covici@ccs.covici.com (John Covici) (06/06/91)
Index Number: 16002
I am posting this article, because we need to get a more accurate
perspective on the issues of treating unconscious patients. There
has been a lot of media propaganda encouraging the starvation of
such patients and a lot of talk about so-called "living wills" on
this eco. Those of you contemplating such documents, or, with such
documents existing, check out this article first before
proceeding.
Coma Recovery: Where There's Life There's Hope
by Linda Everett
People everywhere are inspired by courageous individuals who
overcame extraordinary odds to accomplish incredible feats. For
Liz Hartel, once one of Denmark's leading dressage riders, to win
an Olympic Silver medal in 1952 for that highly disciplined
equestrian event, she had to first learn how to lift her arms, to
crawl, and then, to use crutches. Hartel had to first overcome
her almost complete paralysis due to polio.
There are families like the Applebys of West Virginia, who
lovingly worked round the clock, caring at home for their father
and husband, Earl Appleby, Sr. Besides relentless cuts in
Medicare and veterans' medical benefits, the Applebys repeatedly
battled ruthless hospital physicians who raged that the family
had no right to expect hospital care for Earl, who, they said,
``should have been dead long ago.'' But Earl Sr., even in his
illness, was an inspiration to his family. The Applebys rose
above their immediate crisis, and, seeking to help others in
similar battles, started CURE, Citizens United Resisting
Euthanasia. His work done, Earl Sr., a beefy, strapping
six-footer, died in September 1990, after ten years in
coma--after doctors refused him a critical blood transfusion,
even of his three children's blood.
These stories make clear that the saying, ``Where there's life,
there's hope,'' is much more than a truism. Although Earl
Appleby did not come out of his decade-long coma, recent progress
in treatment of patients rendered comatose by severe head injury
is has spectacularly increased the statistics on recovery from
coma. proving as well that ``Where there is hope, there is
life.''
Every 15 seconds, someone in the United States receives a head
injury--about 2 million Americans every year. Approximately
100,000 people die from head injuries annually. Some 70,000 to
90,000 of those with moderate to severe injuries will endure
life-long debilitating loss of function. Anywhere from 5 percent
to 25 percent of these injuries are serious enough to cause some
period in coma, from which 2,000 may never recover.
Ironically, as this ``silent epidemic'' of brain injuries and
their immense neuropsychological impact spurred a national
determination to discover new, effective therapies, a vocal
opposition has erupted against using them. There has emerged an
increasingly barbaric medical ethic reflective of the prevailing
Malthusian economic policy that says, essentially, ``Don't waste
scarce resources on those who might not make it or who are
`better off' dead.'' And this, in the face of growing evidence
that proper treatment vastly enhances the chance that victims of
severe head injuries will eventually emerge from coma.
What Is Coma?
Coma is generally described as a prolonged state of
unconsciousness and unresponsiveness from which patients cannot
be awakened. It is also often referred to as a state of
nonawareness. But, as many survivors of coma will tell you, they
remember everything, and can reproduce whole discussions about
their care which took place by their bedside, while they were
comatose. Both the depth of coma and its duration, whether of
several minutes, hours, days or months, depends on the degree and
type of head injury sustained.
By far, the most frequent type of coma is caused by brain
injuries sustained in automobile and motorcycle accidents. In
such {closed}
head injuries, the damage to the brain is diffuse and widespread,
caused by the accelerating skull being stopped suddenly by
striking a hard object such as a car dashboard
(acceleration-deceleration). In contrast, with a {penetrating}
injury, caused, for example, by a bullet wound, a specific part
of the brain is destroyed and the resulting disability usually
reflects the specific area damaged.
In closed head injuries, the
type a child might sustain after being violently shaken, the
soft, plastic brain is easily deformed as it slams against the
front of the skull, and rebounding, hits the back skull wall as
well (coup-countercoup injury). As one doctor describes it, think
of the brain as jello sloshing about the skull if the head is
badly shaken. Rotational forces cause shearing of many blood
vessels and nerve fibers, resulting in the loss of motor
function, sensation, intellect, or memory. When the brain moves
over the rough bones at the base of the skull, the nerve fibers
going to the brain stem maybe be disrupted, resulting in coma.
