41 Comments

Brain dead is dead. Hasn’t been any to do over this in the medical world for generations. It merely aids in the recognition of what lay person dead already recognizes; that absent blood flow to the brain, the brain is dead. And the brain is where the physical world of personhood lives. All other organs of the body can be removed or rendered functionless and the person measurably remains. But when the brain is gone, then that is it.

Layperson dead: no circulation of blood to the brain evidenced by absent pulse or other means.
Medical dead: no circulation of blood to the brain evidenced more directly by direct measures of blood flow to the brain, plus some direct measures of brain function.

I feel for the parents. I really do. But she’s brain dead.

What they can do now is donate organs. Jahi may be able to save the lives of multiple children and live on through them.

I pray for this family and Jahi.

Sorry guys this is routine. Adding a PPP and a turbinectomy to a tonsillectomy is very common. If the family wants to lay blame a mirror wod be a good place to start. This procedure would have been unnecessary if she weren’t obese. Also she would have been much more likely to be quickly recessitated before brain damage occurred.

Very sad but this has been crazy she is dead nothing will change that

She was being treated surgically for sleep apnia? Was her life being threatened by it?

From the site linked in the post:

“Various surgical procedures may be recommended for very severe cases of obstructive sleep apnea but there is limited evidence for their effectiveness.”

Also from the same site:

“Obstructive sleep apnea can develop in anyone at any age but most often occurs in people who are:

Overweight
Male
Age 40 and older
Smokers”

No information is given about her weight, but female, early teens and (presumably) non-smoker is the opposite of the stated profile.

She does not appear to fit the profile, and there seems to be little evidence supporting the effectiveness of the surgery undertaken. Whatever the result of the surgery, whether good or bad (and in this case it is horrendous), is this a case of “over-doctored”?

Carey,
You are using adult information in a pediatric patient, and further, confusing descriptions of a representative or median patient for validated risk factors.
This child is quite typical for pediatric OSA. Her photos do make her appear quite heavy. Pediatric OSA is a risk for behavioral problems, poor school performance, cognitive development, and at its worst can progress on to congestive cardiac failure.
The good news about pediatric OSA is that much of the harm is reversible with intervention, much more so than for adults, then actually favoring surgical intervention more in the pediatric population.

But no procedures are without risk, and we do see some serious complications from time to time at our hospital. Less so in the past decade as pediatricians are referring kids well before cardiac effects become an issue. You wonder if this was over doctored – depends on what her symptoms were before the procedure. Maybe weight loss would have been all that was needed, but that is a social and family ill, and also a potential result of OSA itself (vicious cycle). While Michelle Obama wants kids to eat more broccoli and exercise daily, we have to deal with obese patients on their terms since the health care system can’t fix that problem for them.

Carey Gage, read the first part of the text you cited: “anyone at any age.” And as to her weight, have you looked at photos of Jahi? She was huge!

To call this procedure a “routine” tonsillectomy shows breathtaking journalistic incompetence. I wonder if the misleading adjective came from the attorney for the parents? The notion of an unforeseeable bolt from the blue makes their rejection of closure sound more reasonable.

I agree with Dr J that this is a routine procedure. Bleeding is the most serious potential complication of these procedures. It happens infrequently and virtually all patients go home the same day. If anything was going wrong in the recovery area, bleeding should have been the first thought.

Unfortunately, most people accept the diagnosis of brain death as something etched in stone. The California Code for determination of death, like virtually all states, states that there has to be loss of all brain function, including the brain stem. As Dr. Robert Truog at Harvard Medical School has written several times in the New England Journal as well as the Journal of Medical Ethics, these patients still have hypothalamic function and many display cortical EEG activity. They do not meet the legal definition of death. Pregnant women who are diagnosed as “brain dead” have been maintained on ventilators, sometimes for months, until their babies are mature enough to be delivered. No dead person could do this. The Presidential commision on the definition of death addressed this contradiction a few years ago, admitting that the exam criteria used to make a diagnosis of brain death do not adequately meet the requirements of the law. Their weak conclusion was that it was still okay to call someone brain dead.

