Terri Schiavo R.I.P. Part III: The Brain Speaks

Terri Schiavo R.I.P.

The CodeBlueBlog Papers

Part III

This is a summation in three parts.

Part I is here.

Part II is here.

The Third Revelation

After looking at the medical records of TS late in the game (the feeding tube was to be withdrawn any day), last month, I was emailed a link at the The EmpireJournal that gave a chronology of TS's hospitalization, purportedly written by caregivers on the scene. Three CT scans of the brain were listed thus:

2/25: Normal

2/27: Normal

3/30:  noncommunicating hydrocephalus, changes occurred since 2/27 exam

One must remember that a cornerstone of the "dead cortex/dead brain" rhetoric was that there had occurred, before hospital admission, a massive event of hypoxia-anoxia. What does this mean?

Hypoxia means low oxygen concentration (in this case to the brain) and anoxia means no oxygen. The mechanism finally settled on that was blamed for the hypoxia/anoxia was dysrythmmia/arrhythmia of the heart (ineffective heart pumping due to "electrical" disturbance) secondary to potassium deficiency brought on by diet change.

Translated, this means that TS had severe dietary changes that lead to a decrease in blood potassium that disrupted the normal electrical activity that stimulates the heart to beat (contract and relax). The heart thus contracted abnormally, leading to severe decreased blood flow to the brain and resulting in oxygen deprivation. This lack of blood flow/oxygen severely injured the cerebral cortex.

There are plenty of medical arguments and issues that can be raised regarding the above paragraph and the proposed scenario. None of that is important in my analysis. I am starting from the assumption -- now taken as fact -- that TS suffered severe oxygen deprivation to the brain causing massive anoxic (oxygen deprivation) damage to the cortex before she ever reached the emergency room.

Brain cortex is extremely sensitive to oxygen levels in the blood, and certainly, when there is prolonged oxygen deprivation, widespread cortical injury and  destruction can occur. The experts who repeatedly showed TS's CT brain slice in the media were supporting a direct chain of events from:

irregular heart beat ---> oxygen deprivation ---> cortical injury ---> massive atrophy

In order to manifest that degree of cortical atrophy from the single assumed event of hypoxia/anoxia, before admission, the degree of cortical damage, at the time of oxygen deprivation, must have been great.

So how was the CT scan at 48 hours negative?

Mechanisms of Madness

Severe hypoxia/anoxia leads to rapid injury of the cells in the brain's cortex. When the cells are severely damaged, they leak fluid. This fluid rapidly accumulates in the closed space of the skull.

Damage to the brain, from oxygen loss, has been shown to occur within twenty minutes, and in severe cases, begins to show on CT scans within hours. In a case such as TS, where there is proposed massive damage, one would expect massive reaction to the damage. After 24 hours there usually is substantial brain swelling in a case such as this, evident on the CT scan.

My experience with the handful of cases I've seen is that the CT evidence of massive hypoxia/anoxia (of the extent being proposed by the experts who point to TS's CT) is evident soon after the event. By 24 hours, I'd be surprised not to see some evidence; and, if I did not see swelling and abnormalities by 48 hours after the event, I would be perplexed enough to seek alternative explanations or a reevaluation of the case.

Most research concerning massive hypoxia and anoxia is in newborns, and, obviously, a newborn brain is different from an adult brain. Nonetheless, here's a report from one study:

Hypoxic-ischemic insults to the central nervous system of infants may show a characteristic sequence of imaging findings. CT immediately after the insult may be normal or near normal in appearance. Over 24-48 hours, diffuse cerebral edema causes loss of the distinction between grey and white matter, obliteration of cortical sulci, and diffuse low density

Here's a case, reported in the Japanese literature of a woman who suffered massive cerebral anoxia/hypoxia and had immediate follow-up CT (after resuscitation). According to the authors:

CT revealed massive cerebral edema soon after resuscitation ...

And a repeat CT the next day showed:

on the following day (after anoxia/hypoxia) the CT demonstrated low attenuation area of white matter and gray matter in the cerebrum and brainstem

By 48 hours it is hard to imagine that the CT scan would not show some evidence of swelling and/or changes in the relative appearance of different parts of the brain.

The cases of massive hypoxia/anoxia I have seen, have been in adults, and have been grossly, markedly abnormal by 24-48 hours. The swelling can be so bad that a neurosurgeon has to remove a part of the skull so that the brain has an outlet to bulge.

