CSI MEDBLOGS: CODEBLUEBLOG ANALYZES TERRI SCHIAVO'S STARTLING BONE SCAN

WHAT DOES TERRI'S BONE SCAN MEAN?

It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely.

A reader asked me to comment on Terri Schiavo's bone scan report.

Here are my initial thoughts:

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

However, that being said, several things are unusual.

First, the DATE on this bone scan is March 1991. Terri's cardiopulmonary arrest -- as far as I can tell -- was in February 1990; therefore, the abnormalities that are described occured AFTER Terri's February 1990 arrest, probably in the weeks or month(s) just prior to the bone scan, unless she had a second arrest at some point -- and I do not have that history. Certainly there was trauma. As I understand it, the issue is how the trauma occurred.

Trauma from CPR generally involves 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 correlative 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 medications she could have been osteoporotic, in which case some might claim that a mild compression fracture of L-1 would not be so unusual-- however this is only true in ambulatory people, which Terri was not.

The uptake over Terri's 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 Terri's bone scan) the possibility of bleeding underneath the thin covering of the bone (the periosteum) which is a finding that correlates highly with trauma, specifically, abuse.

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

I would want to know if Terri had a BLEEDING problem at any time, because that might explain this finding.

Certainly IN A CHILD (which Schiavo, obviously was not), the combination of posterior 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

It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely.

The x-rays might make all of this clearer if we can obtain them.

n.b.

Teri's fractures could be of the "insufficiency" type (caused by prolonged immobilization/dietary irregularities) and some might posit this explanation; however, in a nonambulatory bedridden patient under careful supervision, I find this untenable, especially given their distribution which are so typical for ABUSE.

Here's the link to the bone scan report: http://www.terrisfight.org/images/bonescan.jpg

Comments

[thoughtomator]

Thanks, I appreciate the time and effort you've put in to help make sense of this report.

[Mike Stiber]

Here's something to consider:

"In general, physicians would consider it unprofessional for doctors to take clinical stands on issues without adequate clinical data," said Dr. Neil Wenger, head of the ethics committee at UCLA Medical Center.

[CodeBlueBlogMD]

I've heard about all I want to from professional ethicists.

I have the expertise. I dealth with the information they claimed was most pertinent.

This is what blogging and the blogosphere is all about.

If, by suggesting that people are misinformed based on the data provided to the public, I am being unprofessional...well, I'll be damned then, I guess.

Mike, in general I find it perfectly unethical to starve a perfectly healthy woman to death, without any indication (other than a casual remark made at a barbecue) that is what she would want. What could possibly be wrong with a frank discussion of the facts?

[bioethics dude]

Interesting site, i do like most of it. One question though, how CREDIBLE is this info? 1) Given the source (I would posit this either way); and 2) what about HIPAA?! Who would have released this, or the CT scan?!

[Scott Chaffin]

CBBMD, you're 100% correct...it's what the blogosphere is about. In fact, I would dearly LOVE to read any other interpretation of the CT scan and bone scan, whether it aligns with yours or not. If you run across one, will you post it?

HIPAA is new-ish (2000 or later?), and these records were released back in the early to mid-90s as part of the initial "pull the tube" case by the lawyer representing the Schindlers. That's my recollection of the 40BB things I've read over the last few days, anyway.

[MyssiAnn]

Bioethics Dude, are you *really* more worried about Terri Schiavo's HIPAA rights than her right to food & water? Don't get me wrong, I understand HIPAA, but this bone scan report is, as I understand it, a court document that is a part of the public record already. And, as someone who works with a hospice organization regularly in my job in order to coordinate Medicare billing, what in the name of medical ethics is she doing being kept in a hospice facility for years at a time??? Hospice is supposed to be re-certified every 6 months and if the patient is not at an end-stage of disease they are supposed to be moved either home or to a skilled nursing facility. Just wondering....

MyssiAnn, that's exactly what we have been discussing here:

http://codeblueblog.blogs.com/codeblueblog/2005/03/csi_medblogs_co.html#comments

[docswede]

CBBMD-
How you can be so certain of a diagnosis of trauma from simply reading a text report of a bone scan is impressive. Nuclear imaging is highly non-specific and the differential diagnosis associated with a positive finding is extensive. Moreover, you are assuming that TS is a normal adult patient. She is not! She was (is) immobilized and malnourished. In and of itself these situations will cause abnormal uptake as the bone is not receiving the usual stress of an ambulatory patient. Bone metabolism is dynamic and dependent upon weight bearing. Think about where this patient is bearing her weight. Lastly, costovertebral fractures can be seen with CPR, especially in a patient with osteopenia, which this patient most likely has.

docswede, at the time the bone scan was taken, Schiavo had been debilitated for (more or less?) a year. What is the common rate of progression of bone density loss in a person of such? She was a young, healthy (?) adult at the time of her "accident".

Just wondering.

[Katrina]

docswede,

You'll have a hard time convincing me that only 12 months, if that, after immobilisation Terri Schiavo was subjected to bone density loss sufficient to cause the injuries revealed in the scan. What a good idea it would be to give Terri a bone mineral density scan now. That would help put an end to the speculation, particularly if her density loss was not to as great a degree as you might think it is.

[Shari]

Here is the testimony from the doctor that did the bone scan:

http://www.hospicepatients.org/dr-walker-t-schiavo-bone-scan-deposition.txt

“On the Record” with Greta van Susteren

Interview with Dr. Michael Baden, Forensic Pathologist, New York , October 24, 2003

Greta: Dr. Baden, a potassium imbalance, let’s first talk about if you have a potassium deficiency, can that cause the condition that Terri Schiavo has?

