Skip to comments.Terri Schiavo Case; Expert Testimony?
Posted on 03/22/2005 6:15:47 PM PST by FR_addict
First segments.... (BEGIN VIDEOTAPE)
DR. SANJAY GUPTA, CNN SENIOR MEDICAL CORRESPONDENT (voice-over): In a medical case as high profile as Terri Schiavo, you would think the medical experts would have all the answers. But just by listening to them and reviewing statements they gave to the court, it's easy to see why a final answer is so complicated.
DR. WILLIAM HAMMESFAHR, NEUROLOGIST: I spent about 10 hours across about three months and the woman is very aware of her surroundings. She's very aware. She's alert. She's not in a coma. She's not in PVS. ...
DR. RONALD CRANFORD, NEUROLOGIST: A vegetative state is a scary diagnosis. Unless you know what you're looking for, it looks like the patient is interacting. But Terri is not interacting.
GUPTA: Both of them are neurologists and their conclusions are based on diagnostic tests that are supposed to be objective. Yet, they tell different tales.
HAMMESFAHR: Her CAT scan has maybe 75 percent of the brain tissue still left. CRANFORD: I've seen her. There's no doubt in my mind, whatsoever, she's in a permanent vegetative state. Her CAT scan shows extremely severe atrophy to the brain. And her EEG is flat. It doesn't show any electrical activity at all.
GUPTA: And, most importantly, their opinions about a possible recovery?
HAMMESFAHR: With proper therapy, she will have a tremendous improvement. I think, personally, that she'll be able to walk, eventually, and she will be able to use at least one of her arms.
CRANFORD: There's no way. That's totally bogus. ...
(Excerpt) Read more at transcripts.cnn.com ...
First, Dr. Cranford makes a very bizarre statement:
CRANFORD: I've seen her. There's no doubt in my mind, whatsoever, she's in a permanent vegetative state. Her CAT scan shows extremely severe atrophy to the brain. And her EEG is flat. It doesn't show any electrical activity at all.
Second, This part is missing from the transcript. Below is my transcription from my tape of the segment.
After the segment above, Daryn turns to Gupta and says. the "EEG was flat what does that mean?"
Dr. Gupta: He said that and I was a little surprised that he said that. I mean that is a very clinical thing when you say someone's EEG is flat that means they are brain dead. That's a really inmportant term for transplant surgeons before they take someone's organs. Terri is not brain dead. I think just about anybody that looks at her can tell that. What exact state she is in. I don't know. I've never examined her but the video along shows that she is not brain dead.
Third, Dr. Cranford is the neurologist that examined her and whose testimony was used to determine that Terri was in PVS. Yet he states above that Terri's EEG is flat, which is impossible.
How come every professional cited as claiming Terri is PVS has a history of "right-to-die" (i.e. euthanasia) activism?
I am LIVID AT THIS MICHAEL SCHIAVO! I THINK A WARRANT SHOULD SWORN OUT FOR HIS ARREST! WE HAVE TO LOOK INTO THIS GUY! HE IS HIDING SOMETHING BUT HE CANNOT HIDE FROM GOD!
DR. RONALD CRANFORD should be known as Dr. Death. He has made an entire career out of testifying that people are vegetables. He is not a real witness, he is an advocate for death.
An article posted here a day or two ago gives the details on this man, who joins George Felos, Judge Greer, and Michael Schiavo in the inner circle of those who are trying to murder Terri.
A CAT scan is useless in any case. And Michael Schiavo has refused to allow an MRI scan, which would reveal the true state of affairs.
muslim fanatics like al-zarqawi behead innocent people with a knife. american judges like greer condemn an innocent woman to death by starvation.....which is worse ???
Here is the MUST READ deposition of Nurse Carla Iyer, found and posted by lanceman(as a separate thread, which was deleted with the suggestion to post it on an existing thread).
She took care of Terri at one of the convalescent homes.
The nurse testifies that Michael didn't want anything done for Terri, including medically necessary treatments, such as giving her antibiotics, that Terri actually used to speak, felt pain, and indicated when she was in pain, that MS acted happy, when Terri got ill and made statements, like "when is the b&^ch going to die"
It's an absolute MUST READ. Thanks lanceman for finding and posting it.
