Family wants to keep life support for girl brain dead after tonsil surgery #1

[wendiesan]

Re 357

You're right, from my experience as well, about signing documents regarding potential risks of surgery, but people sometimes hear what they want to hear or read what they want to read. We have no way of knowing, at least at this time, what the verbal information given the family was. It's possible that the language used in writing differed from that of the spoken consultation, and that the mother believed the risk to be less than what the physician believed s/he was indicating.

JMO, but I think the mother is overwhelmed with sorrow and guilt. I gather that she may have talked her daughter into having the surgery despite her daughter's fear that she would never wake up after the operation. The mother may believe that her daughter can hear her, and will know about her fight to bring her back safe and sound, just as she promised. I can understand that feeling, and I think it may take a long time for the mother to feel she can let her daughter go. It was my impression that Jahi's family felt that they were being rushed by the hospital to take this child off the machine that was keeping her alive, and there would, I think, be a perfectly natural suspicion about the motives of those doing the rushing.

It's hard to tell, but I guess in some way the mother is looking for the cause. Was it a medical mistake that resulted in her child's death, or was it something that could not be avoided? Could it have been an aneurism, or something like that? (Just a totally uneducated guess there.)

I don't know what the parents do for a living, but maybe someone else could find that information. I'm sure other posters will refute or agree with my theories, and may be in a better position to answer your questions.

I hope that the peace of this Christmas Season will have brought some small measure of comfort to Jahi's family, and that they will find the answers for which they are looking.

One more thing. Clips of the marches in support of Jahi's family were included in the Piers Morgan show footage. I think that "annoying" wouldn't begin to describe how those demonstrators would be perceived by families trying to maintain a sense of calm and protection to other children in the hospital.

 

[SwampMama]

It sounds like there's a possibility that the removal of adenoids and tonsils should not have been done at the same time, especially if the child was overweight ... I'm guessing at what may have gone wrong. If her throat was cleared at the same time, it sounds like fibroids, which can also form in the ear canal, leading the difficulties in hearing.

Still, anyone with those problems knows that there's a risk with the surgery. The breathing passage is obviously obstructed if adenoids and tonsils are being removed and the throat is scraped. It sounds like it was touch and go from the beginning.

Even if the hospital were to admit that the surgeries could have been better done separately, it sounds like there were serious health issues and that there was never any guarantee that everything would go well. It seems to me that the parents are having difficulties accepting their daughter's death. Are they a good sound family or is there a possibility that there's an eye on a lawsuit? Sorry for asking, but it's looking to me like that may be an angle.

It may have been felt by the doctors that there was a greater risk by having 2 separate surgeries. Just being under anesthesia is a big risk of surgery.

Also, a poster from a few pages back said that the lawsuit in this case would top out at 250,000 per state law but I do not know the specifics of that or what other damages could be awarded.

Her family is indeed having a hard time accepting what has happened. I feel they will sue (and they would likely be justified to do so) but I also feel that they would be willing to PAY any amount of money just to have Jahi back.

 

[wendiesan]

Hey SwampMama.

I don't have any problem with your postings. I made an error, later corrected it with an edit. I apologize for giving you the impression that I am in any way offended by your response to issues. i find your information very helpful and feel terrible that, because I was tired and didn't proof-read properly, that my error was upsetting to someone who is as diligent as you are.

The family raised this issue in their interviews and in their request for a specialist who seems to be basing his work upon a set of particular set of beliefs which are not necessarily supported by mainstream Catholic beliefs. Your posts provided a background against which to evaluate the descriptions of his work, and, IMO, provided specific references which would allow someone like me to form an educated opinion.

Please accept my apologies, because I think you're ability to research and write is great!!

 

[SwampMama]

Hey SwampMama.

I don't have any problem with your postings. I made an error, later corrected it with an edit. I apologize for giving you the impression that I am in any way offended by your response to issues. i find your information very helpful and feel terrible that, because I was tired and didn't proof-read properly, that my error was upsetting to someone who is as diligent as you are.

The family raised this issue in their interviews and in their request for a specialist who seems to be basing his work upon a set of particular set of beliefs which are not necessarily supported by mainstream Catholic beliefs. Your posts provided a background against which to evaluate the descriptions of his work, and, IMO, provided specific references which would allow someone like me to form an educated opinion.

Please accept my apologies, because I think you're ability to research and write is great!!

Thank you Wendiesan!!
I was really worried that I had offended people, or gone off track and lost it, and I never meant to do that. I was just trying to get the info there so everyone could easily access it and draw their own conclusions because I do love to hear what other people think about things like this. hearing everyone else's views helps me to think of things and consider them in ways that I might not have before and I like that. It's all learning an I love that.

