Rebecca and the 'rescue breaths'

*Lash* said:

I would also like to add, an important document DS put forth 'Summary of Reports' is not authored. In my opinion, you could say the same for the material Dr. Melinek used in her report from the Left Handed Kitten forum.

Click to expand...

*Lash* said:

I would also like to add, an important document DS put forth 'Summary of Reports' is not authored. In my opinion, you could say the same for the material Dr. Melinek used in her report from the Left Handed Kitten forum.

Click to expand...

Gilgamesh said:

I was quite frankly, appalled when Dr. Melinek quoted LHK and Wikipedia. For someone as educated as she is, and as intelligent as she is, why, why, why would she quote those sources? If I had to guess, I would say that (because of Dina's media campaign, and the fact that this is in the public eye) it was a ploy to direct the public's attention to LHK. Could she not see the hate on that site? Could she not see how ridiculous it made her look to quote from such a source? And why would she put herself on the line by naming RZ as a killer? The only thing I can guess is that DS paid her a s*#"''l@d of money. I truly do not get her lack of professionalism. I would have to say that must just have academic intelligence but lack of common sense intelligence.

Click to expand...

freespeech said:

Was that her typo or the hospital's? Did the intubation occur on 7/22/2001? Was versed given before or after the intubation? I highly doubt that a MD would write that versed was given after intubation. Considering Max was unconscious would versed even be necessary? Idk, K_Z?

Click to expand...

K_Z said:

We know from the EMS report Max arrived at Coronado Sharp ED in asystole, with chest compressions and B-V-M ventilation efforts. The EMS report indicates that epi was given 3 times (1020, 1024, and 1028). The EMS report also states Maz regained sinus rhythm "shortly" after arriving in the ED. There is nothing on the EMS report to indicate when exactly intubation was secured, but we DO know from the autopsy report that Max was displaying decorticate posturing in ED. I'm assuming that to be the first emergency dept, as I think it's possible he was a direct ICU admit at Rady, bypassing ED there.

So we don't know when they achieved intubation. If asystole or chest compressions were still in progress, then, no, versed wouldn't have been given at that point during intubation attempts. But if he had already regained a pulse, and was displaying decorticate posturing, then yes, versed would be given in conjunction with intubation.

That was an adult- sized dose (2mg in a 45 pound child), so there was concern about spikes in intracranial pressure with the stimulation of the intubation process. (We anesthetists call intubation "metal-ephrine"-- meaning, the process of intubation using the laryngoscope produces spikes in blood pressure similar to epinephrine or other catecholamines.) A spike in BP in a head injured patient can precipitate herniation. He already had blown pupils and decorticate posturing, so even before a CT was done, it was obvious there were serious concerns about brain injury. (And a history of falling onto his head.)

Click to expand...

MyBelle said:

You seem confused.

No, I'm not confused at all. But thanks for your concern.

Here's what I said which is based on public documents produced by professionals who actually were there and attended Max or who were child abuse investigators. I chose to base my opinion on their observations.

Originally Posted by MyBelle
The paramedics, physicians and parents interest in knowing how long Max was without oxygen was very important. People do survive head injuries. Knowing exactly how long Max was without oxygen would greatly impact his prognosis. A dead brain isn't going to improve.

Nowhere have I said doctors were wringing their hands or were puzzled as to what caused the cardiac arrest.

Dina has indicated publicly multiple times that the docs were "puzzled", ruminating over and over about how "long" CPR was in progress, and how long Max was without oxygen. She has stated they were "puzzled" as to what caused the cardiac arrest. She indicated that docs had many questions for Rebecca-- yet from reports, she prevented Rebecca from coming to the ICU to talk with them, and sent Nina to speak to her. I don't believe Max's docs were puzzled about his injuries at all. They had access to the EMS run reports, and Coronado ED records, as well as probably having phone conversations to accept the child as a direct admit to ICU. They had volumes of diagnostic tests and lab reports within a very short time after admission. And I don't believe anything Rebecca could have told them would have changed any of the medical decisions they made for Max. They knew about his very serious head injuries, and the neurological sequelae that comes from being resuscitated after a 30 min period of asystole. I believe that it was not long after admission before the conversations began turning toward confirming brain death. That process takes several days and multiple providers and tests in a child with a beating heart, but little or no brain activity.

The paramedic noted that it was unknown how long Max had been in cardiac arrest and also noted they had received limited information about the incident. I will continue to hold the opinion this information was critical to the care of Max.

Certainly, we are all entitled to our own opinions. Physicians absolutely knew Max had been in asystole for 30 min.

