Mrs. Schiavo died (or at least her body died) on March 31st and the autopsy was performed by Pinellas County medical examiner Dr. Jon R. Thogmartin on April 1st 2005 (an ironic date). The official report was released yesterday and is available (in pdf format). To summarize the significant findings;

The cause of Mrs. Schiavo’s death on March 31st was from severe dehydration about 2 weeks following the removal of her implanted “feeding tube”. Her serum sodium level at the time of death was an astounding 207 mmol/L (normal being 135-144). What happenes is that the relative sodium concentration of the blood increases as the body becomes dehydrated. This means that Mrs. Schiavo’s body lost a little over 12 liters of water during this time.

She also showed signs of kidney failure (creatinine 1.3 and BUN 133 with evidence of tubular necrosis) from the dehydration and this likely was a main cause of a blood potassium level of 8.5 mm/L. This potassium level is fatally high and could have been the actual mechanism of death (at this level the heart literally slows to a stop).

Interestingly it should be noted that this potassium level usually causes flaccid muscle paralysis and this sodium level induces a deep coma. Essentially electrolyte abnormalities like these from dehydration do not cause pain or suffering and lead to a peaceful passing. The contention by many that this is a painful way to die is often based on erroneous reasoning because they try to imagine what it would be like for themselves to be denied food and water for two weeks. But such a “thought experiment” is hardly firm scientific evidence especially in the context of cognitively impaired patients like Terri who have very limited, if any, capacity to experience suffering.

Neither did Terri Schiavo starve to death as indicted by the adequate fat stores on her body.

Neuropathologist Dr. Stephen Nelson performed the autopsy on Mrs. Schiavo’s central nervous system. Her brain was grossly abnormal and weighed only 615 grams. This is only half the weight of a normal female brain of Mrs. Schiavo’s age. Dr. Nelson noted that this is less than the brain of Karen Ann Quinlan which was 835 grams at the time of her death. Mrs. Quinlan suffered a cardiopulmonary arrest and resultant severe anoxic brain damage in 1975 and lived for 10 more years in a persistent vegetative state.

Dr. Nelson describes Mrs. Schiavo’s brain as having “wide sulci and narrow and thinned gyri” indicating significant volume loss. He notes the presence of hydrocephalus ex vacuo which is enlargement of the ventricles in the center of the brain that normally act as a sort of reservoir for cerebralspinal fluid (CSF). When parts of the brain are irreversibly damaged they tend to atrophy (shrink) over time and this loss of volume is replaced by an increased amount of CSF. The normal amount of CSF in the head is usually 150 cc. The amount of CSF in Mrs. Schiavo’s head was 645 cc!

The case of the missing cerebral cortex.

Microscopic analyses of Mrs. Schiavo’s brain were prepared and Dr. Nelson describes the abnormal findings on the slides as “striking in their appearance, and global in their distribution.” The slides of Mrs. Schiavo’s cerebralcortex (the outer layer of the brain that gives us the ability to think, reason, and to be self aware) showed that “the larger pyramidal neurons were globally absent.” This type of neuron normally makes up 85-90% of the cortex. They have about 20,000 synaptic connections with other pyramidal neurons (compared with 6,000 connections for other types of neurons) and likely make up the brain wiring that allows for consciousness. In short, the part of Mrs. Schiavo’s brain that made her a thinking, feeling, self-aware human being was destroyed and gone (these cells do not regenerate).

Follow the balloon?

The optic nerves were atrophied and the visual centers of the brain, which interpret signals from the eyes and optic nerves and allow for conscious awareness of visual stimuli were completely destroyed. This is important because if you recall Mrs. Schiavo’s parents repeatedly claimed that video of Terri in the nursing home showing her following a balloon around with her eyes was proof of consciousness. However, as the autopsy results clearly show, Mrs. Schiavo would not have been able to consciously “see” the balloon even if she were capable of consciousness. This evidence supports the position that various behaviors by Mrs. Schiavo such as laughing, smiling, and even tracking a floating object were simply non-conscious reflexes. Indeed, the courts found that there was no evidence that Terri consistently tracked the balloon or did anything to indicate conscious awareness.

The deeper parts of Mrs. Schiavo’s brain including the pons and brain stem which control non-cognitive functions like heart rate, respiration, and digestion were found to be relatively intact. Interestingly the part of the brain stem and thalamus known as the reticular activating system was found to be mostly intact. This part of the brain is critical in maintaining a conscious and awake state. Damage to this area can lead to a permanent coma even if the cerebral cortex is undamaged. However, Mrs. Schiavo’s reticular activating system appears to have been operating normally. This is why she appeared to be “wake” despite the fact that she was incapable of consciousness.