You are absolutely forgiven for being tired and having a typo in the early morning after a long eventful day of Christmas and that entails. Thanks for clearing that up. I am greatly relieved!

 

[Donjeta]

I know, and I feel bad about even mentioning that aspect but it is the plain fact with our healthcare system. And to be fair, I don't know that in a country with government-funded healthcare the hospital would even have continued to maintain Jahi on a ventilator this long given that several (six, if I recall correctly) doctors have now given medical opinions following an actual examination that she is brain dead and there is no possibility of recovery. Perhaps someone with knowledge of the healthcare system of (for example) the U.K., etc. could weigh in.

The Finnish law is that a person is pronounced dead once the brain function has irreversibly ceased, either after the heartbeat has stopped or if the heart is still beating, according to the guidelines of diagnosing brain death. So all deaths are brain deaths in a way. A diagnosis of irreversible brain death amounts to a declaration of death.

According to the government guidelines, once patients have been declared dead all life support measures are stopped. They can only be continued temporarily if the deceased is an organ donor. Family consent is not required for stopping the life support of a deceased person. It is considered a medical responsibility to declare death and once a person is dead, life support is futile and should be stopped.

The Swedish law defines death similarly as irreversible cessation of brain functions and notes that if there is artificial respiration and blood circulation there must be a specific brain death examination. If death has been diagnosed, medical interventions may continue if needed to save a viable fetus or for organ transplantation purposes but this should not take more than 24 hours unless there are particular reasons (this legislation that I'm seeing does not define what those particular reasons might be). Nothing about family consent being required here either.

Imagining my own loved ones there in the hospital I think that family consent should absolutely be required for everything but it doesn't really work that way. Most people die regardless of whether their family thinks this is a good time for them to die right now or not. So this kind of legislation makes sense to me. Medical miracles or divine interventions to cure people without brain blood flow don't seem to occur very often so it seems disrespectful of the dead somehow to keep ventilating them in the hopes that they might still wake up.







http://www.finlex.fi/fi/laki/alkup/2004/20040027
http://www.stm.fi/c/document_library/get_file?folderId=28707&name=DLFE-3861.pdf
http://www.finnanest.fi/files/a_randell.pdf
https://lagen.nu/1987:269#P2S2

 

[Donjeta]

Prince Friso was brain dead and kept alive. Eight months later, having had the best possible care in the world:

"The Dutch royal house says that Prince Johan Friso, the brothereh of King Willem-Alexander, has died of complications after the 2012 skiing accident that left him with grave brain damage.

In a statement, the royal house said that the 44-year-old Friso had never regained more than "minimal consciousness" after the accident, in which he was buried by an avalanche."

http://www.huffingtonpost.com/2013/08/12/prince-friso-dead_n_3743226.html

Was it ever reported that he was formally diagnosed as brain dead? I saw reports that he had massive brain damage according to MRI but if someone regains even minimal consciousness it doesn't sound like totally brain dead, just very severely injured.

http://www.neurology.org/content/58/3/349.full

 

[Jacie Estes]

It sounds like there's a possibility that the removal of adenoids and tonsils should not have been done at the same time, especially if the child was overweight ... I'm guessing at what may have gone wrong. If her throat was cleared at the same time, it sounds like fibroids, which can also form in the ear canal, leading the difficulties in hearing.

Still, anyone with those problems knows that there's a risk with the surgery. The breathing passage is obviously obstructed if adenoids and tonsils are being removed and the throat is scraped. It sounds like it was touch and go from the beginning.

Even if the hospital were to admit that the surgeries could have been better done separately, it sounds like there were serious health issues and that there was never any guarantee that everything would go well. It seems to me that the parents are having difficulties accepting their daughter's death. Are they a good sound family or is there a possibility that there's an eye on a lawsuit? Sorry for asking, but it's looking to me like that may be an angle.

This is an article describing one surgery performed and the extent of that surgery.

When Jim Latza was diagnosed with sleep apnea in his early 30s, his ear, nose, and throat doctor suggested an operation. "He told me I had a classic case in which my soft palate was too large, and was sagging down to cover my airways," says the 55-year-old salesman from Lakewood, Ohio. "He explained that surgery wouldn't cure it completely but would make it so I'd live a normal life, to a ripe old age."

