Presented by David Crippen.
After 7.5 years in coma after being shot in the head by a crook, a Chattanooga, Tenn policeman awoke and spoke to his sister. The family had never given up hope, demanding aggressive care even after grim prognoses by his doctors. They insisted that he be kept alive even though he met all the criteria for persistent vegetative state. He was placed in a nursing home on a ventilator and gastric feeding tube and was ultimately weaned off mechanical ventilation. After 7.5 years he developed pneumonia at the nursing home and was transferred to a hospital ICU for antibiotic therapy. After a short period of 104 degree fever, he was seen to suddenly wake up and hold a conversation with his sister in which he "asked questions and cracked jokes". He had no recollection of current events but seemed to be coherent in his conversation. Doctors were surprised and called it a "miracle." They then hastened to add that he requires some sort of unspecified surgery and that the anesthetic may deteriorate his newly enhanced mental improvement.
"This is one of the biggest blessings that has ever happened to me" he said. The family was happy that they "never surrendered hope".
What do you think of this?
Bernie Hansen:
NPR aired an interview with a (Cornell?) neurologist who had spoken with this fellow's primary. Based on the information given to him, the neurologist was quite adamant that the officer had NOT been in a coma - for example he had been able all along to respond to questions by blinking once/twice for yes/no. However, he did not know what it was about the officer's pneumonia (which is apparently life-threatening), febrile response, or therapy that "energized" him to a level that allowed him to speak and perhaps improve cognitive function. The patient apparently has no memory of the past 7 years.
Tom Holian:
Two weeks ago, I was watching the movie "Hard to Kill" where a police officer was in a persistant vegetative state for 7 years, and suddenly woke up, then proceded to get all the bad guys. I was thinking, no way this could happen in real life. This isn't quite the same, but close enough for me to say, "WOW."
The only problem is that this certainly is a RARE event, but the press isn't portraying it that way. Now I fear families moving toward unrealistic goals, because, for example; "we heard of a guy who woke up and was completely normal, so we want everything done for Johnny Doe." I hope this patient does have significant recovery, but I also hope that this doesn't change families expectations of patients with persistant vegetative state.
David Brock:
The neurologist on NPR was JJ Caronna, head of Neurocritical care at Cornell Med (NY,NY,USA) and author of numerous articles on coma, brain death, etc. His most widely qouted article is: Levy DE, Caronna JJ, et.al. Predicting outcome from hypoxic-ischemic coma. JAMA 1985;253:1420-26.
Don Chalfin:
IMHO, people (specifically families) fear the possibility of lingering indefinitely before death along wikth patient abandonment. In such cases, I usually tell them that this are exceptions, not rules, and that is why they are reported in the press or at least the tabloids. Almost always works, especially when there is continued MD presence and continued availability for questions and concerns. Agree, however, that the reporting of this case will engender more suspicion.
Tim Buchman:
Dr. Crippen and other colleagues discussing the case have pointed out three features of this case which bear thoughtful analysis.
None of the above is terribly surprising. First, rare events do happen. That's why we shy away from absolutes when talking about prognoses. Second, we don't know everything. That's one of the reasons that we like our jobs--we have the opportunity to learn new things. Third, the media can reasonably be expected to report what is necessary to gain advertising revenue so long as what is reported is accurate and truthful. I would expect that made-for-TV-movie people are already bidding for the rights to film this story.
We as intensivists will face new challenges in educating our patients' families about the exceptional nature of this case. It would be a service to all members of the group if colleagues would share their experiences and strategies as families bring this particular case up as an argument for persisting with seemingly futile care.
My greatest concern is that we (collectively) may be asked to divert limited resources to support patients who have no reasonable hope for recovery, particularly when the patient has sustained a neurologic injury in the hospital. Again, shared strategies would be a great service to all members of the group.
It also might be helpful if, after the facts are in, the Society of Critical Care Medicine or, perhaps, the Foundation for Critical Care, could begin to grapple more specifically with this notion of "futility". For this policeman and his family, it can hardly be argued that care was futile. I am happy for him and his family. But I am deeply concerned about the implications for legions of patients for who there appears to be no reasonable of improvement --and for those who supply the resources to pay for their care.
David Crippen:
The media frequently chooses to portray newsworthy figures in a light favorable to selling newspapers or periodicals. Recall from The Bonfire of the Vanities (Tom Wolfe)....it was necessary to portray Henry as a tragic figure cut down in the prime of his fertile life by an uncaring aristocrat instead of the dirtball he was. Toward that end, the media looked for ways to make him look better.
Henry's teacher persisted in painting a picture of Henry and his peers as vicious punks. Finally the interviewer, trying to find something positive about the school asked the teacher if there was ANY redeeming quality about the student body.
"Anyone that doesn't pee on me is an honor student"
"Did Henry ever pee on you?"
"No...I don't think so.."
"By that standard then, was Henry an honor student?"
Headlines in next day's paper...."Honor student run down by Wall Street Broker".
In this case, the media would have no idea what coma meant, butthey know what sells papers. They heard a small part of the story that they thought might sell papers or generate viewers so they created a new story more amenable to their purposes. If this patient had simply been brain damaged, and had a temporary increase in brain metabolism such that he was able to say a few words....no one would be interested in paying to hear about it. But if he was COMATOSE" and came back cracking jokes and perfectly lucid after 8 years, especially if those damn doctors, who don't know as much as they think they do, said it would never happen.......that sells papers.
There is something very fishy about this story from A to Z. I seriously doubt that this patient was comatose in the same sense that happens after a big subarachnoid bleed or severe anoxic encephalopathy. I also seriously doubt that his mental baseline has come back to normal and that he was anywhere near as lucid as reported. I think he is a creation of a media that created him to generate publicity and sell papers or generate a viewing audience. I also think that the bad by-product of this will be legions of families marching into the ICU with copies of this article under their arms demanding to maintain till the end of time.