Rise & Shine
Guest Blogger: Claire Fastner
What I wish I had known about coma... no, you don't just open your
eyes
As I promised in my first guest post, here's my second guest post on the
topic of "waking up from a coma". This guest post comes a little sooner than
expected, as it's buying Declan time to transcribe his interviews (I have
done this before and it takes hours!).
The Daily Mail, and even more reputable newspapers, make waking up from a coma out to be
a straightforward process. Here's a quote: "He had been due to have a final brain scan when he opened his eyes,
smiled at his nurse and gave her hand a gentle squeeze."
Yes, the patient most likely did this; that, however, does not do justice
to what actually happens. The most useful description of fully recovering
consciousness I found was the Rancho Los Amigos Scale, and it took Declan approximately two months to
reach level 8.
(1) Level I - No Response. Patient does not respond to external stimuli
and appears asleep.
(2) Level II - Generalized Response. Patient reacts to external stimuli
in nonspecific, inconsistent, and nonpurposeful manner with stereotypic
and limited responses.
When Declan was in Malta, he began reacting. He began reacting by moving
his arms At first, I saw this as a positive sign. That was until I realised
that his reactions were a mere indication of the brain damage sustained.
This is called abnormal posturing, involuntary flexion and extension of arms
and legs. Declan showed decerebrate posturing. He extended his arms in response to external stimuli which
indicated brain stem injury.
Further to that, he moved his toes in response to someone firmly stroking
the sole of his foot. Sadly, he showed the Babinski Reflex, a reflex (normal
in children) on the left. Instead of moving his toes downward, he moved his
toes upwards.
(3) Level III - Localized Response. Patient responds specifically and
inconsistently with delays to stimuli, but may follow simple commands for
motor action.
This is where our journey into throwing the small globe ball began. It must
have been around two weeks into the accident, as he was still in ICU. I
remember one evening. I was in the big ICU hall, and called over the doctors
to show them his tricks. They were quite happy. Yet, in retrospect, this was
a little naive. Clearly, it indicated that Declan understands language, can
follow simple commands.... but, some patients may never develop much further
than that.
(4) Level IV - Confused, Agitated Response. Patient exhibits bizarre,
nonpurposeful, incoherent or inappropriate behaviors, has no short-term
recall, attention is short and nonselective.
Fast forward a week, Declan began pulling at his tracheotomy tube. Hence,
he was given the big blue glove in Malta. Again, a positive sign in the
sense that he felt the object did not belong to his body and he felt the
need to touch it.
I remember one mad incident: Declan was mid-air in a hoist, being
transferred to a chair, wearing a hospital gown and (sorry Declan, but let's
describe the brutal reality of this) nappies. His eyes were open at this
point. I walked in. He smiled and waved. Beautiful progress. But really?
Quite bizarre and sad.
(5) Level V - Confused, Inappropriate, Nonagitated Response. Patient
gives random, fragmented, and nonpurposeful responses to complex or
unstructured stimuli - Simple commands are followed consistently, memory
and selective attention are impaired, and new information is not
retained.
Six weeks post accident, in Hamburg, he was mouthing words. His voice
became more and more audible. Communication became possible. At times, he
said things that made sense. Yet, he hadn't a clue who had visited him two
hours prior, and was now on the way to the airport. Being there with him,
made me see it all. He was on his "best behaviour" with visitors but the sad
reality came crashing down an hour later.
(6) Level VI - Confused, Appropriate Response. Patient gives context
appropriate, goal-directed responses, dependent upon external input for
direction. There is carry-over for relearned, but not for new tasks, and
recent memory problems persist.
He began greeting visitors. He knew who they were. Yet, he asked his friend
Cathal if he came / walked from Busáras, the central bus station in Dublin, to the hospital. At one
point, he also wondered how he should explain my presence to his
friends; he assumed we had just met three weeks prior.
This is when he began being the wonderful, funny person again.
Art and Cath's visit began with a bang: he asked them how the wedding
preparations were going. Seconds later, "Oh, I've been at your wedding"
(about a year ago), he laughed.
(7) Level VII - Automatic, Appropriate Response. Patient behaves
appropriately in familiar settings, performs daily routines automatically,
and shows carry-over for new learning at lower than normal rates. Patient
initiates social interactions, but judgment remains impaired.
Seven weeks post accident, re-learning could begin properly. He understood
(partially) the situation he was in. He was able to comprehend, and retain,
the information his speech and language therapist, Anne, provided him with.
In order to drink and eat safely, he tucked his neck in and swallowed
carefully, only small bites and gulps. On occasion, he needed to be
reminded.
(8) Level VIII - Purposeful, Appropriate Response. Patient oriented and
responds to the environment but abstract reasoning abilities are decreased
relative to premorbid levels.
Awake and alert. This is now. Declan's abstract reasoning abilities are
intact (certified by a neuropsychologist). Minor "odd" behaviour occurs on
occasion.
Let me tell you about one: "Erdbeer-Gate".
Strawberry Gate is what we call the incident when Declan, maybe two months
ago, simply threw his strawberry leaves on the ground, inside the clinic. No
big deal, one may say, some adults do this all the time, but the
pre-accident Declan would not have thrown garbage on the ground. The good
news is that - thanks to Declan's great premorbid shape - he grasps his
"mistake", and can control his impulse. If someone had told me 9,5 months
ago that minor incidents, such as strawberry gate, would be the visible
cognitive effects of the accident, I would not have believed them.
The damage is done and he is working on re-learning to use his body. To
make a long story short: some nurse in Malta said, "Don't use Google". Yes,
if you do not know how to use Google, leave it, as you will predominantly
come across "miracle stories". But, if you do, understanding that waking up
from a coma is slow, and the patient will exhibit bizarre behaviour, Google
can be a saviour.
.jpg)
Comments
Post a Comment