STATE OF ILLINOIS
COUNTY OF COOK
BEFORE ME the undersigned authority personally appeared Sara Green Mele, MS, CCC-SLP, who being first duly sworn, deposes and says:
1. My name is Sara Green Mele, and I have been engaged in the continuous private practice of speech-language pathology since 1996, and have served on the staff of the Rehabilitation Institute of Chicago from 1996 to 1999 and from 2001 to the present. Prior to that I practiced cognitive therapy at Baylor Institute for Rehabilitation in Dallas Texas. In both settings I worked with the broad range of brain injured populations. The Rehabilitation Institute of Chicago is affiliated with Northwestern University Feinberg School of Medicine, and is recognized in the United States rehabilitation community as the top facility in the United States. The Baylor Institute for Rehabilitation is affiliated with Baylor University Medical Center, and is recognized in the United States rehabilitation community as one of the top ten facilities in the United States. I am a clinical lecturer at Northwestern University Feinberg School of Medicine, and lecture for continuing medical education credits (CME) through the Rehabilitation Institute’s continuing education program as well as at national conferences. In April of this year I participated in the presention of a two-day head injury course entitled Interdisciplinary Rehabilitation Management in Traumatic Brain Injury to over two hundred health professionals in Tampa, Florida. My full curriculum vitae is attached.
2. In my practice, I treat many patients who have had diffuse brain injury, both anoxic and hypoxic, and I am familiar with states of impairment known as coma, coma-like, minimally conscious and persistent vegetative state. I regularly participate in the evaluation and cognitive/linguistic diagnosis of patients whose differential diagnosis include such conditions. In connection with my practice of speech-language pathology, I also evaluate patients, and train others in the evaluation of patients for swallowing function. During my career as a speech-language pathologist, I have personally treated approximately thirty patients similar to Terri Schiavo.
3. In evaluating patients for rehabilitation, the Rehabilitation Institute of Chicago does not track the diagnosis of patients by their referring caregivers, but rather evaluates them for itself because the misdiagnosis rate is so high.
4. While I have not physically examined Terri Schiavo, I have looked at her medical records at MediPlex covering the period from January to July of 1991, including physical therapy, speech and language therapy, and occupational therapy. Also, I have studied the video clips presented at the October 2002 Medical Evidentiary Hearing, along with audio recordings of Terri Schiavo interacting with her father in November of 2002. The observations that follow are all within the parameters of speech-language pathology, and are similar to the observations that I am called upon to make regularly in the course of treating patients as a speech-language pathologist. All conclusions are based on standards used in the speech-pathology profession in the treatment of patients such as Theresa Schiavo.
5. Based on my experience and my observations, Mrs. Schiavo is clearly aware of her environment and interacts with it, albeit inconsistently. She is able to comprehend spoken language, and can, at least inconsistently, follow simple one-step commands. This is documented both in the MediPlex records and in the following behaviors noted in the following video segments:
C 01 (Examination of Dr. Cranford on July 9, 2002) – Terri appears to respond to her mother’s voice, although there is not much to differentiate between a generalized and localized response in this clip.
C 02 (same exam as above) – Terri appears to track a balloon. This is difficult to verify with complete certainty for two reasons. First, many of the camera shots are too “tight” on Terri’s face to be certain of the location of the balloon. Second, Dr. Cranford presents a great deal of information to Mrs. Schiavo very quickly. Even moderately brain-damaged patients have severe difficulty responding that quickly to commands. Such patients display a significant delay in processing, which Dr. Cranford does not seem to allow for. In the same clip, Terri appears to move her head toward Dr. Cranford’s voice, despite limited motor ability. Clearly, once her head is positioned, she appears to move her gaze toward a voice.
M 01 (Examination of Dr. Maxfield 9/4/02) – Although it is difficult to hear on the video, Terri appears to respond to the sound of her mother’s voice on a cell phone held to her ear. Additionally, Terri appears to move her head as well as her eyes in tracking a balloon.
M 03 (same exam as above) – Terri appears to have a purposeful laugh in response to the story from her childhood as related by her father in the video. This would appear to be an appropriate emotional reaction to latent memory.
H 01 (Examination of Dr. Hammesfahr 9/3/02) – Although Terri seems to fixate on the source of the music, there is little response until she hears her mother’s voice, at which time she smiles and moans purposefully.