So Latza got the works: soft palate cut back, tonsils and uvula removed, and a deviated septum repaired. The surgery was intense, with a long recovery: "When they take your uvula, they warn you that you're going to choke for a while because the throat has to learn to close on its own," he remembers. "There were several times—and it still happens even to this day—when I eat something with a lot of crumbs, like shredded wheat cereal, and a little piece gets loose in the back of my throat where Im not expecting it. Then it's a 20-minute coughing spell until I get that little piece out of there."

Thankfully, Latza also noticed an immediate improvement in his sleep. "I couldn't believe how well I slept right after the surgery, even with the pain and the stitches. The doctor told me that was normal: He'd had people sleep for three days straight after the operation because they'd been so deprived for so long."
http://www.health.com/health/condition-article/0,,20188724,00.html

 

[K_Z]

I’d like to address the somewhat persistent idea that Jahi was perfectly healthy, and that her surgery was just a routine elective procedure. I have been reading carefully for a week or so to try to put together what happened with this family and this child before and after the surgery. The first, and most obvious impression that has been furthered by the mother and the news reports is that Jahi was “perfectly healthy” going into her surgery.

Just to get to the point in which this collection of procedures would be recommended to the mother, Jahi had to have several docs involved with her care in the year or more preoperatively. No doc will recommend a tonsillectomy after only “one” visit, or “one” episode of tonsillitis anymore. There has to be some kind of chronic condition that the tonsillectomy will likely fix. From everything I can piece together from MSM articles and pictures of her, Jahi was having a number of frustrating medical conditions over time, that lead to pedes ENT consultation.

First, from her pictures, she appears to be approximately two times her ideal body weight. Pediatric morbid obesity is a tremendous problem, and very difficult to treat. News reports state Jahi had ADHD, some degree of involuntary urination, sleep apnea, and weight gain. It is not an enormous leap to also infer that she had additional health problems that were so worrisome that the risks of surgery were outweighed by the potential advantages to her health—the risk/ benefit tipping test. In particular, I suspect she had some degree of reactive airway disease, signs of diabetes, hypertension, hyperlipidemia, and possibly signs of impact on her heart function due to the sleep apnea. She would have had sleep studies to quantify her degree of sleep apnea, and potentially tried a course of mechanical support (CPAP, biPap) at home. She may have had allergy testing, and been prescribed things like nasal sprays to further open her breathing passages. I think she had quite a bit of work up from ENT and other pedes docs in the year leading up to her surgery recommendation. While she may have had chronically infected tonsils, it appears more and more likely that the T & A was just part of the UPPP procedure to remove tissue and enlarge her posterior pharynx so she could breathe more effectively, as was the nasal turbinate reduction.

Sleep apnea surgery in the morbidly obese is somewhat controversial even in adults. The studies are not all in agreement that the surgery solves any of the patient’s physiological problems over time, particularly if the patient doesn’t have a radical weight loss planned. Sleep apnea surgery works best in patients who are close to their ideal body weight, and simply have enormous and saggy posterior pharynx tissues that collapse when they sleep. Obesity is a different problem, with far different respiratory mechanics than for those of ideal body weight (or close to ideal). Pediatric morbid obesity is an even different situation from adults. There is not consensus that sleep apnea surgery is overwhelmingly beneficial in this population, but there is some consensus that it is something to try when other methods have not been successful, as ONE PART of a multifactorial approach to working on the problems secondary to morbid obesity. I have real doubts that Jahi’s mother understood this—surgery is easy to grasp onto as a fix for complex multifactorial (social and physiological) problems. “To cut is to cure” is a closely held belief by a lot of surgeons and lay people alike.

The general guideline we teach our students early on in anesthesia education is that if you can see adipose on the outside of someone’s face and airway, there is lots of adipose on the inside of their airways. Jahi is a darling young teen, but she was morbidly overweight in a very worrisome way. She may or may not have been a difficult airway before the surgery, but that is a moot point because clearly she got thru her surgery ok, and was intubated again in ICU. The main medical issue I see is what may have gone on with her bleeding—how bad was it, what was done “when” (in the PACU and ICU), who knew about it at each stage of her postop care.

She was a planned ICU admit from info in articles. That means the combination of the risks of her underlying conditions, in combination with the risks of the surgery, meant that everyone was fully aware she was high risk. Her mother certainly would have been told this, and given a lot of information preop. Risks of bleeding and airway obstruction were very high in Jahi.

