Saturday, October 4, 2014

Jahi McMath: Alive Again?

GUEST ENTRY BY KZ, a Certified Registered Nurse Anesthetist.

I asked KZ to weigh in on the recent developments in the Jahi McMath case. Enjoy! Sprocket.
T&T''s Jahi McMath Case Quick Links - Case Coverage.

Jahi McMath: Alive Again?
Well, I took one for the team, and subjected myself to watching most of the Dolan Law Firm press conference on JahiMcath last evening. It was an exercise in visual, auditory, and intellectual torture, IMO. I actually quit watching with 30 min to go, and I’m not sure if I have the fortitude to go back and finish it.

Here is a link to the video conference (skip to 13:47 to start—the first 13 min are set up and chatter by media).

Some of my observations:

Dolan had 9 months to prepare for this volley, and IMO, he was woefully unprepared, and tremendously disorganized—which is rather surprising for an attorney. He did have a few nice powerpoint picture slides—ones that any 6th grader could have put together in the 15 min before the press conference. He didn’t have control of his experts by phone, and had no idea what they were going to say, and how far into the weeds they would go when allowed to talk. They rambled on and on and on, and whatever salient points they had were very difficult to ascertain. (Maybe that was the whole point—“baffle ‘em with BS!”)

What I did glean is that the psychologist Elena Labkovsky who did the EEG, actually does not have any experience at all with doing EEG’s for establishing brain death. Her experience with EEG’s is in living patient with significant mental health conditions—which is highly, highly different from traumatic brain conditions. She is not a medical doctor, she is a psychologist—not even a psychiatrist. I highly doubt that she would be qualified as an expert in court for purposes of establishing brain death. Just because she knows how to hook up the electrodes to the patient and the apparatus, does not mean she is qualified to interpret the findings in a case such as this. 

For example, a technician with a high school education can be trained to hook up an EEG or EKG machine, but they are not qualified to interpret the diagnostic test. Reputable medical centers do not use psychologists to administer EEGs to establish brain death, nor do they use psychologists to interpret the findings of EEGs in cases of acute brain injury. There is a place within healthcare for psychologists to consider the results of EEGs in the care of patients with mental health conditions, but this is not such a case, IMO. And as Dr. Arthur Kaplan commented in an article, he could detect some electricial activity in a bowl of jello. (If you doubt this, remember the potato- as- a- battery experiments and lemon battery experiments from grade school?)

Dr. Machado and Phillip Defina talked at length about brain stem function versus higher cerebral activity. This is where the conversation went far into the weeds, IMO. They both seem to embrace that total brain stem death is separate from higher cerebral death. If I understood their garbled audio correctly, they want the brain stem to be considered separately from the higher cerebral portions of the brain. (Again, reference the lemon battery experiments above for my opinion on this.) This is VERY far outside of any kind of mainstream medical or scientific thinking about total brainstem functioning.

They also want to reject the “integrated functioning” explanations of brain death, such that if there is cell functioning, or cell signals anywhere in the body or remnants of brain tissue, that the person should not properly be considered dead. Again, my opinion is that cells can be sustained outside the body for a long time, kidneys and other solid organs can survive outside the body during preparation for transplant, so I’m not sure how an argument about somatic support of cells and organs equals “not brain dead”. 

There appears to be some discernible structure left to Jahi’s brain. MRI appears to establish that. It does mean that whatever changes have occurred inside her skull have not resulted in complete liquefaction of the brain tissue. That still doesn’t mean she is alive, or that her brain has any function .The remnants of structure on MRI cannot automatically be ascribed as living, functioning tissue. Plenty of people have failed, dead organs such as kidneys, that are still in situ (in the body), and even isolated from perfusion, but are basically knobs of non-functioning tissue that have calcified or congealed into a mass. We see these in the OR when they are removed. What Dolan’s team does acknowledge is that Jahi has a VERY serious “brain injury.” I’m sure not an expert at reading brain MRIs, and will leave further interpretation up to qualified neurologists. But the snippet I saw on their screen looked globally horrific, from my experience.

