CSI MEDBLOGS: CODEBLUEBLOG ANALYZES TERRI SCHIAVO'S CT OF THE BRAIN

THIS BRAIN IS NOT THAT BAD

Thanks to reader "primer" I've been directed to the University of Miami Ethics program website where they posted this image from a CT scan of Terri Schiavo's brain in 1996. The sentence attached to the link for this scan on the site says:

CT scan of Ms. Schiavo's brain, showing extensive cortical regions filled with spinal fluid.

If you go to this link you can see the scan in a larger reproduction.

A COURT OF MEDICAL LIGHTWEIGHTS WEIGH IN ON TERRI'S CT.

The Second District's first opinion in this case explained:

Since 1990, Theresa has lived in nursing homes with constant care. She is fed and hydrated by tubes. The staff changes her diapers regularly. She has had numerous health problems, but none have been life threatening.

Over the span of this last decade, Theresa's brain has deteriorated because of the lack of oxygen it suffered at the time of the heart attack. By mid 1996, the CAT scans of her brain showed a severely abnormal structure. At this point, much of her cerebral cortex is simply gone and has been replaced by cerebral spinal fluid. Medicine cannot cure this condition. Unless an act of God, a true miracle, were to recreate her brain, Theresa will always remain in an unconscious, reflexive state, totally dependent upon others to feed her and care for her most private needs.

First, I contest the theory that Terri's brain actively continues to degenerate as implied by the above statement. How could they gage serial brain degeneration without serial follow-up? And by what mechanism would her brain CONTINUE to atrophy? Second, Terri's cerebral cortex has not been replaced by fluid. That is inaccurate. The cortex is thinned and the sulci are enlarged. There is a difference.

Third, and most importantly, given the amount of atrophy on this image I disagree with the court's inadequately considered conclusion.

My Grandmother's Brain -- OK -- But Would I Stop Feeding My Grandmother?

First of all, the University of Miami's appellation for this scan is inaccurate. "Cortical regions" are not and can not be filled with spinal fluid. The sulci (spaces between cortical ribbons) are enlarged secondary to cortical atrophy and these sulci are filled with cerbrospinal fluid.

The most alarming thing about this image, however, is that there certainly is cortex left. Granted, it is severely thinned, especially for Terri's age, but I would be nonplussed if you told me that this was a 75 year old female who was somewhat senile but fully functional, and I defy a radiologist anywhere to contest that.

I HAVE SEEN MANY WALKING, TALKING, FAIRLY COHERENT PEOPLE WITH WORSE CEREBRAL/CORTICAL ATROPHY. THEREFORE, THIS IS IN NO WAY PRIMA FACIE EVIDENCE THAT TERRI SCHIAVO'S MENTAL ABILITIES OR/OR CAPABILITIES ARE COMPLETELY ERADICATED. I CANNOT BELIEVE SUCH TESTIMONY HAS BEEN GIVEN ON THE BASIS OF THIS SCAN.

The worrisome, no alarming thing, for me, was that I heard a bioethicist and several important figures on the major media describe Terri's brain as MUCH WORSE. One "expert" said that she had a "bag of water" in her head. Several experts described her as a "brain stem preparation"

These statements are wholly inaccurate. This is an atrophied brain,  yes, but there is cortex remaining, and where there's cortex (?life) there's hope.

If you starve this woman to death it would be, in my professional and experienced medical opinion, the equivalent of starving to death a 75-85 year old person. I would take that to the witness stand.

All That Glitters is a SHUNT

Next mystery: Why is there a shunt in Terri's ventricle? This CT image is "flipped" (i.e. the CT scan is mirror-image backwards which is just an inconsequential error made when scanning the image into the computer), so the right side is LEFT and vice versa. However, everyone can see, easily, the ovoid white object sitting in the front of the big black butterfly in the center of Terri's brain, correct?

That  shining object is the tip of a shunt.  A shunt is a tube inserted into the brain to reduce pressure caused by build-up of cerebrospinal fluid (CSF) in the brain. That big black butterfly in the middle of Terri's brain is her ventricular system, which holds the CSF and in Terri's case, it is enlarged (dilated).

Now...why was Terri being shunted in 1996? First, if Terri's brain damage was due to oxygen deprivation, her enlarged ventricles would be by a passive mechanism -- which is not amenable to shunting -- not by obstruction of the egress of CSF. To me, the presence of a shunt indicates obstruction to the flow of CSF that needs to be circumvented. Obstruction to flow is hard to postulate given the mechanism of Terri's brain injury (oxygen deprivation).

It would NOT be hard to postulate, however, if she had BLOOD in her head at some point in the past. So did she? Was there a history of trauma? I would like to see the BONE SCAN taken of Terri that purportedly showed evidence of traumatic type osseous uptake!

It is quite unusual to see high-pressure hydrocephalus when the mechanism of brain injury was INFARCTION; and, more so six years after the event.

So

IS THIS REALLY TERRI'S CT?

IF it is then her atrophy is SEVERE, BUT not as bad as has been implicated by the press and the courts

IF it is then why did she have hydrocephalus six years after her non traumatic  infarction 

IF it is... why was she shunted...AND IS SHE STILL shunted? IF not, why was the shunt removed?

IF it is, why does the Second District Court NOT mention Terri's hydrocephalus in it's dissertation on Terri's woeful cerebral condition??

IF Terri DOES have hydrocephalus from ventricle blockage, was there trauma that caused bleeding that lead to hydrocephalus on the basis of a blood clot obstructing ventricular outflow?

