JOURNAL OF THE NATIONAL ACADEMY FOR CHILD DEVELOPMENT
1982, Volume 2, No. 1
Coma
Robert J. Doman, M.D.
Coma: A State of Profound Unconsciousness
Might it be possible to arouse a person
from deep coma? The Medical World has historically answered
with a loud "NO" to that question. During a lecture
on Neurological Disorders, a student nurse asked me a question
which sparked a small ray of hope in my mind. Perhaps it might
be possible to bring a person out of a deep coma. She asked
"If a patient is asleep during patterning, is it helping
him during that time?" My answer was that since the proprioceptive
and other sensory messages which patterning was sending to
the brain were going into the brain stem and other areas of
the brain below the cortex (the thinking portion of the brain),
the brain did not have to be awake to benefit from the stimulation.
During the remainder of the class this
idea so excited me that I ignored the rest of my lecture and
began to talk about consciousness and unconsciousness. It
had occurred to me that physicians tended to be vague about
unconsciousness and coma. I had seen medical charts of comatose
patients where the doctor's progress notes bore the disturbing
evidence of lack of practical knowledge as to the nature of
brain physiology and brain dysfunction following profound
brain injury. I have seen the following progress note in the
chart of a comatose patient: "Today the patient's eyes
opened for the first time; perhaps he is "semiconscious?"
When I read that note proposing that the patient might be
half-conscious l wanted to ask the doctor who wrote the note,
"Which half was conscious?"
I became convinced that, during the
coma, the patient's brain was receiving little or no information
or stimulation through the only pathways to the brain the
five senses (vision, hearing, touch, taste, and smell). I
thought back to the many comatose patients I had seen up to
that point in my medical career. I became a physician in 1946
and this lecture took place in the late 1950's. In the ten
years or so that I was stationed at Walter Reed Hospital and
in my practice as a specialist in the relatively new field
of Physical Medicine and Rehabilitation, I had many experiences
with and concerning the comatose patient. At that time I was
Medical Director of The Rehabilitation Center at Philadelphia,
where the lecture was taking place, and Assistant Chief of
the Physical Medicine Department of the Regional Office of
the Veterans Administration in Philadelphia. I was Chief of
Rehabilitation at two hospitals and Founder and Medical Director
of United Cerebral Palsy of Delaware County, Pennsylvania.
I thought of the care being provided
to the comatose patients we had seen and asked myself "How
much was being done to stimulate the injured brain of each
of the unconscious patients." The answer was the same
in every case Not Enough!
As you enter a hospital you might see
near the front entrance a poster showing a pretty nurse with
her fingers in front of her lips and the words " . .
. Quiet, hospital" imploring us to be quiet while in
the hospital with patients. Now if you've ever been a patient
in the hospital yourself, you know that in general hospitals
are not very quiet places. Except sometimes during the night
they do make an attempt to keep the hospital relatively quiet.
After the comatose patient has been discharged from the intensive
care unit and put in another part of the hospital, it's been
my experience that he is frequently placed in a relatively
quiet part of the hospital. Not because the hospital administration
is afraid other patients might bother the coma patients, but
because they think the coma patient might start to rouse up
and make some noises that would bother the rest of the patients.
It is interesting to note how we would react to that situation,
and how the world in general reacts to that situation. If
a patient in coma started to make sounds of any sort, we would
be excited and encouraged and want to do all we could to get
more sounds from the patient. On the other hand the world
tends to take the opposite attitude and become concerned about
the noise from the comatose patient and, in order to quiet
him, might even give him sedatives.
As you enter the room of the comatose patient you might notice
that the patient is probably in a position known as "de-cerebrate"
rigidity. That is to say, his arms are bent at the elbow and
his hands and fists are clenched against his chest. His legs
are rigid and tight and sometimes scissoring because of spasticity,
and the patient, being in a coma, is unable to move from this
position. Since he is unable to move, should his eyes open,
what might he be able to see? Well if he is on his back, the
only thing he could see would be the ceiling in his room.
I've seen ceilings in many hospitals all over the world, and
I know that after you look at one for about five minutes it's
not very stimulating or interesting. Some coma patients, in
order to prevent bedsores, are placed in "strykker frames"
and part of the time they are turned from their back to a
face down position. In that position all the comatose patient
might be able to see, should his eyes open, would be the floor.
In general, I've found hospital floors to be even less interesting
or stimulating than hospital ceilings. In fact, the only time
a hospital floor might be stimulating or interesting would
be if there was something moving down there. Unfortunately,
that's generally not the case.
