UK - Nurse Lucy Letby Faces 22 Charges - 7 Murder/15 Attempted Murder of Babies #11

[LorriB]

This is the article Dr. J found and it was presented to the court. (edit, let me look back for the link, will produce) This article is from 1989 when there was no surfactant and modern lung protective practices were not available. At this time, neonatologists would have to use very high ventilator pressure, which resulted in air being pushed into circulation from the lungs. That is how the researchers had enough cases to write an article on.

EDIT: Here is the link where Dr. J mentions this article by name "Pulmonary Vascular Embolism in the Newborn." It's not clear to me if the actual article was presented to the jurors or if Dr. J merely summarized it's contents. It's a very interesting article.

Consultant tells trial skin marks ‘didn’t fit with anything he’d seen’

Nurse Lucy Letby denies the murders of seven babies and the attempted murders of 10 others.

www.expressandstar.com

Ah I hadn't realised it was already mentioned, thanks for noting.

To be clear, I wasn't suggesting it explained the presence of air in the babies, but it does explore symptoms and causes which I found interesting.

I am not medically trained so I won't pretend to understand it all. Does it mean the pressure of CPAP isn't enough to cause the condition?

 

[marynnu]

I’m wondering if there is anything about modern medicine that might make an air embolism more survivable? Like resus methods etc ? Looking at that paper it’s a reflection of AE via the ventilator so as you mentioned might involve a much higher volume of air thus increasing the lethality compared to a AE via syringe.

Modern ventilation is completely different. It's responsive to the baby's needs. We also have CPAP which means ventilation time can be reduced, or even avoided entirely. So the profound lung damage we saw back in the 80s has all but disappeared.

 

[marynnu]

Ah I hadn't realised it was already mentioned, thanks for noting.

To be clear, I wasn't suggesting it explained the presence of air in the babies, but it does explore symptoms and causes which I found interesting.

I am not medically trained so I won't pretend to understand it all. Does it mean the pressure of CPAP isn't enough to cause the condition?

CPAP doesn't damage the lungs at all, IMO.

 

[Sweeper2000]

Modern ventilation is completely different. It's responsive to the baby's needs. We also have CPAP which means ventilation time can be reduced, or even avoided entirely. So the profound lung damage we saw back in the 80s has all but disappeared.

CPAP doesn't damage the lungs at all, IMO.

Just wondering if it might be applicable to the case with the butterfly needles? The cpap pressure wouldn’t need to damage the lining of the lungs as the damage had already been done?

 

[GoodDayToYouSir]

Re. the difficulty of pushing air through the line, as we've heard many times nurses prime all lines with fluid to remove air. With wide bore tubes, like the drips most if us have probably seen, gravity is enough. With narrow bore lines you have to push the air out with the syringe. Either way it's evidently easy.
All JMO.

Probably a really stupid question, but in terms of the medical mechanics, how do you treat an air embolism that’s been injected into the bloodstream?

These cases talk about resuscitation efforts (sometimes successful, sometimes not) for babies with suspected AE, which seems to involve chest compressions, oxygen, injections of adrenaline. I’m just trying to picture how any of this actually gets rid of an air embolism. Because presumably once it’s in the blood, you either need to get the air bubble back out through the tube it went in or get it to pop? Is that what the adrenaline and the chest compressions do: make the air bubble pop so that the baby recovers?

(Sorry, I have no medical background whatsoever).

 

[magikarpmagikarp]

I’m wondering if there is anything about modern medicine that might make an air embolism more survivable? Like resus methods etc ? Looking at that paper it’s a reflection of AE via the ventilator so as you mentioned might involve a much higher volume of air thus increasing the lethality compared to a AE via syringe.

Can you explain to me where you are going with this line of questioning?

Ah I hadn't realised it was already mentioned, thanks for noting.

To be clear, I wasn't suggesting it explained the presence of air in the babies, but it does explore symptoms and causes which I found interesting.

I am not medically trained so I won't pretend to understand it all. Does it mean the pressure of CPAP isn't enough to cause the condition?

I'm going disclaim once again that I have not undergone the verified expert process, therefore you should not regard anything I have to say as anything but my opinion.

Back in 1989, without surfactant, preemie lungs were very stiff and hard to keep open. To help them, very very high ventilator pressures were used in combination with a breathing tube. This often led to some pretty serious lung damage, both short and long term. The short term damage included pneumothorax, pulmonary interstitial emphysema, and so on. PVE (the pulmonary vascular embolism) was just one of these complications. In this case, the alveoli rupture which is what allows air to enter circulation. Pneumothorax and PIE still happen at times, but PVE doesn't, presumably because it requires significantly higher pressures to produce. This article describes how the babies it happened to were already incredibly ill, already on maximal ventilator support and 100% oxygen.