IF so, what was that trauma?

IF Terri had hydrocephalus in 1996, she may still have hydrocephalus now; some patients with hydrocephalus respond to shunting with increased mental functioning!

IF THIS IS NOT TERRI'S CT THEN WHERE IS HER CT?

Based on this evidence Terri Schiavo should have a CT scan repeated. She should also have an MRI and a PET scan to gage the severity of her brain dysfunction.

IF THIS IS TERRI'S CT OF THE BRAIN, SOMETHING MAY BE VERY WRONG

Comments

[Craig H]

Unless someone can find evidence that Ms. Schiavo ever had a shunt placed, this is not her head CT. Also, this is one cut -- where's the rest of the CT? Elementary radiologic interpretation: make sure the name on the film matches the name of the patient.

Suspicious, but certainly willing to be informed,

[CodeBlueBlogMD]

There is no name on the CT (I assume) because HIPPA regulations forbid it.

They only provided me with one cut; however, when you have the type of experience I DO (I've seen 10,000 brain CT's) you can pretty well infer the rest of the study. Granted there could be OTHER surprises on the scan; however, I can judge the severity of GLOBAL ISCHEMIA-caused atrophy based on this cut, and I'm willing to BET on it.

You are correct about that shunt -- that is really remarkable. Why would they shunt her unless she had obstructive hydrocephalus -- and how did she GET THAT?!

[Craig H]

Karen Quinlan's pathology was disproportionately subcortical -- bithalamic ischemia -- with relative cortical sparing. That's why the other cuts matter, and why the functional severity of the hypoxic injury can't be inferred from this picture.

No matter though. Tere's no indication from any of the medical or legal timelines available (online anyway) that Ms. Schiavo ever had a shunt.

[CodeBlueBlogMD]

They specifically say, in all documents and releases, that it is Terri Schiav's CORTEXZ that was affected, which is the focus of the injury one would expect given the mechanism of cardiac dysrythmmia leading to global cerebral ischemia.

Selective thalamic ischemia is quite unusual. I don't remember Quinlan's etiology but selective thalamic ischemia is usually a poisoning -- such as carbon monoxide, I believe -- something that has not been adduced as a mechanism for Schiavo.

In any event, I am not saying that I do not want to see the entire CT -- I do! This is all they are providing us with; and if THIS is what they based this case on, they have made a HUGE error.

[CodeBlueBlogMD]

One more thing...part of the perception of Schiavo's atrophy is THE SIZE OF THE VENTRICLES! To the interpreter of a CT scan, hugely dilated ventricles in the setting of diffuse atrophy suggests hydrocephalus ex vacuo: enlarged ventricles due to the NEGATIVE pressure effect of atrophied cortex. And this observation WORSENS the severity of the cortical atrophy in the perception of the interpreter.

[Patricia]

I'm in neuropsych and am not qualified to read CT's, but even I can tell there's a problem with their reading if this is her CT.

It's been reported that she spoke a few words and walked some with parallel bars when she was in rehab, but I don't know if that report is accurate.

What to do???

[DrTony]

I heard an interview on the radio today with a physician who has over 10 hours evaluating Terri. He stated that she is not unconscious. He indicated that when he commented on the scene outside her hospital room window, she turned to look out the window. She vocalizes in an attempt to communicate. The discussion on the radio also discussed affadavits from nurses who swore that Mike refused treatment with antibiotics for UTI's, refused to allow evals by rehab physicians and refused imaging studies such as MRI and PET scans.

The physician being interviewed also stated that his opinion, based on a review of the medical records, is that Mr. Shiavo deliberately moved Terri from nursing home to nursing home whenever the staff would get suspicious about his refusal of care. One nurse quoted Mr. Shiavo as saying, "Let the bitch die."

[NotADoctor]

Are you sure that's a shunt? In the reports filed she had some electronic stimulation gadget implanted in her brain, at the request of her husband, not too long after her "accident".

[Claire]

I have seen a couple of references to a shunt and questions to why it had been allowed to remain in place this long.

Still looking for *where* I saw them...

Also references to full sepsis after a time with no antibiotics for a UTI. At that point a court stepped in and enforced the law that forbids a guardian to withhold basic medical care. There was a reference to the sepsis causing further brain damage, but I've no idea if that is possible. Is it?

[Claire]

I have seen a couple of references to a shunt and questions to why it had been allowed to remain in place this long.

Still looking for *where* I saw them...

Also references to full sepsis after a time with no antibiotics for a UTI. At that point a court stepped in and enforced the law that forbids a guardian to withhold basic medical care. There was a reference to the sepsis causing further brain damage, but I've no idea if that is possible. Is it?

[NotADoctor]

Found this little tidbit in a google search:

27. Judge Greer has allowed violation of 744.3215(b) not requiring Michael to have follow up examinations of electrodes, which were implanted in Terri’s brain. These implants should have been removed years ago, as they are a source for both infection and hydrocephalus. Hydrocephalus may cause pressure that could suppress cognitive function and be responsible for much of Terri’s condition. If so, there could be a vast improvement in her condition if a shunt were placed. Hydrocephalus could also cause pressure that would flatten the brain and show fluid filled areas on a brain scan.

http://libertytothecaptives.net/judge_greer_violations_statutes.html

I am not a physician, that's why I am asking all of you. Is that really a shunt on the CT or one of those implanted electrodes, and could the electrodes account for the amount of hydrocephalus found? Why are people asking for a shunt, if a shunt is already there? Wouldn't placement of such show up in the medical record or be noticed on subsequent physician examinations, and therefore noted?