 The two video snips provided by the Dolan Law Firm, IMO, are not comprehensive enough to demonstrate anything except that Jahi’s body has random spasmodic movements of a hand and foot. We have no context, and nothing to compare these video snips with—for all we know, her body may make random spasmodic movements all day long, and the video with mother coaching is simply “timed” to the spasmodic movements. Nailah Winkfield herself said that hours and hours may go by with no movements, then between 1 and 3 am there is more activity.  Nailah Winkfield interprets this as Jahi being “more awake”—however, the time of day could simply be a rhythmic response. We have no idea how many times Nailah Winkfield has encouraged Jahi to move, and Jahi has not responded. There simply is not enough information in those brief video snips to make any determinations beyond spasmodic movments of the extremities, which is well known in both brain damaged, spinal cord damaged, and brain dead individuals. Like the Lazarus sign (google it), it is impressive to watch in isolation, without proper context or interpretation, which, IMO, is why they used these snips. One snip is from May 20 of this year—were there no more recent video opportunities?

Links to the videos snips:

I also wanted to just touch base briefly on Dolan’s team’s comments that Jahi’s hypothalamic- pituitary- ovarian axis must somehow be intact or functional, since Jahi has had menarche (started her first period.) We have to remember that Jahi was a relatively normal, but very overweight, 13 year old adolescent when the events of last December happened. She was on the verge of menarche when she became brain dead, and had obvious breast development in pictures. That means that until she was brain dead, her hypothalamic- pituitary- ovarian axis was intact and presumably functioning normally. Additionally, her excess body fat would have made her reproductive system somewhat more responsive to endogenous estrogen, which is also produced by fat tissue, as well as reproductive organs. There are studies of children who have experienced traumatic brain injury, with damage to the hypothalamus and the hypothalamic- pituitary- gonadal axis, and still experienced precocious puberty.

I don’t pretend to understand all of the endocrine issues at the level of a specialist physician or scientist, but I know enough to understand that reproductive systems can continue to function in catastrophically brain injured, as well as brain dead individuals, who were previously normal before the traumatic injury. We see brain dead pregnant women being maintained for varying lengths on life support measures to gestate the end of a pregnancy to viability for the fetus. We also saw Marlise Munoz in Texas, at the end of the first trimester, be maintained on life support for weeks to months, after suffering brain death. Even the young boy who was brain dead from meningitis at age 4, for 20 years, went on to develop some secondary sex characteristics, such as pubic hair,and axillary hair, although his testicles never descended. At autopsy, his brain was a calcified into a small lump at the base of the skull. That suggests that there are some corporal mechanisms in children and adolescents for some parts of reproductive maturity to occur, in the absence of hypothalamic- pituitary- gonadal axis function. 

For example, it would be very interesting to know whether or not Jahi has experienced ovulation, or if she has menstruation in the absence of ovarian function. Either way, I am highly skeptical whether the presence of vaginal bleeding (which may, or may not be actual menarche) in Jahi is proof that she has some level of intact hypothalamic- pituitary- ovarian axis for stimulation of reproductive hormones.

To summarize, I’m not persuaded by what was communicated at the Dolan Law Firm press conference yesterday, demonstrates that Jahi McMath is “alive again.” If the family and their attorney chooses to pursue this line of thought in the courts and official agencies (Health Department, Department of Health and Human Services, Medical Examiner—as directed by Judge Grillo), they will have to submit Jahi for extensive testing by impartial experts with appropriate background and education.

Links to documents filed by Attorney Dolan, and USCF Benioff Children’s Hospital (formerly Children’s Hospital Oakland) September 30, 2014:

Who are the experts from the Dolan Law Firm:

Phillip Defina, a PsyD Psychologist

Dr. Prestigiacomo is also on the Board of Directors for Philip Defina's International Brain Research Institute.

Elena Labkovsky is a PhD Psychologist educated in Russia, specializing in mental health of adolescents.

Dr. Calixto Machado, a Cuban neurologist

And some of his many publications: (Scroll past the map for a list, and also note that he and Defina are co-authors on the first 2013 journal article).


Anonymous said...

This is from the allnurses site about her MRI:

"it's markedly abnormal. There's significant loss of gray-white differentiation in the cerebral cortex; the straight sinus in the tentorium cerebellus is widely dilated, as are the lateral ventricles; the cerebellum itself appears amorphous, with no visible sulci; the sella turcica appears to be obliterated as has the pons; there's an increased amount of CSF in the fourth ventricle; there is one large and four smaller infarcted areas near the corpus callosum (actually, I don't even see a corpus callosum) and within the lateral ventricles. All the extra fluid represents areas of necrosis where tissue has been lysed and resorbed."

KZ said...

Thank you for the professional interpretation of the MRI images. The obliteration of the sella turcica means that there is no pituitary at all to speak of. So, the "intactness" of the hypothalamic- pituitary- ovarian axis is really a non-issue, right? If there is NO pituitary left, there can be no "effect" of the pituitary hormones on menarche or reproductive maturity. But maybe that's too logical?!