The reason why this article is significant is because the researchers had observed so many cases of vascular air embolism in their patients that they were able to describe skin changes that might not always be seen. There is no reason that how the air entered circulation should change how it acts once it is there:

From this article:
"Blanching and migrating areas of cutaneous pallor were noted in several cases and, in one of our own cases we noted bright pink vessels against a generally cyanosed cutaneous background. This we attributed to direct oxygenation of erythrocytes adjacent to free air in the vascular system, while the tissues continued to be poorly perfused and oxygenated."

IMO, CPAP, unless somehow grossly misused, would never cause something like this and a baby would not recover after a mere thirty minutes of resuscitation.

 

[magikarpmagikarp]

Probably a really stupid question, but in terms of the medical mechanics, how do you treat an air embolism that’s been injected into the bloodstream?

These cases talk about resuscitation efforts (sometimes successful, sometimes not) for babies with suspected AE, which seems to involve chest compressions, oxygen, injections of adrenaline. I’m just trying to picture how any of this actually gets rid of an air embolism. Because presumably once it’s in the blood, you either need to get the air bubble back out through the tube it went in or get it to pop? Is that what the adrenaline and the chest compressions do: make the air bubble pop so that the baby recovers?

(Sorry, I have no medical background whatsoever).

Treatment is supportive care (in this case chest compressions and positive pressure ventilation) until the body filters the air back out in the lungs - if it can do so. Babies deteriorating and then suddenly recovering after a very prolonged resuscitation (30 minutes is a long time for babies) may fit with this picture. IMO.

edit - small amounts of air do not need to be treated. Your body will just filter it out at the lungs with no negative effects. It's when the air gets to the capillaries around the lungs and displaces all the blood that's supposed to be receiving oxygen or gets up into the brain or to the coronary arteries that a collapse will occur.

 

[magikarpmagikarp]

Just wondering if it might be applicable to the case with the butterfly needles? The cpap pressure wouldn’t need to damage the lining of the lungs as the damage had already been done?

No the damage described in the article is diffuse, over large parts of the lungs, specifically to the air sacks. A butterfly needle would cause local damage. IMO.

 

[Sweeper2000]

Can you explain to me where you are going with this line of questioning?



I'm going disclaim once again that I have not undergone the verified expert process, therefore you should not regard anything I have to say as anything but my opinion.

Back in 1989, without surfactant, preemie lungs were very stiff and hard to keep open. To help them, very very high ventilator pressures were used in combination with a breathing tube. This often led to some pretty serious lung damage, both short and long term. The short term damage included pneumothorax, pulmonary interstitial emphysema, and so on. PVE (the pulmonary vascular embolism) was just one of these complications. Pneumothorax and PIE still happen at times, but PVE doesn't, presumably because it requires significantly higher pressures to produce. This article describes how the babies it happened to were already incredibly ill, already on maximal ventilator support and 100% oxygen.

The reason why this article is significant is because the researchers had observed so many cases of vascular air embolism in their patients that they were able to describe skin changes that might not always be seen. There is no reason that how the air entered circulation should change how it acts once it is there:

From this article:
"Blanching and migrating areas of cutaneous pallor were noted in several cases and, in one of our own cases we noted bright pink vessels against a generally cyanosed cutaneous background. This we attributed to direct oxygenation of erythrocytes adjacent to free air in the vascular system, while the tissues continued to be poorly perfused and oxygenated."

IMO, CPAP, unless somehow grossly misused, would never cause something like this and a baby would not recover after a mere thirty minutes of resuscitation.

That paper says it’s almost invariably fatal. Alleged intravenous AE is present in many of the cases including some without a fatality. Don’t see why something as consistently lethal as AE would be seemingly survivable in some of the cases without changes in its treatment or it’s application.

 

[Officer Dibble]

My strong view is that units with vulnerable patients - babies/old people with severe dementia - should be equipped with cctv.

Such patients cannot complain, they are literally at the mercy of staff.

And some disturbed people take advantage

I followed a horrible case on WS of an American, mute, paralysed girl who was regularly raped at night by a male nurse
It all came to light when she gave birth to a baby.
The perp was jailed.

GUILTY - AZ - Sex abuse probe after patient in vegetative state has baby, Phoenix, 29 Dec 2018 *Arrest*

Woman in vegetative state gives birth in Phoenix health care facility | Daily Mail Online A sex abuse investigation is underway in Phoenix after a woman in a vegetative state in a healthcare facility for 10 years gave birth. Staff at Hacienda HealthCare in Phoenix, AZ had been giving round...

www.websleuths.com

that is horrific

 

[marynnu]

Just wondering if it might be applicable to the case with the butterfly needles? The cpap pressure wouldn’t need to damage the lining of the lungs as the damage had already been done?
[/QUOTE
Wasn't this baby ventilated though? I'd just say that what I'm getting from the article is that it's air pressure which led to the emboli. And as far as I know there's been no suggestion that damage from a needle could cause this. Not sure of any of this though!