Just asking.

[caltechgirl]

I too want to see the rest of the scan if it is indeed Terri's. Thanks for posting what I've been trying to point out, but have far less credibility to say (I've taught 1st year med students what to look for in CTs and done research with MRIs, but I don't do this for a living, being a lowly PhD student). I've seen a worse-looking scan of a conscious, talking person, but again, the differences were in other slices.... I'll look forward to whatever else you dig up.

[CodeBlueBlogMD]

That's a shunt tip, for sure.

First, if you implant an "electrode" the purpose is for the electrode to "stimulate" neural tissue for some effect. There is no neural tissue floating in the CSF inside that venticle. Implantable electrodes would need be superficial.

That is the tip of a venticulatr shunt which we are only seeing on one scan slice (because that's all we have). It was placed there to relieve increased intraventicular pressure which can have 2 causes: overproduction of CSF or obstruction to CSF outflow (= "communicating" and "noncommunicating" hydrocephalus).

Here is the important part: In a patient of her age, given her circumstances, this would almost surely be "noncommunicating" hydrocephalus, which is almost always caused, in this situation, by a "clot" at the level of the ventricular drainage (Foramen of Magendie; which is EXTRAAXIAL, meaning that the clot had its genesis OUTSIDE OF THE NEUROAXIS...to a specialist this means she had BLOOD IN HER CSF.

How do you get that?

From getting smashed on the head (as in an assault).

So how would she have got smashed on the head?

Why don't we know this?

Why can't I find refenerence to this shunt in her case?

Stop the presses, someone.

[NotADoctor]

Thank you very much for your answer. Is there a reason why hydrocephalus would be due more so to old injury than to the long-term effects of the electrode placement?

Just trying to get all my facts in a row....

[CodeBlueBlogMD]

There IS NO electrode.

This is a plastic tube (= a shunt) placed there to RELIEVE an obstruction.

THAT obstruction is the element in discussion: how did she get it?

Most comony THAT obstruction would be secondary to bleeding OUTSIDE of the brain tissue (= subarachnoid or subdural hemorrhage). How does one GET this get of hemorrhage?

FROM TRAUMA. LIKE A SMASH ON THE HEAD.

[NotADoctor]

I'm sorry, I didn't make myself clear. I know what a shunt is, I'm speaking of the electrodes that were implanted in her brain in 1992, which have never been removed, and to which some would explain the resulting hydrocephalus on the CT in 1996.

**Ms. Schiavo could be evaluted with a PET scan in her current condition. However, an MRI cannot be done without first removing experimental electrodes which were implanted within her brain in 1992. The doctor who implanted them instructed Mr. Schiavo to have them removed, but that has not been done.[13]

(http://www.nationalreview.com/script/printpage.asp?ref=/comment/johansen200503160848.asp)**

http://en.wikipedia.org/wiki/Terri_Schiavo

[Mark]

These comments are intriguing. I've linked to them on my blog.

[CodeBlueBlogMD]

I don't see any signs of electrodes on this slice of the CT.

Also, I know of no electrodes that anyone would leave in any brain for any purpose, and in 20 years of seeing more than 10,000 CT's of the brain, I have never observed such a phenomenon.

In addition, it is hard to believe that anyone inserted electrodes, in 1992, that had paramagnetic properties that would preclude an MRI of the brain currently. I doubt that. Most of those devices are titanium or stainless steel, which are unaffected by MRI. Besides, with MRI, in that type of situation, the only reason not to do an MRI is because you are looking for information in the region of the artifact, where there would be distortion of the image.

If the items are not paramagnetic (like iron), there would be no danger and no contraindication to an MRI. Sounds bogus to me.

Finally, yes, if someone penetrated the dural linings of her brain with electrodes, that procedure could possibly (but not likely) have created a hemorrhage that resulted in hydrocephalus. But I have a long way to go before I believe that.

[NotADoctor]

According to Michael Schiavo's November 19, 1993 deposition, case No. 90-2908-GD, the electrodes implanted were platinum.

[NotADoctor]

The experimental procedure was performed by Dr. Yoshio Hosobuchi of the University of California at San Francisco.

[NotADoctor]

Hosobuchi Y, Yingling C.
The treatment of prolonged coma with neurostimulation.
Adv Neurol. 1993;63:247-51. No abstract available.
PMID: 8279309 [PubMed - indexed for MEDLINE]

[Ed Jordan]

CodeBlue,

If you want to contact someone close to the Schindlers to share your discoveries, one person to contact is Rev. Robert Johansen of the Thrown Back blog. Fr. Johansen is a friend of the Schindler family, and he has been gathering the names of physicians who think Terri can recover. I think he would be interested in hearing from you.

http://www.thrownback.blogspot.com/

frrob@earthlink.net

[Michael Ditto]

Have you ever treated a heart attack patient? To suggest that the only way someone could get blood in the CSF is being "smashed on the head (as in an assault)" is curious. Would you care to back that up with some data? Are you saying that there is no such thing as heparin-induced thrombocytopenia?

Michael, he's basing his assesment on "20 years of seeing more than 10,000 CT's of the brain". I think he's perfectly qualified to form an opinion without having to quantify it with data.

Anyway, this whole thread is misleading. You can't judge a patients neurological health TODAY based on a CT from 1996.

The fact that there is no CT from 2005 is what is really disturbing. Also the fact that there has been no INDEPENDENT review of Ms. Schiavo's current neurological condition.

