Terri Schiavo R.I.P.: The CodeBlueBlog Papers
Reconstructing the Dinosaur
Following-up a reader's link, I found the report of a bone scan done on Terri Schiavo in 4/91. This gave me the second real "jolt" in as many days looking at some of the medical details of the TS case.
First, the chronology is important here:
2/25/90 TS admitted to hospital
4/91 Bone Scan
I won't get into why the bone scan was ordered, but there are a lot of interesting avenues of exploration regarding that question. Note that the bone scan is done 14 months after admission.
A bone scan is a test wherein a minuscule amount of radioactive material is attached to a molecule that seeks out bone that is rapidly changing. Bones change rapidly when they are broken, or damaged, as in fractures, cancer, and infection. The patient receives the injection then several hours later lies on a table under a camera that is sensitive to the radioactive emissions. It's like a Geiger counter that takes a picture.
Here's what it looks like when it's done:
A radiologist then looks at the study and interprets the image and the pattern of radioactive uptake. One learns to discern the different patterns of normal and abnormal uptake and to suggest what abnormal patterns mean.
Here is an abnormal pattern typical for the spread of cancer to the bones:
Certain patterns of abnormal uptake are so familiar, and common, that most radiologists can instantly give, with good confidence, a diagnosis. In the image to the left, I'm guessing that there would be 99% agreement of radiologists interpreting this exam as "metastases;" or, spread of cancer to the bones.
Other patterns are not as diagnostic, and the job of the radiologist is to generate a list of possible reasons -- generally from most likely to least likely -- for the appearance observed on the bone scan.
The Patterns of Abuse: Ribs
One pattern of bone scan uptake radiology residents are taught to recognize is that associated with child abuse. Abused children often cannot speak for themselves, and so when a child is brought to the ER with unusual or repetitive bone or head injuries, it is the job of the ER and radiology staffs to sniff out child abuse and act to protect the child. It's not just their job, it's the law. Physicians and other allied health professionals are mandated by law in all 50 states and the District of Columbia to report suspected abuse within 48 hours to Children’s Protective Services .
The radiologist who interpreted TS's bone scan described areas of abnormal uptake that suggested fractures in the ribs, lumbar spine, as well as an unusual pattern of abnormal uptake in the lower right thigh. As I've previously discussed, multiple rib fractures, spinal compression fractures, and long bone injuries are a typical pattern in abuse. If one sees that pattern on a person who is at risk of abuse, one should suggest abuse as a diagnosis and investigate further. It is especially relevant that several of TS's rib fractures are in her back near her spine. If you reach around to your own back, you'll feel the central longitudinal depression that represents your spine, then, on either side of that depression there are humps representing your ribs as they arch out from their spine attachments to begin their circular course around your chest. TS had abnormal bone scan uptake in several ribs in this area. It is difficult to fracture your ribs in this area, and it generally takes a direct blow to do it. Therefore, in TS's instance, one must postulate a mechanism for these rib fractures. Being dropped on the back is one reasonable mechanism that can be postulated for a bedridden patient.
The Patterns of Abuse: Vertebrae
The abnormal uptake in the first lumbar vertebral body ("L1") is also interesting. The radiologist suggested that the uptake was typical for a fracture and, in fact, he then confirmed that impression by obtaining an X-ray (not done for the ribs) that indeed showed a fracture of the upper part of L1.
The vertebrae are the bones that surround the spine. They extend from the base of the skull to the tail bone. Here is an image of the human vertebrae:
Look down to the last fully formed square vertebra. That is L5. Count upwards until you get to L1. That's the vertebra that was fractured.
Here is an image of the type of L1 fracture that was described in TS (double-click to enlarge):
The deformity of the upper half of the L1 vertebra, demonstrated above, is a typical fracture called a "compression" fracture. It is called a compression fracture because it is caused by compressive forces. To compress L1 one must push down on it (called "axial loading") or produce a squeezing like force on it, the same way you might crush a small square cardboard box between your palms. So how might we explain the presence of a compression fracture of L1 in TS? It is difficult to produce an axial load on a bedridden patient. I really can't think of many ways unless one were to drop her on her bottom.
According to the prestigious Armed Forces Institute of Pathology:
Any spinal fracture without good accidental explanation, especially in an infant, is suggestive of abuse.
The Patterns of Abuse: Long Bones
The bone scan showed a linear area of abnormal uptake over the lower right thighbone (the femur) and, an accompanying X-ray revealed an unusual finding. This finding was described by the radiologist as "periosteal elevation."
The periosteum is a skin-like layer that wraps around the bone's surface. It is rich in blood vessels and nerve fibers. In this image, the periosteum is the blue layer:
Look at the bright white area in the middle of the upper part of the arm bone (towards your right in this image). Just above that very white area there is a black line and then a white line. That white line is the periosteum which is lifted off of the bone (= periosteal elevation).
In the abused, periosteal elevation can be caused by bleeding (remember that periosteum has many blood vessels in it) underneath the periosteum which can be initiated by pulling or twisting violently. In a bed-ridden patient one could postulate periosteal elevation of the lower femur being caused by pulling or twisting the patient by the foot or ankle.
Nursing homes and assisted living facilities are recently much under scrutiny for recent reports, including a congressional committee reporting physical abuse of people under their care. The Associated Press reported:
An 18-month congressional investigation has concluded that many physical and sexual abuse cases in nursing homes are not treated the same way as similar crimes elsewhere.
Patients have been dragged down hallways, doused with ice water, sexually assaulted and beaten in their beds, yet few prosecutions or serious penalties have resulted, the investigation found.
2 + 2 = ?
Reading the radiologist's report on the combination of the three findings on the bone scan (ribs, L1, femur), my very first thought was that this would be a typical pattern for abuse. Especially in a bedridden patient with limited responsiveness. Although there certainly may be other explanations for the findings, I believe that one would be obligated to exclude abuse.
When would the abuse have occurred?
The radiologist reported relatively intense radioactive display on the scan, suggesting a recent injury. I would say anywhere in the previous weeks to month. It is difficult to say without seeing the scan itself. Certainly, after such an injury, the bone scan gradually improves, with healing, and there should be little, if any abnormal uptake after one year.
So, if TS was admitted to the hospital on 2/25/90, and the abnormal bone scan was done in 4/91, then the action(s) that lead to the abnormal scan would have occurred during the hospitalization.
For all the outcry my hypothesis about abuse made, I really don't believe any of this is a far stretch of the imagination; and, in my opinion, this hypothesis knits together the facts better than any other.
Tomorrow: Part II Continued...