The concerns reported to LE by Rady personnel were that the description they received did not match the injuries. A prosecutor and child abuse investigator obtained a search warrant. These are known facts. I trust their judgment and find your attempts to discredit them rather bizarre.JMO

I strongly disagree with your comment that I have tried to discredit Rady personnel. If you search my posts, I have had nothing but praise and positive comments for Rady personnel, as well as the paramedics and Coronado Sharp ED personnel. I have even defended Dr. Brad Peterson on several occasions, as I believe it is highly possible his comments to Dina have been misinterpreted by her, or manipulated to suit her own aganda. BP is an anesthesiologist and pediatric intensivist. I have no reason to believe he would have made such outrageous speculation about Max being assaulted or smothered or suffocated in the early phases of what was obviously a terrible fall from a second story onto the child's head, that was so severe it produced asystole at the scene. Dr. Peterson has a lot of professional knowledge about trauma induced cardiac arrests, I'm certain. I continue to believe that Dina pressed him several times for thorough explanations, and in one or more of these conversations, he described various states that can produce hypoxia/ anoxia. I believe Dina latched onto this explanation and manipulated the retelling to suit her own agenda. Then repeated it over and over until she successfully planted the story in the public via interviews that "she believes" Rebecca suffocated Max, and BP gave her this information.

Click to expand...

K_Z said:

My comments in blue, and BBM.

Click to expand...

K_Z said:

I wanted to sort of finish the medical discussion, and leave a brief (lol!) discussion of suffocation, versus trauma-induced cardiac arrest. I'd like to illustrate why I think it is so very unlikely Max was "suffocated and thrown over the railing." Thanks in advance for humoring me! (Please feel free to roll and scroll if this isn't interesting to you!)

The healthy heart undergoes a fairly predictable deterioration thru a variety of rhythms when a person is dying of acute hypoxia/ anoxia. The final "rhythm" is asystole. Asystole (from any cause) is not so much a rhythm to be "treated" as it is usually a confirmation of death. The survival rate (to discharge) from any period of out-of-hospital asystole is abysmal. Only when there is a clearly identifiable cause that is imminently "fixable", is there usually any possibility of reversing asystole. CPR alone virtually never will convert asystole to any rhythm . Docs and nurses learn these few fixable causes in ACLS as the "6 H's and 6T's" (hypoxia, hypovolemia, tension pneumothorax, and so on).

People sometimes ask, "why you don't just "shock" a heart in flatline?" Electricity is not the treatment for aystole, and incorrectly applied, will inappropriately depolarize the heart, making further resuscitation attempts impossible. So the only chance to "fix" asystole is to identify the source, and rapidly intervene, IF POSSIBLE. However, it is not possible for anyone without a cardiac monitor, using absence of a palpable pulse as criteria, to determine which patients are in aysytole, and which are in pulseless rhythms that still have the possibility to be converted. This is an important distinction when we contrast suffocation with trauma induced asystole.

All of the previous sources I've linked on this thread and others highlight the statistical futility of "fixing" the cause of out of hospital asystole in blunt trauma. You may eventually bring a heart back to a rhythm, but virtually never will the person live to discharge-- and even in the rare situation when they do, they are not "neurologically intact". Meaning, they are in a neurologically devastated state permanently. (Most times in a vegetative state.)

When someone is dying from acute hypoxia, the heart initially goes thru a series of various tachyarrythmias (fast rhythms) as the person's endogenous catecholamines are released. BP can soar. ("Fight or flight response".) As they pass thru this phase, rhythms will deteriorate into bradyarrhythmias (slow rhythms), which can include forms of heart block, and junctional and ventricular escape rhythms. Finally, the heart moves into an agonal pattern, with volleys of what we sometimes call "help me" pings of electricity generated, but without any coordinated muscular contractions. There can also be something that looks like a rhythm, but produces no coordinated contractions of the muscle, which is called PEA, or "pulseless electrical activity". These "help me" bits of random electricity become slower and further apart as time goes on (the person is dying), and sometimes a healthy heart can kick out these electrical signals for 15 or more minutes as they complete the dying process, and move into a very quiet flatline asystole. At this point (asystole) the heart is very refractory to any resuscitative efforts (epi, atropine, etc).

To give an example of a hypoxic arrest many are familiar with, Michael Jackson died what most medical professionals believe to be a prolonged (and very negligent) unattended respiratory arrest from inappropriately administered IV propofol (an IV anesthetic). This was followed by an irreversible cardiac arrest. MJ was in complete asystole when paramedics arrived. MJ was initially pronounced dead at the scene, and then when his "doctor" Conrad Murray objected to pronouncing him dead, they took MJ to the nearest hospital. Whereupon, they attempted for another hour or so to try every possible measure (including the extra- extraordinary measure of an intra-aortic balloon pump in a patient with asystole) to resuscitate him, and were unsuccessful. He was pronounced dead a second time.