The reticular activating system (RAS) within the brain stem
serves as the sensory transmission system which activates the
cortex, which controls conscious behavior and awareness. The RAS
itself is key to our ability to be aroused--it's what gets us up
in the morning. So damage to the brainstem or RAS, either from
the initial injury or swelling and pressure later, may result in
coma in which the patient is neither awake nor aware.
Coma may also occur when the brain is deprived of blood
(ischemia), as when the main artery to the brain is blocked as
the result of a stroke, causing damage to specific areas of the
brain. When the brain is deprived of oxygen (hypoxia), as occurs
in a cardiac or respiratory arrest, reaction to anesthesia, drug
overdoses, and near drownings, the damage is diffuse and can
occur soon thereafter, along with hypoxic coma.
Whatever the cause of the coma, the focus of medical attention is
on preventing further damage through emergency management at
specialized traumatic brain injury centers and hospital intensive
care units or neurosurgery/neurology units, where stabilizing the
patient's neurological status is primary. Complications, such as
brain swelling (edema) or bleeding into or around the brain
(hematoma), must be monitored, for they can rapidly create
hazardous intercranial pressure within the skull that in itself
can cause coma or death. Patients often remain in coma throughout
the total period of their acute medical care.
The Central Park Jogger Case
Immediate acute intervention, however, is not guaranteed, as the
following case demonstrates. The woman who became known as the
Central Park Jogger was found only hours after she had been
savagely raped, beaten, and left for dead in Manhattan's Central
Park. When the team of doctors which finally took over her care
congregated around her bed at Metropolitan Hospital Center, a
resident turned to Dr. Beatrice C. Engstrand, the medical team's
neurologist, and asked if she thought the young woman would
survive. Dr. Engstrand deliberated for a moment, knowing that
the way she answered him could influence the way he practiced
medicine now, and for the rest of his life. And mindful of the
morale boost any medical team needs when it must overcome great
odds, she said, ``Yes, I do think she will survive. Where there
is life, there is hope.''
Moments later, a colleague, not part of Dr. Engstrand's team,
told her, ``I overheard your conversation and I disagree with
you. That girl doesn't stand a chance. Look at her!'' When found,
the woman had no pulse, and a crushed windpipe had starved her
brain of oxygen for an extended period of time. She had cerebral
swelling and a blood clot on each side of her brain. Her doctors
testified that ``both halves of her brain were wiped out, and
were not functioning. She had lost three-quarters of her blood.
Her blood pressure was non-existent. She had received a blow so
severe that she suffered a blowout fracture, that is, her eyeball
had exploded back through the rear of its socket. Her brain was
so severely injured that the normal hills and valleys that appear
in everyone's brain were flattened out, obliterated.''
Now, the woman was comatose, her life dependent on a ventilator,
tubes, and IV lines.
``Face the facts now,'' Dr. Engstrand's pessimist colleague
demanded. ``It will make it easier for you later on.... If she
survives, she could be a vegetable.''
As we know, the Central Park Jogger was in a coma, almost totally
unresponsive, for eight months. However, she not only survived,
but after eight months of rehabilitation therapy, returned to
work as an investment banker part time. This young woman was in a
non-responsive coma for eight months. Her doctors attribute her
``miraculous survival'' to her incredible will to live. More
likely, she survived because her doctors gave her a {chance} to
live. Had she been entrusted to the care of Dr. Engstrand's
strident colleague--who saw only a future ``vegetable''--she
might not be alive today.
An Evil Ideology
It is necessary to grasp the evil behind this ideology as well as
the damage it wreaks. The self-avowed Satanist will not hestitate
to sacrifice a human being to the evil deity he worships.
Similarly, the cost-cutting Malthusian will not hesitate to offer
up human victims to his deity, which places more value on
balanced budgets and so-called cost-effective medicine than the
life of a disabled or comatose patient. The difference is that
these thugs are pushing policies whose implementation will
eliminate whole layers of the patient population, from the
elderly patient with Alzheimer's disease, to a critically ill
infant, to keep their usurious economic policy (and the
Medicare/Medicaid budget) intact. Therefore, they produce
{their} brand of ``scientific'' research to ``prove'' their Nazi
policy: that some lives are not worth living. Thus, new killer
diseases known as ``poor quality of life'' and ``poor prognosis''
are rampant in hospitals and nursing homes. Even the terms that
describe patients, as well as the focus of diagnostic and
research methods that ``predict'' their ``odds'' for recovery,
are often developed from a totally pessimistic perspective.
