Family wants to keep life support for girl brain dead after tonsil surgery #4

[otto]

<modsnip>

Thank you!

In addition to being a licensed Vocational Nurse, the grandmother is certified to do something with IV. A Registered Nurse would be the person responsible for reading charts, maintaining levels, suctioning blood and managing patient care. My son spent five days in ICU at the age of five. There were two registered nurses looking after him around the clock for the first 2-3 days. Typically only one family member was allowed to be in ICU with a patient.

I can't imagine what sort of chaos would have devolved in ICU if visitors were messing with tubes, panicking, fainting, and causing a huge disturbance. Everyone would have been compromised.

In my son's case, the registered nurses explained the tubes, and the potassium drip in terms of safe zone numbers. When the numbers were wrong, I would mention it to the RN.

I'm wondering what happened such that the grandmother was handling a suction tube at any time when the child was in ICU? If that was going on before everything went wrong on December 11, then the family has every reason to delay an autopsy that might reveal tears from tube jabbing on soft tissue. Now that I think about it, jabs from a suction tube would be more evident during an autopsy because there would have been no post-trauma healing ... since she was deceased. She also had a heart attack, and I've read that obesity and diabetes were medical issues. She also wet the bed - she had uncontrolled urination. In addition, she had sleep apnea, meaning that she stopped breathing while she was sleeping. In addition, she had breathing problems. Bleeding is a known risk associated with two of the three surgeries that this child had. She had several other medical issues that reduced the probability of a speedy, full recovery ... meaning that she became that one in 15,000 children (out of a total 530,000 tonsillectomies annually) that represents the mortality rate in children under the age of 15 in the US that undergo a tonsillectomy.

There has to be an autopsy because the family wants an explanation. The coroner is the best person to provide that information.

 

[BeginnersLuck]

Here is a different case. It's not the same as Jahi's, this child was not brain dead. It's also a different state with most likely different laws. I'm only posting to show how it ended in court.

The case with Jahi, may very well end up with laws that further define set time periods in which hospitals have to abide by, before removal of ventilator support once brain death is declared.

Sun Hudson case - Wikipedia, the free encyclopedia

 

[Isabelle]

IIRC, Herat or KZ described there being an artery proximal to the tonsils. A branch of the carotid maybe? So, for reasons of my post, let's say that the blood loss may have been from an arterial bleed. Theoretically, A person can bleed out in 3 minutes. So the nurses and doctors would have to have been trying to stem the bleeding, treat vital signs and related symptoms all within 3 minutes or so. OMG what a nightmare for everyone. I have no idea how to stem an arterial bleed from inside the throat other than to try and visualize and throw a stitch in? No clue. Hopefully KZ and Herat could share how they do that. TIA.

BTW, I am not stating this definitively happened. But if something like this did occur, it might explain the "how" part. Once Jahi is transferred out, is CHO still bound by HIPAA not to disclose what happened?

In an earlier thread I posted a link to an article explaining the use of an oropharyngeal airway mask (I think that was the item and wonder if it has an inflatable balloon) by Korean medical personnel to stop bleeding from tonsillectomy in pediatric patient. Your thoughts appreciated. So glad to be 99.9% retired. Oral/gastric/rectal bleeding is so stressful. OT: worst was bleed from esophageal varices seen in ER while a nursing student. Large numbers of pints of blood were delivered to ER on large trays. This man did not survive.

Eta see post 1013 of 12/29. Can't figure out copy and paste on iPad mini. Correct name for airway is laryngeal mask airway and seems it does have a balloon. Thanks.

 

[otto]

Here is a different case. It's not the same as Jahi's, this child was not brain dead. It's also a different state with most likely different laws. I'm only posting to show how it ended in court.

The case with Jahi, may very well end up with laws that further define set time periods in which hospitals have to abide by, before removal of ventilator support once brain death is declared.

Sun Hudson case - Wikipedia, the free encyclopedia

Those cases seem to be more about removing a feeding tube from a person that is still breathing, but is in a permanent vegetative state (worse than a coma). The deceased child in question was never given a feeding tube because she died before one was necessary. She could not breath on her own after Dec 11. It sounds like the problem happened Dec 11, but she was kept on a ventilator until the 12th. Apparently the family wanted more time and the hospital gave more time. Then the family wanted until after the Christmas and a court ordered it, in part because a media frenzy was growing. That has now been extended using the same argument that was given the first time: that the family needs time to make arrangements to a facility where the patient has been accepted as a deceased body. The family has had a month to make the arrangements.

The next question is: how much time is reasonable. Enough time has passed that it should no longer be considered cruel that the hospital wants to put an end to this by following protocol and having the coroner sign off. Once the coroner has signed off, then the status of the body is written in stone as: deceased. This is not what the family wants, but it looks like the only way that the hospital will allow the body to leave the facility is via the coroner, and the courts agree. The papers that the lawyer is referring to probably relate to something other than a funeral home transporting a dead body.

