a molecule that seeks out bone that is rapidly changing. Bones change rapidly when they are broken, or damaged, as in fractures, cancer, and infection. The patient receives the injection then several hours later lies on a table under a camera that is sensitive to the radioactive emissions. It's like a Geiger counter that takes a picture.

Here's what it looks like when it's done:

 

A radiologist then looks at the study and interprets the image and the pattern of radioactive uptake. One learns to discern the different patterns of normal and abnormal uptake and to suggest what abnormal patterns mean.

Here is an abnormal pattern typical for the spread of cancer to the bones:

Certain patterns of abnormal uptake are so familiar, and common, that most radiologists can instantly give,  with good confidence, a diagnosis. In the image to the left, I'm guessing that there would be 99% agreement of radiologists interpreting this exam as "metastases;" or, spread of cancer to the bones.

Other patterns are not as diagnostic, and the job of the radiologist is to generate a list of possible reasons -- generally from most likely to least likely -- for the appearance observed on the bone scan.

The Patterns of Abuse: Ribs

One pattern of bone scan uptake radiology residents are taught to recognize is that associated with child abuse. Abused children often cannot speak for themselves, and so when a child is brought to the ER with unusual or repetitive bone or head injuries, it is the job of the ER and  radiology staffs to sniff out child abuse and act to protect the child. It's not just their job, it's the law. Physicians and other allied health professionals are mandated by law in all 50 states and the District of Columbia to report suspected abuse within 48 hours to Children’s Protective Services .

The radiologist who interpreted TS's bone scan described areas of abnormal uptake that suggested fractures in the ribs, lumbar spine, as well as an unusual pattern of abnormal uptake in the lower right thigh.  As I've previously discussed, multiple rib fractures, spinal compression fractures, and long bone injuries are a typical pattern in abuse. If one sees that pattern on a person who is at risk of abuse, one should suggest abuse as a diagnosis and investigate further. It is especially relevant that several of TS's rib fractures are in her back near her spine. If you reach around to your own back, you'll feel the central longitudinal depression that represents your spine, then, on either side of that depression there are humps representing your ribs as they arch out from their spine attachments to begin their circular course around your chest. TS had abnormal bone scan uptake in several ribs in this area. It is difficult to fracture your ribs in this area, and it generally takes a direct blow to do it. Therefore, in TS's instance,  one must postulate a mechanism for these rib fractures. Being dropped on the back is one reasonable mechanism that can be postulated for a bedridden patient.

The Patterns of Abuse: Vertebrae

The abnormal uptake in the first lumbar vertebral body ("L1") is also interesting. The radiologist suggested that the uptake was typical for a fracture and, in fact, he then confirmed that impression by obtaining an X-ray (not done for the ribs) that indeed showed a fracture of the upper part of L1.

The vertebrae are the bones that surround the spine. They extend from the base of the skull to the tail bone. Here is an image of the human vertebrae:

Look down to the last fully formed square vertebra. That is L5. Count upwards until you get to L1. That's the vertebra that was fractured.

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Here is an image of the type of L1 fracture that was described in TS (double-click to enlarge):

The deformity of the upper half of the L1 vertebra, demonstrated above, is a typical fracture called a "compression" fracture. It is called a compression fracture because it is caused by compressive forces. To compress L1 one must push down on it (called "axial loading") or produce a squeezing like force on it, the same way you might crush a small square cardboard box between your palms. So how might we explain the presence of a compression fracture of L1 in TS? It is difficult to produce an axial load on a bedridden patient. I really can't think of many ways unless one were to drop her on her bottom.

According to the prestigious Armed Forces Institute of Pathology:

Any spinal fracture without good accidental explanation, especially in an infant, is suggestive of abuse.

The Patterns of Abuse: Long Bones

The bone scan showed a linear area of abnormal uptake over the lower right thighbone (the femur) and, an accompanying X-ray revealed an unusual finding. This finding was described by the radiologist as "periosteal elevation."