Some have written me to explain that the CT used may have been an old model and not been as sensitive as newer models; however, as early as 1983 The American Journal of Radiology (AJR Am J Roentgenol. 1983 Dec;141(6):1227-32), reporting on a study of adults said:

Even with no clinical information, neuroradiologists can assess CT signs of cerebral infarction within the first 6 hours of symptom onset with moderate to substantial interobserver agreement.

I was incredulous to read that TS's CT was interpreted as "normal" 48 hours after the proposed event of hypoxia/anoxia. Surely, given the amount of damage being proposed in the media -- with that famous CT slice -- there would be some sign of the brain's distress at 48 hours. But the CT report produced on The Empire Journal said that the 48 hour CT was "normal." And a CT report from a scan done one month later (3/30) reported "noncommunicating hydrocephalus, changes occurred since 2/27 exam." This report was given by a different radiologist than the report of 2/27, indicating that this different radiologist re-evaluated the CT of 2/27 to compare it with 3/30, so the CT of 2/27 was seen twice, by two experts.

Pictures at an Exhibition

Here are some CT images of brains -- taken at 24 hours -- that suffered massive hypoxia/anoxia:

                     

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These brains show diffuse swelling, with loss of the normal spaces between cortical folds, and abnormally different shades of "grayness" that are immediately evident to an interpreter. According to a prominent University's teaching file, here are the CT findings of massive cerebral hypoxia/anoxia after 24 hours:

CT immediately after the insult may be normal or near normal in appearance. Over 24-48 hours, diffuse cerebral edema causes loss of the distinction between grey and white matter, obliteration of cortical sulci, and diffuse low density. Frequently there is relative sparing of the cerebellum and or basal ganglia which appear hyperdense compared to the abnormally low density cerebral hemispheres.

Mirrored Spectacles

How could this be?

Here are the possibilities:

• I think that the least likely explanation is that the CT actually was negative.
• The CT may have been misinterpreted. Sometimes when there is uniform, massive abnormality -- and all things in the brain are equally abnormal -- there can be the phenomenon when the interpreter sees everything in a uniform state and calls it negative. This happens, and it is not necessarily malpractice or incompetence. Interpreting CT's is just that: interpreting. I look at a Rorschach image and call it a butterfly, you call it a wildebeest. However, given the history of a massive event of anoxia/ hypoxia, one is usually on the alert for the appropriate changes.

• The CT scanner may have been an old model that was less sensitive than newer models available at that time. Not everyone upgrades their equipment every time a new generation of equipment is available, same way you don't upgrade your computer every time there is a new memory chip. Older CT's in 1990, could produce pretty poor images, at times, and if you throw in a little motion artifact (patient moving her head, etc), the combination of these two factors might lead to misinterpretation.

• The CT was actually negative, or normal. If the CT was actually normal, it is hard to postulate massive hypoxic injury two days prior. So if the brain was really negative, then the inciting event (massive hypoxia/anoxia) did not occur before TS was admitted to the hospital, it occurred after she arrived at the ER on 2/25/90 occurred after that time.

My impression that this discrepancy needed -- at the very least -- to be reevaluated by a second look at those CT scans before the removal of TS's feeding tube, lead to my attempts to draw attention to my observations.

Once again, my only contention when I reported this finding was that it needs to be explained. That's all. Like the bone scan, it is difficult for me to understand how results like these could be left alone and not commented upon. This was the crux of my issue. If one does not explain why the bone scan was abnormal or why the CT scans did not fit the clinical history, then by everything I know and have learned, one is obligated to investigate and pursue.

Comments

[Dan Patterson]

The interpretations and suggestions in the summary follow a logical path that ends with another very chilling realization: Why have the questions surrounding Terri's care gone unanswered?

The story of Terri's journey from normal to injured, then to the centerpiece of a national drama with no answers to the questions of her circumstances, contains some of the maddening characteristics of a discussion with a 4 year old girl.

"Did you take a cookie when you were told not to?"
"No."
"What is that in your hand?"
"A cookie"
"Where did you get it?"
"I didn't get it. It's in my haaaand."

Here we have a women who came to some injury by some unknown act, and who's health afterward was very poorly managed. Decisions were made on her behalf with no verifiable record of her wishes. None.

Her injury and the motivations for her later care are all suspicious and there seems to be no interest in answering the questions surrounding either event. We were told that she must be allowed to die.

