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« Terri Schiavo and The Living Will: We Will Never Swallow The Same Again | Main | Terri Schiavo: R.I.P. CodeBlueBlog Summarizes the Case, Answers Critics, And Offers Further Explanations »

Comments

Dear Codeblueblog:

Do you mean Dr. Cranford where you say,"whereas I heard Dr. Crandon say he's 'seen' a thousand brain CT's. . ." Also, after the CT myth is dispelled they will start carping on the purported EEG. I have not found much info on this except that movement might cause "artifact" that when screened out can mask other brain activity. I have heard she has had several EEG's but— could you comment? I must admit I have not finished reading this most recent post so if you addressed this I apologize.

JT

med student

I don't think any neurologist has said that he believes she has PVS because of the damage evident on CT. They've merely said that she has severe injury, which pretty much everyone I've heard comment on it agrees with. And, it's usually brought up in the context of why she hasn't had an MRI done, so the point is to say that you can see enough in the CT to not need an MRI. I think you are blowing way out of proportion the implications of a neurologist commenting on a CT scan anyway. To me it sounds like a radiologist whining about someone else reading his scans, just like a neurosurgeon complaining about the ortho guys stealing his spine cases. Besides, your main point is that they aren't giving a full report on the CT, but you're not either.

I just read the hydrocephalus post and still feel that there isn't a complete report on the CT image. You know what I'm talking about - couple of paragraphs explaining what you see. She obviously has hydrocephalus, I don't think anyone's disputing that. It's probably hydrocephalus ex vacuo. But, there's a lot more going on in that scan than you reported in that post.

As far as the corpus callosum goes, not all of it is an anteroposterior band - have you heard of the genu and the splenium? Granted, I definitely don't know as much as you do about radiology, but I'm pretty sure that the level of this scan would include the genu of the corpus callosum. Why do I think this? Well, the corpus callosum pretty much frames the lateral ventricles along the midline, so if we're not seeing the floor of the ventricles, the genu should still be present anterior to the ventricles. And, even though you might not be able to demarcate it very well in a regular CT, in this image there is very little tissue present where it should be.

Also, let's think of the pathogenesis of Mrs. Schiavo and the 80-90 year olds you keep bringing up. Even though the scans may look similar, the path the patient took to get there is totally different. The atrophy present in an 80 year old person usually develops over a long period of time (decades), allowing time for the plasticity of the CNS to adapt to the changes. Mrs. Schiavo's changes happened more in terms of weeks, which doesn't allow for new connections to be formed before they're lost entirely. Therefore, despite similarity in appearance, her injury is probably much more severe. So, to compare her scan to that of an 80 year old is blatantly irresponsible.

I put in the comment about neurologists commenting on images in the chart because the connotation that comes across in your original post is that they aren't qualified to decide things from a CT. You also said "They don't go on the record, alone, in written legal documents stating their impressions about CT's of the brain." Ah, but they do, when they put their interpretation into the chart. Also, they are very much at risk of getting sued if they treat based on their disagreement with a radiologist's report and the report turns out to be true. The point is that neurologists put their judgement concerning imaging on the line all the time, which is exactly the opposite of what you claim in your post. I would also argue with your point that neurologists don't look at CTs, officially, for a living. Again, they look at CTs all the time, it's part of looking at all the info you have available when you're trying to treat a patient. Does this mean they have the same expertise that a radiologist does? No, but, again, I think the sentiment coming across in your post is that we shouldn't listen to what they have to say about it. I think the gap in ability to read CTs between neurologists and radiologists is a lot smaller than you imply. It really sounds like a turf war, honestly.

John Davies

4:1 payout on a 40:60 bet?

If I had $25k I'd take the challenge and I'm not a doctor and have never seen a CT.

susano

"I didn't say they were composing symphonies or designing rocket launchers. No. They are impaired. Many severely. But don't you see what I'm trying to say? What are we going to do with those people? Starve them?"
-CodeBlue


Part of the argument for killing TS is the "life not worth living" mantra being repeated. I've asked the same question on a couple of forums. If severe head injury always has an uncertain outcome, and can end in disabilty (to whatever degree), why bother with ER & trauma heroics only to dehydrate people to death, later, when they are deemd to have a life not up to snuff. The Nazis called it "life unworthy of life" and the German people bought it.

Mike Stiber

I've said before and I'll say it again: I'm always amazed (well, by now, just disgusted) at the propensity of people to think that they can make judgments as good as the involved parties despite their almost total lack of information. The doctors and judges involved have access to an enormous amount of data and personal experience that nobody on the web does. Mrs. Schiavo's medical records have not been made public (nor should they be). Nobody in this forum has seen her in person, let alone been able to run any tests on her. Yet, person after person (including Dr. CodeBlueBlog) feels free to make a diagnosis (or dispute an existing one) based solely on their own ignorance.

