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Girl Brain Dead after Tonsillectomy

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EaglesWings21 is a ASN, RN and specializes in Medical Surgical.

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smartnurse1982 has 7 years experience.

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Well,yes,I know.

Most of my pts have no purposeful movements,can't breathe on their own,and are trached and vented.

Most just have aw/as cycles. Most of course are trached,vent,and gt.

They can maintain their own bp and hr(some do)

I was informed on another thread that they may be in a vegetative state vs brain dead,even though my pts can't breathe on their own.

That's why I'm confused!!!

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Esme12 is a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

4 Articles; 20,896 Posts; 146,316 Profile Views

Well,yes,I know.

Most of my pts have no purposeful movements,can't breathe on their own,and are trached and vented.

Most just have aw/as cycles. Most of course are trached,vent,and gt.

They can maintain their own bp and hr(some do)

I was informed on another thread that they may be in a vegetative state vs brain dead,even though my pts can't breathe on their own.

That's why I'm confused!!!

Brain death has certain protocol to determine brain activity/circulation.
[h=3]American Academy of Neurology Guidelines for Brain Death Determination[/h] Many of the details of the clinical neurologic examination to determine brain death cannot be established by evidence-based methods. The detailed brain death evaluation protocol that follows is intended as a useful tool for clinicians.
American Academy of Neurology Guidelines for Brain Death Determination | Welcome to Clinical Operations | Life Alliance Organ Recovery Agency at Miller School of Medicine

While many patients may be in a persistent vegetative state....they will show at least some brain activity and have some brain stem function intact. A persistent vegetative state IS NOT brain dead.

There are no wake sleep cycles. There are no purposeful movements. They will not withdrawal to pain. There maybe some spinal reflexes at first but those fade as well.

[h=4]The clinical evaluation (neurologic assessment).[/h] A. Coma.

Patients must lack all evidence of responsiveness. Eye opening or eye movement to noxious stimuli is absent. Noxious stimuli should not produce a motor response other than spinally mediated reflexes. The clinical differentiation of spinal responses from retained motor responses associated with

B. Absence of brainstem reflexes.

  • Absence of pupillary response to a bright light is documented in both eyes.
  • Absence of ocular movements using oculocephalic testing and oculovestibular reflex testing. Movement of the eyes should be absent during 1 minute of observation. Both sides are tested, with an interval of several minutes.

  • Absence of corneal reflex. Absent corneal reflex is demonstrated by touching the cornea with a piece of tissue paper, a cotton swab, or squirts of water. No eyelid movement should be seen.

  • Absence of facial muscle movement to anoxious stimulus.

  • Absence of the pharyngeal and tracheal reflexes. The pharyngeal or gag reflex is tested after stimulation of the posterior pharynx with a tongue blade or suction device. The tracheal reflex is most reliably tested by examining the cough response to tracheal suctioning. The catheter should be inserted into the trachea and advanced to the level of the carina followed by 1 or 2 suctioning passes.

C. Apnea Test

  • Absence of a Respiratory Drive.
    Absence of a breathing drive is tested with a CO2 challenge. Documentation of an increase in PaCO2 above normal levels is typical practice. It requires preparation before the test.

Prerequisites:

  1. normotension
  2. normothermia
  3. euvolemia
  4. eucapnia (PaCO2 35–45 mm Hg)
  5. absence of hypoxia
  6. no prior evidence of CO2 retention (i.e., chronic obstructive pulmonary disease, severe obesity).

Procedure:

  1. Adjust vasopressors to a systolic blood pressure _100 mm Hg.
  2. Preoxygenate for at least 10 minutes with 100% oxygen to a PaO2 _200 mm Hg.
  3. Reduce ventilation frequency to 10 breaths per minute to eucapnia.
  4. Reduce positive end-expiratory pressure (PEEP) to 5 cm H2O (oxygen desaturation with decreasing PEEP may suggest difficulty with apnea testing).
  5. If pulse oximetry oxygen saturation remains_95%, obtain a baseline blood gas (PaO2, PaCO2, pH, bicarbonate, base excess).
  6. Disconnect the patient from the ventilator.
  7. Preserve oxygenation (e.g., place an insufflations catheter through the endotracheal tube and close to the level of the carina and deliver 100% O2 at 6 L/min).
  8. Look closely for respiratory movements for 8–10 minutes. Respiration is defined as abdominal or chest excursions and may include a brief gasp.
  9. Abort if systolic blood pressure decreases to _90 mm Hg.
  10. Abort if oxygen saturation measured by pulse oximetry is _85% for _30 seconds. Retry procedure with T-piece, CPAP 10 cm H2O, and 100% O2 12 L/min.
  11. If no respiratory drive is observed, repeat blood gas (PaO2, PaCO2, pH, bicarbonate, base excess) after approximately 8 minutes.
  12. If respiratory movements are absent and arterial PCO2 is _60 mm Hg (or 20 mm Hg increase in arterial PCO2 over a baseline normal arterial PCO2), the apnea test result is positive(i.e., supports the clinical diagnosis of brain death

