Dr Hammesfahr's Recommendations from September 12, 2002

Impression:

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
results.

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
abnormalities.

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
encephalopathic.

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
recommendations.

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.