By JUDY SIEGEL-ITZKOVICHWhen can we expect Prime Minister Sharon to wake up from his coma?
No one can say. It could take days, weeks or even months, or he might never wake up. As time passes from the time when his anesthesia drugs were set very low to allow him to regain consciousness (if he can), the less likely it is that he will wake up. But it is possible that he could open his eyes and begin to react to his surroundings; there have been such cases before. If he does not, damage to his upper brain was so extensive that it does not allow him to regain consciousness, even though his lower brain - which controls breathing, heartbeat and other autonomic functions - appears undamaged, as he is largely breathing on his own and his pulse is normal.
There is no way doctors can "wake up" an unconscious patient whose anesthesia drugs have been minimized. After weeks in a coma, even though a patient reacts reflexively to pain stimulation, doctors could declare a patient hopelessly brain damaged. Mercifully, such patients are not aware and thus do not suffer.
Was the planned catheterization to repair the foramen ovale (little hole between his atria) truly necessary? If so, should it have been planned to be carried out earlier?
Some cardiologists, mainly those who do not have access to Sharon's medical records, argue that it was not certain that his initial stroke - caused by a blood clot in the brain - was due to the little hole in his heart. They argue that the catheterization was not urgent and could have waited, and that he would probably be awake and functioning today if the catheterization had not been planned, if he had not been given powerful anti-coagulants and he had not been so anxious about having to be put under a general anesthetic for the procedure.
Did Hadassah doctors provide Sharon with "too much treatment" in the form of anticoagulant drugs after his first - mild, ischemic - stroke?
Hadassah has official denied such claims, saying that the decision to prescribe twice-daily injections of Clexane, the low-molecular-weight heparin that thins the blood, was taken by a consensus of Hadassah physicians of the various specialties and that it was needed to prevent a recurrent and much more devastating ischemic stroke than that caused by the initial blood clot.
Yet neurologists outside Hadassah, including in various countries around the world who have joined the debate, argued that giving him aspirin and Plavix would have been enough and that the risk of brain hemorrhage posed by Clexane was five percent but too risky for a man of Sharon's age, weight and habits. (One of the neurosurgeons who performed three operations to stop the bleeding in his brain was reportedly not consulted about giving him Clexane after his first stroke and was very upset to learn about it after the fact.)
These critics argue that if Clexane had to be prescribed, it should have been with him under observation in the hospital and while preventing him from resuming his regular hectic routine as prime minister. This subject will certainly become a case study in Israeli medical schools in the future.
Could Sharon's situation have been better if he had been treated at Soroka University Medical Center in Beersheba - not far from his Sycamore Ranch where he felt unwell after his brain hemorrhage - instead of having to wait half an hour for his personal physician to arrive and to be taken by ambulance to Jerusalem?
The faster a stroke patient arrives in hospital, the better. Some neurologists argue that if he had arrived immediately at Soroka, coagulants could have been given to reduce the hemorrhaging in his brain that caused severe damage to his right hemisphere. Others argue that it wouldn't have made much of a difference, and that it was better to have him taken care of by doctors at Hadassah who had already examined and treated him and had full knowledge of his medical file.
Prof. Felix Umansky, one of Sharon's neurosurgeons at Hadassah, conceded that Sharon suffered from cerebral amyloid angiopathy (CAA) a disorder in which protein fibers infiltrate the blood vessels in the brain and make them fragile and at risk of hemorrhaging. If so, why was he given anti-coagulant drugs that could increase the risk of a hemorrhagic stroke?
CAA can not be diagnosed for certain in a living person, but only after death, in an autopsy. Signs of possible CAA can be noted in an MRI scan that shows microbleeds in the brain, but this could result from trauma, like a fall in the bathtub, earlier in the patient's life. Hadassah doctors may have not noticed microbleeds in his brain, if he indeed had them. But the diagnosis could have become more likely after Sharon's neurosurgery after his second stroke, as amyloid could have been detected and removed as samples during the three brain operations at Hadassah. If doctors knew of CAA, most experts declare he should not have been given Clexane.
Is Sharon's life still in danger?
The prime minister remains in serious condition, but he is stable. His doctors have worked hard to keep his vital signs stable, and indeed the drainage tube has been removed from his head because no more hemorrhages or swelling were seen in his last CT scan. But someone in a coma, especially at his age, could develop complications such as infections from bedsores or from pathogens in the hospital.