The original diagnosis came out of a meeting at Harvard in the 1960’s when CT and MRI scans weren’t even being used. The original article was published in JAMA. It contains not one reference to any medical or scientific literature. It was siezed upon by the transplant leadership and they haven’t let go. No other aspect of medicine has relied upon supposition from the 1960’s as its standard of practice. Functional diagnostic studies and deep-brain stimulation by researchers such as Adrian Owen and Nicholas Schiff have provided so much information than was available 45 years ago. It has been ignored by the transplant community.

There is no consistency to the diagnosis of brain death nationwide. That was the conclusion of a 2008 study in Neurology, which surveyed the “top” neurology and neurosurgery programs in the country. Some hospitals did not even rule out drug overdose or hypothermia before allowing a diagnosis of brain death. To try to correct for this, the American Academy of Neurology reissued their exam criteria in 2010. In the article, they admitted that there was no evidence that verified their criteria were valid.

Dr. Truog is not the only expert openly criticizing brain death in the literature. Frank Miller and Allen Shewmon are some of the others.

As for transplants, the 5-year survival of kidneys obtained from patients declared “brain dead” is only 50 percent. An article in the New England Journal a few years ago showed that the ridiculous system of distribution of organs has lead to a decrease of two years in life expectancy of transplant recipients. So the medical profession, to which I belong, has been declaring patients dead who aren’t, in order to sort of-not really help other patients.

Chris Dolan isn’t overlawyering. He’s trying to stop a hospital which appears to have not done the best job for a patient from bullying her parents.

What bothers me about the post-op situation is that I read the bleeding was reported to nursing by a grandmother (whom is a “nurse”, from what I read), and was not taken seriously. I do not know if this is accurate information. I was not there. As an R.N., if I had a report of bleeding, I would have addressed it immediately. If I had identified an immediate emergency I would have activated emergency measures.

Is it any more unethical to insert a g-tube and tracheostomy in her, than to turn off the life support against the wishes of her family? Brain dead people have been on ventilators in nursing homes, this is not a new concept.

I agree with Costa K. If trouble began in the PACU, bleeding should have been the first thought. Additionally, it also should have been on the hospital unit. (I have cared for many ENT cases in the PACU…but few in the SCCU).

In re: another commentator’s remark.

Obesity can make intubation more difficult, especially in an emergent situation. However, I am doubtful that obesity itself is what caused the emergent airway compromise.

Costa K. I too work in the medical profession as an RN in ICU. I disagree with some of what you say and question your integrity. I have worked numerous ICU’s across this country as a travel nurse. It has long been against medical standards to declare any hypothermia patient brain dead and as the old adage goes, they are not dead until they are warm and dead. Furthermore I would like to see your evidence that patients were declared brain dead who weren’t simply for organ harvesting. That is a very serious allegation you are making.

To Dr. J.: Your comments are very insensitive. The girl was not that overweight, and you can’t blame the parents for what happened because she (like most americans) are overweight. Did you think maybe the doctors could have refused to do this surgery and insist on weight loss? These parents followed the doctors’ advice and clearly did not understand the risks. Most people think of tonsillectomy as a simple easy procedure. We now know it is not at all!

The problem this family is having, and why they indeed need a lawyer, is that the hospital waited too long to treat the bleeding with urgency until too late.

I’ve seen my share of dead people. For one, they don’t have a heartbeat. Last time I checked that was a brain function. And then there’s that pesky rigor mortis. True, it’s only temporary, but while a body is in rigor, it cannot be successfully mechanically ventilated. The cascading effects of this are apparent in tissue death and decomp. And interestingly, the concept of organ transplant has at last been broached. I personally find it appalling that a renowned pediatric medical center would take such a brutal and uncaring stance toward this tragic case, and in such a public manner. I am tired of hearing their spox talk past what is happening and all the way into the mortuary. After all, what exactly is the rush here?

Joy, the heart is only beating because she is on a ventilator. The heart beats because there is oxygen in the blood.

I too have looked at the case and have to wonder if the bleeding was reported; If not the hospital needs to put better policies in place such as a rapid response system that the staff or family member can activate If needed. I don’t think that a person being obese is a reason they should bleed to death without any apparent intervention such as going back to the OR and cauterizing the bleed. As a parent and as a nurse this case mskes me very aware that no matter how many safeguards may be in place there are still major problems in health care policies that end in tragedy. There is a book out called safe patient’s smart hospitals by Peter Pronovost and his journey that was inspired by a little girl named Josie King and her tragic death caused by poor policies. There is some great information in this book on how to prevent tragic mistakes that cost lives in health care. Let’s not forget that in all this debate over withdrawing life support there is a little girl named Jahi McMath that is loved by her family and they need our support not our criticism. My prayers are with the family and their friends.

