terrisfight.org with formatting added for readability.
If you are pressed for
time, scroll down and read the passages in blue. Terri can definitely swallow!
According to Dr. Hammesfahr, "It is
unlikely that she currently needs
report of Dr. William Hammesfahr, a
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
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 her falling. He reports that she
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 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.
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
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 Ms. 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,
previously viewed videotape that was first shown at her first trial.
and evaluations were performed on Ms Schiavo on
3 and 4 with videographers present.
reviews of the charts provided were carried out, from which the
history is obtained.
On September 3, I spent
from approximately 11AM until 4PM with Ms.
returning the next day to also observe Dr. Maxfield and complete my
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
The exam started with the
setting up of the video camera by the
with Mr. Michael Schiavo present. I then came into the room and
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
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
immediately showed awareness of the presence of her mother, looking for
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
apparent recognition by the daughter.
The first part of this
exam included observing her interactions with her
and her father. Here she clearly was aware of them and attempted to
with them: the sounds, facial expressions, and searching out and tracking
them. There are several previous reports by
medical personnel and others of her
to live piano music. Accordingly, I asked the mother to bring a tape of
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
sounds with the music. She stopped making these sounds, when the music
During this time, she
would move her head and track her head and eyes to
sound of music, or her mother's voice. I started my exam first on her right
side, introducing myself and then
her contracted right arm, the goal being to get a blood pressure, as
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
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
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
to his daughter. The elbow immediately extended approximately
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
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
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
after this part of the exam, she would also appear to voluntarily move
right upper extremity.
Multiple takes of her
blood pressure were taken, and there were several
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
correlated well with the wrist palpations. Thus, the systolic readings are
probably fairly accurate, although the diastolic
readings cannot be independently
Three readings were successfully obtained 96/65 pulses of 70, 107/78
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
A general physical exam
was also performed, although pelvic, breast, rectal,
sinus and ear exams were not performed. Technical difficulties
the fundoscopic exam from being performed.
The general physical
examination and the neurological examination tended to
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
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,
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
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
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
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
were identified. Cardiac exam was normal to my exam. Interestingly,
the significant arrhythmias identified by
the electronic cuff, as well as my palpation of
wrist exam was not identified during this cardiac portion of the exam,
the arrhythmia is intermittent.
Abdominal exam showed good
GI sounds throughout, and was non-tender.
masses or aneurysms were palpated.
Extremities exam showed
severe contractures in all four extremities. On the
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
and release, the exam in this upper extremity showed spasticity on the
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
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
available in this area.
In the lower extremities,
she has 2/4 about the hips and the knees, meaning
range of motion, but spasticity still present. However, about the ankles, she is
4/4 and I could obtain no improvement in the range
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
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
missed or only able to be identified from sophisticated testing in a
with 3/4 or 4/4 levels of spasticity.
Spasticity generally is
due to neurological injuries, and is aggravated by lack
physical therapy and muscle stretching. To understand spasticity, it is
important to understand what is normal with
In a normal person, a leg,
arm, or other part of the body moves because a
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
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
When the triceps contracts, the arms straightens. Another characteristic of
normal is that when one set of muscles contracts,
the opposite muscles relax. Thus,
the biceps contracts, the triceps relaxes and vice versa.
In spasticity, that
relaxation of opposing muscles does not occur. Thus, even
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
muscles may be so severe, that voluntary motion appears very weak or
In fact, in some of her muscle groups, the severity of the contractures
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
Normal, no spasticity
spasticity, palpated by the physician, but full range of motion of
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
this is a 2.
spasticity, but some motion can be identified. Full range of
does not exist.
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,
or other abnormalities seen.
The first two hours of the
exam, focusing on cognitive awareness of her
was carried out in a chair. The last one hour on videotape was
out in her bed. In neither position did she have difficulty handling
saliva or secretions.
Only briefly, for a few minutes at a time, did she appear to tire
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.
patient was alert throughout essentially the entire exam.
The patient would
immediately respond to sound, tone of voice
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
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
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
look toward the sound of my voice when heard, attempt to find me
then track the sound of my voice in its movements, or track me if I was
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
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
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,
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
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
During various portions of
the exam, she would be moved or have her
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
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,
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
the action. However, when praised for the action, she would then
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.
different portions of the exam, I would ask her to squeeze my hand on
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,
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
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
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
gave verbal commands, but also noted that she would oppose activity
Thus, moving a hand against a thigh would elicit an equal and opposite
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
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
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
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
well. The voluntary control is there, but does not show up well on
as the range that the motion goes through is less.
Cranial Nerve Exam:
Cranial nerve function is present and appears normal
all groups tested. The fundoscopic exam and ophthalmic nerve function could
not be tested directly. She tracks well and
voluntarily. She does not exhibit
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
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
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
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
I would estimate that at least one day should be allotted for the exam
should be carried out her in room.
