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Visit www.freekenmarsh.com for further information I, Thomas A. Schweller, M.D., do declare as follows: 1. I am not a party in this action. I am a physician licensed in California. I am competent to testify as a witness in San Diego Superior Court Case HC 13707, in re Kenneth Marsh, as set forth herein. I am submitting this Declaration in Support of the Traverse. 2. I have reviewed the Declarations of Dr. Roger Williams, Dr. Kenneth Ott and Dr. David Chadwick in Support of Return to Petition for Writ of Habeas Corpus. 3. It was initially thought that Mannitol as a treatment for intracranial pressure was without potential complications, but as has been noted in the current guidelines for the use of Mannitol, it is not a benign agent. It is now understood that it is of primary importance that cerebral perfusion pressure be maintained despite extremely high intracranial pressure. Various therapies including Mannitol therapy and hyperventilation that had been used in emergency conditions we now understand may actually worsen the patient’s intracranial pressure and contribute to cell death if there is inadequate cerebral perfusion. It is for these reasons that it is recommended that the emergency conditions for use of Mannitol be such that there are signs of cerebral herniation or if the CT scan reveals a significant midline shift. Adequate volume status must be present before the Mannitol infusion has occurred in order to avoid hypotension, renal impairment, and systemic hypoperfusion. 4. According to recent guidelines for treatment of intracranial pressure that are defined in an article in Neurosurgery Focus, Volume 15 by Drs. Jeffrey Young, et. al, maintaining adequate cerebral perfusion pressure first provides the important nutrition for the brain that allows the cells to continue to survive. When one observes the course of care following the Mannitol infusion by Dr. Johnson, there was a sudden and dramatic deterioration in Phillip Buell’s medical condition within minutes after the infusion, indicating that this is due to a potential complication of the Mannitol infusion. If the patient’s condition was associated with further impairment of cerebral perfusion pressure associated with hypotension, there is a significant aggravation of the cerebral edema leading to a further and rapid increase in intracranial pressure with subsequent irreversible brain death. 5. Dr. David Chadwick has inadequately addressed treatment issues concerning the use of Mannitol. His statements suggest that he does not understand the physiology of cerebral edema and how cerebral perfusion pressure can play a significant role in brain function deterioration. My criticism of Dr. Johnson is not that he was acting recklessly but that he was inadvertently contributing to the deterioration of Phillip BuelI’s condition. 6. Essentially Dr. Chadwick’s area of interest has been child abuse, not neurology, which is the area that I have spent the past 29 years in study and practice. It is an over simplification of Mannitol use as an osmotic diuretic to say it sucks water into the circulation and excretes it into the kidney and represents a misinterpretation of more complex interactions that occur in the brain. The article that is provided by the University of Virginia Trauma Center in Neurosurgery Focus addresses the need to have careful monitoring of the intracranial pressure and the cerebral perfusion pressure to have the most optimal outcome in 1 conditions of patients who have Glasgow coma score lower than 9. According to Dr. Chadwick, the cessation of breathing in a head injured child requires some brain swelling and brain swelling is never instantaneous. I believe this also oversimplifies what is known about traumatic intracranial swelling and bleeding and misrepresents the facts. 7. In cranial cerebral trauma, the mechanical force of an impact produces a swelling of the brain either bilaterally or unilaterally. Swelling is not mechanically induced but is always the result of a disorder of circulation. Bilateral swelling is usually the result of an acute fall in cardiac output and is common in drowning or near drowning victims. Unilateral brain swelling is due to a local deficit in arterial supply or venous drainage or both. If it occurs in a head trauma, it is secondary to a traumatic alteration such as a fracture of the skull. The cause of swelling is due to alterations in cellular perfusion. This may be the result of an expanding mass lesion or may be due to aggravation of impaired perfusion by a systemic impairment of blood perfusion such as a reduction in blood pressure. 8. As I have stated before, there is association with the impairment of auto regulation of the brain and failure of the brain to adequately shunt necessary nutritional components to the area of injury. There has been a suggestion that the patient had an ineffective coagulation. 9. I would certainly defer to the hematologist to review the patient’s potential history of bleeding and how this might relate to a number of clinical conditions including chronic infectious disorders such as Epstein-Barr virus, and what appropriate diagnostic studies would be necessary to determine the presence of an underlying impairment in coagulation. It is my understanding that clotting times including PT and PTT may be inadequate to diagnose disorders of coagulation. Indeed, if there was an underlying disorder of coagulation, it certainly would play a role in the onset of intracranial bleeding as well as the failure of the intracranial bleeding to be controlled, leading to the presence of a mass lesion that may disrupt the auto regulation of regional circulation in the brain and be a potential source for problems with cerebral protrusion. This cascading series of events can then if unchecked proceed to significant intracranial pressure, impaired perfusion, cell death, and the eventual demise of the patient. 10. The routine use of Mannitol in this case was not beneficial and most likely deleterious to the survival of Phillip Buell. I continue to hold to a reasonable degree of medical certainty that the management of the intracranial pressure with Mannitol by the resident, Dr. Johnston, may have inadvertently contributed to the death of Phillip Buell. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed at ______________, California, on May ____, 2004 _____________________________________ By: THOMAS A. SCHWELLER, M.D. 2
"I Thomas Schweller do declare as follows am not"