Report of Dr. William Hammesfahr
September 12, 2002
Re: Terri Schiavo
I was asked to examine Terri Schiavo per the request of the Second District Court of Appeal. They requested that current information about her present medical condition be obtained. They also requested that an evaluation be performed to ascertain treatment options.
Mrs Schiavo was in her usual state of good health until 2/25/90, when her husband reported that he was awakened from sleep approximately 6:00 am by her falling. He reports that she was unresponsive.
Paramedics were called, and aggressive resuscitation was performed with seven defibrillations en route.
In the Emergency Room, a possible diagnosis of heart attack was briefly entertained, but then dismissed after blood chemistries and serial EKG's did not show evidence of a heart attack. Similarly, a pulmonary or lung cause of the disorder was ruled out in the Emergency Room after normal blood gases and Chest X-Rays were obtained.
The possibility of toxic shock syndrome was also entertained. The diagnosis of the cause of her condition was unknown. Her admission laboratory studies showed low potassium level, markedly elevated glucose level, and a normal toxic screen without evidence of diet pills or amphetamines.
The abnormal potassium level and sugar level were found on admission to the Emergency Room and were successfully corrected by the hospital staff over the next several days. The patient had a difficult hospital course with the development of poorly controlled seizures and prolonged coma state requiring, for a time, ventilator support. However, the staff noted improvement, and it was recommended by several physicians that she be discharged to an intensive rehabilitation center.
She was eventually transferred to Mediplex in Bradenton for intensive rehabilitation. She was poorly responsive. However, after a brain stimulator was placed in 11/90, the staff started to report greater interactions of the patient with her environment, including intermittently apparently following commands, turning her head to voice, tracking visually, etc.
This pattern continued even after discharge to a nursing home, although her course from that time on included multiple medical problems including recurrent urinary tract infections and hospitalizations, at times with severely low episodes of blood pressure due to a lack of treatment of urinary tract infections ordered by the husband and subsequent urinary sepsis requiring hospitalization.
During 1998, she was evaluated by Dr. James Barnhill, neurologist, who testified that he examined her for ten minutes and determined that she had no chance for recovery, and was in a persistent vegetative state. He also identified that her skull was filled with spinal fluid; there was no brain present on the scans. All responses he identified were reported as "reflexes." He obtained no blood pressure nor did anyone else, apparently, on the day of his exam, the closest documented blood pressures being obtained two days earlier and five days later. No tests including Urinary Tract infection evaluations, blood tests, EEGs, evoked potentials, or new CT/MRI exams were ordered.
One year later he again reconfirmed his earlier diagnosis. He felt no tests of any sort were needed for evaluation.
In the spring of 2000, three physicians, including Dr. Jay Carpenter, who is a former Chief of Medicine at Morton Plant Hospital, filed affidavits after observing Mrs. Schiavo. All three physicians stated that it is visually apparent that Ms Schiavo is able to swallow and, in fact, does swallow her own saliva.
The patient continued with no physical therapy, communication or speech therapy, or routine medical screening evaluations and treatment such as dental care, mammography, gynecological exams or pap smears during this time.
In May 2002, access to the patient was allowed for two physicians appointed by the family. At that time, my observation of Terri Schiavo in person occurred, having previously viewed videotape that was first shown at her first trial.
Medical examination and evaluations were performed on Ms Schiavo on September 3 and 4 with videographers present. Medical reviews of the charts provided were carried out, from which the above history is obtained.
On September 3, I spent from approximately 11:00 am until 4:00 pm with Ms. Schiavo, returning the next day to also observe Dr. Maxfield and complete my portion of the exam (which duplicated that of Dr. Maxfield, so I observed without myself specifically repeating that part of the exam that same day).
The exam was videotaped at my request.
The exam started with the setting up of the video camera by the videographers, with Mr. Michael Schiavo present. I then came into the room and introduced myself to Ms. Schiavo. The patient was looking at the ceiling in a chair. She had a wide-eyed look to her. She appeared to be aware of my presence with slight facial changes and tone changes in her body. She did not look at me, or turn to look in the direction of my voice, continuing instead to look directly forward.
