My dad went into surgery today. He got a tracheotomy (to help him breathe without the breathing tube) and a “stomach plug” (to feed without the feeding tube). These had been delayed in the hope that he would be “responsive” by today.

He was under some anesthesia for the surgery, and the surgeon prescribed pain killers in case he needs them afterwards. So it may be a bit before we see further progress, just because of the sedation.

I was a bit down after coming into intensive care today. I did not see much difference between 8:30 this morning and 5:00 PM last night. His legs were still restless, so I rested his right foot on my leg. That calmed him. During that time the nurse came in and points out the PVCs (premature ventricular contractions — irregular heart beats) my dad was giving off.

So I was worried. At least the doctor was cutting back on the nitroglycerin — my dad’s blood pressure had been cut from 200/100 to much lower. They wanted to raise the “factor” (the systolic blood pressure) to 160.

Later in the morning, as we went to see him before surgery, we saw encouraging signs. He now kicks, hard, and nearly whacked my mom’s head with his knee on the uptick. My attempt to calm him by placing his foot on my leg were met with two hard kicks to a sensitive region that is vital to my father’s plans to have grandkids someday. Additionally, when we were talking to him, his shoulders lifted up. (Another, bittersweat, sign is that my dad’s arms are in cloth restraints. His arm movement’s disconnect some monitoring equipment. This is a sign of increased strength and activity, but likewise prevents the “arm wrestling” I’ve enjoyed with my dad.)

After seeing him for the second time I came across the Rancho Los Amigos Levels of Cognitive Function. I’d come across this measure while looking up the Glasgow Coma Score, but this improvements of the past few days have happened without change to his GCS number. However, they do indicate a transition (in my opinion) from Level III to Level IV. Below is a summary of the Rancho Los Amigos scale, paying special attention to Level 3 and Level 4:

Level I No response: unresponsive to stimuli
Level II Generalized response: nonspecific, inconsistent, and nonpurposeful reaction to stimuli
Level III Localized response: response directly related to type of stimulus but still inconsistent and delayed

In this level, the response to stimulation is known as decorticate rigidity or flexor posturing in which:

Shoulders adduct, internally rotate, and flex slightly; elbows flex; forearms pronate; and wrists and fingers flex
Lower extremities extend, adduct, and internally rotate
Hip, knee, and ankle may flex in a spinal reflex known as triple flexion

Level IV Confused-agitated: response heightened, severely confused and could be aggressive

The 4th level response to stimulation is withdrawal in which shoulders abduct and there is more rapid movement than in decorticate rigidity

Level V Confused-inappropriate: some response to simple commands, but confusion with more complex commands; high level of distractibility
Level VI Confused-appropriate: response more goal directed, but cues are necessary
Level VII Automatic-appropriate: response robot-like, judgement and problem solving lacking
Level VIII Purposeful-appropriate: response adequate, subtle impairments persist

The “Rancho Los Amigos- Revised,” apparently a restatement of the original scale, gives the following info for III and IV:

Level III – Localized Response: Total Assistance

Demonstrates withdrawal or vocalization to painful stimuli.
Turns toward or away from auditory stimuli.
Blinks when strong light crosses visual field.
Follows moving object passed within visual field.
Responds to discomfort by pulling tubes or restraints.
Responds inconsistently to simple commands.
Responses directly related to type of stimulus.
May respond to some persons (especially family and friends) but not to others.

Level IV – Confused/Agitated: Maximal Assistance

Alert and in heightened state of activity.
Purposeful attempts to remove restraints or tubes or crawl out of bed.
May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another’s request.
Very brief and usually non-purposeful moments of sustained alternatives and divided attention.
Absent short-term memory.
May cry out or scream out of proportion to stimulus even after its removal.
May exhibit aggressive or flight behavior.
Mood may swing from euphoric to hostile with no apparent relationship to environmental events.
Unable to cooperate with treatment efforts.
Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

What gives me hope is that while my dad has not completely met Level III in the Revised scale (1974), raising his shoulders appear to be the abduction of the shoulders part of Level IV in the original (1972) levels.

But ultimately, the “scale” used is less important that the improvement, than the learning, than the new behaviors we are seeing. I would not have thought that I was ever hoping for my dad to be “Confused/Agitated,” but what I’m really hoping for is him to recovery.

I want my dad back. I want him back healthy. I want him back happy.

And I have hope that I will.

Yesterday I mentioned dad’s “horizontal progress” — two days ago he was opening his eyes, and yesterday he was kicking his feet, but he hadn’t opened his eyes and kicked his feet. I wrote that:

my folk wisdom (and hope) is that the these improvements are cumulative.