Dr. Nelson states that all the findings at autopsy of Mrs. Schiavo’s brain are consistent with damage from anoxia (lack of oxygen) that she suffered at the time of her cardiac arrest. There is no evidence that these changes in the brain were caused by trauma.

Persistent vegetative state (PVS) is a clinical diagnosis.

Dr. Nelson noted that PVS and the so-called minimally conscious state are clinical diagnoses and not pathologic ones. However, at the press conference following the release of the autopsy report Dr. Thogmartin said that the autopsy findings were “‘consistent’ with earlier medical findings that she was in a persistent vegetative state” and that the brain damage that put her in that state was “irreversible”.

An MRI of the head was not needed and was potentially dangerous.

Dr. Nelson stated that the reason why an MRI of Mrs. Schiavo’s head was not done was because of she had had a thalamic stimulator implanted in her brain (it was hoped that this experimental treatment would help increase her level of consciousness -it failed). MRIs can cause the metal in the electrodes of implanted stimulators to heat up and burn the surrounding tissue. In addition, an MRI would not have shown anything significantly different than the CAT scan findings and would not have changed her diagnosis or prognosis. The autopsy findings clearly bear this out.

The cause of Mrs. Schiavo’s cardiopulmonary arrest in 1990 remains a mystery.

Mrs. Schiavo collapsed in the early morning hours of February 25th 1990. Her cardiac rhythm on monitor was ventricular fibrillation and she was cardiverted (shocked) seven times and received 30 minutes of CPR. The total known down time was about one hour. What caused this? In his investigation Dr. Thogmartin notes that initial examination following her cardiac arrest in 1990 did not find any evidence of strangulation or other trauma (such as you might expect of a victim trying to fight off an attacker). Radiographic evaluation at that time did not find evidence for trauma (i.e. a broken or strangulated neck). A toxicology study in 1990 did not find evidence for intoxication or poisoning. Her blood sugar level was normal.

So what caused sudden cardiac death in a previously healthy young woman? Autopsy results of the heart were normal indicating that she did not suffer a heart attack. A genetic study ruled out congenital Long QT Syndrome, which can cause cardiac arrhythmias. Commotio Cordis can’t be ruled out but this is extremely rare and is essentially impossible to intentionally induce without evidence of chest trauma.

Mrs. Schiavo’s potassium level shortly after arrival in the ER was a dangerously low 2.0 mmol/L (normal 3.5-5.0). Potassium at this level can lead to potentially fatal cardiac arrhythmias such as the one Mrs. Schiavo was found to be in at the time of EMS arrival at her home. However, Dr. Thogmartin makes it very clear that her blood sample was taken only after she was given several medications and IV fluids by EMS that could easily cause an erroneous potassium level. Even though bulimia was suspected as a cause of the low potassium levels in Mrs. Schiavo there was no evidence that Terri Schiavo was a bulimic! In addition, the fact that her potassium levels were easily corrected in the ER with IV potassium supplementation indicates that this level was acute and caused by the arrest and medications rather than a chronically low level caused by severe bulimia.

[On a side note; Despite the fact that there was no testimony nor evidence that Mrs. Schiavo was a bulimic, the fact that she had no other known pre-existing medical problems that would have decreased her potassium levels, and the fact that the medications and fluids given to her during her cardiac arrest should be considered to be the cause of her low potassium until proven otherwise appeared to be no problem for husband Michael Schiavo who won the lawsuits he brought against Terri’s physicians for not closely monitoring her potassium levels prior to her cardiac arrest. This underscores the fact that medical malpractice lawsuits need not be subjected to the burden of proof or reasonable doubt to be won by the plaintiff.]

Did Terri have multiple broken bones in 1991?

In March 1991, over a year following her cardiac arrest, Mrs. Schiavo developed redness and swelling in her knees during rehabilitation. X-rays did NOT show any fractures and so her physicians ordered a nuclear medicine bone scan to look for evidence of heterotopic ossification (HO). This condition is common in spinal cord and brain injury patients and involves the formation of bone in areas of soft tissue. This can cause pain and swelling and eventual decreased mobility of the involved joint and a bone scan is the test of choice for detecting early HO so that it can be treated. The scan results showed multiple “abnormal areas” in her ribs, hips, knees, and ankles.

Much has been made of the bone scan report and the fact that the radiologist stated that the patient had a “history of trauma” and the “presumption” that the abnormal areas “relate to previous trauma.” However, this is pure speculation on the part of the radiologist. The problem is that bone scans are sensitive but not very specific. That means these scans are good at detecting abnormal areas but not very good at telling us what exactly they are. The radiologist does note this in the report by stating that the abnormal areas could also be caused by cancer, infection, or infarcts.

