Jahi McMath: Is it safe to have tonsil surgery at Children’s Hospital Oakland?

Feb. 01--Bleeding complications following tonsil surgery are rare at hospitals across the state -- and rarer still at Children's Hospital Oakland, where the medical procedure that left 13-year-old Jahi McMath brain-dead has sparked debate about pediatric hospital care and the risk of tonsillectomies.

Five years of surgery records for the Oakland facility collected by the state show that about 1.4 percent of hospitalized tonsillectomy patients bled following the common procedure. That is below the state average for such complications, according to statewide hospital data requested and examined by Bay Area News Group. Bleed rates for outpatient procedures, considered less serious and where patients do not spend the night, were even lower -- only one instance in 3,100 tonsillectomies performed from 2008 to 2012.

On Dec. 9, Jahi underwent what the Oakland hospital called a "complicated" surgery, involving not just a tonsillectomy but the removal of other throat and nose tissue to treat the 13-year-old's severe sleep apnea. She started bleeding shortly after surgery, eventually going into cardiac arrest and losing total brain function, according to multiple doctor examinations.

Jahi's family thinks the hospital should have done more, and the state Department of Public Health launched an investigation after her mother asserted in court documents and interviews that nurses in the pediatric intensive care unit told her the hemorrhaging was "normal" and left it up to her and Jahi's grandmother to control it. The hospital has said little regarding what may have happened after Jahi's surgery, citing patient confidentiality laws.

Christopher Dolan, the family's attorney, has said a medical malpractice suit is expected, but he declined to comment for this story.

What is clear from the review of state data is that bleeding after tonsillectomy surgeries -- the most common and serious complication -- happens only in a small number of cases.

There were 12,602 inpatient procedures in hospitals statewide from 2008 to 2012, with 1.67 percent experiencing hemorrhaging, according to the Office of Statewide Health Planning and Development, which keeps records of surgery outcomes for 444 facilities across California. The agency provided data to this newspaper specifically geared toward the procedure highlighted by Jahi's tragedy.

Outpatient tonsillectomy bleed rates were 0.15 percent for the 120,349 procedures performed over the five-year span.

State records classify a hemorrhage as any bleeding, whether minor or severe. The agency collecting the data stressed that its numbers only show if a patient receives the surgery and what the disposition was, for example death or bleeding. The data does not necessarily establish that the surgery caused the end result. The agency does not have 2013 results available.

Nationwide, tonsillectomies are performed more than 500,000 times a year on children, largely for sleep apnea, and the number of such surgeries is on the rise, according to medical reports. They are the most common procedure performed on youngsters under general anesthesia; however, the procedures have been debated in medical circles since the time that they were done mostly for repeated throat infections.

The Oakland facility tucked up against Highway 24 with a "One Team, One Goal: 100% Healthy" banner visible to commuters has performed the fourth-most inpatient tonsillectomies in the state over the five years, according to the state data. Dr. David Durand, chief medical officer, said hospitals that treat a lot of children perform a large number of tonsil surgeries and gain expertise, and he's satisfied with the state numbers.

"We are proud of the fact that our (bleeding) rate for tonsillectomies is below the state average," he said in an emailed statement to this newspaper. "As with all surgical procedures, parents need to speak with their child's pediatrician and surgeon before consenting to a tonsillectomy so they understand the indications for the procedure, as well as the anticipated outcome and possible complications."

Children's Hospital Oakland had lower bleed rates than Lucile Packard Children's Hospital, the only similar pediatric-only facility in the Bay Area recorded by the state. Packard experienced postoperative bleeding in 3.47 percent of inpatient cases and 0.23 percent of outpatient cases.

Out of more than 130,000 tonsil surgeries performed statewide over the five-year period, 12 patients died, including one at Children's Hospital Oakland in 2008, according to state data. The East Bay hospital said it could not find confirmation of that fatality in its records.

Dr. Reginald Baugh, professor and chief of Otolaryngology-Head and Neck Surgery at the University of Toledo and a leading expert on tonsil surgery, said he would have no concern about sending his own child to the Oakland hospital.

"I would feel very comfortable at Children's Hospital Oakland. There's nothing in those numbers that says there's any problem," he said.

However, Baugh, who led a nationwide committee of physicians that produced first-of-its-kind tonsillectomy guidelines in 2011, cautioned that the state numbers only reveal so much.

"For the most part, those numbers don't have a lot of relevance as far as the quality of care," he said.

For example, the statistics do not break down each individual surgeon's bleed rates and do not include other possible postoperative complications. Specialty hospitals such as Children's Hospital Oakland also receive the tougher cases, which can inflate their rate, Baugh said.

In addition, he said, post-tonsillectomy bleeding has not necessarily been linked to poor medical procedures.

"The cause of secondary bleeding is unclear and presumably occurs without specific provocation and therefore cannot be prevented," he said.

Inpatient tonsillectomies carry a higher risk because they may be combined with other procedures, as in Jahi's case, and may involve patients with additional health issues. For instance, Baugh said, a very young child, or one with a pre-existing medical condition, such as diabetes or asthma, usually is treated on an inpatient basis.

When Baugh was a medical student, a tonsillectomy required a minimum three-day hospital stay. As his career progressed, the admission time dropped to a one-day stay; by the late 1980s, it was eight hours -- and now it's less than two hours on average, he said.

"The operation has never changed, the patients haven't changed. What has changed is the insurance companies and what they're willing to pay," he said.

A 2011 recommendation in the American Academy of Otolaryngology guidelines report is for individual doctors to annually monitor their bleed rates.

"The purpose of this statement is to encourage self-assessment by clinicians who perform tonsillectomy to determine how their personal rate of hemorrhage compares with expected rates based on audit data and published reports," the report stated.

Durand did not specify if Children's Hospital Oakland surgeons follow this guideline, but he said: "We carefully monitor the outcomes of our tonsillectomy patients, as we monitor the outcomes of all surgical procedures."

Staff writer Danny Willis contributed to this report. Contact Matthias Gafni at 925-952-5026. Follow him at Twitter.com/mgafni.

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