Dr. CBB said: "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."

Do you have access to her complete CT? Do you have any part of it at the original resolution and pixel depth? Do you even know that what you've looked at is actually hers? (The difference between changes that occurred over decades and those that happened over days or weeks was already ably discussed by "med student".)

Maggie4Life and TG said: "As another poster stated, the EEG results are inconclusive because they filtered out tremor."

Do you know for a fact that such filtering occurred? Who says that the EEGs are inconclusive? I've been involved in work on EEGs and EMGs (electromyograms), and it seems unlikely to me that filtering for tremor would produce a "flatline" EEG. In any event, the EEG discussion is moot, because we do not have access to the information necessary to render any judgment (even if we had the expertise).

When I teach students about doing research (here I mean, "searching for information", rather than "experimentation"), just about the first thing I say is that the web is almost worthless for their purposes (immensely low signal-to-noise ratio). Not entirely; there are primary, high-quality sources out there, especially in computer-related areas. But I would say that, in this situation, the web is an especially poor source of information -- that there is almost no credible information about Mrs. Schiavo's medical condition on the web. Nor should there be. Medical information is a private matter. Mrs. Schiavo's situation is a private matter.

susano

The hell it's a private matter. The US is going to grappling with the issue of legalized euthanasia. That is a matter that will be regulated by law. It's a very public matter, and questions need to be asked about who we're going to kill. Don't you think that the general public, when saying they wouldn't want to be kept alive on a machine, and that they'd want the "plug pulled", was pretty much clueless about death by dehydration? You think maybe some living wills are being revised as people decide they wouldn't be thrilled about being starved to death? George Felos is a euthanasia advocate. He is well aware of the precedent setting implications of this case.

When you say, "I'm always amazed (well, by now, just disgusted) at the propensity of people to think that they can make judgments as good as the involved parties despite their almost total lack of information.", you discount all of the people who have spent time with her who say she is CONSCIOUS. What about the nurses who have sworn that she was able to swallow Jello? PVS cases don't swallow. How about that they have sworn she used a limited number of words - momma, help, pain, etc.? Are all of these people liars, epescially her own family? I have no idea what's true but I think that these people who have spent so much time with Terri have to be listened to. Their voices have been completely ignored. In a matter of starving and dehydrating someone to death, I think they count for something.

justwantoknow

I am beside myself - Is the Florida Judge, George Greer legally blind?

No joke . . .here is the link . . .

http://www.iht.com/articles/2005/03/17/news/judge.html

Bottom of first page:
"Greer is legally blind and has a soft voice . . ."


Say it isn't so! The judge that holds the keys to Terri Schiavo's future was metaphorically blind AND LEGALLY BLIND too?!!!!

med student

susano-
I don't know where you're getting your information about PVS, but I think it's inaccurate. Consider the following passage from Goldman: Cecil Textbook of Medicine, 22nd edition, Ch. 437 "Persistent Vegetative States and Brain Death" (This is one of the most well-established general medical texts out there, as evidenced by the fact that this is its 22nd edition):
"Clinically, patients in a persistent vegetative state have signs associated with an intact reticular formation: They open their eyes and have sleep-wake cycles, although these are irregular in timing. Their brain stem reflexes are intact. Pupils react and eye movements occur spontaneously and with the doll's-eyes maneuver. More complex brain stem reflexes are also seen, such as yawning, chewing, swallowing, and, uncommonly, making guttural vocalizations. The brain stem reflexes of arousal and startle are preserved as well, so that eye opening occurs with loud sounds and blinking may occur with bright lights. Tearing may be seen. Spontaneous roving eye movements are particularly characteristic; these are very slow movements of constant velocity, uninterrupted by saccadic jerks, and cannot be volitionally mimicked. These eye movements can be particularly distressing to family members as the patients appear to be looking about the room and at some point the roving eyes are pointed at the observer, who may perceive the patient to be "looking at" or following him or her throughout the room."
All of the people who cite swallowing, or her eyes moving, or making sounds as proof that she's conscious are demonstrating their lack of understanding of what PVS really is. This ought to call into question their ability to make such determinations. It would be different if they have proof that she responds to verbal commands or has attempted coordinated movements, but I haven't heard anyone making that case at all.