The fact that there was hydrocephalus in 1996 just proves the neglect on the part of the Guardian of Ms. Schiavo. That alone should be enough to require a review of her treatment and an independent investigation into factual nature of her disability.

Right now all we have are arguments from two parties that are equally biased. Why won't Michael Schiavo let DCF perform their own investigation as they have petitioned the court to do?

[Curious JD]

Would you allow someone you did not know whose motives are directly adverse to what you believe your spouse wanted just because they petitioned the court?

[Michael Ditto]

So I'm to take his word for it because he's a doctor? Argumentum ad verecundiam.

I don't know that there is no CT scan from 2005, I only know that I haven't seen one posted to the Internet. You haven't seen it therefore it doesn't exist, is that it? Revealing the very existence of a CT, MRI, or PET scan would be a HIPAA violation by the healthcare provider, and Michael Schiavo has no legal obligation to reveal one just because you think he should.

The fact that she had hydrocephalus in 1996 proves nothing other than that she had hydrocephalus in 1996. Secundum quid.

If the court determines that there is sufficient grounds for a DCF investigation, the court will order one. That's what the court is for. Say you have a neighbor who doesn't like you. Would you want the DCF to be able to initiate an invasive investigation into your sex life based only on a child sex abuse report from a guy who thinks you waited too long to pull the weeds in your yard?

The "court" you speak so highly of his the court of Judge Greer. He's the one that denied the DCF petition. He's also on the Board of Directors for Ms. Schiavo's Hospice. The very same Hospice that has been collecting medicaid/medicare for her care even though she was never diagnosed as a "terminal" patient. Being diagnosed as "terminal" is a stipulation in order to collect public monies for a hospice patient. Felos is also on the same Hospice Board of Directors. Rather incestuous, don't you think?

Curious, we don't know what Ms. Schiavo wanted. There are only conflicting bits of hearsay from both sides of the fence.

What if your daughter's husband wanted to stop feeding her when you think you can see signs of cognizance? Wouldn't you fight tooth and nail against your daughters husband?

All things considered, there should be an independent investigation out of Greers court. He has too many conflicts of interest in this case, he should have recused himself long ago.

Michael, I'll take his opinion over yours anyday. While CodeBlue forms convincing arguments based on 20 years experience, you are incoherent with your latin peppered, emotionally driven drivel.

Tace atque abi

[Michael Ditto]

OK, I'll translate for you:

Argumentum ad verecundiam - Appeal to authority. The logical fallacy that because a claim is made by someone who is an authority, the claim is automatically true.

Secundum quid - Hasty induction. The logical fallacy where a claim leads to a conclusion based on insufficient evidence.

Here's some more Latin for you:
Ad hominem abusive (aka argumentum ad personam) - Personal attack. The logical fallacy that insulting one's opponent automatically invalidates the opponent's claim.

So I attempt to engage in a logical debate, in which I invite my opponents to clarify their positions by being accurate and by steering away from logical fallacies, and your counter-argument is "shut up and go away." Whose drivel is therefore more incoherent and emotionally-driven?

[NotADoctor]

There are some very cogent arguments that Michael Schiavo is not acting as a suitable Guardian for his wife:

Michael has committed both perjury (2 counts) and insurance fraud by promising to provide care and therapy for his wife in exchange for the court award of 1.2 million dollars in 1993. No care or therapy has ever been provided to Terri. She receives public assistance to pay for her hospice care.

Michael Schiavo has also prevented Terri from undergoing a barium swallow test, a procedure necessary to ascertain the consistency of foods able to be taken by mouth.

Co-conspirator George J. Felos combined and conspired with Michael Schiavo to arrange for Terri's "free" stay at Hospice Woodside as part of an "exit protocol" designed to advance Felos' self-perceived messianic mission of "helping" incapacitated people to die by categorizing them as "terminal," warehousing them, and depriving them of therapy and rehabilitation services. (Attorney Felos is Director of Florida Right to Die and has testified that he can ascertain a person’s desire to die by “looking into their eyes and letting their spirit speak directly to him”)

Also,

Judge George Greer is not impartial. He has worked side by side as county commissioner with Barbara Sheen Todd (county commissioner) for eight years. Barbara Sheen Todd is on the board of the hospice. Also, Judge Greer's fellow judge, Judge John Lenderman is the brother of Martha Lenderman, also on the hospice board. Greer accepted as the basis of his rulings, the questionable testimony of Michael Schiavo that Terri would wish to be killed, yet Michael never stated this until he had received the 1.2 million dollar settlement. Greer also accepted as the basis of his rulings, the "opinion" of a third doctor who is the brother of a close associate of George Felos, right-to-die attorney, and very significantly, former Chairman of the hospice board.

[plunge]

It still seems far more likely that this is a thalamic implant.

"How could they gage serial brain degeneration without serial follow-up?"

Are you really suggesting that 1996 is the only time anyone did a CT?

[NotADoctor]

plunge, I don't know. But here's an interesting response from Greers consulting physician about why he feels more tests aren't necessary:

"----- Original Message -----
From: Ronald Cranford MD
To: Paul Duke Deland
Sent: Friday, March 18, 2005 12:37 AM
Subject: Re: Information Please

For your information and background on the facts of the Schiavo case, I've attached a background memo prepared by myself and a letter on the issue of a medical panel suggested by Art Caplan. I believe this material will address many of your questions, but here are a more comments.

