Patterico's Pontifications

6/15/2005

Schiavo Autopsy Released

Filed under: Dog Trainer,Schiavo — Patterico @ 12:39 pm

You can read the autopsy report here. (Link via How Appealing.)

I’ll have to read it later. Here’s what seemed significant to me after a brief lunchtime glance: her brain was half the size it should have been; there is no conclusion as to whether she was in a PVS, as that diagnosis must be made of a living person; she probably could not have learned to swallow on her own; there are indications of “cortical blindness”; it’s unclear whether she suffered from bulimia; she apparently did not have a heart attack; there are no signs of strangulation (though this is based primarily upon medical records and not the pathological examination); and there is no sign of trauma (though here again the report relies heavily on contemporaneous records).

Take a look and tell me what you see.

P.S. I have no intention of relying on press reports to interpret the report, since the press can’t be trusted to accurately report on hot-button issues like this. Interestingly, the autopsy report itself confirms this. For example, the L.A. Times reported in March:

Terri Schiavo, now 41, suffered a heart attack Feb. 25, 1990, the result of a potassium imbalance brought on by an eating disorder.

Nope and not necessarily. The report says that “the main piece of evidence supporting a diagnosis of Bulimia Nervosa is suspect or, at least, can be explained by her clinical condition at the time of the blood draw.” It also says there is no evidence that she had a heart attack. No matter; the L.A. Times confidently reported these assertions as though there was not the slightest doubt about them.

Many (including me) had questioned whether Schiavo had truly suffered from an eating disorder. (Many also questioned whether she had suffered a heart attack.) But for others, it was enough that these things had been “widely reported.” Well, that’s true: they had been . . . and the reports were not based on solid evidence. (Of course, when I pointed that out, I was told: “Dude, this is nothing but a blog, not a stinking courtroom.”)

So forget the news reports. Look at the report yourself. Ask a doctor you trust to read it. Let me know if I got anything wrong, or if you see anything else important.

UPDATE: Jeff Harrell in the comments makes an important distinction between cardiac arrest and myocardial infarction. Let me quote the part of the report that caused me to say that, according to the report, there is no evidence that Schiavo had a heart attack (as that term is typically understood):

The common term “heart attack” is generally reserved to describe the medical condition of myocardial infarction. Mrs. Schiavo’s heart was anatomically normal without any areas of recent or remote myocardial infarction.

Her heart (including the cardiac valves, conduction system and myocardium) was essentially unremarkable except for an apparently incidental finding of focal peridcardial adhesions (see cardiovascular pathology report).

I think it’s also important to note that, as far as I can tell, nothing in the report suggests abuse on the part of Michael Schiavo, and plenty (including the major points I noted above) seems to contraindicate that. Again, this is based on a quick skimming, which is all I had time to do over lunch. I am eager to hear from any civil commenters who can provide further illumination, and thanks to Jeff Harrell for that clarification.

21 Responses to “Schiavo Autopsy Released”

  1. “Heart attack” is not a medical term. What people usually think of when they hear “heart attack” is actually a myocardial infarct, which is injury to the heart caused by an interruption in blood flow, usually caused by a clot or other blockage in one of the arteries that supplies the heart with blood.

    But what is believed to have happened to Terri was an electrochemical problem resulting from an excess of potassium in her blood. When you have too much potassium, the electrical activity in the heart can be interrupted which can cause the heart to stop beating, a situation called a cardiac arrest.

    I don’t think it’s technically wrong to say that Terri had a heart attack, but it is pretty misleading. It’s more accurate to say that her heart stopped beating.

    Jeff Harrell (a5b150)

  2. I find it fascinating that the neurological section of the report assumes PVS, but then concludes by saying “Neuropathologic examination alone of the decedent’s brain — or any brain, for that matter — cannot prove or disprove a diagnosis of persistent vegetative state or minimally conscious state.”