Mtaheny

I thought MRI's were needed to determine PVS as well as clinical evaluations? Dr. Cranford only observed Terri for all of 45 minutes. Is it possible for someone to slip a sedative in her feeding tube to make her less responsive prior to the eval? If there was an opportunity for that, as has been attested to by a number of nurses providing her care, isn't it possible that the eval by Dr. Cranston was skewed?

I'm still mystified why technology that has been proven to be more reliable (and available long before the collapse of Terri) was not used. I thought MRI's were the standard these days. Am I off base here, or was her husband just really tight with the money? If that is the case, how could he possibly argue that the information available for Dr. Cranston who had only seen the patient once was accurate? I had to have an MRI, spinal tap and a second MRI before my neuro doc would diagnose something as simple as M.S. (Kudos to the radiologist who nailed it on the very first MRI though!) How could Dr. Cranston accurately assess her with such limited information?

med student

Here's another good resource that tells about PVS:

http://www.medpagetoday.com/tbindex.cfm?tbid=753&thePhoto=Today's&CatName=&CID=

Ceci

I read the long summation of Terri's years of treatment on the Empirejournal blog. From what I can tell, there were very long entries made by caregivers on a frequent basis while doctors visited her once per month or so for only 10 minutes or less. Yet the cargivers' testimonies appear to be considered irrelevant in the courtroom, while the doctors' sentence or two every month is weighted very heavily.

It appears that doctors who spent a large amount of time with Terri (Hammesfar (sp)) seem to agree with the caregivers that she isn't PVS. This concerns me that so much emphasis is given to the conclusions drawn by people (even though they're highly trained and may be talented) who have spent so little time with the patient. In situations where the consequence of a diagnosis can be life ending (PVS) should the courts be more open minded about hearing caregiver/nurse testimony? Did a radiologist testify in Terri's case?

Back to the original topic though...From what I can tell in mainstream media, the doctors interviewed aren't declaring Terri to be PVS by viewing the CT scan, but the media is distorting the conclusions one can draw form a statement like "it's the worst damage I've ever seen". The lay public, not having access to blogs like this, are likely to take this misrepresentation by the media and use it as proof that Terri's brain has "liquified" in their next converstation at the watercooler.

I'm not a doc, but I'd be very hesitant to give a statement to the media since they appear to be willing to hype it up or edit out more temperate statements. Hype sells...and it's all about ratings nowadays. Blech...

At any rate, I'm glad blogs like this one exist. Not having to rely on mainstream media in this case has been heartwrenching due to having a better idea of what is going on, but it's still a welcome "pain".

med student

Mtaheny-
All imaging studies are basically worthless in diagnosing PVS. An MRI is certainly no better than a CT scan. This is from Goldman: Cecil Textbook of Medicine, which I have cited in several other posts: "Results of brain imaging studies depict the sequelae of the causative injury but are not diagnostic of a persistent vegetative state."
MRI is only good for something you can physically see. MS, for example, usually results in a very particular pattern of physical injury that can be visualized on MRI. But the problems associated with PVS are entirely different, the result of a lack of electrical activity in the brain, which you can't see. PVS is a diagnosis based on clinical observation, not a picture. Again, read some of the other comments in this thread and that should help shed some light on this for you.

Jeff Blogworthy

Susano,

Thanks for posting the link to Alternative Science. I have been reading the site - there is much fascinating information there - truly an enjoyable read.

Solalogos

Codeblue:

I am also a diagnostic radiologist. I concur with the position you have put forward. Thanks for your efforts.

Solalogos

Codeblue:

I am also a diagnostic radiologist. I concur with the position you have put forward. Thanks for your efforts.

susano

MedStudent - thank you for the correction. It was Dr. Beatrice Engstrand, neurologist to the Central Park Jogger, who said that PVS patients don't swallow. Can I ask, is there some disticntion here between PVS and minimally conscious? I read some piece from the journal "Neurology" (I think), quoted in a BBC article, that said the diagnosis of PVS is being revised and questioned and that many may actually be in the "minimally conscious" state. It seems as though new things are being learned about the brain, mind, and what constitutes consciousness.

Now this other guy, William Cheshire from Mayo, saw TS in her room, but did not do an exam. He said she had "context specific reaction". And what about the nurses who have said she used a few words, at the appropriate times? Do PVS patients do that? It doesn't seem to me that these nurses would risk their careers to go to bat for TS, nor do they have anything to gain by lying. What do you think? I also saw one them interviewed and she said that she made extensive notes in the chart, over the time she took care of TS, and that these notes were thrown away at the end of each shift. More than one of these nurses have said that TS's blood sugar level went haywire after visits with her husband, which is why they started giving her apple and orange juice, which she swallowed in small amounts. The same nurses have said that they found empty insulin (sp) viles in the wastebasket after Michael left. I mean, wtf??? It seems like A) there is evidence that TS was conscious, and perhaps rehabilitatable (to whatever extent), and B) that there needs to be a criminal investigation.