An MRI was never recommended because, in this case and other patients in a permanent vegetative state, the CT scans were more than adequate to demonstrate the extremely severe atrophy of the cerebral hemispheres, and an MRI would add nothing of significance to what we see on the CT scans. Plus the MRI is contraindicated because of the intrathalamic stimulators implanted in Terri's brain. A PET scan was never done in this case because it was never needed. The classic clinical signs on examination, the CT scans, and the flat EEG's were more than adequate to diagnose PVS to the highest degree of medical certainty, along with the credible testimony of the three neurologists at the longest evidentiary hearing in American law, whose opinions were strongly affirmed by the trial court judge and three appeal court judges. Please see Judge Greer's opinions on the credibility of the experts testifying on behalf of the Schindler family.

In addition, the only PET scan center in the country I would trust right now for doing the PET scan for the determination of PVS is New York-Cornell Medical Center with Niko Schiff. There are other PET scan centers in the US (such as in Miami and Atlanta which I contacted in 2002 as to the feasibility of doing a PET scan at these centers), but the only one doing top quality work with the precision necessary for PVS is the one in New York.

I do not believe there are "a number of other prominent members of your field" who feel these other tests should be done, because these "other prominent members" are physicians with strong conservative credentials who obviously don't know the facts of the case, and some of these physicians have "credentials" similar to Dr. Maxfield and Dr. Hammesfahr (the "HBO and vasodilator experts"). Where were these physicians earlier in the case when they could have examined Terri and testified at trial on behalf of the Schindler family, instead of the two doctors whom Judge Greer found not very credible?

The calls for new tests on Terri are nothing more than one of several last minute desperation moves by the Schindlers and their supporters to delay the withdrawal of the feeding tube from Terri. There has never been a more extensively litigated case in the history of right to die cases in terms of the length of the entire litigation itself, and the extensive medical testimony during the elaborate evidentiary hearing of 2002, and the thorough review of this medical tesimony by the appeals court.

As for the National Review Online article, I stand by my record. The record is very clear that I did not testify that Robert Wendland was in a PVS, and the same applies for the case of Michael Martin in Michigan. Both these patients were clearly not PVS (see Broder AJ, Cranford RE. Mary, Mary, Quite Contrary, How Was I to Know? - Michael Martin, Absolute Prescience, and the Right to Die in Michigan. University of Detroit Mercy Law Review, 1995; 72:787-832. and Nelson LJ, Cranford RE. Michael Martin and Robert Wendland: Beyond the Vegetative State. Journal of Contemporary Health Law and Policy, 1999;15:427-453). In all the major right to die cases on a national level in which I have testified or been heavily involved with (including Brophy, Rosebush, Torres, Cruzan, Busalacchi, Ellison, Butcher, Martin, Wendland, and now Schiavo), my neurological diagnosis and the final opinions of the courts were identical (except for some legitimate differences of opinion on the degree of cognitive functions in Wendland). So my record stands for itself.

I feel that I am well-qualified as a national expert in this field of the neurological diagnosis of severely neurologically impaired patients, and the opinions I, and other qualified neurologists, expressed in Schiavo were strongly endorsed by the trial court and appeals court judges.

Thanks. Any further questions?

Dr. C"

http://pekinprattles.blogspot.com/2005/03/schiavo-dr-cranford-offers-reply.html

[CodeBlueBlogMD]

Please understand that my post was spurred by the disconnect I experienced upon seeing this CT of the brain after hearing bioethicists and others on NPR say that Terri Schiavos' brain was a "bag of water", or some such thing.

The degree of atrophy described in the media was, to me (an expert in evaluating these rather simple CT's), out of proportion to the image I see.

Since most of what I read references the CT scan, this is the only part of her evaluation I have addressed.

Certainly all the other factors, including clinical and eeg evaluations come into play in diagnosing pvs -- I never dispute any other aspoect of the quantitative data in this case.

I also wasa taken aback at the object in Terri's right ventricle. If that is a thalamic implant, then it is floating in the ventricle, which I suppose is possible.

Also, it is not my fault there is only one image to evaluater. I would gladly view the entire examination. As I have stated many times in my blog, in these public cases, all sides are best served by more disclosure of the data so that speculation is less likely.

I believe that given the fact that the amount of atrophy was so overplayed in the press, it is IMPORTANT, at this late date (and certainly ethical) to speculate about the reasons for such a portrayal as weell as reasons for hydrocephalus if that is what we are seeing.

I never said there was only ONE way to wind up with blood in the brain; however, I implied that in a patient of Terri's age (at time of injury), statistically, trauma would be most likely. Certainly, iatrogenic injury (including electrode implantation) cannot be excluded.

My primary focus in this case was, originally, top ;oint out incongruities in the moral stances, especially from a physician's standpoint.

I just have never understood how a physician can support removing food and water from an otherwise living patient.

Yes, there are times when the end of life needs to be faced, and the suffering need to be comforted, but I don't want judges and courts demanding that I actuate a patient's death.

For me it's a moral and ethical problem, less so a religious issue.

[thoughtomator]

Break this down for a layman... to what degree does this support my hypothesis that the most reasonable explanation for events is that her husband caused her condition and has refused therapies and release of guardianship and is trying to get her euthanized in order to prevent her from testifying against him?

Also can you give a layman's version on the implications of this bone scan record?

http://www.terrisfight.org/images/bonescan.jpg

(reload the image page if you get an error and you can see it)

Thanks.

[CodeBlueBlogMD]

Here are my intial thoughts:

It is perilous to try and interpret just the bone scan REPORT. I need to see the scan itself and the correllative X-rays.