 

[magikarpmagikarp]

That paper says it’s almost invariably fatal. Alleged intravenous AE is present in many of the cases including some without a fatality. Don’t see why something as consistently lethal as AE would be seemingly survivable in some of the cases without changes in its treatment or it’s application.

Ok thank you for clarifying. So yes, part of it is the sheer amount of air entering the circulation. The other thing is these (already seriously ill) babies have air entering through severely damaged alveoli, and it doesn't stop until the alveoli heal. Resuscitation doesn't fix that. You could do chest compressions all day and the alveoli aren't going to heal back in that time. But a baby who had a limited amount of air injected into the circulation might possibly be very difficult to revive (30 mins compressions is a long time) and it would seem like nothing is working, then all of suddenly revive and be relatively ok because the air has finally filtered out and their body is otherwise ok. IMO.

 

[LorriB]

Thanks for the informative replies.

I think baby B was ventilated at birth. It says here
Recap: Lucy Letby trial, Friday, October 21

Just for ventilated babies though I think?

 

[katydid23]

It’s referring to the insulin poisoning isn’t it? There was no dramatic collapse of Baby L, except the increased dextrose, the poisoning didn’t become clear until some time later.

It was said that he 'deteriorated' in his crib.
v. 1. To grow worse in function or condition. 2. To weaken

Lucy Letby trial: Nurse ‘sent sympathy card to parents of baby she murdered’

The alleged murder of child I was ‘extreme example even by the standards of this overall case’, court heard

www.independent.co.uk

Letby ‘attacked two sets of newborn twins in similar circumstances’

Letby attempted to murder twin boys, child L and child M, in “similar” circumstances to two other twin boys she attacked, the court heard.

In August 2015, it is alleged Letby murdered child E by injecting air into his bloodstream and the next day attempted to kill his brother, child F, by insulin poisoning.

Letby was working a day shift on 9 April 2016 when she is said to have given an unauthorised dose of insulin to child L. While that attack was under way, Mr Johnson said, Letby turned her attentions to his brother, child M, by injecting air into his circulation.

Mr Johnson said because Letby failed to kill child F, she decided to increase the dose of insulin administered to child L.

Child M came “close to death” after his heart rate and breathing dropped dramatically without warning, Mr Johnson said, but improved on the night shift that followed and went on to make a speedy recovery. Mr Johnson said: “We suggest these cases [child E, F, L and M] are similar in that one of each pair suffered an insulin overdose whereas it is suggested the other suffered an air embolism.”

 

[Sweeper2000]

I know this one’s more out of personal interest but it would be very interesting to find out how the bubble of air in the heart would eventually shift. don’t answer if it’s a waste of time

 

[WaxLyrical]

It was said that he 'deteriorated' in his crib.
v. 1. To grow worse in function or condition. 2. To weaken

Lucy Letby trial: Nurse ‘sent sympathy card to parents of baby she murdered’

The alleged murder of child I was ‘extreme example even by the standards of this overall case’, court heard

www.independent.co.uk

Letby ‘attacked two sets of newborn twins in similar circumstances’

Letby attempted to murder twin boys, child L and child M, in “similar” circumstances to two other twin boys she attacked, the court heard.

In August 2015, it is alleged Letby murdered child E by injecting air into his bloodstream and the next day attempted to kill his brother, child F, by insulin poisoning.

Letby was working a day shift on 9 April 2016 when she is said to have given an unauthorised dose of insulin to child L. While that attack was under way, Mr Johnson said, Letby turned her attentions to his brother, child M, by injecting air into his circulation.

Mr Johnson said because Letby failed to kill child F, she decided to increase the dose of insulin administered to child L.

Child M came “close to death” after his heart rate and breathing dropped dramatically without warning, Mr Johnson said, but improved on the night shift that followed and went on to make a speedy recovery. Mr Johnson said: “We suggest these cases [child E, F, L and M] are similar in that one of each pair suffered an insulin overdose whereas it is suggested the other suffered an air embolism.”

Yes I’m not arguing that the twins weren’t attacked allegedly. There doesn’t appear to be any dispute that L was poisoned and M had a dramatic collapse.

To go back to the original point I don’t think Dr J was involved in bringing L back from the ‘brink of death’ and so I doubt L would have any impact on Dr J’s notes for M. JMO.