I don’t know what happened in the ICU. Clearly she was bleeding. She had at least 4 units of cells from reports. This is a very big risk in this surgery. The tonsils and posterior pharynx receive blood supply from 5 branches of the carotid—so there is always some bleeding with a T & A and a large posterior pharynx resection (and the turbinate procedure). I have a lot of questions about ENT surgery’s awareness of what was going on, and questions about why she wasn’t brought back to the OR if she was bleeding profusely. We only have the family’s interpretation of what they say, what they saw, and what they tell the reporters. That bothers me a lot, because I know how much more information there is. The mother’s interpretation (for example) of the ventilator lines changing color and that indicating Jahi taking breaths is one clear example of misinformation and misunderstanding that is being perpetuated by reprinting it without additional information to correct. The mother, in particular, seems to have a very limited understanding (or denial) of a lot of medical information, which has, unfortunately been published as “fact”. Reporters are not researching any of the medical information, and providing corrective information. That upsets me for the “entire” hospital staff involved in Jahi’s care, who are now perceived as a group as globally incompetent, when in fact, they may not have been. I have to balance the misinformation I hear and read from the family with what I know is a very high level of care in a major urban pediatric OR, PACU, and ICU.

A couple articles on pediatric obesity and sleep apnea:

http://emedicine.medscape.com/article/1004104-overview

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2994651/

http://emedicine.medscape.com/article/1004104-treatment

https://www.bcbsmt.com/medicalpolicies/NewPolicies/ObstructiveSleepApneaSurgical.aspx

Adenotonsillectomy

Three systematic reviews were published in 2009 on tonsillectomy for obstructive sleep apnea in children. (9-11) Kuhle and colleagues reviewed randomized trials on interventions for children with OSA. (9, 10) The single randomized controlled trial on surgical interventions that was identified compared radiofrequency ablation of the tonsils with conventional adenotonsillectomy. Both procedures were found to reduce the RDI (from 7.7 and 7.6/h to 0.3 and 1.6/h, respectively). Friedman et al. performed a meta-analysis of 23 studies (1,079 children with a mean age of 6.5 years) to evaluate success rates of tonsillectomy and adenoidectomy for pediatric OSA. (10) The mean preoperative AHI was 18.6 and the mean postoperative AHI was 4.9, with a mean change after surgery of 12.4 events per hour. Although limited by heterogeneity, the success rate was found to be 66% when success was defined as an AHI less than 5, and 60% when success was defined as an AHI less than 1. Further analysis found that the success rate (AHI < 5) was only 39% in children with co-morbidities such as obesity compared to a 74% success rate observed in uncomplicated patients. Due to likely publication bias, the authors concluded that these rates should be considered an upper limit of success. Costa and Mitchell also reported lower efficacy in obese children from their meta-analysis of 4 studies reporting on this population. (11) The mean pre- and postoperative AHI was 29.4 and 10.3, respectively. Following adenotonsillectomy, 49% of obese children had a postoperative AHI less than 5, 25% had a postoperative AHI less than 2, and 12% had a postoperative AHI less than 1.

 

[K_Z]

http://www.mercurynews.com/breaking...es-have-normal-holiday-celebration?source=pkg

OAKLAND -- In hopes of having as normal a holiday celebration as possible, the entire family of Jahi McMath spent Christmas Day in the waiting room together at Children's Hospital Oakland.

About 15 family members had gathered by Wednesday afternoon, and a tree had been put together, said Omari Sealey, the uncle of 13-year-old Jahi, who suffered cardiac arrest and other complications after a Dec. 9 tonsil surgery that left her brain-dead. She has been on a ventilator since Dec. 12.

There were presents under the tree for Jahi and her siblings, and the family planned to carry on with some of its holiday traditions such as board games, dominoes and playing cards, Sealey said.

"We're trying to make it as normal as possible," he said.

I also have a lot of compassion for the OTHER families of kids in that ICU right now. I don't believe what this family is doing is appropriate to the rights of the other families in the ICU. This, IMO, has crossed the line into insensitive and entitlement behavior. This should not be allowed in the common ICU waiting room. The family should have asked and been provided with an empty conference room to celebrate. How sad for the REST of the families in that ICU.

This ONE family’s situation has grown to dominate that hospital and unit, which really isn’t fair to the other families and patients (and staff). I really hope that those other ICU families have been provided with a lounge type area to go to, or an empty conference room, etc. so they can have some quiet and privacy as well. I don’t imagine any of them would feel comfortable trying to share a waiting room with the large group of Jahi’s supporters putting up a tree in the ICU waiting room and opening Christmas presents.

I recently experienced that same situation when my FIL was in a trauma ICU for 32 days—we couldn’t even get into the ICU waiting room, lockers, etc. because one patient had 20-30 supporters in there 24/7 completely taking over the space for about 10-12 days. The families of the other 12 ICU patients had to wander to other areas, other waiting rooms on different units, different floors, to find a quiet place to make a phone call or get coffee, or take a shower. It was very frustrating and awkward for the rest of the families—and we tried our best to support each other, tell the other families good places to go to rest when we found them, etc.