H&C just said that coming up is a testimony of a nurse, they didn't mention any names, it could be this one.
This is a chilling op-ed written by Dr. Cranford:
Terri never had a chance.
What is the standard procedure used to determine if someone is in a PVS, coma, or brain dead?
This is an issue that has to be made everyday somewhere in some hospital across this country.
Yep, the deck was stacked from the outset.
Apparently if you've decided you want a diagnosis of PVS regardless of the patient's actual condition, you call Dr. Cranford.
Dr. Crwaford was on Hannity & Commie just now - Hannity nailed him but good - Crawford sounds a pro-death advocate...
Cranford was just now on Hannity & Colmes. He repeated his assertion that Terri's EEG is flat. So, it was no mistake or accident on his part when he said this on CNN. He also said that PVS patients have no constitutional rights. Sean Hannity asked him twice if he meant that. Dr. Cranford repeated it twice...PVS patients have no constitutional rights.
Not only did Terri not have a chance,,this man sounds like he is coming for everyone who needs a feeding tube. He sounds like he would like to just do a big ole mass murder.
the man is a psychopath.
Never heard that EEG stuff either. Wonder what the heck he's talking about.
another demonic kevorkian.....these maniacs are committed to see people die
I saw him on Hannity. He seemed very much like a death advocate not a Dr of healing. He stated he wouldn't put a feeding tube in an Alzheimer's patient. That will be next for them to be starve to death. This is sick. I can't believe that his opinion was even considered.
Well, before a diagnosis of "PVS" could be made terminal (i.e. before the days when people could try to make sure PVS patients would never 'snap out of it'), such a diagnosis would mean nothing more nor less than that a doctor was not able to identify any stimulus to which a patient would yield a cognitive response and had given up trying.
The reason Terri's parents didn't initially fight a diagnosis of PVS is that it wasn't considered a terminal condition, and it didn't really matter to them what doctors thought of their daughter. Even if doctors couldn't find stimulus/response combinations that satisfied them, the parents could find ones that satisfied them and that was in their minds sufficient.
Unfortunately, PVS has been morphed into a "terminal" diagnosis without any qualification attached. Whether a particular doctor diagnoses someone as PVS depends in very large measure on how hard they're willing to look for cognitive responses. If a doctor is unwilling to look very hard, he's not apt to find anything.
If one doctor manages to find proof that a patient isn't PVS, the patient is not PVS, regardless of whether other doctors find proof. To prevent "wishful thinking" from being mistaken for evidence of cognition, it would be possible to have protocols by which a doctor who wanted to find a patient non-PVS could demonstrate the stimulus/response combinations he found. If the responses are clear and unambiguous (e.g. when a patient's finger is wiggled 'n' times and released (n less than five or so), the patient will respond shortly thereafter by wiggling the finger the same number of times) it may be taken at face value. If the judgement of the response is subjective, the pro-cognition doctor could perform blind experiments where the patient is given one of several stimuli (which are selected in advance by the doctor, but sequenced randomly) and the doctor has to identify which stimulus caused the patient's response.
Of course, no such drills have been done for Terri.
His article makes that pretty clear. I know how I'll cast my vote between the methods of death due to lack of basic necesseties. Leave me out in the freezing cold. Do it on a clear night so I can marvel at the stars.
I'm just heartbroken, pissed, amazed ... that starving anybody to death is seriously defended, but there are lots of defenders. Chilling.
Was it me or did anyone else noticed how much he was blinking his eyes while being questioned by Hannity?
Compared with the other doctor who is a nobel nominee I can't see how anyone find this guy more credible.
somene today was saying to me "this happens all the time, feeding tubes taken out". I said to her it was not common and only occurred with terminal cancer patients or people on ventilators who were brain dead.
I then asked if that person thought docs were killers. She just had never thought about it, just accepted the idea. I was aghast.
Cranford is the one with the flat EEG.
My observation is that those who are defending the court and defending the practice are adept at conflating issues and drawing false parallels. In short, at making the situation confusion when it could be made clear.
I've learned alot in the past couple days -- didn't follow the case close at all until this weekend, but was generally aware of the issues. I am grateful for the FR tool, it has been somewhat helpful.