Her mother then entered the room, coming toward her and speaking her name. The daughter immediately showed awareness of the presence of her mother, looking for her, then finding her visually when the mother was approximately 8 inches from her face. She then smiled and made sounds. Her father also entered the room with further apparent recognition by the daughter.
The first part of this exam included observing her interactions with her mother and her father. Here she clearly was aware of them and attempted to interact with them: the sounds, facial expressions, and searching out and tracking them.
There are several previous reports by medical personnel and others of her responding to live piano music. Accordingly, I asked the mother to bring a tape of piano music. Two separate pieces were listened to. The first she appeared aware of
the sound, but would not sing or interact significantly. The second she did interact making sounds with the music. She stopped making these sounds, when the music stopped.
During this time, she would move her head and track her head and eyes to the sound of music, or her mother's voice.
I started my exam first on her right side, introducing myself and then examined her contracted right arm, the goal being to get a blood pressure, as neurological abilities are very sensitive to blood pressure. She looked at me and would track me with voluntary facial and upper torso movements.
I later moved to the left arm and attempted to release contractures there. In order to get significant relaxation of the arm to a degree necessary to obtain a blood pressure, I worked for approximately 35 minutes to release the contractures enough to get arm extension to approximately 140 degrees.
During this time, the patient would track the mother or the father, depending on who was interacting with her. Interestingly, she appeared to respond to her mother or father by tone of voice. At one time, after working on her arm for approximately 20 minutes, and no further extension of the elbow was to be had, the father walked up and started speaking reassuringly to his daughter. The elbow immediately extended approximately another 20 degrees. This was during a time period that I had been talking with Ms. Schiavo, and the music was also running. Yet with neither the addition of the music nor my voice did the elbow extend.
With the father coming to his daughter and speaking, she immediately extended the arm further. At other times, he would speak more sharply to her, and she would immediately tighten, and appear to lose her spot of visual focusing, and her expressions would change. At times during and immediately after this part of the exam, she would also appear to voluntarily move her right upper extremity.
Multiple takes of her blood pressure were taken, and there were several readings of "error." During the reading of her blood pressure, I also palpated the median artery at the wrist. In general, the systolic readings on the blood pressure cuff correlated well with the wrist palpations. Thus, the systolic readings are probably fairly accurate, although the diastolic readings cannot be independently confirmed. Three readings were successfully obtained 96/65 pulses of 70, 107/78 pulse of 72, and 101/71 pulse of 70. The pulse was erratic by both machine and palpation. The blood pressure errors occurred due to spasticity in the arm being evaluated.
A general physical exam was also performed, although pelvic, breast, rectal, fundoscopic, sinus and ear exams were not performed. Technical difficulties prevented the fundoscopic exam from being performed.
The general physical examination and the neurological examination tended to be performed in an extremity-by-extremity fashion, as her cooperation was best by focusing on specific regions, and then not coming back to those regions at a later time. Moving rapidly and from side to side tended to result in apparent confusion and stress in the patient, manifested by increased tone and less facial interactions, eye contact, and less accessibility to her limbs due to the increased tone causing contractures to redevelop.
The general facial exam was significant for acne, probably due to a chronic stress induced steroid responses. No bruits were identified. Cranial nerves were intact, and the patient was able to swallow and handle all secretions.
The neck exam was abnormal. She had severe limitation of range of motion in the flexion, and to a lesser degree in extension. Indeed, I was able to pick up her entire torso and head and neck area with pressure on the back of her neck in the suboccipital region. These findings of cervical spasm and limitation of range of motion are consistent with a neck injury. No bruits were identified.
Lung exam showed scattered wheezes in the right lung fields. No rhonchi or rales were identified. Cardiac exam was normal to my exam. Interestingly, the significant arrhythmias identified by the electronic cuff, as well as my palpation of her wrist exam was not identified during this cardiac portion of the exam, suggesting the arrhythmia is intermittent.
Abdominal exam showed good GI sounds throughout, and was non-tender. No masses or aneurysms were palpated.