The periosteum is a skin-like layer that wraps around the bone's surface. It is rich in blood vessels and nerve fibers. In this image, the periosteum is the blue layer:

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Here is the upper arm bone of an abused  child:

Look at the bright white area in the middle of the upper part of the arm bone (towards your right in this image). Just above that very white area there is a black line and then a white line. That white line is the periosteum which is lifted off of the bone (= periosteal elevation).

In the abused, periosteal elevation can be caused by bleeding (remember that periosteum has many blood vessels in it) underneath the periosteum which can be initiated by pulling or twisting violently. In a bed-ridden patient one could postulate periosteal elevation of the lower femur being caused by pulling or twisting the patient by the foot or ankle.

Nursing homes and assisted living facilities are recently much under scrutiny for recent reports, including a congressional committee reporting physical abuse of people under their care. The Associated Press reported:

An 18-month congressional investigation has concluded that many physical and sexual abuse cases in nursing homes are not treated the same way as similar crimes elsewhere.

Patients have been dragged down hallways, doused with ice water, sexually assaulted and beaten in their beds, yet few prosecutions or serious penalties have resulted, the investigation found.

2 + 2 = ?

Reading the radiologist's report on the combination of the three findings on the bone scan (ribs, L1, femur), my very first thought was that this would be a typical pattern for abuse. Especially in a bedridden patient with limited responsiveness. Although there certainly may be other explanations for the findings,  I believe that one would be obligated to exclude abuse.

When would the abuse have occurred?

The radiologist reported relatively intense radioactive display on the scan, suggesting a recent injury. I would say anywhere in the previous weeks to month. It is difficult to say without seeing the scan itself. Certainly, after such an injury, the bone scan gradually improves, with healing, and there should be little, if any abnormal uptake after one year.

So, if TS was admitted to the hospital on 2/25/90, and the abnormal bone scan was done in 4/91, then the action(s) that lead to the abnormal scan would have occurred during the hospitalization.

For all the outcry my hypothesis about abuse made, I really don't believe any of this is a far stretch of the imagination; and, in my opinion, this hypothesis knits together the facts better than any other.

Tomorrow: Part II Continued...

Terri Schiavo: R.I.P. CodeBlueBlog Summarizes the Case, Answers Critics, And Offers Further Explanations

After The Deluge

My method for dealing with the thousands of emails, hundreds of posts and far-flung inquiries has been to try to read them all and triage my responses.

Major issues -- regarding my Schiavo posts only --  raised repeatedly on the boards are:

• the method of my blog
• the tenor of my message
• my orientation and biases
• my "interpreting" and "diagnosing" from one single cut of a 1996 CT scan
• my "interpreting" and "diagnosing" a bone scan report done in 4/91; and, two CT reports done on 2/25/90, and 2/27/90
• criticism /questioning of experts
• my credentials and expertise
• my unabashed listing of my credentials and expertise

I am going to encapsulate my coverage of the case -- including the CT scans and bone scan -- while explaining and defending my positions.

This is the first of TWO PARTS:

PART ONE

My Way: The Method

It is important for all readers to understand that this is a personal web log, or blog. This is my personal blog, run for no profit, designed mainly as an outlet for my opinions.

These are opinions. Like all opinions, they may be loud or soft, informed or rash, prescient or foolhardy.

This is neither a newspaper nor a scientific journal. I do not present my ideas as peer-reviewed, double-blinded results.  People frequently -- and harshly --question my qualifications to express the things that I say. In the past I have responded (sometimes pre-emptively) with a discussion of my expertise or experience. This in itself has instigated harsh rebukes from some who claim I am thus being arrogant or supercilious. I have found this "Catch 22" to be impossible to deal with so I am resolved to mostly not defend myself by constantly restating what I know, where I trained, and how my light is spent. Reader are referred to my about page.

My blog represents what I'm thinking as I read the news. I am usually asking questions. It's sort of letting you into my perspective as I read things in the headlines that don't make sense or don't fit correctly or don't add up -- according to my fund of knowledge. If that is useful for people...good; they'll read and benefit. If it is not useful, then people Will move on.

I will continue to ask questions in this blog. Because almost nothing I read or hear-- about health care and specific medical issues-- from MSM makes sense to me.

