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.