A comatose patient receives relatively
little stimulation in his hospital environment, but we must
not assume that they receive no stimulation. Indeed, most
comatose patients must receive extraordinary care in the form
of respirators, monitors, intravenous feedings, etc. And so
it seems that, with the comatose patient, doctors tend to
stick a tube into the patient every place that one could put
a tube in an unconscious patient. That is to say, in addition
to the intravenous feeding tubes, the comatose patient frequently
has a catheter passing through his nose down into his stomach
for feeding purposes, and if that becomes too difficult a
way for feeding a patient, they remove it and put a tube directly
through the abdomen into the stomach, known as a gastrostomy
tube. In addition, the patient in coma frequently has a urinary
tube to drain his urine. So the simple care of all of the
patient's needs in the hospital, in terms of tending to his
tubes, does provide some stimulation to the patient's body
and, therefore, to his brain. In addition to caring for his
tubes and feeding, the patient is frequently turned and bathed
during the course of his hospital day. Physical therapy, if
provided, tends to be very minimal and usually consists only
of moving the patient's joints through their range of motion,
a treatment meant to prevent tightness in the joints. However,
in many instances because of the tremendous spasticity and
rigidity produced by the injured brain, such physical therapy
is relatively useless in preventing the joints from becoming
tight. In my experience, the stimulation derived from such
care is not enough to bring a comatose patient out of deep
coma. Indeed, it occurred to me during this lecture that maybe
we should be taking more steps in our efforts to arouse the
comatose patient. In fact, the possibility occurred to me
of using a patterning at some stage with the comatose patient
a thought which up to this point has not occurred to any of
us who had developed the idea of patterning as a treatment
of the brain injured.
It was not many months after that lecture
that the opportunity presented itself to me. The first patient
to my knowledge to ever receive an organized program of stimulation
of this type was a child that I saw in a hospital in Chester,
Pennsylvania where I was Chief of Rehabilitation. This child
had been struck by a truck nine weeks prior to this time.
He was still in a coma and had not, in the entire nine weeks,
made a sound or moved his body. Indeed, it was the opinion
of the neurosurgeon that the child was "lucky" to
still be alive. It's interesting now as I think back on that
boy, that my world of rehabilitation, and the medical world
in general, held such little hope of any possible recovery
for such patients that the patient in coma was frequently
referred to by physicians as a "vegetable." That
is to say, an individual who wasn't living and acting in his
environment but instead was only existing in a vegetable-like
state. As you might imagine, I abhorred the term "vegetable"
being applied to a brain injured person. It was later that
I realized that in some of the other English speaking countries
physicians have a term that is even worse than "vegetable"
that they use to describe the unconscious patient. In England
such patients are frequently referred to as "cabbages."
Well, this little boy hit by a truck
was certainly not a cabbage. He was in a deep coma, so I was
called upon to see this child on consultation. I can recall
the reaction of the pediatric nurse, who assisted me during
my examination of that child, when I attempted to use various
forms of stimulation to see if I could produce any reaction
in this unconscious boy. The usual methods of stimulation
of a comatose patient simply did not produce any response
in that child. Hard pressure above the eyebrow at the orbit
of the eye, which occasionally brings a response from a person
in late coma, brought absolutely no response from this child.
Other pressures with my hand and thumb, and the usual stimulation
of the foot with a testing needle, likewise brought no response.
As I tried these various means of arousing the child I could
see the nurse becoming more and more upset at me, perhaps
feeling that I was picking on this helpless, nearly naked
child who lay before me in a state of deep coma. Noticing
her anxiety, I sent her out of the room in order to bring
me some ice. However she was even more horrified when I put
the ice on the bare abdomen of this child. She gave a gasp
of surprise and so did the child! Not only did the child give
forth a sound, but he gave forth his first movement in the
nine week period since he had been hit by a truck. When this
happened the pediatric nurse suddenly realized the purpose
of all of the strange things I had been doing to this helpless
child. When I instituted a program to stimulate this child,
this nurse became one of the best nurses in pediatrics with
following through on the program. When she realized the purpose
of what I was trying to do, she was indeed very helpful and
cooperative.
I began a program for this child that
attempted to stimulate him through his five senses, stimulating
the unconscious brain with the hope of raising the brain's
level of consciousness. So instead of following the advice
of the hospital poster to be quiet, I had the family bring
in a transistor radio with an earplug. My order was to stimulate
that child's brain by playing that radio « hour out
of every two hours, around the clock. In addition to the stimulation
of the radio, I had my physical therapist, nurses, and staff
members talk to this unconscious child every chance they had
even though he was unable to respond.
We also began to stimulate the child's
brain through the pathway of vision. We used flashlights,
pictures, toys, and other objects to do this periodically
throughout the day. We had the family bring in the blinking
type of Christmas tree lights, which we strung around the
curtain holders of the bed to give the child's eyes something
to see.