The problem is further confused because even dedicated physicians
unwittingly promote the euthanasia lobby's agenda by using their
terminology and research. Patients are often labeled as
``permanently unconscious,'' ``brain dead,'' or in a ``persistent
vegetative state''--all labels which serve only to create a bias
against treating and even feeding such patients. As one
occupational therapist said, ``How do they {know} these people
are {permanently} unconscious?'' Patients in coma are considered
``terminally ill,'' only because some doctors have predetermined
that they will not prevent death in coma patients whose ability
to clear their throat or lungs is impaired, thus leading to
frequent respiratory infections which, if not treated, lead to
death.
Every time the death lobby campaigns to broaden euthanasia laws,
they say that there are about 10,000 ``vegetative'' patients in
institutions across the United States. But nurses and therapists
working with patients in coma and others with developmental
disabilities suggest that many of these people have been wrongly
diagnosed and, in fact, are severely disabled but could benefit
greatly from intensive rehabilitative services.
One immediate example is the case of Christine Busalacchi in
Missouri. Christine, 20, has severe brain damage from a 1987
auto accident. Her father wants court permission to starve her
because, he says, ``The poor kid's gone. What's left is a
machine.'' For years, Christine did little more than turn her
head or follow her nurses with her eyes. Then, after receiving
six days of physical therapy,
in January 1991, Christine regained the ability to sit up, to
swallow and eat pureed foods,
and to use special devices to tell nurses when she wants more
food or when she wants them to talk to her.
Christine's father's consulting neurologist, Ronald Cranford,
stubbornly asserts that she is in a ``persistent vegetative
state.'' But, as documented in papers filed with the St. Louis
Circuit Court in February, Christine laughs at her nurse's comic
behavior and jokes, and smiles at the taste of ice cream.
The euthanasia mob uses the misconception that once individuals
begin receiving their daily nutrition via a stomach or
naso-gastric tube, they will have that tube the rest of their
lives. Christine Busalacchi proves that this is not true.
Occupational therapist Desi Cheney from the Midtown Habilitation
Center in St. Louis demonstrated just how untrue this is with
the quick and remarkable training of Christine to take food
orally, after not having done so for four years.
Midtown's is a wonderful program, that works with those who have
severe mental or physical impairments, whether from disease,
developmental disabilities, or head injuries. A test called a
Modified Barium Swallow is used to examine what, if any,
inability or impaired swallowing capability the patient may have.
As the individual swallows the liquid, a film of the process is
taken and then studied. Unless the impairment is irreversible,
therapists like Cheney, armed with an array of methods, including
using food of the appropriate texture for that particular
individual, can train the person to swallow.
As in the case of Christine, before a person can eat orally, he
or she has to be trained to sit up--no simple task for those who
have not used their muscles for years. Building up Christine's
sitting tolerance was helped with the use of adaptive equipment
built to meet her specific supportive needs. In less than a week
after getting this equipment, Christine was sitting
up for several hours--despite the fact that she had not had any
active therapy for two years.
Levels of Coma
The various levels of coma are described as follows: In ``light
coma,'' the patient responds to noxious stimuli by withdrawing;
in ``deep coma,'' there is no response to noxious stimuli; in
``stupor,'' an unconscious patient can be awakened briefly but
only by vigorous stimulation. The Glasgow Coma Scale (GCS)
assesses the depth of coma on a
scale of three, totally unresponsive, to 15, fully conscious with
voluntary movements, and response to commands.
Unfortunately, research has proven that the GCS is often used and
interpreted incorrectly--leading to, no doubt, more than a few
patients diagnosed as ``hopeless.'' Also, the GCS is often
employed to {predict} a patient's outcome, rather than as an
evaluation and a starting point for intervention and improvement.
Thus, when someone does recover from deep coma, it is seen as an
exception to the rule, or a misdiagnosis.
However, as the editors of a new volume on rehabilitation, {The
Coma-Emerging Patient,} write,
``One of our former patients, who was comatose for several weeks
and who had a GCS score of 3 (the lowest) on admission to the
trauma unit, completed undergraduate studies and began law school
this fall. An anecdote such as this serves to remind us that we
do not have all the answers about predicting the outcome from
patients who are comatose. We are inspired by such stories to
explore new areas of research and treatment for patients who have
experienced traumatic brain injuries.'' ({Physical Medicine and
Rehabilitation,} Vol. 4, Number 3, 1990)
Textbook definitions of coma and post-coma levels and laws
concerning them mean nothing, since they are often superseded by
protocols developed by the modern Nazi doctors, who are backed up
by new legislation that gives credence to their deadly approach.