Is her brain deprived of cerebral spinal fluid? I have read that her brain was deprived of blood, but that doesn't seem right. If her heart is pumping, then her blood should be circulating. I can't imagine that the blood suddenly bypasses the brain, but I could understand that CSF is no longer functioning (is that related to the pituitary gland?). If that's the case, then the brain is truly flat dead ... a mass with no texture.

 

[jjenny]

From what has been reported, the test showed she does not have blood flow to her brain. I don't know how many extensions they can get on "extracting" her from the hospital either.
Seems like lawyer wants to ask for another one.

 

[txsvicki]

I guess 35 kids die each year from tonsillectomies in this country. That's still too high for me.

 

[I Object!]

And his comments included a multi-word euphemism for 'death certificate'.

He specifically deleted multiple references to "airvac" from the settlement agreement posted yesterday and changed them to transfer team or similar.

jmo

 

[Herat]

Is her brain deprived of cerebral spinal fluid? I have read that her brain was deprived of blood, but that doesn't seem right. If her heart is pumping, then her blood should be circulating. I can't imagine that the blood suddenly bypasses the brain, but I could understand that CSF is no longer functioning (is that related to the pituitary gland?). If that's the case, then the brain is truly flat dead ... a mass with no texture.

Warning: My description may be graphic and unpleasant and if you think it will disturb you, then please don't read any further.

In brain death, the brain and brainstem lose their solid integrity and the tissue softens and begins to collapse. It does not resemble the pictures you see of brain specimens. The relatively avascular structures of the dura mater and other membranes stay intact, but they support only a softening aggregate of dead neuronal and supportive cells that lack the recognizable anatomic landmarks. The blood vessels constricted in the original anoxic insult and no more inflow of arterial blood happens. No CSF circulates. What is there stays and gradually the collapsed neural tissue just sort of coagulates. The pituitary is also infarcted. CSF is not related to the pituitary. One of the hallmarks of brain death is the hormonal deficits from the non-functional pituitary. There are good examples of the scans of brain dead individuals and you can see the absolute lack of blood perfusion in the brain.

Brain death is not just a functional finding by neurologist's examination, or abnormal images on scanning, it is also a very obvious pathologic finding of severe damage at autopsy. It is dramatic, massive, and absolutely irreversible.

As I looked at those scans on the site with examples of brain dead findings, it made me realize, once again, that Jahi should exist as a memory of a very loved happy child, and that the person that was Jahi not longer exists. It is indeed cruel to perpetuate vital activities into the physical shell that exists. Allowing that physical shell to further deteriorate is a kind of torture and should not be allowed to happen. The vent should have been turned off three weeks ago.

 

[I Object!]

Oh, they don't want to sit with them. They want to fly them across the country so former hairdressers can sit with them. No offense to any current or former hairdressers.

The US could be the first country in the world to build facilities to house dead people so that the families can just sit with their deceased relatives.

 

[Herat]

There has to be an autopsy because the family wants an explanation. The coroner is the best person to provide that information.

There will be an autopsy because her death falls under the statutes of deaths that are investigated by the coroner, by state law. What the family wants is not relevant here.

It's not done because the coroner is the best person. The coroner's office has the legal duty to investigate and report the findings. You can be sure board certified forensic pathologists (and I mean pleural), probably also with a forensic neuropathologist will be performing the autopsy.

 

[otto]

From what has been reported, the test showed she does not have blood flow to her brain. I don't know how many extensions they can get on "extracting" her from the hospital either.
Seems like lawyer wants to ask for another one.

If there is no blood flow to the brain, wouldn't that meant that there is also no blood flow to the arms and legs?

If the heart is beating, doesn't that mean that there is blood circulation? In this case, the blood flow is artificially stimulated with a breathing machine (ventilator). If there is blood flow to the arms and legs, why wouldn't there be blood flow to the head ... since it's on a circulation system?

 

[K_Z]

In an earlier thread I posted a link to an article explaining the use of an oropharyngeal airway mask (I think that was the item and wonder if it has an inflatable balloon) by Korean medical personnel to stop bleeding from tonsillectomy in pediatric patient. Your thoughts appreciated. So glad to be 99.9% retired. Oral/gastric/rectal bleeding is so stressful. OT: worst was bleed from esophageal varices seen in ER while a nursing student. Large numbers of pints of blood were delivered to ER on large trays. This man did not survive.

Eta see post 1013 of 12/29. Can't figure out copy and paste on iPad mini. Correct name for airway is laryngeal mask airway and seems it does have a balloon. Thanks.

I know a thing or 2 about LMA's (lol!), so I can discuss a little.