"Why?, some of us asked.
"Because she wanted it that way", someone else declared.
"How will she die?"
"We will starve her and withhold water so that she slowly wastes away like the POW's on Bataan. But we won't inject her with malaria. It's the humane thing to do, you see."
"Oh really? The men that starved and murdered POW's were found guilty of war crimes and hanged. People that intentionally mistreat dogs are found guilty of cruelty. Men that torture women are Sadists with severe psychological damage. Anyone who causes intentional injury of someone else is guilty of assault at least. Anyone who intentionally causes the death of an innocent person is guilty of murder. So, someone who does all these things to a bedridden and defenseless human is doing the right thing?"
"Exactly", they stated. "Now you see".

What I see is a women who's death is clouded by very questionable circumstances, and a giant, thick coat of whitewash covering trail. More questions than answers and a very telling look into the soul of the secular crowd that supports her killing.

Dan Patterson
Winston-Salem, NC

[AAA]

CBB,

I have been reading your blog for some time and cannot understand why you're doing this in the TS case.

1. It is well-known that CTs can be read as negative 36-48 hrs post. You have enumerated some of the reasons yourself. This sort of thing, while of course infrequent, is common enough that cases are not even reportable.

2. You are basing your entire analysis on chronology provided on an unofficial internet website. Which has a rabid, pronounced bias in the TS case. Worse, the chronology is not even purpoted to be directly from TS's medical chart, but copied from an unknown(?) caregiver's notes (presumably from the Schindler side).

3. The notes were not done by a professional. There is no way for outsiders to verify the dates. The times themselves are vague:

2/25 CT normal
2/27 CT normal

Huh? At what TIME were the scans taken? Are these the dates of when the scan was taken, Or when the radiologist intepreted it? Or when the report was filed in the chart? Or is it when the relative received news of the result and wrote it in a diary? How do you know a mistake was not made by whoever scribbled this down? When was it scribbled down - 15 years ago, as it happened? Or last year, by someone just plowing through charts? You have been through med school, you must know how easy it is, especially with handwritten charts, for date mistakes to occur during transcribing. And when once a med student makes a mistake, the intern copies it, and the resident, etc etc.. And this was done by a complete non-professional. When? How? did someone write this down from a diary kept at home? Was the date simply when she was told of tests and results? Do you know?

Now, If the dates indicate when the scans were taken, the interval could EASILY be just 24 hours. If the dates indicate when the radiologist read it, the two scans could easily have been done just hours apart! That often happens in the ER - say after the first scan had too much motion artifact etc. There is SO MUCH here that you do not know, and yet you are sensationalizing in what I think is a pretty unprofessional, irresponsible way. I don't mean to be rude, but this whole thing on your blog is so... emotional.

4. I think one problem some medical bloggers have is that they get so excited about their expertise and an interesting "media case", they completely forget what's going on. TS and her husband are the ones who went through this. Her medical information is HER business, and HERS alone, with her doctors. Michael as her husband (and the courts and legal representatives where necessary) is the only person entitled to that info now that she's gone - it is not public property.

Yuschenko's illness was also his business. His test results were between his doctors and him. There were not your business, or ours, or anyone else's, and people who ranted and raved that this must be released and that must be released were seriously missing the point. There was so much ridiculous OUTRAGE at that time, over why this or that result was not "released", which is absurd. *Yuschenko doesn't owe anyone jack.*

You can be very sure that there are thoroughly sensible explanations to these questions you've raised, likely mundane ones you yourself have suspected.

The suggestion that MS is some kind of murdering abuser is just so crackpot insane it is a marker for paranoia as far as I'm concerned. MS SUED the doctors and the hospital after this happened to TS. Does anyone seriously think that an abuser would put his victim under that much scrutiny, and actually get the medical professionals with the most access to her the most powerful motivation to find out if *he* caused her illness (and not their negligence)? That's batshlt crazy, no? And this bonescan was on her chart long ago. It was part of the evidence that must have been considered when the negligence suit was going on, not to mention when the TS tube cases were going one. Does anyone seriously think that this repeated examination of the evidence, in so many courts, actually overlooked any evidence he was a criminal? And ALL THESE CASES were brought by MS!!!

Cripes people. Get a grip. He did what was best by his wife, and what she - what 99.999% sane people anywhere - would have wanted. Now let her RIP.