The medical profession, the courts, and the general public have
been taken in by these ``experts'' who supposedly ``know what
they're talking about.''
For instance, the term ``persistent vegetative state'' or PVS was
created by the renowned Dr. Fred Plum, to describe the patient
who has emerged from coma to a state of ``wakeful
unresponsiveness'' in which the patient will ``never regain
recognizable mental function.'' Plum states that PVS patients are
``awake but unaware'' and have regular sleep/wake cycles, open
their eyes, breathe, digest, swallow, and clear their throat on
their own. The problem is that Plum, the expert quoted in
pro-death court rulings, refuses to save so-called PVS patients
who prove to be quite aware. In the case of Nancy Jobes, not only
did he refuse to testify for the nursing home which opposed the
starvation of Nancy, Plum asserted Nancy was ``vegetative''
before he even examined her. Meanwhile other neurologists
testified to the court that Nancy responded consistently and
correctly to their request to lift her leg or arm, or to stick
out her tongue.
Neurologists like Plum and the infamous Ronald Cranford of the
Hennepin County Medical Center in Minneapolis, are constantly
held up as experts, in the euthanasia lobby's efforts to push the
``right to die'' on the elderly, sick, and disabled.
But consider the case of David
Mack. In 1979, Sgt. David Mack, a member of the Minneapolis
Police Department, was shot several times, stopped breathing, and
lapsed into coma. ``Sargeant Mack will never regain cognitive,
sapient functioning,'' announced Ronald Cranford, Mack's
physician, six months later. ``He will never be aware of his
condition nor resume any degree of meaningful voluntary conscious
interaction with his family or friends.''
Cranford, along with three other neurologists and an ethics
committee of 18 members, determined Mack's situation to be
hopeless. Cranford declared that Mack's ``prognosis for higher
cortical function is virtually zero.''
Twenty-two months later, Sgt. Mack recovered consciousness and,
proving that he, like others who have been in coma, had been
aware of activities around him, asked for the private duty nurse
who had been taking care of him, {by name.}
Cranford said at the time, ``The reason they (PVS) never recover
is that they are never given the opportunity to recover. We
decide not to treat their complications and they die. Mack got
much better nursing care for a longer period because the case got
publicity. If he had been treated like everyone else, I don't
think he would have stood a chance.'' Cranford had to admit,
however, that ``the fact that Mack awoke calls into question the
way we assess these cases.''
Pushing the Right to Die
It would be wrong to simply shrug off Cranford as ``just one
kook.'' The ``expert'' whom the media always seeks out, Cranford
has been pivotal in a number of policy-making endeavors which
have successfully instituted euthanasia in its myriad forms as
medical protocol. In a much-publicized Society For the Right to
Die/Concern For Dying statement (1984), Cranford called it
appropriate to starve and dehydrate severely demented patients to
death if they reject spoon-feeding. This announcement by 12
``prestigious'' experts, half of whom belonged to the Society for
the Right to Die, was published in the influential {New England
Journal of Medicine}--the largest medical journal in the
world--as well as hosts of nursing and other medical
publications.
In 1987, Ronald Cranford published what can only be called an
outright fascist document, ``Consciousness: The Most Critical
Moral (Constitutional) Standard For Human Personhood'' ({American
Journal of Law and Medicine,} Vol. VIII, Nos. 2 & 3, 1987).
Written with David Randolph Smith of Vanderbilt University School
of Law, Nashville, the paper declares that all categories of
``permanently unconscious patients'' (he includes those diagnosed
as comatose or in a ``persistent vegetative state,'' or the
anencephalic, that is, children born lacking a brain or with an
underdeveloped brain, have no civil and constitutional rights,
because they lack consciousness--``the most critical moral,
legal, and constitutional standard, not for human life itself,
but for human personhood.''
Here is a sampling of Cranford's fascist pronouncements:
``Once it can be determined that a human being is permanently
unconscious, the traditional goals of medicine can no longer be
served....
``Medicine cannot promote the best interests of these patients
because these patients have no interests in further treatment or
discontinuation of treatment, or in continued existence at all.