Baden: Um, can, but unlikely. Potassium is very interesting. It’s probably the most lethal poison we have when it’s injected rapidly, and that’s why it’s the poison that kills people, capital punishment by lethal injection. And it stops the heart from beating properly — too much of it. But also too little of it., hypo-potassium, can also cause the heart to stop beating properly and lead to lack of blood flow to the brain and death of brain cells by lack of oxygen. But that’s very unusual, Greta, extremely unusual.

Greta: A normal healthy woman, I assume, would have no reason, for instance, to take potassium supplements unless, perhaps, she’s on a diuretic or some other medication that would cause a potassium depletion. Is that right?

Baden: That’s correct. That’s right.

Greta: Is there any explanation then in your mind, and I realize you were not her team physician, but why would a woman at her age have a potassium imbalance?

Baden: Extremely unusual unless she had certain kinds of diseases, which she doesn’t have. She was in her twenties. The reason that she’s in the state she’s in is because there was a period of time, maybe 5 minutes or 8 minutes, when not enough oxygen was going to her brain. That can happen because the heart stops for 5 or 8 minutes, but she had a healthy heart, from what we can see. The other thing, though. . . I’m sorry Greta?

Greta: No, go ahead.

Baden: Yeah, your staff has provided me with a bone scan that you guys obtained ah from her initial admission in 1991 to the hospital. And that bone scan describes her as having a head injury. That’s why she’s there, that’s why she’s getting a bone scan. And a head injury can cause, lead to the vegetative state that Ms. Schiavo is in now, and it does show evidence that there are other injuries, other bone fractures, that on healing-stage, so that....

Greta: So, let me back up a second. Head injury. Could she have had, could she have passed out from a potassium imbalance causing a falling head injury? Is that what you’re talking about, or are you suggesting some pre-existing head injury to her passing out?

Baden: Something totally different. That it’s extremely rare for a 20-year-old to have a cardiac arrest from low potassium who has no other diseases. So the other issue is could it have been due to some other cause, which is raised by the family, has to be looked at.

Greta: Alright, other injuries and bone injuries, what does that suggest to you?

Baden: Some kind of trauma. The trauma can be from an auto accident, the trauma can be from a fall, or the trauma can be from some kind of beating that she obtained from somebody somewhere. It’s something that should have been investigated in 1991 when these findings were found, and….

Greta: They were fresh.

Baden: Maybe there were, Maybe they were investigated by police at that time.

Greta: Alright. Dr. Michael Baden, thank you.

Baden: Thank you, Greta.

[end transcript]

[ahem]

The point, now that it may be too late, is to make sure her husband doesn't cremate her immediately as planned. He may just get away with it...

[thoughtomator]

I'm impressed... with only the bone scan report, the doctor here came to nearly the exact same conclusions as the doctor who signed it 14 years ago.

[err on the side of life]

Main point all seem to be missing in media and elsewhere: why were not the charges of questionable abuse by DCF not looked into by the law at the time? Easy, from the little I have read from Terri's blog and a blogger in New York (Empire Journal).

The sheriff Rice of Pinellas County during Terri's initial hospialization and rehab, who did not investigate abuse claims, is reportedly a friend of Judge Greer (who has given Terri the death sentence and other courts have ruled on law instead of investigating records).

Ole Sheriff Rice is now a State Congressman who, guess what !, voted to pull her peg tube. It gets worse, again from reading last weekend: Sheriff Rice employed Michael Schiavo, a RN, to work in a jail. And, even more, there are connections with Rice and Schiavo's attorney being on the Hospice board (where Terri has resided for years instead of the requisite 6 months which is law). She was placed in a hospice facility when she was not actively dying.

Hmmmmm.One may ask,too, why this seems to be getting brushed aside as it smacks of criminal neglect, illegal denial of rights for the disabled and conflict of interest. Why is this ignored and not in the headlines?That I don't have an answer for.

Also, huge point finally making some media today: Terri could probably swallow and not even need a peg tube for feedings as she does not appear to choke on her secretions in the old videos (Michael will not allow new ones---the ones we see are years old). It is reported her husband would not allow her to be fed orally. Due process of her rights...I don't think so.

[bioethics dude]

The Dude got a letter from a firm alleging to be working with the Schiavo family, you can see the letter at the blog (don't mean to self promote, honest

http://bioethicsdude.blogspot.com/2005/03/dude-gets-letter-from-admirer.html

[Sparrow]

Where the heck is Jessica Fletcher when you need her?

[Shera]

I am afraid that I am very sad for this young lady. There is nothing in any of this that makes any sense. Why should a young otherwise healthy woman be sentenced to die in such a horrible manner, when in fact it looks like her husband in truth is the criminal? He has misappropriated funds that were meant to care for Terry. It appears from much evidence that his fight to end her life is meant to cover up some indiscretion on his part that caused this state that she is in. She has been touted by many physicians to have the capacity to improve given proper treatment, and yet she has been denied proper rehabilitative care for many years. Her rehabilitation was stopped at a time when she was showing improvement in her verbal acuity. What is Micheal afraid of her telling? Would she tell the truth about what happened to her if she was allowed to continue therapy? It is a shame that someone could shamelessly use the courts of this country to his own means at the expense of a precious life. Now she will starve to death, one of the most horrible and terrifying ways to die I could ever imagine, and nothing will be done to stop the torture of this precious soul. These doctors and judges should be unseated for the decisions they have made regarding this young woman.