    Bebeaux (at DOUBLE TOOTHPICKS) (b1c210)

  3. Michael Schiavo as Innocent as Jacko

    Today’s non-news dressed up as big news is that Terri Schiavo’s autopsy uncovered no evidence of abuse by Michael Schiavo. Unfortunately, it didn’t seem to offer much evidence of anything else, either. While the Ass. Press reports …

    damnum absque injuria (38c04c)

  4. What the heck, I don’t feel like doing real work today, so I’ll just read an autopsy for fun. Here’s the one thing that looked very weird to my untrained eye:

    “What was the cause and manner of death? Mrs. Schiavo suffered a sever anoxic brain injury. The cause of which cannot be determined with reasonable medical certainty. The manner of death will therefore be certified as undetermined.”

    Maybe coroners all speak this way, I don’t know. But wasn’t the cause and manner of death that her feeding tube was removed and she gradually was starved and dehydrated to death? I mean, if this report cannot even be clear about that, how can it be relied on for anything?

    Either this is coronor-speak, or else this is a rather crass way to say that no one should have really cared what happened to her because she was already dead years ago. Maybe Florida law says that “death” occurs whenever someone is incapacitated, I don’t know.

    Whatever one may think about the rightness or wrongness of removing the tube and denying her oral nutrition, the woman was not dead until 2005. But maybe coroners speak a different language.

    Andrew (d85f42)

  5. The following is from a Washpost.com report on the autopsy..

    “Instead, the principal evidence for that theory was a very low level of bloodstream potassium when she was admitted to the hospital about an hour after being found unconscious. Vomiting and laxative abuse can cause this condition.

    Normal blood serum potassium is 3.5 to 5 millimoles per liter. Schiavo’s was 2, a level that can cause the heart to beat weakly, or stop. However, intravenous fluids and the heart stimulating drug epinephrine — both given in large quantities in an effort to revive the young woman — can lower potassium. He suspects that’s the explanation.”

    It seems that Teri Schivao was dead as a post before she died; Micheal Schiavo is completely exonerated; and I am sorry for all of it, and am glad it is over.

    RJN (813cdf)

  6. I am not a pathologist, but I have completed death certificates (as well as remembering trying to get the concept of how to fill it out in med school, as a resident, and in CME lectures).

    As one could learn and observe on this website,
    the cause of death is the cause of death. (Immediate cause, not the underlying conditions/predisposing factors).

    Reviewing the info in the autopsy report quickly, I would suggest the cause of death was pneumonia. The pneumonia had underlying causes of dehydration, malnutrition, and complications of previous post-anoxic encephalopathy.

    It is not very satisfying that we are left with all of the questions of her long medical history supposedly condensed for us in the autopsy report.

    I am surprised the report includes some things that are puzzling to me, that perhaps someone can address to more satisfaction. The intial blood work showed a low potassium, it also showed a remarkably low albumin level of about 2 as I recall looking at data many weeks ago. An albumin of 2 (in a living person) suggests one of the following: significant (obvious to sight) malnutrition, severe liver disease, certain types of severe kidney disease (“nephrotic syndrome”), or lab error- either an inappropriate sample of mistake in processing in the lab. If post death processes routinely mess up lab values to this degree then I don’t know how to believe anything.

    If she had an albumin of 2 in reality from an eating disorder I would have thought it would have been obvious, and she apparently did not have liver or kidney disease of the necessary types.

    I am not sure why (at the time of death) there were ulcerations on her epiglottis, unless it was from erosion from bacterial infection allowed from the extremely dry conditions of her mucous membranes. (The epiglottis is the “flap” that covers “the wind pipe” when one swallows.)

    The autopsy report seems to me to go out of its way to try to justify the course of events. I am not sure who really cares, except reporters wanting to make another story out of something. If “they” really wanted to try to help resolve anything, they would have allowed one or more forensic examiners not from the area to be “friends of the proceeding” observers.

    Those are my thoughts, maybe someone else reading has more expert knowledge to contribute.

    MD in Philly

    MD in Philly (1b0bc5)

  7. The web site didn’t show. It is
    http://www.le.ac.uk/pathology/teach/va/titlpag1.html

    MD in Philly (1b0bc5)

  8. One of the things that I find most interesting about the report is how it addresses the second guessing regarding the MRI or lack thereof. Many articles on your site and on NRO, produced neurologists who were “shocked” that no MRI had been done–the implication was that Michael had something to hide or his doc was incompetent. If the report in the autopsy was correct,the cited neurologists either did not know about the stimulator that had been implanted or they simply weren’t up to speed on current practice.