Continued existence and treatment or non-treatment may be of
enormous importance to the patient's loved ones and to society,
but not to the patient.''
Cranford then states that, since ``anencephalic infants are never
conscious, and they are terminally ill and, therefore, could be
considered a non-person, should it be homicide to take its vital
organs?''
Cranford questions the fundamental value of all human life:
``Should homicide laws refer only to persons, rather than all
live human beings? An anencephalic infant or a persistent
vegetative state patient cannot be harmed by either continued
treatment or discontinued treatment. Therefore, how can an
anencephalic infant or any permanently unconscious patient, who
cannot be morally harmed, be a victim of a homicide?''
Cranford's bottom line tells it all: Given ``society's limited
resources ... it becomes increasingly difficult to justify
financial or other burdens on family, health care providers, and
society.... Society would be far better served if these resources
were focused on preserving health and rehabilitating persons who
could experience benefit from medical care....
``Do any constitutional rights exist for a patient who is
permanently incapable of experiencing or exercising those rights
in any way?'' Since a person who is unconscious has no will,
thought, expression or consciousness, Cranford argues, ``legal
rights and liberties have no reference and thus, no meaning....
''
Cranford bases his argument that PVS patients are ``permanently
unconscious'' on the official position paper of the American
Academy of Neurology, which states: ``Persistent vegetative state
patients do not have the capacity to experience pain or
suffering. Pain and suffering are attributes of consciousness
requiring cerebral cortical functioning, and patients who are
permanently and completely unconscious cannot experience these
symptoms.'' The perspective of the academy's testing is not to
intervene to help the patient but to support the Academy's aim to
eliminate them.
The academy gives three points
as ``evidence'' that PVS patients are ``permanently
unconsciousness.''
1) ``Clinical experience demonstrates that PVS patients do not
demonstrate behavioral indication of awareness of pain.'' This is
nonsense. The Glasgow Coma Scale and other measures of recovery
use behavioral indications like grimacing or withdrawing from
pain as indicators of improvement. Were the patients whom the
academy studied given aggressive sensory stimulation therapy or
were they left in a state of sensory deprivation, which, in
itself, is so damaging that doctors now insist the stimulation
therapy begin as early as possible, even while the patient is in
intensive care?
2) The academy claims that in
all PVS patients studied to date, all post-mortem examinations
``reveal overwhelming bilateral damage to cerebral hemispheres to
a degree incompatible with consciousness or capacity to feel
pain.'' Even if this were true, the academy has ignored the
research that has found some of the pharmacological keys to
stemming that damage, as well as studies that indicate that the
nervous system can overcome the damage caused by oxygen
deprivation by sprouting new nerve fibers and rerouting messages
(S. Varon, {Advances in Neurology}, 1988).
Equally ludicrous is the third point the Academy makes: ``Data
utilizing Positron Emission Tomography (PET) indicates that the
metabolic rate for glucose is greatly reduced in PVS patients, to
a degree incompatible with consciousness.'' The only legitimate
question here is what is the baseline metabolic rate for
life--not consciousness. But, if this were a legitimate question
and if a patient fell below the metabolic rate for consciousness,
then the focus for a physician must be to find the methods to
reverse this state. One study using PET revealed the level of
metabolic hypoactivity for PVS patients to be similar in nature
to that which occurs during deep anesthesia. So we know the rate
is not incompatible with living.
Despite the fact that Cranford was completely wrong when he said
there was no hope for recovery for his comatose patient, Sgt.
Mack, the largest, most influential medical association in the
United States, the American Medical Association, cited Cranford
as their source in their {amicus curiae} brief in favor of
starving Nancy Cruzan, a woman with severe brain damage whose
Missouri family demanded and received court permission to kill
her. With no evidence supporting their claim, the AMA has
asserted: ``Vegetative state patients may {react} to sounds,
movements,
and normally painful stimuli, but they do not {feel} any pain or
{sense} anybody or anything'' (emphasis in the original).
Pronouncements by the American Academy of Neurology and the AMA
on starving so-called PVS patients weigh heavily in courts of
law, and have been used for over a decade to broaden patient
killing via judicial precedents. The policy statements are handed
down as if from on high, and replicated by state medical
associations. The broad judicial rulings they influence are, in
turn, used by the euthanasia lobby to bamboozle state legislators
into supporting bills that declare open season on anyone who can
be tagged as ``permanently unconscious.''
