After The Deluge
My method for dealing with the thousands of emails, hundreds of posts and far-flung inquiries has been to try to read them all and triage my responses.
Major issues -- regarding my Schiavo posts only -- raised repeatedly on the boards are:
- the method of my blog
- the tenor of my message
- my orientation and biases
- my "interpreting" and "diagnosing" from one single cut of a 1996 CT scan
- my "interpreting" and "diagnosing" a bone scan report done in 4/91; and, two CT reports done on 2/25/90, and 2/27/90
- criticism /questioning of experts
- my credentials and expertise
- my unabashed listing of my credentials and expertise
I am going to encapsulate my coverage of the case -- including the CT scans and bone scan -- while explaining and defending my positions.
This is the first of TWO PARTS:
My Way: The Method
It is important for all readers to understand that this is a personal web log, or blog. This is my personal blog, run for no profit, designed mainly as an outlet for my opinions.
These are opinions. Like all opinions, they may be loud or soft, informed or rash, prescient or foolhardy.
This is neither a newspaper nor a scientific journal. I do not present my ideas as peer-reviewed, double-blinded results. People frequently -- and harshly --question my qualifications to express the things that I say. In the past I have responded (sometimes pre-emptively) with a discussion of my expertise or experience. This in itself has instigated harsh rebukes from some who claim I am thus being arrogant or supercilious. I have found this "Catch 22" to be impossible to deal with so I am resolved to mostly not defend myself by constantly restating what I know, where I trained, and how my light is spent. Reader are referred to my about page.
My blog represents what I'm thinking as I read the news. I am usually asking questions. It's sort of letting you into my perspective as I read things in the headlines that don't make sense or don't fit correctly or don't add up -- according to my fund of knowledge. If that is useful for people...good; they'll read and benefit. If it is not useful, then people Will move on.
I will continue to ask questions in this blog. Because almost nothing I read or hear-- about health care and specific medical issues-- from MSM makes sense to me.
And, although I am happy to explain the rationale for my thinking, or the process through which I came to my conclusions, I cannot spend endless hours of time involved in circular arguments repeating things I've said in a different way.
So, if you are interested in the questions that occur to me as I read about the medical issues of people in the news; the health care studies and advice that are generated daily; as well as the medical news, tune in and take a few minutes to see what's going on from my vantage point.
I guarantee you two things. My vantage point is almost always different from what you are hearing and reading. And I can afford you insights to the health care system you may not otherwise be privy to.
The Tenor: or Soprano?
Until the Terri Schiavo posts, my blog has basically been a small circulation letter to regular readers. Sure, during posts about Yasser Arafat and Viktor Yushchenko, I had a lot of visitors from around the blogosphere; however, they were mostly searches and one-time hits.
Regular readers are used to my style, and I am used to their responses. With the Terri Schiavo posts my style of writing in this blog was suddenly broken open to a wide audience, and many had severe stylistic objections, which I understand.
I have taken this under serious consideration. Certainly if there are going to be large numbers of readers who come repetitively to this URL, I cannot expect them all to be my regulars who are familiar with me, what I stand for, and how I express myself; so, this is certainly something I will monitor and adjust as need be.
The Schiavo Issues
None of this changes the observations I have made on the Schiavo case and I stand by every single one of them. I have been grilled -- live -- on the radio twice by neurologists, neuroradiologists, and sundry experts concerning everything I have said, and I have not been knocked off any point.
The problem always seems to come down to people not reading what I said. Because I usually mean exactly what I say and no more. But people cannot help expanding, changing, and transmuting what I've written.
I do not come from the perspectives of what people would consider a strict "right to lifer," the "religious right," or a "radical conservative."
My original issue was the feeding tube. I did not -- and still do not --understand how food and water came under the rubric of life support in the same category as intubation, forced breathing, and cardiac pacing. The best analogy I can use is the Foley catheter (tube through the urethra into the urinary bladder to allow urine to drain). If you are going to remove food, then why allow patients to urinate?