[pull your own damn plug]

Blah, blah, blah, precise medical analysis and then again, the rabid Mengele like "Cripes people. Get a grip. He did what was best by his wife, and what she - what 99.999% sane people anywhere - would have wanted. Now let her RIP"

The closest thing we have to compare the TS incident to is the Nazi experimentation on, toture of and murder of infant and adult mentally handicapped. 99.9 of the German people agreed with that.

I am a lawyer, not a doctor, but don't doctors take an oath to "do no harm". Umm is starving a human being that "3 out of 5" neurolgist think is brain dead doing no harm.

Lawyer and doctors murdered this gal and lawyers and doctors are going to vindicate her.

[pull your own damn plug]

Blah, blah, blah, precise medical analysis and then again, the rabid Mengele like "Cripes people. Get a grip. He did what was best by his wife, and what she - what 99.999% sane people anywhere - would have wanted. Now let her RIP"

The closest thing we have to compare the TS incident to is the Nazi experimentation on, toture of and murder of infant and adult mentally handicapped. 99.9% of the German people agreed with that also. In your mind I guess that makes it right.

I am a lawyer, not a doctor, but don't doctors take an oath to "do no harm". Umm is starving a human being that "3 out of 5" neurolgists think is brain dead doing "no harm". What is there is a 30% chance that she suffered. Is that not good enough not to take the chance that you are torturing her while killing her.

Lawyers and doctors murdered this gal and lawyers and doctors are going to vindicate her.

By the way, I do agree with you that she suffered the brain damage prior to being admitted to hospital. Either way, who the hell are you to judge the quality of another person's life. I might view you as being morally brain dead, which is more culpable than being physically brain dead, but I am not pleading with a court to pull your plug. Brian Nichols is not brain damaged, but I don't see anyone clamoring to have him starved and dehydrated to death.

[pull your own damn plug]

And isn't the slogan "4 out of 5 dentists prefer Crest toothpaste" and that is talking about toothpaste, but you can starve and dehydrate a defenseless 41 year old woman on the basis of only 3 out of 5 neurologists.

[AAA]

CBB,

I just revisited that site. The bias is incredible. I am not sure why you place so much faith in it.

They also don’t seem to have a clue about the medical issues:

“A person with no cognitive skills, or as Mr. Felos claims, is brain dead cannot either recognize her mother, speak words, feel pain and do specified commands when requested.”

Uhh, no one was claiming she was *brain dead*. Jesus. Brain death = Death. Anyone looking at her for two seconds would know she was not dead. The finding was that she was in *PVS*. A finding, incidentally, made by every single neurologist (7 of them, all board-certified) who examined her, over 15 years, except for Hammesfahr – charlatan extraordinaire. (the guy’s been known as a kook for years, long before this case, just ask florida neuros).

I have no clue why anyone would trust stuff off this site. At the bottom of the page, I’ve just seen this fine print:

"The above chart was prepared by an assistant for a lawyer for the Schindlers. Given the HIPAA laws, The Empire Journal did not seek actual medical records."

If these notes weren’t from the actual medical records, where were they from? Someone’s diary? If the lawyer’s assistant indeed copied them from the medical records, is the Empire Journal really so stupid to think HIPAA doesn’t cover that? Jesus. You can’t even transmit patient information on an elevator orally with other medical professionals not involved in the case. Do these guys think posting a copy from her medical chart on the internet is all fine and dandy? What right did this assistant have to disclose private patient information to a publication, especially one as irresponsible as EJ?

And since this was a Schindler person doing the copying, how accurate is it? Are the entries just like their spliced video, showing just those little chance bits that can be misunderstood by lay people ?

God. If I were MS, I’d sue the pants off these people.

[AAA]

pull your own damn plug,

You misunderstand me. If you think that withdrawal of care is being like Mengels, there is little I can say for you. Millions of people do it for themselves and their loved ones. (Delay did it for his own dad). It is inhumane not to.

The 99.99% is not the number of people who would wish TS dead. It is what I would think is the number of people who would want to go if they were in TS situation.

Remember, in the Quinlan case, the SC put it very fairly:

*The issue is WHAT THE PATIENT WOULD WANT, IF SHE COULD WAKE UP for 15 minutes AND TELL US NOW.*

That is what the judgement should be.