 

[magikarpmagikarp]

I know this one’s more out of personal interest but it would be very interesting to find out how the bubble of air in the heart would eventually shift. don’t answer if it’s a waste of time

Well anything in the bloodstream will generally only move if the blood is moving. Blood usually moves because it's pumped by the heart, but during a resuscitation, chest compressions are what move the heart so that the heart can move the blood. You can kind of draw your own conclusions from there.

 

[katydid23]

Yes I’m not arguing that the twins weren’t attacked allegedly. There doesn’t appear to be any dispute that L was poisoned and M had a dramatic collapse.

To go back to the original point I don’t think Dr J was involved in bringing L back from the ‘brink of death’ and so I doubt L would have any impact on Dr J’s notes for M. JMO.

Dr J didn't do his deep dive research on the AE's until after L and M's cases were over. So I don't see why that should have any impact upon his notes that day?

As to L and M, they were both having sudden, unexpected health issues at the same time. I think that could have an impact upon him. JMO

 

[esther43]

Can you explain to me where you are going with this line of questioning?



I'm going disclaim once again that I have not undergone the verified expert process, therefore you should not regard anything I have to say as anything but my opinion.

Back in 1989, without surfactant, preemie lungs were very stiff and hard to keep open. To help them, very very high ventilator pressures were used in combination with a breathing tube. This often led to some pretty serious lung damage, both short and long term. The short term damage included pneumothorax, pulmonary interstitial emphysema, and so on. PVE (the pulmonary vascular embolism) was just one of these complications. In this case, the alveoli rupture which is what allows air to enter circulation. Pneumothorax and PIE still happen at times, but PVE doesn't, presumably because it requires significantly higher pressures to produce. This article describes how the babies it happened to were already incredibly ill, already on maximal ventilator support and 100% oxygen.

The reason why this article is significant is because the researchers had observed so many cases of vascular air embolism in their patients that they were able to describe skin changes that might not always be seen. There is no reason that how the air entered circulation should change how it acts once it is there:

From this article:
"Blanching and migrating areas of cutaneous pallor were noted in several cases and, in one of our own cases we noted bright pink vessels against a generally cyanosed cutaneous background. This we attributed to direct oxygenation of erythrocytes adjacent to free air in the vascular system, while the tissues continued to be poorly perfused and oxygenated."

IMO, CPAP, unless somehow grossly misused, would never cause something like this and a baby would not recover after a mere thirty minutes of resuscitation.

Interesting read and interpretation. I am not medical at all but in trying to understand why some episodes of alleged air embolism were fatal and some non fatal, I wondered if it depended on where in the blood circulatory system the air bubble ended up for example if it ended up in the chamber's of the heart could it cause cardiac arrest? Then what if resuscitation and ventilation moved the air bubble away from the heart and it's the vigorous pumping of blood that is helping to shift it along and eventually pop?

 

[esther43]

Can you explain to me where you are going with this line of questioning?



I'm going disclaim once again that I have not undergone the verified expert process, therefore you should not regard anything I have to say as anything but my opinion.

Back in 1989, without surfactant, preemie lungs were very stiff and hard to keep open. To help them, very very high ventilator pressures were used in combination with a breathing tube. This often led to some pretty serious lung damage, both short and long term. The short term damage included pneumothorax, pulmonary interstitial emphysema, and so on. PVE (the pulmonary vascular embolism) was just one of these complications. In this case, the alveoli rupture which is what allows air to enter circulation. Pneumothorax and PIE still happen at times, but PVE doesn't, presumably because it requires significantly higher pressures to produce. This article describes how the babies it happened to were already incredibly ill, already on maximal ventilator support and 100% oxygen.

The reason why this article is significant is because the researchers had observed so many cases of vascular air embolism in their patients that they were able to describe skin changes that might not always be seen. There is no reason that how the air entered circulation should change how it acts once it is there:

From this article:
"Blanching and migrating areas of cutaneous pallor were noted in several cases and, in one of our own cases we noted bright pink vessels against a generally cyanosed cutaneous background. This we attributed to direct oxygenation of erythrocytes adjacent to free air in the vascular system, while the tissues continued to be poorly perfused and oxygenated."

IMO, CPAP, unless somehow grossly misused, would never cause something like this and a baby would not recover after a mere thirty minutes of resuscitation.

Interesting read and interpretation. I am not medical at all but in trying to understand why some episodes of alleged air embolism were fatal and some non fatal, I wondered if it depended on where in the blood circulatory system the air bubble ended up for example if it ended up in the chamber's of the heart could it cause cardiac arrest? Then what if resuscitation and ventilation moved the air bubble away from the heart and it's the vigorous pumping of blood that is helping to shift it along and eventually cause it to pop?