Liability issues for the death of Jahi McMath

Friday, January 3, 2014

Good afternoon:

I never did figure out why the comments were closed on yesterday’s post. Crane deserves the credit for correcting the problem. She republished the post without changing it and deleted the original. I have no idea why that worked, but I’m delighted that it did.

Many excellent comments and I hope y’all will continue commenting as the tragic circumstances engulfing Jahi’s family touch us emotionally and focus our attention on the fundamental question of identity

Who are we and what is consciousness?

In what sense are we alive, if we are not conscious?

Do we want our body to be kept alive by a machine when we can no longer be conscious?

If you do not want your body to be kept alive by a machine after your brain ceases to function, please consider making a written document expressing your intent so that it can be provided to your physician if you should be in that situation.

Cielo commented yesterday about Jahi’s cause of death. Since this is a law blog, I’m going to answer her question and assume for the sake of argument that death may be defined as absence of brain activity. Pursuant to that definition, Jahi is dead and she should be disconnected from life supporting equipment.

Here’s Cielo’s comment.

Also, you wrote: except to say that I believe the anesthesiologist may be liable for her death.” I would very much like to read your reasoning. Jahi made it through the surgery alive, conscious and wanting a popsicle. The complications began AFTER she was transferred to the ICU. Several things to remember that are NOT always mentioned in the news: Jahi was obese, had sleep apnea, uncontrolled incontinence and maybe diabetes. The tonsillectomy was NOT routine but complicated by the health issues as well as the fact that they ALSO removed additional sinus material. My personal belief is that Jahi fell asleep, had a sleep apnea episode, woke up coughing violently (I get occasional sleep apnea and it is very frightening to wake up unable to breathe), tore any number of internal sutures from the coughing, drowned on the blood draining to the lungs triggering a heart attack and then she died from being unable to get any oxygen. An autopsy could find the torn sutures UNLESS after 3 weeks, no such evidence could be found. I’ve read the body continues to heal. I’ve also read that the body begins to decompose, so I don’t know WHAT is happening inside the body right now. In either case, malpractice will be very difficult to prove. Were I on a jury of this case, I could easily see a tragic medical complication that was not caused by negligence or incompetence. Not every death is someone’s fault. Your thoughts?

My answer:

You may be right about her being OK until she suffered a sleep apnea episode in the ICU. Unfortunately for us, but understandable for the protection of Jahi’s privacy, the hospital records have not been released to the public. We need the records, our own experts to read and interpret them, and an opportunity to depose their witnesses under oath in order to determine her cause of death and identify who is responsible.

The problem for the hospital is that a 13-year-old girl died in the ICU after her tonsils and some excess sinus tissue were surgically removed. That result wasn’t expected and will have to be explained.

The legal doctrine of res ipsa loquitor may prevent the hospital from escaping liability by claiming that responsibility cannot be assigned to any particular person. The plaintiff, which probably would be her mother suing for wrongful death, would only need to show that she died while in their care and she would not have died unless someone was negligent.

I don’t believe there is any question about whether she died while in their care. Therefore, I will focus on what caused her death and whether it was a reasonably foreseeable event.

Under the circumstances you have described, death occurred in the ICU due to heart failure caused by excessive post-operative bleeding into the lungs from the surgically repaired area brought on by a fit of coughing and choking during a sleep apnea episode.

With all due respect, I am going to stick with my original best guess, which is to suspect the anesthesiologist. I suspect the anesthesiologist may not have inserted the endotracheal tube properly at the junction that leads to the two lungs or it may have become displaced during surgery resulting in an insufficient flow of oxygen to the lungs. Insufficient oxygen to the brain will cause brain death.

Alternatively, I suspect the surgeon may have nicked a blood vessel causing extensive bleeding that could not be stopped precipitating a heart attack.

I believe something went wrong during surgery or she would not have been placed in the ICU. She would have been intubated in the ICU, so the scenario you described is unlikely.

I do not believe the uncle who said she asked for a popsickle in the recovery room because she would have been intubated and unable to speak. I also believe she would have been taken directly to the ICU from the OR because she was in trouble or already dead and the ICU is better equipped to deal with an emergency than the recovery room.

Finally, I do not believe Jahi underwent a difficult surgery. On the contrary, I think it was an easy surgery and she should be alive today, but for negligent acts that occurred in the OR during surgery.

Liability in tort depends on the existence of:

(1) a duty to exercise due care to avoid injuring foreseeable plaintiffs;

(2) a breach or violation of that duty;

(3) injury to a foreseeable plaintiff; and

(4) injury proximately caused by the breach of duty.

Now, the analysis:

Jahi was a foreseeable plaintiff because she was a surgical patient and the surgeon who performed the surgery had a duty to perform it according to the medical standard of practice in his community. At this time, we lack sufficient information to conclusively determine whether he violated his duty, even though the episode of excessive bleeding suggests that he did.

We differ regarding when it happened, but even if you are right and it happened in the ICU, nurses are trained to deal with that problem and should have been able to stop the bleeding. If not, then the likely cause of the bleed was something that happened in the OR, not coughing or a sleep apnea episode since she would have been intubated.

The ultimate question is whether the cause of Jahi’s death was a reasonably foreseeable event and whether the hospital acted reasonably to prevent it from happening.

This case does not involve strict liability. The legal standard is negligence and proof of negligence requires evidence that it’s more likely so than not so (i.e., preponderance) that someone breached their duty to do something they were supposed to do and, but for that breach of duty, Jahi would not have died.

I think they are going to have a difficult time escaping liability, no matter how difficult the surgery may have been, because I doubt this surgery is considered to be risky and the ICU nursing staff should have been able to prevent her death.

This is our 831st post.

103 Responses to Liability issues for the death of Jahi McMath

  1. Stanley says:

    I would suspect –even after a surgery– there is some kind of warranty on the product. Just because she was fine after she left the shop doesn’t mean the mechanic did a good job.

  2. Laura says:

    Mr. Leatherman,
    I am curious as to why the scenario you describe differs so radically from what is described in Mr. Dolan’s court filing as to the sequence of events. Are you thinking events are described untruthfully or have you not seen the documents?
    Laura

    • I haven’t read Christopher Dolan’s court filing and the medical records are not available. I’m having difficulty with the scenario described by the family, as reported in the various news accounts that I’ve read, because I believe Jahi would have still been intubated after surgery and would have been taken to the ICU pretty quickly after surgery. There wouldn’t be any reason for her to be in the ICU unless she was intubated. So, I don’t think they extubated her between the OR and the ICU.

      I have since discovered that she underwent a high-risk surgery in which death and permanent neurologic injury occurred in 86 out of 111 cases (77%) reported in a recent study. See: Cote CJ, Posner KL, Domino KB. Death or Neurologic Injury After Tonsillectomy in Children with a Focus on Obstructive Sleep Apnea: Houston, We Have a Problem! (Anesth Analg 2013 Jul 10). http://www.ncbi.nlm.nih.gov/pubmed/23842193

      The authors recommend respiratory monitoring throughout first and second stage recovery.

      I do not want to be too hard on the family because I feel badly for them and know they are under terrible strain, so I am only going to say that I do not understand what they are saying because it does not sound right to me.

      But I wasn’t there and do not have a source who was.

      • JJ says:

        If there was a 77% chance of a bad outcome, was the family informed? Was the surgery absolutely necessary?
        The family seems to be viewing this case as: my child went into surgery for a simple tonsillectomy and ends up dead. But now the story is that it was a complex surgery with 77% chance of a bad outcome. Which story is the truth?

      • gblock says:

        The article was published just a few months ago (July 2013). Sounds like someone may not have been up on their reading of medical literature and didn’t realize how risky the surgery was when they advised the parents on a course of treatment.

        • Lyn says:

          I have no doubt that the family was fully informed of the risks.
          No surgeon would put themselves in this position with high risk surgery. I don’t know any of the details, but perhaps there was no other alternative.

          • Rachael says:

            I haven’t read any of it, so I don’t know – but there is also the possibility that the parents did not disclose everything either. Again, no surgery is without risks.