Anonymous said...

Golden, why are you asking questions that would require KZ to have seen the medical records to be able to answer? You also ask " How did they localize the obstruction without doing an upper airway endoscopy to inspect the airway prior to surgery?" How do you know what was done or not done? And if you know why are you asking KZ? Explain to us how your experience proves microcirculation is enough for the brain to survive.

Anonymous said...

So what's the benefit for the family? If she's "alive", will the State pay for her care for the rest of her life? she could "outlive" her sister's grandchildren.

KZ said...

As far as what happened last December at Children's Hospital Oakland, none of us know any more than what has been officially released-- that there was a postoperative hemorrhage and cardiac arrest event, that unfortunately lead to a diagnosis of brain death. At this point in time, we cannot second guess what went on in the preoperative evaluations weeks ahead of Jahi's surgery, nor do any of us know with certainty what exactly transpired in surgery, and in the hours after. More of that information will come out if and when the family files lawsuits. So, for now, I'm not going to address baiting questions any further about what happened last December. There may be an opportunity to discuss all that further if lawsuits, such as a wrongful death suit, is filed. And I believe there is a 2 year statute of limitations on that in CA, so we still have more than a year on that.

At this point in time, the focus of the current court challenge/ petition is on 2 things-- whether or not Alameda County Judge Evilio Grillo has jurisdiction to hear the petition brought by the family and Attorney Dolan, and act on it, and secondly, whether the evidence offered by the family is sufficient to go forward with some kind of official action to declare Jahi "alive again."

Judge Grillo himself has expressed doubt that his court is the proper place to hear the Dolan petition to declare Jahi "alive again".

Quote from one article:

Grillo held an initial hearing on Tuesday on the family’s request that he reverse his ruling that Jahi is brain dead, but he said in an order afterward that the general rule is that a court loses jurisdiction over a case once it enters its final judgment and he issued his final judgment in Jahi’s matter on Jan. 17.

Grillo said he has:

“…no opinion on the proper procedural vehicle for petitioner (Jahi’s family) to request a determination that Jahi McMath has not suffered brain death, is not deceased under the law and that her death certificate should be voided.”

But Grillo said his tentative thinking is that:

“… the issue is not presented properly in this case.”

Sprocket said...

Please remember T&T's commenting policy.

All comments are moderated. T&T is not obligated to publish your comment. All we ask is that you be respectful.

I hope I don't have to explain in detail how to be respectful to each other.

KZ said...

As far as what is the benefit for the family, Nailah Winkfield has been quoted back in the Essence Magazine interview in June, that the focus of trying to "revoke" Jahi's death certificate is to be able to qualify for both state benefits, as well as state health insurance and other financial benefits.

There has been much speculation and discussion about the California Prop 46 on the ballot in November, which would raise caps on maximum amounts awarded for non-economic damages in med mal cases, currently at $250K (which Uncle Omari Sealey has described publicly as "chump change").

Attorney Dolan has some involvement in the political push to eliminate these caps, and has been variously quoted as contributing $75K to the campaign. Complicating things, Sam Singer, who represented CHO back in December as a public relations person for the hospital, is also involved in this Prop 46 campaign to KEEP the caps in place. You can read more at the link below. But suffice to say, there is a lot of money involved in this case, both directly and obliquely.

KZ said...

In previous writing, I have discussed the work of Dr. D. Alan Shewmon, professor emeritus of Neurology at UCLA. Dr. Shewmon doesn't believe in brain death scientifically, and has been the voice of dissent during professional "think tanks" on brain death determination. Dr. Shewmon has produced some of the best and only retrospective reviews of the very few brain dead patients with prolonged somatic support, who have been studied.

Wesley J. Smith is a writer for the National Review Online. They have posted an article today that claims that Wesley J. Smith has been given a copy of a declaration filed with the Alameda County Court by Dr. Alan Shewmon. He is reportedly testifying that not only is Jahi not dead, but he believes she is "awake." This is quite an interesting read, and will certainly (if authentic) re-open national debate if this case survives and moves through the courts.

Here are some very interesting links to other articles and comments by Dr. Shewmon about brain death, for those interested.


KZ said...

Paper presented in May 2014 at an American Academy of Neurology meeting.

"Re-evaluating Brain Death: The Potential for Treatment and Recovery after Brain Injury"

Note: 4 of the co-authors are Philip Defina, Dr. Calixto Machado, Dr. Charles Prestigiacomo, and (former) Dr. Jonathan Fellus (who had his medical license revoked this past summer.) The first 3 are part of Dolan's team of medical experts.