However, that being said, several things are unusual.

Certainly there was trauma. As I understand it the issue is how the trauma occured.

Trauma from CPR generally invoves the anterior aspects of the ribs where they join the sternum. This is usually due to vigorous compression during CPR. Any other proposed trauma during CPR would need to be documented by the notes or by eye witnesses as to the mechanism (e.g.: did she fall off the stretcher?).

The bone scan report of TS describes an injury NOT to the anterior ribs, but, to a different part of the ribs-- posteriorly -- namely at the juncture of the ribs and vertebrae(the costovertebral juncture, or CVJ). In addition, although the report mentions several rib fractures, it does not specify if they were all CVJ located or in different/various locations. This is important. Finally, I do not see a report of correllative x-rays for the ribs, which would be helpful to determine the TIMING of the injury (fractures look very different depending on WHEN they occurred).

The compression fracture of L-1 is interesting. This is certainly NOT a typical injury that occurs during CPR as it generally involves an AXIAL load (i.e. on the top of the head; or from the top DOWN); a caveat here: if TS was anorectic for a prolonged period or on certain madications she could have been osteoporotic, in which case a mild compression fracture of L-1 would not be so unusual; however,in the setting of trauma one would have to assume this to be associated with that trauma in which case I find in strange.

The uptake over the distal right femur is the most peculiar element in this report. This is an unusual finding in ANY situation and I would have to see the scan and films to be sure of what it means; however, if there is PERIOSTEAL ELEVATION then one would have to posit (as did the person who interpreted TS's bone scan)the possibility of bleeding underneath the thin covering of the bone (the periosteum) which is a finding that correllates highly with trauma, specifically, abuse.

It would be difficult to propose a mechanism that caused this type of problem during CPR unless a specific witness arises to declare he or she remembers a specific event during the CPR that would have caused this UNUSUAL finding.

I would want to know if TS had a BLEEDING problem at the time, because that might explain the finding.

Certainly IN A CHILD (which Schiavo, obviously was not), the combination of rib fractures, vertebral compression fractures, and distal femoral periosteal elevation is ABSOLUTELY POSITIVELY DIAGNOSTIC for child abuse and any radiologist who missed this diagnosis would be subject to disciplinary action from his peers and state licensing board. SEE: http://radiographics.rsnajnls.org/cgi/content/full/23/4/811

[CodeBlueBlogMD]

I just noted the DATES on this bone scan so I have redone the above letter in a post on the blog. SEE:
http://codeblueblog.blogs.com/codeblueblog/2005/03/csi_medblogs_co_1.html

[Daniel Frazier MD]

HIPPA rules for release of information, have been in effect for only the last few years. Any data available prior to this unfortunate law(Immense amount of useless paperwork. Feelgood laws again), could have been available. Now with HIPPA they have limited release.
Nevertheless if another CT scan was done prior to the passing of HIPPA, it would have been available then, but not now.
As a physician with no dog in this hunt, it still seems strange that a repeat CT isn't done. There is no medical reason for NOT doing it.
A friend of mine was one of the physicians envolved in the malpractice case. She had been on an ice tea diet, and had drunk nothing but ice tea for multiple weeks. Her condition may have been, as hinted here, from a blow or fall, but at the time it was considered strictly diet induced, which seems much more likely to me. The award was considered at the time to be unjustified by the facts by the medical community, and a sympathy verdict.
One physician was sued and lost on the basis that he should have known that the Gyn he referred her to had had multple malpractice cases, and therefore he did not make a proper choice in referring her. Under HMO rules at the time, he had limited choices, and I believe the Gyn was her own choice. Seemed and still seems nutty to me.
When 2.5 million is thrown arround as the amount of the awards, that is before the probable 35% or so that the attorneys kept, along with their costs.
That money has surely been exhausted by now.

Terri Was Advised Not To Go Home The Last Night
From Dee Rohe
drrohe@bellsouth.net
10-25-3

This is a letter written by Kathleen to the St. Petersburg Times

Dear Mr. Levesque,

I am sure that you wrote your article on Theresa Marie Schindler Schiavo in what you believed was the truth. However, I can stay quiet no longer.

It is a proven fact that Mr. Schiavo had at least one affair and fathered an illegitimate child while still married to Terri before she was injured,

He is paying child support. Since her injuries, it is also a proven fact that he has been with numerous women one with whom he now has one child with another on the way.

No one has investigated nor seems to even care that the night that this happened to Terri they had had a huge fight. She had confided to family members and friends that he had become abusive and controlling. She was advised not to go home that night but to spend the night with a girlfriend but she went home. Hours later he called Bob Schindler saying Terri was on the floor hurt. He did not call 911 first.

There are medical records that sustain the fact that Terri suffered multiple broken bones that night and came to the hospital with a rigid neck. I have all that info if you are interested and would be happy to send to you.

To say that Mr. Schiavo loves Terri is nonsense.

He lost the ability to say "my wife" with any credence a very long time ago.

I wish that just one person would print the truth about this guy. I truly believe that the only reason he wants her dead so much is because he never wants her to come out of this and point the finger at him for battering her almost to death. He wants to finish what he started that night.

You probably won't investigate any of this. No one seems to care what happened to Terri but at least I know I have tried.

Sincerely, Kathleen Walker
St. Petersburg, Fl.

[Brian Pearson]

There is a 2005 CAT scan:
http://www.miami.edu/ethics2/schiavo/CT%20scan.png

I think it will help. BTW, it does have her name on it.