 

[danzn16]

Is it possible she may have a bleeding disorder? Would she have been tested for that before surgery? Von willebrands disease is the most common bleeding disorder.


Sent from my iPhone using Tapatalk

 

[Karmady]

It may have been felt by the doctors that there was a greater risk by having 2 separate surgeries. Just being under anesthesia is a big risk of surgery.

Also, a poster from a few pages back said that the lawsuit in this case would top out at 250,000 per state law but I do not know the specifics of that or what other damages could be awarded.

Her family is indeed having a hard time accepting what has happened. I feel they will sue (and they would likely be justified to do so) but I also feel that they would be willing to PAY any amount of money just to have Jahi back.

The non-economic damages for med mal claims are capped at $250K, but economic damages are not (I figured there was a way around the cap, but got it backwards, sorry! lol). Here's a Cali medmal lawyers explaining how to try and get large settlements from docs and hospitals in life support situations involving children. He also expresses his view that the hospitals prefer to terminate life support for financial/liability reasons due to the cap, etc.

http://www.fagellaw.com/Articles/De...al_of_Life_Support_and_Medical_Malpracti.aspx

Also, I assume Cali has already addressed the argument that the tort reform cap is unconstitutional since the law has been around for a long time. But since the family's attorney is a civil rights lawyer, I'm guessing he'll take a run at that angle as well since the 9th circuit court of appeals is notoriously activist (and also has some of it's arguments live streaming now). Here's a snip from a Florida legal website discussing that issue in a recent florida case.

~snip

The Florida Supreme Court has agreed to determine whether a limit on noneconomic damages in medical malpractice cases violates the state's constitution. The law was passed in 2003 as part of a Republican-led effort to limit the rights of medical malpractice victims. The damages cap in Florida is $500,000 per claimant and practitioner with an aggregate cap of $1,000,000.

Here are the facts of the case as reported by FJA:


... The medical staff dismissed the family’s concerns, claiming her condition was stable. Following complications delivering the placenta, Ms. McCall’s blood pressure began to drop rapidly and remained dangerously low for an extended period of time. The nurse anesthetist monitoring Ms. McCall’s vital signs failed to notify staff, and Ms. McCall’s doctor failed to inquire of the vital signs.


Subsequently, the assigned doctor requested an “immediate” blood count. One hour and twenty minutes later, a nurse finally attempted to draw blood from Ms. McCall, who was unresponsive. She had gone into shock and cardiac arrest due to severe blood loss. Ms. McCall never regained consciousness and was removed from life support on February 27, 2006.

The McCall family filed suit in federal court. In addition to actual damages, the court found noneconomic damages totaling $2,000,000, but limited them to $1,000,000 due to Florida’s medical malpractice statute. Plaintiffs appealed the case to the Eleventh Circuit Court of Appeals, arguing that the cap on damages was unconstitutional.

The appellate court ruled in favor of the defendant on federal constitutional grounds; however, the three judge panel certified four state constitutional questions to the Florida Supreme Court. The questions to the state high court are whether the medical malpractice statute violates the Florida’s Constitution’s provisions pertaining to equal protection, access to the courts, right to trial by jury, and separation of powers.

http://www.dayontorts.com/cat-tort-reform.html

jmo

 

[Donjeta]

http://sanfrancisco.cbslocal.com/20...h-oakland-hospital-on-jahi-mcmaths-condition/

Family Considers Appeal After Judge Agrees With Oakland Hospital On Jahi McMath’s Condition
December 26, 2013 7:57 AM

Christopher Dolan, the family’s attorney, said that a decision to file an appeal will be based on firm conviction.
“This involves some very serious religious beliefs about life and death, the fourth and fourteenth amendment’s right to privacy because we have privacy rights that say we get to make decisions over our body,” he said.
“Those are the same privacy rights that led to contraception, the foundation of Roe v. Wade.”

Fourth Amendment:

The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.