God Bless the Parents of Terry Shiavo.
I will grieve with you for the loss of our country's concious as well as the precious life of your daughter.

If y'all are following these comments, make sure you catch Hannity and Colmes today.

One of Schiavos neuro guys (Cransford, appointed by Greer, who said she was PVS....bag 'o water brain) was on. Hannity nailed him. He got the guy to admit to an article he previously wrote claiming PVS patients have NO constitutional rights. Of course, 40% of PVS diagnoses are wrong so the guy looks like a nutter.

Then Hannity asks him how long he studied Terri. Answer: 45 minutes.

Hannity says when was the last time Terri had a CT scan. Answer 1996.

Hannity says his bro in law is a radiologist and that PET and MRI are indicated if you want to be 1000% sure before you kill somebody. The Doc just kinda shrugs.

Judge Greer should be impeached.

Also, this verfies that NO CT scans were done after 1996.

Don't usually watch H&C but today the subject matter was compelling.

[Jennifer]

I'm just wondering what is wrong with our country? How is this being allowed to happen right before our very eyes? This is reminiscent of Nazi Germany.

[thoughtomator]

We're even closer to Nazi Germany than you think.

In tomorrow's Washington Post:

http://www.washingtonpost.com/wp-dyn/articles/A58069-2005Mar22.html

Compare that to the Nazi T-4 Euthanasia program:

http://en.wikipedia.org/wiki/T-4_Euthanasia_Program

All this time we were expecting the next Hitler would be a head of state, and it's been sneaking up on us in the form of a totalitarian judiciary and a left-wing press.

[Richard]

Shera: The correct name is Cranford. Just see how he "studied" Terri for 45 minutes - the creap! - just like her "husband":
http://nationalreview.com/comment/johansen200503160848.asp

Starving for a Fair Diagnosis
Terri Schiavo is not out of medical options. But that’s the “fact” her husband wants you to believe.

(excerpts)

THE CRANFORD DIAGNOSIS
… the star medical witness for Michael Schiavo, Dr. Ronald Cranford of the University of Minnesota, has repeatedly dismissed calls for MRI testing, and his opinion has prevailed.

…Dr. Cranford examined Terri on one occasion, for approximately 45 minutes.

…In Cranford’s examination, described by one witness as “brutal,” he discounted evidence under his own eyes of Terri’s responsiveness. At one point, Dr. Cranford struck Terri very hard on the forehead between her eyes. Terri recoiled and moaned, seemingly in pain. In his court testimony, Cranford dismissed the reaction and moan as a “reflex.”

Richard, twas me that mangled Cranford's name, not Shera. My bad.

[Texas Cowboy]

Please leave the Hitler crap and personal attacks out of this. Thanks.

[Texas Cowboy]

yay, the ruling came down. now you guys can find another ambulance to chase. :)

TC, nice to see you have such a cheerful attitude about a human being slowing dehydrating and starving to death. That's the spirit! No wonder you defended Hitler, you two have much in common.

[NotADoctor]

Previous poster, I think you meant "slowly dehydrated and starved to death".

Have to agree with you. TC seems to have some special mandate in regards to "useless eaters", much like Hitler.

His atttitude doesn't concur with any Texan that I ever knew. Must be one of those "carpetbaggers".

[thoughtomator]

Any reasonable person who compares the sources I referenced can see that there is no hyperbole whatsoever in making the comparison. The T-4 program is rhetorically and historically the direct predecessor to the travesty we are witnessing in the Terri Schiavo case.

[Texas Cowboy]

Hitler and Bush, one and the same. Well okay, Bush only killed 100,000 civilians. So much for the culture of life! :)

[realtexan]

Texas are you sayin you support Bush AND Hitler? Are you one of dem dere skinheads I herd tell of?

[Jeremy]

Let's all remember Godwin's law and drop the Nazi comparison.

Thanks.

[Ed Jordan]

CodeBlueBlogger,

The law firm representing Terri's parents (the Gibbs law firm) emailed me by mistake because I had posted on my blog what you have been writing about Terri's scans and reports.

They want your help.

I have forwarded to you the email they sent me by mistake. Please check your email to get their phone number, etc.

If you can't find it, email me.

[Rob]

Michael Shiavo's lawyer said Friday Terri took Communion. If she can't swallow how did she take Communion? There are so many questions concerning her. She doesn't derserve to lose her life in this cruel way. I do not know anyone her age especially in 1990 who would say no to a feeding tube. Tragic.

Rob, the poor girl never said that she wouldn't want to live via feeding tube, she made a casual remark that she "wouldn't want to live like that" in regards to a ventilator when they were discussing Michael Schiavo's grandmother. Judge Greer blocked testimony from acquaintances of Terri's that stated otherwise. Greer and Felos are bent on killing her now because they have extracted all the money they can from her guardianship account.

How is it you can publish medical records without that person't permission?

Physicians and Hospitals can't release records without the permission of the patient or guardian or a court order.

Once they are in the public domain, they are fair game, however they happened to get there.

November 21, 2003, deposition

(excerpts) taken from Dr. Walker, a board-certified radiologist at Manatee Memorial Hospital. Dr. Walker is the doctor that prepared the bone-scan report from the image of Terri Schiavo taken on March 5, 1991.

15 Q What is a total-body bone scan used for

16 typically?

17 A It's to look for abnormalities of the

18 bone, whether they -- if they would be recent

19 abnormalities.