When a radiologist reads a film usually the only history they have of the patient is the sex, age, and a single word or blurb about the patient’s history or why the attending physician ordered the test. Often this brief history is filled out on the requisition form not by the physician or even the nurse but by the unit secretary! An entirely plausible and very likely scenario was that her doctors ordered the x-rays to rule out trauma or fracture as a result of her rehab. When the bone scan was ordered someone likely used the same “history” of rule out trauma and this became “history of trauma” in the radiology report. Skeptical? In my practice it happens all the time when I read the radiology reports and I just ignore it. When a radiologist is uncertain about the possible cause of an abnormality he/she often refers to the history to give a differential diagnosis. If the history had been “fever and swelling” the same radiologist would have said the likely diagnosis was infection or other inflammatory process. Nowhere else in Mrs. Schiavo’s medical records is a history of “trauma” given.

The radiographic testing in 1991 did detect a small fracture in the L1 vertebral body of her lumbar spine. Such a fracture is inconsistent with trauma from an assault and is very consistent with advanced osteoporosis (softening of the bones). Osteoporosis is very common in paralyzed patients and can occur as early as a year following the injury. Mrs. Schiavo was diagnosed with osteoporosis in 1991 and this was confirmed at autopsy. Vertebral body fractures are common in severe osteoporosis and can happen with only normal amounts of activity such as rehab.

At autopsy no evidence was found of old or new fractures aside from the spinal fracture as noted above. In fact, despite multiple radiographic evaluations in 1990, 1991, and at autopsy no evidence of other fractures was identified. The web site that published Mrs. Schiavo’s bone scan report claimed that the “bone scan revealed that Terri had a broken pelvis, broken femur, broken ribs, broken knees and broken ankles!” But bone scans are not intended to detect fractures and all the rest of the evidence is to the contrary. Another Schiavo myth bites the dust.

Mrs. Schiavo could not safely take food or fluids by mouth.

After reviewing the autopsy results and the medical records Dr. Thogmartin states that “oral feedings in qualities necessary to sustain life would have certainly resulted in aspiration.” The later half of the swallowing mechanism is automatically controlled but the initiation of swallowing and the mastication process (including the gradual movement of food towards the rear of the mouth in preparation for swallowing) are under conscious control. Since she was not capable of consciousness it was very dangerous to put food into her mouth and expect her to safely swallow it 100% of the time.

At autopsy Mrs. Schiavo’s neck muscles were noted to be atrophied (shrunken) from nonuse. In pictures and video of Mrs. Schiavo while in the nursing home you notice that her head always appears to be kind of cocked backwards if not propped up by a pillow. This is because of a lack of muscle tone to the support muscles in the neck. These muscle are normally under conscious control and without their support it makes swallowing even more difficult. Try it for yourself. Let your neck go limp so that your head hangs off the back of your neck and try and swallow something. Be careful!

Multiple swallowing studies and evaluations by speech therapists were performed on Mrs. Schiavo in the years after 1990 and she failed all of them. Without her feeding tube Terri would almost certainly have aspirated on food or fluids and either choked to death or succumb to an aspiration pneumonia. Either that or as Dr. Thogmartin stated, she would not have taken in enough to properly nourish or hydrate herself.

Terri Schiavo was not euthanized.

Despite media claims, Mrs. Schiavo was not given a morphine infusion (drip) in the last few days before her demise. According to medical records she was given two separate doses of 5 mg morphine suppositories (low dose) during this time and nothing else. No detectable morphine was in her blood at the time of death and acetaminophen (Tylenol) levels were nontoxic (opiates are often used as formulations that combine them with Tylenol). Why give a painkiller to a patient who is said to be not capable of consciousness? It is common practice in hospice programs to give patients analgesics even if it is uncertain if they are having any discomfort or not. The rational is to err on the side of treating any potential discomfort. Unofficially it makes the nursing staff feel as if they have done at least something for the dieing patient.

Neither the autopsy nor my discussion here was meant to address the many ethical and moral issues surrounding this case. However, in the months and years leading up to her death the types and amounts of misinformation being bandied about was staggering and all too often given more than enough credence by the press. This autopsy of Terri Schiavo answers many more questions and puts to rest many more myths about this case than the lay press trumpets. It’s not unusual for the media to hype the accusations and then ignore or downplay the truth when it finally surfaces. In this context I wanted to expand on the autopsy results least the myths continue to fester and the truth be ignored about the sad case of Terri Schiavo. May she finally rest in peace.