14th Amendment:

Section 1. All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside. No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.
Section 2. Representatives shall be apportioned among the several States according to their respective numbers, counting the whole number of persons in each State, excluding Indians not taxed. But when the right to vote at any election for the choice of electors for President and Vice President of the United States, Representatives in Congress, the Executive and Judicial officers of a State, or the members of the Legislature thereof, is denied to any of the male inhabitants of such State, being twenty-one years of age, and citizens of the United States, or in any way abridged, except for participation in rebellion, or other crime, the basis of representation therein shall be reduced in the proportion which the number of such male citizens shall bear to the whole number of male citizens twenty-one years of age in such State.
Section 3. No person shall be a Senator or Representative in Congress, or elector of President and Vice President, or hold any office, civil or military, under the United States, or under any State, who, having previously taken an oath, as a member of Congress, or as an officer of the United States, or as a member of any State legislature, or as an executive or judicial officer of any State, to support the Constitution of the United States, shall have engaged in insurrection or rebellion against the same, or given aid or comfort to the enemies thereof. But Congress may, by a vote of two-thirds of each House, remove such disability.
Section 4. The validity of the public debt of the United States, authorized by law, including debts incurred for payment of pensions and bounties for services in suppressing insurrection or rebellion, shall not be questioned. But neither the United States nor any State shall assume or pay any debt or obligation incurred in aid of insurrection or rebellion against the United States, or any claim for the loss or emancipation of any slave; but all such debts, obligations and claims shall be held illegal and void.
Section 5. The Congress shall have power to enforce, by appropriate legislation, the provisions of this article.

I am not a lawyer so that may be why I have a hard time seeing how any of this can be interpreted to mean that hospitals must continue to provide life support measures to people who are legally dead.

 

[Trino]

Was it ever reported that he was formally diagnosed as brain dead? I saw reports that he had massive brain damage according to MRI but if someone regains even minimal consciousness it doesn't sound like totally brain dead, just very severely injured.

http://www.neurology.org/content/58/3/349.full

I doubt we'll ever know the extent of Prince Frisco's injuries, but I suspect he was more than in a coma, which was what was reported. He was also kept at the palace until he died.

 

[Donjeta]

I doubt we'll ever know the extent of Prince Frisco's injuries, but I suspect he was more than in a coma, which was what was reported. He was also kept at the palace until he died.

Who knows if the Royals put accurate information out there but it was reported that he was initially in a coma for months after his Feb 2012 accident but in November 2012 the Dutch royals started saying that he had begun showing minimal signs of consciousness. He was treated in a couple of hospitals and was at the palace only for about a month before he died in August 2013. (That's a year and a half after his accident, not eight months like one of the reports earlier in this thread.)

Communique of the Government Information Service, Prince Friso, 12 August 2013
His Majesty the King announces with deep regret that His Royal Highness Prince Johan Friso Bernhard Christiaan David, Prins van Oranje-Nassau, Jonkheer van Amsberg passed away this morning at Palace Huis ten Bosch in the Hague at age 44.

Prince Friso has died of complications related to the hypoxic brain injury, which he suffered as the result of his skiing accident in Lech, Austria on 17 February 2012.

Following initial treatment at the Intensive Care Unit of the Innsbruck University Hospital, Prince Friso was transferred in early March 2012 to the Wellington hospital in London, his place of residence. In November 2012, Prince Friso begun showing signs of limited awareness ('minimal consciousness') and remained in that state since then. In early July 2013, he was transferred to Palace Huis ten Bosch in The Hague, the Netherlands.

The Royal family wholeheartedly thanks all persons who have looked after Prince Friso for their excellent and devoted care.

http://www.koninklijkhuis.nl/globale-paginas/taalrubrieken/english/news/news-archive/

 

[wendiesan]

Thanks K_Z for explaining the many consultations and procedures that had to occur before Jahi was approved for surgery. You made it very clear that this was far from a simple operation.

I'd like to know more about the possible causes of the post-operative bleeding, the speed with which the bleeding was handled by the nursing staff--what would normal protocol be, what actually happened, the actions of Jahi's family when they suctioned the blood and the effects that would have on Jahi's body. Would patient notes include the nursing staff's remarks about their own and the family's actions, or would they only include the actions of hospital staff? Would there be records from any machines used to monitor Jahi's condition following surgery? Would CCTV recordings be made in this ward? Is this a teaching hospital in which medical personnel at different levels of training might be monitoring Jahi's responses and might have different interpretations or recollections of what happened post-surgery?

 

[Trino]

http://sanfrancisco.cbslocal.com/20...h-oakland-hospital-on-jahi-mcmaths-condition/

Family Considers Appeal After Judge Agrees With Oakland Hospital On Jahi McMath’s Condition
December 26, 2013 7:57 AM

Snipped...

Really, the family is considering an appeal? Where will this end?

