CSI MEDBLOGS: DOES TERRI SCHIAVO HAVE HYDROCEPHALUS?

THE FEEDING TUBE MUST BE REINSERTED IN ORDER TO GET A NEW CT OF THE BRAIN

I have offered the following proposition to Terri Schiavo's legal team today:

The single CT image I was able to access at the U of Miami's web sight raises the following ESSENTIAL questions/issues:

Issue: There is something in Terri's right ventricle (the image is reversed). I know she had thalamic implants, but on this one slice the "thing" in Terri's ventricle is not projected to the thalamus, it is projected within the ventricle. She needs a follow-up scan to  see what this is and where it is

 

Issue: If the "thing" in Terri's ventricle is a "shunt tip" -- who put it there and why is it there and was it removed? If she was shunted to relieve hydrocephalus then she must have follow-up exams and someone needs to postulate the most common mechanisms for hydrocephalus (which, I believe, is blood in the cranial vault)

 

Issue: Given this ONE image, NO ONE can exclude the possibility that Terri, at that time, had hydrocephalus.

I see all the classic signs: 

1. Enlarged ventricles
2. Rounded, bulbous front and back ventricle horns
3. "Pressure" effect on the occipital lobes of the brain (which, by the way, do not -- on this image -- demonstrate the atrophy seen everywhere else)

*People with untreated hydrocephalus OFTEN SHOW IMPROVED MENTATION WHEN THE OBSTRUCTION IS RELIEVED.*

So, if the other images bear out my impression from this one slice, then Terri MUST have a follow up CT or MRI or BOTH and if she is hydrocephalic she needs to be shunted, because there are possible positive therapeutic implications that no one can deny.

 
What if The State and Terri's Tube-Remover Ignore This ?

If she is NOT shunted it is my contention that there is no physician ANYWHERE who could say, in the future,  definitively, that Terri did not have hydrocephalus at the time of that particular CT slice.

What does this mean? Everything.

As I said, nonshunted hydrocephalics can experience improved mental functioning after shunting. I am not saying this would be the case with Terri (because of how long this has gone on); however, what I AM saying is that if they DON'T do a repeat CT scan NOW BEFORE TERRI DIES, the evidence will be on that scan forever. They will never be able to say it wasn't so.

Do they want to face their own carnivorous legal system when the dogs of war are let loose after Terri dies? I WILL BE THE FIRST TO TESTIFY. I will say that one cannot exclude hydrocephalus on that image. ONE MUST REPEAT THE SCAN. Basically, given THAT image the onus is on them to prove she is NOT hydrocephalic -- meaning she needs a repeat CT, and to do that they need to reinsert the feeding tube.

If they proceed as is, with that image out there on the internet, the person(s) who pulled that tube had better be aware that they are in jeopardy of actuating a death when there were standard medical procedural methods that had yet to be deployed.Here's what they can look forward to at the trial:

Dr. Boyle:             ONE MUST REPEAT THE CT SCAN

Tube-Puller:          Why?

Dr. Boyle:              BECAUSE SHE MAY HAVE HYDROCEPHALUS.

Tube-Puller:          O come on, that's ridiculous.

Dr. Boyle:             MAYBE. BUT SHE MAY HAVE HYROCEPHALUS.

Tube-Puller:          O come on. So what?

Dr. Boyle:             HYDROCEPHALICS CAN IMPROVE WITH SHUNTING.

Tube-Puller:         But she was brain dead. You're insane

Dr. Boyle:            MAYBE. JUST REPEAT THE CT SCAN AND PROVE ME CRAZY.

Tube-Puller:         we can't do that

Dr. Boyle:            WHY?

Tube-Puller:        She's dead. I pulled out her feeding tube.

Dr. Boyle:           DEAD? HOW DID SHE DIE?

Tube-Puller:       Dehydration. Starvation.

Dr. Boyle:           I'M SORRY FOR HER. I PITY YOU.

Tube-Puller:       Why?

<>

Dr. Boyle:   I CANNOT CHANGE WHAT IS ON THAT FILM. SHE MAY HAVE HAD HYDROCEPHALUS.   IF SHE DID, SHE MAY HAVE EXPERIENCED IMPROVEMENT WITH SHUNTING. 

Tube-Puller:        That's a lot of maybes.

Dr. Boyle:         THAT'S ALL TERRI HAD.
YOU SHOULD NOT HAVE PULLED THAT TUBE.  YOU ARE CULPABLE.  I'M AFRAID IT'S MURDER.

Tube-Puller:        that's idiotic. I only did what I was ordered by the courts to do.

Dr. Boyle:    

I'VE HEARD THAT BEFORE.
  IT DOESN'T FLY.

ONE MUST REPEAT THE SCAN. PUT THE TUBE BACK AND REPEAT THE CT SCAN.

Comments

[Jeremy]

Is this not just hydrocephalus ex vacuo which can occur with ischemic brain injury?

And have there been follow-up CT's that we just don't have access too? Do we know?

[Jeremy]

too=to ugh.

[marsha]

http://pekinprattles.blogspot.com/2005/03/dr-cranfords-complete-terri-schiavo.html

have you see this? I really have no idea about any of this.

Jeremy, Cranford stated on Hannity & Colmes yesterday that Terri hasn't had a CT since 1996. I heard it myself.

[Jeremy]

So perhaps this was the followup scan? And we'd need to see earlier ones? If this is the follow up then would there really need to be more?

Just curious.

[Jeremy]

Okay...actually that report you linked says she had a CT in 2002(and she's had multiple):

"The initial CT scan on the day of admission, February 25, 1990, was normal but further CT scans documented a progression of widespread cerebral hemisphere atrophy, eventually resulting in CT scans of 1996 and 2002 showing extreme atrophy (CT scans-1996, 2002: “diffuse encephalomalacia and infarction consistent with anoxia, hydrocephalus ex vacuo, neural stimulator present); prior to these most recent two CT scans, CT scans had been performed on February 25, 1990, February 27, 1990, and March 30, 1990, with an MRI scan on July 24, 1990.The two most recent EEG’s have demonstrated no electrical activity-on July 8, 2002: “no evidence of cerebral activity;” and October 4, 2002-“does not have any definite brain activity. However, most of the tracing is obscured by artifact from muscle and eye movement.” The clinical exams over the years were entirely consistent with diagnosis of permanent vegetative state secondary to hypoxic-ischemic encephalopathy. From the initial hospitalization in February, 1990, until the present time, there have been no significant changes in Terri’s neurological findings, and nothing in the medical records to suggest any disagreement whatsoever among Terri’s attending and consulting physicians about the underlying diagnosis and prognosis for recovery. A deep brain stimulator was placed in Terri’s brain on December 12, 1990 at request of the husband who flew with his wife to San Francisco for the procedure. This highly experimental form of medical treatment did not result in any clinical improvement in Terri’s condition."

I personally have my doubts in Dr. Cranfords ability to evaluate this case. He stated on National televison yesterday that the complete amount of time he has ever taken to evealute Ms. Schiavo is 45 minutes. He said yesterday that Terri hasn't had a CT since 1996, but in the above link to his email response, he suddenly remembers that she had a CT in 2002. I have my doubts that this is her actual CT.

[Jeremy]

No I think it's her actual CT. I'm 99.99999% positive of that.

I haven't seen Cranford talk...I'm just going on his full report here.

