Jahi McMath: Frequently Asked Questions - Part I

GUEST ENTRY by KZ, a CRNA.

 I asked KZ to share some of her thoughts on what might be happening to Jahi's body.  This is Part I of a two-part series. Part II will be posted next week, covering three more topics. Sprocket.

Jahi McMath: Frequently Asked Questions - Part I
by guest writer, KZ

The very sad saga of Jahi McMath continues on. Last week, a Facebook posting put out the information that she is “doing great”, “responds to her mother’s touch”, “healing”, but is “not awake yet.” A brief video clip showing her feet moving was posted, then abruptly pulled off Facebook, but was reposted on YouTube.

1. If those really were Jahi’s feet in the video originally posted on Facebook, how is it possible, if she has brain death, that her feet could move when ice is rubbed on the soles?

Stimulating soles of the feet can produce something called “spinal reflexes”, which are mediated by the spinal cord and peripheral nerves, and does not require higher brain function. Here are some examples.

Changes in spinal reflex excitability in brain-dead humans.

The excitability of proprio- and exteroceptive spinal reflexes was monitored electrophysiologically and clinically during the occurrence of brain death (BD) in 8 patients. After a period of total reflex unresponsiveness, the soleus H reflex attained a steady-state excitability level in 2-6 h. The recovery cycle of this response regained its normal shape at 10-20 h.



Digital responses to mechanical stimulation of the foot sole were evident after 6-8 h.

It is concluded that the human spinal cord reacts to BD with a spinal shock, characterized by sequential recovery of reflex transmission. The overall timing of this process appears to be much shorter than that previously described for the spinal shock following traumatic transection of the cord, but the latter was never studied in the earliest phases.

Changes in spinal reflex excitability in brain dead humans

KZ note, the area that they are stimulating in the video is L5- S1 dermatomes- quite low in the spinal column.

Dermatome (anatomy) - Wikipedia, the free encyclopedia 

Lessons From the Pithed Frog

And this shows what muscles in isolation can do, given the right stimuli

If one were to apply a peripheral nerve stimulator to Jahi's body-- the hand and wrist area, for example, it would be quite easy to induce muscle twitching in response to electrical impulses. If you put the stimulator in certain positions, you can even induce a whole joint to flex or contract (like a wrist). This type of stimulation and response is independent of brain function. It would not be a "reaction" to pain, even though someone who isn't knowledgeable might be tempted to interpret it as "withdrawal to painful stimuli."

Here is a quick example. Train of Four 



2. What could happen if Jahi’s heart stops?

I think it is probable that Jahi's heart will stop while she is still on the ventilator. I don't see them taking her off the vent, and letting her heart stop. Mrs. Winkfield has said many times that she will not remove the ventilator until her heart stops. And it is definitely possible to have cardiac arrest, and also have a ventilator still cycling and blowing air into her lungs.  



If Jahi's heart stops while she is on the ventilator, it depends on "how closely" she is being monitored, how quickly this is detected, and whether or not they have decided to try to do anything about it.



It is "possible" that her heart and other functions (like pulse oximetry) are not being monitored continuously, if she is in a long term care facility. We have no idea what they are monitoring, and the capabilities of the staff and the facility. Particularly if Mrs. Winkfield has decided not to try to do anything medically if her heart enters an abnormal rhythm-- for instance, if she is on palliative care, she may not be on typical ICU monitoring, but just have the ventilator cycling.

If she is receiving heart monitoring and pulse oximetry, and if appropriate alarm limits are enabled and audible, then if her heart enters an abnormal rate or rhythm, the alarms will sound as the limits are violated. Then the staff would have to decide if they are going to attempt to treat whatever is going on (with drugs, and intravenous fluids, and/ or electricity), or "let her go", or call 911, etc. I have no idea what they have decided to do.

If, for example, they have decided to "let her go", hopefully they will silence alarms, allow family to sit quietly with her body, hold her hands, etc, and at some point an appropriate staff member will quietly turn off the ventilator. 



Very seldom does a heart go from a normal rhythm to complete stand still (asystole) abruptly-- it's more likely her heart would experience rate and rhythm abnormalities as a prelude to the final pings of electricity that precede asystole (standstill). That could be minutes, or hours. Often, the final bits of electricity can kick out for 15-20 min or more, once a rhythm has ceased. The other situation, is that the heart continues to put out electricity, but there is no "squeeze" to produce a pulse that can be felt. This is called “pulseless electrical activity.” That is a common ending, too, with that rhythm deteriorating to remnants of electricity that eventually stop. PEA is typically only treatable when there is an obvious thing to fix right away—medical folks call these the “Hs and Ts”, from the ACLS algorithms. Otherwise, it’s a sign that the end has come for the function of a heart.