Without the brain there is no life.

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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Vegetative state had brain activity (definite brain stem activity if able to maintain HR & BP without medication /intervention) kind of the "lowest" form of coma. There is blood flow/perfusion to the brain and activity on an EEG. There are some reflexes, sometimes only the primitive reflexes.

Brain death is death. The ventilator is doing all the breathing without sedation HR & BP only exist due to pressors and other drugs via biochemical reaction. There is NO EEG activity even at the primitive brainstem level. No reflexes (corneal or muscular), no pupil reaction. In this case the nuclear cerebral brain blood flow studies show NO blood flow/perfusion to the brain. No spontaneous respiration.

There is a remote chance of recovery from PVS (the longer in a PVS the less chance of recovery). There is no chance of recovery from brain death no matter how much you wish for it.

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KelRN215 has 10 years experience as a BSN, RN and specializes in Pedi.

1 Article; 7,344 Posts; 67,646 Profile Views

Well,yes,I know.

Most of my pts have no purposeful movements,can't breathe on their own,and are trached and vented.

Most just have aw/as cycles. Most of course are trached,vent,and gt.

They can maintain their own bp and hr(some do)

I was informed on another thread that they may be in a vegetative state vs brain dead,even though my pts can't breathe on their own.

That's why I'm confused!!!

Your patients are not brain dead. Brain dead people have NO brain activity and therefore have no asleep/awake cycles.

Brain death is determinant of death in New Jersey: Brain Death.org Legal Resources as it is in all 50 states. California doesn't have a different definition of brain death.

There are any number of reasons why a patient with brain activity may need a chronic vent.

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uRNmyway is a ASN, RN and specializes in Med-Surg.

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Absolutely.

I've been following this thread and story and I am just stunned at this family's ignorance and willingness to subject their loved one to years of torture -- although I guess if she's brain dead she's not feeling or understanding any of this. That's a blessing.

How long until pressure ulcers kick in? How long until limbs fall off after extended vasopressor use? How long until osmotic pressure fails and she's leaking fluid from every pore? How many times will they have to code her before this family accepts and is able to grieve properly?

I feel sad for them.

Sent from my iPhone using allnurses.com

And how much do you want to bet that when she does get those pressure ulcers, as she inevitably will, this is the type of family that will attempt to sue the pants off of anyone and everyone at the facility dumb enough to accept her 'care'. I don't envy them one bit.

And yes, I know I sound kind of cold. I know that much of this is coming from parents whose lives have just been torn apart. I can't even begin to imagine putting myself in their place. As others have mentioned, my mind refuses to even go there. However, I'd like to think that if I were (knock on every darn piece of wood around me), I would have the courage to love my child completely unselfishly and not keep her husk on machines with all the lack of dignity that goes with it.

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KelRN215 has 10 years experience as a BSN, RN and specializes in Pedi.

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The nursing home that supposedly agreed to accept the transfer has backed out: Nursing home says it won't take brain-dead teen Jahi McMath - CBS News

Supposedly another has agreed to accept her body: Jahi McMath's family finds another care facility for brain-dead teen after first nursing home backs out - NY Daily News

Now the family's lawyer is "drafting a federal civil rights lawsuit" to force the hospital to operate on her. I may be wrong but I don't think the dead have the same civil rights as the living. Doing surgery to insert a trach or G-tube in this girl seems like it would be akin to desecrating a corpse. Not to mention, living persons do not have a universal right to have inappropriate surgeries either. I am a 29 year old woman who does not want children. I am quite certain a large percentages of GYN surgeons would refuse to perform a tubal ligation on me, if I asked. When I had brain surgery 10 years ago, I had to go through a number of tests to determine if it was appropriate since my temporal lobe was involved. Had testing determined my right side was my dominant side for verbal memory, I would not have been considered a candidate for surgery. And it wouldn't be a violation of my civil rights for the surgeon to refuse to perform a surgery which would have destroyed my quality of life as a normal 19 yr old... it would have been good medical practice.