20 Q Recent --

21 A Recent.

22 Q -- abnormalities?

23 A Correct.

24 Q Is it also a technique to diagnose

25 osteoporosis?

1 A No.

3 Q And the next sentence, "There are an

4 extensive number of focal abnormal areas of nuclide

5 accumulation of intense type." What does that mean?

6 A Well, that means that there are a lot of

7 areas that look black on the images because lots of

8 that radioactive decaying material was happening at

9 those points and was being recorded by the imaging

10 system.

11 Q Okay. "These include multiple bilateral

12 ribs." What would that mean to you?

13 A Well, you know, there's left ribs and

14 right ribs. And that would mean that more than two

15 ribs on each side were involved.

13 Q "Several of the thoracic vertebral

14 bodies, the L1 vertebral body, both sacroiliac

15 joints." These are all areas that were abnormal on

16 the scan?

17 A That's what this indicates, yes.

18 Q "The distal right femoral diaphysis,"

19 what area of the body is that?

20 A That would be the right leg, the upper

21 part of the right leg.

22 Q Distal?

23 A Above the knee.

5 Q So on the thigh bone above the kneecap

6 but not involving the joint?

7 A That's what that particular thing says,

8 but I think somewhere in there also, it mentioned

9 that both knees --

10 Q Right. Right after that.

11 A Right after that. So that's different

12 from the knee activity.

13 Q And, "Both ankles, right greater than

14 left." Those are two additional areas that showed

15 up as abnormalities on the scan?

16 A That's correct. Correct.

13 Q Would you draw any conclusions from that

14 how old the ossification was?

15 A You could say that it wasn't real old,

16 because typically, as we mentioned, the bone is a

17 dynamic structure, and it's constantly being

18 remodeled normally. So the body tends to take away

19 extra bone eventually to remodel it to look like

20 normal bone. So typically old bone injuries are

21 remodeled so that eventually they may almost

22 disappear, particularly in young people. In the

23 very young, a fracture you won't even see in three

24 or four years, it will be totally erased.

8 Q Then you go on to say, "Most likely the

9 femoral periosteal reaction reflects a response to a

10 subperiosteal hemorrhage." Would that be a bone

11 bruise?

12 A Correct.

16 Q Then you go on to say, "And the activity

17 in L1 correlates perfectly with the compression

18 fracture which is presumably traumatic."

19 A That's what it says.

20 Q In other words, the x-ray confirmed the

21 L1 fracture?

22 A The x-ray shows an abnormality at L1

23 which happens to correspond with the abnormal bone

24 turnover on the bone scan at that point.

7 Q Is this compression fracture, then, in

8 common parlance, a broken back?

9 A Yes.

10 Q Is there any way to tell how old that

11 fracture would be?

12 A Well, as I've alluded to, the bone scan

13 gives some suggestion of that.

14 Q More recent rather than less recent?

15 A Correct. Typically in trauma the rule of

16 thumb is that a traumatic fracture is not active on

17 the bone scan after 12 to 18 months.

9 Q The report goes on to say, "The

10 presumption is that the other multiple areas of

11 abnormal activity also relate to previous trauma."

12 A That's what it says.

13 Q And, again, that's based on the fact that

14 Dr. Carnahan is a rehab physician, that you were

15 asked to evaluate for trauma?

16 A And the pattern of activity is fairly

17 typical of multiple traumatic injuries of relatively

18 recent origin.

19 Q I realize you can't assign a cause to

20 these injuries that you picked up in this report.

21 But typically in your experience, what would be the

22 causes of this pattern of abnormality?

23 A In somebody her age, an auto accident is

24 by far the most typical cause.

25 Q Assume that she was not in an auto

1 accident but that she had suffered an anoxic or

2 hypoxic encephalopathy type of injury from a cardiac

3 arrest and had been bedridden for a year at this

4 point. What might account for these abnormalities?

5 A In my knowledge, that type of injury

6 would not account for this pattern of abnormalities.

5 Q Okay. Is this a pattern of heterotrophic

6 ossification as reported in the literature that you

7 looked at?

8 A Not typically.

9 Q What makes it atypical?

10 A Well, if I were to pick one thing, I

11 would say the activity in the ribs is not typical.

12 And typically heterotrophic ossification occurs

13 around the joints because they're not being moved.

14 And typically you will see on the radiographs

15 calcium deposits actually sitting there. And they

16 don't look like periosteal reaction typically

17 either; they have a different appearance.

4 Q Can you say, then, within a reasonable

5 degree of medical certainty whether this bone scan

6 is consistent with heterotrophic ossification?

7 A In my knowledge, it's not consistent with

8 heterotrophic ossification as I typically see it.

21 Q Okay. And later on in your direct

22 examination you were saying that traumatic fractures

23 typically are not active on a bone scan after 12 to

24 18 months. Is that correct?

25 A That's correct.

19 Q Okay. Is there any way for you to say

20 from looking at this report when any of these

21 occurrences took place that caused the abnormality

22 to appear on the bone scan?

23 A I can only say that if they were

24 traumatic that they probably occurred within 18

25 months.

1 Q Is it possible that the abnormalities

2 that you noted on the right femoral diaphysis and

3 metaphysis could have occurred if the patient was

4 standing and suffered a cardiac arrest and fell to

5 the floor?

6 A Probably not. That wouldn't be a typical

7 mechanism of injury that would cause a periosteal

8 bruise. Typically you need a direct blow of some

9 kind. I suppose one could speculate that she fell

10 on a piece of furniture, that that could produce

11 that injury. But just typically falling on the

12 floor would not do that.

