Just kidding, Cory.
So without further ado, here is Dr Franklin's full and unabridged opinion:
Doc: First off, let me say you have a great blog. I retired from critical care after 30 years and while I teach, I don’t go to the ICU much anymore so I have to learn my critical care other places, and your blog is one of the best there is. Kudos on a job well done. Keep it up.
You’re right – I did diagnose a lot of brain death- I’ll estimate between 100-200 cases. 80% was medical, but about 20% of the time the trauma guys would call me for my opinion. I gpt along quite well with them and learned plenty from them. I wrote the criteria for two major medical centers back in the day so I’ve been around the block.
With your indulgence, I’m going to give you a long answer. I write now, primarily for the Tribune here in Chicago, but sometimes in papers around the country and there was no way I could address the question adequately to a lay audience (and a medical one also) in the standard 750 words. In fact the SF Chronicle editor had me edit the piece down from 905 to 755 as it was. But that’s the nature of the beast. I can give you the long version of a nuanced issue.
The short answer to your question is no. I don’t think the girl has recovered from brain death, not in the classical sense we think of when we talk about recovery from neurologic insult. But Fate has presented us with a more complex question, which could even be looked at as an opportunity to better understand this area.
Brain death is an artificial, but necessary construct we developed 50 years ago. When we deal with insults to the central nervous system- blunt and penetrating trauma, anoxia, bleeds and other pressure phenomena, and infections (and I believe all of those are related but slightly different insults), the question naturally arises “at what point of insult do we say the person is medically and then legally dead”. We have to ask and answer that question for public policy reasons, transplant issues, so people aren’t on life-support unnecessarily, and for compassion sake – it’s a legitimate question and one that we have a professional responsibility to answer. (It’s clearly not the simple “she’s never going to wake up” that most Internet and newspaper commenters opine- or perhaps existentially it is, but we’ll let that go for a minute).
Now the way we have decided to answer it, quite reasonably, is cessation of measurable cortical activity, through lack of responsiveness, and cessation of measurable brain stem activity – brainstem reflexes, and apnea (although most people don’t perform a good apnea test- but for the sake of argument I’m going to assume it was done correctly here and not make it an issue). For the most part, no problem- it’s been accepted as death and it’s as reasonable as anything.
The fiction that has been passed off since the Harvard guys did this in 1968 is that this was irreversible cessation of all brain function. You can look at their wording. You know and I know that can’t be true, simply because we can’t easily measure all brain function – hell we don’t even know what all brain function is. And this was done before CTs (I’m old enough to remember the time before CTs) and now MRI’s and PET scans where we can actually measure brain metabolism. I’m not saying we should get these tests, just pointing out what should be obvious.
So let’s come back to this case. As I said, I believe in all likelihood they followed the criteria and made the “right diagnosis” and that should have been that. I wrote for the Tribune at the time the right thing to have done was to have discontinued support – and I believed that. But for social reasons, which I’m not really concerned with other than their consequences, they didn’t. And some unusual things have happened.
First she didn’t “die”. Yes I know there are a few long-term somatic survivors – but this alone clearly puts her in a small category (the funny thing is that meningitis kid at UCLA who has been around so long scared them so much they went and got MRIs on him – that tells you they were out of their comfort zone before they actually saw brain liquefaction). Second of all she starts menstruating, which means in all likelihood there is some hypothalamic function – not cessation of all brain activity. Third- she moves a bit – I have no idea what that means – but I sure as hell didn’t see anything more than an occasional spinal reflex in the earliest hours of brain death. Fourth – they say there is some activity in some of the imaging. I’m prepared to say this is wrong if I see it can’t be duplicated in a reliable fashion in a major medical center but all this means she is an outlier- and any time you have a diagnosis with an outlier, it’s a good idea to review your original assumptions. In this case our assumptions about what brain death actually is.
I bet there is a good chance, if you were to run the same brain death criteria on her today you might get the same results- brain death. But that begs the question. It may be fine to reassert those brain death criteria, but this case has given us an opportunity, which we don’t get every day, to reevaluate what the criteria mean- a very important point.
I would also guess, and it’s only a guess, that this girl is on the “edges” of brain death, straddling the line between life and death as it were. Her injury was anoxic- the outcome of which is notoriously difficult to predict. While I don’t think she has “recovered”, I would not rule out some isolated neuronal watershed recovery – some neurons may actually have recovered. The girl is young – she has a good heart, and for all we know there may also be some plasticity in this situation in her brain, which allows just enough autonomic function to permit her to "survive". I don’t know. Is that death? Depends on how you define it. It might be just as legitimate to simply say “she will never wake up’ –though I don’t believe that would be a good line to draw to define death.
Normally none of this would matter – let the family do whatever they want and who cares? But this is exactly one of those public policy questions –legally where it’s important to define exactly what we are calling death (if for no other reason tens of millions of dollars in damages – but it would be important anyway). The judge could take a narrow view and say it’s been litigated – the experts did the test and she was dead. I think that would be understandable but a mistake. And I think doctors who understand what’s really at stake here should agree with me. This is a rare opportunity where we get to examine brain death, and brain function, more closely (PET scans, hormone assays etc.) At the end of this we may come away saying – look we don’t want to change the neurologic definition of death- keep doing it the way we always have. But it may turn out we will dispense forever with the fiction this is total cessation of all brain activity. And there is always the possibility we will redefine how we diagnose brain death in the future. That’s why the stakes- from a medical standpoint – are so high. And from a legal and public policy standpoint also. It just happened the chips fell right and that this was the case to ask the questions.
Sorry to be so long-winded. I wanted you to know where I am coming from. I don’t have the answer here. But I have a pretty good idea what the questions should be.
As I said, keep up the great work on the excellent blog. I’m a big fan. And don't worry about being confrontational. No problem for me. Intelligent confrontational is good. Stupid confrontational is bad.
And hey, maybe you might want to buy my new book. It’s enjoyable reading, lots of good war stories- and no I didn’t write that SF piece to sell more books. But I’m not going to turn down the opportunity if it arises.
That would be brain dead.