ARTICLE IN BRIEF
In response to a report in the lay press about a “miracle recovery” from coma, neurologists who deal with coma and neurocritical care urge caution in addressing the inevitable queries that such reports, often inaccurate, will come from patients.
Neurologists received holiday news reports of a coma patient whose awakening was trumpeted as a “miracle” with mixed emotions.
The story, as reported by ABC News and other national media outlets, claimed that Sam Schmid, an Arizona college student who was critically wounded in an Oct. 19 five-car accident in Tucson — and “believed to be brain dead and poised to be an organ donor — miraculously recovered just hours before doctors were considering taking him off life support.
“The 21-year-old's brain injuries were so severe,” the report continued, “that the local hospital could not treat him. He was airlifted to the Barrow Neurological Institute at St. Joseph's Medical Center in Phoenix, where specialists performed surgery for a life-threatening aneurysm.
“As hospital officials began palliative care and broached the subject of organ donation with his family, Schmid began to respond, holding up two fingers on command. Today, he is walking with the aid of a walker, and his speech, although slow, has improved.”
Some criticized the exaggerated, even distorted picture conjured by the pre-Christmas news stories, noting that the 21-year-old Arizona patient had never been diagnosed to be in as dire a situation as headlines suggested.
“That is sensational, shoddy journalism,” said Edward Manno, MD, head of neurological intensive care at the Cleveland Clinic. “There's a huge disconnect between the patient's presentation and what's written in the article.”
On the other hand, some neurologists said the patient's recovery, news coverage aside, underscored the legitimate progress being made in the care and treatment of people with seemingly devastating traumatic brain injuries, intracranial hemorrhages, aneurysms, and anoxic brain injury.
“The amazing thing is that it is not an entirely uncommon event nowadays,” said Romergryko “Romer” Geocadin, MD, associate professor of neurology, anesthesiology and neurocritical care at Johns Hopkins University. “There's been an increasing realization that patients once thought of as hopeless can actually recover some function. I've seen patients who by initial assessments appeared to have lost all clinical brain function that with careful re-evaluation showed viability, and with aggressive management, regained some meaningful recovery.”
THE FACTS OF THE CASE
The headline from ABC News, published online on Dec. 22, stated: “Poised to Donate Organs, 21-Year-Old Emerges From Coma.” [See http://abcn.ws/A8U1NG.]
In fact, as the text of the report made clear, the patient, Schmid, was never “readied” by the hospital for organ donation. Nor was the subject even broached with his family by hospital personnel.
Although the young man had been unresponsive since being injured in the car crash, he had never shown signs of the kind of massive stroke or blood clot that might have spelled a grim prognosis, according to a news conference held by Robert Spetzler, MD, chief of neurosurgery at Barrow Neurological Institute in Phoenix.
“There was plenty wrong — he had a hemorrhage, an aneurysm and a stroke from the part of the aneurysm,” Dr. Spetzler said. “But he didn't have a blood clot in the most vital part of his brain, which we know he can't recover from. And he didn't have a massive stroke that would predict no chance of a useful existence.”
After Dr. Spetzler ordered an updated MRI more than a month after Schmid's initial injury, the young man finally began to awaken, and by the week before Christmas, he was able to walk unaided into the news conference, where he was able to speak clearly.
RESPONSE TO PATIENT QUERIES
“It wasn't entirely clear from the news reports what was going on with this patient,” said James L. Bernat, MD, a neurologist and medical ethicist who specializes in the treatment of coma and vegetative states at Dartmouth-Hitchcock Medical Center in New Hampshire. Dr. Bernat also serves on the editorial advisory board of Neurology Today.
In response to a family member of a coma patient who asked him about the case, he said, “I told them I don't know what happened and there's no way to know from the published accounts. Obviously the public appetite for these kinds of stories is insatiable. One thing I advocate to neurologists is to be cautious, be conservative, and don't claim knowledge you don't have.”
Even when the impetus is a distorted news report, neurologists should welcome such inquiries from family members, said Kevin N. Sheth, MD, assistant professor in the division of neurocritical care and stroke at the University of Maryland School of Medicine, who also serves on the editorial advisory board of Neurology Today.
“Families rightly ask about these news reports,” he said. “We have to deal with it. People ask about some rock star who came out of a coma — we get these kinds of questions all the time. Embedded in these questions is something that is very important and a challenge to our prognostic certainty. This challenge is critical in order to take care of the patient in front of you. It also forces you to re-examine your hypotheses over and over again.”
When having conversations engendered by such news stories, he said, “I try to invoke a sense of humility. Even in cases where the prognosis looks incredibly poor, I tell them that ultimately I cannot know with certainty what the outcome will be. Having that kind of humility shows a vulnerability which allows family members to trust you.”
Dr. Geocadin said the optimal care in the days and weeks immediately following a neurological injury maximize the changes for significant recovery. He laid particular emphasis on advances in critical care and in the growing use of therapeutic hypothermia and hypertonic saline solutions as treatments that can make a difference.
While reports of miracle recoveries will likely continue to irk and perplex physicians, the lay public appears to have grown somewhat inured to them, Dr. Manno said. “People are more sophisticated now about the vegetative state than they were even five or ten years ago,” he said. “For the most part, they understand today that brain dead is dead. We still run into occasions where people say, ‘He's a fighter,’ or ‘What do you mean the patient is dead, he looks alive.’ I still get those questions, but I get less of them than I did 10 or 15 years ago.”
As important as discussing the possibility of recovery from a severe brain injury, said Dr. Sheth, is having a conversation about the unavoidable challenges such a recovery would demand of patient and family alike.
“Irrespective of what people think the eventual outcome will be,” he said, “I always tell them to consider the road they will travel between now and the finish line they may have in their mind — the journey they and their loved ones will have to travel to get there.”©2012 American Academy of Neurology
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