Jahi McMath: Frequently Asked Questions, Part II

 Alleged feet of Jahi McMath, in response to ice. Source: Video 
originally posted on a Facebook Jahi McMath support page.

GUEST ENTRY by KZ!

This is Part II, of a two part series by T&T's guest writer, KZ, a Certified Registered Nurse Anesthetist. I asked KZ to share some of her thoughts on what might be happening to Jahi's body. Part I covered questions 1 and 2. You can find Part I HERE. Sprocket

Jahi McMath: Frequently Asked Questions, Part II

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

I haven't ruled out a private home setting either. Or perhaps a church building, etc.

They have a large following of supporters. Some of them are bound to be nurses aides, LPNs, or RNs. It is possible that they have accepted donated machinery, hospital bed, and supplies, and donated volunteer nursing services. That would keep costs down. And keep things very quiet and away from the media. The grandmother is an LPN-- she probably has a lot of connections to people who know how to do physical care. A small cadre of dedicated volunteers, who agree to keep quiet, could accomplish the task for a while.



I've cared for people on ventilators in the back of transport military planes, in the back of trucks, in tents, etc. If you know how to set up some equipment, oxygen, meds, IV's, and work out the electrical and oxygen issues, etc, it wouldn't be hard to set up a place to provide custodial care to a body, especially if it were classified as a home care situation. That is essentially what the "facility" in New York was going to do. I imagined that they were going to put her in an empty office space at their main building (the one without automatic doors, lol!) if she ever arrived there.



I do think the coroner knows where they took Jahi's body. I think that was almost certainly part of the arrangement to release her body to Mrs. Winkfield. It's standard procedure when a body is released to family members for transport, or for religious/ cultural rituals, etc. Basically, the receiving person has to fill out forms and disclose what they intend to do.



I think we will continue to hear occasional social media reports of "She's doing great! She's healing every day, and responds to her mother's touch", right up until the day that it is announced that she has been called home to be with God. I expect there will be an enormous funeral, eventually, with thousands in attendance. They do have a really amazing number of supporters, whatever we may think about that. Since everything they are doing is framed within their faith, there is no way for them to lose face within their religious community of supporters, IMO. If she rises up and lives, prayer worked. And if she doesn't, then God called her home, and they will continue to praise God. Their supporters will be there for Mrs. Winkfield's emotional needs when the time for the funeral comes, I think. 



But then I think that they will immediately become immersed in the process of litigation, which will go on and on for years on end. I really hope the other kids are having their needs attended to, and have returned to some kind of regular routine. Sadly, instead of mourning their sister, I think that this atmosphere of prolonged "conflict", followed by litigation, will define their childhood. I feel like their identity has been buried in all this, with all of the adults around them focused on prolonging the "conflict". Jahi might actually BE the only one in this whole mess who is "healing". JMO.

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?

Just a guess, as I have no earthly idea what they really are doing, or hope to accomplish.



My best guess is that Jahi's body is not receiving the same level of care and monitoring that is "possible" in an ICU setting, or even a med surg bed in an acute care hospital. If I had to generalize, I'd say what they may be doing could be classified as "custodial care" or possibly palliative care (though palliative is an odd descriptor for a patient who is deceased).



There is an adage in palliative health care that you don't do a test if you don't want to know the answer (meaning, you don't intend to treat).



I could be wrong , but I think any labs potentially being done would probably be "bedside" labs, such as a urine dipstick, urine specific gravity, or a fingerstick blood glucose. As far as "send out" labs to monitor kidneys, liver, etc, I doubt that they are doing this. A LTC center would not have an in house lab, so would have to send out. (And may not have in house ability to draw labs into the proper tubes, etc.) If she is at a private home, same. And whose name would be put on the send-out lab tubes? The bigger question is what would be done with abnormal results? It's not like they are going to put her body on peritoneal or hemodialysis if her kidney function is wildly abnormal. I think they probably have a very limited ability to correct electrolyes. I suspect her liver function tests would be pretty abnormal at this point.



I know a body has diabetes insipidis for a "while" following brain death, but I have no idea if it continues beyond 6 weeks to 2 months duration? If she is still having DI symptoms, they might "chase" it with vasopressin to slow down how fast she is losing fluids, and try to keep her BP up, but if her kidneys are in the process of shutting down, I could also see retention of fluids and low urine output. They might be giving her thyroid hormones, but the dose wouldn't necessarily be dependent on a lab value. All this is dependent on a doc to write a prescription, and a pharmacy able to fill it.



Her heart is only 13 years old, and even with the cardiac arrest, must still be in good enough shape to pump regularly and sort of effectively without too much intervention. Pre load and after load is a big issue, as her body has lost the ability to regulate the expansion and contraction of her peripheral circulatory system. I doubt they have ability to do hemodynamic monitoring beyond external BP (blood pressure) cuff pressures. 



She may or may not have a central IV access line, but I doubt they would use it for central venous pressure monitoring. I seriously doubt she has an arterial line for BP monitoring and blood gas analysis, so any ventilator setting changes would be based, probably, just on physical symptoms, perhaps end tidal CO2, and pulse oximetry. And "guesswork". 



I suspect her body is refractory (less able to respond) to a number of vasoactive drugs at this point. She may no longer be responsive to vasopressin. Who knows? There aren't too many health care providers who are "experts" at caring for brain dead patients 2 months out from brain death.