And, although I am happy to explain the rationale for my thinking, or the process through which I came to my conclusions, I cannot spend endless hours of time involved in circular arguments repeating things I've said in a different way.

So, if you are interested in the questions that occur to me as I read about the medical issues of people in the news;  the health care studies and advice that are generated daily; as well as the medical news, tune in and take a few minutes to see what's going on from my vantage point.

I guarantee you two things. My vantage point is almost always different from what you are hearing and reading. And I can afford you insights to the health care system you may not otherwise be privy to.

The Tenor: or Soprano?

Until the Terri Schiavo posts, my blog has basically been a small circulation letter to regular readers. Sure, during posts about Yasser Arafat and Viktor Yushchenko, I had a lot of visitors from around the blogosphere; however, they were mostly searches and one-time hits.

Regular readers are used to my style, and I am used to their responses. With the Terri Schiavo posts my style of writing in this blog was suddenly broken open to a wide audience, and many had severe stylistic objections, which I understand.

I have taken this under serious consideration. Certainly if there are going to be large numbers of readers who come repetitively to this URL, I cannot expect them all to be my regulars who are familiar with me, what I stand for, and how I express myself; so, this is certainly something I will monitor and adjust as need be.

The Schiavo Issues

None of this changes the observations I have made on the Schiavo case and I stand by every single one of them. I have been grilled -- live -- on the radio twice by neurologists, neuroradiologists, and sundry experts concerning everything I have said, and I have not been knocked off any point.

The problem always seems to come down to people not reading what I said. Because I usually mean exactly what I say and no more. But people cannot help expanding,  changing, and transmuting what I've written.

Orientation

I do not come from the perspectives of what people would consider a strict "right to lifer," the "religious right," or a "radical conservative."

My original issue was the feeding tube.  I did not -- and still do not --understand how food and water came under the rubric of life support in the same category as intubation, forced breathing, and cardiac pacing. The best analogy I can use is the Foley catheter (tube through the urethra into the urinary bladder to allow urine to drain). If you are going to remove food, then why allow patients to urinate?

As a physician, I strongly object to actuating death. That is not what I was trained to do, and if society decides that is what it wants, I would propose some different professionals be assigned the duty to pull these tubes when the law orders it. For me, as a physician, it is an act that is inimical to all the reasons I went into the health care field.

Making terminal patients comfortable during their last days is, to me, is in a different philosophical and ethical cosmos than removing a feeding tube from a severely impaired patient.

The Infamous CT Scan

I saw, and heard neurologists, ethicists, and hospice physicians in media outlets such as NPR,  Fox News, MSNBC, CNN, and all the newspapers, declaring that Terri Schiavo's higher brain functions were nil. To describe this they used terms like: "her brain is: "water," a "bag of water," and "totally without cortex." One medical ethicist on NPR said (paraphrased) that Terri's brain was completely without a functioning cortex and since the cortex is where the complex functions and emotions of life are carried out, she is therefore not alive, but dead.

I, like every one else I assume, took this as it was stated (it didn't change my mind about the feeding tube anyway) until I stumbled on the single mid-ventricular CT image of Terri's brain that was done either in 1996 or 2002 (no matter).

Upon seeing the CT slice I was shocked that, yes there was severe atrophy, yes, there was severe damage, and yes the cortex was markedly thinned, but the CT itself did not reflect the descriptions I'd heard; and worse, I have seen many old and debilitated nursing home/assisted living patients as well as younger patients with chronic brain damage, with similar or worse atrophy. And not all of these patients were nonfunctioning.

That same CT slice was used as a visual graphic on television and in the newspapers -- by the same group of experts -- to demonstrate why Terri Schiavo was suitable for euthanasia. I objected to this strongly as, to me, the implications for all the other patients with similar or worse CT scans was morally and ethically frightening (talk about slippery slopes!).

