Jahi McMath: Follow-up

After I posted my thoughts on the Jahi McMath case a good friend of mine (Hi, K.S!!) e-mailed me this article that posits Jahi can regulate her own body temperature, therefore her hypothalamus is working, and therefore she is not brain dead.

I’m always fascinated in what people think of these issues and instead of just waving things to the side as nonsense, I try to look at things in a logical sense to see if they have merit. I think all people on BOTH sides need to do this.

Now, it is an interesting point that if she can do this– is part of her brain functioning?

The first thing to note is the post is authored by Dr. Byrne whose bio states is a certified neonatologist and pediatrician. I mean, to be honest, his bio is impressive. It seems he should be quite knowledgeable in this area.

The first issue I have with his article as that the medical information he has is not sourced. So, how did he get this information? He doesn’t state in his own piece that he examined the child though this article states he did. But if you read through Dr. Byrne’s piece– it seems as though he has collected facts from elsewhere. I mean, why not say, “I examined Jahi and these were my findings.”

At one point, the doctor states:

“The ‘poor care’ I am referring to here is the prolonged starvation; the protracted and unnecessarily repeated apnea testing conducted in a potentially deleterious manner; the deprivation of needed thyroid medication; refusing to treat an adrenal gland problem that arose; et cetera.”

From the hospital stand-point, they were waiting for her family to come to terms with the brain death issue– which is likely why they weren’t feeding her. My guess is they were providing IV fluids to keep her hydrated. The apnea test he refers to is a test for brain death and he doesn’t expand on what he thinks was deleterious. The deprivation of thyroid medication actually supports the theory of brain death because her brain was not signaling to produce these hormones– and same with the adrenal gland issue.  

The only other instance I found that mentions her self-regulation of body temperature is this article where her attorney, Christopher Dolan, states this. Well, one, he’s not exactly unbiased. And two, I’m always wary of medical information coming from a non-medical person. BEWARE. I mean, don’t come to me for advice if you’re in jail. What makes me more suspicious is that Christopher Dolan, according to this article, is trying to change state law from using brain death as legal death. He sates it should always be the family’s decision to terminate life support— not the state’s.

This is my personal opinion but the more he keeps this case in the forefront– the more he is paid. I may be cynical but he has reasons other than family advocacy to keep this case going ($$$ and notoriety to name a few.) I pray he is doing this for the right reason.

This is just a big can of worms. Again, I am pro-life. I believe in the value of life but there does come a point that because we can doesn’t mean we should and, for me, prolonging a death is just that.

What about you? What should be considered legal death: the heart stopping or loss of brain function? Who should decide to withdraw care when there is no hope of recovery?

The Jahi McMath Case

My very first nursing job was working in an adult ICU. This was over twenty years ago. Even then, there was discussion of futile care and the withdraw of medical support in cases where further medical intervention would not constitute recovery for the patient.

The Jahi McMath case is an interesting one. In case you’re unfamiliar with the story, she is a 13 y/o girl who suffered bleeding after a tonsillectomy (and removal of other things), arrested and suffered irreversible brain death after her cardiac arrest. These have been widely reported. One of the reasons I had Dr. Mabry post about tonsillectomies is that bleeding is a known (though low) risk of the procedure due to the location of the tonsils by a major artery. Even though the risk is low– it can and does happen. I’ve cared for post-tonsillectomy patients that did require blood transfusion after surgery.

Though this case is tragic and I grieve for the family– it also doesn’t necessarily mean the hospital did something wrong though one blogger states, “Children’s Hospital faces serious malpractice questions about its care of Jahi.” Let’s let the courts iron that issue out. I know from personal experience that a patient’s death in a hospital does not automatically mean malpractice occurred. However, I don’t think this is a commonly held public opinion- particularly when a child has died.

What’s interesting about this case is what has transpired after she was declared brain dead. Brain death is considered legal death– even above cardiac death because we resuscitate people from cardiac arrest all the time. In fact, in his book Proof of Heaven, neurosurgeon Eben Alexander discusses this very difference.

How do we know a patient is brain dead? I did a three-part series on this very issue that you can read here, here and here. These tests were done on Jahi and it was determined by multiple medical experts that she’d suffered whole brain death– so not even her brainstem had bloodflow. Whole brain death is considered legal death. It cannot be reversed.