The `Brain Death' Fraud
The concept of ``brain death,'' used to define the legal basis
for terminating life, is built on the hoax that death occurs when
present-day tests can no longer discern brain {function}. The
Uniform Determination of Death Act (UDDA), which is law in many
states, declares: ``I. An individual who has sustained either
cessation of circulatory and respiratory functions, or II.
irreversible cessation of all functions of the entire brain,
including the brain stem, is dead. A determination of death must
be made in accordance with accepted medical standards.''
The main fraud involved here is simple: Cessation of brain
function is {not} the same as when an individual's brain has been
grossly damaged or destroyed. The accusation that hospitals are
wastefully ``ventilating corpses'' is pure nonsense. Swedish
researchers have proven that when an individual's brain is truly
destroyed, regardless of technological assists in the way of
ventilators and such, the individual will die within a matter of
days. A non-functioning brain cannot be assumed to be destroyed.
Studies using the strictest criteria for determining brain death
have proven that the concept is quite wrong. The National
Institutes of Health ran a two-year study attempting to prove
that the cessation of brain function coincided with brain
destruction, referred to as ``respirator brain.'' It included 503
patients in unresponsive coma and apnea. The results were called
by Dr. G.F. Molinari, an organizer of the collaborative study,
``one of the major and most disturbing findings.'' Autopsies
performed on half of the patients who died during the study found
that, in 60 percent of the cases, destruction throughout the
brain could not be found. Some 43 percent of the brains of
patients who met the strictest criteria for determining brain
death--the Harvard criteria, {did not have} such brain
destruction. And, in 10 percent of the cases, no abnormality of
the brain could be found. Yet, the move to massively revamp state
laws and medical protocols went forward.
There are thousands of brain death ``mistakes.'' A physician from
a Jamaica, New York hospital removed a respirator from his
``brain dead'' patient as is routinely done after 48 hours. He
then went to lunch, expecting his patient soon to be ``gone.''
She fooled him though. On his return, he found his ``brain dead''
patient enjoying lunch (even though it was hospital food)!
Many who have seen their sons or daughters through coma and the
arduous rehabilitation process have proven such experts wrong.
There's Harold Cybulski, 76, who, after doctors declared that he
had suffered ``irreparable brain damage'' from a heart operation
and was ``brain dead'' for ten weeks, was taken off a
life-support system and given Last Rites. When his two-year-old
grandson yelled from the door to his hospital room, ``Hey,
Grandpa!,'' Grandpa sat up in bed and stretched out his arms for
his grandchild.
Literature on coma and traumatic brain injury warns you that
things like this don't happen--except maybe in the movies. This
is generally true, since most folks recovering from any lengthy
coma must relearn how to walk, talk, feed and dress themselves,
and many need enormous psychological supports to get through it
all. Nevertheless, within two weeks, Cybulski and his wife
celebrated their 52nd wedding anniversary. A month later, he
bought a new car and was out visiting his relatives.
Fighting for Recovery
While each patient's injury, therapy, and response is different,
the almost universal method used to revive people in coma and
prolonged coma (unfortunately referred to as `` persistent
vegetative state'') revolves around a program of structured
stimulation of the senses of sight (visual), hearing (auditory),
touch (tactile), taste (gustatory), and smell (olfactory). The
theory behind intense multisensory stimulation is the stimulation
by sensory bombardment of the reticular activating system (RAS)
of the brain, which is primarily responsible for arousal and
wakefulness. As one doctor describes it, whether you're awake or
asleep, the RAS is continually monitoring the outside world,
ready to sound the alert, whether the stimulus be a crying child
or a ringing bell. If functioning, it normally responds to all
sensory stimulation.
It is theorized that repetitive stimulation trains previously
unused parts of the brain, and brings the patient to a higher
level of awareness and functioning. Coma care programs were
almost nonexistent a decade ago; now they are proliferating
throughout the United States. Rehabilitation hospitals and
skilled nursing facilities often employ some form of sensory
stimulation as a way to gauge a patient's progress, while
providing the family a structured system within which they can
participate in working with the patient.
It is now known that there is a major impact on electrical brain
activity of deep coma patients when active therapeutic sensory
stimulation encouraging patient motor response is carried out in
neurological intensive care units for at least three consecutive
days (P. Weber, {Archives of Physical Medical Rehabilitation,}
August 1984). It is this {active,} direct impact on the cortical
activity of acute comatose patients, as opposed to the {passive}
stimulation a patient receives during family visits or bathing,
that can actively assist their neurological recovery.