The article I read stated she had gone to the ICU post-op and that the procedure was “complicated”. As an SCCU nurse, I did see this practice. This was intended to monitor her more closely.

I also read there were “many container’s” of the patient’s blood in the room, and that she was receiving blood transfusions.

It would help to know a time frame for all of this. Why was she kept in the unit being transfused vs. going to the OR . (Blood is often transfused in the OR). Additionally, unstable and bleeding patients often need to go to the OR to get their issues resolved.

Did the patient’s condition get communicated to the surgeon in an appropriate time frame and did the surgeon address the issues within a proper time frame?

Routine or not, a tonsillectomy is not an appropriate surgery to treat an obesity related symptom (sleep apnea). If any surgical procedure was needed, it would have been a lap band to reduce the child’s weight. It is also routine and, to my knowledge, people don’t bleed out or go into cardiac arrest in the process.

For people wondering what took so long – have you ever seen a carotid artery rupture? I’ve only seen it once in a post carotid endarterectomy patient and it was crazy how much they bled and how fast they bled. We were lucky and they patient had only just rolled into PACU, the doctor and anesthesia were right there and no one had started turning over the OR room yet. It still took seven minutes to get back there. Those were seven of the longest minutes of my life as an RN as I held pressure on that neck and prayed we’d make it back to the OR in time.

Since tonsils and adenoids are on both sides and very near the carotids, how do you figure out which side is the one that ruptured? You can’t put pressure on both (unless you want to strangle someone).

If you’ve ever worked in a CCU or PACU then you know even when the situation is emergent, it still takes time to get to the OR. You need an empty, clean room plus at least one surgeon, anesthesia, nurses, scrub techs etc. ORs are busy places and empty rooms (especially over winter break when people can take time off to heal) are hard to come by. Surgeons are busy doctors and at least where I work, they do multiple procedures each surgery day. After (and sometimes between) they round on post-op/pre0op patients and/or do office hours. If they’re mid procedure when an emergency happens you’re often looking for their on-call partner as your next bet and so on down the line until you find someone available. Same goes for anesthesia. Same goes for other OR staff. Did you know on-call staff have to be within 30 minutes of the hospital when they are on call? They do not necessarily have to be in house (depending on the facility – some places require in-house call for physicians).

The bottom line is it’s not as simple as saying the second she started bleeding they should have rushed her to emergency surgery as if that would have solved everything. I’m sure they did rush, but it’s not an instantaneous process. It takes a minimum of several minutes and sometimes much longer if all the variables do not align. In the meantime you follow emergency procedures and do everything in your power to keep your patient going until you CAN get them to the OR. Sometimes they die. That’s why people have to sign consents before any and all surgical procedures.

It’s not perfect, but its the way it goes.

As a nurse of many years working post op ENT, ER and I know that there may not be an OR readily available. I also have seen many emergent procedures done at the bedside in order to save a life and waiting on an OR suite shouldn’t stand in the way of perventing a young girl from bleeding to death. You know as a healthcare profession we often say oh well that’s the way it is. what if it were your child bleeding to death would you have the same attitude of oh well its busy or would you expect someone to help her insted of turning a blind eye to our failed system thats supposed to protect us? maybe we as healthcare professionals should stand up and say you know it’s not right for a 13 year old child to bleed to death in a hospital because we are too busy to correct the situation. I am very painfully aware of our situation in healthcare and OR space I just don’t buy the excuse that a child has to bleed to death waiting on one. I am sad to see that we as a profession will not stand up and say hey this is a problem how can we fix it insted of sitting there playing the blame game.

The study I quoted in Neurology can be accessed by anyone. I didn’t come up with the survey questions. I agree that hypothermia is supposed to be ruled out prior to a diagnosis of brain death. The people who wrote the article also agree with that. That’s the point. They were surprised and disappointed to discover that some hospitals that they surveyed did not have a protocol to rule out hypothermia. They approached this scientifically, not just from their own personal experience.

