A Flicker of Consciousness (Review)

http://www.time.com/time/magazine/article/0,9171,2099727,00.html

A healthy 45 y. man falls from a 3 foot stepladder striking his head, spends some time in a hospital unresponsive, ultimately progresses to unresponsive wakefulness (“persistent Vegetative State”), and is transferred to a skilled nursing facility. The family told not to expect much for the rest of his life, such as it is.  Then after a while, the persistent family gets a second opinion from a group in Belgium specializing in “coma”, and it’s found that the patient exhibits some sympatico with his wife. Emotional responses on command, and interestingly, following his reflection in a mirror (nothing else).

Somewhere Pete Townshend is smiling.

“You don’t answer my call
With even a nod or a twitch
But you gaze at your own reflection!
You don’t seem to see me
But I think you can see yourself.
How can the mirror affect you?”

From “Tommy” (1969)

Nobel laureate Francis Crick took a reductionist view of consciousness, postulating that the ghost in the machine is simply grounded in brain tissue somewhere and when that tissue is damaged, the effect on consciousness disappears commensurately.  Hawking likens the brain to a computer. When the power switch is flicked off, the screen goes black. Mike Darwin says the essence of personality can be cryopreserved and retreived at a much later date.

But the diagnosis of Persistent vegetative State (PVS) seems to be expanding as relatives continue the search for understanding this difficult diagnosis. “Time” says that as many as 40% of patients previously diagnoses as PVS may actually have more interaction of their environment than previously thought, including some understanding of commands but inability to interact with them in traditional manners.

Of particular interest is the occasional patient that improves their alertness following the administration of zolpidem (Ambien), a popular sleeping medication. Ambien is a very effective  omega 1 specific indirect GABA agonist that has been reported to show some effect, but never for long periods and never promoting a regain of functional consciousness. Other studies show no effect.  My personal opinion FWIW is that zolpidem may suppress sub-clinical seizures in some brain injured patients. Just to see what might happen, we have occasionally given an occasional PVS patient that crosses our border a dose, and we’ve never noticed any change at all.

Of course, “Time” then hastens to add that after much study, the subject of this discussion has shown no further improvement and is unlikely to do so.  So their rhetorical question is “have we opened up a big mess identifying an marginal expansion of consciousness that doesn’t mean anything as a practical matter. None of these patients will ever be self sufficient again. What has it gained them or their families that we think they now have some form of nonfunctional cognition?”

Of course, this invariably means that families of all PVS patients will develop a strong interest in having their patients evaluated by lots of expensive tests to see if they might be better than thought, then requesting lots of long term expensive rehabilitation therapy in the hope that in time the patient might have some communicative ability.

This dovetails with the current thrust of neurologists that we are writing off some extensively damaged patients too soon, and if we continue to be aggressive with them longer, we might convert some outright deaths to skilled nursing home admissions.

As I sit here, a Hunt & Hess Grade V patient resides in the NICU, intubated and unresponsive except for a flicker for a week. NS told the family they “might get better in time” if aggressive care was continued. Then the social worker is left to drop the bad news that they have no resources for any of that rehabilitation, and if the patient lands in a skilled nursing facility, they will not even get much basic medical care, much less rehab care and the State will take all the family’s resources to finance it.

My question is and continues to be, who will be willing to pay for this enhanced care of non-functional patients in an economy, and I mean a GLOBAL economy that is quickly circling the drain. As I sit here, reimbursement to reverse active disease processes in potentially viable patients is dwindling and promises to continue.  The issue is not the continuance of aggressive care on the off chance that an unexpected outlier might appear.  the issue is is open ended optimism that in order to select out one true miracle, 99 unfortunates will be condemned to life-in-death of a skilled nursing facility, and who is going to pay for that. Where is the balance?

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s