When I was a young nurse in ICU many, many years ago, I was privileged to see a number of hearts “die” on the monitor, in patients on a ventilator, who were “do not resuscitate” status. We had to leave the vent on and cycling until the doc or resident came up and pronounced them dead. Those patients, in their last minutes, taught me a lot of lessons that have helped me anticipate declines in my patients for my entire career. I feel very privileged to have been able to witness those dying hearts, and learn what I was seeing, without the typical hustle and rush of resuscitation.



There is no suffering for someone with brain death whose heart stops. Their color will become pale (most noticeable in the lips and inner mouth, and the palms, in someone with darker complexion), and the skin takes on an ashy or waxy, pale color as circulation ceases.

 Jahi’s body wouldn't gasp or convulse.

In fact, if she is not on a heart monitor or a pulse oximeter, the staff might not notice that her heart isn't beating well for quite some time. The vent will continue to cycle, even if her heart isn't beating well enough to circulate blood effectively, or if her blood pressure is very, very low.

I want to add that if she is in a home care, or long term care facility, that the monitors themselves are not as sophisticated as an ICU setting. They may not have any central telemetry monitoring-, but may have a type of transport bedside monitor- meaning, only when someone is in the room looking at her monitor would they be evaluating what is going on. We cannot assume what kind of monitoring her body is receiving, or not receiving, since there is really no "standard of care" for the level of care her body is receiving. Basically, they are free to do whatever monitoring they want, or are capable of doing. I doubt she has continuous arterial blood pressure monitoring, for example-- so may be on intermittent blood pressure cycling using an external cuff (such as a dynamap). They might set that to go off every one minute, or set it to go off every 15 min, or longer, etc. Or just manually cycle the automatic BP when they are in the room.I doubt they have noninvasive cardiac output capability (which uses the ventilator circuit to calculate cardiac output). All of this monitoring is dependent on having staff who understand how to do it, and how to interpret it. We just have no idea what the capabilities are where she is.

While Jahi isn't capable, thankfully, of feeling any distress when her heart stops, the living people around her certainly are capable of feeling distress. Whether or not Jahi's family has a peaceful experience when Jahi's heart stops (which it most assuredly will, at some point), depends on the decisions they have made/ are making about what they want to do when that time comes. From what they have demonstrated over the past 6+ weeks, they are in denial about her brain death, and continue to use social media to proclaim her improvement and that she will fully recover. Perhaps they are saying and feeling differently in their private, family moments together. I'm sure we will never know, nor should we.

If Mrs. Winkfield has decided that Jahi's heart is not a "DNR" (do not resuscitate), they she may have made arrangements with the staff and facility to do whatever they are capable of doing to keep her heart going. That means it could be a very emotional, chaotic situation, as well, if they decided to jump on her chest and do CPR, and attempt ACLS maneuvers. As it has been told that she is in a long term care facility, and given that she is legally dead with a death certificate, it is extremely doubtful 911 would transport to any ER. The capabilities of a nursing home, even one with ventilator and IV capability, are extremely limited, when it comes to providing ongoing "ICU" type support during and following cardiac arrest. They might get her heart back for a few minutes, or a few hours more, but there is a limit to how much you can "flog" a dying heart in a brain dead body.

And keep in mind that if Jahi is in a long term care facility, the capability of the nurses (and physicians) is definitely not the same skill level and knowledge level as that of ICU nurses and pediatric intensivists. In other words, most LTC, LPN's and RN's nurses are very good at what they do, but they are not ICU trained and skilled. They would have a very limited ability to know how to run vasoactive IV drips and monitor them, if they even had access to vasoactive drugs in their facility, etc. Long term care facilities don't have the kind of pharmacy support that acute care hospitals do. There is probably no physician in house 24/7 to tell the nurses what to do (if the doc even knows what to do), beyond BLS, (basic life support) and possibly some ACLS interventions. 



What I am getting at is that the stopping of Jahi's heart could indeed be a very chaotic event, and it is also possible that Mrs. Winkfield might "blame" them for not being able to resuscitate Jahi's heart when it happens.

I genuinely hope that the staff "there" is preparing the family for the inevitable, and talking about how to make Jahi's cardiac arrest be as peaceful as possible for the family. I hope this, but I also strongly doubt that anyone is willing to do the intervention with the family that is necessary to get them to the point where they will face reality. Anyone who doesn't speak their party line that Jahi will recover, is summarily dismissed as being "negative", and a "hater", and not trusting God to resurrect her.

All that means is that when cardiac arrest does happen, the family's emotional coping will be hampered even more, and for much, much longer. I wouldn't want to be one of the staff caring for Jahi's body-- I wouldn't trust this family's reactions, based on their conduct over the last 6 weeks. To be continued in Part II, when KZ will address the following questions:

3. Where is Jahi? Could she be in someone’s private home getting care?

4. What kind of care would Jahi’s body need, wherever she is? Is she just laying there like she is asleep? Does she look normal?

5. Are there any odors because she has been dead so long? Is her body decomposing?