How many people do you think will wake up and say:

"Oh, Well Ive had the mental capacity of an insect (if that) for 15 years, and my immobile bed ridden incontinent body has become a breeding ground for bacteria and bugs. The persistence of my heart beat depite the destruction of my brain has led to the complete estrangement of my family, who prior to this loved each other so much. My parents hate my husband and think he is a murderer. I can look forward to increasing breakdown of this body, with infestations, massive, puss filled sores, ravaging pneumonia, all going on for a long time before finally stopping the heart. And I get all this without ever being "alive" - I have no brain, no mind, no memory, no feeling, no joy, no nothing. Yes Judge, I've decided, and I WANT THIS TO GO ON!! GIMME ANOTHER THIRTY YEARS!!"

People on both sides of this have to admit: even the "lifers" who say they are "defending" TS always preface their remarks with: "If I were in TS shoes, there is no way I would want to live like that..."

That's sane. 99.99% of people will say that, because they can really see, no matter what they say about the TS case, that that sort of existence is just... wrong.

You have to admit that, whatever you feel about greer, the decision he made is FAR FAR more likely to accord with TS wishes than not. I agree with you we cannot be 100% sure, but this decision, because of its humanity, is far likely to be what TS would have wished.

[AAA]

pull your own damn plug, you said:

I am a lawyer, not a doctor, but don't doctors take an oath to "do no harm". Umm is starving a human being that "3 out of 5" neurolgist think is brain dead doing no harm.

The 7 out of 8 neurologists (the 8 unfortunately a quack), were not deciding whether to starve TS or award her a caribbean cruise. They were asked to decide only one thing: Whether she was in PVS or not. That's within their expertise, and their job. The decided she was in PVS, and after 15 years of no cortical function, will never "return".

They were not "doing any harm."

I'm interested in your viewpoint here. Are saying that a doctor should never diagnose PVS, or death, or brain death - because then some judge could "harm" the patient?

Is it your view that an ethical doctor will always have to lie even if everything he knows says his diagnosis is correct?

[Susan Nunes]

Sure Michael did "right" by his wife, sure.

He was a real sweetheart, all right, the minute he got the malpractice money and wanted her dead and suddenly realized what "her wishes" were.

God are you dense or what?

Not everybody who thinks this case stinks is a right-wing religious nut, by the way. The disabled rights community and many liberals thought the case stank from the get-go.

[Maggie4life]

Dan,

bravo. Yes there are more and more questions that do deserve an answer.

Something is very wrong in this case and at the very least there should be a malpractice suit brought by the Schindlers against those doctors who declared that their daughter was PVS.

I am still waiting for someone to tell me why is it that a woman is supposed to be declared comatose, if in a medical report she is described as neurolgically awake.

[lisa]

thanks, triple a, for your cogency.

i share your outrage at the illogical and imprecise methodologies and source materials being bandied about here.

being in possession of medical expertise or medical factoids does not give license to rape reality, to use hateful preconceptions as the frame for an argument.

by clothing malicious conclusions in pseudo-scientific and amateur forensic terms -- born of too much "CSI" and "Law and Order" -- much of the argument is lost.
CBB has every right, of course, to do as he wishes on his own blog... but i, too, question the validity of spinning possible [sometimes far, far from probable] interpretations of a long ago reality -- a reality documented by very human, and therefore flawed, people... aw, heck, my prose is out of control.

intentionally or not, this blog has attracted some polarized hatemongers, decked out as crusaders for justice... [you can be sure that "god's on [their] side"]

lastly, i've never seen so much hate so desperate to glom onto some vehicle that might provide some respectability -- what better vehicle than a doctor's blog?

[retired doc]

Bravo, Lisa and AAA

[n@mdjd]

