Terri Schiavo R.I.P. Part II: The Story In The Bones

Terri Schiavo R.I.P.: The CodeBlueBlog Papers

Part II

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.

Scanning Bones

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:

*****

*****

Here is the upper arm bone of an abused  child:

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...

Comments

[purple_kangaroo]

So, your opinion is that the bone scan would be inconsistent with injuries either at the time of Terri's collapse or from the auto accident she experienced at some time before her collapse?

As for the compression fracture, we know from the malpractice trial testimony that as part of her therapy Terri was raised to a standing position on a regular basis. Would this impact the likelihood of her being dropped in a position that would cause that type of fracture?

[purple_kangaroo]

Here's another question--not dealing with the bone scan, but relevant to the question of whether a significant injury could have taken place after Terri's hospitalization.

According to information I've seen, there were a total of 5 CT scans. Her injury was 2/25/1990.

2/25/1990

CT Scan Report Dr. Hameroff

Normal

2/27/1990

CT Scan Report Dr. Greenberg

Normal CT Scan

3/30/1990

CT Scan Report Dr. Abramson

CT Scan shows noncommunicating hydrocephalus, changes occurred since 2/27 exam

Those are from the Empire Journal website http://www.theempirejournal.com/02230551_medical_observations_sh.htm and I am not sure where they got the information.

The 2002 trial spent a lot of time establishing the fact that there was no significant change or degeneration between the 1996 CT scan and the 2002 scan. What would be probably more telling would be to compare the 1990 and 1996 CT scans to see if there was any difference. I wonder why that wasn't done in the trial? (2002 trial transcript can be found here: http://www.geocities.com/purple_kangaroo_angela/terrischiavotimeline.html )

Also, as CBB has brought up before, what is the likelihood of an injury showing no changes to the brain in the CT scan a few days afterwards, but showing very significant damage a month later?

I know several people have said these changes can happen gradually over a period of time, but how long would it take to show significant change in such a case, and how gradual would it be?

Would it be unusual to show (hypothetically) no change at all over the first few days, profound damage a month later, and then little to no change in the 14-15 years after that? If that were the case it wouldn't seem to support the gradual change idea, would it? Wouldn't it be more consistent with an injury happening that caused significant damage sometime between the second and third CT scans? These seem like questions that really should be considered.

[purple_kangaroo]

Also, I hate to bring up this insinuation, but if Terri did have fragile bones would someone lying on top of her have any possibility of causing these types of fractures?

I am basing this question, which is admittedly complete conjecture, on the testimony of the nurses that Michael would go in and close (and maybe lock?) the door of Terri's room for some time and then when he would come out she would be upset and withdrawn. And then Michael's girlfriend said in her testimony at the guardianship hearing (I believe it was) that when he got angry with her he would say that he would rather be at the hospice in bed with Terri than there with her.

Is it possible he could have taken or attempted to take his "conjugal rights" with Terri in her state (after all, he was still her husband), and that in her rigid and relatively unresponsive state this could cause some (even if completely unintentional) damage to her bones and possibly affect her recurrent bladder/vaginal infections, etc?

Or is this totally a ridiculous conjecture, as I'm sure it might be?

[CodeBlueBlogMD]

The way these abnormalities are described on the bone scan report, they are consistent with relatively recent phenomena occuring approximately around the same time. This would need to be confirmed by actually looking at the scan.

Bone injury sustained 14 months prior to 4/91 should not show the kind of uptake described. There should be faint, if any activity from such remote trauma.

Although one could speculate many different ways each abnormality could be generated, the occurence of all 3 lesions (multiple ribs, L1 vertebra, and right femur)simulatneously on the scan warrant an all-encompasing hypothesis. Thus the idea of abuse/mishandling.

I will discuss the CT brains of 2/25/90 and 2/27/90 tomorrow.

[Maggie4life]

This is very interesting. I have the same question as Angela, but what I am wondering is whether Michael was allowed to be alone with TS in that one month period, especially around 25/3.