Extremities exam showed severe contractures in all four extremities. On the left upper extremity, she initially showed 4/4 on the Allen's spasticity scale about the wrist, fingers, and the elbow. However, with approximately 40 minutes of massage and release, the exam in this upper extremity showed spasticity on the Allen's scale, and at times, later in the exam, would show 2/4 on the Allen's exam. The right upper extremity also showed 4/4 on the Allen's scale, and also improved with efforts at muscular tension release. However, time did not allow me the same degree of effort on her right upper extremity, and thus I am unsure of the degree of relaxation available in this area.
In the lower extremities, she has 2/4 about the hips and the knees, meaning full range of motion, but spasticity still present. However, about the ankles, she is 4/4 and I could obtain no improvement in the range of motion.
With levels of 3/4 and 4/4 spasticity, it is frequently difficult to determine the degree of voluntary control if any a patient has over an extremity. The internal spasticity and stiffness of the limb, makes gauging voluntary efforts very difficult. Efforts that may be easily seen or felt in a patient with no spasticity may be completely missed or only able to be identified from sophisticated testing in a patient with 3/4 or 4/4 levels of spasticity.
Spasticity generally is due to neurological injuries, and is aggravated by lack of physical therapy and muscle stretching. To understand spasticity, it is important to understand what is normal with muscle activity
In a normal person, a leg, arm, or other part of the body moves because a muscle contracts and moves a nearby bone. However, muscles exist on both the front and the back of joints. When the muscles in the front of the joint move, the bone moves forward. When the muscles on the back of the joint move, the bone moves backwards. If the bone is your arm, then when the biceps contracts, the arm bends. When the triceps contracts, the arms straightens. Another characteristic of normal is that when one set of muscles contracts, the opposite muscles relax. Thus, when the biceps contracts, the triceps relaxes and vice versa.
In spasticity, that relaxation of opposing muscles does not occur. Thus, even if the biceps tries to contract to move a muscle, the opposing contractures of the triceps, prevents motion. In severe cases, like Ms. Schiavo, the contractures of the opposing muscles may be so severe, that voluntary motion appears very weak or non-existent. In fact, in some of her muscle groups, the severity of the contractures has grown so severe, that even an outsider cannot move the joint.
The Allen's scale is a 0-4 scale with 0 as normal or no spasticity. The scale is as follows:
0 Normal, no spasticity
1 Slight spasticity, palpated by the physician, but full range of motion of a joint
2 Moderate spasticity, but full range of motion. Here the examiner may be allowed to use a great deal of his own muscle contraction to straighten a joint. If the joint can be straightened to its full range of motion, this is a 2.
3 Severe spasticity, but some motion can be identified. Full range of motion does not exist.
4 Severe spasticity, no range of motion.
Pulses in these extremities were symmetrical. Skin was intact in these areas.
The patient wore a diaper, and this was not removed for the exam.
Back exam was carried out and there were no evident areas of tenderness, masses, or other abnormalities seen.
The first two hours of the exam, focusing on cognitive awareness of her surroundings, was carried out in a chair. The last one hour on videotape was carried out in her bed. In neither position did she have difficulty handling any saliva or secretions. Only briefly, for a few minutes at a time, did she appear to tire and lose the ability to respond, track or interact with her surroundings.
She had no tube feedings or water during the entire time of the exam.
Alertness: The patient was alert throughout essentially the entire exam.
Responsiveness: The patient would immediately respond to sound, tone of voice and to touch and pain. With respect to responding to those around her, she had limited responsiveness to me personally until approximately 45 minutes into the exam. She started to look at me, against her traditional right gaze preference, about the same time that we started getting significant relaxation in her contracted left arm (the arm that had been contracted for several years.) She appeared to identify the sound of my voice, with the relaxation of the arm.
From that point, she would generally look toward the sound of my voice when heard, attempt to find me visually, then track the sound of my voice in its movements, or track me if I was within approximately one foot of her eyes. Prior to that time, she did not track me, or try to locate me visually.
When playing music, she had a clear preference to the specific sound track played, and would listen to piano music, but change levels of listening depending on the track played. Her attention to the music would not wander during the track she preferred.