Absolutely chilling. We are in the clutch of a culture of death. Nobody learns from history. (consider Germany under Hitler)
Many people are waking up to this case. My sister just started reading about it yesterday.
Some more about Dr. Cranford. Thanks for the find, FR_addict.
Videos of Terri. She doesn't look vegetative to me.
What is significant, however, and what [undermines] his creditability is that he did not present to this court any evidence other than his generalized statements as to the efficacy of his therapy on brain damaged individuals like Terry Schiavo. He testified that he has treated about 50 patients in the same or worse condition than Terry Schiavo since 1994 but he offered no names, no case studies, no videos and no tests results to support his claim that he had success in all but one of them. If his therapy is as effective as he would lead this court to believe, it is inconceivable that he would not produce clinical results of these patients he has treated. And surely the medical literature would be replete with this new, now patented, procedure. Yet, he has only published one article and that was in 1995 involving some 63 patients, 60% of whom were suffering from whiplash. None of these patients were in a persistent vegetative state and all were conversant. Even he acknowledges that he is aware of no article or study that shows vasodilatation therapy to be an effective treatment for persistent vegetative state patients. The court can only assume that such substantiations are not available, not just catalogued in such a way that they can not be readily identified as he testified.
It was a very good show anyway. Hannity has definitely put some work into learning the facts in this case.
The only thing he missed is, when Dr. Cranford said she had a flat EEG, which is not true. Other than that he nailed him good!
Didn't it seem like he didn't want to answer these questions? He sure has questionable opinions to be considered seriously as a Dr. of healing medicine. He's a creepy death Dr. Sean did a wonderful job interviewing him.
Cranford is also the so called "doctor" that administered the balloon test to Terri that is available for video viewing on Terrisfight.org
Listen to him and then read his findings. Certainly a man with a mission.
Your point is well taken - For some reason moral issues like this one bring out the worst in illogical left wing thinking. The argument that "this happens all the time.." and therefore somehow it is OK is just nonsense. Lots of things "happen all the time" that aren't OK - like clerks in convenience stores being shot by robbers. No one in their right mind should think that just because something happens frequently it is acceptable, or a good thing to have happen.
And if you read the first doctor's complete transcript, he mentions the EEG is not a good tracing because there is so much artifact from her shaking...So the EEG is not technically a good measure of her brain's status. Your'e going to need different tests...like a PET scan. Or remove those thalamic stimulator clips (as was recommended years ago) and get an MRI.
Yeah Crawford is a Dr. Death flake, but unfortunately William Hammesfahr is a total quack that was disciplined by both the Florida and California Medical Boards for false and deceptive practices and bilking patients.
Terris parents are fools to keep using Hammesfahr. The man has ZERO credibility before the Bar. No first class attorney would represent the Schindlers if they insisted in using expert witnesses like Hammesfahr, and the man has greatly hurt their case.
I dont like it, but sorry those are the hard facts.
Sorry typo I meant Cranford
The only charge against Hammesfahr for which he was not exonerated was something to the effect that a patient had prepaid for one treatment plan, had signed up on arrival for a cheaper plan, and was given the cheaper plan but charged for the more expensive one.
To be sure, Hammesfahr and his billing staff should not have made such a mistake, but his having made it hardly makes him a 'quack'.
Pretty weak form of argument. Anyway, who in their right mind would request to be starved to death? That is just nuts on its face.
But in spite of the lack of advanced testing, such as an MRI, attorney George Felos has claimed that Terris cerebral cortex has liquefied, and doctors for Michael Schiavo have claimed, on the basis of the CT scans, that parts of Terris cerebral cortex have been replaced by fluid. The problem with such contentions is that the available evidence cant support them. Dr. Zabiega explained that a CT scan cant resolve the kind of detail needed to make such a pronouncement: A CT scan is like a blurry photograph. Dr. William Bell, a professor of neurology at Wake Forest University Medical School, agrees: A CT scan doesnt give much detail. In order to see it on a CT, you have to have massive damage. Is it possible that Terri has that sort of massive brain damage? According to Dr. Bell, that isnt likely. Sometimes, he said, even patients who are PVS have a normal or near normal MRI.