[zheka]

Dr Boyle,

You might be interested in reading transcript of deposition of the doctor who performed the bone scan and wrote the report. Dr Walker was questioned about it during deposition in November of 2003

http://www.hospicepatients.org/dr-walker-t-schiavo-bone-scan-deposition.txt

Now, the Dr. Walker does not remember this particular patient and the film of the scan is lost. So basically he comments on his own report.

[purple_kangaroo]

Zheka, thanks for sharing that link.

CBB, thanks for answering my questions. Also, I think you may have a typo in this sentence of your post: "Although there certainly may be other explanations for the findings, I believe that one would be obligated to exclude abuse."

Did you mean to say "one would be obligated to not exclude abuse," or "to include abuse?" The way it's worded here doesn't fit with the rest of the paragraph.

[DaVis]

I think that there's too little evidence to accuse Mr. Schindler of abuse. Yes, I know that bulimia is often associated with childhood abuse. Yes, I know that he was caught on video roughly jabbing her in the head. Yes, I know he berated her for not responding the way he wanted. Yes, I know others told him not to treat her that way.

But those are merely circumstantial.

Rather than think he was just trying to avoid guilty feelings, couldn't it be that Mr. Schindler just cared for his daughter, liked attention, and was unable to accept that her cognition was permanently gone?

[purple_kangaroo]

Da Vis, I haven't heard anyone accuse Terri's father of abuse. Could you share links where you read that?

[CodeBlueBlogMD]

Da Vis:

I nowhere in my post accuse anyone of abuse.

I simply observe that the pattern of abnormal uptake on the bone scan and the fractures/abnormalities seen on x-rays are consistent with a bedridden patient who has been dropped, or dragged, or...you need to fill in the blanks. That someone abused TS in the hospital would be a pretty good bet (see my reference on the problem of abusing disabled/poorly functional patients), but it could have been anyone from a truculent orderly to a visitor.

Purple:

You've picked up a piece of medical jargon. When a particular diagnosis is manifest in the evidence, one is obligated to pursue that diagnosis until it is either proven right, or wrong, or you are at a stalemate.

So, in this example, given the findings on the bone scan, one is obligated to exclude (prove it not a viable hypothesis) abuse from the list of possible causes for these tests results.

[CodeBlueBlogMD]

zheka:

Thanks. I've read this transcript and I find it interesting. One problem is that the radiologist is very stilted and guarded in his responses, as would I be in this situation.

[purple_kangaroo]

Oh, that makes sense, codeblue. Thanks for explaining the wording . . . that type of medical jargon is something I'm not altogether familiar with. I see now--you were saying that if evidence shows even the possibility of abuse, you have the obligation to look into that and possibly rule it out. Gotcha. :)

[Maggie4life]

CBB,

a very good observation and analysis concerning the transcript from Dr. Walker.

In all of that hesitancy though, he suggested that the time frame for the injuries could be up to 14 months.

I can, through experience with having a bone scan, accept that there more or less needs to be a recent injury for that kind of activity. My last scan showed intense activity near my toes and the doctor came to check with me as to whether or not I had any recent trauma. My history at that stage happened to exist of two recent falls, one in August and another in December. In August I fell out of a lift (do not ask) and in December, a parent got the child's stroller in the way of my feet. I did not have any fractures in the toes at that time, but my feet were inflamed.

The reason that I mention that information is that the scan was done in the March, which is 3 to 7 months after the falls in question.

Also, Dr. Walker indicated that the compression fracture is usually seen when someone lands against a piece of furniture.

There are witnesses who have stated that Terri had a fight with Michael during the previous day because she had spent $80 at the hairdresser. The witnesses said that she had been crying. It is possible (and I am posing this, not saying it happened)that she was struck and fell heavily onto her bottom, or even against a piece of furniture in the flat. It is possible that she was in a lot of pain from an injury caused by the earlier fight.

Now the way I see it, there is the possibility that there was another fight, and there was an attempt to strangle Terri. That might explain the statement in the police report where Michael stated he did not know why Terri would want to try to kill herself. Personally, I would like to know more about her condition when she was discovered by the paramedics and then admitted to hospital. There is something missing here.

I have also noted the time line between the timing of the fall, and the timing of the brain damage being visible on a CT scan. There is a delay of one month between these two events. Why?