          • fauxmccoy says:

            @rachael who says “no surgery is without risks”

            – – – – – –
            so true, my friend, so very true.

            even if this tonsillectomy was routine (and it was not, which is why it was done at the bay area’s premier facility for pediatric surgery) most folks do not even comprehend the extreme and inherent risks of anesthesia alone.

            at one point, i had considered a few cosmetic items i would correct if i ever got to the point where i could afford them. now, after having had open chest surgery, i can tell you that i would never consent to voluntary surgery because of anesthesia risks alone. so i’ll let those eyelids and triple Ds continue to droop until i draw my last breath and learn to love them anyway.

          • towerflower says:

            Exactly Rachel, it doesn’t matter what type of surgery you have it will always have the wording that death or serious injury may result from it when you sign the release papers for approval. My son had his tonsils and adenoids taken out when he was 5. I had seen a special on 60 mins about sleep disorders and children being misdiagnosed as ADD.

            My son had snored even as a baby, loudly sometimes. He had no other medical issues except an almost runny nose which was believed to be allergies. He was not overweight, and the doctors on the show basically said that there should be no reason for a child to snore when they are not overweight. When a child is sleepy due to the sleep problems then they become hyperactive during the day in which teachers and doctors then say they are ADD. The school wanted my son tested for ADD and I resisted because I did not want him medicated for that. I took him to an ENT and found that his tonsils were large for his size and recommended that they come out.

            The surgery went well and from what I was told before hand he was only given a mask for putting him to sleep and was not intubated. I was told afterwards that his adenoids were also bad and that I could stop all allergy medications since his bad adenoids were the result of the runny nose. He was discharged a couple of hours after recovery to go home. He almost ended up back in the hospital because he refused to eat or drink and it took 3 people to hold him down to take his medicine. He was starting to dehydrate. It came down to a nerve problem that runs from the ear to the throat. It became irritated during the surgery and the pain was too much for him. I found out that a simple ear drop took care of this–it numbed the nerve and took the pain away and he would then eat and drink.

            I wonder about the intubation with this young girl because they needed access to her throat and putting a tube into her would hamper them reaching the tonsils.

      • carroll says:

        “There wouldn’t be any reason for her to be in the ICU…..” You have your facts wrong. Her stay in the PICU ……the post operative ICU was planned pre-surgery, as per standards of care for the extensive nature of her surgery and her co-morbid factors.

      • Just another point of view says:

        Why do you think she had to intubated just because she was in the ICU? The way you have described your theory makes it sound like you think all ICU patients are intubated and on a vent and patients go to the unit for many reasons and they are not all on a vent. However if she was on a vent she could have still coughed and or fought the vent. My concern is that she had more medical history problems than what has been shared by family. She was 14 years old and incontinent stands out to me as a clue to the unknown medical history. I can only say that yes it is sad that a 14 year old went in to have a tonsillectomy and died but she was not a healthy normal 14 year old. The surgery was done to help improve the quality of her life and to try to decrease the risk of death related to the sleep apnea. Sadly she has been found to be brain dead and her mother who consented for her to have surgery to improve her quality of life has lost site of this goal. Keeping her body alive with false hope is for the families quality of life and not for Jahi.

      • From what I have read, it was pre-planned (I assume due to her health combined with the surgery she was having) that she would go into the ICU after surgery. So I believe that any conclusions you have reached based on her admittance to the ICU should be reconsidered.

        • I have decided I was mistaken.

        • Tina Armstrong says:

          With major surgery you go to the ICU for 24 hours in case of complications. I had major surgery in 2012 and have sleep apnea like her. The anesthesia makes sleep apnea worse. You have to do breathing treatments to clear your lungs of the anesthesia or you could get pneumonia . After you seem to be good you get moved to a regular room.

          • Hillary Ignacio says:

            In my experience, it is standard of care for children undergoing this type of surgery to correct obstructive sleep apnea to be observed at least overnight in an intensive care unit post surgery – specifically because they are at higher risk of post-operative complications. Her presence in the ICU does not imply a mistake was made. There are indications that she had multiple risk factors for complications, including OSA and obesity. Diabetes, if she did indeed have this condition, would be an additional risk factor. We know very little about the true medical facts of this case, but enough has been acknowledged by all parties to conclude that this was not a “typical” or “routine” tonsillectomy. The speculation that the anesthesiologist or surgeon must have done something wrong is absolutely specious and shows a lack of knowledge of the risks inherent in this type of surgery. There is no such thing as a surgery without risks. Excessive and life-threatening bleeding is a known complication of this procedure. To say that a bad outcome implies there was a mistake is to make the magical assumption that all aspects of health and disease are able to be managed and controlled. This is not possible, given the current state of medical knowledge, hence the term “risk.” Additionally, it is also completely incorrect to assume she would have had to be still intubated. Frequently, someone undergoing this procedure would be extubated in the post-operative care unit, before reaching the ICU. It is also incorrect to assume that she could not have had an endotracheal tube because it would obscure the operative site. One can be nasally intubated, for instance. The amount of absolutely groundless speculation here is shocking. It is irresponsible and unfair to all parties involved. The public may or may not ever be privy to the details of Jahi’s medical course. There may or may not have been mistakes. The only thing that is clear is that this was a totally unnecessary media circus and there are exponentially more groundless opinions than there are people who know the first thing about medicine.

      • Gayle says:

        The assumptions made in the above posts are not accurate. While tonsillectomies have historically been performed for chronic tonsillitis, removal of the tonsils for severe sleep apnea in children has become prolific. This surgery was by no means “routine”. No “routine” surgical patient is admitted to the ICU.

        The assumption that the child could not have been extubated (removal of the endotracheal tube) is incorrect. It is highly possible that this girl was doing well in the recovery area and asking for a popsickle. Until hospital records are released and a time line with information is established, we can only guess what caused her to bleed or become hypoxic in the ICU. Tissue swells after surgery. Perhaps she worked the sutures loose with her tongue and opened a bleeder or perhaps in an attempt to establish a life saving airway, her sutures were compromised . . . .
        Obesity is dangerous, folks! Medical providers can not refuse to care for patients with serious (often self induced) risk factors; yet, they are expected to be miracle workers with the outcomes of a patient with no comorbidities. The referenced article (above) is correct! We have a serious problem called obesity. Please note that the statistics are referenced out of context. The reported statistics come from closed claim data. Closed claim data does not directionalize fault, nor does it represent the thousands of cases that were successful, nor does it represent cases that could have been malpractice but never were brought to suit.

        Where is the parental responsibilities in all of this? Is it OK to let your child become so obese that they can not breath? Is it OK to put genetically engineered food on the market and make it more accessible than “real” food? While obesity can be associated with conditions other than caloric intake, the overwhelming majority of cases essentially equate to a balance of intake and activity.

        • Thank you for your comment.

          I have acknowledged in the comments that I made incorrect assumptions about the surgery (it was high risk, not low) and her placement in the ICU (it was customary because the surgery was high risk).

          I have no reason to suspect anyone of medical malpractice.

      • Stephanie Grow says:

        The pubmed article you referenced above states the following. Note that 111 cases are the cases meeting “inclusion criteria” whatever that means, and 19 of those cases come from ASA’s closed claim project, a project that tracks cases where complications or death transpired:

        “Adverse events during or after tonsillectomy with or without adenoidectomy in children were included. Children at risk for OSA were identified as either having a positive history for OSA or a post hoc application of the American Society of Anesthesiologists OSA practice guidelines. These children were compared with all other children by Fisher exact test for proportions and t test for continuous variables.RESULTS:A total of 129 cases were identified from the 731 replies to the survey, with 92 meeting inclusion criteria for having adequate data. Another 19 cases with adequate data were identified from the 45 from the American Society of Anesthesiologists Closed Claims Project. ”

        What is the percentage of deaths from all UPPP+T&A+SMR?

        • Hello Stephanie/Dr. Grow? I have to apologize, I found only the abstract on PubMed and not the full article, so best to scratch this from the discussion, my fault. (I think the ASA would likely charge us to have a look at their closed claims project and inclusion criteria!)

          Very sorry!

