The delicate job of waking the prime minister

Q & A with Dr. Ofer Keren, a veteran expert in brain rehabilitation at Jerusalem's Alyn Hospital.

heart monitor 88 (photo credit: )
heart monitor 88
(photo credit: )
How does one determine whether a person remains unconscious because of the anesthesia drugs he received to keep him in an induced coma or whether it is due to any neurological or cognitive damage in the brain? A patient who is unconscious in such a situation is under the influence of anesthesia drugs. Only when they are completely eliminated from the brain and the patient does not regain consciousness can one blame something else - either damage to brain tissue, metabolic reasons or others. Brain tissue is fatty, thus it holds chemicals in the cells for a longer time than other cells, and it takes more time for the brain to be free of them. If a patient in a deep coma doesn't wake up, even after the brain is free of anesthesia drugs, can anything be done to trigger a return to consciousness? There is no drug or electrical stimulation that can do this. A patient may be physically unable to open his eyes because of paralysis, but usually they open spontaneously if brain damage does not prevent this. The medical staff can open the patient's eyelids for him, but they may show lack of communication with the environment if there is serious brain damage. What about music, sounds, relatives talking to him or the odor of favorite foods? There has been anecdotal evidence that people awake from a coma because of stimulation by loved ones or familiar things, but we don't have proof. There is some evidence that voices of relatives or hearing a familiar piece of music causes blood pressure to increase and other positive physiological signs, but that does not mean they trigger consciousness. This does not mean a patient will not regain consciousness without stimulation. It doesn't cause any harm, and the relatives probably get some relief because they feel they are doing something. In the past, it was thought that the patient had best be kept in complete silence. Then active stimulation was recommended. Today, we believe in a middle path. Too much noise can create overstimulation and cause the brain to block out the disruption. When should a coma patient be breathing completely on his own? When the anesthesia drugs wear off and the brain stem has not been damaged, gradually the patient begins to take the chore of breathing over from modern interactive respirators. The pace and depth of the patient's breathing are constantly checked to see if they are steady and the patient can manage on his own. When would hospital staffers feel they could do nothing more for a stroke patient? Is it better for him to get out of a general hospital, with its dangers of infections, and be moved to a rehabilitation facility? When the patient's vital signs are steady and when there is no more danger of infections, bleeding or complications, the patient should be moved to a rehabilitation facility even if he has not regained consciousness - and the sooner the better. When can one say whether a coma patient's cognition is OK or damaged? What tests are done? Is the wake-up sudden or gradual? Will the patient react with emotion? Neurological tests are conducted to check brain wave patterns. But the best way to know, if he has regained consciousness, is to speak to him, test his ability to hear, see, smell odors and respond to simple requests. The restoration of consciousness is almost always gradual, except in a case in which the patient had a concussion from being hit in the head by a ball, for example; in such a case, the patient often wakes up suddenly. But this is not so after brain surgery. The person who wakes up in a strange place, with unfamiliar things and people around him, can experience fear. But damage to parts of the brain can affect the emotional centers and produce a different reaction. When should a patient be put in a vertical position? This should be done as fast as medically possible, even before a person regains consciousness. There are special beds that rotate to hold the patient in a vertical position. This helps reduce the risk of bedsores. Do movements of arms and legs in response to pain stimuli mean that the comatose patient will not be paralyzed in those limbs? No, one can move reflexively, but not intentionally and consciously. Reflexes, however, are a good sign. There has been publicity for electric-stimulation devices that supposedly get paralyzed limbs to move. Is there anything to these claims? Claims for these devices are very exaggerated. The technique was developed for people with partial spinal injuries, and then they were applied to stroke and head injury patients. But the devices did not restore movement except in people with minimal damage and those who suffer from spasticity. Electrical stimulation may improve muscle tone, so there is less spasticity and then intentional movement can improve. Dr. Ofer Keren, a veteran expert in brain rehabilitation at Jerusalem's Alyn Hospital and previously at the Beit Loewenstein Rehabilitation Hospital in Ra'anana, assisted in the preparation of this article.