The scan indicates that Terri had a lot of fractures, and when quizzed about this kind of activity being noticeable on scan for a bedridden patient, Dr. Walker said it was very rare.

From what I understand Dr. Walker did mention something about what is observed as a very early stage of osteoporosis, but that did not mean that brittle bones was the cause of the injuries. If the doctor thought that there was a possibility of osteoporosis then he would have ordered a bone density scan. Dr. Walker stated in the trial that the scan he did is not for osteoporosis.

When I looked at the transcripts relating to the malpractice suit, I noticed that Terri's weight had been a very healthy 145 to 200 lbs. For her height the 200 lbs is in the obese range. Her doctor was monitoring her every month. It is probable that when she reached the 200 lbs that he told her she needed to get rid of the excess if she wanted to fall pregnant. The weight did not fluctuate all that dramatically over the period that is recorded in her medical history. However, her weight did go down to about 120 lbs and that is still a very healthy weight for her height. There is nothing in the doctor's notes that indicate that she was ever bulimic and that there was cause to be concerned.

From that point of view, I doubt that MS ever told his wife to put on more weight. I would think that it is more than likely that he called her porky. He was insensitive to the feelings of others, and I suspect that he was not insensitive to the idea of inflicting further pain onto his wife. If he is cruel enough to deprive her of all stimulation so that she would lose interest and die, then he would be cruel enough to make fun of her weight.

I am putting forward these thoughts for further consideration because I am not happy about the fact that there is a one month delay between the two CT scans when the abnormality finally showed up. That really bothers me, because I would like to know if any of the carers ever saw Michael being left alone with Terri.

[CodeBlueBlogMD]

Again, I'd have to see the bone scan. However, the admission was in February, 1990 and the bone scan was in April, 1991...that's 14 months.

As I mentioned in the post, acute fractures start out very "hot" or "intense" on bone scans and then gradually taper off in intensity over the ensuing months. So, if the bone scan showed a collection of relatively equal areas of intense uptake this would indicate that the injuries were relatively recent and close together in chronology.

One would not expect any injury from 2/90 to still be "intense" on the scan in 4/91.

Insofar as osteoporosis, this problem, in itself, does not show up on bone scans. There are types of fractures, called "insufficiency" fractures that can occur without -- or with little -- trauma, and these fractures are seen in the setting of altered metabolic states.

The correllative x-rays, however, should have been indicative of insufficiency fractures because they look different from traumatic fractures. Again, it would be necessary to review all of these exams before coming to a final conclusion, but from the data I have, I still believe that abuse is the first item on the diagnostic list that needs to be evaluated and excluded.

I'm posting on the CT's later today -- I hope.

[Beaker]

Terri Schiavo did receive intensive therapy in the first years following her cardiac arrest. There will have been too many opportunities for rough handling by various persons to pin it on any particular person based on mere access to the patient.

My understanding is that as a matter of routine she was placed into a chair. Is being accidentally dropped or roughly plopped into a chair ( or onto the floor in an attept to move the patient) a reasonable method of the compression injury you describe to ( possibly weakened) bones?

[mod ervador]

" I am not happy about the fact that there is a one month delay between the two CT scans when the abnormality finally showed up"

As pointed out in another discussion, it is not unusual for a CT scan to look "normal" 2 days after the hypoxic ischemic insult. Such a "false negative" can happen in up to 50% of the cases that become PVS. An early CT scan is nevertheless useful because it can reveal subdural hematoma or local infarct (stroke), among other things, which arise form different causes and may suggest different treatments.

Her EEGs on 2/26 and 2/28 were abnormal, so together with other contemporaneous clinical observations, there's more than enough evidence that the damage was already done.

[soxfanpfs3]

I'm not medically trained nor am I in law enforcement. As I've read these disturbing and fascinating posts, it's clear that many or most of you think foul play was involved either on the night of Terri's collapse, afterwards, or both. I don't know what I think right now.
If foul play led to her collapse that night, how did her husband get away with it? Is there any way for him to put her into cardiac arrest without leaving obvious signs of trauma? Eventually, I began to wonder: Could he have suffocated her with a pillow? He was much bigger than she was. Could he, in a rage, have flipped her over to avoid her fingernails (or just pushed her face first onto the bed?),covered the back of her head with a pillow, and jammed her face down into another pillow? Might he have pinned her down with his knees as he suffocated her? Could that cause her rib injuries?
If this all happened, the crime scene, the bed, could be concealed, I'd think. I can imagine this whole terrible affair as a crime of rage, not as a premeditated act.