Per the last judge's ruling, her ET tube will be removed in 48ish hours (I was going to say less than 48 then remembered she's on the West Coast and I'm on the East). It is time for her to be at peace. This case gets more ridiculous by the day...

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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It is time for her to be at peace. This case gets more ridiculous by the day...
exactly. Since when do the dead have civil rights to inappropriate surgery. The one article stated they were going to file a federal suit to force the Oakland hospital to permit a non-staff outside physician to perform the surgery they desire. No one has a civil right to inappropriate surgery. There was a case a number of years back of a young man who wanted a bilateral below the knee amputation because he didn't want his legs anymore. The court disagreed. The man subsequently "killed" his legs by freezing them in dry ice to frostbite and gangrene thus making the amputation a life saving necessity. A PEG and tracheostomy are NOT going to save this brain dead child's life especially since digestion will stop soon. She isn't starving or in pain....she's dead

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Emergent has 25 years experience.

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Family members in these cases seem to end up getting off on all the support they get from the inevitable pro-life extremists who rally around them. The media flocks around them, money pours in, and it all takes on a life of its own. It happened in the Schiavo case and it's probably happening here. A previously unknown woman is now in the limelight and feeding off the attention.

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Her mother just released an open letter.

"I am a mother. She is my daughter. I am alive. Despite what they say, she is alive. I can touch her, she is warm. She responds to my touch. I can love her - I can feel her love. When she was in my belly I fell in love with her. Her heartbeat for the beginning of her life was my heartbeat until God, through a miracle, sparked her heart into existence. Given time I know he will spark her brain awake.

She is Jahi a name that means known by many. If she knew about all this attention she would blush. She is very shy. My daughter sits on life support. I feel like she is on death row. The clock is ticking - ticking down. Children's Hospital Oakland says she is dead. She was not dead when I brought her here on December 9th for a routine tonsillectomy. I put her in their hands, now they want to wash their hands of her.

Jahi had an operation. I was told it went well. Then she started bleeding from her mouth. They gave me a cup for her to bleed into and said it was normal. She bled more and more. I couldn't keep up with it. I asked for help, they gave me a bigger bucket. She bled more. They did not answer our pleas for a doctor. Her surgeon never came back. She had a heart attack and her heart stopped beating. Then they came- then. They shocked her back into life. Now they say she is dead.

Before the surgery she said I am scared mommy. I said why Jahi? She said I am afraid I won't wake up. I told her it was going to be fine, it was a simple procedure. I should have listened to her.

She is on a respirator - with air she lives, her heart beats, her kidneys produce urine, she is warm and soft. They have been pressuring me to "pull the plug." I can't. I won't. I can't let them kill my baby a second time.

I am fighting for her life. Each breath the vent gives her one more chance to live and gets her one step closer to the hospital's deadline. What a word. I never thought they could tell me, her mother, they were going to pull the plug take her body to the morgue and send us home on Christmas while she lays in a freezer. She is warm now. I want my baby to be warm. We need time.

The Hospital says she is legally dead. That they can legally stop her breathing. I am not a lawyer. We called many in the middle of the night Monday as they were coming to unplug her Tuesday night. One answered the call. We stopped them. Every day is a struggle. We fight for Jahi. We have a temporary restraining order until Monday - then the Judge can say my baby is legally dead and Children's can unplug her. It doesn't matter what I say. I never thought I would have to go to court to get a hospital to treat my child.

Hold your children tight. Tell them you love them. I tell my daughter over and over. I know she can hear me. If she has any brain activity when they do the independent tests she will be kept alive. Pray for my daughter Jahi, pray that she will get better so they don't kill her. Pray for me, mothers, that my love can bring her life once more."

In response, Children's Hospital Chief of Pediatrics Dr. David Durant released a statement.

It reads:

"Our hearts go out to Nailah, her family and the community. We understand the intense grief of a mother who has lost a child. We are committed to fully investigating what caused this catastrophic outcome from this complicated surgery. As medical professionals, it is our responsibility to ensure that we don't create hope where there is none. When one's brain ceases to function, it never restarts. We have the deepest sympathy for Jahi's mother who wishes her daughter was alive; but the only thing maintaining this child is a ventilator machine and it would be unfair to give false hope that Jahi will come back to life."