We stimulated his brain through the
sense of touch in virtually every way you might think of,
plus some ways you wouldn't think of. For example, we tickled
him, rubbed and massaged him, we used heat and cold on his
body, we pinched him and slapped him, pouring into his subconscious
brain stimulation through his sense of touch.
His senses of taste and smell were stimulated through various
odors placed under his nose and tastes placed on his tongue.
As we did this day after day, we were delighted to see more
and more response from this child.
At first he seemed annoyed and on many occasions seemed to
resist our efforts to stimulate him. But eventually, with
his eyes opened, we became aware that he was following us
and objects with his eyes. Soon he was moving his arms and
legs and reaching for objects! Before long, we were able to
remove his nasal tube for feeding and began feeding him by
mouth. In the course of time, we were able to get him moving
and the child gained full consciousness. When he finally left
the hospital some months later, the child was able to walk
and talk thanks to a very intensive program of rehabilitation.
His walking and talking were not completely normal, his balance
was not as good as it might be, and he would occasionally
fall. His voice was effective in that he could speak in short
sentences, but sometimes his sentences were not complete.
There was an interesting nasality in his voice. Over the years,
we've come to know these types of residuals to be rather common
in brain injured patients, particularly when the brain stem
has been injured. We have since developed some techniques
to minimize these complications of the brain stem injury.
This child was my first patient who
was subject to a program of intensive sensory stimulation
while in coma and who, to my amazement and delight, responded
and became conscious. Since that time, I have had the good
fortune to have been able to rehabilitate hundreds of comatose
patients throughout the world in our various clinics. To my
knowledge, I believe I have rehabilitated more comatose patients
than anyone in the world.
Coma patients tend to respond to programs
of stimulation differently. Indeed, not every patient who
is in a coma responds to a program of stimulation to a point
of recovery. There are various degrees of improvement in coma
patients: from those patients whose recovery is complete,
to the point that they can in fact, return to school, find
work, marry and have families, and live what I would consider
a normal life, to those patients who respond very little and
never totally come out of their comatose state to the point
of being able to communicate.
Since that first comatose patient,
over twenty years ago, we have been able to refine our treatment
techniques to a great degree. We've learned a great deal about
the coma patient and his response to his environment. We are
now aware of the fact that, in many instances, the coma patient
has not had too little stimulation reaching his brain through
one or another of his five senses. We now believe, that in
many instances (in some senses at least), the brain may be
receiving from one or more of the senses, too much stimulation
while the patient is in a state of coma, and the brain is
unable to integrate this information being received through
the senses with all of the other information coming into the
brain. Therefore, unless proper measures are taken in the
treatment of such a patient, his progress may be delayed until
the right techniques are used to overcome this aspect of the
problem. As you proceed with the stimulation program on a
comatose patient and when the program is starting to become
effective, you frequently become aware of the fact that the
patient is able to take in a great deal of information, and
is becoming far more alert and aware of what's happening to
himself and around him. Yet, on the other hand, he may be
having great difficulty trying to express what he wants to
say, and communicate. With persistence of a good program of
neurological organization, combined with stimulation, speech
can in fact, return. Mobility tends to be slow and difficult.
But in many instances, mobility does return to the point of
the patient being able to walk, and even in some instances,
to run.
There are many causes of coma. The
most frequently seen is coma due to trauma or injury to the
brain as the result of an automobile accident, a fall, or
a blow on the head. In addition to trauma, we see brain injury
of a severe nature such as occurs with near-drowning. In this
instance, the brain is injured as the result of lack of sufficient
oxygen. We have seen and treated many near drowning coma patients.
There are other causes of coma, including coma which results
from severe, uncontrolled diabetes. Other causes may include
hepatic (or liver) coma, as well as uremic (or kidney) coma.
Coma may occur as a result of an infection of the brain such
as encephalitis, or such problems as brain tumors. Coma may
result from increased pressure on the brain, as is seen with
severe hydrocephalus. Fortunately, for patients with hydrocephalus,
surgical procedures to relieve the pressure through shunting
operations are often helpful.
Unfortunately, the medical world in
general is still unaware of the fact that, in many instances,
coma can be successfully treated through a program of stimulation.
So there are still patients throughout the world suffering
from coma, who eventually die without help. It is sad to think
that many such patients die without anyone ever trying to
stimulate the brain. On the other hand, it is encouraging
to realize that we are seeing more and more patients in coma
whom we have been able to help.
Our program at NACD incorporates the
advances that we've been able to develop in the last twenty
years of treating comatose patients. We look forward in the
future, through research, to developing additional techniques
that may be of value in dealing with the difficult and challenging
problem of coma.
Reprinted from the Journal
of the National
Academy for Child Development
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