1. CBB seems to be backing away from his earlier contention of a shunt tip in the lateral ventricle.
2. Based on literature I summarized in an earlier post on the CT discussion (and will repost below), it is common for post-cardiac arrest patients with neurologic defects to have a normal interpretation of their CT scan 3 days following arrest.
3. Although the first two illustrations posted by CBB are clearly abnormal, the third is actually relatively normal and could easily be read as such.
4. The likely clinical information provided with the early CT requests was probably limited to something along the lines of "decreased consciousness" or "r/o brain trauma" or some similarly vague and limited infromation. I am sure that CBB, as an experienced radiologist, is familiar with this type of request.
5. The interpreting radiologist probably read the scan with a view of ruling out treatable conditions such as a cerebral or subdural or epidural hematoma.
6. It is unlikely that significant intraventricular blood was missed.
7. The literature references (case reports) cited by CBB refer to an infant with trauma and to an adult with brain death, neither situation comparable to that of TS.
8. Neither these references nor the single case of suspected child abuse in the UNC teaching file represents a study in a series of patients with out of hospital cardiac arrest with CPR.
9. I have no doubt that TS's brain had marked cellular and molecular abnormality two days following the original hypoxic event; the issue is whether we should expect to see these changes on CT and the literature suggests that often we do not.
10. For his $100K challenge CBB understood that the interpreter would need to distinguish scans of patients with PVS from those of patients not in a PVS without the use of clinical information. Similarly, the question of whether CT can detect the early global post-hypoxic insult is best determined by testing an observer blinded to the patients clinical status, not one who reads the history onto the film.
11. CBB might want to ask himself whether many years of reading brain CT scans on primarily elderly patients in his hospital practice have influenced his impression of how easy or hard it may be to detect the signs of increased pressure in young adults.
12. Does anyone know whether TS in fact had papilledema at the time of her second CT?
13. CBB states that in his admitedly limited experience, CT evidence of massive hypoxia, when he has seen such evidence, has been present very early. This does not, however, address the issue of how frequently there is in fact CT evidence of the hypoxia. For those cases in which he sees no such dramatic findings, CBB would simply read the case (as normal or near-normal) and move on to the next case, blithely unaware in most cases of either the details of the initial clinical diagnosis or the subsequent development of later atrophy.
14. Organized studies as reported in the literature, and not the limited experience of individual physicians, are the appropriate source for determining the incidence of various findings in particular disease states.

[n@mdjd]

Posted by: [email protected] | April 1, 2005 04:11 PM

“Also, since you sound like you know what you're talking about, do you realize that they are saying that Terri had massive anoxic infarction of the brain on 2/25/90 and yet had a "normal" CT of the brain on 2/27/90??? OMFG! I hope that blows you away as much as it does me because either they have one totally blind radiologist or Terri's brain injury ocurred after her admission.”

Actually, the report of a “normal” CT 2 days after the initial insult doesn’t surprise me at all.

Your comment reflects a basic misunderstanding of the evolving experience with and knowledge of the pathophysiology and imaging findings associated with hypoxic cerebral insult caused by out of hospital cardiac arrest treated with closed chest cardiopulmonary resuscitation (CC-CPR). Unlike the situation in an occlusive infarct, post-resuscitation patients undergo a relatively brief period of complete lack of perfusion followed by a period of hypoperfusion during resuscitation. After successful cardiopulmonary resuscitation, cerebral recirculation disturbances and complex metabolic postreflow derangements lead to death of vulnerable neurons with further deterioration of cerebral outcome. Recent experimental studies have brought new insights to the pathophysiology of secondary postischemic anoxic encephalopathy demonstrating a time-dependent cerebral oxidative injury, increased neuronal expression, and activation of apoptosis-inducing death receptors and altered gene expression with long-term changes in the molecular phenotype of neurons. Morimoto Y, et al, Acute brain swelling after out-of-hospital cardiac arrest: pathogenesis and outcome. Crit Care Med. 1993 Jan;21(1):104-10. (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=8420715&dopt=Abstract)

Modern imaging techniques such as CT scanning, MRI, and single-photon emission CT can provide significant information concerning the status of the brain in ischemic situations. In general, the early findings produced by generalized cerebral hypoxia consist of edema early and atrophy late. However, these imaging modalities cannot differentiate between permanently damaged brain tissue and reversible damage or edema in the acute phase. In addition, MRI and CT are known to have a limited capacity to detect generalized brain edema except in the most severe cases with markedly obliterated CSF spaces and abnormal signal intensity in the brain parenchyma. Furthermore, transportation of the artificially ventilated patient may impair the quality of imaging methods and may also make it difficult to provide adequate intensive care during imaging, especially in case of circulatory instability. Schoerkhuber, W. et. al., Time Course of Serum Neuron-Specific Enolase Stroke, Vol 25, 2091-2095, (http://stroke.ahajournals.org/cgi/content/full/30/8/1598?eaf#R15)

