A federal appeals court rejected a request to reinsert Terri Schiavo's feeding tube today. The tube has now been removed by court order on three occasions: on April 24, 2001; on Oct. 15, 2003; and finally last Friday. The multiple removals and reinsertions have led many Slate readers to wonder: How hard is it to get a tube into someone's stomach?
Not hard at all, thanks to a couple of doctors in Cleveland. In 1979, Jeffrey Ponsky and Michael Gauderer performed the first percutaneous endoscopic gastrostomy; they were able to insert a feeding tube without invasive surgery. Up to that point, feeding tubes were put in on the operating table, and surgeons had to cut holes first in a patient's abdomen and then in the wall of his stomach. Ponsky and Gauderer were able to insert the feeding tube during an office visit, using only local anesthetic.
The endoscope was their secret weapon. First they would slide it into a patient's mouth and down into his stomach, so they could observe the procedure on a video monitor. Then they would inflate the stomach with air, pushing its walls flush up against the inside of the abdomen. This allowed them to poke a needle directly through the abdominal wall and into the stomach and pass a string in through the tiny hole. Using the endoscope as a guide, they would then pull the string up and out of the mouth of the patient.
In the "pull method" of performing a PEG, doctors attach a feeding tube to the string coming out of the patient's mouth and then gently pull it down into the stomach and out through the needle-hole. The hole stretches open, and doctors pull the tube until the end-which has a rubber ridge or a small balloon attached to it-lodges against the inside of the stomach. In the "introducer method," doctors use needles of increasingly large sizes to stretch the hole in the abdomen to the requisite 6 or 8 millimeters and then insert the tube directly through that hole.
These procedures take no more than half an hour. They can be performed on a conscious patient without much pain. Removing the tube is a simple matter of yanking it out with a firm tug-doctors sometimes rub a little bit of topical anesthetic to dull the burning sensation.
What if you have to put the tube back? After a patient spends about a month with a feeding tube, the holes in her abdomen and her stomach begin to fuse together. In this case, a "track" is formed where a feeding tube might be easily reinserted. But the hole can close up pretty quickly: If the federal judge had ordered the reinsertion of Schiavo's tube, doctors might have been able to slide it right back in, or they might have been forced to perform a new PEG.
Tubes wear out every year or so: They become distended, or they spring leaks. Schiavo's tube was probably pulled out and replaced multiple times over the years for reasons that had nothing to do with the legal battles over her care.
When it was time to feed her, caretakers would have attached a syringe to the end of her tube, and pulled out the plunger to see how much fluid came out of her stomach. If there wasn't too much in there already, they'd fill up the syringe with a commercial liquid diet product like Ensure. (A single meal consists of 2 or 3 cans, or you can use regular food that's been liquefied in a blender.) It's also possible that Schiavo received continuous feeding using a 24-hour pumping mechanism, which is used for patients at higher risk for regurgitation and aspiration pneumonia.
Explainer thanks Dr. Jeffrey Ponsky of Case Western Reserve University, Dr. Mark Delegge of the Medical University of South Carolina, and Dr. Alan L. Levin.
Daniel Engber is a writer in New York City.
The Terri Schiavo Roundup Who's paying for her care, how long can she live without food, and what's with the bill written just for her? By Daniel Engber <http://slate.msn.com/id/2115064/> Posted Friday, March 18, 2005, at 5:31 PM PT
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Who's paying for her care?
Schiavo resides at a nonprofit hospice that has assumed part of the cost of her care. Medicaid pays for the rest. According to this AP story, keeping her alive costs about $80,000 per year, and at least $350,000 of the malpractice settlement awarded to Schiavo and her husband in 1992 has been spent on her care. Florida Medicaid normally offers hospice coverage for those with a life expectancy of no more than six months, but Schiavo has received assistance from the state for the last two years.
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Can Congress pass a law that applies only to specific, named individuals?
Yes, it can, provided the law doesn't penalize or punish a single person or group. A piece of legislation that punishes someone without a trial is called a "bill of attainder," which is explicitly forbidden by the Constitution. Schiavo's husband, Michael, could have challenged a federal law that addressed only this particular case by arguing that it penalized him without a trial. He could also have challenged the Senate's proposed law on the grounds that Congress was flouting the separation of powers (by choosing to overturn a specific judicial decision) or that the new law inappropriately granted Schiavo's parents the right to pursue their claims in federal court. -- Yoshie
* Critical Montages: <http://montages.blogspot.com/> * Greens for Nader: <http://greensfornader.net/> * Bring Them Home Now! <http://www.bringthemhomenow.org/> * OSU-GESO: <http://www.osu-geso.org/> * Calendars of Events in Columbus: <http://sif.org.ohio-state.edu/calendar.html>, <http://www.freepress.org/calendar.php>, & <http://www.cpanews.org/> * Student International Forum: <http://sif.org.ohio-state.edu/> * Committee for Justice in Palestine: <http://www.osudivest.org/> * Al-Awda-Ohio: <http://groups.yahoo.com/group/Al-Awda-Ohio> * Solidarity: <http://www.solidarity-us.org/>