 

[K_Z]

There is some discussion upthread questioning the efficacy of doing the 3 procedures Jahi had separately. Please reference the links in my post a couple up, on pediatric obesity and sleep apnea. The "two" procedures, UPPP and adenotonsillectomy occur at the same time. There really wouldn't be any indication to "separately" perform these procedures when the intent is to attempt to correct sleep apnea. They are "paired" procedures with the UPPP. The only reason to do "just" a UPPP is if the patient has had tonsils removed some time in the distant past. The nasal turbinate surgery "can" be performed as a stand alone procedure, but I can't think of any reason to do so if the pt is undergoing UPPP to "open up" their airways to more airflow. The risks of another General Anesthetic far outweigh the risks of the few minutes of extra surgical time.

This case has been persistently presented as a tonsillectomy gone wrong, and not as a complex surgery for sleep apnea and other sequelae related to pediatric morbid obesity. When the case first reached the national news, I was as captivated as everyone by the reports of a "routine" T & A and brain death. I knew immediately there was much more to the story that wasn't being told. And when I saw the first pictures of Jahi (where she is both very cute with a great smile, AND clearly morbidly obese with a lot of facial and upper body adipose), I knew with 90+% certainty that she was having sleep apnea procedures, not "just" a tonsillectomy.

This persistent presentation in news articles of "healthy" and "elective", IMO, is denial of the very serious issues this young girl faced in her condition in the months and years leading up to surgery, and in the hours and days after surgery. She didn't develop the need for the surgery over a few months; this is a situation of very long standing--years. It also does nothing to educate the public about the very serious risks of this kind of surgery in obese children and teens.

I posted a few days ago that the only reason I can think of why this very obvious condition of the surgery being needed due to her morbid obesity and co-morbidities is that these medical issues are being minimized and omitted in news articles out of some worries about appearing to "blame the victim" for her size and complications. No one wants to appear to engage in "fat shaming" in a catastrophe such as this, but there are ways for reporters to respectfully phrase their words and present a far more accurate picture of why this young girl was undergoing this complex surgery. It is hard enough to discuss obesity and health in general articles,. It is even harder to understand and accept the impact of these issues when you see the face of a cute young teen, facing many physical, physiological, social, and psychological complications of her size. It breaks your heart to see a child like this, and I am sure with all my soul that Jahi's mother was very worried about her daughter's size, and the impact on her health and future. I understand why she considered and brought Jahi for the surgery. I ache for the guilt she feels and expressed in that article. I think the mother did what the doctors recommended to try to begin to help Jahi with her weight and other health problems. I don't think she fully understood Jahi's risks, but I do think she is a wonderful, loving mother trying to help her child. I have tremendous sympathy for her.

But for the news reporters and articles written, I believe it is extremely misleading to the general public to frame this catastrophic situation as just a routine elective tonsillectomy gone wrong in a healthy young teen.

A collection of postoperative events lead to her cardiac arrest. She was bleeding badly enough to have 4 units of blood. And now she is brain dead on a ventilator, with the family in extreme denial about the reality of her condition.

There are hug gaps in what we know about what happened in the ICU. It will all come out later-- of that I'm certain. The family will be compensated for their tremendous loss-- and hopefully it won't need to be in the court system very long. "Even" if the staff did everything "right" in her care, and still she had complications and died, the fact that she is brain dead from an elective procedure (elective, meaning non-emergency), means that the hospital will take out the checkbook to compensate the family. If things happened that should not have happened, the check will be bigger.

Because of this case, there may even be a moratorium on pedes sleep apnea surgeries at that hospital for a while, until a thorough review of the procedures and hospital care can be done. I think that would be a good thing. But I am not ready to condemn the entire OR, PACU, and ICU staff for inadequate care until I learn more about what happened.

 

[otto]

Was it ever reported that he was formally diagnosed as brain dead? I saw reports that he had massive brain damage according to MRI but if someone regains even minimal consciousness it doesn't sound like totally brain dead, just very severely injured.

http://www.neurology.org/content/58/3/349.full

He was dead. No one can survive 20 minutes without oxygen.

"Prince Friso of the Netherlands, the second son of Queen Beatrix, was on Saturday night fighting for his life in Austria after an avalanche left him without oxygen for up to 20 minutes. And the Dutch royal family are now facing up to the agonising realisation that the 43-year-old may never recover from his injuries."

http://www.telegraph.co.uk/news/wor...ble-trauma-facing-the-Dutch-royal-family.html

 

[otto]

There is some discussion upthread questioning the efficacy of doing the 3 procedures Jahi had separately. Please reference the links in my post a couple up, on pediatric obesity and sleep apnea. The "two" procedures, UPPP and adenotonsillectomy occur at the same time. There really wouldn't be any indication to "separately" perform these procedures when the intent is to attempt to correct sleep apnea. They are "paired" procedures with the UPPP. The only reason to do "just" a UPPP is if the patient has had tonsils removed some time in the distant past. The nasal turbinate surgery "can" be performed as a stand alone procedure, but I can't think of any reason to do so if the pt is undergoing UPPP to "open up" their airways to more airflow. The risks of another General Anesthetic far outweigh the risks of the few minutes of extra surgical time.