H 04 (Same exam as above) – A loosening of Terri’s muscular tone appears to be a result of a soothing effect on Terri of her father’s voice. This could indicate recognition of the voice as her father’s, and an appropriate emotional response. Later in this clip, Terri’s behavior of looking first at Dr. Hammesfahr and then at her mother appears to be responsive to the request that she do so. When she opens and closes her eyes, she clearly appears to be following the commands of Dr. Hammesfahr to do so, although she cannot engage in this behavior consistently .
H 09 (Same Exam as above) – Terri appears to keep her eyes closed on command, but it would be helpful to assess in other venues, such as relative to her neck position and visual stimulii.
H 11 (Same exam as above) – Terri appears to track a balloon but appears to be challenged by motor deficiency to move past midline. This could be secondary to an oculomotor dysfunction.
6. Terri is clearly vocalizing. She does not appear to vocalize at random during these examinations. Her vocalizations are generally purposeful and usually in response to specific environmental stimuli, most particularly family members.
7. Over the years since her injury, Terri has infrequently spoken audible words. The records of MediPlex reflect the fact that she has said “stop” in apparent response to a medical procedure being done to her. The family reports that they have heard Terri say “ugh-hugh,” ugh-ugh,” and “No” on a few occasions.
8. Since the time of the medical evidentiary hearing in October of 2002, family members have made a concerted effort to encourage Terri to vocalize, and have attempted, as laypersons, to coach her in basic speech.
Most prominently, they have coached Terri in trying to say “yea”, as a way in which she may answer “yes” to questions. The family has an audiotape recorded in November of 2002 in which Terri vocalizes in apparent response to her father. Her vocalizations include repeated sounds which approximate the word “yeah,” in the same manner in which she was coached. Prior to that time, no member of her family recalls Terri being able to approximate the “yeah” sound. I cannot conclude that Terri can accurately answer a yes/no question without the therapy suggested below.
9. The apparent addition of an approximation of the word “yeah” to Terri’s repertoire of responses is clearly a learned behavior. Her use of this sound on the audiotape is apparently in response to her father. It is reasonable to conclude that Terri is trying, despite her motor deficits, to speak as best she can. Terri is clearly a suitable candidate for speech-language therapy.
10. It is not my opinion that Mrs. Schiavo is in a coma or in a persistent vegetative state. In my opinion, she exhibits purposeful though inconsistent reactions to her environment, particularly her family. Her eye movements, easily observed on the videotape, are particularly suggestive that she recognized family members and responded. She also appeared to have sufficient sustained attention to track a balloon. It is not my opinion that these behaviors are merely reflexive. The entire range of behaviors listed above, and each and every one of them, are inconsistent with a diagnosis of persistent vegetative state.
11. Even without the benefit of any medical treatment which successfully improves this patient’s organic medical condition or cognitive abilities, in my opinion Terri would benefit from speech-language therapy, physical therapy and occupational/recreational therapy. Her ability to interact with her environment and her ability to communicate can be enhanced. Her quality of life can be significantly enhanced.
12. I would specifically recommend that Terri be given access to a system known as an environmental control system. We use such systems at the Rehabilitation Institute of Chicago to permit patients such as Terri to exercise control over their environment, such as to turn their television or radio on or off, change channels, and to control volume. Such environmental controls may also permit Terri to control room lighting. In my opinion, Terri could make use of such a system if it were made available and she received training in its use. I would further recommend that a yes/no system be implemented, and that Terri be trained in its use from the beginning of her rehabilitation regimen. Such a system could permit Terri to more effectively communicate.
13. It is apparent that Terri has sufficient swallowing ability to handle her own secretions, therefore it would be my recommendation that she receive a modified barium swallow study to assess swallow function for intake trials of thin and thick liquids and pureed consistencies. It has been my experience that patients similar to Terri have been able to accomplish food intake. This would permit Terri greater interaction with her family and in social situations through the enjoyment of mealtimes. I have worked with numerous disabled patients who have expressed to me that being able to eat would make the difference between their desiring to live or die.
14. It is my judgement based on my training and clinical experience working with patients similar to Terri that she would, within a reasonable degree of clinical probability, be able to improve her ability to interact with her environment, communicate with others, and control her environment if she were given appropriate therapy and training as outlined above. These recommendations, in my opinion, would greatly improve Terri’s quality of life.
FURTHER AFFIANT SAYETH NAUGHT.
Sara Green Mele, MS, CCC-SLP