[h0mi]

Has anyone seen the Wolfson Report?

http://abstractappeal.com/schiavo/WolfsonReport.pdf

[Joe Miller]

You didn't really mean "nonplussed," did you?

[Brian Pearson]

Very sorry, my mistake. :{
It appears to be the same scan.

[EyeDoc]

Brian,

That looks like the same scan as before.

[Michael Ditto]

CodeBlue: I certainly appreciate the clarification. Thank you.

It is possible that the rib fractures and the compression fracture were a result of the combination of retching and osteoporosis due to long-term bulimia. In the unfortunate case of a friend's sister, she had several broken long bones just doing everyday things in the months leading up to her death, which was caused by a hemothorax due to a rib fractures along the spine after violent retching. Bulimia caused a significant reduction in her blood's ability to clot. That combined with her reticence to seek medical treatment led to her bleeding to death.

I would note that Cranford refers to CT scans in the plural, which would suggest (as with most things in life) that there is more than meets the eye.

On HIPAA: I develop HIPAA-compliant software applications. Most of HIPAA is actually technical in nature, including the ANSI 837/835 medical claims and electronic remittance protocols (specifications approaching 1,000 pages in combined length). Much of the secrecy and privacy provisions were implemented to protect data that, as mandated by the law, is much more fluid and more easily compromised than the old HCFA-1500 paper forms--but, on the upside, much less error-prone and much faster to process. When it is fully implemented (which I don't foresee for at least 10 years), all medical information that is pertinent to insurance claims, including diagnostic notes, secondary and tertiary claims, and even electronic medical records including imaging will be transmittable and storable electronically (there is no standard for EMR as of yet). When it's fully implemented, it has the possibility of completely *eliminating* paperwork, with the exception of one-time business associate agreements and once-per-year acknowledgments of patient privacy practices.

Daniel: 35%? That's cheap! I know lawyers who keep half and still think they are being screwed!

[Joe]

From the blog of "Michael Ditto" regarding his 'commentwar' here:

"It’s really quite entertaining"

He finds an argument over whether ot not someone should be starved to death 'entertaining'.

[Steve J.]

"I HAVE SEEN MANY WALKING, TALKING, FAIRLY COHERENT PEOPLE WITH WORSE CEREBRAL/CORTICAL ATROPHY."

Please give even ONE example of this, with references and scans.

NOTADOCTOR:"No care or therapy has ever been provided to Terri.

This is false:

Theresa spent two and a half months as an inpatient at Humana Northside Hospital, eventually emerging from her coma state, but not recovering consciousness. On 12 May 1990, following extensive testing, therapy and observation, she was discharged to the College Park skilled care and rehabilitation facility. Forty-nine days later, she was transferred again to Bayfront Hospital for additional, aggressive rehabilitation efforts. In September of 1990, she was brought home, but following only three weeks, she was returned to the College Park facility because the “family was overwhelmed by Terry’s care needs.” On 18 June 1990, Michael was formally appointed by the court to serve as Theresa’s legal guardian, because she was adjudicated to be incompetent by law. Michael’s appointment was undisputed by the parties. The clinical records within the massive case file indicate that Theresa was not responsive to neurological and swallowing tests. She received regular and intense physical, occupational and speech therapies. Theresa’s husband, Michael Schiavo and her mother, Mary Schindler, were virtual partners in their care of and dedication to Theresa. There is no question but that complete trust, mutual caring, explicit love and a common goal of caring for and rehabilitating Theresa, were the shared intentions of Michael Shiavo and the Schindlers. In late Autumn of 1990, following months of therapy and testing, formal diagnoses of persistent vegetative state with no evidence of improvement, Michael took Theresa to California, where she received an experimental thalamic stimulator implant in her brain. Michael remained in California caring for Theresa during a period of several months and returned to Florida with her in January of 1991. Theresa was transferred to the Mediplex Rehabilitation Center in Brandon, where she received 24 hour skilled care, physical, occupational, speech and recreational therapies. Despite aggressive therapies, physician and other clinical assessments consistently revealed no functional abilities, only reflexive, rather than cognitive movements, random eye opening, no communication system and little change cognitively or functionally. On 19 July 1991 Theresa was transferred to the Sable Palms skilled care facility. Periodic neurological exams, regular and aggressive physical, occupational and speech therapy continued through 1994.

http://jb-williams.com/ts-report-12-03.htmA REPORT TO GOVERNOR JEB BUSH AND THE 6TH JUDICIAL CIRCUIT IN THE MATTER OF THERESA MARIE SCHIAVO

[NotADoctor]

I am sorry, I should have been more specific. Michael Schiavo, 1n 1993, swore in testimony that he would use any malpractice funds to take care of his wife. At the same time he was planning to move in with another woman. After winning 1.2 million dollars, he conveniently decided that Terri was not treatable, and really "would not want to live this way". And after which, declined to spend money on her care and treatment.

The Interview That Wasn't
by Wesley J. Smith
10/28/2003 9:00:00 AM

MICHAEL SCHIAVO, Terri Schiavo's husband, finally went on national television last night to tell the world his side of the story. Appearing on "Larry King Live," he strived mightily to play the loving husband. Until more than half way through the interview, when King got around to tentatively asking Schiavo whether or not it is true that he has a girlfriend. (King, who must have known the answer, somehow failed to mention that Schiavo has already sired two children with this woman, who he calls his fiancé.)

The loving husband answered, "I'm lucky. I have two great women to love." He then paused to take a swipe at Terri's mom, "My girlfriend has done more for Terri than her own mother." Asked what that might be, Schiavo answered, "She washed her clothes."