Think of what the brain controls— everything. It is the computer hard drive of your body. If it has died– it is no longer signaling the production of hormones that control vital body functions. If the brain isn’t doing this– then we as medical providers have to administer medications that will do this. Because of this, the whole body begins to decompose and the heart will eventually stop beating.

Because brain death has occurred– the care provided to her is futile– because she has no hope of recovery. What comes in to play is who pays for her medical bills because the family insisted she be transferred to another medical facility due to the fact the hospital refused to provide further medical care. The coroner has issued a death certificate. There are news reports that after transfer from the hospital her body is in a state of decline

Likely, the family is going to be responsible for the medical bills after she was legally declared dead. This will easily add up to hundreds of thousands of dollars. So, what is fair? To burden this family with medical bills when their daughter will not recover from this tragedy?

There has been criticism of the hospital. One such article outlines that hospital staff began to use terms like “the body”. Though it may seem cruel, I know exactly why they did this.

It was in hopes of trying to get the family to accept that Jahi was no longer with her body. That her spirit had gone on so they could discontinue the very expensive medical care keeping her body alive.

I’m a pro-life girl but what I know from 20+ years in nursing is that whole brain death (which is different from living in a vegetative state where there is still brainstem function) is death and the care being provided for Jahi is sadly not going to bring about any sort of recovery.  Personally, I think it is giving false hope and a large medical expense to boot.

I am continuing to pray for this family.

What do you think? Should hospitals be required to continue to provide care when a patient has been declared brain dead by multiple medical experts? Who should pay those bills if the family cannot pay if it’s the family’s decision to continue medical care?

Strangulation: What Really Kills the Victim 1/3

I got a message from a new blog reader with this comment:

Finding this blog is so timely for me, as my protagonist witnesses a strangulation in the first scene of my WIP, and I haven’t been able to find out the precise observable symptoms.  I wanted to ask if you’d done a posting on strangulation.  I’ve looked back a bit in the blog archives, but haven’t seen that topic yet.

Well, let’s just fix that for Colleen.

I’m sure many of you, particularly if you’re an avid crime show TV watcher, have seen the scene with the medical examiner and the victim splayed open on the table talking about damage to the “hyoid” bone. Though this is true, damage to this bone or the trachea itself is not what ultimately kills a victim who is strangled to death, though it can complicate their care if they live.

For instance, there have been instances of individuals with tracheotomies hanging themselves and the ligatures were above the level of the trach– which means the person would still be able to breathe.

So the following theories are proposed as explanations for the cause of death related to strangling.

Venous obstruction, leading to cerebral stagnation, hypoxia, and unconsciousness, which, in turn, produces loss of muscle tone and final arterial and airway obstruction.

Arterial spasm due to carotid pressure, leading to low cerebral blood flow and collapse.

Vagal collapse, caused by pressure to the carotid sinuses and increased parasympathetic tone.

Which is a lot of scientific language to say “death ultimately occurs from cerebral hypoxia and ischemic neuronal death“.

Which means– when a person is strangled, they die because their brain is no longer getting blood flow from the carotid arteries, which leads to brain cells dying from lack of oxygen.
As you can see from this photo, the major blood vessels that drain blood from the brain but also, more importantly, feed it with oxygen– are in very close proximety to the trachea or windpipe.

It is the vital oxygen these vessels carry to the brain that upon slowing or stopping– is the biggest problem for the victim.

Next post we’ll discuss some strangulation facts. Third part of this series will include treatment of the strangulation victim.

Source:  http://emedicine.medscape.com/article/826704-overview

Other Resources:

Wisconsin Medical Journal: Strangulation Injuries http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/102/3/41.pdf

Emergency Medicine Reports: Strangulation Injuries. http://www.ahcmedia.com/public/samples/emr.pdf:

How to Improve Your Investigation and Prosecution of Strangulation Cases. http://www.ncdsv.org/images/strangulation_article.pdf:

Determining Brain Death: 3/3

Last post, we talked about the use of apnea testing to determine brain death after the patient meets certain criteria.

There is one additional test that may be done to determine brain death and that is a brain perfusion scan.

This procedure is done in radiology which can make it very difficult. Imagine taking a ventilated patient through the halls of the hospital along with several IV pumps giving medication that are keeping the patient alive. That in itself is not a fun excursion.

Once the patient is in radiology, they are given an injection of a radioisotope—something that will trace where the blood is flowing. After the injection, photos are taken of the patient’s brain. If there is no blood flow to the brain, and this must include the brain stem as well, then the patient is said to have “brain death” and is clinically dead at that point.
This You Tube video provides a very good explanation of these concepts.