The CT hallmark of brain edema is obliteration of the basal cisterns and slit-like ventricles, findings that are particularly difficult to appreciate in a young patient in her twenties, and especially on the kind of limited quality scan often obtained in acutely ill patients on the slower scanners still in widespread use in 1990. Furthermore, many post-arrest patients do in fact have a normal scan within the first three days. For example,, Morimoto et. al. studied 53 patients with brain CT on day 3 following out of hospital cardiac arrest. Of these, 25 showed edema and 28 did not have noticeable brain swelling in a study designed to look for such swelling. Of interest, 23 of the 25 patients with swelling had cardiac arrest secondary to respiratory arrest, whereas only 5 of the 28 lacking brain swelling had a respiratory arrest. Stated differently, of 25 patients who had cardiac arrest not secondary to respiratory arrest (presumably the case with Mrs. Schiavo), only 2 demonstrated brain edema on day 3! Morimoto et. al. Acute brain swelling after out-of-hospital cardiac arrest: pathogenesis and outcome.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=8420715&dopt=Abstract

In light of the peer-reviewed literature (easily available to all with a simple Pubmed or Google search), it is neither surprising nor unusual that the CT on Mrs. Schiavo two days following her resuscitation was reported as normal, and that nonetheless her injury, already present at the cellular and molecular level, evolved to demonstrate the profound atrophy demonstrated by CT several years later.

What is significant in light of various speculations regarding possible head trauma on this blog and elsewhere is that there was no report of intracranial bleeding or other evidence of trauma on the early CT.

A final point. I read my first brain CT scan on an EMI water bath scanner, but despite long experience, and although I know edema may be harder to detect in young patients, until I turned to the literature I did not realize that the majority of post-resuscitation patients who have a primary out of hospital cardiac arrest without respiratory arrest fail to show demonstrable cerebral edema in the first 3 days. Having read a gazillion studies is no longer enough. Physicans are under an increasing legal and practical obligation to either be familiar with or research the relevant literature pertaining to their cases. Using readily availavble internet resources, patients become instant experts on their own disease and they expect no less of us.

[n@mdjd]

Is CBB a neuroradiologist?

Several posters have assumed that CBB is a neuroradiologist (presumably based on the number of brain CT studies he says he has read), and at least one poster has asked whether CBB is a neuroradiologist.

As he makes clear in his brief bio on the blog, CBB is a general diagnostic radiologist trained and experienced in brain CT, but he is not a neuroradiologist.

However, note that additional fellowship training and/or certification in neuroradiology is not required to read brain CT studies, and that many (if not most) brain CT exams are read by general radiologists.

[retired doc]

Perhaps cbb should also back away from his comments about neurologists. Would you rather have your brain studies interpreted by a radiologist in East Podunk, who spends most of his time looking at sprains and broken bones, or by the Chief of Neurology at Hopkins.

[Maggie4life]

AAA,

the information that is on the Empire Journal site is available elsewhere. I have seen an image of the hospital record and it is exactly the same as the information on that site.

You are only saying that the Empire Journal is biased because you believe that the piece of scum did not murder his wife. Also, I think that Dr. Hammesfahr should sue you for claiming that he is a quack doctor, since that is libel.

There is sufficient cause to doubt the honesty of Michael Schiavo especially when his behaviour deteriorated so badly over the 15 long years of abuse that Theresa Schindler endured at his hands (and that is not including the 4 years previous to her collapse). It is abusive to fail to provide a patient with stimulation. It is abusive to ban all forms of therapy. It is abusive to attempt to refuse her treatment with antibiotics. It is abuse to attempt to ensure her death by pneumonia by insisting that the covers come off her when she was sick. It is abuse to have deprived her family from visiting. Should I go on about the various abuses that were committed here. That is not the decision making of a loving husband.

Now the hospital was not a part of the malpractice, so that is a score against your knowledge of the facts of this case. The malpratice case was based upon the provision of false information. Going by what the lawyer who handled the malpractice suit said in an interview, I think that there would be every reason to insist that Michael Schiavo is charged with obtaining money under false pretences. The lawyer claimed that she collapsed after vomiting up her dinner. That is blatantly not true. Also, the deposition for the malpractice suit actually shows that Theresa's weight was in fact reasonably steady. It is true that it did go up and down a bit, but that was in a confined range. From what I could see of her weights she was never in the unhealthy range that I would expect of a woman with bulimia. People who are obese can also come up with similar blood readings, and be considered malnourished. The blood tests did not prove bulimia. That was something seized upon by Michael Schiavo. We will never know precisely how much of his testimony in that trial was utter trash.

Now back to the analysis. What CBB has here is the correct chronology. The first two scans were considered to be showing no abnormality in the brain. However, the scan taken one month later is a different matter. That is what needs to be investigated. Why is there a month delay between the normal readings and the abnormal reading?

