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I was asked to examine Terri Schiavo per the request of the Second Distri ct Court of Appeal. They requested that current information about her pr esent medical condition be obtained. They also requested that an evaluat ion be performed to ascertain treatment options. HPI: Ms 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 Am by h er falling. Paramedics were called, and aggressive resuscitation was performed with 7 defibrillations en route. In the Emergency Room, a possible diagnosis of heart attack was briefly e ntertained, 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 b lood gases and Chest X-Rays were obtained. The possibility of toxic shoc k syndrome was also entertained. The diagnosis of the cause of her condi tion was unknown. Her admission laboratory studies showed low potassium level, markedly elevated glucose level, and a normal toxic screen withou t evidence of diet pills or amphetamines. The abnormal potassium level and sugar level were found on admission to t he 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 st ate requiring, for a time, ventilator support. However, the staff noted improvement, and it was recommended by several physicians that she be di scharged to an intensive rehabilitation center. She was eventually transferred to Mediplex in Bradenton for intensive reh abilitation. However, after a brain stimulato r 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 h er 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 ur inary tract infections ordered by the husband and subsequent urinary sep sis requiring hospitalization. James Barnhill, neurologist, who te stified that he examined her for ten minutes and determined that she had no chance for recovery, and was in a persistent vegetative state. He al so identified that her skull was filled with spinal fluid; All responses he identified were reported as "reflexes." He obtained no blood pressure nor did anyone else, apparent ly, on the day of his exam, the closest documented blood pressures being obtained two days earlier and five days later. No tests including Urina ry 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 tes ts of any sort were needed for evaluation. Jay Carpenter, who is a former Chief of Medici ne at Morton Plant Hospital, filed affidavits after observing Ms Schiav o All three physicians stated that it is visually apparent that Ms Schi avo is able to swallow and, in fact, does swallow her own saliva. The patient continued with no physical therapy, communication or speech t herapy, or routine medical screening evaluations and treatment such as d ental care, mammography, gynecological exams or pap smears during this t ime. In May 2002, access to the patient was allowed for two physicians appoint ed by the family. At that time, my observation of Terri Schiavo in perso n occurred, having previously viewed videotape that was first shown at h er first trial. The examination Medical examination and evaluations were performed on Ms Schiavo on Septe mber 3 and 4 with videographers present. Medical reviews of the charts p rovided were carried out, from which the above history is obtained. On September 3, I spent from approximately 11AM until 4PM with Ms Schiav o, returning the next day to also observe Dr. Maxfield and complete my p ortion of the exam (which duplicated that of Dr. Maxfield, so I observed without myself specifically repeating that part of the exam that same d ay). The exam started with the setting up of the video camera by the videograp hers, with Mr Michael Schiavo present. I then came into the room and in troduced myself to Ms Schiavo. 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, conti nuing instead to look directly forward. Her mother then entered the room , coming toward her and speaking her name. The daughter immediately show ed awareness of the presence of her mother, looking for her, then findin g her visually when the mother was approximately 8 inches from her face. 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 person nel and others of her responding to live piano music. Accordingly, I ask ed the mother to bring a tape of piano music. The first she appeared aware of the sound, but would not sin g or interact significantly. The second she did interact making sounds w ith 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 he r right side, introducing myself and then examined her contracted right arm, the goal being to get a blood pressure, as neurological abilities a re 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 l eft arm and attempted to release contractures there. In order to get sig nificant relaxation of the arm to a degree necessary to obtain a blood p ressure, I worked for approximately 35 minutes to release the contractur es enough to get arm extension to approximately 140 degrees. During this time, the patient would track the mother or the father, depending on wh o was interacting with her. Interestingly, she appeared to respond to he r mother or father by tone of voice. At one time, after working on her a rm for approximately 20 minutes, and no further extension of the elbow w as to be had, the father walked up and started speaking reassuringly to his daughter. The elbow immediately extended approximately another 20 de grees. This was during a time period that I had been talking with Ms Sc hiavo, 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 h is daughter and speaking, she immediately extended the arm further. At o ther times, he would speak more sharply to her, and she would immediatel y tighten, and appear to lose her spot of visual focusing, and her expre ssions would change. At times during and immediately after this part of the exam, she would also appear to voluntarily move her right upper extr emity. Multiple takes of her blood pressure were taken, and there were several r eadings of "error." During the reading of her blood pressure, I also pal pated the median artery at the wrist. In general, the systolic readings on the blood pressure cuff correlated well with the wrist palpations. Th us, the systolic readings are probably fairly accurate, although the dia stolic readings cannot be independently confirmed. Three readings were s uccessfully obtained 96/65 pulses of 70, 107/78 pulse of 72, and 101/71 pulse of 70. The bl ood pressure errors occurred due to spasticity in the arm being evaluate d A general physical exam was also performed, although pelvic, breast, rect al, fundoscopic, sinus and ear exams were not performed. Technical diffi culti...
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