This case has been persistently presented as a tonsillectomy gone wrong, and not as a complex surgery for sleep apnea and other sequelae related to pediatric morbid obesity. When the case first reached the national news, I was as captivated as everyone by the reports of a "routine" T & A and brain death. I knew immediately there was much more to the story that wasn't being told. And when I saw the first pictures of Jahi (where she is both very cute with a great smile, AND clearly morbidly obese with a lot of facial and upper body adipose), I knew with 90+% certainty that she was having sleep apnea procedures, not "just" a tonsillectomy.

This persistent presentation in news articles of "healthy" and "elective", IMO, is denial of the very serious issues this young girl faced in her condition in the months and years leading up to surgery, and in the hours and days after surgery. She didn't develop the need for the surgery over a few months; this is a situation of very long standing--years. It also does nothing to educate the public about the very serious risks of this kind of surgery in obese children and teens.

I posted a few days ago that the only reason I can think of why this very obvious condition of the surgery being needed due to her morbid obesity and co-morbidities is that these medical issues are being minimized and omitted in news articles out of some worries about appearing to "blame the victim" for her size and complications. No one wants to appear to engage in "fat shaming" in a catastrophe such as this, but there are ways for reporters to respectfully phrase their words and present a far more accurate picture of why this young girl was undergoing this complex surgery. It is hard enough to discuss obesity and health in general articles,. It is even harder to understand and accept the impact of these issues when you see the face of a cute young teen, facing many physical, physiological, social, and psychological complications of her size. It breaks your heart to see a child like this, and I am sure with all my soul that Jahi's mother was very worried about her daughter's size, and the impact on her health and future. I understand why she considered and brought Jahi for the surgery. I ache for the guilt she feels and expressed in that article. I think the mother did what the doctors recommended to try to begin to help Jahi with her weight and other health problems. I don't think she fully understood Jahi's risks, but I do think she is a wonderful, loving mother trying to help her child. I have tremendous sympathy for her.

But for the news reporters and articles written, I believe it is extremely misleading to the general public to frame this catastrophic situation as just a routine elective tonsillectomy gone wrong in a healthy young teen.

A collection of postoperative events lead to her cardiac arrest. She was bleeding badly enough to have 4 units of blood. And now she is brain dead on a ventilator, with the family in extreme denial about the reality of her condition.

There are hug gaps in what we know about what happened in the ICU. It will all come out later-- of that I'm certain. The family will be compensated for their tremendous loss-- and hopefully it won't need to be in the court system very long. "Even" if the staff did everything "right" in her care, and still she had complications and died, the fact that she is brain dead from an elective procedure (elective, meaning non-emergency), means that the hospital will take out the checkbook to compensate the family. If things happened that should not have happened, the check will be bigger.

Because of this case, there may even be a moratorium on pedes sleep apnea surgeries at that hospital for a while, until a thorough review of the procedures and hospital care can be done. I think that would be a good thing. But I am not ready to condemn the entire OR, PACU, and ICU staff for inadequate care until I learn more about what happened.

Thank you so much for your professional input. That certainly puts things in perspective. It's a tragic situation, but it can't be undone.

 

[Donjeta]

He was dead. No one can survive 20 minutes without oxygen.

That doesn't seem to be true. For example, consider this drowning victim:

The longitudinal profile of a 2.5-year old child, after 66 minutes of submersion in icy cold water in Utah and resuscitation on CPB, indicated a pronounced pattern of broad cognitive difficulties [18]. Although, in the original widely referred case report, the child was reported “recovering completely” [17,18]. Subsequent neuropsychological examination revealed impairment of visual-spatial abilities, mild dyslexic characteristics, dramatic memory impairment, full scale IQ of 85, impulsivity, poorconcentration and difficulty in sequential planning and organization. However, the patient's recent MRI and magneto-electrography were within normal limits [18].

http://www.sjtrem.com/content/20/1/55
http://jama.jamanetwork.com/article.aspx?articleid=372951


His condition was very bad for sure but if true that he regained minimal consciousness he can't have been brain dead. Hypothermia is thought to have some neuroprotective effect in drowning victims, maybe it works under the snow too, and if he wasn't crushed under too much weight to prevent breathing movements there might have been enough air left in an air pocket to keep the hypoxia only partial for a while.