She would pick out her mother's voice or her father's voice separate from the music or other voices or sounds in the room, and re-fix her gaze to those people. She would tend not to blink when watching those people. She ignored her husband's loud foot-tapping that went on for approximately five minutes at one point. She also ignored his voice and did not try to seek him out visually when he would at times interject comments during the exam or immediately afterwards.
During various portions of the exam, she would be moved or have her position readjusted. She continued to handle her saliva during this time, never being observed to choke on her saliva.
Following Commands: At various times during the exam, I asked her to close her eyes, or open her eyes widely, look towards her mother, or look towards me. At times, she appeared to properly follow these commands. Interestingly, some of the commands, such as close your eyes, open your eyes, etc. she tended to do several minutes after I gave her the command to do so.
She had a delay in her processing of the action. However, when praised for the action, she would then continue to do the action repetitively for up to approximately 5 minutes. As we had moved on to other areas of the exam, at times she was continuing to do the previous command, then at inappropriate times since the focus of the exam had changed.
During different portions of the exam, I would ask her to squeeze my hand on command, or, in the lower extremities, to pick up her right lower leg to command.
The upper extremities are contracted and weak. She appeared to squeeze my hand, and then relax her grip, in the upper right extremity, possibly in the upper left extremity. I am unsure if she was doing it to verbal command, or in response to
body language; however, it was voluntary activity and not reflex.
In the lower extremities, she showed these same abilities, marked on the right and to a lesser degree on the left (voluntary control over the ankles could not be determined due to the severity of the contractures there). However, in the right lower extremity, I again gave verbal commands, but also noted that she would oppose activity voluntarily.
Thus, moving a hand against a thigh would elicit an equal and opposite reaction from her. She would gauge the degree of pressure, and counteract it equally. This is not a reflexive movement. With respect to her lower leg, we were able to clearly show that on videotape. I had her push her lower leg against my hand; my hand was on the top of her leg.
Removing my hand suddenly, allowed her leg to suddenly continue voluntarily rising up and be seen on videotape. We had her do this repetitively on videotape.
Her right lower leg is quite strong. Other areas are either not as strong, or have such high spasticity brought on by neglect that voluntary activities are able to be felt, but difficult to show large degree of motion that are represented on videotape so well. The voluntary control is there, but does not show up well on videotape, as the range that the motion goes through is less.
Cranial Nerve Exam: Cranial nerve function is present and appears normal in all groups tested. The fundoscopic exam and ophthalmic nerve function could not be tested directly. She tracks well and voluntarily. She does not exhibit "Doll's Eye" motion, an abnormality seen in coma patients whose eyes move back and forth like a doll's when their head is moved.
Coma patients cannot direct their gaze to specific things and maintain their gaze on those things regardless of head motion or motion of the object.
She can do these things. She appears to see things best at approximately the 8-12 inch area. She was best able to track large reflective objects like aluminum balloons or sparkling lights (for which a focal length limitation is not an issue.)
This is a patient who has very poor language abilities. Her interactions with the world, as well as her ability to convey thought will depend in large part on her visual abilities and limitations. Thus a complete opthamological exam and evoked potential exam needs to be performed. This needs to be performed in comfortable situation and the patient needs to be comfortable with the examiner and the examinations. I would estimate that at least one day should be allotted for the exam and should be carried out her in room.
Sensory Exam: The patient was tested to light touch, pressure, and sharp touch and pain in all four extremities and on her face. The pain portion in the extremities was conducted by pinching the nail beds of her hands and feet. She clearly feels pain as the videotapes show.
On the face, noxious stimulation including cotton swab up the nose and gag sensation and papillary touch with cotton evidenced a pain response. These were more than just reflexes, as she appeared to be annoyed by these painful responses long after they had stopped, and would not smile at me again for the rest of the day.
She certainly feels pressure, as was discussed earlier, and opposes pressure with voluntary motor activity. When using a sharp piece of wood, which she found uncomfortable, and going over her entire body (except diapered areas and breast areas), we found that sensation is present everywhere. Sensation on the right side as evidenced by moaning or tightening up muscles or withdrawal and was more prevalent than on the left.