Well, they are cumulative. He’s opening his eyes and kicking his feet. And his arm-wrestling strength is getting stronger, too.

Another “vertical” sign is that when I came in they had my dad’s bed upright, lazy-boy style. He’s lying on his back again, but my dad is active enough that they want to find a comfortable position. (Earlier the nurse experimented by putting up the bed’s guard rails around his foot, but he kicked through them, nixing that idea.)

They are also giving my dad 2100 calories a day for nutrition. Lady of tdaxp told him that it was a good thing she wasn’t in the hospital — that was more than she eats!

My family talked to the cardiologist today, who like everyone else these days if optimistic but stresses patience. He reminded us that as dad recovers he will be tired. I’ve seen this: after a few rounds of “arm-wrestling” my dad’s muscles relax.

I had a dream last night that I was with him and he was responding to commands. For now that’s a dream, but it’s not so fantastic as it would have been only a few days ago.

“We’re greedy,” I told my father today. “We see one sign of progress, and we want two . We see two and we want four.”

My dad remains in a coma.

In the comments to the previous post I mentioned that my father was holding his arms together and kicking his legs off the bed. Those behaviors repeated many, many times today. (Besides regularly kicking off his blanket, he repeatedly let his leg fall of the bed so many times that the nurse joked that he was teasing my girlfriend, who was immediately placing the leg back on the bed.)

We don’t see the eye openings from yesterday, but my folk wisdom (and hope) is that the these improvements are cumulative.

Another good sign is that when I try to lift up his hands, arm-wrestling style, my dad will typically apply counter-pressure. This normally happens when his heart rate is high (around 90 beats/second) and the exceptions are when his heart-rate is low (around 80 beats/second). So I now have a useful way to distinguish “rest” and “stirring” in my dad’s deep sleep.

A conversation with a doctor and another with a nurse also made me hopeful. The doctor, who I spoke to in the morning, confirmed that my dad’s tracheotomy was delayed until Monday because of the good news. If he starts “responding [to commands]” by then, there will be no need for either the tracheostomy or his breathing tube. However, even if this progress continues it may be two or three weeks until we reach that stage.

Later, at early evening, a nurse mentioned that she had removed my dad’s arterial blood pressure meter. ABP is a very accurate measure of blood pressure because it is not skewed by physical movement as non-invasement measures are. The downside is that the ABP is somewhat dangerous (“blood what shoot to the wall if it came out,” we were helpfully told). The NBP is less accurate, but as Wikipedia describes:

The non-invasive auscultatory (from the Latin for listening) and oscillometric measurements are simpler and quicker, require less expertise in fitting, have no complications, and are less unpleasant and painful for the patient, at the cost of somewhat lower accuracy and small systematic differences in numerical results.

So we take this as a good sign: the hospital is no longer so worried about my father’s health that they have to use a complex, slow, expert, complicated, unpleasant, and painful method of measuring his blood pressure.

Another good sign was something that didn’t happen. During the first few days, and even that period when there was no progress, we were visited by social workers. We aren’t any more. Nor are we told we may have to make “serious decisions” soon.

I think my father is in a moderate coma. Considering what we know, that would be a good thing.

Over the last few days I have been trying to find what information I can. I came across the Glasgow Coma Scale, which divides measures eye response, verbal response, and motor response. Here’s the scale, with where dad seems to be bolded:

Best eye response (E):

4. Eyes opening spontaneously.
3. Eye opening to speech.
2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
1. No eye opening.

Best verbal response (V):
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange).
2. Incomprehensible sounds. (Moaning but no words.)
1. None.

Best motor response (M):

6. Obeys commands. (The patient does simple things as asked.)
5. Localizes to pain. (Purposeful movements towards changing painful stimuli; e.g. hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
4. Withdraws from pain (pulls part of body away when pinched; normal flexion).
3. Flexion in response to pain (decorticate response).
2. Extension to pain (decerebrate response: adduction, internal rotation of shoulder, pronation of forearm).
1. No motor response.

This adds to a score of nine:

Generally, comas are classified as:

* Severe, with GCS ≤ 8
* Moderate, GCS 9 – 12
* Minor, GCS ≥ 13.

The motor responses came to their current level in the first few days. First they were happy with his reaction to pain, then he would posture, and finally (in the last truly hopeful report we had from a neurologist) it appeared he localized to pain. Then for 36 or 48 hours no improvement. This brought me down, as what we need to see is steady improvement.

