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.
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 was unresponsive.
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
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
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,
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 11AM until 4PM 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
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
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
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
The convention of the 0-5 scales for testing voluntary motor strength is as
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
3 Movement against gravity
4 Movements against examiner's actively resisting the patient's
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
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
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
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
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.