Abstractappeal.com confirms the 2002 CT:
http://abstractappeal.com/schiavo/trialctorder11-02.txt

[Kevin]

For ... the ... love ... of ... God ... can you all just please let the poor woman die? YOU all need counseling! YOU are trampling over HER rights! I hope the hell none of you ever find yourselves in her situation and are denied the right to choose what you want. Then you'll see how selfish you all are!

[Raquel]

This is supposedly an "accurate" timeline/history of the testing done to Terri (written by Dr. Cranford though...), although IF these additional tests were done, Greer has them sealed in the court records.

[The initial CT scan on the day of admission, February 25, 1990, was normal but further CT scans documented a progression of widespread cerebral hemisphere atrophy, eventually resulting in CT scans of 1996 and 2002 showing extreme atrophy (CT scans-1996, 2002: “diffuse encephalomalacia and infarction consistent with anoxia, hydrocephalus ex vacuo, neural stimulator present); prior to these most recent two CT scans, CT scans had been performed on February 25, 1990, February 27, 1990, and March 30, 1990, with an MRI scan on July 24, 1990.The two most recent EEG’s have demonstrated no electrical activity-on July 8, 2002: “no evidence of cerebral activity;” and October 4, 2002-“does not have any definite brain activity. However, most of the tracing is obscured by artifact from muscle and eye movement.” A deep brain stimulator was placed in Terri’s brain on December 12, 1990 at request of the husband who flew with his wife to San Francisco for the procedure.]

[JOMarley]

HEY...Check Dr Hammesfahrs Report. He also spoke about it on an interview with Ron Panzer at Highway2Health.net on 1/07/04
He tells that an experimental electrode was implanted in her brain,. Michael was told by the doctors that the electrode increased the risk of infection, encephalitis and a build up of excessive fluid. He was told that the electrode reqwuired ongoing medical monitoring. He removed Terri from the program and there was no medical monitoring from 1991-2 to now. The fluid is there and compressing the brain and diminishing her capabilities. It can be drained via a shunt and then the btrain would decompress and the diminished capabilties would return. Michael has refused all medical treatment. CRIMINAL ACT.

You can contact Dr Hammesfahr at Hammesfahr Neurological Institute HNI.com

Kevin, Terri made a casual remark, at a barbecue, that she would never want to be on a ventilator. Her husband is using this remark to starve her to death. There is evidence to suggest that she may not be PVS. Has it ever occured to you that Terri may not WANT to die this way?

[Jim]

Kevin, For the love of the same God, can't you let this poor woman LIVE? I can't believe you are serious in saying we are violating her right to death by starvation. I guess if wanting to let someone live is selfish, then count me in.

[GrenfellHunt]

Can we get some discussion of the no EEG in the last CT of 2002? To those of us non-medical readers, that sounds like no EEG=PVS or brain-dead.

[maggie]

Why is there so much inconsistency about the alleged CT scans? When did Cranford examine and do the scan on Terri in 2002? As far as I am aware he examined her only the once for about 45 minutes. He did not order any tests. Where is all this extra medical testing coming from?

Maggie, my point exactly. Frankly, I don't find any opinions (or information) from Cranford to be credible. He has his own agenda with Felos and that whole euthanasia crowd.

Dr. Cranford seems to have a knack for finding PVS. Cranford also diagnosed Robert Wendland as PVS. He did so in spite of the fact that Wendland could pick up specifically colored pegs or blocks and hand them to a therapy assistant on request. He did so in spite of the fact that Wendland could operate and maneuver an ordinary wheelchair with his left hand and foot, and an electric wheelchair with a joystick, of the kind that many disabled persons (most famously Dr. Stephen Hawking)use. Dr. Cranford dismissed these abilities as meaningless. Fortunately for Wendland, the California supreme court was not persuaded by Cranford's asessment.

Poor Mr. Wendland had a wife who wanted to remove his feeding tube. Thankfully for Mr. Wendland, he wasn't living in Pinellas County, Florida at the time.

[Delores]

Whats the harm in reinsurting the feeding tube and getting another cat scan. I think it is a sick day in America when we guickly kill criminals, or allow murders to spend a whole life time in prison, yet, we can starve the disabled or elderly. God have mercy on the husband and the judges, they are going to need it, they are nothing more than cold blooded killers.

[CodeBlueBlogMD]

Again, I only have the image on the website at u of Miami.

I have told Terri's legal team that I am willing/ would like to review any and all CT's and/or radiological examinations that have been done on Terri.

What may also be important here is the timeline of her cerebral atrophy as it relates to her cerebral atrophy.

Because I have another amazing question I am going to post on right this minute!

[Anon]

This info needs to get to the Florida Governor's Office and/or the DCF in Florida in order to help them in thier claim and legal authority to take Terri Schiavo into protective custody.

[Jeremy]

Cranford didn't have to order the 2002 test for it to be read/interpreted by him. But the court acknowledges that it was done...and it was read by all the physicians involved in the 2002 case.

The CT was done and reviewed in 2002 by all parties involved...doesn't matter who ordered it.

[jack]

Again we are treated to this highly emotional and alarmist rhetoric--based on a single screen capture of a CT scan and a bone scan.

We have not been treated to the supposed hundreds of CT scans of functional seniors whose scans are as bad as or worse than Terri's.

Instead we are expected, on this paucity of evidence, to believe that a radiologist knows better that all the doctors--among them neurologists and neurosurgeons, at least one of which has actually operated on Terri's brain--all the investigators, judges and other people who have been dealing with this first hand for 15 years?

Jack, there's enough chicanery going on with Greer's court rulings (and these learned neurologists and Felos who have ties to pro-euthanasia groups) to give the situation an element of reasonable doubt. If you want to keep drinking the kool-aid and believing the propaganda, go ahead.

[Phil Calvert]

According to an article posted at the Captain's Quarters blog, Terri allegedly does have hydrocephaly:

"Terri had a CT scan done, which Morin says is analogous to a poorly-focused photograph. It only has use as a diagnostic tool when dealing with major acute trauma to the brain, not in determining chronic brain death, and does not reveal the hydrocephaly that Schiavo and his doctors claim Terri has."

See:
http://www.captainsquartersblog.com/mt/archives/004092.php

Just thought I'd pass that along...

Phil

[Maggie4life]

I am waiting to see what your next question will be because I have already found the questions that you are posing to be absolutely fascinating. I do not have any medical qualifications but that does not stop my interest.

I have seen some ill founded remarks about Terri's bone scan indicating arthritis. As someone who has undergone two bone scans, and the second one definitely showing signs of osteoarthritis, I feel that I can speak up about the use of Keflex as an anti-inflammatory for Theresa Schindler. I have been struggling with arthritic type pain for a period of more than 15 years. At age 28 I was the front seat passenger when our car was hit from behind. I received a whiplash injury from that accident. At the time it was diagnosed as a torn neck muscle as well as stretched ligaments. The situation in my neck was worsened when I began working for a government department here in Australia. Without giving all of the details of my own case, I just want to highlight that in dealing with my pain and inflammation I have been treated with a variety of the NSAIDS including Keflex, Celebrex and Orudis. This was well before any diagnosis of arthritis was viable.

