Archie Battersbee case

[whynotwhatknot]

I was just wondering why we're not allowed to post about this case-the deletion message mentioned it was ongoing so wouldnt be fair to the family

Charlie gards case was on going and there was numerous threads about it

Anyway if this stands maybe we can discuss

I was just pointing out the family have refused further neuroimaging, now they understand it is risky

The poster who was asking about scans didn’t seem to realise how many had been done, with those addressed in the High Court judgment ordered by the court.

The BBC recording from yesterday also throws up questions about “down time”. Hollie initially said she was in the house when it happened, with initial estimates 40 min or so until adequate oxygenation in hospital. Then she said 3 min.

However, the BBC report on Wednesday says that she came home and found him lying on the floor so time without oxygen is unknown.

He couldn’t be reliably tested on the last one because his peripheral nerves don’t respond (because he’s dead)

apologies for the stupid question, I’m trying to get my head round this medically. I think it’s right that in order to conduct the brain stem test, someone’s peripheral nerves have to be responsive for the test to be accurate.

but how can you have responsive peripheral nerves and be brain dead? Wouldn’t the fact your nerves were responding mean you were not brain dead and the test is redundant?

(this question is just for my own interest and education, I’m not making any point or suggesting for a second the medical position outlined for Archie is incorrect)

@hepatocyte yes, yes I know allll that! Maybe if you had read what I wrote....

I've read the case....I read what everyone involved said....did you?

I’m glad you asked as I don’t get it either 🤷‍♀️

but how can you have responsive peripheral nerves and be brain dead? Wouldn’t the fact your nerves were responding mean you were not brain dead and the test is redundant?

The brain stem death protocol is based on assessment of cranial nerves, an apnoea test (ventilator stopped, and no breathing noted)and a test of motor function.

It’s the motor function test that’s relevant and a brain dead person isn’t supposed to respond to painful stimulus.

However, the motor response can’t be properly interpreted if the patient has a peripheral nerve issue (ie brain wants to respond but peripheral nerves don’t work so muscles don’t move). Some of the drugs used in ICU are paralysing so they need to have worn off before the motor function test can be done.

Hollie at one point was posting about how it took longer than expected for these paralysing drugs to leave Archie’s system, although this was a long time ago, way back when he was first intubated.

Presumably in order to avoid legal wrangling about potential prolonged effects of paralysing meds peripheral nerve function tests were done, but these showed a lack of neuromuscular activity. Really just because his whole body is dead, but it opened up legal opportunities to argue that Archie’s brain might have wanted to respond but couldn’t because his peripheral nerves weren’t functioning meaning his muscles didn’t move.

In real life, unless there are clinical concerns, you don’t need to have nerve conduction tests before assessing motor function but obviously there is massive scrutiny here.

Essentially - the peripheral nerve conduction tests were done to prove that the chemical communication signals between peripheral nerves and muscle was intact. To try to show that his muscles were capable of moving, so that if he didn’t respond to painful stimulus by withdrawing then it was because his brain was the issue.

Thank you for responding - that’s a really helpful explanation of something I had been confused by!

Except I’ve just realised I’ve lumped peripheral purely nerve testing (electric impulses) with neuromuscular junction testing (chemical communication between nerves and muscles). I don’t know whether he just had one or both but in this situation the principle is the same (can imagine neurologists shaking their head at me!)

If your peripheral motor (movement) nerves are severely damaged or they can’t transmit impulses to the muscles your muscles won’t move. Your brain can want them to move but they won’t.

So did they do any of the other tests?

Pouring cold water in his ear? Stroking his pupil to try and trigger blinking? Testing his gag reflex etc?

Or was not of it done based on the fact he didn’t respond to the nerve stimulation test?

According to the court documents every other test was done.

As an aside, blocking the neuromuscular junction, which is how nerves and muscles communicate, is how paralysing drugs work. It’s standard to paralyse with initial intubation so they need to be well gone in someone’s body before brain stem death tests are done.

So did they do any of the other tests?

Yes, it’s in the High Court document. No response, obviously.

So you would expect movement from that test even if the person was brain stem dead?!

Sorry to keep asking but I just can’t make sense of it in my head.

In my head all seeing is the idea of “we are going to do this test to prove his muscles work and if they do then we’ll do the brain stem death testing, but if his muscles don’t move then it could be that he isn’t brain stem dead.”

It all just seems backwards?

Some reflexes are mediated by the spinal cord rather than the brain, which is why you could reasonably expect a peripheral nerve response to demonstrate the nerves are capable of communicating with each other.

The aim of this is rule out certain circumstances that would dampen ALL nerve responses, for example barbituates I think can do this. If you establish that the nerves are capable of responding and THEN carry out the brain stem test and elicit no response, you can say with a high degree of confidence that the problem lies in the brain stem ie. Brain stem death. All cranial nerve responses are tested, so if you get no response at all, you have established that the essential functions of the brain stem are no longer working.

The tricky part-and I believe this urgently needs to be properly reviewed as a general point in law, not just for AB-is what can be done to establish brain death if the peripheral nerve system is incapable of response by the same pathology causing the brain death.

This is the difficulty facing the courts now-because no matter how conclusive an MRI, EEG or angiography are, this is simply not the way brain stem death is established. Although it will be better to wait for the CA to publish the appeal judgement rather than speculate-I think this may be the crux of the issue with AB and why it has been sent back for consideration of best interests. It would possibly be too long a process to redefine how brain stem death is diagnosed for AB (thus CA may have taken the opinion this would not be in ABs best interests).

Best interests is probably the best way forward now.

So you would expect movement from that test even if the person was brain stem dead?!