I highly doubt she would be a candidate to receive blood products, so monitoring those labs might be kind of pointless.



I think they probably provide hygiene care, skin care, turning, bathing, mouth care, lubricating eyes, trach care, peri care, etc. All that is fairly straight forward, and doesn't require a high level of skill, except trach care. I think she probably has lots of lung issues at this point-- even with antibiotics. Lots of atelectasis (small airway collapse) fluid filled areas, "pus" and either dried out thick secretions, or soupy secretions. She has no ability to mobilize secretions, so is dependent on suctioning, aerosolized humidification and medications, and maybe lavage (fluid instilled to thin secretions). They might be dripping some tube feed solution into a PEG. They might be giving IV vitamins or hyperal (TPN), and/ or lipid solution. Who knows what their capability is?

I do know that she will progressively deteriorate. Her periphery, in particular, is vulnerable to dehydration (tip of nose, lips, ears, fingertips, toes), as well as poor circulation. Eyes are vulnerable to drying out and becoming gummy on the surface, and would need protection and frequent lubrication. Her gums and the lining of her mouth may slough. Fungal infections, like thrush, are a constant issue, and she may have a coated tongue (white patches), or it could be blackened if her mouth is open all the time, or may look sort of normal. (There is only so much you can do with a sponge on a stick and a toothbrush.) Areas of skin compression may not have circulation restored just by turning her in bed. (I don't want to think too much about perineal care issues, but things like fungal infection is a realistic issue down there, too, along with urinary tract infection, etc. She may have a urine foley catheter, or be diapered. There may, or may not be bowel issues.)

And then you also have issues of contractures from immobility. Hands and wrists would need to be splinted, in normal position, as well as have range of motion. Needs heel protectors, and foot drop splints, in addition to the sequential compression devices seen in the video. All of the physical care that would ordinarily be given to someone with PVS or comatose condition.



From CHO report, she was very unstable just with turning. I can't imagine doing upper and lower body range of motion twice a day or so, with all of the issues. She may be quite stiff in her limbs, joints, and spine. (Not rigor mortis, just stiffness from immobility.)



I would be very curious to know the date of the video posted on Facebook, then abruptly pulled. If it was recent, her feet look to be in better condition (better hydration, no foot drop) than I would expect. My strong suspicion is that the video wasn't from last week. Why would anyone go to such measures to conceal the embedded data? Almost seems like it was baiting for some kind of response, but unwilling to provide details to authenticate. They could have posted it as a private video, and given the access code to people they approved-- but didn't.



The way that video was posted, altered in the embedded data, then abruptly pulled, seems very manipulative, IMO.



Organ systems will shut down. How long that will take is any one's guess. 



The above is my best guess. I'd be interested in hearing any other health care professionals opinions, too.

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

One thing that is a bit of a blessing about "odor control" is that Jahi's body is on a ventilator. The breathing circuit is "closed"-- meaning, both the inhalation and exhalation takes place inside of hoses that are not open to room air. The lung secretions are likely to be a dominant source of bad odors at this point, very icky and infected smelling. The circuit on her trach will somewhat contain these odors.



When someone on a ventilator has a breathing tube inserted through the mouth, or as a tracheostomy, the suction catheters can be contained within this closed circuit, with a type of sterile plastic sleeve over the catheter. This is usually the method used in a hospital situation. This way suctioning can occur without disconnecting the circuit every time, thereby the patient has decreased exposure to infection, as well as the staff having less contact with secretions.



There are also suction catheters which require the circuit to be removed from the trach every time, and a clean or sterile catheter is used. A lot of people with long term home ventilator care situations don't need to practice "strict" sterile technique, but instead use "clean" technique.



For those interested, here are some pics of suction catheters, and a guide to "home care" suctioning of pediatric trachs. The procedure is pretty much the same for kids as well as adults. There are some risks with suctioning-- and prolonged or inappropriate deep suctioning can cause low oxygen conditions, as well as serious and abrupt slowing of the heart rate, with abnormal rhythms. Jahi's body can't cough up or mobilize secretions, so she would have to have deep suctioning to get the gunk out. She also can't cough or react to suctioning, so while she may have heart slowing or oxygen issues, it wouldn't cause her distress. Long term scarring of her lungs from deep suctioning probably isn't much of a concern, since she is deceased, and we are waiting for her heart to finish.



http://www.tracheostomy.com/care/suction

http://www.bing.com/images/search?q=suction+catheter+for+trach&qpvt=suction+catheter+for+trach&FORM=IGRE

Her PEG probably isn't all that smelly, unless the insertion site has infection. AFAIK, she has no major sources of open infection, like deep bedsores, or infected surgical wounds. Her mouth has no "breath" going in and out, so it may be somewhat smelly if you are close enough, and her mouth is open. (We have a saying in anesthesia that "bad breath is better than no breath at all".) 



We can all imagine the types of odors produced "down below". Many of the odors of the bed bound can be controlled with scrupulous hygiene of the body, prompt changing and replacing of soiled linens, prompt removal of medical equipment containing secretions and body fluids, and odor masking things like scented body lotion, air fresheners, etc. This is a great deal of work, by the way, and requires very dedicated caregivers.



In my experience, comatose patients do have a type of "sickness" odor emanating from the skin itself, but if you are motivated enough, you can manage (but not eliminate) all of the odors associated with a comatose, bed bound patient. It is a lot of work, though. (IMO!)