Has Zabiega seen the CT of Terri? Perhaps he would change his mind on the need for an MRI or PET.
If not, I'd like him to show CT scans of other patients similar to the one of Terri's you posted, with comparison MRIs and PETs, and accompanying descriptions of the patients and their progress in therapy.
BTW, do you have a source/link for the photo?
does this look like a vegetable?
ROFLMAO!! Check out this post!
One of my liberal axioms: the more people do a wrong thing, the less wrong it becomes. Therefore, if you've done something wrong, it's better to encourage others to do it than to discourage them from repeating your mistake.
Another liberal axiom: everything is relative. The existence of a good person makes everyone else worse by comparison, and that of a bad person makes everyone else better by comparison. Hence opposition to the death penalty but eagerness to kill Terri.
Flat EEG, is that Doctor out of his mind??
Isn't "kill" too strong a word for euthanasia?
Answer: No. The word "kill" means "to cause the death of." In 1989, a group of physicians published a report in the New England Journal of Medicine in which they concluded that it would be morally acceptable for doctors to give patients suicide information and a prescription for deadly drugs so they can kill themselves. Dr. Ronald Cranford, one of the authors of the report, publicly acknowledged that this is "the same as killing the patient." While changes in the law would lead to euthanasia being considered a "medical intervention," the reality would not change -- the patient would be killed. Proponents of euthanasia often use euphemisms like "deliverance," "aid-in-dying" and "gentle landing." If a public policy has to be promoted with euphemisms, that may be because the use of accurate, descriptive language would demonstrate that the policy is misguided.
In cases where other doctors dont see it, Dr. Cranford seems to have a knack for finding PVS. Cranford also diagnosed Robert Wendland as PVS. He did so in spite of the fact that Wendland could pick up specifically colored pegs or blocks and hand them to a therapy assistant on request. He did so in spite of the fact that Wendland could operate and maneuver an ordinary wheelchair with his left hand and foot, and an electric wheelchair with a joystick, of the kind that many disabled persons (most famously Dr. Stephen Hawking) use. Dr. Cranford dismissed these abilities as meaningless. Fortunately for Wendland, the California supreme court was not persuaded by Cranfords assessment.
Expert witnesses in court are supposed to be unbiased: disinterested in the outcome of the case. Part of the procedure in qualifying expert witnesses is establishing that they are objective and unbiased. But given Dr. Cranfords history of advocacy in the right to die and euthanasia movements, and given his track record of almost always coming down on the side of PVS and removal of nutrition and hydration, one might question his objectivity. Indeed, the Schindlers attorneys attempted to do so in the 2002 evidentiary hearing at which Cranford testified, but went unheard. Organizations such as the International Task Force on Euthanasia and Assisted Suicide submitted amicus curiae (friend of the court) briefs in the appellate proceedings in Terris case, demonstrating Cranfords bias in detail. But these arguments also seemed to fall on deaf ears.
"Flat EEG, is that Doctor out of his mind??"
Sounds like he is incompetent to me.
After reading the 17 affidavits, plus the report of the examining physician on whose findings Schiavo's parents are basing their case, plus the rulings from the trial court and the court of appeals.
None of the 17 affidavits are by providers who examined Schiavo. Only one of the 17 providers claims to have reviewed her medical records. The remaining 16 providers apparently based their statements primarily on six snippets of videotape, totalling 4 minutes and 20 seconds, which have been posted on Schiavo's parents' website and broadcast repeatedly on the news. Several of them explicitly say that they viewed these clips on the net, and the others all refer to the same short samples of behavior (e.g., Schiavo's eyes tracking a balloon). Many of them say they read news stories about Schiavo. One admits to only seeing news stories and photographs. They all reference their experience with "similar patients," but without qualifying what they mean by "similar." For example, one doctor draws comparisons to catatonic patients - but catatonia simply refers to an absence of voluntary motion or interaction, and can be caused by any number of things. Another references stroke patients, and two more talk about patients with Alzheimer's. As Ampersand points out, not one of them mentions the specific degree and type of brain damage that Schiavo has, as documented by her CAT scans:
Theresa's brain has deteriorated because of the lack of oxygen it suffered at the time of the heart attack. By mid 1996, the CAT scans of her brain showed a severely abnormal structure. At this point, much of her cerebral cortex is simply gone and has been replaced by cerebral spinal fluid. Medicine cannot cure this condition. [...]