Sensory Exam: The patient
was tested to light touch, pressure, and sharp
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
feels pain as the videotapes show.
On the face, noxious
stimulation including cotton swab up the nose and gag
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
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
motor activity. When using a sharp piece of wood, which she found
and going over her entire body (except diapered areas and breast
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
on the left.
We found that she had two
sensory levels. The first is the side-to-side
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
spinal injury and spinal cord injury near this level.
Motor Exam: As
discussed earlier, it is difficult to measure motor strength
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
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
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. Ifthose muscles don't relax, they tend to keep the
fingers straight, and thus give a
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
spasticity is so severe that a muscle tested may not be strong enough to
the opposing muscles, and no evidence of voluntary muscle movement is
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
that is good control over her facial musculature. Formal testing of those
cranial nerves showed no weakness or facial
In the upper and lower
arms, however, the spasticity is severe. She at times
voluntarily move her right arm/ hand complex against gravity, which is
a strength of 3/5 or greater by convention. When squeezing my hand
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
approximately 3/5, but not to command (probably due to the aphasia). The
side was stronger than the left.
The leg motion on the
right was generally approximately 2-3/5 in all groups
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
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
The convention of the 0-5
scales for testing voluntary motor strength is as
movement able to be felt
Movement of an extremity if gravity is removed. Thus if
of a leg occurs in a bed while a patient is lying down,
he cannot move that same area up off of the bed, this is
Movement against gravity
Movements against examiner's actively resisting the patient's
The scale has some
additional aspects, in that a - or + sign may further
an examiner to delineate a specific number into sub-gradations.
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
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
were 2++ and symmetrical. Reflexes at the ankles could not be obtained
due to the severe contractures. Babinski
exam did not show abnormal reflexes,
due to the severity of the contractures in the feet. Both glabellar and
palmomental reflexes were mildly abnormal.
The patient is not in
She is alert and
responsive to her environment. She responds to specific
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
specific people's voices from others.
She differentiates music
from stray sound.
She attempts to
She has voluntary
control over multiple extremities
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
frequent medication administered for pain by staff.
With respect to specifics
and specific recommendations in order to carry out
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
and checkerboard patters. The opthamological examination is to evaluate her
retina and her ophthalmic nerve to try to
determine the cause of her visual
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
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
others, they must know what sort of limitations she has. This
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
to properly examine her, it would help if one knew the full extent of these test
can communicate. She needs a Speech Therapist,
Pathologist, and a communications expert to evaluate how to best
with her and to allow her to communicate and for others to
with her. Also, a treatment plan for how to develop better
needs to be done.
The patient has severe contractures. She needs a
to evaluate these and develop a treatment plan.
patient has clinical evidence of an abnormally functioning
system. Her blood pressure is abnormally low. Many patients with
neurological injury have low blood pressure due to an abnormally
endocrine system. The reason for this should be determined and
as with a more normal blood pressure, she is likely to have even better
functioning. She has facial acne consistent with hormonal
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
feeding tube. She should be evaluated by an Ear Nose and Throat
specialist, and have a new swallowing exam.
Mammography needs to be
Spinal Exam: The
patient's exam from a spinal perspective is abnormal.
degree of limitation of range of motion, and of spasms in her neck, is
with a neck injury.
The abnormal sensory exam, that shows evidence of her
encephalopathic strokes (right side sensory responses are different from
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
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
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
functioning. This should be looked for, as may be treatable. Thus,
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
with a spinal cord injury and hypoxic encephalopathy will need different
and rehab recommendations than one who just has a hypoxic
Interestingly, I have
seen this pattern of mixed brain (cerebral) and spinal cord
in a patient once before, a patient who was asphyxiated.
A urological consultation
should be obtained: I disagree with Dr.
view that the patient's bacteria in the urine may be ignored. In my
colonization of the bladder can very distinctly affect the patient's
status and affect their rehabilitation. The patient needs a urological
both to examine the bladder issue, resolve if there are possibly
and kidney stones (that may be the source of recurring bladder
Also, one significant mechanism of diagnosing and finding and
spinal cord injuries is through sophisticated bladder EMG and other
This should be done.
The neurosurgeon who
placed the implant should be contacted for
A neurological examination can only be carried out
in the context of a complete
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
EEG: I have reviewed
the EEG recently obtained. The EEG has large
of artifact. The technician's attempted to remove artifact by filtering.
filtering also affects and reduces evident brain electronic activity.
EEG is not adequate and should be repeated. It should be repeated at the
patient's bedside, with the patient in a
SPECT scan: A SPECT scan
prior to and after several days of Hyperbaric
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
However, it is a useful technique to assess the likelihood of
using hyperbaric oxygen. I would defer to Dr. Maxfield on the
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
William M. Hammesfahr,
With Dr. Hammesfahr: Startling Revelations
Terri could swallow food!
See the sworn affadavit
of Carla Iyer.
Vs Terri Schiavo