If Terri's scan was showing signs of repair from injury, then the results do not indicate either the earliest forms of osteoporosis or arthritis. The activity on the scan is more than likely related to repair activity in her bones after she had suffered some form of severe trauma. To this I can add from experience that my last scan showed up a lot of activity in my feet and the doctor actually came and asked me if I had suffered recent trauma near my toes. I do fall a lot and I do mostly soft tissue damage. I would expect that doctors who are experienced with such scans would be able to state straight off if there was arthritis present. The doctor who interpreted the scan did not make any such comment.

Also, as a result of my own experience, especially with enthesitis, one's muscles and tendons attached to the joints can become severely atrophied when there is insufficient exercise taking place. Michael's denial of any form of rehabilitative therapy also precluded any effort to exercise Terri's arm and leg muscles, thus contributing to the worsening of her condition

Oh yes, I will be doing further research into the activities of Dr. Death Cranford and I will be writing a piece on my own blog with my findings.

This issue is about legalizing murder for those who are not able to look after themselves. There is a big scandal here involving guardianships in Pinellas County Florida. That scandal must be investigated.

(the Australian observer)

Would authorities be able to remove Terri from the hospice if she were admitted to the program fraudulently?

1. Hospice is for the terminally ill. *Was she certified as terminally ill by her physician and the hospice team?

2. Admission to a hospice program is done along the guidelines of specific criteria. *What criteria did they use to say that she was terminally ill?

3. Terminally ill is defined in hospice as a prognosis of 6 months or less. *How long has Terri been in hospice? What source is paying for her stay in the hospice? If her hospice funding is through medicare or medicaid, are we all paying to kill her?

4. The hospice she is residing in is a part of Hospice of the Florida SunCoast. *Are they fraudulently billing for Terri when she was not even appropriately admitted to the program?

5. Profiting from her death. *When will the husband's book deal be announced? Who is going to be writing the screenplay? What will they title the television mini-series?

Terminally ill is reserved for those who are dying or those who choose no treatment. If she felt something bad happening before her collapse and decided that it really sucked and wanted to live, but could not verbalize it.... as an American citizen, as a person, as an innocent victim, as a woman, doesn't she have the right to change her mind?

I've begun steps to get my wishes clearly stated in the event that I am unable to communicate them under my own power. I'll not leave it simply to an Advanced directive or to a Living Will. There will be more. Much more, including, but not limited to my writings, discussions with family and friends, a clearly appointed Health Care Representative, and personal hand written letters to people who love and care about me.. and one to a lock box at the bank!

Don't let them kill you without your expressed written request.

Was Terri terminally ill BEFORE they pulled the TUBE???

NO.. they're all saying she could live on for years and years.

http://suebobsdiary.blogspot.com/2005/03/why-terri-schiavo-is-in-hospice.html

I apologize sincerely for posting again.

I am a hospice nurse, wishing I were better with computer tech.

Be well all.

Thanks Anon Hospice Nurse, we all have questions why Terri has been in a hospice for 5 years instead of a nursing home where the focus of care, and legal/medicare reporting requirements are very different.

[CTM]

Because I have another amazing question I am going to post on right this minute!

That was March 24, 3:34 on my computer. What happened to the question?

CTM, I'm sure CodeBlue is referring to the latest blog entry:

http://codeblueblog.blogs.com/codeblueblog/

[RD]

For the sake of argument I define these levels or "stages" of hope for a patient's rehabilitation:

Stage 1 - Beyond hope ("pull the plug")
Stage 2 - Hope ("let them live but don't rehabilitate them")
Stage 3 - No need to 'hope' ("rehabilitate")

We know from patient interviews that Terri is a Stage 3 patient. As pointed out on another thread here, this CT scan is clearly a Stage 1 patient. Therefore, it can't be Terri's brain scan.

It is my contention:

1. Whatever blood or other fluid entered Terri's brain from head trauma early on in her treatment was well-contained (though potentially causes her symptoms even now) and DID NOT lead to the CT scan we have been given.

2. The patient here in this scan is a very sick person indeed. Their cortical atrophy puts them in Stage 1 (no hope).

If we get our heads out of the weeds a minute and THINK, it's obvious this can't be Terri's CT scan.

RD

Come over & visit and I'll explain the whole thing. Am working on a follow-up PROOF for which I will need your help! I'll keep you posted.

[Maggie4life]

I think that there is grounds to follow through with the comments made by Kat-Missouri. Since I am not in the medical field, I will defer to the doctors on the matter of the CT scan and whether or not it belongs to Terri. I am already having doubts that this is the case. It sounds logical that those who want people to think that this is a scan of Terri's brain to prove that she is far gone have blundered.

The evidence that I have seen that makes any sense is the evidence that points to an argument followed by an attempt to strangle, followed by the shaking, which is admitted in evidence.

This is a clear cut case of insurance and medical fraud. (of course I am not a special investigator or a lawyer so I might be speaking out of turn - somehow I am not sure that I am speaking out of turn.

[concerned citizen]

Re: hospice. My mom has been receiving hospice care since September. Yes, you are correct that docs must certify that there is generally 6 months or less to live, and that there is no hope of recovery. Every 6 months, the doc must re-certify that the patient still is in this same status.

Also, amazingly enough, we have found out through my mom's supplemental insutance bills, that medicare does indeed reimburse hospice. How disgusting to think they ask for donations, then they are getting their pockets lined from medicare!!!!

[Maggie4life]

Since I have no medical background I have been clutching for information on the alleged Bulimia angle. Thanks to an off-hand comment, I think that I can now put it to rest that Theresa was Bulimic and that was the cause of her collapse.

If you check the hospital medical records as to what they found and how she was treated, you will find that she had a parasite in her stomach. If it was gardia that she had, then that poor girl would have been very sick with it, and yes she would have been vomiting (been there done that twice).

When I saw the off hand remark, I remembered that amongst the medication that she was given was Flagyl. Please correct me if I am wrong, is that the medication that is given for that kind of stomach upset?

If Terri had this particular parasite, she would have had extreme stomach pain and yes as it grew worse she would have been very nauseous, until she could no longer keep the nausea at bay.

I have been looking at this angle because it is probably something that I understand quite well. I have not been bulimic but I have for example suffered nausea throughout the whole of three pregnancies, to the point that I could not walk any distance without wanting to retch. I have also had two bouts of problems with gardia and there is a lot of vomiting. This could easily explain the loss of potassium.

Can one of the doctors please check into this aspect because I think that this is just another aspect of this case.

[A.W.]

I love this blog. interesting stuff. i am going to quote extensively from it on my blog, freespeech.com.

A dumb question, though. The husband now says he wants an autopsy. Is it safe to assume an autopsy would answer the same questions, if done right?

Mind you, i am not a medical guy, but i am bright enough to understand medical stuff if it is dumbed down a little.

Of course, to do it by autopsy is idiotic, when it can be done before death. i mean what if it turns out he is wrong. what is he going to say to the shindlers? "sorry, my bad"? But still i am curious on what an autopsy can be expected to show.

[Tom]

This is silly and bizarre. Putting a shunt in will not regrow her cortex. The lack of cortex is her major problem, not any pressure on it. You are a quack.

[Steve]

The "thing" in Terri's ventricle is NOT a "shunt tip"“ it is "thalamic stimulator implant” placed there Feb 1990 in California.

At that time it was considered an experimental procedure that Michael chased down in order to help his wife, they spent I believe 9 months in Calif working with the device and rehab.

