Feb 01 2018

A Case of Brain Death

The New Yorker magazine’s latest issue features an article about the sad story of Jahi McMath. Jahi was a 13 year old girl who four years ago underwent a routine tonsillectomy to treat severe snoring and breathing problems. Unfortunately the surgery was complicated by severe bleeding post-op, leading eventually to a cardiac arrest. After a sustained effort at resuscitation the doctors did manage to get her heart working, but by that time her brain was severely damaged by lack of oxygen. She was declared clinically brain dead.

This is not where the story ends, however. Since then the family has refused to accept the diagnosis of brain death, prompting a prolonged conflict with the hospital. Eventually Jahi was removed by the family to an undisclosed hospital in New Jersey, and ultimately discharged to home care, where she remains.

I have had several questions about the story, and I will try to add some insight, with the caveat that I have no direct knowledge of the medical facts of the case beyond what is reported in the New Yorker article and elsewhere. I have not examined her, spoken directly to anyone involved in her care, or reviewed medical records. But there is a lot of information in the public domain and I can speak to that information, as far as it is accurate.

There are several layers to this story. There is a legal layer, as the family is suing the hospital for malpractice. I will not address that aspect of the case. There is the neurological layer – what is brain death and is this girl dead? There is also a personal and cultural layer here in terms of the family’s reaction. Let me start with some thoughts on this.

I will first say that I completely sympathize with the family. Of course it is horrible and tragic to lose a healthy 13 year-old child to a routine surgical procedure gone horribly wrong. I understand their anger, frustration, and grief. In addition, the family (again, according to public reporting) has lost trust in the hospital and in the system. They are African American and feel that there is an aspect of discrimination in how Jahi was treated. The mother, Nailah, is quoted in the New Yorker article:

Nailah, who worked in contractor sales at Home Depot, said, “No one was listening to us, and I can’t prove it, but I really feel in my heart: if Jahi was a little white girl, I feel we would have gotten a little more help and attention.”

This is an extra layer of tragedy in the case – the family was meant to feel as if an element of racism played a part in Jahi’s outcome. I have encountered this myself numerous times, sometimes with some legitimacy, but often (from my perspective) when no racism was present. I can’t speak to the state of mind of any of the caregivers in Jahi’s case. But the reality is that her family lived with enough racism in society that it affected their ability to trust the system.

Allowing your child to go under the knife requires a tremendous amount of trust. Further, medical care can often feel impersonal, and can be intimidating when scary things are happening that you do not fully understand because you are not an expert yourself. When that trust, and that feeling of lack of control, is paired with a horrible outcome, it is natural to feel betrayed.

Those feelings, in the context of a minority family, appears to be driving this case to a significant degree. Now those same doctors are telling the family that Jahi, who looks alive, is actually dead. They don’t want to let Jahi down again by trusting those same doctors.

Unfortunately, when there is a critical break down of trust like this in a complex case, we don’t really have a good mechanism for resolving any conflict. Doctors and hospitals usually defer to the family as much as possible, giving them time to process their grief, having family meetings, calling in other experts to weigh in, etc. None of this was enough, however. It also seems that the family has dug in their heels, and may now be too invested in their belief that Jahi is alive to let her go.

This leads us back to the neurological layer of this story. The New Yorker article framed their piece as a question – what is the definition of life. There is a legitimate question in there, but I don’t think it is actually that controversial outside of certain religious sects.

Obviously, when someone stops breathing and their heart irreversibly stops beating they can be declared dead. For a time, however, the cells in their body are not dead. There is a window when someone may be dead, but it is not necessarily impossible to resuscitate them. Doctors use their judgement when deciding to stop attempts at resuscitation. Part of that judgement is how much brain damage may have resulted from the prolonged arrest. There is no point in getting a heart beating again if the brain is dead or almost dead.

For this reason the medical and legal concept of brain death was developed. You can also declare someone dead even if their heart is beating if a thorough examination clearly indicates that there is zero brain function. Not only the higher parts of the brain, but the brain stem and the brain reflexes must also have no function. You can still have spinal cord reflexes, however, and still be considered brain dead. You can also demonstrate the complete absence of brain wave activity, or the complete absence of blood flow to the brain.

In Jahi’s case, a neurological exam specifically designed to test for any flicker of brain activity was consistent with brain death. Further, a blood flow scan showed no blood flow to the brain. She was declared brain dead, and is legally a corpse (to be blunt). That is why the family moved her to New Jersey, which is one of only two states that recognize religious objections to the notion of brain death.

This is where we now get some complexity, although I honestly don’t think it changes the situation. Dr. Alan Shewmon got involved with the case – he is a neurologist who objects of ideological and religious grounds to the notion of brain death. He reviewed video of Jahi and concluded there is evidence in the video of brain activity, therefore she is not dead.

Essentially, Jahi occasionally twitches her fingers or toes. These are almost certainly spinal reflexes, and not inconsistent with brain death. Nailah, her mother, believes that Jahi is responding to verbal commands. She will tell her to move a finger, and then sometime later Jahi will move a finger. If it’s not the right finger Nailah will say, “Not that one” until she twitches the correct finger.

This is also very common – family members tend to overinterpret random movements as if they are deliberate. Shewmon believes that the movements are more accurate than can be explained by random chance, but I am doubtful. Further, he may not be accounting for selection bias in the videos he is being shown.

There is good reason to believe that Jahi simply cannot be following verbal commands. The New Yorker reports:

On the scans, Machado observed that Jahi’s brain stem was nearly destroyed. The nerve fibres that connect the brain’s right and left hemispheres were barely recognizable. But large areas of her cerebrum, which mediates consciousness, language, and voluntary movements, were structurally intact.

There are two things to note here. This study apparently does show some remnant of brain tissue. If there were zero blood flow the brain would be entirely gone by now. So there is likely a small amount of residual blood flow, too little to show up on the prior scan, that is keeping some brain tissue alive. However, that does not mean that this remnant is functioning at all.

But perhaps more important is the fact that the brain stem is “nearly destroyed.” The brain stem is necessary for a person to be conscious. Even if your entire cortex were intact and unharmed, without a brain stem you would be in a permanent coma, without the ability to generate wakeful consciousness.

Further, without a brain stem there is no way for auditory signals to get to the brain. Jahi cannot hear, and therefore cannot respond to verbal commands. Therefore the video evidence of her finger twitching is not evidence of consciousness.

There is perhaps a legitimate discussion to be had about whether or not the remnants of brain tissue mean Jahi is truly completely brain dead or not. But in my opinion, this is a distinction without a difference. She is clinically brain dead, and any remnant is irrelevant. She is not aware of her own existence. Without a brain stem she cannot be conscious. It is sad to say, but there is no functional difference from Jahi’s perspective between being fully dead and whatever flicker of brain activity may plausibly remain. It is effectively nothing.

The family may be beyond the trust necessary to accept this reality. They also appear to be enabled in their denial by Shewmon, who has an agenda of his own.

Meanwhile millions of health care dollars have been spent maintaining this poor dead girl’s body, with no end in sight. The family remains in a limbo of denial. The other child in the family must live in the shadow of their dead sister, who absorbs much of the family’s time and resources. Legal expenses are also piling up. The entire saga furthers a narrative of distrust. It is a tragedy from beginning to end.

34 responses so far

34 thoughts on “A Case of Brain Death”

  1. tb29607 says:

    Nice summary of a topic lettered with emotional land mines.

    I think it is worth mentioning that the blood flow and EEG are confirmatory tests only and this point needs to be explained to parents prior to test. Far to often someone will take the easy path of telling the family that if there is no brain blood flow, the patient is dead, and not address that families often hear this to mean that if there is flow, the patient alive. Finding blood flow, or some residual activity on EEG does not change the diagnosis of brain death.

    It is incredibly difficult to help families process brain death in a child and one wrong word by anyone can completely derail the discussion. That cases like Jahi’s are so rare speaks well of how they are handled in general. Unfortunately, I think cases like this are inevitable in our our health care system which gives families the final decision.

  2. tb29607 says:

    littered, not “lettered”.

  3. Willy says:

    I’d like to ask some questions. From the descriptions above, it sounds like brain tissue is “disappearing” in cases like this. Is this correct? Is the skull becoming an empty cavity? If the tissue is/was dead, why is necrosis not an issue? Why, if the heart is beating, is there no blood flow to the dead brain at present? As I read it, it seems the heart and lungs are functioning without a brain (I see no medical equipment in the photo). Is this correct?

    Sorry if these are dumb questions or if I’ve misinterpreted the article.

  4. MikeB says:

    The quotation from Mark 11:24 referred to in the photo is “Therefore I tell you, whatever you ask for in prayer, believe that you have received it, and it will be yours.”

    Oh, humanity.

  5. bachfiend says:

    ‘There is a legal layer, as the family is suing the hospital for malpractice. I will not address that aspect of the case.’

    It seems to me that this is a major part of the story. If the patient is dead, then damages are capped at $250,000. If she’s not dead, then damages are virtually unlimited allowing the very considerable costs already incurred to be recovered in addition to further costs, and damages for future losses and suffering.

    I don’t think that there are clearly defined boundaries between medical states that the Law assumes exists for convenience in being able to make clear cut decisions.

    Is the patient (brain stem) dead? Is she in a persistent vegetative state? Is she in something else? Or a mixture (brain stem badly impaired plus a lot of persistent vegetative state)?

    The patient has apparently started menstruating so she has at least hypothalamic (and pituitary) function. The pituitary is especially vulnerable to ischaemic damage. There’s Sheehan’s syndrome which follows massive postpartum haemorrhage resulting in isolated pituitary gland damage.

    I suppose our troll Michael Egnor will eventually comment giving his take. Fortunately for him the hospital doesn’t seem to be a Catholic one. He managed to get himself into considerable difficulties previously in arguing that the lawyers for a Catholic hospital in Colorado were right in defending against a medical malpractice case involving 7 month gestation twins by arguing that unborn foetuses under Colorado law aren’t ‘persons’ legally.

  6. sarah_theviper says:

    This was the reason the DNR patient I mentioned on the Organic food post gave for why she did not want to be resuscitated. No terminal illness, and it seemed like she had a good outcome from it. She was more disturbing to me than this guy I encountered one time working in the psych ward, who really wanted to talk to me. He had shot himself in the head twice because he had debilitating back pain that was interfering with his passion in life, motorcycles. I suggested he branch out, and maybe he could find something related that he could still do. He said no. I hope things turned out for that guy. I understand him more than the DNR lady. He wanted die because things seemed bleak and weren’t going well. It seemed like she was angry she didn’t die more out of spite.

  7. SleepyJean says:

    The reported case of Jahi McMath is sad because The New Yorker is not a substitute for a medical record, nor is the reporter even medically knowledgeable about what she is observing. The family has one member involved in the nursing field, who is, like the rest of the family stressed by the burden of her relative’s clinical death. Unfortunately, the family is creating a memorial of expense to prove one point, triage is difficult for standard care providers. Clinical death comes too soon after negligent hospital care.

  8. bachfiend says:

    SleepyJean,

    ‘Nor is the reporter even medically knowledgeable about what she is observing.’

    I thought that the journalist, Rachel Aviv, actually did a very good job in reporting a very difficult story. And she does seem to have some expertise in reporting medical and legal matters.

    The question is whether Jahi McMath is clinically dead (brainstem dead) – there’s some dispute about that. She is legally dead, she was declared to be legally dead as a ploy for the family to gain control of her body and move her to another state

  9. Willy says:

    I want to repeat my earlier request as I am genuinely curious about some of the medical details:

    “I’d like to ask some questions. From the descriptions above, it sounds like brain tissue is “disappearing” in cases like this. Is this correct? Is the skull becoming an empty cavity? If the tissue is/was dead, why is necrosis not an issue? Why, if the heart is beating, is there no blood flow to the dead brain at present? As I read it, it seems the heart and lungs are functioning without a brain (plus, I see no medical equipment in the photo). Is this correct?

    Sorry if these are dumb questions or if I’ve misinterpreted the article.”

  10. tb29607 says:

    bachfiend/SleepyJean,

    The picture shown in The New Yorker article displayed some tubing that looks very much like the tubing of a home ventilator circuit but the picture above covers her neck which is where the vent circuit would connect to her tracheostomy. In unventilated patients covering the trach in a similar way would put a spontaneously breathing patient at high risk for suffocation. Based on this I think it is safe to say Jahi is on a home ventilator and, given the slant of the article, any suggestion of respiratory effort from Jahi would have been mentioned.

    For other brain stem functions I thought the wording was unclear (deliberately?). Jahi has had an ABR (auditory evoked brain stem response) test which detects the electrical conduction of an auditory stimulus. Jahi’s showed no hearing so she can not respond to verbal commands, (which would be true even if she were otherwise completely normal). So hearing is definitely not present and the wakefulness discussion was based on Jahi having inconsistent responses to commands.

    The description of heart rate variability was completely inadequate for me and this is not hard to test. Just go pinch the nail bed of a finger (in this case one that moves). Pain and heart rate control are part of the brain stem responses so the heart rate normally goes up. Surely one of her caregivers did this simple bedside assessment, and yet there is no mention of a pain response or lack there of. Either the author was not knowledgeable enough to mention it, or she did know and chose to leave it out.

    Rachel Aviv also gave short service to the brain death exam. Saying “With the help of a ventilator, she was breathing…” followed by “She was briefly disconnected from the ventilator, as a test, but her lungs filled with carbon dioxide.” could be argued as technically true but at a minimum is ridiculously misleading. The “briefly disconnected” description of the apnea test does not convey the reality of disconnecting the ventilator, continuously looking at the patient for any sign of respiratory effort, and checking CO2 levels every 5 minutes by arterial blood gas sampling until levels have increased by at least 20 and are above 60. This typically takes from 5-15 minutes, and anyone who considers this “brief” should try not breathing for a similar time period. Jahi met brain death criteria so she clearly had no respiratory Drive or effort, her contribution to breathing was having functional lungs, everything else was ventilator dependent.
    Not mentioned but included is a Glasgow Coma Score which is based on responses to voice and pain. No response is a 3 and higher means no brain death. She mentions testing pupillary and gag reflexes but why leave out the corneal, oculocephalic, and cough? She does include the oculovestibular, but describing that as no eye movement when “ice water was dripped in each ear” denies the reality which is to forcefully squirt at least 10 mL of ice water directly onto the ear drum (I had a medical student who squirted ice water on his own ear drum and his report of the experience was unpleasant to say the least).

    I agree the menstruation aspects are reason to stop and think. Would have been nice to know what medications Jahi is given. The only medication mentioned was a steroid (hydrocortisone is the standard choice). Others are very likely to include thyroid and antidiuretic hormones. If her doctor considers her alive, then treating Jahi like kids without a functioning pituitary might make sense and would include providing hormones to promote growth (growth hormone) and reach puberty (sex steroids). Also, did these “menstrual cycles” continue? What about secondary sex characteristics (axillary hair, etc.)?

    To bad a more mainstream expert did not get equal time in the article.

  11. tb29607 says:

    Willy,

    When lack of oxygen and/or blood flow injures brain tissue, the brain tends to swell (also with trauma but that is not a part of Jahi’s cape). If the swelling is severe eventually there is no more room in the skull and the pressure increases. When this pressure exceeds the body’s blood pressure, blood flow to the brain stops and the cells die. Eventually, any dead tissue will be cleaned up/absorbed by the body (mostly via macrophages and monocytes). When brain tissue gets absorbed it is replaced by cerebrospinal fluid (CSF).
    Necrosis just describes the process of cell death so is a problem when the dead cells provide a critical structure or function. The dead cells are not typically themselves a problem except when a site for infection.
    Once a blood vessel gets crushed and flow stops, reestablishing flow is prevented by clotting which forms on the damaged lining of the vessel, and blood vessels without a blood supply die just like everything else.

  12. Willy says:

    Thanks, tb29607. I appreciate your explanation and time.

    Given what I now THINK (not know), shouldn’t a radiograph or similar be definitive evidence of brain death and irreversibility, especially after several years? If critical parts of the brain are “gone”, doesn’t that make things pretty black and white?

    If I misused “necrosis”, it’s because I considered the term a synonym(ish) for gangrene. Why can the brain “rot” (?) in some cases at least and not lead to “gangrene” like extremities do–like severely frostbitten toes/fingers and such?

  13. BillyJoe7 says:

    Willy,

    Yes, “necrosis” and “gangrene” are synonyms, and are defined as “localised death of cells, tissue,or organs due to infection, injury, disease, or interruption of blood supply”.

    So, when a brain “rots” it is undergoing “necrosis” or “gangrene”.
    I can’t think of any situation where you would use “necrosis” but not “gangrene”, or vice versa.
    A gangrenous toe is also a necrotic toe. A necrotic brain is also a gangrenous brain.
    However, you would generally use the word “gangrene” if it applied to an extremity, and then classify it as dry gangrene (interrupted blood supply), wet gangrene (infection), or gas gangrene (infection with a bacteria that generated gas).
    But, it’s also used to describe internal organs: gangrenous appendicitis

    A couple of personal anecdotes:

    My sister had her right leg, and then her left leg, amputated just below the knee as a result of gangrene/necrosis due to diabetes. The first was due to infection of a minor injury to her big toe which gradually spread up her lower leg over a period of twelve months. The second was due to blocked blood vessels caused by the diabetes (and probably obesity, cholesterol, and smoking).

    Many years ago I came upon a man who had killed himself with CO2 poisoning in his car. The sun was shining through the front windscreen and, as I approached from behind, I saw a gas bubble float up through fluid that had accumulated between his hand and the skin. I’m pretty sure that was the result of gas gangrene.

  14. BillyJoe7 says:

    The following is an account (with some partial quotes) of the neurologist who supports a diagnosis of “minimal conscious state” in this case:

    “When Shewmon was a college sophomore, at Harvard, he listened to Chopin’s Trois Nouvelles Études No. 2, in his dorm room, and the music lifted him into such a state of ecstasy that he had an epiphany: he no longer thought it possible that all conscious experience, particularly one’s perception of beauty, could be a “mere electrophysiological epiphenomenon,” he said. The music seemed to transcend “the spatial limitations of matter.” An atheist, he converted to Catholicism and studied Aristotelian-Thomistic philosophy. He went to medical school, in 1971, and then specialized in neurology, because he wanted to understand the relationship between the mind and the brain”

    Sounds like the neurologist counterpart to the neurosurgeon who occasionally graces this blog with his pedagogical presence.

  15. BillyJoe7 says:

    I hope that she is comatose.
    It would be a tragedy if she had any awareness of her present state.

  16. Willy says:

    Thanks, BJ7.

  17. Cdesign Proponentsist says:

    Wow. That last paragraph really got to the emotional heart of the issue. Got me right in the feels. 🙁

  18. lourasaur says:

    Statement by a couple of defense experts on why she must be dead: http://thaddeuspope.com/images/Rosen_case_mgmt_statement_Mar_2017_.pdf
    Statement by the plaintiff expert contending she is still alive: http://www.thaddeuspope.com/images/Winkfield_v_Rosen_Declaration_Shewmon_06-29-17_.pdf
    There were extensive and repeated tests for brain death at the time because the family objected so much. But none recently. There were some later nonstandard tests which suggested she might be alive, but the defense experts say those tests don’t mean anything and are consistent with brain death. There was a brain MRI in 2014, on which Dr. Shewmon said a lot of her cerebrum was still there, not liquefied. Do experts generally agree on MRI interpretations, or not?
    Dr. Shewmon claims that her brain stem died, so she didn’t have various reflexes when tested for brain death – but that her cerebrum is still alive. Is this possible?
    Could brain death be seen on a brain biopsy? Even if the brain structure looks like it’s still there on the MRI, would a brain biopsy show that it can’t be functioning?
    It seems like the mother Nailah has searched hard for validation of her beliefs and has avoided any further testing that might confirm brain death. There haven’t been recent medical tests. Maybe she’s afraid that a brain MRI would show only liquid in there now.
    But the defense will be getting new testing done on Jahi as part of their discovery process.
    It’s dubious whether Jahi actually is menstruating, I read that a nurse testified that the “menstruation” was actually fecal matter that was leaking due to decomposition. I also read that there’s an odor of decomposition around her. But if that were true, wouldn’t she have died of infection by now?
    There has never been anyone who has been diagnosed brain dead according to the standard diagnostic procedure who later regained consciousness. If this is true of Jahi, it would be quite amazing.
    Lots of questions …

  19. David Twitch says:

    tb29607

    Thank you for your posts, the blog post and accompanying picture left me completely confused as a layman, as I couldn’t see any sign of a ventilator and couldn’t reconcile the picture with the article.

  20. bachfiend says:

    tb29607,

    She has a tracheostomy. The surgeon who performed the procedure was criticised for doing it on a dead person.

    The site of the tracheostomy is covered by the blanket, so any tube leading from a ventilator to the neck would be hidden.

    On the far side of the bed, there’s railing visible. And in addition there appears to be an additional white tubular structure above the railing to the left of the mother. I suppose there may be a ventilator below the level of the bed.

  21. bachfiend says:

    Sorry, my comment should have been addressed to David Twitch.

  22. BillyJoe7 says:

    Hmmm…thought it was “tracheotomy”, but apparently “tracheostomy” is acceptable.

  23. bachfiend says:

    BillyJoe,

    ‘Tracheotomy’ is cutting into the trachea. ‘Tracheostomy’ is forming a ‘stoma’ in the trachea, which is a potentially permanent opening.

  24. lourasaur says:

    Stem cells are being tried to bring the brain of a brain-dead person back to life. Along with an “injected protein blend, electrical stimulation and laser therapy directed at the brain”. https://www.statnews.com/2017/06/01/brain-death-trial-stem-cells/
    So somehow the neurons in the brain-dead person might help stem cells to form a new brain, even though they’re dead? What are the neurons like in a brain-dead person?

  25. tb29607 says:

    lourasaur,

    There is no real controversy regarding imaging (MRI, etc.), and it is much like brain flow and EEG tests in that an absence of any brain tissue (or flow, or electrical activity) would confirm brain death, but the presence of brain tissue does not tell you anything. Brain tissue being present in no way suggests that the tissue is functioning and it is not uncommon to diagnose brain death in patients with fairly normal looking MRI’s.

    A brain biopsy could not tell you much of anything, especially since brain function (or lack there of) is the key to brain death.

    As far as the cerebrum still being alive and producing consciousness but no movement, the flat EEG rules this out. The EEG is so sensitive that it will pick up another person’s EKG signal if a hand or foot is held during the EEG (the patient’s EKG signal is monitored and filtered out from the EEG tracing). So whatever tissue is there, is not doing anything.

    There is a “locked in” syndrome where the brain stem dies but consciousness is intact. That seems to be what is tangentially being suggested, however even with locked in syndrome the person retains some vertical eye movement and blinking (EEG would be normal as well).

    Bloody bowel movements can represent “sloughed gut” which is when part of the lining of the intestines dies due to some insult (infection, inadequate blood flow, etc.), disconnects from the other layers, and is passed from the rectum with lots of blood and any fecal matter. This is often seen as part of decomposition but the lining can also grow back if the insult was transient.

  26. tb29607 says:

    Lourasaur,

    The nerve stimulation referenced in the article you linked is talking about stimulating peripheral nerves and spinal cord nerves. With those signals hopefully stimulating and directing growth of the stem cells. Presumably from the brain stem up?

    The idea came from studies using nerve stimulation to improve outcome of trauma patients with a Glascow Coma Score of 4 (scale is 3-15) so those patients were not brain dead. Their brain stems worked and so the signal could be conducted normally to injured and recovering neurons. This idea was hijacked by the linked study for a very different purpose.

  27. SlowlyButSurly says:

    Re: “She is not aware of her own existence”

    Is that because she is in a coma, and if so, can one dream while in a coma? I ask, because I’ve tended to assume, until now, that a coma is roughly equal to sleep, and that dreaming was a form of awareness, or is it more like the times between dreams when one has no consciousness?

  28. lourasaur says:

    Jahi hasn’t had any medical testing since Sept. 2014, so far as I’ve heard.
    So the areas of cerebrum that were intact in the MRI that was done then, had living neurons in them, because if the neurons had died, those areas would have lost their stucture?
    What Dr. Shewmon is hoping is that her brain has been regenerating and she’s become minimally conscious – slipping in and out of consciousness, so that she sometimes responds to her mother’s voice and sometimes doesn’t. He believes that her mother’s videos show that she’s responding; he says he doesn’t know how to reconcile this with the tests in Sept. 2014 that showed no auditory evoked potentials, so she couldn’t have been hearing anything.
    He might be right about one thing: she might not meet California’s statutory definition of death if she still has a functioning hypothalamus, making her menstruate and (he says) grow pubic and axillary hair.
    But the defense will be injecting a large dose of reality into these speculations when their experts get to examine Jahi.

  29. tb29607 says:

    lourasaur,

    I think you are considering all brain tissue as consisting of neurons only. There are many other cell types though including (but not limited to) astrocytes, oligodendrocytes, microglia, and ependymal cells. Their functions include structure and support, they are more robust (tolerant to hypoxia/ischemia) than neurons, and they do not have any neurological function outside of supporting neurons. So having living tissue in the skull does not mean there are living neurons.

  30. lourasaur says:

    tb29607,
    OK, thanks.
    Apparently Dr. Shewmon last examined Jahi in Dec. 2014 and she was not responsive then (see http://www.docbastard.net/2017/09/no-jahi-mcmath-is-still-not-alive.html ) So in his statement he’s going by whatever he observed then, and the videos that her family made. I don’t know whether he observed the pubic and axillary hair he mentions in 2014, or is just taking her family’s word for it.
    They have an incentive to fake these videos, because they want to go back to California and have Jahi’s body cared for there, and they would be able to sue for more money if she’s ruled to be alive. And Dr. Shewmon has training as a neurologist, but he probably doesn’t have training in detecting deception or self-deception.
    It seems like her family ought to be able to prove that she is actually responding, if she is – come up with something better than cellphone videos. Get her examined again. Surely their supporters would pay for it.
    Dr. Shewmon said in his statement that perhaps her EEG is flat at some times and not at others. Does this happen more often than rarely?

  31. tb29607 says:

    lourasaur,

    I am not aware of any case in which an EEG has changed from flat to normal that did not involve medications or some well defined disease states. And the STAT article you referenced cited a review showing no cases of brain death regaining function.
    If Dr Shewmon really believes there are periods of activity a 24 hour video EEG is a common test and would show movement along with any associated neurological brain activity. That he has not ordered this test suggests even he doubts there are active periods.

  32. SlowlyButSurly says:

    Maybe answering my own question, but the Wikipedia entries for https://en.wikipedia.org/wiki/Coma and https://en.wikipedia.org/wiki/Consciousness suggest that one can’t dream while in a Coma.

    I find it creepy/interesting to think that I become unaware of my own existence every night between dreams, even with a fully function brain. Raises lots of questions of what my Brain is up-to during these periods and what wakes me up in the morning?

    Thanks for the compelling post…

  33. bachfiend says:

    SlowlyButSurly,

    ‘I find it creepy/interesting to think that I become unaware of my own existence every night between dreams, even with a fully function(ing) brain.’

    Well, for most of your day when you’re awake, you’re not laying down memories capable of being retrieved of being aware of your own existence. You have the feeling that you’re aware of your existence in the present, and assume that you were aware of your existence in the past, say an hour earlier, and that you will be aware of your existence in the future, say an hour later. You may deliberately lay down a memory, as a result of thinking it repeatedly, ‘I’m aware of my existence now at (whatever time and date it is)’, but even that memory will eventually disappear over time as it becomes no longer retrievable, along with all the memories of vital facts you learned for examinations.

    Whenever you remember a dream, you’re retrieving memories layed down during the dream (something I find difficult to do, I very rarely remember having any dreams).

    Consciousness, along with self-awareness and the feeling you’re in control, are really just illusions created by your subconscious. Benjamin Libet showed that decisions are made around half a second before you’re consciously aware of the decision, and sensory inputs to the brain have to last about half a second before you’re consciously aware of them (and the subconscious is capable of responding to the sensory input, for example by brushing away a fly crawling on your face near your eye).

    The conscious rationalises decisions already made by the subconscious so as to give the illusion that it’s in control. And sensory inputs that are significant – because they last longer than half a second or because they’re strong (such as a fly crawling on your face near your eye) are back-timed to the instant the sensory reached your brain in the subconscious.

    You don’t want to be aware of all sensory inputs reaching your brain. You’d be overwhelmed by an enormous amount of sensory information. But you need the illusion that you’re in control of your actions. It would be a peculiar experience to brush away a fly from your face and then to become consciously aware of the fly a fraction of a second later. You have the illusion that you felt the fly and then you brushed it away.

    Michael Egnor as usual manages to get Libet’s research wrong. He has asserted repeatedly that Libet has shown that conscious awareness of sensory inputs are shifted back in time to the instant the sensory receptors are stimulated not the time the sensory input reaches the brain (a very short time later) as ‘evidence’ somehow that the mind is immaterial. That the mind is aware of the form of objects at their location in space, whether the tree in the backyard or the Moon 400,000 km away.

  34. lourasaur says:

    Dr. Shewmon did a good job of making it plausible that the videos show Jahi consciously responding to her mother. No person diagnosed brain-dead has ever regained consciousness – but then, almost everyone diagnosed brain-dead is quickly disconnected from the ventilator. About 30 pregnant women have been maintained on a ventilator for a few months, until the baby could be delivered.
    But very few brain-dead people have been maintained on a ventilator for longer than a few months, right? It only happens if someone who knew the person is very insistent on it. And Dr. Shewmon says that “the fact that it took several months before Jahi began to show signs of intermittent responsiveness is consistent with the time course of brain plasticity”. So why are doctors so sure it’s impossible for Jahi to have regained consciousness after several months?
    An objection that occurs to me is that it’s rare even for someone in a vegetative state to regain consciousness after a certain amount of time has passed, and they’re in much better shape than someone who’s brain-dead – they can breathe on their own, they have various reflexes that a brain-dead person doesn’t. And they would often be maintained for a long time, because they’re considered still to be alive.
    I hope when the defense examines Jahi, they do tests other than just re-doing the procedure to diagnose brain death, because a jury might not have as much faith in that procedure as doctors do. They watch movies and TV shows where improbable things happen all the time, after all, and the underdog turns out to be right. So I hope the defense does things like repeating the MRI; and an EEG, preferably for a week or so because the times when Jahi is said to be responsive are as long as a week apart. They say she’s likely to be responsive when her heart rate is over 80.
    And hopefully they do tests to see if her hypothalamus is actually working, as claimed. If it is, Dr. Shewmon might be right that technically she isn’t brain-dead under California law, because the law says the entire brain is supposed to be irreversibly non-functional in brain death, and the hypothalamus is part of the brain.
    And I hope they explain why the unusual aspects of Jahi’s case don’t make it likely that she’s regained consciousness: that large areas of her cerebrum were still there in Sept. 2014, nine months after the brain death diagnosis; and that she’s survived this long. There was a boy who became brain-dead from bacterial meningitis, whose body lived on for 20 years on a ventilator. I read that his mother believed she was able to communicate with him. But after his body died, his skull was autopsied and there was no neural tissue left in it; just some goop encased in a shell of calcium … He had become brainless, not just brain-dead. Do you know of a counterexample where a lot of someone’s cerebrum was still mostly there, nine months after brain-death?
    And I hope they explain why the videos are not good evidence.
    The defense needs to get inside the jury’s head and explain why the many holes that Dr. Shewmon tried to poke in the brain death diagnosis aren’t really plausible. The defense expert statements relied a lot on assertions of their authority, and that might not be convincing to a jury. Our culture gives people lots of practice in “believing as many as six impossible things before breakfast”.
    What Dr. Shewmon wrote reminds me of arguing for the existence of ghosts or God: there’s lots of evidence for them, but somehow nobody ever gets really good evidence … So excuses are made for them by believers: ghosts are nearly transparent, God hides, Jahi is only intermittently responsive, that’s why her EEG was flat in Sept. 2014 …

Leave a Reply