After brain death is determined, the patient is not immediately withdrawn from life support but a conversation will ensue with the family that the patient has died and they will be encouraged to discontinue life support.

Generally, families are given a lot of time to come to terms with this decision. Anywhere from 1-3 days is reasonable. They may want to fly in additional family members to be present when life support is discontinued. I’ve never been part of a situation where, when the finding of brain death were fully explained, where families chose not to discontinue support.

This is not to say that the patient may not proceed to circulatory death despite receiving life support. Once the brain has died, it does become very difficult to keep the body functioning.

Does this change your mind about how brain death is determined?

Determining Brain Death: 2/3

I’m continuing with a series on how brain death is determined. All hospitals likely have a policy in place with strict guidelines on how brain death is determined. Check last post for the beginning stages.

Now, we’ll move onto actual testing.

Can the patient breathe on their own? This is a relatively simple test. It’s called apnea testing. The ventilator is turned off and we see what the patient will do. Naturally, when we stop breathing, carbon dioxide will build up in the blood stream. Your body has receptors that monitor the level of CO2 and it will initiate a breath when the levels rise.

Here is the procedure for performing an apnea test.

1. The patient will be on an ECG and pulse ox monitor.

2. Give the patient 100% oxygen for five minutes.

3. After five minutes, disconnect the patient from the vent, but give oxygen via T-piece. The breathing tube will still be in place. At this point, the patient is off the vent and no longer being assisted but will have needed oxygen if they do initiate a breath.

4. Watch the patient for breathing. If any attempt is made to breathe, it is inconsistent with brain death and the test is stopped and the patient is placed back on the ventilator.

5. If the patient has any cardiac arrhythmias, low blood pressure or oxygen level that falls to less than 80% (normal level is 90-100%) then the test is discontinued. These finding will lead more to a conclusion that brain death has occurred.

6. If the carbon dioxide level increases above 60 (normal level is 35-45)—the apnea test is consistent with brain death. The brain is very sensitive to rising levels of carbon dioxide and the absence of a response is consistent with brain death.
Next post, we’ll talk about brain perfusion studies.

Determining Brain Death: 1/3

Several months ago, I skewered a Hallmark movie for its unrealistic portrayal of discontinuing life support. In light of that, I thought I’d do a special series on determining brain death.

How do medical personnel determine a patient has suffered brain death?

Brain death means that your brain as an organ has died. It is no longer receiving blood flow. Without blood flow, no oxygen is being delivered. Without oxygen, an organ dies. Your brain is your body’s main control. If it has died, you have died.

If you have a character that is brain dead, they should be on life support. Again, if the brain isn’t working, it’s not telling your lungs to inhale. However, we can do this medically with a ventilator. This is why families sometimes have trouble understanding brain death means ultimate death. If we provide oxygen to the lungs, the heart will continue to beat and bodily functions can be maintained for a limited amount of time. A family sees the rise and fall of the patient’s chest and assume the patient is initiating those breaths when in fact it is the machine doing all the work.

There are several ways to determine brain death. Some are not as precise as others. I’ll try to cover least precise to most precise.

Before testing, there is generally an observation period. My hospital uses the following guidelines:

Less than 7 days: Not applicable
Age 7 days-2 months: 2 exams 48 hours apart
Age 2-12 months: 2 exams 24 hours apart
Over 12 months: 2 exams 12 hours apart
Adults (18 years and older): 2 exams 6-12 hours apart.

Also, prior to the exam to determine brain death, the patient must also meet the following criteria:

1. Absence of a reversible condition. The cause of the coma must be documented.

2. Absence of hypothermia. The patient must have normal body temperature.

3. Absence of hypotension. The patient must have normal blood pressure.

4. Absence of drugs or toxins in significant amounts as to interfere with the diagnosis of brain death.

5. Absence of a metabolic cause of the coma.

6. Normal levels of carbon dioxide.

Once these are met, the patient should be observed for the following:

1. No cranial nerve reflexes. Here is an extensive list of what those are: http://www.clinicalexam.com/pda/n_cranial_nerves_exam.htm

2. Flaccid tone in all extremities.

3. No response to deep pain.

Once these are met, the patient proceeds to apnea testing. That’s where we’ll pick up next post.