Thalamic stimulatorsare now used tor the treatment of Parkensons tremors

[CodeBlueBlogMD]

Tom:

Watch what you say.

And look at what you are reading.

Did I say putting a shunt in would regrow TS's cortex? Did I say putting a shunt in would definitively help TS?

Here's what I said:

"As I said, nonshunted hydrocephalics can experience improved mental functioning after shunting. I am not saying this would be the case with Terri (because of how long this has gone on)"

Read it. If you atill need help interpreting what it means, let me know.

[CodeBlueBlogMD]

Steve:

On this single image (the only one I have) that "thing" projects within the ventricular fluid. Are you saying that it popped out of the thalamus and is now floating in the ventricle? These are two entirely separate anatomic areas.

I already said somewhere that it is possible that this could be the thalamic implant projected to the ventricle because of an extreme effect of "volume averaging" -- an artifact induced by the computer algorithms that "average" nearby pixels--and that might be possible if the anatomic distortion induced by her atrophy has juxtaposed the thalamic stimulator to the mid-ventricle and we just happen to be provided with the one image on which this artifact creates the illusion that there is something in the ventricle. However, that does not change the fact that on this one image, as of now, that "thing" is undefined, and the only other possibility is that it represents a shunt tip.

[Steve]

Kevins recount of events is pretty close.

Another blog has a well written piece

http://talesofawanderingmind.blogspot.com/2005/03/more-to-story.html

[mod ervador]

The Miami CT looks like it could be the section superior to the thalamus. The thalamus could be just below the section (it somewhat depends on the thickness of the sections). The "blotch" could be the thalamic implant partly in the focal plane in the region of the thalamic anterior nucleus. The body of the electrode could follow a trajectory similar to that of some types of shunt, which would put it in every section from the thalamus up to the area of the superior saggital sinus.

EEG only measures SURFACE brain activity. Someone could have the outer surface of brain tissue wasted, be flatline, and be have a conversation with you about nuclear physics.

[Maggie4life]

Why is it that the doctor who put in this implant has not ever made a statement about his treatment or his prognosis on Terri?
It seems really odd to me that perhaps the one person who could answer some of the questions that have been raised was not called upon to give any form of expert testimony in this particular case.

If this man worked with Terri why was he not called as a witness regarding his diagnosis of her state? Why was he not asked to review her status after say 3 to 12 months of the implant being in the brain?

[Craig H]

Ugh, indeed.

It doesn't take volume averaging to make that spot. The spot itself is part of the stimulator, the other part of which is stuck into or near the anterior thalamus. Thalamic stimulators have a long, stemlike, rodlike projection that runs FROM the thalamus up to the surface, either through medial parenchyma or sometimes, as in this case, through the ventricle. Here's an illustration: http://www.henryfordhealth.org/images/Activa.GIF
That's why you see it in the ventricle.

And NO to whoever posted that tripe about holding a conversation with a flat EEG. What part of the brain were you thinking of using to hear, reason and talk through the conversation? The cortex. That's where your language reception, comprehension and expression lives. It doesn't have to be functioning perfectly, but if it's electrically silent, you're not holding a conversation.

[Maggie4life]

Craig,

the only hole in your excellent explanation is that the EEG was not in fact flat. There was interference because of the high level of muscle activity, and when that was filtered out the EEG result was useless. The recommendation of other doctors happened to be that the test should be repeated at the bedside. That did not happen. Therefore we are back to square one with regard to a proper diagnosis in this particular case.

BTW thanks for the explanations that you have given, since I do not have a medical background I do not know if you are right or wrong. I will leave that to CBB.

[Craig H]

Thanks Maggie. I wasn't trying to make an inference about Ms. Schiavo's EEG. Sorry that wasn't clear.

[mod ervador]

I think there were several EEGs over the years. In his report, Hammesfahr chose to look at just one EEG, didn't like it for technical reasons (filtering of muscle activity), and discounted it. He doesn't comment on asking for previous EEGs to compare it to, or what those traces revealed to him. From what I could get of his testimony at trial in 2002, he was never asked about any EEG readings in trial, and his report was not entered into evidence.

[Maggie4life]

Mod ervador,

from what I have been reading, there had been no further EEGs after the one dismissed by Dr. Hammesfahr. This is the EEG that was used by Cranford to claim that Terri was PVS stage 1.

It was very wrong of George Greer to dismiss the testimony of Dr. Hammesfahr. I noticed that in his judgements he stated that he considered all evidence that claimed she was not PVS to be flawed. He was not willing to double check before issuing again his death sentence.

From what I can tell, this woman had severe brain injury and she had a spinal cord injury. Her neck remained somewhat stiff, as it was on the morning that she was taken to hospital. I am mystified as to why there was no follow-up on the cause of that stiff neck. There has been a wall of silence.

There are at least 3 doctors who have stated that they believe her injuries have come as a result of an attempted strangulation. This was ignored by George Greer. In fact the last doctor who gave that opinion was dismissed as not being credible. I wonder how Dr. McClane felt about his credibility being dismissed in that fashion.

So far no one has answered me as to why an attending neurologist at Bayfront wrote in his notes that Terri was in the neurological sense "awake". If that is what I think it means then descriptions of her being comatose are in error and perhaps even fraudulent, since those descriptions were used to hasten her death.

I have not seen any satisfactory answers to this type of question.

[mod ervador]

Cranford used more than one EEG to make his diagnosis. He may have illustrated his point with the latest one. Just because Hammesfahr dismissed it doesn't mean it was bad. It was inconsistent with Hammesfahr's "diagnosis" so I opine that he may have just wanted to make it go away, and he certainly didn't jump at the chance to explain the earlier EEGs because they would have posed the same problem.

Hammesfahr had no basis to claim strangulation. He saw a stiff neck in one strangulation victim. As if strangulation is the single cause of stiff neck? Her whole body was hypertonic on admission. Stiff neck is evident in most PVS patients regardless of what put them in that state. The stiff neck is basically a non-issue, if there's silence it's because it's already been said.

The allegation of neck or spinal cord injury by Hammesfahr was uncorroborated by other expert testimony or by any objective test. The 1991 bone scan (and Walker's 2003 deposition) and the Humana discharge papers mention no such injury.

Hammesfahr's testimony was dismissed with good reason. If you knew something about neurology you would cringe at his testimony in the 2002 trial. He was either incompetent or deliberately rigged the result. I've written more about his testimony on another page.

Unless I've missed something, Greer did not simply consider all testimony that TS was in PVS to be flawed. He considered Hammesfahr and Maxfield's testimony to be flawed. They just happened to be the only ones at the 2002 trial that said she was not PVS.

McClane's affadavit was educed by the Schindlers' legal team, based on information they presented to him. He said "the circumstances surrounding her initial anoxic episode and subsequent neurological status are consistent with a victim who has been strangled." That's true. The problem is, there are other causes consistent with the outcome. He did not say "the circumstances surrounding her initial anoxic episode and subsequent neurological status suggest strangulation to the reasonable exclusion of other causes."

McClane also said "a 'heart attack' precipitated by severe metabolic disease secondary to an eating disorder is inconsistent. Such a severly compromised heart would never continue to pump effectively for 15 more years." Notice how he used "heart attack" in quotes and not the condition that was actually diagnosed, cardiac arrest. He is strictly correct: a heart attack severe enough to lead to cerebral ischemia would also lead to a severely damaged heart. But nobody with a firm grasp of the details has said she had a heart attack, so he is disputing nothing of substance. It is a straw-man argument.