The original paper in JAMA from the working committee at Harvard had as its intent a way for physicians to turn off ventilators on patients who were not “waking up.” ICU medicine was still relatively new at the time and no one had thought ahead to determine the best way to treat chronic ventilator patients who showed no obvious signs of awareness. Transplant surgery was also in its infancy(the first successful transplant of a kidney had occurred between identical twins) and there were not a whole lot of willing volunteers or identical twins in need of transplants. When the concept of “brain death” was introduced, this opened up a potential stream of available organs that was not to be ignored. I didn’t exactly understand the question that was being asked, but, yes, sometimes people are declared brain dead just to turn off the ventilator. I have also taken care of patients who were followed by organ collection services in anticipation of their impending “brain death,” only to get better and require actual surgery. Why were they involved before an actual diagnosis?

The hope that researchers such as Dr. Owen and Dr. Schiff bring is that someday brain injuries can all be treated and our understanding of awareness will become so accurate that the current situation won’t ever happen. I too find it very curious as to why the hospital staff are behaving so badly towards the family. I would think they would be bending over backwards to help them.

I worked in PACU/SCCU settings for 14 years, and am now in ER/hospital. (Also have cardiac ICU, med surg., renal oncology background). I have seen a lot over the years.

Due to what I have experienced, I continue to question the timeline of the bleeding, transfusing and the patient’s return to the OR. I am not saying it was inappropriate as I do not have enough information to make that judgment.

Questioning what happens during these types of events provides us with information to help improve outcomes.

If procedures, policies and other changeable factors may have contributed to the horrific outcome for this poor child, why NOT examine those things?

Commitment to ongoing quality improvement is our responsibility as healthcare providers. We hold a lot of power and control in our hands at times, and need to be thoughtful about it.

“It should be apparent that with the sparsity of facts agreed on it is still extremely early to begin speculating what went wrong in McMath’s case and what kind of medical negligence if any might have been involved.”

Seems to me this statement is very reasonable, and that the above string of comments serves mainly to illustrate how reasonable the statement is.

[…] Mayo Clinic National Institute of Health MedScape WebMD WebMD Hypothyroidism Pediatrics American Thyroid Association Mercury News Overlawyered.com […]

How is it unreasonable to question what happened in this case Mr. Fembup?

The level of ignorance of science and medical care I read above is amazing. The heart has its own nervous tissue that creates the resting heart beat. As long as the blood continues to be oxygenated, the heart can beat in absence of brain function. The brain stem, specifically the medulla, controls respiration rate. A person who has complete death of cerebral cortex can continue to have a normal sleep/wake cycle, beating heart, spontaneous respiration, and reflexes (which presentation show no higher cortical function).

If there are so many “experts” out there on brain death, why haven’t they petitioned to have the court hear them? Independent physicians who have thoroughly examined her, have all agreed so far.

I can tell you, that girl has a BMI of over 30, which would at least classify her as obese. Her insurance would have not allowed her to have this surgery (yes, it would have been pre-authorized) if she didn’t have such a high degree of decreased quality of life issues. These surgeries are common, but not “routine”. Her parents would have had plenty of time to weigh the options, get second opinions and have all the risks explained in full detail. It isn’t like this was a split moment decision and she was rushed to the OR. This was after plenty of failed conservative treatments, I guarantee it.

It is very unfortunate and I feel so sad for her family, and her too. However, people.. wake up.. medicine isn’t perfect. The best baseball players get paid millions to hit the ball 1 out of 3 times at bat. Do you get everything at YOUR job right all of the time, I bet not. Yet, a physician gets it right 99.9% of the time and everyone wants to ruin their life when that .01% happens, even if it isn’t their fault. And.. who is to say it was all the doctor’s fault to begin with? Complications happen, live with it. We don’t know all the details and when we do, I am sure we will be able to analyze what happened and learn from it.

How is it unreasonable to question what happened in this case Mr. Fembup?”

Because, JH/RN, “It should be apparent that with the sparsity of facts agreed on it is still extremely early to begin speculating what went wrong in McMath’s case and what kind of medical negligence if any might have been involved.”

Mr. Fembup,

Your response did not answer my question. It was a quote of your statement.

Sincerely,

JH/RN

In neither of my postings did I suggest that a beating heart indicates brain activity of any kind.

