An Awareness Of What's Happening

Establishing simple categories for states of awareness is often best for effective communication between family members and members of the patient’s health care team. The first thing that a physician will determine when asked to see a patient who’s inattentive is whether the person is awake. A range of possible diagnoses then flows from there. When we see a patient who’s staring quietly and inattentive, the person’s condition may be hard to identify. Delirium includes several disturbed elements, including language, perception, orientation, mood and sleep. Traditionally, delirious patients are loud, agitated, accusatory, paranoid and offensive. Some of my medical colleagues say they’ve seen patients who are very quiet while hallucinating and delirious, but I’m not so sure about that. The delirium I typically see is restlessness with sweating, rapid heart rate and wide pupils. There’s a tendency to just call this acute brain failure, but vague terms have little medical value. Alert patients are observant and may say hello. They are fully attentive, complete tasks promptly when asked, actively ask questions and are engaged and with it. Delirious patients, as just described, are in a deeply disturbed state characterized by restlessness and incoherence.

When The Lights Go Out

Patients who are drowsy can be awakened and will stay awake when engaged in conversation. They have a reduced attention span and may drift off during a conversation. The term stupor describes a condition in which the eyes remain closed if the person is lightly prodded but open in response to something painful. The individual will also tend to make movements as if to push away what’s causing the pain. When the stimulation is absent, the patient immediately becomes unresponsive once again. The simplest definition for comatose is an unreceptive and unresponsive state. Unlike patients who are sleeping, those who are comatose don’t wake up, speak, or open their eyes when someone talks loudly or pinches them. In response to stimuli, their arms and legs may react by withdrawing or as a reflex. If comatose patients move at all, the action isn’t done with a purpose. Lack of content also is an important hallmark of coma. Content refers to an awareness of what’s happening in one’s surroundings. An example would be knowing that a family member is at the bedside, recognizing the family member or being able to communicate in a rational, logical way.

The Song Remains The Same

People who’ve regained consciousness after being comatose often don’t recall what happened while they were unconscious. In coma, the door closes fully. Their eyes are open and the eyes blink and move vertically, but they make no other movements. These individuals are more or less awake but unable to show it. It’s as if there’s a major barrier they cannot overcome and they’re boxed in. The pons is the site of several nerve bundles that create most eye movements, facial movements such as grimacing and head movements. Patients who are locked in can move their eyes vertically because the syndrome doesn’t affect the upper part of the pons, called the mesencephalon, which produces vertical eye movements. When people have surgery or are intubated, before the procedure, they’re given a drug that paralyzes their muscles, making it impossible for them to move. Because they’re sedated, however, they’re not aware of this. In rare cases, the drug paralyzes the muscles, but the sedation isn’t sufficient, and the person becomes very much aware of the fact that nothing moves. This may happen because the drug cleared from the person’s body more quickly than what’s typical or the dosage was insufficient. Again, this truly is very uncommon.

Shadows and Tall Trees

It became a bestseller, raising awareness about this very uncommon condition. Coma can be prolonged, and some patients transition to a vegetative state. They believed that the diagnosis could only be reliably made after six months had passed and noted that the condition was extremely rare. In doing so, the task force deliberately avoided use of the word unawareness and inaccurately claimed that detailed evaluation could reveal a certain level of awareness in some patients. The term unresponsive, however, is problematic, simply because many patients show some level of response, albeit at the level of primitive reflexes. I think unresponsive wakefulness syndrome is a very confusing term and a tongue twister, and in my experience, family members find it confusing as well. Patients in a vegetative state open their eyes and have moments of sleep and wakefulness. Their brains don’t function, but from the outside, they appear conscious. These individuals are eventually able to breathe on their own. With adequate nutritional support and meticulous nursing care, many live for years and even decades. Diagnosing a vegetative state is very difficult, even for the most senior physicians. To be certain of the condition, physicians must examine an individual repeatedly over time. Brain scans of individuals in vegetative states typically show devastating damage. Only a handful of people in vegetative states surprise us by becoming more aware of their surroundings and transitioning to what we now know as a minimally conscious state. At times, however, they look about, make sounds, and may even say a word. Minimally conscious patients are still very severely disabled, although some can be cared for at home. The term brain death refers to a medical state in which the automatic systems fail and the brainstem loses all its function. Essentially, physicians detect no signs of life. If no reflexes are found, the patient is unable to breathe and medical staff has ruled out all other conditions, the person has legally died. Only then can the family consider organ donation. In summary, there are a number of terms that physicians use daily as part of their medical vocabulary to describe states related to coma. Neurologists generally remain wary of many of these terms because they’re vague and their use can mask serious evolving diseases. For now, they’re labels, and most attempts to rename states of unconsciousness have led to even more ambiguity. A final issue with terminology that bothers me is the use of metaphors for prolonged coma.