Although the physicians are not in complete agreement concerning the extent of Mrs. Schiavo's brain damage, they all agree that the brain scans show extensive permanent damage to her brain. The only debate between the doctors is whether she has a small amount of isolated living tissue in her cerebral cortex or whether she has no living tissue in her cerebral cortex.
Most of the affidavits mention sophisticated new neuroimaging techniques which have been developed since the 1996 exams, and recommend that Schiavo receive a functional MRI (which tracks blood flow in the brain in response to specific stimuli) or a neuroSPECT exam (another functional imaging test). They note, correctly, that functional tests are capable of providing much more information about the nature and extent of brain damage than structural tests like a CAT scan. Yet Terri Schiavo's cerebral cortex is not damaged, it is absent. The affidavits repeatedly fail to engage with this finding. Thus, we have Dr. Ankerman: "The long duration lack of speech seen after injury trauma is not always due to destruction of brain structure. Sometimes it is due to a state of brain dysfunction that is reversible." Dr. Uszler: "Standard MRI or CAT scans are anatomy scans; they tell you if the tissue is there and its current structure, but these tests do not tell you whether the brain is working." And, most incredibly, Dr. Terman: "If the results of her response to certain neurological tests, for example the fMRI, were similar to that of normal individuals with undamaged brains, such data might indicate that there is some potential for her rehabilitation."
I suppose that these statements are technically true. Speechlessness is not always due to destruction of brain structure, but if massive destruction of brain structure is present, that's certainly the way to bet. CAT scans tell you if tissue is present and structured normally, but not if it's working; however, if tissue is absent, you'd think its lack of functionality could be assumed. And yes, if Terri had the same fMRI results as a healthy person, that would bode well for rehabilitation - but as we sometimes say here at Respectful of Otters, it's equally true that if my aunt had testicles, she'd be my uncle. Terri Schiavo doesn't have a cerebral cortex. She's not going to have a normal fMRI pattern. She simply couldn't. So it's pointless to speculate about what it would mean if she did.
What about the "new treatments" which might help Schiavo? Many of the providers assert that she could be trained to swallow, and they're probably correct. Swallowing is a brainstem reflex, and Schiavo still has her brainstem. The muscles of her throat could be stimulated - Mr. Lakas suggests using electric shock - to produce an automatic swallowing response to liquid nutrition. It's hard to see how that would amount to an increase in quality of life, however, given the mechanical nature of the reflex and the likely increased risk of choking or aspiration pneumonia. What else? One of the doctors (Ankerman, again) recommends the off-label use of an Alzheimer's drug, based on unpublished anecdotal evidence that it helps catatonic patients (not patients in a persistent vegetative state). Another recommends hyperbaric therapy, about which the trial court judge had previously pointed out, "It is interesting to note the absence of any [published] case studies since this therapy is not new and this condition has long been in the medical arena."
Two others make unsubstantiated claims that Schiavo could somehow be taught to communicate: "By helping Ms. Schiavo to communicate she will be able to tell us things, such as whether or not she wants to die, and if she wants a divorce" (Ms. Hyink), "sometimes even if a patient can only answer "Yes" or "No" it is still possible to determine what that patient wants in terms of end-of-life medical care" (Dr. Terman). Indeed, if Schiavo were capable of speech or meaningful communication it would be much easier to determine her wishes. That hypothetical, however, is completely irrelevant to the case.
The 17 affidavits all put considerable weight on the fact that, in the video snippets on Schiavo's parents' website, she appears to be responding to stimulation. Her eyes track a balloon. She smiles in response to her mother's voice. The affidavits therefore conclude that Schiavo is appropriately responsive to external stimuli, and that she is at least minimally conscious - not in a persistent vegetative state (PVS) at all. Yet none of the exhibited behaviors are, in themselves, unusual for patients with PVS. According to the National Institute of Neurological Disorders and Stroke:
Individuals in such a state have lost their thinking abilities and awareness of their surroundings, but retain non-cognitive function and normal sleep patterns. Even though those in a persistent vegetative state lose their higher brain functions, other key functions such as breathing and circulation remain relatively intact. Spontaneous movements may occur, and the eyes may open in response to external stimuli. They may even occasionally grimace, cry, or laugh. Although individuals in a persistent vegetative state may appear somewhat normal, they do not speak and they are unable to respond to commands.