People do not just wake up from comas, we are told over and over again. That is Hollywood. In the real world people slowly recover.

So we look for signs of slow recovery.

Last evening I spent a half hour with my dad, then a half hour working, then another hour hour working. I would talk about this and that, the normal happenings in our lives, but I kept repeating “That’s very good. Now more your arm farther, across your body” whenever I would see his arm move. “I know it’s hard, but you need to move your arm farther.”

Around five thirty I stopped talking for a bit. I held his hand and laid my head down on the side of his bead. When I looked up again I saw his hand resting on his chest. This was the greatest self-initiated movement I had seen from him.

Today was even better. Twice when I was talking to him he opened his eyes and kept them open (if only half-way). (Once my words to him immediately previous to that were “open your eyes,” but that may be a coincidence.) Each time I positioned my head so I was looking right at him and I talked loudly, clearly, and slowly to him. I was holding one of his hands and he started moving the other, so I held that one too. He relaxed as I put my hand over his body. He smiled as I said, again and again, the names of the people who were there with them. After he closed his eyes I wiped away a tear.

I do not know for sure what is really going on with my father. What I know makes me think we are beginning to see mental reflexes, better than mere physiological response but still in deep sleep. But whatever we are seeing, it is greater than anything since Saturday. My dad is better this morning than he was last evening, and he is better last evening than he was yesterday morning.

I love my dad. I want him back.

I wish I had some good news. I don’t. At least there is no bad news.

I met with another neurologist and his interns. He re-examined the original EEG and agreed on what it did not show (much neural involvement with the reflexes we see). He examined the CAT scan for the first time, and noted that it did not show damage. They lifted my father’s sedatives enough for an “examination” (really, just talking loudly and pinching — I’m beginning to see what they mean by “clinical nihlism”) and he was as he was yesterday, as he was two days ago.

I feel cold.

I want my dad to be better. I want him to be healthier. I want him to be back.

Sometimes my dad’s eyes water when we talk to him. My mom said his eyes fluttered when she was around. My brother says he smiles if his chin is scratched the right way.

But I want the dad who was going to drive down and see me tomorrow.

I just wish this week never happened. I want to go back in time to Saturday.

Driving to buy soup.
Talking to my dad on the phone.
And knowing I will see him, two days after St. Valentine’s.

While the hospital staff has been helpful, I was getting frustrated by the lack of precision in what I was hearing. So when I talked to the neurologist today I mentioned that I was at an academic institution and had access to medical journal article databases. Could she recommend any terms that I might search for in them?

Yes, and she gave me four: cardiac arrest neurological prognostication.

I also found out that another term for my father’s condition is hypoxic (lack of oxygen)-ischemic (resulting from a blood-clot heart-attack) coma (deep sleep). So I searched articles, and I searched the web. I found this, and many other things, saying the same thing

During cardiac arrest or states of profound hypotension, cerebral blood flow falls to minimal levels and global cerebral hypoxic-ischemic injury begins within minutes. If reperfusion is not instituted within minutes, a high rate of major morbidity and mortality ensues. In fact, there is probably no clinical condition in medicine today which engenders a more overwhelming sense of clinical nihilism than hypoxic-ischemic coma. The role of the clinician in managing these patients has, until very recently, been restricted to prognostication, and little else.

My reading followed some dispiriting talks with staff regarding my dad’s lack of progress, and what that may mean. Probably means.

So I am down.

We are still seeing some pretty involved reflexes. If his foot is tickled he will move his foot out of the way and rebalance himself. He grimaces on hearing a nurse who sounds like a particularly ill-liked business associated. He cries, sheds tears, when my brother or I talk to him.

But an EEG reveals that most of the reflexes we see are driven by the spinal column, and not the brain.

The tears disturb me.

I told him a story today. I have always reacted negatively to cold water: after I get out of cool water I become stiff, painful, and generally disagreeable. One time, years ago, my father took me and my brother to Chicago and we went swimming in Lake Michigan. After an ornery day and night we went to a hotel restaurant to eat breakfast. I loved (and still love) toast and pancakes, so I completely pulled myself together to order my delicious deal in a refined and dignified (for a kid) manner.

“So you were faking,” he said to me, obviously tired by 16 hours with this little hellion. I took offense, and an argument later ensued.

I told all this to my dad today, and then said “If you get better now, I promise not to say you are faking.”

“I love you so much.”

I miss my dad.

I have not seen it yet, but the staff and my family are reporting that my father is opening his eyes now and again. This appears to be a reflex, but the progressively higher reflexes being shown are hopeful signs. (On Saturday my dad reacted to sensation by posturing, yesterday he began reacting in specific ways, by withdrawing a foot from tickling and so forth, and now the eyelid control.) So the neurologist tells us.