The fact that Max was resuscitated from asystole to a sinus rhythm after "only" 3 rounds of epinephrine, to me, argues very strongly that he experienced a traumatic cardiac arrest, and that 911 WAS contacted promptly when he was discovered, as reported by RZ and XZ. Paramedics noted no "help me" agonal beats, or other rhythms, only aystole in their documentation. Both on initial assessment, and ongoing as they transported Max to Sharp Coronado.

At least one poster has commented here that she believes Rebecca "waited" to call 911 until Max was in cardiac arrest. This is unlikely (and completely absurd, imo). If Max had been "suffocated", the absence of a palpable pulse soon after would not guarantee that he was in asystole without other forms of electrical activity being discharged. If Max was suffocated and she "waited too long" to call 911, Max's heart never would have responded to epi after such a prolonged arrest. If she had suffocated him and called "too soon", there likely would have been electrical activity still going on in his healthy 6 year old heart when paramedics arrived. This is what you could call a very "narrow" window, and I sincerely doubt even a talented medical professional could call it that closely without a cardiac monitor-- let alone a lay person with no critical care experience.

Max was perilously close to being a DOA at Coronado, but finally responded to the 3 rounds of epi with a sinus rhythm. (Circulation time is very slow with CPR.) I believe that this argues very strongly that Max had a traumatic arrest from the fall onto his head, just as promptly reported to 911 by Rebecca and her sister.

Click to expand...

MyBelle said:

BBM. I think Dina is blaming Rebecca for Max's death because he did DIE while in her care and I can't say that I wouldn't do the same thing if I was in Dina's shoes. As far as the CPR goes, Rebecca should have at least tried and the fact that no CPR was given simply adds to the fuel that this was not an accident. She was a trained medical professional and knew rescue breaths were useless without compressions. To me, the excuse that "it wouldn't have made a difference" points to guilt. The only way Rebecca would know that is if she waited until he had no pulse to notify 911.

JMO

Click to expand...

Zinn said:

Thank you, JBean.

To be clear, my goal is to explore the origin of the belief that Rebecca falsely claimed to provide CPR. My goal is not to rehash whether she performed CPR or rescue breaths or neither, though it is certainly a related topic. Maybe my exploration of this would make more sense attached to the thread about the message on the door as I find it thematically similar to claims that Rebecca did not provide CPR. If so, feel free to move my comments to the thread about the message on the door.

Click to expand...

K_Z said:

I understand the temptation to reduce a cardiac arrest to something simple, as in “air is good”. It’s important to remember that Max did not suffer cardiac arrest as a result of oxygen deprivation. He suffered complete asystole secondary to blunt force cranial trauma that produced a very serious central nervous system insult at the highest point in the spinal cord, where it joins the brain stem. His cardiac arrest was about 30 min in length, and he ultimately died as a result of the brain swelling following his resuscitation.

If you go to the EMS report thread, there are a number of studies I posted that document the outcomes of children who sustain cardiac arrest in the field secondary to blunt force trauma. Some of the retrospective studies were done in San Diego, with hundreds of patients, in the same place Max was. The overall survival rate hovers around 1%-- and of those 1%, none were even close to neurologically intact (only one had any level of consciousness), and the rest were in a persistent vegetative state. Cardiac arrest in children secondary to blunt force trauma is better than 99% fatal, no matter what kind of out of hospital care they received. One study suggested that health care professionals should acknowledge that prolonged resuscitative efforts are often successful only as to maintaining a potential organ donor.

It’s also important to understand that cardiac arrest physiology is not the same as “living” physiology. No matter how much oxygen you “pump” in, there is seriously altered chemistry at the cellular level. Even with some circulation from very high quality chest compressions, the ability to load and unload oxygen at the cellular and tissue level is severely altered—and gets worse as time goes on. All cellular metabiolism is severely deranged. Meaning, red cells don’t carry oxygen like they normally do, and what little oxygen they do have is not easily released at the tissue level. (This is a greatly simplified summary-- entire textbooks are written on this.)

Max was in a full cardiac arrest at the scene—asystole. Rescue breaths would be "nice", but wouldn’t make a bit of difference in the big picture of what his injuries were. The persistent focus on “rescue breaths” and “CPR or no CPR” is a complete distraction from acknowledging that Max’s injuries were devastating, and virtually assured he would not survive to discharge from the hospital. He had a healthy 6 year old heart, which paramedics were finally able to restart.

I seriously doubt any of his physicians held out any hope for him to live, let alone recover any meaningful neurological function. I’m confident Max’s hospital records document how dismal his prognosis was on arrival at Rady—and certainly after the first MRI (within minutes to hours) this would have been confirmed. I understand that Dina has said things to the contrary that indicate she either did not understand what the docs were telling her, or she was in a state of denial due to shock. She has not released any of the documentation in Max's medical records to support her claims and accusations. I personally do not believe there is anything in Max's records to support what she has said about her knowledge of his prognosis in the first couple days.

The EMS thread has some good conversation on this, Ausgirl.

Click to expand...