I've been heavily criticized as unethically interpreting Terri's CT from this single slice, and speculating from the limited data. Let's get something straight. First, this was the only slice available. Second, it was the same and only slice everyone other expert was commenting upon. The University of Miami bioethics webpage thought it was appropriate to use that single slice on their web page as a testament to Terri's brain damage. Third, I made observations, not a diagnosis. Fourth, this was a scan done in the remote past. Looking at that slice and speculating about questions it raises is no more unethical than looking at a fossil and speculating on the size and shape of a dinosaur. It's a fragment of an old map, or a puzzle. And putting puzzles together to try and figure out possibilities is one of the things radiologists do for a living.

I also felt strongly that it was disingenuous for experts to put Terri's CT slice side-by-side with a normal 25 year-old female's CT. To the nontrained eye, the striking disparity nailed the case shut. To me that was unfair journalism and tendentious in the worst way. It would have been far more appropriate to put up the CT of a patient with severe cerebral palsy or chronic atherosclerosis. But this would not have made their case so strong, and one must question why these experts were given a pass for passing judgment on a single slice of a CT and for a deceptive comparison. I certainly was given no similar pass by readers and commentators when I said something different using the same data set.

It is also my contention that if the media are going to  use limited data to solidify important and weighty issues, then there better be someone in the audience who asks these questions. Because the reporters don't The reporters and interviewers often try to probe deeper, but they cannot sidestep trained physicians and academics whose depth of knowledge and familiarity with the issues easily circumvent and obviate any inquiry that might undermine their theory or proposal. I have never seen a medical "expert" exposed, thwarted or seriously undermined by a question from the journalistic audience. I am reminded strongly of press conference at Columbia Presbyterian last month (covered in CodeBlueBlog) where the physicians told the audience that he was undergoing a "routine procedure for a rare complication" when actually he was undergoing a complex operation for a common complication. The statement went unchallenged (and no thanks to all of the mean-spirited bloggists who did not read my pieces on the Clinton case and proceeded to use my analysis of that case to label me as a gadfly, and much worse).

End of Part One.

Part Two will discuss the bone scan, the defense of my observation,  Terri's two CT scans done after initial admission to the hospital; and, my $100,000 challenge.

CodeBlueBlog Issues $100,000 Challenge to Terri Schiavo Neurologist Experts

A Few Good Men

I'm getting tired of hearing what neurologists have to say about Terri Schiavo's CT of the brain. Real Tired. The Florida Sun Sentinel had a gang of neurologists analyze one of Terri's CT's of the brain. Here's what they said:

About 70 percent to 90 percent of Schiavo's upper brain is gone, and there's also damage to her lower brain that controls instinctive functions such as breathing and swallowing, said three Florida neurologists who viewed 12 of her CT "computed tomography" X-ray scans Tuesday and Wednesday.

"This is as severe brain damage as I've ever seen," said Dr. Leon Prockop, a professor and former chairman of neurology at the University of South Florida College of Medicine in Tampa, upon viewing the scans.

Then there's the infamous Dr. Ronald Cranford, who has the double-whammy credentials of neurologist AND bioethicist (have you had enough of bioethicists for a while? Why is it they all have the same opinion and they all start out their spiels by saying "this is a tragic case for everyone involved...") who also defined Terri's CT of the brain as  being as bad as he's seen.

So What Have You Seen?

I've watched a steady stream of neurologists, bioethicists, and neurologist/bioethicists from Columbia, Cornell, and NYU interviewed all week on Fox and CNN and MSNBC. They all said about the same thing, that Terri's CT scan was "the worst they'd ever seen"or "as bad as they've ever seen."

Here's the problem with these experts: THEY DON'T INTERPRET CT SCANS OF THE BRAIN. RADIOLOGISTS DO.

*Oh*

You see, a neurologist will look at the CT of the brain of one of his patients, but this is entirely different from interpreting CT's of the brain de novo, for a living, every day, without knowing the diagnosis and most times without a good history. In addition, whereas I heard Dr. Crandon say he's "seen" a thousand brain CT's... well I've interpreted over 10,000 brain CT's. There's a big difference.

When I look at a CT of the brain every case is a new mystery about a patient Idon't know. I must look at the images, come to a conclusion, dictate my findings and report a conclusion. This becomes a part of the official legal record for which I am liable. I bill Medicare for a CT interpretation and am paid for this service.