I mentioned several authors of articles critical of the brain death diagnosis to let people know that there is a divergence of opinion on the subject. The articles are very comprehensive and well written. One, in particular, “Death and Legal Fictions,” by Truog and Shah, in the Journal of Medical Ethics, is a good starting point and to try to discuss its content in entirety in this kind of a posting would be a huge task.

It is a shame that these authors choose to speak out only in academic journals and neglect to involve the general public. This has always been a fault of medical academia.

I raised the issues to point out that the family is doing nothing wrong. Some states do recognize religious beliefs as a contra-indication to the brain death diagnosis. If we are to give the hospital and its staff the benefit of the doubt, which we should do, then it would only seem fair to give the family the benefit of the doubt as well.

Needless to say, if the family had accepted the “brain death” diagnosis and consented to have the girl’s organs donated, the hospital would have gladly arranged for the “surgical intervention on a dead person” required to obtain the organs and have been much more pleasant to the family. They should amend their official position to state that it is unethical to perform some surgical procedures on dead patients.

JH/RN

The comment certainly does answer your question.

You say you do not have enough information. I accept that statement.

You also say “Questioning what happens during these types of events provides us with information to help improve outcomes.”

I accept that statement as well. And I offer my apology, I did not realize that you have been appointed to the investigative committee for this incident.

I would also suggest your powers of observation need sharpening. My “quote” is not mine, but Walter Olson’s. You know, Walter Olson?

So I also recommend you actually read his post.

Thank you.

Mr. Fembup,

Thank you for response. However, I respectfully disagree with your assertion that I have been “appointed to the investigative committee for this incident”.

I am, however a practicing professional in the medical field who strives to provide individuals with quality, and above all SAFE medical care and treatment.

The time to start questioning is BEFORE incidents occur. In doing so, we are always being astute in our duties. Doing so does make a difference, and does save lives.

What is your occupation Mr. Fembup? And are you a healthcare professional?

Respectfully,

JH/RN

Mr. Fembup,

I have read Walter Olson’s post. In quoting his statement, you obviously agreed with it. My question was “How is it unreasonable to question what happened in this case”? I ask this as, IMO it is never too early to speculate what happens in these tragic types of situations. I also don’t feel it’s unreasonable to wonder what did happen.

This is an unusual medical case. It is not often this type of thing happens in my experience, and I have a good many years of surgical experience to draw back on.

My position is not that it is time to file a lawsuit again Children’s Hospital of Oakland. As I before mentioned, there has not been enough information made available to determine what happened.

No need to apologize for your not having recognized me as the newly appointed member of this incident’s investigative committee. Your revelation that I was, is news to me to0. I just thought people were free to express themselves here.

I agree with JW… people seem to gloss over the sometimes laundry list of possible complications inherent to invasive and surgical procedures. When they occur, everyone wants the doc held responsible in every way possible. The yeilds of medicine are not perfect, as those that deliver it are’nt perfect. It’s no joke that a Tonsillectomy alone carries the risk of post-op hemorrhage… that’s 101. We (docs, nurses) all know (or should know) that a post T, T&A, etc. bleed is serious… vigilant observation is fundamental. But, there are many other complications that could also be the etiology of the arrest. We just dont know right now. Someone will get to the bottom of whether or not the situation was reasonably recognized and dealt with according to protocol (assuming one was in place).
I would like to know, If anyone is willing to shed some light, mom reports her daughter responds to her presence, touch, and voice with movement,and increased heart rate; what sensory-motor pathways would have to be intact for this to happen.? I would assume that cranial nerve cells have died…. but what about the portion of the nerve-cells that exists outside the cerebrum, like the Vagus nerve for instance?

The responses that the mother reports would involve brain function. They are responses that the official investigators have been unable to elicit, which is why they gave the diagnosis of “brain death.” That the mother says she sees the response where others can’t is not unusual. It may or may not be accurate on her part. We can all see things that we want to see, whether or not they are actually happening. Awareness is a field that is only really beginning to be explored with functional MRI’s and other tests, which can measure awareness where routine exams(such as the physical exam in a brain death examination) cannot.

As for assuming that the cranial nerves have died, this is not clear. Autopsies of brains from patients that have been declared “brain dead” show no pathology compared with brains of patients with other cause. The brains look the same. There are no “brain death” lesions that a pathologist can point to to confirm the diagnosis.

The vagus nerve is a cranial nerve.