The nurses, doctors, physical therapists, and other health team
members who work in the coma recovery program do not wait for
``nature'' to take its course with comatose patients. They are
treating patients with frequent intense multisensory stimulation,
vigorous exercise and all the measures required to prevent
complications of immobility and unconsciousness.
Innovative Approaches
One unique program, described by
R. Grass and S. Young ({Rehabilitation Nursing,} May-June,
1987) is the International Coma Recovery Institute in New York.
All the patients accepted there had a prognosis of ``hopeless.''
The institute first evaluated patients, attempting to wean them
off of drugs such as valium, dilantin, and phenobarbital, which
are often given in such high doses that they contribute to the
patient's lack of awareness. Instead, low doses of drugs that do
not sedate the patient are used to control muscle spasticity and
rigidity.
Correcting the patient's nutritional intake is also critical to
his healing. Many patients were found to be given what can only
be called starvation diets at their previous hospitals. It can
take weeks of slowly increasing the increments of nutrition until
an appropriate level is reached, at which the patient is not
losing weight and the body is not cannibalizing itself.
The institute trains each family to carry out the 45-minute cycle
of stimulation exercises that they later perform with the patient
in the home. Friends, volunteers and the family give eleven
45-minute sessions every day. For example, if the patient's eyes
are always closed or there is a lack of a blink reflex, visual
stimulation is done by shining a 650-watt light on the eyes (it
has no harmful effects on the retina), one second on, one second
off. This is repeated several times.
Some 99 percent of the
patients in this program were diagnosed by experts as
``irreversibly comatose,'' and ``permanently unconscious.'' They
were all ``brain dead,'' with flat brain waves. Interviews with
some of the families working with the institute have revealed
that spouses were told they ``would be better off without their
loved one'' or ``nobody wants to live like a vegetable, let him
die,'' or ``stop wasting your time, your wife will never wake up,
let her die, go on with your life.'' Parents were told it would
be better if their child died. Yet, there was a 92 percent
recovery rate for those in coma for up to two years! And 35
percent of these returned to a completely functioning state.
The family involvement here is critical to the patient in coma.
Often when the patient first responds it is usually to someone in
his family. The families themselves also need tremendous support
throughout the long process.
Research indicates that if sensory stimulation is provided early
enough and intensively enough, it can save the lives of people in
coma, as well as enhance both the percentage and rate of recovery
from coma.
Drs. E. R. LeWinn and Dimancescu
report ({Lancet,} 1978) of their pilot study of 16 comatose
patients, resulting from head trauma, hypoxia, or brain tumor,
who had initial Glasgow Coma Scale scores of 3, 4, or 5.
Environmental enrichment programs were begun 12 to 14 hours after
the patients were admitted to the hospital, except in two
postoperative cases where it was initiated ten to 14 days after
surgery. Follow-up of the 16 patients, ages ranging from four to
80 years, occurred after several days to ten months. There were
no deaths and all 16 patients ``fully recovered'' from coma.
Twelve patients regained functional independence; eight of these
returned to their pre-coma state. The others were said to be
progressing. In the comparison group of 14 patients with similar
severe coma levels who did not receive the stimulation program,
11 patients died.
In a more recent study ({Brain Injury,} 1990), Mitchell, et al.,
evaluated the effectiveness of coma arousal procedures among two
groups of 12 patients each, who were matched for age (17 to 42
years), sex, type, location and severity of brain injury,
surgery, and GCS score at the time of hospitalization. Once the
patients were medically stabilized, stimulation was started
within four to 12 days of injury. Stimulation of all the senses
was provided for one or two one-hour sessions daily to the
experimental group. The control group received none. Mitchell et
al. determined that the coma had ended once the patient could
respond to commands and showed purposeful movements. The results
showed that even with this most minimal of stimulation protocol,
the total coma duration for the experimental group was
significantly shorter than for the control group, which suggests
that stimulation should be a standard part of the treatment of
severe brain injuries to facilitate rapid recovery.
