Some Numbers And Percentages

Over the years, I’ve seen individuals in very poor condition, including some with brainstem injuries, crawl out of a deep pit and make gradual improvements. These aren’t unequivocal indicators of a prognosis in every case. It doesn’t seem like he’s improved. I’m sorry, but I have the unfortunate responsibility of telling people things they’d rather not hear. Please be frank with us about his condition. Tell us what decisions we may need to make. Neurologists often see patients who have devastating neurologic injuries and are not expected to improve, or who may even get worse. Only after we’ve observed a patient for a sufficient time, performed important clinical assessments and have test results that definitively point toward a bad outcome do we broach the subject of lack of recovery with family. At times such as these, doctors need to call it as they see it. Deliberate exaggeration has no role in any profession and certainly not in a medical environment. Equally, truth doesn’t come in small steps or after detours. Family members want to know and understand, and they should be reassured that no physician takes these conversations lightly.

No Questions Asked

We don’t take hope away, but we need to be realistic. What’s gone is gone. But that doesn’t mean recovery is impossible. Are other parts of the brain taking over? Are parts of the brain simply stunned and getting ready to function again? Do we just need to await regrowth with new connections? Who has a chance and who doesn’t? When doctors discuss a patient’s outcome, we never forget we could be wrong and sometimes very wrong. I accept unpredictability with brain injuries and acknowledge that I sometimes might have to reconsider the diagnosis. I’m mindful of situations that can fool us and prompt an incorrect outcome assessment. Sometimes a patient’s recovery will take longer than expected, and doctors need to postpone important decisions and step back. Some circumstances that lead to coma are so rare that it’s impossible to predict the outcome among patients who experience them. Environmental injuries such as electrocution and lightning strikes are examples. When we see them, we can’t rely on prior examples and other accounts in the medical literature. When an individual is found unconscious without clues about the circumstances that caused it, predicting outcome is difficult. Neurologists often work differently from other specialists.

Everybody Has A Dream

When we encounter comatose patients whom we consider to be in bad situations, we’re seeing them at the most severe stage of their illness. Reliably predicting an outcome isn’t possible for many of these individuals, and we have to base our clinical judgment on test results. We always want to give an individual a fighting chance to improve, but on the other hand, in some situations, that’s extraordinarily unlikely. It’s also not possible to estimate a patient’s odds of recovery using percentages, although some people want us to do that. That’s because even if the chances of recovery are less than 1%, some patients will still jump through all the hoops and make a recovery. We simply have no way to identify them. Medicine is full of elusive numbers, and all the percentages can be dizzying. For example, let’s assume studies looking at the chance of recovery for certain causes of coma show that 3% will recover. That means there is still a 5% chance that recovery could be greater than 10%. Some could argue this isn’t certain enough. We often must hear this a few times to understand it properly. Even then, some family members may still be optimistic despite hearing the physician express serious doubt.

A Good Old Brain Shake

Clearly, numbers or graphs are difficult for many of us to grasp or see in a larger context. One in 25 is better understood than the abstract 4%. This isn’t a trivial matter. The images below are examples of what 4% looks like in graphic form and how different it may seem when presented in other ways. This graphic displays different ways of showing and interpreting percentages. 1 in 25, 9 in 225 and 4 in 100 all equate to 4%. You may have heard the phrase reasonable medical certainty. What does that mean? Rappeport said, There’s no simple answer. Reasonable medical certainty is not what I thought it was. It’s neither reasonable nor certain. It may be futile and perhaps even exasperating, but it’s human nature to leave no stone unturned, so we can honestly say we tried everything. That said, there’s a limit to what can be done, and we don’t necessarily do everything when it makes no sense. Brain surgery, for example, shouldn’t be offered if a patient’s brain is terribly damaged. We know that the outcome will be poor. Damage from some brain injuries is so overwhelmingly catastrophic that nothing can be done. In addition, we’ve learned over many years that brainstem injuries are often very significant. We discover significant injuries by testing the brainstem for the absence or failure of common reflexes. What we do know, however, is that long waiting times don’t necessarily lead to full recovery. Although most comatose patients do awaken, it doesn’t mean they awaken wholly restored. That’s why with each person we must look at the bigger picture. Sometimes we have to consider the functioning of other organs and whether a brain injury on top of an already marginal preexisting medical state will make recovery impossible. Let’s review those conditions that experience tells us are most likely to lead to a poor outcome in which a patient is unlikely to improve. Predicting how an individual with a brain injury from trauma is likely to fare can be difficult. That’s because these individuals tend to be younger, and they have resilient brains. A result, they may improve, often to a very surprising extent. Rarely do physicians come to a definitive conclusion that care is futile unless the person is close to losing all brain function. For example, a penetrating injury, such as from a gunshot, in which an object has traversed both parts of the brain can be considered unsalvageable, and this is often evident when the person is first examined.