We found that she had two sensory levels. The first is the side-to-side asymmetry, where she feels more on the right than the left. The second is a major increase in pain approximately C4 and cephalic to the head. This is consistent with a spinal injury and spinal cord injury near this level.
Motor Exam: As discussed earlier, it is difficult to measure motor strength on the classical scales. The classical motor strength scale is a 0-5 scale and is described as patient's voluntary motor strength score /normal which is represented as a 5. Thus a person with no voluntary motion would be 0/5 and a person with normal voluntary motion is a 5/5.
Normal motor strength requires relaxation of the muscles around the muscle being tested. Thus, if grip squeeze is being tested, the muscles that straighten the fingers must relax in order to have a good squeeze. If those muscles don't relax, they tend to keep the fingers straight, and thus give a weaker squeeze than if they did relax.
When the muscles near the area being tested don't relax, that is called spasticity, and makes the exam less accurate. At times the spasticity is so severe that a muscle tested may not be strong enough to overcome the opposing muscles, and no evidence of voluntary muscle movement is seen even though there is in fact voluntary control over those muscles.
This is the problem that we have with Ms. Schiavo. She clearly has voluntary control that is good control over her facial musculature. Formal testing of those cranial nerves showed no weakness or facial asymmetry.
In the upper and lower arms, however, the spasticity is severe. She at times would voluntarily move her right arm/ hand complex against gravity, which is considered a strength of 3/5 or greater by convention. When squeezing my hand and relaxing on the right side, she had approximately a 2-3 (-)/5 but range of activity was severely limited by spasticity. On the left side, it appeared weaker. In the upper extremities, she would oppose pressure on her, or try to move her arms
with approximately 3/5, but not to command (probably due to the aphasia). The right side was stronger than the left.
The leg motion on the right was generally approximately 2-3/5 in all groups except around the ankle. However, when opposing my hand in the lower leg, she was 3+ -4-/5 and the voluntary action caught on videotape was clearly a strong 3/5 or better. On the left side the strength appeared to be more of a 2/5 range in all groups, but due to the difficulty of the exam, may actually have been stronger than this.
The convention of the 0-5 scales for testing voluntary motor strength is as follows:
0 No voluntary movement
1 Trace movement able to be felt
2 Movement of an extremity if gravity is removed. Thus if movement of a leg occurs in a bed while a patient is lying down, but he cannot move that same area up off of the bed, this is considered 2/5.
3 Movement against gravity
4 Movements against examiner's actively resisting the patient's muscular activity
The scale has some additional aspects, in that a - or + sign may further allow an examiner to delineate a specific number into sub-gradations.
Reflexes: Were 2+ throughout on the left side, and slightly brisker on the right side. The reflexes to my exam were slightly brisker in the upper extremities than in the lower extremities. These reflex findings may be related in part to differing level of tone due to spasticity. No clonus was identified. The reflexes at the pectoralis muscles were 2++ and symmetrical. Reflexes at the ankles could not be obtained due to the severe contractures. Babinski exam did not show abnormal reflexes, probably due to the severity of the contractures in the feet. Both glabellar and palmomental reflexes were mildly abnormal.
The patient is not in coma. She is alert and responsive to her environment. She responds to specific people best. She tries to please others by doing activities for which she gets verbal praise. She responds negatively to poor tone of voice. She responds to music.
She differentiates sounds from voices. She differentiates specific people's voices from others. She differentiates music from stray sound.
She attempts to verbalize.
She has voluntary control over multiple extremities
She can swallow.
She is partially blind
She is probably aphasic and has a degree of receptive aphasia.
She can feel pain.
On this last point, it is interesting to observe that the records from Hospice show frequent medication administered for pain by staff.
With respect to specifics and specific recommendations in order to carry out the instructions of the Second District Court of Appeal:
From a neurological standpoint: The patient appears to be partially blind.
She needs a full opthamological evaluation and visual evoked potentials done to flash and checkerboard patters. The opthamological examination is to evaluate her retina and her ophthalmic nerve to try to determine the cause of her visual limitations and if any treatment exists. The evoked potentials looks at the nerve between the eye and the visual centers in the brain, to see if there is treatable damage and the type of damage, if any in these areas.