Anonymous said...

KZ: what is your opinion of Dr. Shewmon making his determination without examining her or performing any of the tests according to the criteria he cites? Seems pretty sketchy to rely on those videos and personal testimonies.

KZ said...

Well, one observation I have is that as the week has gone on, the same "names" from a year or so ago keep popping up. Meaning, Dolan's list of experts is far more predictable than I had hoped. I had hoped to see a list of little known ICU intensivists from the St.Peter hospital in NJ, or researchers with unbiased histories, emerge. But what we see is the same people with the same ideas that they have held for many years. Confirmation bias can be a seductive mistress, IMO.

I will continue to keep a somewhat open mind, but I'd be much more persuaded if the experts had less of a history of rejecting brain death.

IMO, Dr. Shewmon is the most reputable of the team of Dolan's specialists. I'm quite interested to read what he may have submitted to the court. At this point, we only have a few sentences from the National Review article (which may or may not be accurate or even true). Who really knows what Dr. Shewmon saw, or what he reviewed, until we have a more reliable source, such as the actual document he supposedly filed with the court.

Anonymous said...

For KZ, this a link to the full submission/declaration of Dr. Shewmon.,_2014-10-03.pdf

KZ said...

Thank you! I'm subscribed to the Medical Futility blog, but hadn't got that far in my research today! Much appreciated!

Anonymous said...

Glad I could help, KZ. Can't wait to hear your take on it. Seems kind of strange that he's relying on second hand info and tests and willing to testify to that.

Anonymous said...

I, for one, am fascinated with this case. What appears to be such a clear cut issue is muddied by some blood sucking lawyers pushing their own agenda. Thanks KZ for helping to clarify some of the medical aspects.


Anonymous said...

KZ, this link has all of the declarations filed with the court so far: At the end of Dolan's declaration are the pictures of the MRI that was shown during the press conference as well as the picture of the MRA

Sprocket said...

Anon @5:31 PM

Thank you. The Thaddeus Pope link is on T&T's Jahi McMath Quick Links Page.

Anonymous said...

I can't comment on the medical stuff, but the legal implications are fascinating.

My guess, at this point, is that the hearing on 10/9/14 is going to result in a whole lot of nothing. Judge Grillo seems to feel that not only is jurisdiction an issue, but that an entirely new action should be filed naming the correct parties.

Mr. Dolan attempted an ex parte end run around CHO and was soundly smacked down by the court. I'm sure he's an excellent personal injury lawyer, but frankly, after reading his filings on this matter, he's out of his depth.


Anonymous said...

What's remarkable to me is that Jahi spent 8 months at St. Josephs in New Jersey and 6 weeks ago was discharged to home care. The court papers indicate that the family requested medical tests and treatment that St. Josephs refused and responded with, "we don't want to get involved". Jahi was only able to get this last round of tests after she went home.

It's telling that in the 8 months at the hospital sympathetic to her religious beliefs, she was unable to garner support for her position that Jahi is alive. Surely, if she were alive, someone at the hospital would've spoken up.

Her mother is free to bring Jahi home to California and continue caring for her in a home setting - where she is currently. The judge gave custody of the body to her for this reason.

The only reason why they are doing this is for money. She wants taxpayer money to fund the medical care of a corpse.

Anonymous said...

Epic smackdown by Dr. Fisher. His letter starts on pg. 5:

KZ said...

Hot off the presses! This evening, Attorney Dolan withdrew his error coram nobis request, effectively cancelling any court action tomorrow. This, after a flurry of other motions today (aimed at getting Dr. Paul Fischer off the case as a court appointed consultant/ expert).

So for now, Jahi remains brain dead, and Dolan is going to try to organize a play date for all the experts to dialogue freely together, lol! Maybe they'll have milk and cookies, too.

Love the "I'm a lawyer, not a doctor" comment in the press release, lol!

Additional court actions:

Go to "search by case number", then choose "probate" and enter case # RP13707598 for a full list of all motions in this case.

Anonymous said...

So Dolan wants them to dialogue freely over the tests that were done to come to consensus over their areas of disagreement and agree she's not brain dead.

That's just nuts. He's treating it like a symposium on brain death and not a clinical diagnosis.

There is nothing to dialogue about. Do the appropriate tests or just stfu.

Anonymous said...

Very odd that no witnesses from that hospital are coming forward to say she's alive. No doctor, nurse, nursing assistant who interacted with her during that time period can corroborate that she moves purposefully, she can move on command, she can hear. If she were alive, where are the credible witnesses?