    I’d love to see your analysis– it may be that you were lead down a path by not so expert “experts”

    Robert Payne (ed0252)

  9. No, everyone knew about the stimulator. The theory was that it could be removed. If her life was at stake, the theory went, why not?

    Patterico (756436)

  10. Are you sure they all knew? I did not see anything at the time suggesting that the stimulator be removed, then the MRI being done, but I may have missed it.

    Again, what I worry about is, that if the autopsy is right, a bunch of back benchers who informed all of us that Terri could easily be rehabbed leas us all down a rosy path–good god! don’t you rember what Frist’s neurologist buddy confidently assserted?

    Bottom line, I am afraid that you sought out only meidcal opinions/ second guesses that jibbed with your presuppositions. Again, you guys may fisk the autopsy report, but I think you should spend some time doucmenting for the benefit of your readers those sources that you cited who ultimately called it wrong– had the autopsy turned out otherwise, I am sure you would be doing the same to your critics.

    Robert Payne (ed0252)

  11. Who’s fisking the autopsy report, dude? I’m just trying to figure out what it says! I assume it is going to be some of the most reliable evidence there is.

    I can’t speak for others, but I knew that there was something in her head preventing an MRI. It was widely discussed.

    And I don’t know that I cited anyone who called it wrong. I am studying for a promotional exam right now, but if you want to run that down for me, you’re welcome to.

    Patterico (756436)

  12. The report does deserve a little fisking on the point about the MRI. First, it conveniently overlooked the fact that thalmic implants can be – and per the directions of the doctor who originally implanted them, should have been – removed. Second, it overlooks the possibility of a PET scan, which would not have had any such problems. Third, and most generally, it is based on the fact that MRIs on persons with implants can be fatal. Think about that for a minute: “if we run an MRI on this woman before starving her, she might die.

    Nothing against the report generally, but this part was hella-stupid.

    Xrlq (717f9d)

  13. The same argument was made about spoon feeding by Greer. In that cynical aspect, the report seems consistent with the approach to murder that is worthy of 1984. Absolutely Orwellian in the doublespeak.

    Paul Deignan (664c74)

  14. A few points in the discussion-

    -Concerning “To do, or not to do, an MRI, that is the question”. We understand that journalists and editors are not held legally accountable for journalistic malpractice (although maybe you folks can figure out how to do it , when it is warranted). Hence, we get quotes out of context or in response to questions based on only a specific amount of given information (but we don’t know exactly what that was). My guess is that some comments were made without specific knowledge of the existence of the stimulator wires, but I also remember some discussion concerning the removal of the wires prior to an MRI, as Patterico mentions.

    Concerning the cause of death again. In the text of the autopsy report it is stated that dehydration, hence electrolyte imbalance, was the immediate cause (see chemistry results of vitreous fluid- the gel-like material inside the eye). I had listed pneumonia in my previous post because of the findings/diagnosis in the microscopic examination of the lungs that was clearly stated. (The risk of pneumonia was given as the reason to not attempt feeding by mouth.* Apparently she developed it anyway.) But in the specific documentation they list post-anoxic brain damage (or an equivalent term).

    Anyone who takes the time to look at the “Virtual Autopsy” web site will see this is just not the way death certificates are completed. For example, Ms. Schiavo could have developed a blood clot in her leg (because of her lack of mobility caused by the brain damage). A piece of the clot can commonly “break off” and travel to the heart and then into the lung (called a “pulmonary embolus”) causing death by literally plugging the blood flow to the lungs and back to the heart. The cause of death would be the pulmonary embolus, and the prior brain damage causing the immobility would be an underlying cause. For Ms. Schiavo the dehydration and elecrolyte imbalance and the pneumonia were the two processes that immediately contributed to her death. As the report was completed, it would seem that she had actually died 15 years ago and that just recently her body found out about it. That may or may not be true in a figurative sense, just as someone’s career may have already died even though they are still going into the office and collecting a paycheck.

    As Bebeaux states above, after a long and detailed discussion of neuropathology, including many references to conditions that have NOTHING to do with the situation being addressed, the final comment is that all of it can’t prove anything in regards to PVS (as the MRI, even if done, could not have given any definitive proof).

