Joan Didion distorts the record on Terri Schiavo in the June 9th issue of the New York Review of Books.
Didion disingenuously implies that there is little evidence that Schiavo suffered from bulimia:
However comforting it may have been to believe this, the suggestion (no diagnosis exists) of an "eating disorder" appears to have been entirely assumptive, based on no evidence beyond the unexceptional facts that she had some years before gained weight, gone on a diet, and lost the weight. We do know that on Theresa Schiavo's initial testing the level of serum potassium was 2.0, not only well below the "normal" range, which is 3.5 to 5.0, but also below the level, 3.0, at which cardiac effects may be expected. Bulimia, or any vomiting at all, can cause potassium deficiency. Since other common causes include kidney disorders, colon polyps, and the ingestion of diuretics, laxatives, asthma medications, certain penicillins, or even large amounts of licorice, the lowered serum potassium level on its own does not tell us what led to the deficiency that is believed to have triggered the cardiac arrest.
"What was finally diagnosed as the reason for what happened to her?" Larry King asked Michael Schiavo on CNN on March 21.
"They're speculating that she had bulimia," Michael Schiavo said. (Who "they" might be was left unexplored.)
"Did you have any knowledge of that?" Larry King asked.
"No, I did not," Michael Schiavo said.
If the NYRB has any fact-checking standards at all, Joan Didion must be disingenuous when she says that "no diagnosis exists" of Schiavo's bulimia. Of course no diagnosis exists. That's how Michael Schiavo was able to successfully sue Terri's doctors for failing to diagnose her bulimia, despite overwhelming evidence that she was suffering from a severe eating disorder:
During the malpractice case, at least one of Schiavo's friends testified they knew she was bulimic because after meals out, she always immediately excused herself to go to the bathroom. Her husband also knew she had peculiar eating patterns but did not realize they were dangerous, Fox said.
Medical records from the hospital where Schiavo was treated after her collapse note that "she apparently has been trying to keep her weight down with dieting by herself, drinking liquids most of the time during the day and drinking about 10-15 glasses of iced tea."
Fox said that in the months before her collapse, Schiavo went to the doctor because she had stopped menstruating. It was a silent "cry for help," the lawyer said. But the doctor did not take a complete medical history that might have revealed an eating disorder.
The jury put the damages at $6.8 million but reduced the verdict to about $2 million because it felt [Terri] Schiavo was partly at fault for her collapse. [AP/USA Today]
Didion apparently knows about the lawsuit, but distorts the substance of the case:
In 1992 [Schiavo] had pursued (and finally settled, for approximately $1.1 million after fees) a medical negligence suit against the doctors who had supervised Theresa Schiavo's infertility treatment, arguing that they had failed to pick up the potassium imbalance.
Wrong. Michael sued Terri's doctors for failing to pick up on the pattern of symptoms that pointed almost unequivocally to bulimia. Her medical records document several major warning signs including recent history of massive weight loss, excessive concern about eating and weight, amenhorrhea, and, of course, infertility.
Despite what Didion says, Schiavo didn't sue Terri's doctors for failing to detect a potassium imbalance, per se. That would have been unrealistic. There's no reason to believe that Schiavo had a chronic potassium imbalance that would have been detectable at any specific medical checkup. The hypokalemia that ultimately destroyed Terri was probably induced by intense bingeing and purging near the time of her death. Obviously, as a bulimic, Terri might have been hypokalemic on a regular basis. However, electrolyte imbalances are not invariably, or even usually fatal. Of course, if Terri had been found to have been hypokalemic at any of her checkups and her doctors hadn't asked about bulimia, that would have been even more evidence of malpractice. However, I don't know whether any of Schiavo's bloodwork revealed any prior hypokalemic episodes.
Since Schiavo's autopsy results became public, various media reports have stressed that the autopsy showed no proof of an eating disorder. No doubt this statement is accurate, but it is of little probative value. There's no reason to expect that Terri's eating disorder would have been evident upon autopsy, seeing as it had been over 15 years since her last possible bulimic episode.
Didion goes on to claim that it's doubtful that Schiavo suffered a heart attack. This is a semantic game that Schiavo conspiracy-mongers are fond of. Colloquially, we refer to most cardiac arrests as "heart attacks." Medically, the term "heart attack" maps roughly onto the term "myocardial infarction." A myocardial infarction occurs when the blood flow to the heart is interrupted and parts of the heart muscle die from lack of oxygen. Cardiac arrest may ensue if the infarction knocks out enough of the heart muscle. Usually, myocardial infarctions are caused by blood clots and/or narrowing of the arteries. Terri Schiavo's heart stopped, but not because the blood supply to her heart was cut off. We know this because doctors found no evidence of disease in her heart or blood vessels. As Didion notes, she was suffering from severe potassium depletion at the time of her collapse. Potassium deficiency impairs the heart's ability to conduct the electrical impulses that sustain a normal heartbeat. If Didion wants to be a stickler for terminological precision, she might want to describe Terri's collapse as "a cardiac arrest" rather than "a heart attack"--but there are no honest rhetorical points to be scored by this distinction.
The rest of Didion's article is a meandering, pretentious recycling of the conventional wisdom as reflected by mainstream news coverage. In fairness, it must have been written long before the Schiavo autopsy results became public.
Update: Great post on Schiavo's autopsy from Jonathan, an internal medicine resident blogging at J Train, including a link to the full autopsy report.
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