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:
http://youtu.be/jsSeM0RVKuA
http://youtu.be/yh4YC-XjG9k
http://blog.sfgate.com/stew/2014/10/03/jahi-mcmath-videos-released/



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.



http://en.wikipedia.org/wiki/Hypotha...93gonadal_axis


http://www.jpeds.com/article/S0022-3...497-3/abstract



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:

http://www.docstoc.com/docs/172795721/jahidoc100214.pdf
http://www.mercurynews.com/breaking-news/ci_26644995/jahi-mcmath-family-seeks-have-brain-death-ruling

Who are the experts from the Dolan Law Firm:

Phillip Defina, a PsyD Psychologist
http://www.nj.com/news/index.ssf/2012/01/meadowlands_hospital_neuroscie.html

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



http://www.ibrfinc.org/bio_charles_prestigiacomo.htm



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

http://www.afgfamily.com/index.php?rmm=Meet%20the%20Staff

Dr. Calixto Machado, a Cuban neurologist

http://www.changesurfer.com/BD/
http://www.biomedexperts.com/Profile.bme/861718/Calixto_Machado

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).