First, if you stick an LMA into a post surgical airway bleeding like a sieve, it's gonna bleed MORE, lol! The gold standard is cuffed ETT. That said, LMA's have a valid and lively role in management of the difficult airway.

There are a vast number of laryngeal mask airways on the market- some with suction ports, some are disposable, etc. LMA's are always part of the difficult airway algorithm, and there are some that feel the cuff on the LMA better protects the lungs from aspiration of blood than other methods, in the situation of post surgical hemorrhage of tonsil beds. In addition, the patient can be intubated thru the ventilation port, using a smaller ETT, and the LMA can be left in place. But the gold standard is not LMA, but cuffed ETT. Intubation can be accomplished under direct visualization, or using various camera devices, and other adjunctive methods.

The cuff of the LMA sits considerably lower than the tonsillar beds, so the goal would not be tamponade of the hemorrhage, but rather, an attempt to get control of the airway in the face of serious hemorrhage (and aspiration). Anesthetists use LMA's every day in the OR- they are commonplace there, but rare anywhere else in the hospital. They would be part of a difficult airway cart. In this discussion, I'm not talking about LMA's for routine surgery-- only the use of an LMA in a difficult airway scenario, which is what the poster refers to.

Here are some pics and very basic info on LMA's:

http://www.bing.com/images/search?q=laryngeal+mask+airway&qpvt=laryngeal+mask+airway&FORM=IGRE

Laryngeal mask airway - Wikipedia, the free encyclopedia

http://www.deepdyve.com/lp/elsevier...p-to-protect-the-lungs-and-control-qruueETwEm

** NOTE: the patient in this discussion had a posterior tear in the throat area from conventional intubation attempts below where a tonsil bed would be, so tamponade was a reasonable goal.


Airway management with all of the various approaches is a considerably lengthy topic that I'm not going to try to boil down to a brief post at this point.

Safe to say that airway management was a concern at the time of Jahi's hemorrhage and cardiac arrest, and we have not heard ANY comments from the family that the team was unable to secure the airway. All of their comments have been related to the amount and rapidity of hemorrhage. So, my assumption at this point is that there was not a crisis obtaining control of the airway itself. The tonsil beds are the likely cause of hemorrhage, compared to the UPPP area, IMO.

I would be interested in knowing at what point the 4 units of blood were ordered and given, how fast were they given (ie, were all 4 units called for at once? Were they running 2 units at a time in different peripheral IV's? Were they using a Level One or similar infuser? etc.) You see, we really have very little information beyond "4 units of blood given" as a statement from the family.

When there is post tonsillectomy hemorrhage, everyone is alert. The gold standard is return to the OR. The tonsil beds are not easily compressible for tamponade, though some recommend epi soaked gauze on a magill forceps as a temporary measure.

Here is a very nice summary of post tonsillectomy hemorrhage, complete with a beautiful and reassuring pic of "char" on the tonsil beds-- dry as a bone, in this pic.

http://pedemmorsels.com/post-tonsillectomy-hemorrhage/

In extreme cases of hemorrhage, I have heard of intraoperative ligation of the carotid on the hemorrhaging side, to get control of the situation. Most of the time, post tonsillar hemorrhage is treated with additional cautery in the operating room, to further coagulate (char) the area.

(This is a long post, but I feel I've barely touched on the pertinent areas. Airway management and post tonsillectomy hemorrhage is a big topic!)

 

[K_Z]

If there is no blood flow to the brain, wouldn't that meant that there is also no blood flow to the arms and legs?

If the heart is beating, doesn't that mean that there is blood circulation? In this case, the blood flow is artificially stimulated with a breathing machine (ventilator). If there is blood flow to the arms and legs, why wouldn't there be blood flow to the head ... since it's on a circulation system?

BBM. No. Circulation to arms and legs is still occurring, but mechanisms to control the dilation and constriction of vessels is compromised.

Blood flow to the brain ceases due to swelling and death of brain tissue.

 

[MsSeal]

Is her brain deprived of cerebral spinal fluid? I have read that her brain was deprived of blood, but that doesn't seem right. If her heart is pumping, then her blood should be circulating. I can't imagine that the blood suddenly bypasses the brain, but I could understand that CSF is no longer functioning (is that related to the pituitary gland?). If that's the case, then the brain is truly flat dead ... a mass with no texture.

I found this YT by a neurosurgeon with an animated description of brain death. He speaks slowly and it is very elementary but I think is a good explanation for those the lay person.

[video=youtube;Ffqz-vKZO5Q]http://www.youtube.com/watch?v=Ffqz-vKZO5Q[/video]

This is a demo of the brain stem tests. It is from the UK but I imagine it is a standard test.

Brain Stem Testing - A Demonstration - YouTube

I realize both of these videos can be disputed for accuracy but they do seem to be a good guidline for educating the lay person. Interesting. I also realize if you don't believe in brain stem testing or brain death all of this moot.