So the presence of smiles, grimaces, vocalizations, and eye movements alone is not relevant to the question of whether Schiavo has retained any degree of consciousness or may benefit from therapy. They may be in part reflexive - as when she "smiles" when her cheek is stroked - and they may be completely random. The key to the 4 minutes and 20 seconds of video is that Schiavo seems to be responding in a meaningful way to specific stimuli. All 17 experts who reference the videos take for granted that they demonstrate meaningful emotional or communicative responses. Could they really all be wrong?
Oh, yes. All you need to know to illuminate the question is that the six snippets of video were selected from 4 1/2 hours of tape. As do most people with PVS, Schiavo emits random behaviors and noises. If a person gives enough commands or makes enough interaction attempts over the course of several hours, by sheer coincidence some of Schiavo's random behaviors will appear to coincide with their commands. Both the trial court and the appeals court viewed the entire 4 1/2 hour tape, and both concluded that her responses were indeed random. As the original court decision pointed out:
Dr. Hammesfahr testified that he felt that he was able to get Terry Schiavo to reproduce repeatedly to his commands. However, by the court's count, he gave 105 commands to Terry Schiavo and, at his direction, Mrs. Schindler gave an additional 6 commands. Again, by the court's count, he asked her 61 questions and Mrs. Schindler, at his direction, asked her an additional 11 questions. The court saw few actions that could be considered responsive to either those commands or those questions. The videographer focused on her hands when Dr. Hammesfahr was asking her to squeeze. While Dr. Hammesfahr testified that she squeezed his finger on command, the video would not appear to support that and his reaction on the video likewise would not appear to support that testimony.
Hammesfahr's own report makes clear that he relied on a ludicrously low standard to conclude that Schiavo's responses were purposeful:
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.
He commanded her to emit some of her known behaviors, such as closing or opening her eyes. If she did, that was a "hit" - a sign that she had obeyed the command. If she did so several minutes later, that was still a "hit," apparently no matter what else he'd asked her to do in the interim. If she continued , long after he'd moved on, that was not a sign that she was unresponsive to his subsequent commands but, instead, a sign that she was responsive to praise. Almost any response, correct or incorrect, could apparently be interpreted to signal consciousness. Hammesfahr, like Schiavo's parents, wanted to be convinced.
Terri Schiavo's case is tragic, but not medically complicated. Nothing about it suggests any room for diversity of medical or neuropsychological opinion. The "experts" who submitted affidavits appear to know little about her case beyond what they were able to glean from cherry-picked videotape segments only a few minutes in length. They recommend sophisticated neuroimaging techniques which are not relevant to the question of the feasibility of rehabilitation when the cerebral cortex is gone. Frankly, I can't imagine what led any of them to believe they had sufficient information to submit an affidavit. But some of their statements offer disturbing clues.
Dr. Eytan would seemingly reject any pre-injury statement about the conditions in which a person would prefer to refuse medical treatment, "because we are all in the process of changing." In the greatest unintentional irony of the entire stack of affidavits, she remarks that "Ms. Schiavo is not the same person as she was when she made her alleged remarks about not wanting to live in a certain condition." By this logic, she would apparently argue to invalidate any Living Will or advance directive. Dr. Senno states that just because Schiavo hasn't had any higher neurological functions for the past fifteen years, that doesn't mean she won't suddenly develop them today or tomorrow. By that standard, again, no one could ever be removed from life support. These doctors reject the fundamental right to refuse unwanted medical intervention. Imagine being kept alive forever in a mindless, volitionless, decerebrate, unresponsive condition, regardless of anything you might previously have said about your wishes to avoid such a state - just in case some new treatment were developed in the future which might cure you. That appears to be the new standard these medical providers are advocating.