I hope & pray that “recovery” will actually be part of the long-term recovery process we hear about. My dad loves reading, especially history and biographies. Even if he is ill, if he can read, understand, and remember, he will be happy. But I know that even if his body is healthy, if reading is stolen from him he won’t be happy. I hope & pray so much that he will be happy and healthy.

I hope & pray so much that he will live.

My dad is still in critical care, and the hospital has a little waiting room just for his family and friends. I am there now, typing this. I thank you all for your prayers and thoughts.

Keep them coming!

How quickly I learn to say “anoxia-induced coma” without scaring people.

I last talked to my father by cell 2 PM Saturday, as I was getting soup for myself and Lady of tdaxp. At 3PM he suffered a heart attack and had labored breathing, while sitting near my mother. For about seven minutes after that my mother gave him chest compressions, and then the paramedics arrived. After two shocks and thirteen minutes be began breathing again.

He has not woken up.

The question “How many minutes was he without oxygen?” gets different answers depending on who you ask. The highest number we have heard is twenty, which is pretty universally fatal. However, assuming that the compressions were getting air to the lungs, and the paramedics were able to force air in after working on him, the real period may be significantly shorter.

Considering that yesterday morning we were asked questions about what to do in case there was a second heart attack, and told the good news was that there was not brain stem damage, things are OK. Now they talk about nutritional needs, the stages of long-term rehabilitation, and such. We were told “He will not just wake up, open his eyes, and start talking. It doesn’t work like that.” But if guarded, realistic optimism is optimism, then we are optimistic.

Lady of tdaxp and I prayed for him last night. We would appreciate yours.

I have left Nebraska and am back in South Dakota. My father is ill. He had a heart attack and, after the ambulance arrived, stopped breathing for several minutes.

Pack your bags, look to the stars, and prepare to go in search of…

THE WARY STUDENT.

The first, and most important, result of this experiment will be…

… Nobel Prizes in Peace and Economics. However, until that happens…

Findings are expected to be as they are expected to be. If the results of my previous experiment are any guide, what I will actually find is something entirely different.

Rational behavior in the ultimatum game, which is the basic of the wary guerrilla categorization, can be taught. Either prior knowledge (Lusk & Hudson, 2004), repeated tries (Slonim & Roth, 1998) or group deliberation (Robert & Carnevale, 1997) results in more rational behavior. It would be interesting and useful to see if similarly “rational” group behavior can be taught. Tuovinen & Paas (2004) give a quantitative description of teaching efficiency that could show how cognitive load interferes with learning correct decision-making strategies. Likewise, research that shows that self-explanations improve understanding (Chi, de Leeuw, Chiu, & LaVancher, 1994; de Leeuew & Chi, 2003) may be combined with research on rational and moral development (for example, Moshman, 2005) and how technology can be used to increase critical thinking (Dempsey, PytlikZillig, & Bruning, 2005).

Similarly, dynamic task selection allows training to vary by cognitive ability of the learner (Salden, et al., 2004). One could apply cognitive load training to group work and the wary guerrilla game, and discover the best way to train students to interact with one another. This could be combined with variations of the ultimatum game, such as where a third player is absolutely helpless (Oppewal & Tougareva, 1992) or the participant should shrink the size of the pie while still accepting (Andreoni, Castillo, & Petrie, 2003). Besides being intellectually interesting in themselves, these twists provide room for developing ultimatum game expertise within the time constraints of running of an experiment on volunteer undergraduates.

Another question to be asked is how technology can be altered to increase a sense of community. Community-building is a recommended feature of online courses (Horn, PytlikZillig, Bruning, & Kauffman, 2003), and public goods contribution has been found to be positively impacted by video (Kurzban, 2001) and possibly increased by pictorial (Fulwider & Saferstein, 2007) representations. A resource allowing the testing of pictorial representations is readily available at no charge (Minear & Park, 2004), and could easily be added to the experimental design. The author is at an institution which has studied computer-mediated v. face-to-face interaction via commonly used educational software (PytlikZillig, Bruning, Horn, & Bodvarsson, 2005), thus such a study would fit well into the current research.

In The Wary Guerrilla‘s original research on the wary guerrilla, the subject of cultural variability was brought up. Cognitive load effects social behavior in different groups differently, apparently because levels of social automaticity vary by culture (Knowles, Morris, Chiu, & Hong, 2001). Further experimentation has only emphasized the need for such a study. