Posts Tagged ‘New York’

On brain death and the Jahi McMath story

January 21, 2014  |  General  |  44 Comments

The recent and unfolding tragedy of Jahi McMath, the 13-year-old girl who died following complications of tonsillectomy and adenoidectomy, has focused many people on the question of brain death. Although I have no more details about this case than anyone else reading the news, I am quite familiar with the sort of things that happened to this unfortunate child. As many of you know, her family does not believe she is dead, although multiple physicians have documented she is and the county medical examiner’s office (the coroner) has issued a death certificate. The latest news is that she has been transferred from Oakland to a facility in New York.

So what is brain death? It means no function at the level of the brain stem or above. Function stops where the spinal cord joins the base of the brain. How do we know somebody is brain dead? There are a series of standard and relatively low-tech bedside tests to determine that. We first make sure the patient has a normal body temperature and has no sedating drugs in their system. There should be no purposeful response to any stimuli. The muscles are flaccid. Then we test for brain stem reflexes. One of these is response of the pupils to light — there should be none. There needs to be absence of normal movement of the eyes to motion of the head (called doll’s eyes) or no movement when we put cold water on the ear drum (called cold calorics); both of these measure the same reflex. There should be no blink reflex, called the corneal reflex, when a wisp of cotton is brushed on the eyeball. There should be no gag reflex when we stimulate the back of the throat with a wooden tongue depressor. Finally, the last test of brain stem function is the apnea test: we allow the blood carbon dioxide level to rise and look for any effort to take a breath. Rising blood carbon dioxide level is a strong trigger to the normal brain to breathe, and failure to do so means this ability is lost.

What happens after the bedside brain death determination varies a little from hospital to hospital. Many hospitals require 2 tests 24 hours apart; if both show no brainstem function, the patient is legally dead at the conclusion of the second test. As an alternative, we can do the bedside test followed by a simple scan to determine of there is any blood flowing to the brain. These two tests together give us an immediate answer, and many hospitals require the flow study for children. If the bedside examination shows no brainstem function and the flow study shows no blood flow to the brain, the patient is legally dead. I write the time of death on the death certificate as the time of the scan.

When I do these things I always want the family with me and watching what I do as I explain what is happening.

That all seems straightforward. As with this case, sometimes it’s not. For one thing, not all cultural traditions recognize brain death as real if the heart is still beating. I’ve been in that situation. For another, sometimes there are reflexes at the spinal cord level that look as if the patient is alive. That’s a difficult thing to watch.

The upshot is that I have continued support — mechanical ventilation, often medicines to support heart and other organ function — on a brain-dead patient for some time. Usually this is because the family wants some time to cope with things, or else there is a family member traveling to the hospital. I’m always OK with that, up to a point. A key principle here is that a family cannot force me to behave unethically, and continuing organ support of a dead person is disrespectful of the dead — mutilating to the body. Many ethical traditions, including my own, refuse to do that.

The longest I have ever continued organ support on a dead person was 6 weeks. We had a huge court battle similar to this case, with the court ultimately allowing us to withdraw support. A family member then attempted to enter the hospital with a gun. It was ugly.

The bottom line is that, with the exception of the one case above, I have always been able to mediate the situation by listening to families, being frank about my own duties (both legal and ethical), and allowing them time to grieve. I have always regarded caring for dying people and participating in their death as an honor granted me by the family.

I think there is more going on in this case than we know. Why this case became so adversarial is probably a complicated issue, and these complexities do not translate well to the evening news. At the very least, clearly the hospital and doctors failed to establish a relationship of trust with the family.

Regarding the child’s cause of death, I’d lay odds she had sudden bleeding from the tonsilar bed, the tissues under where the tonsils were. This is a well-known complication after tonsillectomy if the clots fall off. After that I think she probably lost her airway, either from obstruction from blood clots or some other reason. She was a large girl undergoing the procedure because of sleep apnea. Such people often have difficult upper airways to access and control with a breathing tube in a hurry, and that was what she probably needed. The back of the throat is also quite inflamed immediately after this kind of surgery and a rebleeding tonsil site can obscure everything with a large quantity of blood. I know this from experience. It’s a difficult situation to manage. I assume she went 4-5 minutes without an adequate airway, leading to brain damage and subsequent brain death. This is a common progression after anoxic brain injury — lack of oxygen — from any cause.