I swear, you couldn't make up. It reads like a Dominick Dunne piece.

wannabe

Bravo Code Blue. Anyone take up the challenge yet?

While this is a digression, seeing the CT scan of Terri Schiavo's brain several times this week reminded me of one of the most compelling documentaries I have ever seen.

It concerned the brains of a group of children that were treated for hydroencephalitis at birth with shunts.

If you examined standard scans of their brains, you would see that most of the brain in each of these children had been damaged by the shunt.

But there was just one problem. Not only did these children have normal functioning brains, they were all child prodigies, in one field or another.

This defied all the medical textbooks at the time of the documentary.

When you used a thermal scan, and forgive me, I'm not sure the proper name of the scan where you can see activity levels of the brain, you could see that the children's brains had merely adapted, and other parts of the brain took over the functions that the damaged part of the brain would have provided. I mean we've always been taught that most humans really only harnass about 10 per cent of their brain power as it is.

PLUNGE

"I thought MRI's were needed to determine PVS as well as clinical evaluations?"

No. Think about what PVS is: it's ultimately a lack of cognitive function that renders the patient unresponsive (even, to the best we can tell, internally, at least in the higher brain). There are obviously many many different sorts of damage that can cause this: the brain is incredibly complicated, and there must be any number of ways that it can be damaged enuogh to lead to PVS. That's why there can be no definitive clinical sign seen on a CT or an MRI. A PET/PEP scan might be able to tell us more about what sort of things are going on in the remaining tissue, but even so, we don't know anywhere near enough about how the brain works to be able to point to any particular scan and say "see here? That's why she has no cognitive function." That's why none of these tests can be definitive for or against PVS, even if they gave us a complete picture of every neuron in the brain.

Mtaheny

So, in your opinion, was the error in judgement belonging to the Florida Legislature who allowed for this can of worms through the law that stated a patient in PVS could be dehydrated and starved? Or was the error on the part of the judicial branch (and a blind swamp judge, as Michael Savage puts it) to believe it could be simply assessed in the course of 45 minutes?

I have trouble understanding why a neurologist who spent more time observing Terri was discredited but one who spent 45 minutes with her was revered.

Also, what is the frequency rate of misdiagnosis for PVS? Are there any statistics for that anywhere?

Jody

Mtaheny:

The occurence of misdiagnosis of PVS is 37%. http://www.neurology.org/cgi/content/abstract/43/8/1465

med student

Jody and Mtaheny-
Don't jump to conclusions on that journal article. The population includes patients diagnosed with coma or persistent vegetative state more than one month out from injury. Of those 49 people, 18 were misdiagnosed, but were they misdiagnosed as having coma or PVS? You can't tell. It might be that there were 18 misdiagnosed PVS patients, 13 coma and 5 PVS, or 18 coma misdiagnoses, or anything else in between. This is a relatively small sample size, only 49 patients, so it is not wise to draw any broad conclusions from it. Also, some of the patients included in the study had experienced trauma, which is now known to have a different course than those experiencing hypoxic injury, like Mrs. Schiavo. So, it's kind of like talking about apples and oranges as one big group. It is also only one article, which doesn't mean that it's worthless, but it does mean that you have to realize that it's one article reporting on 49 of the 10-25,000 adults in the US in this condition. Also, without reading the full article you cannot know if these are all patients from one center, how many docs were involved in the original diagnosis, etc. So, is PVS misdiagnosed in general, or is it docs in one particular town that are having trouble with it? Again, without reading the paper you can't tell. This paper is also about 12 years old, which is ancient as far as neuroscience is concerned. It also means that I can't access the article online to answer all these questions, and I'm already home from the library for the day. So, the point is that may be an underestimate of misdiagnosis, an overestimate, or right on, but it is certainly not a statistic that you can state as a fact that 37% of the time PVS is misdiagnosed.

med student

susano-
I did a quick scan of the Neurology article about MCS. I'd like to read the whole thing, but I've already spent too much time on this and not enough on what I'm being tested on next week. They list four things that can happen to lead to diagnosis of MCS rather than PVS:

# Following simple commands.

# Gestural or verbal yes/no responses (regardless of accuracy).

# Intelligible verbalization.

# Purposeful behavior, including movements or affective behaviors that occur in contingent relation to relevant environmental stimuli and are not due to reflexive activity. Some examples of qualifying purposeful behavior include: – appropriate smiling or crying in response to the linguistic or visual content of emotional but not to neutral topics or stimuli – vocalizations or gestures that occur in direct response to the linguistic content of questions – reaching for objects that demonstrates a clear relationship between object location and direction of reach – touching or holding objects in a manner that accommodates the size and shape of the object – pursuit eye movement or sustained fixation that occurs in direct response to moving or salient stimuli

The only thing I've heard anyone say anything about from that list is verbalization. I haven't been there to hear any of her vocalization so I can't say if she has actually spoken words or not. I will say that I am skeptical about the veracity of any reports of her using language when the only report I've seen is that she made an "ahhhhh waaaaa" sound that was interpreted as "I want..."

Also, the same thing I was mentioning in my previous post about how much weight to put in one journal article applies here as well. I think that there are a lot of reasonable points in the article and there is certainly more investigation to be done, but you can't totally change the way medicine is practiced on the basis of one article.

I have no idea what Dr. Cheshire's "context specific reaction" is. But, just like many people have criticized Felos for being pro-euthanasia, Dr. Cheshire is clearly anti-euthanasia and his testimony should be considered in that context.

I also had not heard anything about the blood sugar disturbances, so I can't answer those claims at all. But, as I mentioned in my earlier posts, there is no way that Judge Greer's court, the state appeals court, the state supreme court, the federal district court, the federal circuit court and the Supreme Court are all in collusion to suppress evidence like this from being considered. If these things haven't been presented by the Schindler's attorneys, then of course the courts wouldn't have considered them. And, if they have been presented, I can't believe that all those judges/justices would throw them out without examining their veracity.

Booster

Thanks for your blog and all your efforts and your challenge. I knew all the feathers were going to hit the fan after....she goes. Too late for this American. I am no where near in the medical field, but close enough to realize, after reading the diagnoses from those six doctors, two of them where close and the other four were on the payroll and pathological liars. On the court record it stated Dr. Cranford has been TS Doctor for seven years. He perjured himself on Fox News. Hannity had him backed into a corner and he admitted on National TV, he had only spent 45 minutes with her, on one day. MS did a Freud slip on CNN when he said "he didn't know what TS wishes were, but this is what we want..." March 18. Larry King didn't even catch it. Nobody seemed to have caught it but the Impire. I have the CNN transcript saved on my hard drive. So, is Greer, Felos and MS going to get away with this? What about the blatant medicaid fraud. Who put Terri in hospice with a post it note, 6 months to live and terminal. I know who did. I just wonder why John Ashcroft didn't do something about it when he was asked to in 2003.
Penellos County doing the autopsy per MS sacrifice to prove he is innocent per the ghoul Felos-most people bought that, but it just happens to be common sense and the only time Florida State Law protected TS. Cremation, autopsy first. If I were the Schindlers I wouldn't let anybody touch TS body with a ten foot pole, especially Crist's office. They do have the say so, it is supposed to be a mutual agreement with the next of kin, per the law, at least from what I read. I guess Jeb Bush could go and stand over them and watch, he ought to. Getting him out of his spider hole in the problem. Why not a test while she is alive. I think all our Judges should move into the White House. They might as well.

What a sick society we have today. Chin up all. Tyranny is here. This Republican is going on strike and not voting again either way. Stupid choice of me? No, what was stupid that America let these criminals get away with barbarically killing Terri Schiavo. Do you think she ever dreamed in her lifetime, as a kid, a bouncing teenager, as she grew up loving America, that her own the country that would do her in. I am crushed.

Good Luck on your challenge Code Blue Blogger. I hope you knock all their heads together!

Sylvia

Med Student, you may know your medical lingo, but you need to catch up a little on legal stuff. Other than the death Judge Greer, no other judge actually looked at the evidence. The appeals court, the Federal courts all the way to the Supreme Court -- they only checked to see if the judge was following procedures. Some of them didn't even grant the motion or hearing, so they didn't even go that far.
When Congress made the Palm Sunday legislature to grant jurisdiction to the Federal Courts for a de novo review, it was meant to have the Federal courts look at all the evidence, basically a new trial. But the Federal Courts didn't do that.
So to go back to your statement that "...all the judges/justices would throw out evidences...", ONLY ONE judge actually made the decision to admit or reject any evidence presented and that's Judge Greer.

Jody

Medstudent:

While your criticisms are valid, here's a different study (London instead of Austin) that comes up with 40% and it only looks at PVS cases.
http://bmj.bmjjournals.com/cgi/content/full/313/7048/13

So that 37% number may be pretty close...

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