The nerve stimulation tests don’t test for muscle movement though. They just test whether the nerves are OK (electrical impulses) and/or whether the chemical communication between the muscles and nerves work.

A nerve conduction study records the electrical activity that occurs when a nerve is stimulated. A “failed” test is a lack of electrical response, not a static, non-moving muscle.

The brain stem death protocol is based on assessment of cranial nerves, an apnoea test (ventilator stopped, and no breathing noted)and a test of motor function.

It’s the motor function test that’s relevant and a brain dead person isn’t supposed to respond to painful stimulus.

However, the motor response can’t be properly interpreted if the patient has a peripheral nerve issue (ie brain wants to respond but peripheral nerves don’t work so muscles don’t move). Some of the drugs used in ICU are paralysing so they need to have worn off before the motor function test can be done.

I'm probably being thick here, but according to the judgments, it was the apnoea part of the test that was the problem, not the motor function element? The first judgment was about the family's refusal to agree to the apnoea test, the court ordered that it be done, but when it came to the second judgment they seemed to be saying that they hadn't been able to carry out that final test?

An informal test was carried before the first judgement, this indicated a formal test of brain stem death testing should be done. The family opposed it. The court ruled it ahould be done.

When the two doctors came to carry out the formal test, they could not elicit a peripheral nerve response so therefore they could not carry out the test as it may produce a false negative as per guidelines. This is outlined early in the judgement.

As an interesting aside, it seems on 14th April, the family asked for a further month to see if AB could recover. This has now long since passed of course.

I'm probably being thick here, but according to the judgments, it was the apnoea part of the test that was the problem, not the motor function element?

You’re not being thick, it was an issue for a while because the family refused this. But then it was superseded by the lack of peripheral nerve response. Like the appeal on brain stem death, it seems to have been swerved?

It’s Friday evening in Australia and I’m drinking wine after work and doing a literature search on brain death criteria.

It’s interesting because the initial criteria in the US (which is pretty much the same as the UK) was established over 30 years ago. It seems like all countries use neuroimaging and blood flow studies a lot as part of their analysis but this hasn’t been incorporated into official guidelines. So the imaging tests that Archie had aren’t new of innovative, they just haven’t been coded into decades old criteria.

I wonder if this is because:
a) 99.9% of the time families appreciate what is blatantly obvious and let their clearly Dead relative go
b) an MR angiogram showing blood flow, or lack of, is conclusive but not accessible for remote/peripheral hospitals. If this became part of the brain death criteria then patients would have to be transported to have this done which is untenable both ethically and medically.

As it stands, the brainstem death test is clinical and can be performed anywhere.

If new criteria are introduced to incorporate the imaging that loads of patients already have, then allowing people to die and pass peacefully will be much more complicated

I saw an interesting summary of what is involved in keeping a person who is brainstem dead going - usually only for a day or two if there is a delay in relatives getting there or for organ donation:

1. Patient must be ventilated as their brainstem is gone so they cannot breathe or initiate breaths for themselves. That includes everything that comes along with ventilation, e.g. clearing secretions, chest care, managing how much oxygen/CO2 etc goes in and out.

1. Cardiovascular support. Making a patient breathe will initiate some cardiac response but it'll need to be backed up by medications such as inotropes/vasopressors which after a while are pretty nasty to your body. They will be being titrated regularly. Turning someone, adjusting someone's O2, anything, can affect their BP meaning they need more/less medication. Also temperature needs managing. And then things like potassium, sodium, bicarb, blood, everything.

1. Skin will become mottled and vulnerable. Pressure sores, skin breaking down, etc.

1. Kidneys will begin to fail so clearing toxins will become difficult and fluid won't shift as it should. Won't produce as much urine etc.

1. Patient will need feeding via a tube in nose/stomach, but this is usually stopped as there is no point. Bowels will stop working, stomach will stop absorbing the liquid feed.

1. Vulnerability to infection as the body can't fight anything any more.

1. Pain relief is often given, though it almost certainly isn't necessary.

It really must be an incredibly precarious balancing act every hour of every day, the longer this goes on.

I read what you wrote and was replying to it:

But would they allow the parents to fund Archie's care until a change of mind occurs? Someone mentioned someone they knew took home a child in a coma and fully funded treatment themselves. I know that may not be in the child's best interests but may be the final push to make the parents realise the hopelessness of the situation

And so I pointed out the the level of manual intervention (hour by hour monitoring and adjusting of drugs) could never be achieved at home, as you suggested.

This would lead to a distressing cardiac death (for HCPs and loved ones) of Archie.

It wasn't clear you knew this from your post, which is why I mentioned the documents.

Yes @AmaryIlis , sadly he has developed diabetes insipidus which means he's not producing the hormones needed to communicate with the kidneys. Probably due to a loss of function of pituitary gland.

It's all very bleak and upsetting.

I just looked at the facebook group and his mum is posting about all the things she's going to try with him today, leading to lots of of army members saying they know today is the day he'll wake up. I really feel for her.

an MR angiogram showing blood flow, or lack of, is conclusive but not accessible for remote/peripheral hospitals. If this became part of the brain death criteria then patients would have to be transported to have this done which is untenable both ethically and medically

would it be possible to have it as an alternative? So that either the current method OR the MR angiogram is used?

In this case, I suspect people are right that the court of appeal thinks it will be quicker for Archie to remit it for a best interests decision (which can only really have one outcome) rather than have the method of establishing death argued. The treatment he is continuing to undergo and what is happening to his body is very distressing to read. I hope for his sake he survives until the court makes the decision and he can be allowed to pass away with his family beside him.