9 Q Okay. The bone scan and radiographic

10 report shows only one fracture. And that is a

11 compression fracture to L1. Correct?

12 A Well, I should clarify that by stating

13 that not all of the areas of bone-scan abnormality

14 were imaged concurrently. Okay. And that's

15 important. In other words, we didn't x-ray every

16 area that was hot on there. A couple of typical

17 areas were imaged but not all. Of those areas that

18 were imaged, the only area that showed what was a

19 clear fracture was L1.

2 Q The radiographs did not show any

3 fractures of the right femur. Correct?

4 A They don't show a typical fracture. They

5 show periosteal reaction, which could be the result

6 of a bone bruise, which is a bone injury that's not

7 a loss of continuity of the structure of the bone.

8 So to the extent that you define fracture as a loss

9 of structural continuity, then, yes, that is an

10 actual fracture as is typically described.

10 Q Okay. If an immobile patient is going

11 through physical therapy and part of the physical

12 therapy is to have manual manipulation of the legs,

13 particularly flexing of the knees, is it possible

14 that that physical therapy would result in an

15 abnormal appearance on a bone scan?

16 MS. ANDERSON: Objection. That question,

17 I think, is virtually unanswerable because it

18 is so vague.

19 A I could only speculate.

20 Q Okay. In your opinion, is that something

21 that would show up on a bone scan?

22 A I would think only if the joint were

23 injured would it show up on a bone scan. Just

24 simple manipulation of an injured part should not

25 show up as an abnormality on a bone scan.

22 Q Would a kick be the kind of direct blow

23 that would produce that femoral abnormality?

24 A That would be a possibility, yes.

25 Q Would being thrown into a sharp furniture

1 corner?

2 A That would be a possibility.

3 Q Would being struck with some sort of

4 blunt object like a golf club or something do it?

5 A Yes.

22 Q You mentioned that you have seen

23 fractures in bedridden patients before?

24 A Yes.

25 Q How frequently have you seen that?

1 A Rare.

2 Q It's rare?

3 A Yes.

http://www.zimp.org/stuff/03%20-%20WalkerDepositionDepo.htm

[Dita]

Dr. Baden was on Fox last week singing a whole different tune than the transcript cited from October 2003 you posted. He said, after reviewing all the available records, that everything was consistent with Bulimia.

Where did he get the idea back then that she had a head injury? All I see is consistent with osteopenia, a year in bed, PT, CPR, and a collapse.

Wouldn't the scan show calcium activity that had been delayed during the years she was so low in calcium? Her exit summary http://www.terrisfight.org/documents/Humana%20Discharge%20Summary%20050990.pdf says she was low in calcium on admittance, and generally malnourished.

Wouldn't there be obvious bruises? If so, why would they wait until a year later to take a scan?

He's been very cold-hearted toward her parents, in my opinion, but I don't buy the bone scan as evidence of abuse when the rest of the profile seems classic for an eating disorder.

[CodeBlueBlogMD]

Dita:

The constellation of bone scan findings (posterior ribs, periosteal changes of distal femur, and vertebral fractures) are assumed abuse UNTIL PROVEN OTHERWISE. This is a radiological maxim. Ask ANY radiologist. It's standard training.

It is NOT normal for PT to be breaking ribs.

A vertebral superior endplate fracture indicates an AXIAL LOAD (top to bottom) that is unusual in a bedridden patient.

The periosteal elevationm of the distal femur is a typical finding once encounters when a baby or an uncommunicative patient's leg is GRABBED AROUND THE ANKLE AND PULLED/TWISTED.

There typically are NOT bruises in abused patients. Rib fractures are notoriously occult and there is rarely associated bruising. Same with vertebral body fractures.

Bone scans do not show "calcium activity." They show osteoclast (bone cell) activity indicative of excessive BONE TURNOVER. The scan WOULD NOT show activity due to any kind of rebound effect from calcium levels (up or down). Absolutely not.

With THAT bone scan it would be considered malpractice NOT to suggest that Terri Schiavo was abused (I'm not saying by whom or how)UNTIL PROVEN OTHERWISE.

These are facts. I am an expert in this subject. There is absolutely NO denying what I am saying and I will (and may) say it in sworn testimony in court. I also have the literature (check my link above) solidly in my corner on this.

[Dita]

Her attending physicians, including the doctor who ordered the bone scan, testified by affidavit that the assumptions of trauma by the radiologist were wrong.

As for axial load, of course, but she was ambulatory a year before the scan, and the radiologist himself said it could have happened when she collapsed.

He also said what he saw in her ribs could be attributable to CPR.

The femur is interesting, but she had a radiograph of that knee at the hospital a year before, and it showed no bony abnormalities at that time. There was discussion about possible causes, something about a restraint, if I recall.

[mod ervador]

I think it's better to go to the horse's mouth if possible. Here's what I got from reading radiologist Walker's deposition several days ago.

Radiologist did not see the patient.
Injuries were not considered life-threatening enough to notify the referring physician (Carnahan).
No evidence of blow to the head.
Use of words "trauma" and "traumatic" is based in part on the type of patient typically referred by Carnahan and on the instruction to "evaluate for trauma".
Right ventral femur injury is consistent with falling against a piece of furniture.(1)
Minor L1 fracture is possible from falling to the floor.

Drs. Alcazaren and Carnahan, both of whom had direct contact with the patient and the latter having ordered the bone scan, did not corroborate the view that the patient had a "history of trauma", specifically abuse. Certainly the defendants in the 1992 malpractice case would have liked to deflect the blame for Mrs. Schiavo's fate onto an abusive husband, but they were not able to do so.

I just don't see a case for abuse here.

(1) According to the police report, she was found with her feet in the bathroom. If she had just emptied her bowels or vomited, she could have done a Valsalva's maneuver which precipitated the cardiac arrest and subsequent collapse. The injury to the front of her thigh could have been from falling against the toilet or bathtub rim, for example, assuming it occured at time of cardiac arrest and not subsequently or previously.

[mod ervador]

Oh, I forgot to mention in my last post, also from Walker's deposition,

rib abnormalities are consistent with resusitation.

[Hamlet]

When you are CRUSHED.... you get.... COMPRESSION FRACTURES... which set off a Potassium Imbalance.....that can cause Life-threatening rapid, irregular heartbeat. This is more severe than with hyperkalemia..... and then you get....hydrocephalus caused by obstructed CSF flow in the ventricular system caused by ambulatory mishandling due to the unknown injuries to the spinal column........???

Ideas anyone... not a doctor... but being CRUSHED could lead to the potassium imbalance....

[Hamlet]

Just wanted to add to the above... if he was on top of her... his weight 250 lb? and used his weight to crush her there would be little to no outward signs...but deep brusing??? Could explain the broken ribs too??

[Kate Killebrew, MD]

More on bone disorders and eating disorders: I researched the radiologic literature from 1997-2004 on anorexia/bulemia/osteoporosis/fractures etc and came up with one article linking anorexia and osteoporosis, in addition to a body of literature I found on MedLink from the National Library of Medicine, which includes 10 million articles. There are a lot of reports on osteoporosis and anorexia, well-documented in female athletes, and are a number of articles on fractures and bulemia. There is a strong evidence that Mrs. Schiavo was bulemic, according to testimony from friends. Tho' she was not thin-thin, she was thinner at the time of her cardiac arrest than she had ever been. She weighed between 200-250 lbs apparently in high school, and was definitely obese on the school photo I saw. She was average on her wedding photos,becoming thinner later. She was seeing a GYN for irregular menses, which can also be a complication of anorexia. Regarding abuse, two of her brain CT's on admission were read as normal. NO blood, no fractures, not even a scalp hematoma from her fall. Normal.
I am a neuroradiologist. I have seen two images from two different CT scans of hers, the latter in 2002. The grey and white matter damage was devastating. The flaccid dilatation of the ventricles is most compatible with ex vacuo hydrocephalus. The CT findings are compatible with severe diffuse infarction, NOT myocardial infarction, but that of brain tissue. You cannot diagnose PVS from a CT scan. PVS is a clinical diagnosis, not a radiologic diagnosis. But you could infer severe global neurologic damage from her scan. AN MRI could not be done bec. of her experimental indwelling electrodes inserted years ago. An MRI would add little additional useful information. In order to remove these electrodes, she would have had to undergo an operation with some sort of anesthesia, risky business in view of her neurological state and her atrophic brain, which raises the risk of subdural hematoma due to tearing of cortical veins. Then there's the problem of not resuscitating her if she arrested. She has had a number of EEG's read as flat, no activity, one compromised by motion artifact. More EEG's are not necessary unless there is a marked improvement in her condition, which there never was.

[Kate Killebrew, MD]

More on the Bone Scan: ( I am a board-cert. radiologist, and a neuroradiologist) I just read the deposition of the radiologist who interp. the scan. He mentions multiple bilat. ribs, L 1, which was xrayed, Bilat SIJ, knees(I think-unclear), ankles and periosteal reaction R femur.I mentioned previously the lit on eating disorders/osteoporosis and fractures. The ribs may be due to the resuscitation. The bilat joints--SIJ's, knees(?), ankles-unusual in abuse.Common in metabolic disorders. I can think of two: a formerly starving person who is now adequately nourished (feeding tube).Then there would be increased joint activity, bilateral and diffuse. Also now adequately nourished but with disuse osteoporosis due to immobility, making the (natural) joint activity stand out. Periosteal reaction could be trauma, also reflecting healing insufficiency fracture. Children get diffuse periosteal reaction when the grow fast. Re the K+ 'imbalance'--remember that Mrs. S had a very LOW K, not just an 'imbalance'. It is virtually impossible for a well young woman to have low K,unless she is vomiting and drinking quantities of water or-iced tea. Then it could happen.

[Larry McGuire]

Another question.
Did Michael Schiavo's "beating" that you accuse him of giving Terri cause her to miss her period for several months before she collapse?
Damn. That's what I call a beating!

Think.

[Larry]

One more question.
Does a beating really cause a Potassium imbalance capable of causing such a great brain damage?
Is it me, or is this a lie? Can you provide a link in which we can read the relationship and the extent of Potassium imbalance and bone fractures (minor fractures for what I heard)?

[Hamlet]

SECONDARY AMENORRHEA

Pregnancy
Anxiety over pregnancy may cause a missed period, thereby increasing the anxiety even further
Drastic weight reduction
Vigorous athletics
Obesity
Emotional distress
Menopause (normal for women over age 45)
Endocrine disorders such as thyroid disease or pituitary disease/tumor

They DO cite DRAMATIC weight loss... which was not the case here.... Terri had been maintaining her present weight.... she had SLIMMED down by all accounts...

Speaking from experience... anxiety CAN and WILL cause problems... thus the admonishment of most ob/gyns to RELAX and let nature take it's course... is the first treatment employed in cases where the patient claims a failure to get pregnant or delayed or missed periods.

Also Emotional Abuse I believe would be cause for extreme emotional duress...

Once again.... there is NO way to know for sure.

[purple_kangaroo_Angela]

She did have a very serious pelvic infection (I think in her vaginal area) that she was being treated for, and had had a fairly serious allergic reaction to the medication for that, according to Michael's testimony in the malpractice trial and the Humana records. Could that affect any of this? Also, it seems significant that the Humana Hospital records did mention that malnutrition was a possibility for some of her chemical results.

[Hamlet]

???Crushing Syndrome/rhabdomyolysis: I just found out they gave her a blood transfusion... as per her release records.... testimony of the radiologist can be found here.... It is pretty clear that she was abused.... she suffered a broken back... can compression injuries... low K amoung other things.... and stopped her heart... arrest may also have been from actually crushing the air out of her lungs....... she was found face down with her arms in front of her holding her neck...

http://www.zimp.org/stuff/

[mod ervador]

Hamlet,

that's an EXCERPTED version of the radiologist's testimony. Find the entire testimony somewhere and get the real story. Here's the synopsis:

Radiologist (Walker) did not see the patient.
Injuries were not considered life-threatening enough to notify the referring physician (Carnahan).
Right ventral femur injury is consistent with falling against a piece of furniture.
Minor L1 fracture is possible from falling to the floor.
Rib abnormalities are consistent with resuscitation.
No actual evidence of blow to the head.
The phrase "closed head injury" on the form was an order for Dr. Walker to perform a panel of tests of the type one would perform on a patient who has suffered a closed head injury.
Use of words "trauma" and "traumatic" is based in part on the type of patient typically referred by Carnahan and on the instruction to "evaluate for trauma".
Drs. Alcazaren and Carnahan, both of whom had direct contact with the patient and the latter having ordered the bone scan, did not corroborate the view that the patient had a "history of trauma", specifically abuse.

Now, despite Terri's doctors' not being able to deflect blame from bulimia/hypokalemia/cardiac arrest in civil court, you want to bring up the idea of malicious asphyxiation again. Therefore you should take the next step and research the symptomology of asphyxiation and whether it's a good match for the symptoms Terri presented.

[Old Farmer Type]

Keep rattling their cages! Dig deeper into their "sludge-pile" of obvious deciets! sift out who they associate with. How many, if any, have ties with the infamous Skull & Bones outfit. George W. Bush is one of them. They are a super-secret bunch that glory in crime, murder, homosex, torture, drugs and such. To get a stomach-turning glimpse of Bush, type in the internet seach box: "Trance Formation of America," by Cathy O'Brien & Mark Phillips in the search box of the computer. Cathy is a rescued-victim of drugs, mind control and torture. How many attended Yale, site of S&K? Is it against law for kids to bring water to starving people? How were those kids recorded in police arrest records, if at all? Why are they violating "open records" by holding back two videos of the examination? If Schiavo uses that money for personal purposes, why is he exempt from income tax laws?
Isn't diverting money designated for Terri's treatment, to for pay lawyers, a personal profit, because he would be making an investment for his eventual gain?

[retired doc]

I fould the comments by Dr. Kate Killibrew to be most interesting. Could the increased label involving the sacroiliac joints and other sites be physiologic?

[Maggie4life]

Angela, we are on the same track here. You are right, it looks like there was only brief mention of malnourishment as a possibility for the collapse but the hospital made no further comment or enquiry based upon the blood test results.

I have seen no evidence that she suffered the kind of soft tissue damage in the throat that would indicate that she had bulimia. There is no evidence that she used items that would make sure that she used her bowels regularly. No one has really come forward to state that they heard her throwing up after a meal.

Another inconsistency is that the doctor, according to the transcript of the deposition in the malpractice case, was checking her weight on a regular basis. Every visit she was weighed. That sounds like she had been told to take off some of the weight to see if that made a difference.

Also, I suspect that Terri had a PID that could have caused her to miss her periods and also stop her from becoming pregnant. It seems odd to me that she did not have that particular problem until they went to Florida. She had not shown any signs of missing periods as a result of her diet when they were living in Philadelphia.

When weight loss is being supervised, as it was in Terri's case then I doubt that one can argue that this is a case of bulimia. The only evidence presented that gave any weight to this notion that she was bulimic is that given by Michael Schiavo. As far as I can see everyone else said that they did not notice the obvious.

As far as I can see Terri did not show any of the other signs that she had an eating disorder. These are the non-medical but psychological signs such as obsessive compulsive disorder. That kind of thing is missing in the equation.

Keep up this line of inquiry, because I am still convinced that there was an attempted strangulation, and that this has been covered up through subterfuge, that is the malpractice suit that was won because of alleged bulimia.

[kate killebrew]

More on the bones. I'm a radiologist and a neuro-radiologist and commented previously on the bone scan. In answer to an inquiry re the increased SIJ uptake as indicative of possible metabolic disease: yes, increased uptake is often indicative of metabolic disease. Also there is increase in young, growing persons, arthritis, and anything causing increased bone turnover. Very rare in trauma, unless accompanied by obvious pelvic fractures, usually from a car crash. Sometimes we see bilateral SIJ insufficiency fractures in persons who have received radiation to the pelvis, or in elderly ladies w/ severe osteoporosis. Knees ditto. Any weight-bearing joint with bilateral increased uptake. The rib uptake may be associated with (I understand) her prolonged resuscitation. The first lumbar fracture is common in osteoporosis, age, metabplic disease. It's very non-specific. Her femur wasn't broken in the usual sense of the word but may have been injured when she fell. I would need the xrays on this one. I understand that post-mortem xrays are being obtained. I wish that they would CT scan her entire body with thin sections, but don't know if that was done.