THAT EXCHANGE should have opened the door to some very interesting conversation. King could have asked Schiavo if he is raising children with another woman--a matter finally brought up by a caller near the end of the show--why he should continue to have any say over Terri's care, given that the sanctity of the marriage vows he took are no longer operable. King didn't, of course, which is precisely the reason why people in the center of heated public controversies like to go on his show.

There are a number of questions King should have asked Schiavo:

(1) Why did Schiavo tell a medical malpractice jury in 1992 that Terri would live a normal life span? After Terri's collapse, Schiavo sued for
medical malpractice. Under civil law, the longer Terri was expected to live, the larger the verdict would probably be. This fact of legal life could explain why Michael presented evidence to the malpractice jury not only that Terri would likely live a normal life span but also that he intended to be a good and loyal husband and care for her for the rest of his life.

(2) Why did Schiavo have a rehabilitation expert testify in front of the malpractice jury to present a detailed plan of therapy for Terri? Schiavo and his lawyer claimed that Terri is incapable of improving physically, but during the 1992 trial, a rehabilitation plan and its anticipated undertaking provided one of the underpinnings for the jury's $1.3 million award. Of that money, Schiavo received $300,000, lawyers' fees were paid, and about $750,000 was put in trust to pay for Terri's rehabilitation.

(3) Given that the jury awarded $750,000 to be used in part for Terri's therapy, why hasn't Schiavo provided any rehabilitation for her since 1991? When asked by King about the issue of rehab, Schiavo described some early efforts to help Terri, such as an experimental surgery in 1990. But he never identified when this rehab took place.

Which is an important point. The only efforts ever undertaken to improve Terri's condition took place in 1990 and 1991. They had ceased by the time of the malpractice trial in 1992 because her insurance coverage had run out. Indeed, the pressing need to restart therapy was an urgent part of the malpractice case. It could have--and should have--paid to restart the rehabilitation that had been abandoned due to lack of funds.

Once Terri's $750,000 was in the bank, however, Schiavo would not approve a single cent of it to be spent on rehabilitation. Not only that, but once the money was in the bank, Schiavo ordered a "do not resuscitate" order placed on Terri's chart so that if she had a cardiac event, the doctors would not attempt to save her. And within a few months of the money being deposited, Schiavo also refused to permit curative treatments, such as antibiotics for infections. If Terri had died during the early or mid-1990s, as Schiavo's orders were designed, he would have inherited somewhere around $700,000.
The issue of Terri's money did come up several times during last night's interview. Schiavo assured King he isn't in it for the money because there is only about $50,000 left in Terri's estate.

(4) Is it true that Terri's money has paid for attorneys to make her dead, instead of therapists to make her better? The answer is, unquestionably, yes. According to court records, George Felos, the dutiful "right to die" attorney who sat at Schiavo's side on King's show, has been paid over $350,000 from Terri's trust fund. Another of Schiavo's attorneys, Debra Bushnell, has received about $90,000. These two lawyers alone have received more than half of Terri's entire trust.

According to court records, when Schiavo began his quest to pull Terri's feeding tube in 1998, she had more than $700,000 in the bank. This was primarily because Schiavo generally refused to authorize payments for any nursing home
services on Terri's behalf beyond the basics of room and board. Thus, only about $50,000 was paid on her behalf in the five years following the jury verdict. Since 1998, about $650,000 (not taking into account any earnings from the fund) has gone out--not for therapy, but primarily for lawyers.

And yet on "Larry King" Schiavo went so far as to suggest that Bob Schindler, Terri's father, is fighting to save Terri's life because he wants her money.

(5) So how could Terri's father make any money off the case? Schiavo's story is that once Schindler became Terri's guardian, he would get her a divorce, and then he would stop her food and fluids. The alleged point of such a scheme being that as next of kin, the Schindlers would inherit their daughter's money.

This sounds like a mighty stretch, particularly given that Bob Schindler has spent every nickel he has--including his entire retirement fund--desperately trying to save his daughter's life. If Bob Schindler is a venal man, he has a funny way of showing it.

Schiavo told King that his falling out with his father-in-law occurred in February 1993, when Schindler demanded a share of the proceeds in Terri's trust fund. But Schindler and his wife Mary tell a different story. They claim that the argument was over their insistence that the long-suspended rehabilitation recommence, since there was finally money available to pay for it. They contend that the breach of relationship occurred because Schiavo refused. The behavior of both parties since seems much more consistent with this story than with Schiavo's version of events.

Too bad Larry King didn't ask.

http://www.weeklystandard.com/Content/Public/Articles/000/000/003/306hhsrh.asp?pg=2

Interesting article.

Feb 1990 - Terri Collapses in her home. May 1990 (3 months since collapse) - Terri discharged from Humana Hospital in St. Petersberg, Florida.

Dec 1990 - Terri taken to California for experimental implant.

Jan 1991 - Terri moved to Bradenton Mediplex Rehabilitation Center.

Feb 1991 - Terri moved to home with husband.

Apr 1991 - Terri's condition is assessed as improving.

Apr 1991 - Terri's husband advised to move her to Gainesville Rehabilitation Center to receive advanced therapy to continue Terri's recovery.

Jul 1991 - Terri moved to Sable Palms Nursing Home.

Aug 1992 - Terri awarded $250,000 in malpractice settlement.

Nov 1992 - Terri awarded $1.4 million in malpractice trial.

Nov 1992 - Michael Schiavo award