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KelRN215 has 10 years experience as a BSN, RN and specializes in Pedi.

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If she has any brain activity when they do the independent tests she will be kept alive.

This woman is experiencing an unhealthy level of denial. SIX different doctors have examined her and agreed that she is brain dead.

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sofla98 has 14 years experience and specializes in Peds, PICU, NICU, CICU, ICU, M/S, OHS....

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A few things: I feel for this family, I truly do and I never want to be in their shoes. I pray that their God gives them the strength to make the right decision for JAHI, not themselves... With that said, I cannot help but also feel they are turning this into nothing but a possible payday and a publicity stunt. The countless press conferences, interviews and appearances on the news, with nails and makeup flawless, is just disgusting to me. Thought this was about their precious baby Jahi? Not momma and daddy on every freaking news channel, newspaper, and website out there! If that was my kid? If I was on the news, after facing so much grief and the loss of my child? I'd look a mess! I would not have my hair and nails done, wearing custom tee shirts with different slogans; that's FOR SURE.

The news cannot even keep up with what the family "wants". In fact, they're now asking for "donations" to have her "airlifted" out of the STATE to another facility (sorry, but I PRAY to GOD that it isn't where I work) that will "take her the way she is, ET tubed, probable pressors, NG/NJ and all. What type of facility, I mean reputable facility, would get involved in this? I cannot think of any that would take on a brain dead patient, who is not trached and without a PEG tube, which leads me to believe this family is looking for more attention and a $20k payout from the delusional people donating. The $20k is the amount THEY say it'll cost to have her FLOWN to another state. Last time I checked, it cost a LOT more than $20k to move an ICU patient by air, to another facility.

The point is, this girl has been found (by several docs, including one appointed by her family) to be BRAIN DEAD, not in a PVS, BRAIN DEAD, BRAIN DEAD, BRAIN DEAD. The fact that this "lawyer" and her family keep going to the media, going on and on, saying that she is "alive" and they're just waiting for her to "wake up" is just sickening to me, as a nurse and a mother. As a mother, I hope to never have to go through this, but I also know that my daughter would NEVER want to go through something like this and I will respect her wishes. Yes, we've talked about this very thing, more than once.

As far as her procedure goes, that was quite an extensive surgery to go through for OSA. I bet her ENT docs suggested a trach, given how much work they had to do in order to "create" an open enough airway to circumvent the OSA. Again, the hospital wants so badly to share "their side of things" but are prevented because of HIPAA.

As a side, I also read in the comments of one of the other news articles (SF Chronicle) that her family was encouraging her to laugh and also gave her a HAMBURGER to eat, shortly after surgery....Weather this is true or not remains to be seen, but until and if the hospital's side of things come out, no one should just assume that they (the hospital, docs, and nurses) did something wrong or made a mistake.

I pray the Lord takes this girl's body all the way home, without anyone "pulling the plug", and puts an end to all of this. It is disgusting to me that the media is SO INTO THIS and it baffles me that the parents and family are ready, at the blink of an eye, to give interview after interview...Why aren't they by their precious baby's side? Like I said before, I would be a hot mess and in no way in any shape to talk to the media, regardless of how many days have passed.

Sorry for the rant, but if you have never cared for a TRULY brain dead child, being kept alive by a vent and tube feeds, etc., you just don't and will not understand. I have and it is by far the creepiest thing I have ever done, ever. "THEY" are GONE! There is NOTHING there and the times I have cared for these kids I knew that THEY had already passed on to the other side (please, don't ask me how I knew, I just did as some of us are more intuitive than others when it comes to things like this). The body is nothing but a shell, a vessel for the soul.

My prayers go out to the girl, and her family. I pray the family gets it together and does the RIGHT THING for their daughter and puts an end to this media, legal, and possible payday madness.

Edited by Esme12
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sofla98 has 14 years experience and specializes in Peds, PICU, NICU, CICU, ICU, M/S, OHS....

64 Posts; 2,449 Profile Views

Can someone, anyone, tell me what the actual **** CIVIL RIGHTS has to do with this? What a mess...This lawyer needs to stop looking for the eventual payday, book deal, and the inevitable Lifetime movie deal.

This is just SO sick to me, all of it. I'm praying for that girl to pass on, all the way on, on her own.

Can any of you imagine being her nurse? Jesus, strengthen them, all of them. The residents, fellows, and attending MD's too. This is SO out of control!

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