Neurologists do not do this. They don't go on the record, alone, in written legal documents stating their impressions about CT's of the brain. The neurologist doesn't get sued for making a mistake on an opinion of a CT of the brain THE RADIOLOGIST DOES.

A neurologist has no where near this type of practical experience. And their cases are skewed according to where they practice and what their specialty is. Now, some of my best friends and some of the smartest docs I eve4r met are neurologists, but that doesn't change my observation that most neurologists I've met, in my experience, show an incomplete grasp of the nuances involved in image interpretation.

I have seen several neurologists -- in the printed media and on television -- put up a Representative CT of the brain of a normal 25 year old female and contrast this with Terri Schiavo's CT. This is a totally spurious comparison. No one is disputing that Terri Schiavo does not have the CT of a 25 year old female.

What I'm saying is that Terri Schiavo's CT could be the brain of an eighty or ninety year old person who is not in a vegetative state. THOSE are the CT scans we should be showing next to Schiavo's, because in THAT case you would see similar atrophy and a brain much closer to Schiavo's.

Who Wants To Be A Millionaire?

To prove my point I am offering $100,000 on a $25,000 wager for ANY neurologist (and $125,000 for any neurologist/bioethicist) involved in Terri Schiavo's case--including all the neurologists reviewed on television and in the newspapers who can accurately single out PVS patients from functioning patients with better than 60% accuracy on CT scans.

I will provide 100 single cuts from 100 different patient's brain CT's. All the neurologist has to do is say which ones represent patients with PVS and which do not.

If the neurologist can be right 6 out of 10 times he wins the $100,000.

I Said What I Meant, And I Meant What I Said

My points are what I first said about the image from Terri Schiavo's CT scan:

1) It is NOT as bad as the neurologists and bioethicists play it up to be; and,

2) There are many elderly patients with various levels of mental functioning who have severe atrophy that is difficult to distinguish from Terri Schiavo's atrophy

I stand by what I said. And I'm putting my money where my mouth is.

Terri Schiavo and The Living Will: We Will Never Swallow The Same Again

Does It Matter That Terri Can't Swallow? No.

The Absent Reflex

Much has been made over the issue of Terri Schiavo’s swallowing. It is because Schiavo cannot swallow that a feeding tube was inserted directly into her stomach.. It is this feeding tube that has been the object of gargantuan legal, moral and ethical struggles.

But what is swallowing and why should it carry such import?

There are three stages of swallowing: the oral, chewing phase; the pharyngeal reflex phase wherein the food is propelled over the vocal cords and into the esophagus; and, the esophageal stage, during which food travels to the stomach.

The fight over Terri Schiavo involves only one of these three stages and that is the pharyngeal stage.

During the pharyngeal stage of swallowing, the body senses there is food in the back of the throat. This “sensation,” initiates a reflex:  an involuntary muscle contraction akin to a knee jerk.

In one rapid sequence the body shutters the nearby opening to the lungs (the trachea) and shunts the food to the esophagus. The reflex is over and the food travels down the esophagus to the stomach.

Swallowing, Breathing, Beating – Not The Same Family

In this way swallowing is entirely different from breathing and heart beating. Breathing and heart beating go on constantly, without stop. Although they too have reflex properties associated with certain of their functions, the motors for breathing and heart beating are in an ever-on position, the alteration of which would mean rapid demise of the organism.

This is not the case with swallowing which, being a reflex, is only used sporadically, during feeding. This is the crux of the case that has been ignored – no abused – by the ethicists and lawyers involved with the Terri Schiavo case.

Most reflex circuits are local, and wired differently from other motor functions. When there is pizza in the back of the mouth the body cannot wait for the cerebral cortex to give permission to swallow. Instead, the rapid swallowing reflex obeys a different, shorter circuit, (much the same as the knee jerk) involving a brief pathway to the nearby brainstem. Studies show that the cerebral cortex is important only in the voluntary initiation of swallowing.

So Why Are We So Focused on Terri’s Cerebral Cortex?