I've never seen any report attributed to the Bayfront neurologist that Terri was in the neurological sense "awake", only that she was awake in the sense that her eyes were open and therefore not in a coma.

I don't know if any of this satisfactory to you, but maybe it at least addresses the issues.

She had a broken neck. How is that for layman's terms.

[mod ervador]

No, she did not have a broken neck. There is no evidence whatsoever of a broken neck.

[ddb]

hmmm, according to Dr. Baden on Greta tonight, one of the 89 charges of abuse in 2000-2003 was complaints of multiple fractures of the back and 1 leg fx. He just talked about it tonight. It was found unfounded but he
did talk about it.

[mod ervador]

Right, those allegations of fracture may have arisen from someone reading the famous 1991 bone scan report. That report did not find actual evidence head or neck injury. Alternatively, someone picked up on Hammesfahr's vague, uncorroborated hypothesis of a spinal cord injury at C4. Certainly not the same thing as corroborated evidence of an actual broken neck.

I guess I'm holding hypothesis, allegation, complaint or insinuation to be not the same thing as evidence.

Thanks for the tip on Greta. I'll look for a transcript.

[gloriadeo]

http://newsmax.com/archives/articles/2005/3/30/144422.shtml
Reprinted from NewsMax.com
Top Neurologist's Report on Terri Released
NewsMax.com Wires
Wednesday, March 30, 2005
Here is a comprehensive report by Dr. William Hammesfahr, a world-reknowned neurologist, on Terri Schiavo's condition as of September 12, 2002:

Re: Terri Schiavo I was asked to examine Terri Schiavo per the request of the Second District Court of Appeal. They requested that current information about her present medical condition be obtained. They also requested that an evaluation be performed to ascertain treatment options.
HPI:
Ms Schiavo was in her usual state of good health until 2/25/90, when her husband reported that he was awakened from sleep approximately 6 Am by her falling. He reports that she was unresponsive.
Paramedics were called, and aggressive resuscitation was performed with 7 defibrillations en route.
In the Emergency Room, a possible diagnosis of heart attack was briefly entertained, but then dismissed after blood chemistries and serial EKG's did not show evidence of a heart attack. Similarly, a pulmonary or lung cause of the disorder was ruled out in the Emergency Room after normal blood gases and Chest X-Rays were obtained. The possibility of toxic shock syndrome was also entertained. The diagnosis of the cause of her condition was unknown. Her admission laboratory studies showed low potassium level, markedly elevated glucose level, and a normal toxic screen without evidence of diet pills or amphetamines.
The abnormal potassium level and sugar level were found on admission to the Emergency Room and were successfully corrected by the hospital staff over the next several days. The patient had a difficult hospital course with the development of poorly controlled seizures and prolonged coma state requiring, for a time, ventilator support. However, the staff noted improvement, and it was recommended by several physicians that she be discharged to an intensive rehabilitation center.
She was eventually transferred to Mediplex in Bradenton for intensive rehabilitation. She was poorly responsive. However, after a brain stimulator was placed in 11/90, the staff started to report greater interactions of the patient with her environment, including intermittently apparently following commands, turning her head to voice, tracking visually, etc.
This pattern continued even after discharge to a nursing home, although her course from that time on included multiple medical problems including recurrent urinary tract infections and hospitalizations, at times with severely low episodes of blood pressure due to a lack of treatment of urinary tract infections ordered by the husband and subsequent urinary sepsis requiring hospitalization.
During 1998, she was evaluated by Dr. James Barnhill, neurologist, who testified that he examined her for ten minutes and determined that she had no chance for recovery, and was in a persistent vegetative state. He also identified that her skull was filled with spinal fluid; there was no brain present on the scans. All responses he identified were reported as "reflexes." He obtained no blood pressure nor did anyone else, apparently, on the day of his exam, the closest documented blood pressures being obtained two days earlier and five days later. No tests including Urinary Tract infection evaluations, blood tests, EEGs, evoked potentials, or new CT/MRI exams were ordered.
One year later he again reconfirmed his earlier diagnosis. He felt no tests of any sort were needed for evaluation. In the spring of 2000, three physicians, including Dr. Jay Carpenter, who is a former Chief of Medicine at Morton Plant Hospital, filed affidavits after observing Ms. Schiavo. All three physicians stated that it is visually apparent that Ms Schiavo is able to swallow and, in fact, does swallow her own saliva.
The patient continued with no physical therapy, communication or speech therapy, or routine medical screening evaluations and treatment such as dental care, mammography, gynecological exams or pap smears during this time.
In May 2002, access to the patient was allowed for two physicians appointed by the family. At that time, my observation of Terri Schiavo in person occurred, having previously viewed videotape that was first shown at her first trial.
The examination
Medical examination and evaluations were performed on Ms Schiavo on September 3 and 4 with videographers present. Medical reviews of the charts provided were carried out, from which the above history is obtained.
On September 3, I spent from approximately 11AM until 4PM with Ms. Schiavo, returning the next day to also observe Dr. Maxfield and complete my portion of the exam (which duplicated that of Dr. Maxfield, so I observed without myself specifically repeating that part of the exam that same day).
The exam was videotaped at my request.
The exam started with the setting up of the video camera by the videographers, with Mr. Michael Schiavo present. I then came into the room and introduced myself to Ms. Schiavo. The patient was looking at the ceiling in a chair. She had a wide-eyed look to her. She appeared to be aware of my presence with slight facial changes and tone changes in her body, She did not look at me, or turn to look in the direction of my voice, continuing instead to look directly forward. Her mother then entered the room, coming toward her and speaking her name. The daughter immediately showed awareness of the presence of her mother, looking for her, then finding her visually when the mother was approximately 8 inches from her face. She then smiled and made sounds. Her father also entered the room with further apparent recognition by the daughter.
The first part of this exam included observing her interactions with her mother and her father. Here she clearly was aware of them and attempted to interact with them: the sounds, facial expressions, and searching out and tracking them. There are several previous reports by medical personnel and others of her responding to live piano music. Accordingly, I asked the mother to bring a tape of piano music. Two separate pieces were listened to. The first she appeared aware of the sound, but would not sing or interact significantly. The second she did interact making sounds with the music. She stopped making these sounds, when the music stopped.
During this time, she would move her head and track her head and eyes to the sound of music, or her mother's voice. I started my exam first on her right side, introducing myself and then examined her contracted right arm, the goal being to get a blood pressure, as neurological abilities are very sensitive to blood pressure. She looked at me and would track me with voluntary facial and upper torso movements. I later moved to the left arm and attempted to release contractures there. In order to get significant relaxation of the arm to a degree necessary to obtain a blood pressure, I worked for approximately 35 minutes to release the contractures enough to get arm extension to approximately 140 degrees. During this time, the patient would track the mother or the father, depending on who was interacting with her. Interestingly, she appeared to respond to her mother or father by tone of voice. At one time, after working on her arm for approximately 20 minutes, and no further extension of the elbow was to be had, the father walked up and started speaking reassuringly to his daughter. The elbow immediately extended approximately another 20 degrees. This was during a time period that I had been talking with Ms. Schiavo, and the music was also running. Yet with neither the addition of the music nor my voice did the elbow extend. With the father coming to his daughter and speaking, she immediately extended the arm further. At other times, he would speak more sharply to her, and she would immediately tighten, and appear to lose her spot of visual focusing, and her expressions would change. At times during and immediately after this part of the exam, she would also appear to voluntarily move her right upper extremity.
Multiple takes of her blood pressure were taken, and there were several readings of "error." During the reading of her blood pressure, I also palpated the median artery at the wrist. In general, the systolic readings on the blood pressure cuff correlated well with the wrist palpations. Thus, the systolic readings are probably fairly accurate, although the diastolic readings cannot be independently confirmed. Three readings were successfully obtained 96/65 pulses of 70, 107/78 pulse of 72, and 101/71 pulse of 70. The pulse was erratic by both machine and palpation. The blood pressure errors occurred due to spasticity in the arm being evaluated.
A general physical exam was also performed, although pelvic, breast, rectal, fundoscopic, sinus and ear exams were not performed. Technical difficulties prevented the fundoscopic exam from being performed.
The general physical examination and the neurological examination tended to be performed in an extremity-by-extremity fashion, as her cooperation was best by focusing on specific regions, and then not coming back to those regions at a later time. Moving rapidly and from side to side tended to result in apparent confusion and stress in the patient, manifested by increased tone and less facial interactions, eye contact, and less accessibility to her limbs due to the increased tone causing contractures to redevelop.
The general facial exam was significant for acne, probably due to a chronic stress induced steroid responses. No bruits were identified. Cranial nerves were intact, and the patient was able to swallow and handle all secretions.
The neck exam was abnormal. She had severe limitation of range of motion in the flexion, and to a lesser degree in extension. Indeed, I was able to pick up her entire torso and head and neck area with pressure on the back of her neck in the suboccipital region. These findings of cervical spasm and limitation of range of motion are consistent with a neck injury. No bruits were identified.
Lung exam showed scattered wheezes in the right lung fields. No rhonchi or rales were identified. Cardiac exam was normal to my exam. Interestingly, the significant arrhythmias identified by the electronic cuff, as well as my palpation of her wrist exam was not identified during this cardiac portion of the exam, suggesting the arrhythmia is intermittent.
Abdominal exam showed good GI sounds throughout, and was non-tender. No masses or aneurysms were palpated.
Extremities exam showed severe contractures in all four extremities. On the left upper extremity, she initially showed 4/4 on the Allen's spasticity scale about the wrist, fingers, and the elbow. However, with approximately 40 minutes of massage and release, the exam in this upper extremity showed spasticity on the Allen's scale, and at times, later in the exam, would show 2/4 on the Allen's exam.
The right upper extremity also showed 4/4 on the Allen's scale, and also improved with efforts at muscular tension release. However, time did not allow me the same degree of effort on her right upper extremity, and thus I am unsure of the degree of relaxation available in this area.
In the lower extremities, she has 2/4 about the hips and the knees, meaning full range of motion, but spasticity still present. However, about the ankles, she is 4/4 and I could obtain no improvement in the range of motion.
With levels of 3/4 and 4/4 spasticity, it is frequently difficult to determine the degree of voluntary control if any a patient has over an extremity. The internal spasticity and stiffness of the limb, makes gauging voluntary efforts very difficult.
Efforts that may be easily seen or felt in a patient with no spasticity may be completely missed or only able to be identified from sophisticated testing in a patient with 3/4 or 4/4 levels of spasticity.
Spasticity generally is due to neurological injuries, and is aggravated by lack of physical therapy and muscle stretching. To understand spasticity, it is important to understand what is normal with muscle activity
In a normal person, a leg, arm, or other part of the body moves because a muscle contracts and moves a nearby bone. However, muscles exist on both the front and the back of joints. When the muscles in the front of the joint move, the bone moves forward. When the muscles on the back of the joint move, the bone moves backwards. If the bone is your arm, then when the biceps contracts, the arm bends. When the triceps contracts, the arms straightens. Another characteristic of normal is that when one set of muscles contracts, the opposite muscles relax. Thus, when the biceps contracts, the triceps relaxes and vice versa.
In spasticity, that relaxation of opposing muscles does not occur. Thus, even if the biceps tries to contract to move a muscle, the opposing contractures of the triceps, prevents motion. In severe cases, like Ms. Schiavo, the contractures of the opposing muscles may be so severe, that voluntary motion appears very weak or non-existent. In fact, in some of her muscle groups, the severity of the contractures has grown so severe, that even an outsider cannot move the joint.
The Allen's scale is a 0-4 scale with 0 as normal or no spasticity. The scale is as follows:
0 Normal, no spasticity
1 Slight spasticity, palpated by the physician, but full range of motion of a joint.
2 Moderate spasticity, but full range of motion. Here the examiner may be allowed to use a great deal of his own muscle contraction to straighten a joint. If the joint can be straightened to its full range of motion, this is a 2.
3 Severe spasticity, but some motion can be identified. Full range of motion does not exist.
4 Severe spasticity, no range of motion.
Pulses in these extremities were symmetrical. Skin was intact in these areas.
The patient wore a diaper, and this was not removed for the exam.
Back exam was carried out and there were no evident areas of tenderness, masses, or other abnormalities seen.
The first two hours of the exam, focusing on cognitive awareness of her surroundings, was carried out in a chair. The last one hour on videotape was carried out in her bed. In neither position did she have difficulty handling any saliva or secretions. Only briefly, for a few minutes at a time, did she appear to tire and lose the ability to respond, track or interact with her surroundings.
She had no tube feedings or water during the entire time of the exam.
Alertness: The patient was alert throughout essentially the entire exam.
Responsiveness:
The patient would immediately respond to sound, tone of voice and to touch and pain. With respect to responding to those around her, she had limited responsiveness to me personally until approximately 45 minutes into the exam. She started to look at me, against her traditional right gaze preference, about the same time that we started getting significant relaxation in her contracted left arm (the arm that had been contracted for several years.) She appeared to identify the sound of my voice, with the relaxation of the arm. From that point, she would generally look toward the sound of my voice when heard, attempt to find me visually, then track the sound of my voice in its movements, or track me if I was within approximately one foot of her eyes. Prior to that time, she did not track me, or try to locate me visually. When playing music, she had a clear preference to the specific sound track played, and would listen to piano music, but change levels of listening depending on the track played. Her attention to the music would not wander during the track she preferred. She would pick out her mother's voice or her father's voice separate from the music or other voices or sounds in the room, and re-fix her gaze to those people. She would tend not to blink when watching those people. She ignored her husband's loud foot-tapping that went on for approximately five minutes at one point. She also ignored his voice and did not try to seek him out visually when he would at times interject comments during the exam or immediately afterwards.
During various portions of the exam, she would be moved or have her position readjusted. She continued to handle her saliva during this time, never being observed to choke on her saliva.
Following Commands: At various times during the exam, I asked her to close her eyes, or open her eyes widely, look towards her mother, or look towards me. At times, she appeared to properly follow these commands. Interestingly, some of the commands, such as close your eyes, open your eyes, etc. she tended to do several minutes after I gave her the command to do so. She had a delay in her processing of the action. However, when praised for the action, she would then continue to do the action repetitively for up to approximately 5 minutes. As we had moved on to other areas of the exam, at times she was continuing to do the previous command, then at inappropriate times since the focus of the exam had changed. During different portions of the exam, I would ask her to squeeze my hand on command, or, in the lower extremities, to pick up her right lower leg to command.
The upper extremities are contracted and weak. She appeared to squeeze my hand, and then relax her grip, in the upper right extremity, possibly in the upper left extremity. I am unsure if she was doing it to verbal command, or in response to body language; however, it was voluntary activity and not reflex. In the lower extremities, she showed these same abilities, marked on the right and to a lesser degree on the left (voluntary control over the ankles could not be determined due to the severity of the contractures there). However, in the right lower extremity, I again gave verbal commands, but also noted that she would oppose activity voluntarily. Thus, moving a hand against a thigh would elicit an equal and opposite reaction from her. She would gauge the degree of pressure, and counteract it equally. This is not a reflexive movement. With respect to her lower leg, we were able to clearly show that on videotape. I had her push her lower leg against my hand; my hand was on the top of her leg. Removing my hand suddenly, allowed her leg to suddenly continue voluntarily rising up and be seen on videotape. We had her do this repetitively on videotape.
Her right lower leg is quite strong. Other areas are either not as strong, or have such high spasticity brought on by neglect that voluntary activities are able to be felt, but difficult to show large degree of motion that are represented on videotape so well. The voluntary control is there, but does not show up well on videotape, as the range that the motion goes through is less.
Cranial Nerve Exam: Cranial nerve function is present and appears normal in all groups tested. The fundoscopic exam and ophthalmic nerve function could not be tested directly. She tracks well and voluntarily. She does not exhibit "Doll's Eye" motion, an abnormality seen in coma patients whose eyes move back and forth like a doll's when their head is moved.
Coma patients cannot direct their gaze to specific things and maintain their gaze on those things regardless of head motion or motion of the object.
She can do these things. She appears to see things best at approximately the.8-12 inch area. She was best able to track large reflective objects like aluminum balloons or sparkling lights (for which a focal length limitation is not an issue.)
This is a patient who has very poor language abilities. Her interactions with the world, as well as her ability to convey thought will depend in large part on her visual abilities and limitations. Thus a complete opthamological exam and evoked potential exam needs to be performed. This needs to be performed in comfortable situation and the patient needs to be comfortable with the examiner and the examinations. I would estimate that at least one day should be allotted for the exam and should be carried out her in room.
Sensory Exam: The patient was tested to light touch, pressure, and sharp touch and pain in all four extremities and on her face. The pain portion in the extremities was conducted by pinching the nail beds of her hands and feet. She clearly feels pain as the videotapes show.
On the face, noxious stimulation including cotton swab up the nose and gag sensation and papillary touch with cotton evidenced a pain response. These were more than just reflexes, as she appeared to be annoyed by these painful responses long after they had stopped, and would not smile at me again for the rest of the day.
She certainly feels pressure, as was discussed earlier, and opposes pressure with voluntary motor activity. When using a sharp piece of wood, which she found uncomfortable, and going over her entire body (except diapered areas and breast areas), we found that sensation is present everywhere. Sensation on the right side as evidenced by moaning or tightening up muscles or withdrawal and was more prevalent than on the left.
We found that she had two sensory levels. The first is the side-to-side asymmetry, where she feels more on the right than the left. The second is a major increase in pain approximately C4 and cephalic to the head. This is consistent with a spinal injury and spinal cord injury near this level.
Motor Exam: As discussed earlier, it is difficult to measure motor strength on the classical scales. The classical motor strength scale is a 0-5 scale and is described as patient's voluntary motor strength score /normal which is represented as a 5. Thus a person with no voluntary motion would be 0/5 and a person with normal voluntary motion is a 5/5. Normal motor strength requires relaxation of the muscles around the muscle being tested. Thus, if grip squeeze is being tested, the muscles that straighten the fingers must relax in order to have a good squeeze. If those muscles don't relax, they tend to keep the fingers straight, and thus give a weaker squeeze than if they did relax. When the muscles near the area being tested don't relax, that is called spasticity, and makes the exam less accurate. At times the spasticity is so severe that a muscle tested may not be strong enough to overcome the opposing muscles, and no evidence of voluntary muscle movement is seen even though there is in fact voluntary control over those muscles.
This is the problem that we have with Ms. Schiavo. She clearly has voluntary control that is good control over her facial musculature. Formal testing of those cranial nerves showed no weakness or facial asymmetry.
In the upper and lower arms, however, the spasticity is severe. She at times would voluntarily move her right arm/ hand complex against gravity, which is considered a strength of 3/5 or greater by convention. When squeezing my hand and relaxing on the right side, she had approximately a 2-3 (-)/5 but range of
activity was severely limited by spasticity. On the left side, it appeared weaker. In the upper extremities, she would oppose pressure on her, or try to move her arms with approximately 3/5, but not to command (probably due to the aphasia). The right side was stronger than the left.
The leg motion on the right was generally approximately 2-3/5 in all groups except around the ankle. However, when opposing my hand in the lower leg, she was 3+ -4-/5 and the voluntary action caught on videotape was clearly a strong 3/5 or better. On the left side the strength appeared to be more of a 2/5 range in all groups, but due to the difficulty of the exam, may actually have been stronger than this.
The convention of the 0-5 scales for testing voluntary motor strength is as follows:
0 No voluntary movement
1 Trace movement able to be felt
2 Movement of an extremity if gravity is removed. Thus if movement of a leg occurs in a bed while a patient is lying down, but he cannot move that same area up off of the bed, this is considered 2/5.
3 Movement against gravity
4 Movements against examiner's actively resisting the patient's muscular activity
5 Normal
The scale has some additional aspects, in that a - or + sign may further allow an examiner to delineate a specific number into sub-gradations. Reflexes: Were 2+ throughout on the left side, and slightly brisker on the right side.
The reflexes to my exam were slightly brisker in the upper extremities than in the lower extremities. These reflex findings may be related in part to differing level of tone due to spasticity. No clonus was identified. The reflexes at the pectoralis muscles were 2++ and symmetrical. Reflexes at the ankles could not be obtained due to the severe contractures. Babinski exam did not show abnormal reflexes, probably due to the severity of the contractures in the feet. Both glabellar and palmomental reflexes were mildly abnormal.
Impression:
The patient is not in coma.
She is alert and responsive to her environment. She responds to specific people best.
She tries to please others by doing activities for which she gets verbal praise.
She responds negatively to poor tone of voice.
She responds to music.
She differentiates sounds from voices.
She differentiates specific people's voices from others.
She differentiates music from stray sound.
She attempts to verbalize.
She has voluntary control over multiple extremities
She can swallow.
She is partially blind
She is probably aphasic and has a degree of receptive aphasia.
She can feel pain.
On this last point, it is interesting to observe that the records from Hospice show frequent medication administered for pain by staff.
With respect to specifics and specific recommendations in order to carry out the instructions of the Second District Court of Appeal:
From a neurological standpoint: The patient appears to be partially blind.
She needs a full opthamological evaluation and visual evoked potentials done to flash and checkerboard patters. The opthamological examination is to evaluate her retina and her ophthalmic nerve to try to determine the cause of her visual limitations and if any treatment exists. The evoked potentials looks at the nerve between the eye and the visual centers in the brain, to see if there is treatable damage and the type of damage, if any in these areas. This is important, as for individuals to interact with her, and possibly teach her better ways of communicating with others, they must know what sort of limitations she has. This even extends to whether she can see people or objects in specific areas of her vision, and what size objects need to be to be accurately seen. Additionally, if one were to properly examine her, it would help if one knew the full extent of these test results.
Communication: She can communicate. She needs a Speech Therapist, Speech Pathologist, and a communications expert to evaluate how to best communicate with her and to allow her to communicate and for others to communicate with her. Also, a treatment plan for how to develop better communication needs to be done.
Rehabilitation Medicine: The patient has severe contractures. She needs a specialist to evaluate these and develop a treatment plan.
Endocrine: The patient has clinical evidence of an abnormally functioning endocrine system. Her blood pressure is abnormally low. Many patients with severe neurological injury have low blood pressure due to an abnormally functioning endocrine system. The reason for this should be determined and corrected, as with a more normal blood pressure, she is likely to have even better neurological functioning. She has facial acne consistent with hormonal abnormalities.
ENT: The patient can clearly swallow, and is able to swallow approximately 2 liters of water per day (the daily amount of saliva generated). Water is one of the most difficult things for people to swallow. It is unlikely that she currently needs the feeding tube. She should be evaluated by an Ear Nose and Throat specialist, and have a new swallowing exam.
Mammography needs to be performed.
Spinal Exam: The patient's exam from a spinal perspective is abnormal. The degree of limitation of range of motion, and of spasms in her neck, is consistent with a neck injury. The abnormal sensory exam, that shows evidence of her hypoxic encephalopathic strokes (right side sensory responses are different from left) also suggests a spinal cord injury at around the level of C4. Her physical exam and videotapes also suggest a spinal cord injury is also present, as she has much better control over he face, head, and neck, than over her arms and legs. This reminds one of a person with a spinal cord injury who has good facial control, but poor use of arms and legs. It is possible that a correctable spinal abnormality such as a herniated disk may be found that could be treated and result in better neurological functioning. This should be looked for, as may be treatable. Thus, there may be an injured disk or spinal cord; the disk injury is more treatable, the spinal cord injury, if present without a disk injury, may be more difficult to treat. A person with a spinal cord injury and hypoxic encephalopathy will need different treatment and rehab recommendations than one who just has a hypoxic encephalopathic.
Interestingly, I have seen this pattern of mixed brain (cerebral) and spinal cord findings in a patient once before, a patient who was asphyxiated.
A urological consultation should be obtained: I disagree with Dr. Gambone's view that the patient's bacteria in the urine may be ignored. In my experience, colonization of the bladder can very distinctly affect the patient's neurological status and affect their rehabilitation. The patient needs a urological consultation both to examine the bladder issue, resolve if there are possibly colonized and kidney stones (that may be the source of recurring bladder infections). Also, one significant mechanism of diagnosing and finding and diagnosing spinal cord injuries is through sophisticated bladder EMG and other testing. This should be done.
The neurosurgeon who placed the implant should be contacted for recommendations. A neurological examination can only be carried out in the context of a complete understanding of the patient's physiology, including current blood tests. Thus the tests that Dr. Gambone did months ago, before we had access to the patient, should immediately be repeated.
EEG: I have reviewed the EEG recently obtained. The EEG has large amounts of artifact. The technician's attempted to remove artifact by filtering. Unfortunately, filtering also affects and reduces evident brain electronic activity. This EEG is not adequate and should be repeated. It should be repeated at the patient's bedside, with the patient in a non-agitated state.
SPECT scan: A SPECT scan prior to and after several days of Hyperbaric Trial should be obtained. Such a Hyperbaric Oxygen trial does not constitute treatment, as the length of time of such hyperbaric is inadequate to render any treatment. However, it is a useful technique to assess the likelihood of improvement using hyperbaric oxygen. I would defer to Dr. Maxfield on the specifics of testing, but believe that it is generally accepted by those in the field who have experience with hyperbaric treatment, that Dr. Maxfield's recommendations in this area are accurate.
William M. Hammesfahr, M.D.

[mod ervador]

"At one time, after working on her arm for approximately 20 minutes, and no further extension of the elbow was to be had, the father walked up and started speaking reassuringly to his daughter. The elbow immediately extended approximately another 20 degrees."

Classic clasp-knife effect. It had nothing to do with the father speaking. Hammesfahr just timed his extension so that he could say the release of the contraction coincided with the father's speaking. Just like all the other physical manipulations and stimuli he did at the same time as giving a spoken command, so he could say she was "following orders."

Even if he feels the most recent EEG is flawed (and he's the only one to feel that way) why doesn't he comment on the past CT scans and EEGs? Because he didn't look at them? Because he looked at them and didn't like them because he'd have to explain them away? Because they are an objective measure by which another physician could judge her condition, as opposed to his subjective "when I push against palm and tell her to squeeze my finger, she squeezes my finger" where we have only his word that it happened?

[tom]

He was told that the electrode reqwuired ongoing medical monitoring. He removed Terri from the program and there was no medical monitoring from 1991-2 to now.

[Maggie4Life]

I have just reviewed the post and comments, including some of my own more ignorant questions and comments. Over the last year I have learned so much more that has made no difference in my belief that Mrs Schiavo was a victim of abuse, and probably collapsed as a result of the policeman's hold. Oddly enough, I believe this to be possible because of a case in Nth Qld Australia involving a young schizophrenic who was man-handled by police. He ended up in the same state as Terri Schiavo - I observed this young man on video, in the same way I observed Terri, and I saw little difference between their state of consciousness. The only difference is that his neurologist honestly assessed him as in the minimally conscious state.

Now that I have reviewed the evidence of Dr. Hammesfahr, a new inconsistency has come to light. I am intrigued as to why Dr. Hammesfahr mentioned that Michael Schiavo said that he was awakened at 6.00 a.m. when he heard the thud, when in other evidence Michael Schiavo has variously mentioned waking at 4.30 a.m. and again at 5.30 a.m. There is a lot of unexplained time discrepancy that needs to be properly resolved.

I remain interested in the comments about Terri's neck because it seems that the observation of her neck being "somewhat stiff" has remained consistent amongst the notes of her physicians.

Not even the autopsy came up with an adequate explanation as to why Terri's neck remained stiff. Could it be that she had a torn neck muscle at the time of her collapse? Over time this tissue would have repaired but due to the disuse of her neck the atrophy of the muscles could contribute to ongoing stiffness. Is that possible?

Once again I can only go on personal experience. I know that a torn neck muscle can cause stiffness in the neck. One way a neck muscle can be torn is in a whiplash incident. What if, for example, there had been a fight, and what if, Terri had been thrown against the wall in such a way that she ended up slipping into unconsciousness? What if the incident happened in another room in the unit? What if any signs of struggle were removed prior to the calling of the ambulance? What if Terri was dragged to the location where she was found? This is all speculation but the fact remains that I am totally unconvinced that there has ever been a proper investigation into the collapse of Mrs Schiavo.

The medical evidence,especially the autopsy report proved two main things: she was not bulimic and she did not have a heart attack. This was the stance that I took from the moment I became interested in the case.

It seems to me that the pulling of the tube on Mrs Schiavo resulted in her murder through dehydration and starvation.

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