Abuse in ADULTS usually involved the facial bones and brain in severe cases. The pattern in children (described in this blog) and adults is totally different. Remember that her first 2 CT's were normal, including skull and scalp. If the ER docs had seen facial bruises, they would have gotten CT of the facial bones.

RE communicating hyprocephalus: a poorly understood entity. Again a CLINICAL diagnosis, like PVS. NO one can diagnose PVS OR communicating hydro on a CT OR an MRI alone. Commun. hydro means that the ventricles are NOT blocked but that the flow of CSF is abnormal. There's classical a triad of findings: broad-based gait, dementia, and urinary incontinence (Don't ask me why--it's empirical). Of course, Mrs. S had none of these. Dx of Commun. hydro is clinical or with a dynamic nuclide CSF flow scan which can only be read (if positive, which is rare) as 'compatible with commun. hydro"--not diagnostic of hydro. Mrs. S did not have this study because clinically she did not have communic. hydro., she had PVS.

I saw two images of her CT's, a single image from 1998 and one from 2002. Devastating injury in both images, involving all visualized white and grey matter with a ventricular dilatation which appeared secondary to the immense loss of cortex (grey) and white matter. There were not subtle changes, they were grade 4 out of 4 changes. NO possible subtle enlargement depending on positioning, etc.It is known that she did have CT scans after 1996. There is no point in getting more CT's, MRI's, PET's etc. inview of her terrible, unchanged clinical state.

Re EEG's. Apparently they measure only cortical activity. Two were reported as flat. SHe had a positive brainstem evoked potential which (I believe) indicated that her brain stem was alive, which we knew.

Re the two normal CT's. This is typical in any brain injury which does not involve bleeding. It takes time for the devastating injury to show. In her case, her ventricles (apparently) began to dilate before all the cortical injury began to surface, instigating an interpretion of communicating hydrocephalus. I don't know the details and haven't seen this CT, so can only surmise. Unfortunately, there is often poor communication between neurologists and radiologists, so the interpreting radiologist may not have know her clinical state.

Re her being able to swallow, getting a swallowing study, etc., Mrs. Schiavo could not swallow. She could not follow directions. Feeding her would have caused aspiration. Her final communion consisted of one drop of wine.

Re Dr. Hammesfahr, the 'world famed expert nominee for the Nobel Prize", etc. He is a neurologist who has published NOTHING on his treatments or on any medical research he has performed on any medical topic. He may have called people back from the dead, for all I know, but he has NO ARTICLE on ANY medical subject on a medical website which lists 10 MILLION published medical articles, and which included (all of my) six articles dating back to 1970.( I looked these up to test the completeness of the sites' listings).

Mrs. Sl's clinical state does not in any way resemble that of a mildly or even severely retarded person, so inferences should not be made about one's retarded relatives being euthanized. People are making a common mistake about Mrs. Schiavo--they think that there was a real, intact person somehow trapped inside her body, trying to get out. This was not the case. There is a very rare (fortunately) syndrome of being 'locked in' where in the cortical function is intact and people ARE locked in-usually able to blink their eyes--these poor individuals soon learn to communicate very well with their eyeblinks--now with a computer. Steven Hawking, the brilliant physicist, is somewhat like this now, due to ALS.

Finally--this supposedly is a medical blog-sort of. I don't see a lot of medical comments in many of the comments posted--they appear indistinguishable to what is undoubtedly on a lot of other blogs. Stick to medical questions, or subjects in this discussion. And calm down. This is reasoned discourse, folks.

Isn't that what Mengele said?

[ddb]

As I sit here I do not believe the TEXT for the
bone scan for 1991 "went" with Terri Schiavo.

It would be very nice to have the actual scan to
look at and see if what you read in the report
is what is on the scan.

And then it would have been mighty important to
have the body (Terri's) to see if the body matched up with
the actual scan you may beholding in your hand.

That is the ONLY way you will be sure this
is Terri's scan....and more importantly,
that the typed report goes with Terri's
body.

And with so much controversy (even
with the correlation x-rays retired doc mentioned were
in existence) over the incidence of apparent
things she had going on on this scan, I have much trouble
using this scan as any sort of evidence for the
rest of this case.

The MT could have pulled into the screen of her
computer a macro
for Terri (using her pt #/and maybe entered
wrong #)
and typed a dictation that the doctor
did on a completely different patient. If the MT did not
glance up and note that the pt name the doctor was
dictating (if he/she even said a name)(most of the time they say: "next")
is the NOT the same that is that on the screen,
it is very easy to put somebody else's dictation on another
person's hard copy.

There is also a stamp that was used a lot back then
and it said "Dictated But Not Read" and it was stamped
on reports - !!isn't that an incredulous thing to say!!

Anyway, getting back to this Schiavo bone
scan report.........it had
2 sets of initials on it - though the radiologist
says neither set is his - AMAZING! Never saw that before.

This Schiavo requisition even mentioned CLOSED HEAD INJURY,
yet this radiologist neither mentions the skull, nor
worries that he has nothing to read on it....again making me think
the radiologist was reading an entirely different
person's nuclear scan.

I would look for Terri's nuclear scan dictation to be one
of another typed that day, and it may be
under another name.

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