Neurologists, ethicists and hospice specialists are parading across the news each day affirming that Terri Schiavo has so little cerebral cortex that she cannot possibly think, feel or act volitionally. Yet the debate over ending her life is centered NOT on any essentially cortical activity – the debate is over a reflex that occurs on a different neurological level.

What the courts have decided is that because Terri Schiavo has lost the ability to initiate and reproduce this local, noncortical neurological reflex, her fate rests in the hands of Michael Schiavo.

The obtrusive error that has been made here, by the ethicists and the courts, is in centering this case on that reflex.

There can be no doubt that if Terri Schiavo maintained the brainstem swallowing reflex -- everything else being equal -- there would be no court case, and no national hand-wringing. Ms. Schiavo would be left alone to live out her life under the care of her parents.

But we should no more be basing the life and death of Terri Schiavo on this reflex than we should on a knee jerk.

Can’t Pee? Stay Away From Florida’s Courts

What the courts have done is to pick one reflexive neural pathway and decide that this is the critical and key determinant of life and death.

The mistake that has been made – the knot that is being undone – is in centering this legal and ethical decision around the swallowing reflex. Because, the case can now be made that other similar reflexes may similarly be exploited.

Namely, I am thinking of micturation. Urination. Peeing.

Urinating is more akin to swallowing than swallowing is to breathing or heart beating. The urinary bladder fills with liquid and thus stimulates neuroreceptors in the bladder wall that in turn leads to the urination reflex.

Another Tube, Another Problem?

More frequently than swallowing, urinating is a reflexive process that is frequently dysfunctional. For many reasons there are people who cannot adequately perform this reflex and who therefore need the assistance of a tube. In this case it is not a feeding tube allowing ingress to the body; rather, it is a urinary catheter which allows egress.

Tens of thousands of Americans live today with catheters in their urinary bladders. These catheters may be transurethral (through the penis or female urethra) or percutaneous (stuck through the body wall directly into the bladder).

What would happen if one were to remove the urinary catheter from those who have them? They would die. Slowly, urine would accumulate, the kidneys would become engorged via backflow, and nitrogenous wastes would build up in the bloodstream leading to coma and death.

In this sense, there is no difference between a feeding tube and a urinary catheter. So why are we not talking about removing Terri Schiavo’s urinary catheter? Why are we focused on the feeding tube?

That the courts should decide that the primitive local reflexive action of swallowing is the deciding physiological factor between life and death makes no sense physiologically, teleologically or morally.

There is nothing inherently nutritive about swallowing. Neither does the absence of this reflex necessitate death, as would one see were respiration or circulation suddenly be cut off.

The Living Will of the Future?

The bogus argument over Terri Schiavo’s “living will” or desire “not to live like this” has devolved into the presence or absence of this swallowing reflex. Therefore, all living wills in the future will, by necessity, need to be broken down into checklists of neurological items constituting an inventory of both voluntary and reflexive neurological activities that we are either willing, or not willing, to live with.

Would you live without a knee-jerk reflex? Without a sneeze? Without the exhaustive reflexes of micturation and defecation? Which will you choose?

CSI MEDBLOGS: FURTHER INVESTIGATION OF CT BRAINS TURNS UP NEW ASTOUNDING EVIDENCE

Terri Did Not Suffer Her Brain Damage Outside The Hospital--It Occurred While She Was Hospitalized

According to a time-line of physicians and therapists reports, posted on The Empire Journal, Terri's injury occurred on 2/25/90:

2/25/1990		Terri's Injury
2/25/1990	X-Ray Report Dr. Hameroff	Images taken of cervical spine, no acute bony pathology - straightening of normal cervical lordosis
2/25/1990	Neuro Consult Dr. DeSousa	Deeply comatose.  No evidence of acute process in CT scan.  Evidence of myoclonic seizures.  Rule out acute myocardiac infarction, seizures as cause.  Neck is somewhat stiff as is all of the muscles of the body.  No jugular venous distension.  WBC 26,300, drug screen negative
2/25/1990	CT Scan Report Dr. Hameroff	Normal