This is important, as for individuals to interact with her, and possibly teach her better ways of communicating with others, they must know what sort of limitations she has. This even extends to whether she can see people or objects in specific areas of her vision, and what size objects need to be to be accurately seen. Additionally, if one were to properly examine her, it would help if one knew the full extent of these test results.
Communication: She can communicate. She needs a Speech Therapist, Speech Pathologist, and a communications expert to evaluate how to best communicate with her and to allow her to communicate and for others to communicate with her. Also, a treatment plan for how to develop better communication needs to be done.
Rehabilitation Medicine: The patient has severe contractures. She needs a specialist to evaluate these and develop a treatment plan.
Endocrine: The patient has clinical evidence of an abnormally functioning endocrine system. Her blood pressure is abnormally low. Many patients with severe neurological injury have low blood pressure due to an abnormally functioning endocrine system. The reason for this should be determined and corrected, as with a more normal blood pressure, she is likely to have even better neurological functioning. She has facial acne consistent with hormonal abnormalities.
ENT: The patient can clearly swallow, and is able to swallow approximately 2 liters of water per day (the daily amount of saliva generated). Water is one of the most difficult things for people to swallow. It is unlikely that she currently needs the feeding tube. She should be evaluated by an Ear Nose and Throat specialist, and have a new swallowing exam.
Mammography needs to be performed.
Spinal Exam: The patient's exam from a spinal perspective is abnormal. The degree of limitation of range of motion, and of spasms in her neck, is consistent with a neck injury. The abnormal sensory exam, that shows evidence of her hypoxic encephalopathic strokes (right side sensory responses are different from left) also suggests a spinal cord injury at around the level of C4.
Her physical exam and videotapes also suggest a spinal cord injury is also present, as she has much better control over he face, head, and neck, than over her arms and legs. This reminds one of a person with a spinal cord injury who has good facial control, but poor use of arms and legs.
It is possible that a correctable spinal abnormality such as a herniated disk may be found that could be treated and result in better neurological functioning. This should be looked for, as may be treatable. Thus, there may be an injured disk or spinal cord; the disk injury is more treatable, the spinal cord injury, if present without a disk injury, may be more difficult to treat.
A person with a spinal cord injury and hypoxic encephalopathy will need different treatment and rehab recommendations than one who just has a hypoxic encephalopathic.
Interestingly, I have seen this pattern of mixed brain (cerebral) and spinal cord findings in a patient once before, a patient who was asphyxiated.
A urological consultation should be obtained: I disagree with Dr. Gambone's view that the patient's bacteria in the urine may be ignored. In my experience, colonization of the bladder can very distinctly affect the patient's neurological status and affect their rehabilitation. The patient needs a urological consultation both to examine the bladder issue, resolve if there are possibly colonized and kidney stones (that may be the source of recurring bladder infections).
Also, one significant mechanism of diagnosing and finding and diagnosing spinal cord injuries is through sophisticated bladder EMG and other testing. This should be done.
The neurosurgeon who placed the implant should be contacted for recommendations.
A neurological examination can only be carried out in the context of a complete understanding of the patient's physiology, including current blood tests. Thus the tests that Dr. Gambone did months ago, before we had access to the patient, should immediately be repeated.
EEG: I have reviewed the EEG recently obtained. The EEG has large amounts of artifact. The technician's attempted to remove artifact by filtering. Unfortunately, filtering also affects and reduces evident brain electronic activity. This EEG is not adequate and should be repeated. It should be repeated at the patient's bedside, with the patient in a non-agitated state.
SPECT scan: A SPECT scan prior to and after several days of Hyperbaric Trial should be obtained. Such a Hyperbaric Oxygen trial does not constitute treatment, as the length of time of such hyperbaric is inadequate to render any treatment. However, it is a useful technique to assess the likelihood of improvement using hyperbaric oxygen.
I would defer to Dr. Maxfield on the specifics of testing, but believe that it is generally accepted by those in the field who have experience with hyperbaric treatment, that Dr. Maxfield's recommendations in this area are accurate.
William M. Hammesfahr, M.D.