JH/RN says, “IMO it is never too early to speculate ”

IMO, it is often too early to speculate.

Which I think is Olson’s point– and with which I still agree.

IMO it is frequently too early to speculate when, as in this case, facts are sparse, and unreliable besides because they are known only thru the media. Wondering what happened is one thing; but actually debating hypothetical causes, errors, etc. is quite another when facts needed to reach valid judgments are sparse and unreliable. In this case, because reliable information will surely become known, it seems to me a waste of time to debate hypothetical possibilities now.

“I just thought people were free to express themselves here.”

Of course people are. Even when the people offer opinions that cannot objectively be supported – people have the freedom to express themselves. But that freedom does not ensure a rational analysis when facts are sparse and unreliable. In those circumstances, it’s not much more than a freedom to gossip

IMO, questioning minds are often intelligent minds.

My hope is that the attention called to this case, will in some way help to avoid future incidents. Obviously, all such cases will never be eliminated, but I choose to be on the side of attempting to help to keep those numbers as low as possible.

All my best to all of those on this forum who showed compassion regardless of arguing who was “right or wrong”, or whose point carried more merit.

I am off to do what I have done for 20 plus years…care for patients..

JH/RN

Can someone who works in medicine answer: if the girl started bleeding over a long period of time – time enough that they asked her to collect the blood clots in a cup and then to be given blood transfusions which are a slow process – why was this not treated as an emergency and she be taken to the OR? The mother said blood was pouring out of her nose, to the point that Jahi thought she had a runny nose?

There are a lot of assumptions. But as a surgeon, I have seen this story in my office. I have a patient (44yo) who presented w a breast mass. When it was removed by another surgeon, she bled so much that she had a hematoma and tissue loss requiring reconstruction. That surgery bled so much that she developed and clot around her implant with subsequent hardening. Her history was LATER revealed that when she had a tonsillectomy as a kid, she bled so much that she had to be replaced on the ventilator for days and taken back to the OR. When she had a kid, she bled so much that she had to have a hysterectomy to stop the bleeding. She ended up have a severe bleeding factor deficiency that was undiagnosed until I worked her up. She required transfusion of factors BEFORE and after surgery to be safe. Most likely, that’s what caused this degree of bleeding and one doesn’t to suspect it until severe bleeding occurs. Routine testing doesn’t pick it up. And worse yet, the diagnosis cannot be made now because the hospital has likely transfused the clotting factors into her system in an effort to stop the bleeding.

Thank you for comments that reflect an understanding of not only neurological functions but also cardiac. I’m amazed at the craziness of the responses that are being thrown about in the non medical community. I’ve been an EMT for 38 years and even with my limited understanding of this subject I know the bottom line. I want to thank everybody that have posted responses. You’ve given me the opportunity to hear from people with far more medical understanding than myself. My heart goes out to the family. It’s too bad organ donation wasn’t a consideration.

there are people who can express this tragedy

Costa! I was just reading up on poor Jahi and saw your name -I believe I know you! We met at the Smart Bar when you where in med school in Chicago…… Wow! That was a long time ago!!email me Drkittykathy@hotmail.com
As a pediatrician ( yea, I actually graduated college & went to med school!), I have seen patients diagnosed with brain death – it is heartbreaking and stressful to care for these patients. Although details of intial events are not known, CHO cared for Jahi w current standards/laws regarding brain death; they had an ethics committee determine what would be acceptable interventions/surgeries. Currently, actual brain death is considered irreversible by most neurologists- but I am interested in reading articles cited by Costa above.
The sad fact is that brain death occurs everyday to people of all ages- but is hardest to face when children are involved…..

Kathy, you are a doctor. Please give your opinion: why did they not send Jahi to the OR to try to cauterize the bleeding? They just gave her blood transfusions and had her spit clots into a cup to measure..? the bleeding was going on and on and quite profusely, but no emergency action taken. Thank you.

Brian- we have only heard one side of the story- from the family. CHO cannot comment due to HIPAA laws. A small amount of bleeding would be normal after such a procedure but the timeline is not clear to me – how long did the bleeding last? At some point- emergency action was taken but what did it involve? Obviously, if she was given blood transfusions- CHO was aware of a critical situation – we just don’t know the details. And I know (from personal experience) family recollection of events is NOT always accurate…….