There are some directly antagonistic ethical issues in play here. Patients, and their families, are in charge of medical decision making. But they don’t have the right to demand whatever they want. This can be as simple as requesting a test that is not medically indicated or as complicated as this case. Futile care is unethical, particularly if it causes pain to the patient. Of course in this case the patient is already dead, so one could argue that there is no harm in persisting. But there is ethical harm, I think.

I have been in the situation of requesting, on behalf of a family, transfer of their brain dead child to another facility when we have reached an impasse. That is my obligation to them. But no facility I have ever dealt with would accept transfer of a dead person; I wouldn’t, and I am surprised the family was able to locate one.

One other thing I’m occasionally asked: Has anyone who was declared brain dead ever been found later not to be dead? I am unaware of any cases of this. If you hear of such things you need to understand that a patient in a deep coma, totally unresponsive to the world, is not dead. They still have the reflexes I described above intact. Once in a while such a person awakens.

At any rate, nature has a way of deciding these things no matter what we puny humans do.

How are doctors trained anyway? (Part 3: resident life)

May 4, 2011  |  General  |  No Comments

In spite of all its scientific underpinnings, medicine is not really a science; rather, it is an art guided by science. Medical students spend long hours learning about the science of the body, but they really do not become doctors until they have learned the art at the bedside from experienced clinicians. Medical practice is called practice for a reason; we learn it by practicing it in a centuries-old apprenticeship system, which is really what a residency is. As we do so, and again, in spite of the scientific trappings, we imbibe ways of thinking, of talking, and of doing that are as old as Hippocrates. This post will show you that aspect of medicine. Seeing it is fundamental for your understanding of what doctors do and why.

Although physicians learn at the feet of their elders — the experienced practitioners — a young doctor’s peers also heavily influence his training, and through that, his outlook; resident culture is important. Residency is an intense experience that comes at a time in life when most new doctors are relatively young and still evolving their adult characters. In a manner similar to military training, residency throws young people together for lengthy, often emotion-laden duty stints in the hospital. Not surprisingly, and also like military service people, residents often form personal bonds from this shared experience that last for the rest of their lives. Most physicians carry vivid memories from their residency for the duration of their careers.

Recent regulations have limited the maximum number of hours a resident may work each week. These rules came from two sources. One was the common-sense observation that tired residents cannot learn or work well. Common sense, however, cannot change hidebound traditions; what really changed resident work hours was a famous court case in New York (the Libby Zion case), involving a girl who died under the care of overworked residents. The particulars of that case did not clearly establish that resident fatigue caused Libby’s death, but the uproar started a sea change in how residents are trained.

The mandated maximum of an eighty-hour workweek is still long by any standard, but it had been much longer, and many of today’s doctors (myself included) trained under the old system when 110 hours or more per week was not uncommon, with perhaps the gift of every third Sunday off. My own residency program director told us, intending no irony: “The main problem with being on-call only every other night is that you miss half the interesting patients.” So, like garrulous ex-Marines, doctors swap tales of the time that, although brief in comparison to a lifelong career, was extraordinarily important in forming their professional behavior. Generalizations are tricky, especially when applied to such a diverse group of people as resident physicians. This caveat aside, parents who understand something about resident culture will gain useful insights into why many physicians think and act the way that we do.

Residents have come through a pathway that generally fosters intense competition and that values academic achievement above all else. In recent years, medical schools and residency programs have, to varying degrees, tried to emphasize the importance of more humanistic skills like empathy and compassion, and the specialty of pediatrics has been among the leaders in doing this. However, it remains true that physicians are the products of a system that rewards those who excel at competing with their colleagues at how much information one can learn, remember, and then produce when asked for it by a superior.

Resident culture encourages young doctors to appear and act all-knowing and self-confident even when they are not. This skill is often called “roundsmanship” and is inculcated from early on in their training. Residents get much of their teaching during the time-honored ritual of rounds, in which a team of residents and their supervising physician walk around to their patients’ rooms, pausing at each doorway to discuss the case. The discussion typically begins with the resident presenting the patient’s problem and the resident’s plan to deal with it to the assembled group, following which the supervising physician often grills the resident about the case. Residents adept at roundsmanship are quick thinkers and have rapid recall of pertinent facts. Master roundsmen, however, are best characterized as fearless when clueless—they appear assured and in control of the situation even when they are not.

I am exaggerating a little for effect, of course, but my point is to show you how years and years of this kind of environment affect most doctors to some extent. Such a background can cause doctors to seem defensive when questioned, for example by a parent, because doctors spend their formative years defending what they are doing to both their peers and to their exacting teachers. It can also make it difficult for a doctor to admit he does not know what to do with a patient, since physicians are conditioned to regard that admission as a real defeat. This attitude is encapsulated in the saying, often applied to surgeons but relevant to all physicians: “Seldom wrong, never in doubt.”

How are doctors trained, anyway? (Part 3 — the training culture)

June 11, 2009  |  General  |  No Comments

In spite of all its scientific underpinnings, medicine is not really a science; rather, it is an art guided by science. Medical students spend long hours learning about the science of the body, but they really do not become doctors until they have learned the art at the bedside from experienced clinicians. Medical practice is called practice for a reason; we learn it by practicing it in a centuries-old apprenticeship system, which is really what a residency is. As we do so, and again, in spite of the scientific trappings, we imbibe ways of thinking, of talking, and of doing that are as old as Hippocrates. The rest of this chapter will show you that aspect of medicine. Seeing it is fundamental for your understanding of what doctors do and why.

Although physicians learn at the feet of their elders — the experienced practitioners — a young doctor’s peers also heavily influence his training, and through that, his outlook; resident culture is important. Residency is an intense experience that comes at a time in life when most new doctors are relatively young and still evolving their adult characters. In a manner similar to military training, residency throws young people together for lengthy, often emotion-laden duty stints in the hospital. Not surprisingly, and also like military service people, residents often form personal bonds from this shared experience that last for the rest of their lives. Most physicians carry vivid memories from their residency for the duration of their careers.

Recent regulations have limited the maximum number of hours a resident may work each week. These rules came from two sources. One was the common-sense observation that tired residents cannot learn or work well. Common sense, however, cannot change hidebound traditions; what really changed resident work hours was a famous court case in New York (the Libby Zion case), involving a girl who died under the care of overworked residents. The particulars of that case did not clearly establish that resident fatigue caused Libby’s death, but the uproar started a sea change in how residents are trained.

The mandated maximum of an eighty-hour workweek is still long by any standard, but it had been much longer, and many of today’s doctors (myself included) trained under the old system when 110 hours or more per week was not uncommon, with perhaps the gift of every third Sunday off. My own residency program director told us, intending no irony: “The main problem with being on-call only every other night is that you miss half the interesting patients.” So, like garrulous ex-Marines, doctors swap tales of the time that, although brief in comparison to a lifelong career, was extraordinarily important in forming their professional behavior. Generalizations are tricky, especially when applied to such a diverse group of people as resident physicians. This caveat aside, parents who understand something about resident culture will gain useful insights into why many physicians think and act the way that we do.

Residents have come through a pathway that generally fosters intense competition and that values academic achievement above all else. In recent years, medical schools and residency programs have, to varying degrees, tried to emphasize the importance of more humanistic skills like empathy and compassion, and the specialty of pediatrics has been among the leaders in doing this. However, it remains true that physicians are the products of a system that rewards those who excel at competing with their colleagues at how much information one can learn, remember, and then produce when asked for it by a superior.

Resident culture encourages young doctors to appear and act all-knowing and self-confident even when they are not. This skill is often called “roundsmanship” and is inculcated from early on in their training. Residents get much of their teaching during the time-honored ritual of rounds, in which a team of residents and their supervising physician walk around to their patients’ rooms, pausing at each doorway to discuss the case. The discussion typically begins with the resident presenting the patient’s problem and the resident’s plan to deal with it to the assembled group, following which the supervising physician often grills the resident about the case. Residents adept at roundsmanship are quick thinkers and have rapid recall of pertinent facts. Master roundsmen, however, are best characterized as fearless when clueless—they appear assured and in control of the situation even when they are not.

I am exaggerating a little for effect, of course, but my point is to show you how years and years of this kind of environment affect most doctors to some extent. Such a background can cause doctors to seem defensive when questioned, for example by a parent, because doctors spend their formative years defending what they are doing to both their peers and to their exacting teachers. It can also make it difficult for a doctor to admit he does not know what to do with a patient, since physicians are conditioned to regard that admission as a real defeat. This attitude is encapsulated in the saying, often applied to surgeons but relevant to all physicians: “Seldom wrong, never in doubt.”