As a physician, I strongly object to actuating death. That is not what I was trained to do, and if society decides that is what it wants, I would propose some different professionals be assigned the duty to pull these tubes when the law orders it. For me, as a physician, it is an act that is inimical to all the reasons I went into the health care field.
Making terminal patients comfortable during their last days is, to me, is in a different philosophical and ethical cosmos than removing a feeding tube from a severely impaired patient.
The Infamous CT Scan
I saw, and heard neurologists, ethicists, and hospice physicians in media outlets such as NPR, Fox News, MSNBC, CNN, and all the newspapers, declaring that Terri Schiavo's higher brain functions were nil. To describe this they used terms like: "her brain is: "water," a "bag of water," and "totally without cortex." One medical ethicist on NPR said (paraphrased) that Terri's brain was completely without a functioning cortex and since the cortex is where the complex functions and emotions of life are carried out, she is therefore not alive, but dead.
I, like every one else I assume, took this as it was stated (it didn't change my mind about the feeding tube anyway) until I stumbled on the single mid-ventricular CT image of Terri's brain that was done either in 1996 or 2002 (no matter).
Upon seeing the CT slice I was shocked that, yes there was severe atrophy, yes, there was severe damage, and yes the cortex was markedly thinned, but the CT itself did not reflect the descriptions I'd heard; and worse, I have seen many old and debilitated nursing home/assisted living patients as well as younger patients with chronic brain damage, with similar or worse atrophy. And not all of these patients were nonfunctioning.
That same CT slice was used as a visual graphic on television and in the newspapers -- by the same group of experts -- to demonstrate why Terri Schiavo was suitable for euthanasia. I objected to this strongly as, to me, the implications for all the other patients with similar or worse CT scans was morally and ethically frightening (talk about slippery slopes!).
I've been heavily criticized as unethically interpreting Terri's CT from this single slice, and speculating from the limited data. Let's get something straight. First, this was the only slice available. Second, it was the same and only slice everyone other expert was commenting upon. The University of Miami bioethics webpage thought it was appropriate to use that single slice on their web page as a testament to Terri's brain damage. Third, I made observations, not a diagnosis. Fourth, this was a scan done in the remote past. Looking at that slice and speculating about questions it raises is no more unethical than looking at a fossil and speculating on the size and shape of a dinosaur. It's a fragment of an old map, or a puzzle. And putting puzzles together to try and figure out possibilities is one of the things radiologists do for a living.
I also felt strongly that it was disingenuous for experts to put Terri's CT slice side-by-side with a normal 25 year-old female's CT. To the nontrained eye, the striking disparity nailed the case shut. To me that was unfair journalism and tendentious in the worst way. It would have been far more appropriate to put up the CT of a patient with severe cerebral palsy or chronic atherosclerosis. But this would not have made their case so strong, and one must question why these experts were given a pass for passing judgment on a single slice of a CT and for a deceptive comparison. I certainly was given no similar pass by readers and commentators when I said something different using the same data set.
It is also my contention that if the media are going to use limited data to solidify important and weighty issues, then there better be someone in the audience who asks these questions. Because the reporters don't The reporters and interviewers often try to probe deeper, but they cannot sidestep trained physicians and academics whose depth of knowledge and familiarity with the issues easily circumvent and obviate any inquiry that might undermine their theory or proposal. I have never seen a medical "expert" exposed, thwarted or seriously undermined by a question from the journalistic audience. I am reminded strongly of press conference at Columbia Presbyterian last month (covered in CodeBlueBlog) where the physicians told the audience that he was undergoing a "routine procedure for a rare complication" when actually he was undergoing a complex operation for a common complication. The statement went unchallenged (and no thanks to all of the mean-spirited bloggists who did not read my pieces on the Clinton case and proceeded to use my analysis of that case to label me as a gadfly, and much worse).
End of Part One.
Part Two will discuss the bone scan, the defense of my observation, Terri's two CT scans done after initial admission to the hospital; and, my $100,000 challenge.