[Maggie4life]

AAA,

the information that is on the Empire Journal site is available elsewhere. I have seen an image of the hospital record and it is exactly the same as the information on that site.

You are only saying that the Empire Journal is biased because you believe that the piece of scum did not murder his wife. Also, I think that Dr. Hammesfahr should sue you for claiming that he is a quack doctor, since that is libel.

There is sufficient cause to doubt the honesty of Michael Schiavo especially when his behaviour deteriorated so badly over the 15 long years of abuse that Theresa Schindler endured at his hands (and that is not including the 4 years previous to her collapse). It is abusive to fail to provide a patient with stimulation. It is abusive to ban all forms of therapy. It is abusive to attempt to refuse her treatment with antibiotics. It is abuse to attempt to ensure her death by pneumonia by insisting that the covers come off her when she was sick. It is abuse to have deprived her family from visiting. Should I go on about the various abuses that were committed here. That is not the decision making of a loving husband.

Now the hospital was not a part of the malpractice, so that is a score against your knowledge of the facts of this case. The malpratice case was based upon the provision of false information. Going by what the lawyer who handled the malpractice suit said in an interview, I think that there would be every reason to insist that Michael Schiavo is charged with obtaining money under false pretences. The lawyer claimed that she collapsed after vomiting up her dinner. That is blatantly not true. Also, the deposition for the malpractice suit actually shows that Theresa's weight was in fact reasonably steady. It is true that it did go up and down a bit, but that was in a confined range. From what I could see of her weights she was never in the unhealthy range that I would expect of a woman with bulimia. People who are obese can also come up with similar blood readings, and be considered malnourished. The blood tests did not prove bulimia. That was something seized upon by Michael Schiavo. We will never know precisely how much of his testimony in that trial was utter trash.

Now back to the analysis. What CBB has here is the correct chronology. The first two scans were considered to be showing no abnormality in the brain. However, the scan taken one month later is a different matter. That is what needs to be investigated. Why is there a month delay between the normal readings and the abnormal reading?

[med student]

With all due respect to all of the people whose posts I've read here in the last couple of weeks, I have to say that those of [email protected] are by far the most informative and most elegantly composed. But, I have yet to see anyone attempt to provide a rebuttal for his arguments, despite the fact that he's made his arguments more than once and that I've referenced them several times in my own post. And, many people obviously don't accept what he says as true. So my question to those who fit that description is: "Are you just ignoring this information because it doesn't support your position?"

[med student]

Another observation I've made is that the discharge summary that is often discussed here says: "EEG's and CAT scans were repeated several times to see development of any new CNS pathology." This suggests to me that there were probably more than the three scans from 2-3/90 that haven't been referenced online. Can we know this for sure? No, but neither can you be certain that there were only those three.

[retired doc]

Maggie- re Hammesfahr the quack.
http://www.hni-online.com/national_enquirer_1998.htm

[med student]

Maggie-
Why would you expect a woman with bulimia to have a weight in an unhealthy range? I consulted five textbooks concerned with primary care and psychiatry and all of them say that most bulimics are of normal weight. In the past you've also written about the lack of any evidence of her purging as reason to conclude that she wasn't bulimic. But, there are two types of bulimia - purging and non-purging. Non-purging bulimics compensate for their binges with fasting or excessive exercise. Most people would consider a diet of 10-15 glasses of iced tea per day fasting.

I'm not arguing that she was bulimic because I think the evidence of her diet alone explains any hypokalemia came about. She may have been bulimic, but even if she wasn't there is a plausible explanation for her hypokalemia. I wish you would realize that the notions you are basing your theories on are not based in fact.

[maximumbob]

Med Student - why bother? Maggie's on a witch hunt. Anyone ever heard of a place called Salem?

[AlohaRN]

according to the discharge summary from human hospital, terri had persistent tonic-clonic seizures for quite some time after her admission, requiring an additional anti-seizure medication be added to the dilantin. perhaps she suffered additional hypoxia due to the seizures, leading to worsening of the brain CT scan by the 3rd day.

here's link to an intereting article on pubmed where oxygen saturation was measured via pulse oximetry during tonic clonic seizures- 6 of 8 true seizure patients demonstrated striking falls in oxygen saturation during the seizures.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1671426&dopt=Abstract

AlohaRN

[med student]

maximumbob-
Apparently I'm a glutton for punishment. Plus, I can't help but think that maybe the next point will be the one that makes the light bulb go off.