Anyone know whether Terri and Michael had nearby neighbors? Were any of them interviewed?

Please understand, I am not claiming that the above scenario is what happened. I'm just asking the question, "IF foul play led to her collapse, THEN what sort of foul play might go unsuspected?"

So, my basic question to anyone with the expertise to comment is, could an attempted suffocation with pillows account for Terri's medical records as we know them?

[CJ]

Here is some interesting reading about the effects of apoxia. Note the effect on serum potassium.

http://www.jephc.com/full_article.cfm?content_id=185

[Tim]

I believe the bone scan report is dated March 05, 1991, 53 weeks after TS's injury. ... Fascinating discussion, well explained for a non-medic like myself. Many thanks!

[Maggie4life]

CJ

thank you for posting that link. It was very interesting, and yes, that could very well explain the combination of a high glucose level and low potassium level as indicated in the blood test results.

Perhaps the doctors reviewing all the information simply failed to see the connection, or MS successfully deflected attention away from the possibility that there was an attempted strangulation.

The report makes sense to me, since I did have a choking event almost two years ago. I was lucky because I managed on my own to get the situation under control. It related to the taking of various medication and the timing of when I was taking the pills before going to bed. I was then diagnosed with GERD as well as a bronchial-asthma that has cleared up over time.

Keep up the good work

[Maggie4life]

CBB

could the bone bruising have been the more recent event, and the fractures perhaps an earlier event?

I would love to hear from the therapists at the Mediplex facility because they could possibly throw some light onto the type of treatment that Terri was receiving and whether or not it could be possible that she was mistreated.

What I am getting at, is that it was the staff who brought it to the attention of the doctor that Terri was in a lot of pain when they were doing the intensive therapy. That is when she was taken to be evaluated for trauma. The scan note says that she had a closed head injury.

Maggie

[zheka]

CJ

thank you for the link.

[retired doc]

Late in the comments following the initial codeblueblog analysis of the bone scan, there were two posts by a Dr. Kate Killibrew. One of these suggested that the findings on the bone scan could be physiologic. From the written report of the nuclear scan, it appears that except for the femoral diaphysis, the findings might be largely symetrical. Would one expect abuse to produce bilateral symetrical fractures of the knees and sacroiliac joints?

[Maggie4life]

Retired doc, if she ended up on her bottom with a very hard thud, it is possible to have that pattern. It is also possible, if the injury came from a car accident to be obvious only on one side ;-)

With regard to the knees, might it be possible that if she was dropped and landed on both of them? Dr. Walker did give another possible explanation but he also dismissed it. George Felos tried to lead questions or at least intimate that this is the result of osteoporosis, but that bone scan is not a measure for osteoporosis. Then I am left with the personal difficulty that there is little evidence of any bulimia and that could rule out brittle bones.

I have been reading the information again, and one thing came through is that the bone bruise was on the one leg, not both.

Please keep asking the questions, because I am learning from this experience, and it helps me to sharpen my own ideas about what might have happened.

Also, and I think CBB might have already picked up on this point, and x-ray taken at the time of admission indicated no abnormalities, then 14 months later she has all these multiple hot spots? I really would like to know what when on and who is responsible for the bone bruising and the fractures.

[purple_kangaroo]

Would a bone bruise show up on x-ray at the time of injury? I was under the impression that if a bone was not fractured but just bruised, nothing would show up on x-ray.

Also, I may be wrong here but I thought they just x-rayed her knee while she was at Humana, not her whole body? Because of the potential risk of X-ray exposure, I can't imagine they would preemptively x-ray every part of her body just in case there was a broken bone somewhere. Even after the bone scan, the doctors decided it wouldn't be worth the x-ray exposure to the core of her body to x-ray the areas of her ribs where the bone scan showed hot spots.