Also significant is a pilot study by Rader, Alston, and Ellis
({Brain Injury,} 1989) of six ``vegetative'' patients at an
average of 15.5 months post-injury. It found that warm, loud
affectively charged verbal encouragement of the patients during
stimulation sessions elicited higher levels of eye openings and
motor responses than did quiet interactions. Placing patients in
an upright position with supports to maintain the head and trunk
also facilitated response to the stimulation.
Helping Hands
Many individuals who emerge from coma sustain varying levels of
paralysis from the shoulders down as the result of injuries to
their spinal cord, in addition to head trauma. To live
independently, people with these injuries require anywhere from
four to
six hours of help per day from a paid personal care attendant, or
family member who helps them in the morning and evening with
daily activities like bathing, dressing, bowel and bladder
routines, and transfer in and out of a wheelchair. In between,
there are countless small manual tasks to be done, from turning
the pages of a book to getting lunch. Those who could not afford
a full-time attendant, had to simply go without, until
psychologist Mary Jo Willard created an ingenious non-profit
program called ``Helping Hands: Simian Aides For the Disabled.''
For over a decade, the Boston-based program has successfully
trained capuchins (also known as organ-grinder
monkeys) to assist people who are quadriplegic, giving them
increased self-reliance. The monkeys follow verbal commands and
visual cues from laser-pointers, to open or close doors, change
books or magazines for reading, feed their owner, serve food from
a microwave, clean up afterwards, retrieve objects, and more.
These ``formidably bright'' animals, that learn new tasks in a
single half-hour session, have a performance reliability rate
close to 100 percent. They live 30 years, and are toilet-trained,
very clean, affectionate, immensely loyal and highly
entertaining.
One of the first participants of the program was Sue Strong, who
became quadriplegic after an auto accident 15 years ago. Strong
said that having her capuchin, Henri or Henrietta, has completely
changed her life. A simple thing like getting a meal could be
delayed hours if an attendant arrived late. For Strong, the
mouthstick is the primary tool for dialing a telephone, turning
pages and just about everything. When Strong drops it, she
quietly says, ``Mouth, Henri. Mouth!'' The capuchin searches
until it finds the tool and gently returns it to Strong's mouth.
The monkeys are rewarded after each completed task with a bit of
fruit juice.
When Henri is dispatched to the kitchen for a sandwich, she
returns and positions it in the holder to the feeding tray. When
she takes a small bite for herself, she instantly realizes she
has screwed up and clambers to her cage almost before her master
gives the command. When Strong says disapprovingly, ``Door,
Henri,'' the capuchin yanks the cage door closed, and anxiously
looks out, awaiting her reprieve.
Strong gives in, ``Oh, all right.'' The capuchin is liberated.
Then Henri settles at her mistress's ankles, craning her neck to
gaze up at Strong, the very picture of contrition. Strong,
laughing, says, ``Look at that, will you. A face only a mother
could love.''
Another innovative approach, the Eyegaze System, is the opening
of a whole new world for patients in recovery from coma. For
individuals with good control of at least one eye, Eyegaze allows
severely disabled individuals to do with their eyes what most of
us do with our hands. Simply by looking at control keys displayed
on a computer monitor screen, the user can perform a broad
variety of functions including speech synthesis, environmental
control, like turning on lights, appliances and televisions,
playing games, typing, as well as operating a telephone. It is
also an invaluable diagnostic tool for those who are both
physically impaired and nonverbal.
The Eyegaze System, produced by LC Technologies, Inc. in Fairfax,
Virginia, consists of monitors, cameras, computer, and control
devices, all designed for table-top mounting. When the user sits
before the monitor, a video camera located below the Control
Monitor observes one of the user's eyes. A low-powered infrared
light mounted in the center of the camera lens illuminates the
eye and provides a bright image of the pupil and a bright spot
reflecting off the cornea. The image of the eye is displayed on a
second monitor called the Eye Monitor.
Sophisticated image-processing software continually computes
where on the Control Monitor screen the user is looking. The
system predicts the gaze point with an accuracy of better than a
quarter of an inch. As a form of feedback to the user, the
Eyegaze System displays a cursor on the screen at the user's gaze
point. To ``press'' a key, the user simply looks at the key for a
specified time called the ``gaze duration,'' the key flashes to
give him feedback that he has pressed it. The gaze duration can
be adjusted to the speed of the user, but the typical gaze
duration time ranges between two-thirds and one-quarter of a
second.
>From New Federalist V5, #20.
John Covici
covici@ccs.covici.com