    Concerning looking to experts that tell us what we want to hear, that is exactly the concern of many who point out that Michael Schiavo sought legal representation from a high-profile figure in the “Right-to Die” movement, who picked prominent physicians in the same movement to be the medical witnesses. While some (irresponsible) “experts” chimed in that she would be “easily rehabbed”, most of us critical of the situation in my circles were more concerned by the claimed lack of all rehab efforts, including those that may have made it easier for her to be cared for whether she would regain any higher cognitive function or not.

    Again as said above, the fact that she had suffered extensive brain damage and her brain was severly underweight (and had architecture similiar to some multicystic malformation found in newborns with a rare condition incompatible with life) is a “duh” (so what’s the point?). The fact that so much effort was spent on describing this nonconclusive nonnews could seem by some to be an effort to get as much info as possible, or simply as another attempt to justify actions that many found questionable.

    To say that the report exonerates Mr. Schiavo is a gross overstatement.

    I am open to criticism by someone in forensic pathology, but I stand by the general statement that listing the cause of death as anoxic brain injury is simply not the way it is done.

    * (Pneumonia is a common cause of death in anyone who is malnourished and/or limited in physical strength, especially of the torso. The lungs/body cannot “clear secretions” adequately, the bodies first line of protection against lung infection. It is traditionally held as true that tube feeding is safer in someone at risk of aspiration, but there is data that suggests this is not the case. (But I would need to look up my notes from Grand Rounds about 2 yrs ago to be specific, so you can beleive I’m making a valid, though nonconclusive point, or just giving BS).

    MD in Philly (b3202e)

  15. […] reporting about it, few have probably read it. Take me, for example. I’ve turned to Patterico and Capt […]

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  16. I agree MD in Philly. If I were writing the death cerificate, it would have dehydration first, aspiration pneumonitis second. Anoxic encephalopathy would be listed last. The potassium level of 2 was obtained during her resusitation, and is not an unexpected value after large amounts of saline and epinephrine. It tells you nothing about what her potassium level was at the time of her collapse, which most likely was caused by an abnormal heart rhythm that degenerated into the ventricular fibrillation that was noted by EMS.

    What I found fascinating was that the bulk of the anoxic damage occurred from the thalamus to the occipital lobes with relative sparing of the frontal and temporal lobes. I’d like a neuropathologist to explain that more fully.

    Charles D. Quarles (593219)

  17. Three strange things among many others:

    1. The neuropathologist upon viewing the thalamus finds it to be relatively preserved in the medial portions–upon microscopic examination he finds damage–but does not quantify the damage.

    2. He compares Terri’s brain to Karen Anne Quinlan who had intact cortex but severe damage to the thalamus. (Quinlan’s thalamus was apparently the most damaged part of her brain) After Quinlan’s autopsy, the thalamus has been reevaluated by the medical community as more important then thought in terms of effect on consciousness.

    3. When he compares Terri’s brain to Quinlan’s–HE MAKES NO COMPARISON BETWEEN THE THALAMUSES–WHY?

    The report seems to say that Terri has some cortex–especially in the frontal lobes (which is the “thinking and personality part of the brain)and apparently some viable tissue in the thalamus.

    Given the importance that the medical profession has given the thalamus in effecting consciousness–why did he compare only weight and not kinds of brain damage?

    Sue Bob (d7ff57)

  18. In response to MD in Philly’s question about the ulcerations on the uvula, I suspect this was simply the result of chronically dry mucous membranes, the inability to swallow and spending long periods of time with the mouth open.

    Chadly (e99e16)

  19. To Chadly,

    Your answer may be correct, but you state “uvula” (or “shirt-tail”, in the language of my youth, which hangs from above at the back of the palate). My mention of the autopsy report had to do with the epiglottis, which is not readily visible in most adults (can be seen easily in some children) and springs up from the larynx, deep to and “behind” the base of the tongue.

    MD in Philly (b3202e)

  20. […] dibility when you make those arguments. P.P.P.S. This is especially true given that, as I observed when the autopsy report came out, “nothing in the report suggests a […]

    Patterico’s Pontifications » Give It Up (0c6a63)

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