 

[Herat]

If there is no blood flow to the brain, wouldn't that meant that there is also no blood flow to the arms and legs?

If the heart is beating, doesn't that mean that there is blood circulation? In this case, the blood flow is artificially stimulated with a breathing machine (ventilator). If there is blood flow to the arms and legs, why wouldn't there be

The brain is a highly oxygen-sensitive organ, actually far more so than cardiac or renal tissue. The blood supply to the brain is also more vulnerable than in other organs or extremities. The vessels to the brain constricted and shut off with the major damage and there is no more circulation. The vascular scans in brain dead individuals show the hallmark big nose where blood supply that would have entered the brain through the carotids is shunted to the nose and other facial structures. There is no blood flow into the brain.

Other organs are also damaged due to the hypotensive/anoxic event. She probably has some kidney damage, although she is young enough that it might not affect function that much. The anoxic injury can cause sections of the bowel to die.

There are also other circulatory problems. Our daily muscle movements act as a secondary pump to promote circulation. In a brain dead patient with no volitional muscular activity, the secondary pumping action doesn't exist, and fluid begins to seep into the most peripheral tissues - the skin. The skin and underlying soft tissues become edematous and susceptible to breakdown.

 

[otto]

If a person that is declared dead has been kept breathing on a ventilator for two long, I wonder if, during the 18 minutes it takes for the heart/circulation reflex to stop, there is heaving or whether it's quiet with lower blood pressure.

This situation sure brings up weird questions.

 

[K_Z]

Warning: My description may be graphic and unpleasant and if you think it will disturb you, then please don't read any further.

In brain death, the brain and brainstem lose their solid integrity and the tissue softens and begins to collapse. It does not resemble the pictures you see of brain specimens. The relatively avascular structures of the dura mater and other membranes stay intact, but they support only a softening aggregate of dead neuronal and supportive cells that lack the recognizable anatomic landmarks. The blood vessels constricted in the original anoxic insult and no more inflow of arterial blood happens. No CSF circulates. What is there stays and gradually the collapsed neural tissue just sort of coagulates. The pituitary is also infarcted. CSF is not related to the pituitary. One of the hallmarks of brain death is the hormonal deficits from the non-functional pituitary. There are good examples of the scans of brain dead individuals and you can see the absolute lack of blood perfusion in the brain.

Brain death is not just a functional finding by neurologist's examination, or abnormal images on scanning, it is also a very obvious pathologic finding of severe damage at autopsy. It is dramatic, massive, and absolutely irreversible.

As I looked at those scans on the site with examples of brain dead findings, it made me realize, once again, that Jahi should exist as a memory of a very loved happy child, and that the person that was Jahi not longer exists. It is indeed cruel to perpetuate vital activities into the physical shell that exists. Allowing that physical shell to further deteriorate is a kind of torture and should not be allowed to happen. The vent should have been turned off three weeks ago.

Excellent summary. It is quite unpleasant to say this, but I suspect her brain will be so softened that it will not be able to be sent for sectioning and path. That is the absolute truth of brain death. There is no recovery. None.

 

[otto]

BBM. No. Circulation to arms and legs is still occurring, but mechanisms to control the dilation and constriction of vessels is compromised.

Blood flow to the brain ceases due to swelling and death of brain tissue.

What role does cerebral spinal fluid play in terms of ensuring that the brain mechanism functions? What is blood nose in brain dead people?

 

[K_Z]

The brain is a highly oxygen-sensitive organ, actually far more so than cardiac or renal tissue. The blood supply to the brain is also more vulnerable than in other organs or extremities. The vessels to the brain constricted and shut off with the major damage and there is no more circulation. The vascular scans in brain dead individuals show the hallmark big nose where blood supply that would have entered the brain through the carotids is shunted to the nose and other facial structures. There is no blood flow into the brain.

Other organs are also damaged due to the hypotensive/anoxic event. She probably has some kidney damage, although she is young enough that it might not affect function that much. The anoxic injury can cause sections of the bowel to die.
There are also other circulatory problems. Our daily muscle movements act as a secondary pump to promote circulation. In a brain dead patient with no volitional muscular activity, the secondary pumping action doesn't exist, and fluid begins to seep into the most peripheral tissues - the skin. The skin and underlying soft tissues become edematous and susceptible to breakdown.

BBM. Exactly. And if there is bowel infarction, a feeding tube is pretty much a moot point. No absorption. And the gut then begins to break down from the infarction.

 

[K_Z]

What role does cerebral spinal fluid play in terms of ensuring that the brain mechanism functions? What is blood nose in brain dead people?

Herat explained that in the post above. Also called "hot nose".

Post 378, from Herat:

The vascular scans in brain dead individuals show the hallmark big nose where blood supply that would have entered the brain through the carotids is shunted to the nose and other facial structures. There is no blood flow into the brain.