  3. cielo62 says:

    Oh professor, we are NOT going to see eye to eye on this one! ;) The anesthesiologist was DONE with Jahi BEFORE any complications developed. I’m using the words of the FAMILY, the ones who would benefit financially if Jahi had indeed died ON the operating table, that she WAS AWAKE, speaking and alive in the post op recovery room. That she was moved to ICU was probably more indicative of the FACT that she had had no “routine” surgery but was something that the hospital did anticipate might involve infection or complications. In the ICU, they provided her 4 units of blood while trying to find the source of the bleeding. It was at that time that she had the cardiac arrest and died. My father went in for “routine” angioplasty and ended up with triple bypass surgery. A room had already been reserved from him in ICU for such a foreseeable complication. She had a complication indeed, but one probably NOT anticipated.

    • Al Winston says:

      Yeah, you’re right. It’s a case of the lawyer looking to find as many people to sue as possible, regardless of whether they actually could have contributed. I’m surprised he didn’t mention the janitor. On the other hand, in the face of profuse bleeding after tonsillectomies, prompt reintubation and takeback to the O.R. is common.

  4. fauxmccoy says:

    due to lack of additional information, i am not willing at this point to assign negligence to the hospital or its staff. my experience with this hospital is outstanding, it is where most of the most challenging of juvenile cases are sent in the bay area.

    my very personal experience with this hospital was when my 4 year old nephew had appendicitis. it is rare in a child so young and he was not adequately able to express his complaints to any degree beyond ‘my belly hurts’. my sis in law works for the contra costa county hospital and her health plan pretty much requires that patients be treated AT the county hospital, unless very precise conditions are met.

    when my nephew was brought in, the docs at county were concerned, observed for about 12 hours and then sent my nephew immediately to Children’s Hospital in Oakland for the surgery and follow up. i cannot stress the high quality of care in this facility — this comes from my own very complicated medical history of more surgeries than any one would want and my mothers 55 years of nursing (the last 30 as Director of Nurses). we were impressed.

    this is not to say that accidents do not happen, because they always can. what i am saying is that this is where i would want my children treated for a seriously complicated condition. i strongly suspect (as does my retired mom who i am caring for as i type) that Jahi’s condition was far more complicated than we have been made aware at this point. a tonsillectomy is routine and can be performed at almost any hospital, so the question for me is what was so complicated that a 13 year old was sent to Children’s Hospital. there is more to be revealed, i am sure.

    – – – – – –

    as for myself, i have signed advanced directives all too many times that i do not wish to be kept alive via machine when there is no brain activity. it is something i have had to discuss with my family since i was a young adult and we are all clear as to what is and what is not ‘life’. because of my health history, i have had a living will since i was a young adult and my husband has the legal ability to make decisions for me if i am unable via a medical power of attorney. i would encourage every one to come to terms with this uncomfortable stuff while still sound of mind and body.

    i can empathize with the anguish of these parents. any one of us would give anything, up to and including our own lives to preserve that of our children. i simply see no hope in this situation.

    • William Walton says:

      Faux, as my Dad would tell nurses, interns, residents, etc. “If you are to be involved in the practice of Medicine, you need to come to the realization that folks have a habit of dying.” That statement kept my daughter going while I was undergoing brain surgery for a subdural hemotoma. Underwent two surgeries for this condition. In late December of that year, the hospital wanted to pull the plug. The Doctor who happened to be Chief of Neurology prevented this by allowing all systems to be in place for another week. I came out of the coma one day prior to the pulling of the plug. He called oldest son and told him to come to the hospital with his sister and younger brother in that I was stirring, mubling, and even talking. The Doctor met them and escorted them into ICU where I was talking up a storm. Told daughter that Dad wanted a copy of the surgical report, wanted to know if the surgeon had checked the subarachnoid artery, cerbrial artery, cerbrial vein, circle of Willis, etc. The doctor asked oldest sons mother if I had ever been involved in human anatomy and she said no in all that I had been involved in was Chemistry and Chemical Engineering. She also told him that my Dad was a Physician/Surgeon and I had followed him around on house calls. The Doctor’s statement was that this was not something that a person would make not being involved in human anatormy and/or surgery. He also stated that the preliminary surgical report was completed and if oldest son wanted he would have a copy made and he could take it to his Grandfather. Oldest sons Mother smiled and the Doctor stated he must have missed something. She told him oldest son was born in 1973 and Bill’s Dad died in 1960 so oldest son never knew his Grandfather. The Doctor stated he never had this experience before. So the point is I went visiting and this is something that cannot be explained. However, if I were declared brain dead, I would want to pass rather than remain in a vegitative state for however long.

      • fauxmccoy says:

        there can be a world of difference between a coma (which can be the body’s last resort to protect itself – whether self induced or medically) and brain dead. i’m sure glad you showed signs of recovery prior to plug pulling, otherwise, we would not have you here now. :) sounds like you went on a real adventure there!

  5. aussie says:

    Because the family has not given permission, the hospital has not released any details about what happened. We have the family’s slightly garbled version, plus some items mentioned in pleadings in the various court cases so far. Taking all this together with some googling, we get
    * Jahi looks overweight, only borderline obese, certainly not “morbidly”
    * she had tonsils adenoids and other tissue removed, a “triple-header” surgery that is riskier than a simple tonsillectomy
    * because of this, and the added risk of any surgery for an overweight patient, instead of being sent home she was being kept overnight for observation in the PICU.
    * she was NOT intubated by the anesthesiologist. They don’t intubate for throat operations or they’d not be able to reach to do the surgery.
    * She did not suffer a sleep apnea episode. She was awake, alert and talking when the family went in to see her. They themselves claim she asked for a popsicle, though don’t say if they got her one or not (and no mention of the cheeseburger some blogs are alleging they gave her).

    THIS is where they are claiming negligence. She started to bleed, eventually quite a lot, from the mouth/throat. The mother was given cups or bowl to catch the blood and was told it’s normal nothing to worry about (she says). Some doctor started suction to remove blood from the lungs, and instructed a brother(uncle) to do it, but grandmother (apparently an LVN??) arrived and took over.

    Somewhere after this, glossed over the family completely, she had blood transfusions, GOT INTUBATED, had a cardiac arrest and was resuscitated from it, and ended up declared brain dead 3 days later.

    The negligence they are claiming is not taking the bleeding seriously enough and doing something about it soon enough.

    ==()==
    =This is also the first I’ve heard of “uncontrolled incontinence”. The closest to it I’ve seen is a claim of diabetes insipidus from a doctor who only saw her post-trauma charts, and admitted not seeing blood tests to confirm his guessagnosis. Insipidus is caused by lack of hormones (chiefly from the hypothalamus) resulting in the kidneys failing to concentrate urine, so the person produces vasts amounts of it. It does not make them incontinent, they just have to “go” more often. The doctor was claiming this showed brain damage in the hypothalamus region. It is and was not associated with her weight and not claimed as a per-existing condition, nor has Type11 diabetes been claimed for her except by the “blame the parents” style bogs. .

    I don’t like the family’s chances of winning this at all, ESPECIALLY if they DID giver her something to eat (which would be against the rules) or if they INSTIGATED any suctioning on the nurse-grandmother’s say-so. There’s a good chance the whole ICU is monitored by a recorded video system, which would allow everyone to put accurate times on who did what and when.

    About half a million tonsillectomies are done each year in the US and about 1 in 15 – 16000 results in death. So it is a small but real risk. Bleeding and post-op drug mistakes cause most of the deaths.

    • * she was NOT intubated by the anesthesiologist. They don’t intubate for throat operations or they’d not be able to reach to do the surgery.

      I do not agree. Trachea is not the esophagus. They have to knock her out to do the surgery and administer oxygen to keep her breathing. Tubes are small enough to share the throat with the surgeon.

      • “I do not agree. Trachea is not the esophagus. They have to knock her out to do the surgery and administer oxygen to keep her breathing. Tubes are small enough to share the throat with the surgeon.” says the Professor.
        *******************************************************************************
        LOL I was slowly composing my long post below when you put this up. Give it up, Professor, stick with the law…medicine is not your forte.

        You know that stuff Michael Jackson was given each night? Takes you to la-la land.

        The doctor looking around with a long tube with a snipping devise on it would be mighty po’d at that tube in his way. That breathing tube is bigger than you think. It’s hard to get one in an overweight youngster with that short neck….

        Professor did you know they even have robots that do heart surgeries now….smiles….google it.

        • Wow!

          Sent to the woodshed.

          You folks are a tough audience.

        • danielle says:

          Are you in the medical field? Bc I do anesthesia and Intubate almost all tonsillectomy with an oral RAE tube. Yea look it up. You cannot perform surgery in such a delicate area and use prayer to prevent the patient from moving. Even though they may be given propofol it doesn’t knock out the body’s normal reaction to stimulation. I.e. Gagging.

          • Curious, who was the manufacturer on that RAE tube? I used to work for a catheter company, and we made airway devices, so that is why I am curious. I miss it because we attended the ASA every year, and it was a lot of work/fun, learned a lot!

      • William Walton says:

        Prof, a trach is placed below the mouth area. Had one when I had the brain surgery for the subdural hemotoma. My trach was in the lower part of the neck.

    • Thiosux says:

      Aussie, ‘ she was NOT intubated by the anesthesiologist. They don’t intubate for throat operations or they’d not be able to reach to do the surgery’ and Hinkman ‘That breathing tube is bigger than you think. It’s hard to get one in an overweight youngster with that short neck…’

      Please would you all stop making daft ill informed assumptions about this?

      I assure you as an anaesthetist (anaesthesiologist to you) who specialises in shared airway care and ENT surgery: it is routine to intubate for many throat operations. The exact method chosen will depend on the patient, surgical and other risk factors but there are many ways to provide a secure surgical airway when operations are being done on the throat, nose, oral cavity, pharynx and larynx, often involving different techniques, specialist equipment and a high degree of cooperation between the surgeon and anaesthetist, including changes of tube/position/airway access during the operation. In this particular case the anatomic locations of the tissues being resected (nasal, uvula tonsils and palate) actually make oral intubation with a microlaryngeal or small, flexible tube relatively simple and easy to manage.

      Some anaesthetists might chose to carry out tonsil surgery with a less secure airway in selected patients (eg low risk, uncomplicated, appropriate weight, otherwise healthy adults planned for day surgery) and this is acceptable practice

      In this situation and with an overweight patient (thus more difficult to ventilate), history of sleep apnoea (in other words, altered control of brainstem ventilatory centres and control of breathing patterns) and complex surgery (3rd time resection of multiple highly vascular areas so high risks of bleeding and likely prolonged surgery) I suspect this patient would have a secure airway (eg a cuffed tube into the trachea, to allow ventilation and prevent lung contamination from blood and debris) She sounds very much high risk as evinced by her planned ICU stay postop for observation.

      Hinkman you are right in that she would probably be a more difficult intubation than the next person due to some of her physical characteristics – but this would actually make it more imperative to have a secure airway for the surgery initially as establishing intubation during the case would be technically more challenging, especially if specialist equipment or techniques were required.

  6. Trained Observer says:

    Reportedly by the mom’s own admission, this obese and quite dead child was fed ice cream by a family member within 48 hours post surgery — a definite WTF, if true.

    Apparently the parents also failed to disclose other family genetic and health issues to the hospital.

    Given certain apparent glaring omissions, I would not be too quick to blame an anesthetist, other surgical team members, or any of the ICU staff.

    Ice cream for Christ’s sake. Even the best docs nurses often can’t overcome stupid.

    Now it appears courts from coast to coast will need draft guidelines on interstate transport of corpses still hooked up to respirators and feeding tubes.

    • gblock says:

      Remember that ice cream is thought of as a standard post-operative treat for kids who have successfully come through a tonsillectomy, as a pleasant way to help numb the throat. Are you saying that she was fed the ice cream after she had started to suffer complications?

      • bettykath says:

        This whole discussion is above my paid grade but I remember my tonsillectomy, sort of, especially the ether mask that I fought physically and vocally. (Never did like people telling me what to do.) The nurses finally held me down and the ether shut me up. The ice cream after I got home was good. That was almost 70 years ago. Time flies whether you’re having fun or not.

        • William Walton says:

          Bettykath, I can one up you. When I had my appendectomy at age 4, Dad took me to the hospital where he was preparing to perform a surgery. Turned me over to Johnny H another surgeon and went on to perform his surgery. They tried to put the ether mask over my face and I fought back. So, a nurse had to scrub up, gown up, mask up, etc. and go into Dad’s OR and tell him “Doctor you need to go in the next OR and calm your kid down so we can put him under and get his surgery undeway. So, Dad had to degown, deglove, washup, gown up, glove up, etc. and come into the OR where I was and hold my hand and talk to me until they put me under. As I found out when I was 10 years old that he did not stay for the surgery but went back to the surgery he was about to perform. His comment was that Johnny H was an excellent surgeon so he knew I was in good hands. Dad also tried to con me that the liquid in the IV bag was what I liked for breakfast; bacon, eggs, and hash browns. Told him right, you cannot get that stuff down that small tube. The nurses left my room because they were laughing so hard. Dad would also get surgical patient up walking the day after surgery. I was told that Dr. Dad said I could have all the popcicles I wanted but had to walk down the hall to get them with a nurse and student nurse on either side of me. One would sturdy me and the other would move the IV apparatus along. You and I have interesting memories of our surguries.

      • Trained Observer says:

        I well remember the grape popsicle I was offered after my tonsillectomy. But I wasn’t a high risk kid and I wasn’t sent to the ICU. Rules in most if not all ICUs involve no food or drink, and with good reason. Patients aren’t placed there for the fun of it. BTW, as for a much earier comment, it is wrong to assume all patients in ICUs are intubated.

      • fauxmccoy says:

        it would all depend on if the family just supplied food/drink on their own (some do) or if they had medical clearance to do so. this was certainly no routine tonsillectomy and folks in ICU generally have strict dietary orders.

  7. Sorry Prof, but you are wrong on this one.

    The child did not have a breathing tube during surgery. How could they do the surgery if a tube is blocking their surgical area? (agreeing with Aussie and the other posters.)

    The surgery was not just a simple snip, snip the tonsils out. It was removal of adenoids,plus the little flap that hangs in the back of your throat, AND soft tissue around the area.Quiet a major surgery with the list of problems the little girl had coming into surgery. Not only the history of sleep apnea…but….possibly diabetes, and definitely obesity along with a short neck that is surrounded by layers of fatty tissue….and all in a young child.

    She made it through surgery and recovery and was awake and communicating. (She should absolutely not have been talking! She would have been told that before surgery to not try to talk afterwards)…..per her mother she said she had saliva in her mouth and could not swallow, then she began to write notes per her mother. Soon Mom realizes it is blood and we have bits and pieces from there on. Family had not allowed the hospital to release any medical statements.

    Remember all the hulabaloo about GZ’s bloody nose and how these area’s are very vascular and bleed profusely? So, does some of the area’s that were surgically manipulated on the girl.

    From a medical professional viewpoint from what the mother and uncle have said I see nothing that was done incorrectly. A nurse assessed the bleeding, assured the family some bleeding was to be expected…..even gave Mom a cup to hold so the girl could spit the blood in it so medical persons could measure the amount of blood.

    We do know that grandma who is a nurse in another hospital came in and used a suction apparatus to suction the blood. (With my years of experience as an ER nurse…no way would I go anywhere with suction except mid tongue with a child especially.)

    There would have been an apparatus attached that would beep to let the nurses know if there was a problem with the girl’s ability to breath. The mother EVEN stated there were clots of blood coming out…..we nurses like to hear that! The blood at least is clotting and not free flowing without the capability to clot.

    So what went wrong? What is it 6 minutes the brain can go without oxygen before damage occurs? Can you imagine a doctor in a crash and burn situation where a patient is suddenly unable to breath and you know you have to put a tube into the area where there are fresh surgical cuts and active bleeding? Did they chose to do a tracheotomy and go below the area? Or did they go by mouth? You can bet your bottom dollar they were working and they were working fast and furiously. Neither way is a good choice.

    And by the way, when did the serious bleeding start? Was she bleeding out before she went into cardiac arrest, or did she even go into cardiac arrest? Has that information been released by the hospital? Whatever happened, her brain was without oxygen for more than 6 minutes and she is brain dead. :(

    Seems the state of Cali has laws that define brain death and the hospital is just following the law. The laws are specific and although very sad….it does take away the guilt or religious aspects of a family not having to make the decision themselves.

    One more thing. I did not research all of this a lot, but heard the uncle or mother one state that the doctors tried to suction the blood out of her lungs……A tube can be put in the side of your body into your lung in about a minute and the blood will come right out.

    Anyway, we probably will never know the whole story as an autopsy is not going to tell us why she died at this point I do not think. Too much time passed for healing in the throat area.

    JMO

    • William Walton says:

      As my Physician/Surgeon Dad would have told you, you are very astoute in your observations. He would have been very impressed.

    • Rachael says:

      I agree with this. I realize, Professor, that as an attorney, you will always be looking for liability, but sometimes stuff just happens. NO surgery is without risk, and this had plenty of preexisting conditions. Sometimes things happen. It isn’t always someone’s “fault,” and not every patient can be “saved.” That doesn’t mean someone did anything “wrong.” I don’t think you will ever have a tonsillectomy without bleeding – it goes with the territory. Obviously something “went” wrong, but I can’t see anything that anyone did to cause it to go wrong. When you sign the permit, you are acknowledging that you have been told of the possible complications. ALL surgery has risks. Even the most routine surgeries have inherent risks. Most of the time no one even thinks about it. It sucks though when you are one of the statistics.

      • fauxmccoy says:

        rachael — i had a long talk with my RN mom about this last night, sharing with her the details of a family member attempting to suction blood. it was said here that a family member who was an LVN was doing this at request of children’s hospital.

        i do not believe that for a minute. as i’ve stated previously, i know the facility well. my mom has a number of personal and professional relationships with the nursing staff there.

        CA law requires a nurse to patient ration of 1:2 in ICU. what we could easily imagine is a family member who with some medical training (LVN who cannot even start an IV) panicked and tried to perform some treatment that was well beyond their level of training and did more harm than good. we do not even know if this person’s license is active at this point. bottom line is that much more information is needed.

        i can imagine the nursing staff of childrens hosp giving the mom an emesis basin for spitting up blood, but there is no way they would ask a family member to be suctioning blood.

        • kathy says:

          The Grandmother has an active LVN license in CA. She has IV certification, this can be verified for any nurse on the state board of nursing website.
          I would NEVER work on my own children though. My daughter recently had surgery (minor) if there is a minor thing with anesthesia. I did not tell a SINGLE SOUL I am a nurse.
          I have also read this is Jahi’s 3rd procedure, did scar tissue exercerbate the problem? There is SO MUCH more to this story…

          • fauxmccoy says:

            thanks for adding more to the story. as i said above, my mom is an RN since 1958, who just gave up her license last june at age 76. my love for nurses is unconditional due to my mamma and some a complicated health history — that would include you too, kathy! bless you for all you do.

            i had no way to verify this particular license (but have done so many times through the consumer affiars web site) because of the various stories i had read/heard, so i did not have a name to start searching. the scenario i was presenting was a ‘what if’ in absence of actual names of the nurse.

            my mom was rather forced a few times to start an IV on a couple of her kids, but that was at the hospital where she was the Director of Nurses, several others had tried to start the IV and in our community, my mom is the undisputed best in the tough stick situations. i know by the look on her face that she would rather be doing anything else. it was an act of maternal love and great skill. as a rule, i think it is bad medicine to practice on family members, as does my mom. the only thing that changed that for us was the rather smallish community which we lived and necessity.

            i had not heard this was jahi’s 3rd procedure. lord only knows what complications were present that we may never know, but i’m betting on numerous. the other thing on which we clearly agree is that no procedure including anesthesia should be considered ‘minor’. the surgery itself might be, anesthesia is not.

            i will still stand by my statement that children’s hospital in oakland would not ever ask a family member (even if an LVN) to suction blood for an ICU patient with surgical complications. i can see a family member panicking and starting something on their own.

            thankd you so much for your thoughtful response.

        • Pam Supenia says:

          @ fauxmccoy, You are wrong. I am an LPN…practical nurse/vocational nurse. Depending on your area of training but the same license. I worked in ER and started IV’s. I also drew blood. I agree tho, if a nurse is not on staff there, she/he cannot do procedures.

          • you asked says:

            Pam, You are correct that LVN/LPN’s can insert IV’s – but only if they take special training to do so. We don’t know if Grandma had any special training. She certainly shouldn’t have been suctioning Jahi. But then again, neither should they have allowed Jahi to suction herself & the Mother & Step Dad have also admitted suctioning Jahi.

            I also recently read that the State of Calif. investigated Children’s Hospital & found that nothing that would indicate that CH did anything wrong. They followed proper procedures & protocol & now the family & their attorney is angry that the State didn’t interview them. My question to the family is why would they need to interview the family. The state was investigating the Hospital. But, maybe the State should investigate the family – since they want to speak to the State so bad – it might be a good place to confront the family about their interviews regarding suctioning Jahi.

    • Madeline Grace says:

      “we nurses like to hear that! The blood at least is clotting and not free flowing without the capability to clot.”

      I hope I am never under your care. In a moist area, the blood clots are all that stops the bleeding, so if it’s true, her grandmother/mother could be found to be contributing factors in her death. In fact, scabs are just dried blood clots. In essence, they said “we removed all the scabs and now the bleeding won’t stop.” While I understand you got all giddy about knowing clotting means the body is capable of healing, the clotting process started when the first cut was made, so the doctors were well aware of her clotting ability before she went into the PICU.

      If her PICU nurses were happy that her blood clots were being disturbed, they should face legal action. For all we know, the suctioning loosened a blood clot that led to Jahi’s death.

      Also, an autopsy will still show a lot. Her body/metabolic processes stopped/greatly slowed a long time ago, which means there has been little healing. Your body breaks down dissolvable sutures because your blood is flowing and breaking down the natural materials they are made from via enzymes in the blood. This girl hasn’t had blood going to brain since shortly after the surgery, so I’d venture to guess not much of her head is receiving blood. The artificial life that has been maintaining her has probably maintained evidence as well. Plus, bodies are exhumed all of the time and cause of death found.

      Also, there’s not going to be some lackey assigned to investigate cause of death. There is a crap ton of money riding on it, as well as legal precedent. Some real life Bones-type will conduct the autopsy and there will also be a independent autopsy performed by someone the girl’s mother’s lawyer chooses.

      I have known people who have children in the hospital short and long term. These parents tend to form groups because they have a sick kid in common. Even the rudest moms get some leeway because of how stressful it is to have a sick child. I say this, because I can’t imagine the level of bad behavior shown by Jahi’s family at the hospital that has led to no one else in the PICU standing up for them, only sharing horror stories.

      • Larry Leverett, MD says:

        There are a lot of assumptions. But as a surgeon, I have seen this story in my office. I have a patient (44yo) who presented w a breast mass. When it was removed by another surgeon, she bled so much that she had a hematoma and tissue loss requiring reconstruction. That surgery bled so much that she developed and clot around her implant with subsequent hardening. Her history was LATER revealed that when she had a tonsillectomy as a kid, she bled so much that she had to be replaced on the ventilator for days and taken back to the OR. When she had a kid, she bled so much that she had to have a hysterectomy to stop the bleeding. She ended up have a severe bleeding factor deficiency that was undiagnosed until I worked her up. She required transfusion of factors BEFORE and after surgery to be safe. Most likely, that’s what caused this degree of bleeding and one doesn’t to suspect it until severe bleeding occurs. Routine testing doesn’t pick it up. And worse yet, the diagnosis cannot be made now because the hospital has likely transfused the clotting factors into her system in an effort to stop the bleeding.

  8. JJ says:

    Hospitals are not completely trustworthy. I used to be on a discussion group with healthcare professionals. Two described incidents mentioned concerned me: 1) Newborn immediately snuffed out because it was grossly misformed. 2) A live baby was sent for autopsy, and the pathologist sent it back saying he couldn’t perform an autopsy on a live aby.
    We recently had a customer relate their personal story. The wife was called to the hospital to sign a consent form to have her deceased husband’s organs donated. When she came in, she could hear her husband yelling – and she found her husband very much alive.
    I suspect that hospital decisions are made with primary focus on financial implications. Your care may be dependant upon how the insurance company pays. On some plans, the hospital is paid a set amount based on the DRG. On other plans 100% covered (like Medicare Supplement F), the HC system may provide unneeded care subjecting the patient to higher risks of adverse effects.
    If hospitals and doctors had stellar reputations, the parents of this young girl would trust their pronouncement of “dead” and move on. Instead, the parents are convinced that the hospital HC team messed up and are covering up their mistakes.

    • Rachael says:

      I don’t believe the parents would “trust their pronouncement of “dead” and move on.” While I do agree that people would trust more if hospitals and doctors had stellar reputations, this is their child. In the mind of most people, a tonsillectomy is a totally routine procedure. People don’t associate risks with routine procedures, EVEN when there are preexisting conditions that make it riskier. And again, this is their child. Logic doesn’t always have anything to do with it. You can be told there are no brainwaves, your child is “dead,” but when you see that child appearing just to be asleep, all the logic in the world won’t prevent you from wanting them to open their eyes and it to all be a big mistake. And also, trust or not, when something goes wrong, it is hard to accept that things can just plain go wrong. It is so much easier to assign blame. Often there is blame, sometimes there is enough blame to go around. It is so much easier to accept that someone messed up. “God works in mysterious ways” flies out the window.

      But sometimes stuff happens.

  9. Trained Observer says:

    FYI, on Friday, the Alameda County coroner issued a death certificate stating that Jahi died on DECEMBER 12, three days after doctors at Children’s Hospital performed a tonsillectomy that led to complications.

    I can’t believe statements here that the anesthetist/anesthesiolgist
    are or surgeons to blame, or that it was obvious she was intubated just because she was in an ICU.

    The longer the family drags this out, the less likely an autopsy will be all that helpful. Given what little we know so far (including talk about grandma — supposedly a nurse — doing some DIY suctioning, and another family member giving the kid ice cream, I seriously doubt any jury will come down overly hard on the hospital or its medical team.

    The family needs to understand that the child is DEAD, and it needs to accept whatever settlement, if any, the medical facility offers.

    Otherwise the family needs to be prepared to incur a great amount of debt in keeping a corpse warmed up with a machine. The child deserves better.

    • Lyn says:

      There are lots of different types of “nurses”. All the way from nursing assistants who empty bed pains to the highly educated Registered Nurses who run the Units.
      I think a jury will fine the hospitals and docs lots of money. The medical professionals doing all the maneuvering trying to put this child in the ground ASAP is not helping their cause. Who are we to say when a family should bid adieu to their child? The realization will come to them soon enough as they realize, dead is forever. Burying this child is not going to bury hospital/Doc liability. Every effort should be made to assist this family in their quest to find a facility to care for her until they are able to let go.

      • Trained Observer says:

        Most of us are well aware that nurses range from RNs and LPNs on down. Nurses aides are aides, not nurses. The grandma, alllegedly, is a nurse.

        Burying or cremating the child won’t erase liability, but there’s an excellent chance no liability or minimal liability will be found in this case.

        If families can afford to warehouse their dead loved ones on machines, let them go for it. But don’t expect taxpayers, insurance companies, or medical facilities to gladly foot the bill.

    • Lyn says:

      When I lost my eldest son, some people felt the need to say “Well, Let’s pull our socks up and move” for which I replied “Tell me that when it is your kid”.

    • The problem we have regarding a discussion of potential liability issues is that the hospital records have not been released and some of the statements by family members appear to be more hopeful than credible.

      Therefore, with one notable exception, we are navigating in the dark and cannot have an evidence-based discussion.

      The exception is Jahi McMath underwent a high-risk surgery.

    • Pam Supenia says:

      No I believe the parents are under educated and unable to understand the definition of brain death.

    • Pam Supenia says:

      The mother quit her job to stay beside this child. We know who is going to be paying for all this, and it is not the family. The hospital does not owe a settlement to this family. Life is not always fair

  10. mom22girls says:

    I have been a RN for 19 years. The past 14 in intensive care. Jahi was admitted to ICU aftef her surgery because she was a complicated case. She was obese and had sleep apnea. Just because you are in ICU you are not always intubated. She suffered a post op complication that unfortunately in her case can happen. I think it is deplorable that an attorney and anyone else are feeding her family with sheer lies about her possibly recovery. She is brain dead and will not recover. Her organs are no longer donatable to someone who really needs them. Let this child rest in peace. Stop torturing her body with pointless medical care.

  11. lavinia says:

    Very interesting discussion. I think I was given more food for thought here than in any other site regarding Jahi McMath.
    I have come across reports that she was fed cheeseburger during recovery. However, it’s not clear whether that is accurate or not. I am curious if it is true and whether that played a role in the complications that occurred afterward.

    • I do not know if the story is true, but I doubt that it is because I do not believe the nursing staff would have permitted it to happen.

      I also doubt that Jahi would have wanted to eat anything or that her family would have offered her a cheeseburger.

      I suspect the story was made up by some mean-spirited person full of hate just to denigrate the family in the eyes of the public.

      • fauxmccoy says:

        @professor — although i cannot confirm the accuracy of the cheeseburger story, i can tell you that it originates from another parent in the recovery room who claimed to witness the incident. we do know that the family provided other food items against medical orders (popsicles), so i am keeping my mind open.

        • Just now read your comment. Missed it earlier while watching closing arguments in the Kelly Thomas case.

          Didn’t realize that the source of the story was another parent in the recovery room.

          • pete says:

            I’ll chime in here. I’ve read in news reports that Jahi did have a popsicle. What struck me as odd was that the popsicle was pink. I can tell you that there is no way the staff would give Jahi is PINK popsicle. The pink and red ones are usually eaten by the nurses, other staff, or guest because the coloring looks too similiar to blood. If they see redish like liquid, or drips, they would be looking for its source making sure the patient isn’t bleeding. I would not be surprised if the popsicle was brought from outside. Possibly the cheeseburger as well. This isn’t intended to be mean, but obviously Jahi had a fond relationship with food.

        • Pam Supenia says:

          If she was fed more salads and less cheeseburgers maybe she would not have had the risks associated with obesity

        • iwoks98 says:

          @ fauxmccoy – popsicles aren’t against policy after post op throat surgery. In fact popsicles are recommended (except red ones) because they ease the discomfort of throat surgery. I doubt the cheeseburger story too, even if someone ‘claims’ they were in the ICU, we don’t know that for a fact – just another rumor. I have watched news interviews where the mother, stepfather & grandmother all admit to suctioning Jahi & even admit that Jahi suctioned herself. It is normal to have some bleeding after UP3 & tonsillectomy & I wonder if the family didn’t expect it. My bet is that their inexperience & aggressive suctioning, probably led to the increase in bleeding.

  12. a2nite says:

    FYI as a retired anesthesiologist, I want to clarify a couple of points:

    Tonsil surgery is done with a breathing tube placed in the windpipe. There are two good reasons why. One, the patient is under general anesthesia & cannot breathe for themselves. Two, the operating field is in the airway & the airway (windpipe & lungs need to be protected) from the crap that can go in during the operation, blood, tissue, mucus, regurgitated stomach contents.
    There is plenty of room in the mouth for the tube & the surgeons instruments. The breathing tube is removed after the surgery is completed & the patient is awake enough to breathe AND protect their own airway.
    I cannot comment on her care without looking at the medical chart. I’m not going to speculate. If you want more detail I can give more detail when I have access to a computer w/keyboard. This girls death does make me sad. Pardon the typos because this was written on an IPhone.

    • Thanks for clarifying that point. I was reasonably certain that was true, but apparently mistaken that her trip to the ICU necessarily meant that she was in trouble and intubated. Evidently, her trip to the ICU was a planned event, no matter how well the surgery went, because it was a high risk surgery and they wanted her to be in the ICU in case of complications.

  13. Tina Armstrong says:

    I also have sleep apnea and had a surgery last year so let me help out here. Anesthesia makes sleep apnea worse so does anything to put you to sleep such as sleeping pills. After surgery you are supposed to do breathing treatments to clear the lungs of the anesthesia otherwise you can develop pneumonia. I did my treatments but it hurt to breathe sometimes. I that the mother gave her daughter a cheeseburger because she was so hungry on the all liquid diet she was on. That could rip the stitches and also cause her to choke. She had surgery on 6 part of her face that would make it impossible to eat solids.

  14. The most common severe complication of any tonsillectomy is the risk for bleeding, and the older the patient, the more severe that risk becomes because larger blood vessels mean larger and more unstable clots. Add in the co-morbid conditions and the (yes, MORBID) obesity, and you have a set up for a big problem, no matter how well the procedure may have been managed. No competent nurse would stick a suction catheter down the throat of a fresh post-op tonsillectomy because of the risk of dislodging clots and causing further bleeding, much less have instructed a family member to do it. Bleeding that required that level of intervention would have also required an emergent call to the surgeon to come to the bedside. If the grandmother did that, she was way out of line. A nurse would NOT have the ability to stop such hemorrhage; that would generally require a trip back to the OR. Should the procedure have been attempted? Sleep apnea in a 13 year old is potentially life-threatening too. I don’t believe a surgeon would recommend a procedure that was not indicated in a child with so many complications. Surgeons don’t like to lose patients, either. Please remember most health care professionals are very ethical people who want the best outcomes for their patients. What happened to Jahi was a tragedy, but a poor outcome does not mean the health team did something wrong. It is unfortunate that her general weight and health were not kept under better control to keep her from getting to the point of so many medical problems in the first place.

  15. Allison says:

    Late to the party here and maybe it’s been said already, but your entire rationale for why the complications must have occurred during surgery and the surgeon or anesthesiologist is to blame is based on a misunderstanding of how pediatric ICUs work.

    Not everyone in the PICU is intubated. We get obese patients who are post-op tonsillectomies all the time because they go to the OR, have their procedure done and get extubated (breathing tube removed), go to the PACU (recovery room), and still end up getting sent to the PICU because they’re still having sleep apnea. Why? Because they’re obese! At any rate, they come to the PICU for airway watch.

    All to say, it is completely possible that Jahi was transferred to the PICU awake, alert and not connected to a breathing machine. I see it all the time.

    • Yes, thanks to several people who have commented, I realize and have acknowledged that I was mistaken about that point.

      I guess the next issue is why did the heavy bleeding start.

      Any ideas?

      • Any disruption or irritation to the throat could have done it. Coughing, sneezing, eating or drinking, even straining motions could dislodge any unstable clots. There are many things that could cause post-op bleeding, especially in the region of the upper airway and throat. That is why immediate post-op orders for nothing by mouth, progressing to clear liquids are so important to follow. My 17 year old son started bleeding several days post op for no apparent reason and had to go back to surgery emergently, and he was being extremely careful about following his diet restrictions..

  16. Larry Leverett, MD says:

    There are a lot of assumptions. But as a surgeon, I have seen this story in my office. I have a patient (44yo) who presented w a breast mass. When it was removed by another surgeon, she bled so much that she had a hematoma and tissue loss requiring reconstruction. That surgery bled so much that she developed and clot around her implant with subsequent hardening. Her history was LATER revealed that when she had a tonsillectomy as a kid, she bled so much that she had to be replaced on the ventilator for days and taken back to the OR. When she had a kid, she bled so much that she had to have a hysterectomy to stop the bleeding. She ended up have a severe bleeding factor deficiency that was undiagnosed until I worked her up. She required transfusion of factors BEFORE and after surgery to be safe. Most likely, that’s what caused this degree of bleeding and one doesn’t to suspect it until severe bleeding occurs. Routine testing doesn’t pick it up. And worse yet, the diagnosis cannot be made now because the hospital has likely transfused the clotting factors into her system in an effort to stop the bleeding.

  17. caitlyn says:

    My son had a similar surgery done for similar circumstances when he was one at that same hospital … They are put in Icu right after surgery even if there are no complications … He had to stay there overnight … Also any surgery is risky … And the removal of sinus tissue and tonsils isn’t just a walk in the park … And when you throw someone overweight under the knife it can raise that level of risk even higher … My son was not overweight he was only one years old but had enlarged adnoids which made him stop breathing at night while he slept – after trying different medication to open his air ways and also a humidIfier on all day I decided surgery was the only option that would show results. Jahi’s story is sad , but her mother should have tried other options than surgery to begin with … The girl was overweight and I am almost positive that most if not all of her problems would have been solved if put on a healthy diet … I do not think the hospital is liable … They are professionals who have to remain silent due to hipaa … Which is what it should be … But I am sure the family probably, unfortunately played a sold in the death of jahi …

  18. F. Anthony Edwards says:

    Res Ipsa loquitor is not the standard the surgeon will face. It will be whether be fell below the standard of care in his community. Expert witnesses will testify on the standard of care. Case could go either way. If the surgeon performed the procedure within the standard of care he cannot be liable, irrespective of the outcome.

    • In the comments I have acknowledged that I made an incorrect assumption that something went wrong in the OR or Jahi would not have been taken to the ICU. I also mistakenly believed that this was not a high risk surgery.

      I now realize this was a high risk surgery and taking her to the ICU was standard procedure.

      I am not presently aware of any reason to believe that any medical person was negligent.

      If a lawsuit were to be filed against the surgeon, I agree that you have stated the correct legal rule to be applied.

    • iwoks98 says:

      The State of California has already performed an investigation as to whether proper procedure was done in the case of Jahi & found that the hospital followed proper protocol & found absolutely nothing to indicate that the hospital or their staff was at fault in the death of Jahi.

      I still believe the news interviews I personally saw where the Mother, step father, grandmother all admitted to suctioning Jahi & also stated that Jahi had suctioned herself. The Mother admitted suctioning her first & handed the suction tubing to step dad so she could go out & get grandma. Due to their inexperience, they could have panicked if they saw a little bit of blood & became too aggressive in their suctioning technique. The Mother stated the nurse handed the suction tubing to her, but I don’t believe this for 1 minute. I have worked in ICU for years & I don’t know of any nurse that would ask a parent or any family member to suction a patient. Even if the Grandma was on staff at another hospital as an LVN, it still does not give her priviledges at any other hospital & she should have known that. I also don’t believe they staff gave the family a “cup” to catch the blood. When there is some bleeding or even emesis involved, the patient will be given an emesis basin, which I’m sure everyone has seen 1 at one time or another if they’ve been in the hospital. “Cups” usually aren’t required equipment that is kept in any hospital room, let alone in ICU.

  19. Mary Smith says:

    You say there’s no reason for Jahi to have been in ICU because she wasn’t intubated; or, to put this another way, if she WAS in ICU, she would have been intubated.

    My mother was brought into the ICU after her heart surgery. When I visited her later in the day, she was still in ICU and was not intubated. She stayed in ICU for around five days–and never was intubated. The only time she was intubated was upon being taken to ICU. They extubated when she was conscious enough to respond to the command to swallow and take a breath.

    Since when is intubation an requirement for being in the ICU?

    Jahi’s family was with her after she was extubated. Family is not allowed to see a patient after surgery until after they’re extubated AND aware enough to know what’s going on.

    • Yes, you’re correct and I have admitted my mistake in the comments.

      I also have admitted that I was mistaken in believing that she underwent low risk surgery. It was high risk with a 77% probability of death or serious neurological damage, according to a study published in July, 2013.

      As things stand now, I have no reason to suspect medical negligence by anyone.

      Thanks for stopping by. I believe it’s important to get things right.

  20. dawn says:

    A doctor’s declaration of brain death is tantamount to his admission of malpractice, negligence, denial of care, deliberate indifference and conspiracy to obtain organs or to cover-up the deliberate intention to obtain organs.

    Brain death does not happen in a parallel universe. It is caused by medical failure or refusal to act. If a doctor declares brain death he must also say what he did to cause it. There is, in every modern hospital, every tool available to prevent brain swelling. It is an easy and established medical treatment. Michael Schumacher is getting that care. We need to move on from what is brain death to WHO causes it? And why? It happens in a hospital and is certainly not caused by the patient or family. Jahi’s was caused over 3 days.

    We also need to understand why a bang to the head and a few dead brain cells is increasingly equating to the medical declaration of “brain death” to an anxious family. Is the term “brain death” meant to imply that a loved one was hit on the head as opposed to the arm? And that, after they recover there will be some of those dreaded behavioral effects? Is this why families donate organs? Because ugly isn’t “in” at the present time?

    Is the term “brain death” more intended to be understood in its popular use meaning rather than a medical one? That of, “you’re a nutbar if you even try to talk your way out of this one…?” That’s not medicine, it’s fraud and false imprisonment. Like duct tape to a kidnapper.

    • cielo62 says:

      Dawn, you are 100% WRONG. Not each death is someone’s fault. I can tell you have ZERO understanding of medicine and medical procedures. Maybe you should let the grown ups handle this one, honey.

    • Jayna says:

      Wow. I can’t believe people that think the way you do exist. Do you know anything about science, or do you believe in resurrections? Also, organ donation is a wonderful program that has saved many lives. Who wants to “live” on a vent with zero brain activity. That’s not a life. That is merely corpse support.

    • iwoks98 says:

      Dawn, Your comments make absolutely no sense. Did you ever consider that it was the actions of the family that caused Jahi’s increased bleeding, that resulted in her heart stopping & ultimately lack of oxygen to the brain? If you haven’t seen the multiple news interviews the family has given, then you should. They admitted that not only did Jahi suction herself, but that they suctioned her (Mom, Step Dad & Grandma). If you fail to watch the news interviews, then you are missing out on the bigger picture here. Instead of blaming the surgeon, anesthesiologist or nurses, you need to gather all the facts (or as much as possible) before making a decision that could ruin a person’s career.

      Jahi was in recover after her surgery & had no complications & was then taken to ICU, as planned when she was admitted. It wasn’t until ICU, with family around, that she began having problems.

      In case you haven’t heard, the State of California has investigated Children’s Hospital & found that they did not violate medical standards in Jahi’s case. Of course, now the family is blaming the State of Calif. for not doing a ‘thorough’ investigation because they didn’t interview the family. Who are they going to blame next? Do you see the nonsense this family is spewing to the media? Why would the State of Calif. need to interview the family when they were doing an investigation on the hospital per the family’s complaints.

      It’s obvious by your comments, that you are first, not in the medical
      field & secondly, haven’t read court documents or medical reports on Jahi’s case. I have (they are posted online if you care to read them). I have also been in the nursing profession for 22 years, so I understand not only why the tests were ordered, but what the results mean.

      I also have to correct a statement you made. It didn’t take 3 days for Jahi to become brain dead. It took 3 days to be declared brain dead – big difference. If you aren’t familiar as to how brain death is diagnosed, then that might be why the confusion as to why you think it took her 3 days for her injuries to result in brain death.

      Jahi started bleeding profusely, the day of her surgery & her heart stopped the same day. She remained unconscious & on a ventilator on Tuesday & at 2 a.m. on Wednesday, (< 48 hours after surgery) hypoxia brain injury, due to lack of oxygen to the brain & brain swelling was observed.

      As soon as this was noticed, testing began. In Jahi's case, serial exams were performed, on Wednesday, as well as a brain perfusion scan, EEG's & several physical exams, an apnea exam, reflex testing, etc. Jahi was declared brain dead on Thursday the 12th, only after numerous tests were performed, to confirm that the hypoxia, which caused her brain to swell, resulted in brain death.

      Jahi's family couldn't accept these results, so they had 3 independent physicians examine Jahi & even their own physicians came to the same conclusion. They still couldn't accept that Jahi was brain dead, so the courts went above & beyond what is accepted & ordered another independent exam by a pediatric neurologist from Stanford (Dr. Paul Fisher). If you haven't read his report, I'd advise you to do that. He did a very thorough exam of Jahi & ordered numerous tests be performed, including blood tests, including ABG's while she was on the vent & after it was turned off. He also ordered an EEG, radionuclide cerebral blood flow studies (SPECT scan), apnea tests & a host of others. He did all the perfunctory neurological tests to test reflexes, which included touch, air & gag. His testing also confirmed that Jahi was brain dead. Yet, the family still refused to accept the fact that Jahi was brain dead. I don't think the family would accept it, even if 100 doctors had examined Jahi.

      You should also read the report submitted to the courts on January 7th by Dr. Heidi Flori. She stated that Jahi had no evidence of bowel functioning for weeks, but on Jan. 2nd, Jahi passed material that was consistent with the lining of the gut. Basically, Jahi's bowels were sloughing off & she was passing that. She also noted that even though Jahi was getting excellent skin care, the subcutaneous tissue & muscle showed signs of deterioration & increased muscle contractions. She also stated that the hospital staff had been performing inhaled therapy to help with clear Jahi's pulmonary secretions, but that too was not helping because the secretions were now thick & malodorous. A 'normal' brain also controls the body's temperature, but due to Jahi's loss of function to her brain stem, they had to keep Jahi on a warming blanket to maintain temperature.

      Had the hospital not done these different things, the family "might" have seen the true nature of Jahi's injury & realized that her body was only warm, because of the warming blanket & not that her body was maintaining it's own temp. They also see the vent moving the chest up & down, but it's not Jahi breathing, because when the vent was turned off during testing, she was unable to take a breath on her own. As hard as it would be for them to see, it's too bad the family wasn't in the room when the vent was turned off & "maybe" someone would have been able to get them to see that Jahi could not breath on her own & that she wouldn't recover.

      Based on what medical reports I have read, I think Children's Hospital did everything in their power to save Jahi's life. Sometimes, no matter the efforts of the hospital or their staff, it isn't always possible.

  21. Amazed says:

    Amazed says:

    To Dawn,

    You are way off base! All that you wrote is just your own uneducated opinion and makes you sound like a raving lunatic.

    You wrote: [“A doctor’s declaration of brain death is tantamount to his admission of malpractice, negligence,….”]

    ??!! SMH!

    Another snippet of your madness: [“Brain death does not happen in a parallel universe. It is caused by medical failure or refusal to act. If a doctor declares brain death he must also say what he did to cause it….”]

    Do you realize the irony of your rant?! “..a parallel universe…”
    (Meaning) Parallel universe: “Is a hypothetical or fictional self-contained separate reality coexisting with one’s own.”

    What SOME people believe >: “How You Can Use Parallel Universes To Improve Your Life; There are some people who believe that jumping from one universe to another is already a possibility and claim to do it frequently.”

    My advice for Dawn is this: Go take a quantum leap or jump. ;)

  22. Jim says:

    well first off, author, she was placed the ICU AFTER she started bleeding, not before, you’re wrong there. So how does that in your mind indicate improper anesthesiology? That makes absolutely no sense. If an artery was nicked during surgery, bleeding would have been immediate, considering how much blood she lost. Your story holds no water. Perhaps what is most interesting though, is that even the family hasn’t been claiming malpractice, the only they’ve sued for is to keep life support. Seems they don’t think the hospital at fault, yet.

    • iwoks98 says:

      Jim, actually you are incorrect about 1 thing. Jahi was taken to recovery after her surgery & then taken to ICU. Jahi was taken from recovery to ICU without complications. It wasn’t until she was in ICU that the family claims she started bleeding profusely. However, the family has also admitted in several news interviews that the Mother, stepfather, Grandma & even Jahi herself suctioned Jahi.

      An investigation has been performed by the State of California & found that the hospital did not violate medical standards in the the case of Jahi McMath. Of course, the family is now claiming that the California DOH didn’t conduct a thorough investigation, because they didn’t interview the family.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 1,084 other followers

%d bloggers like this: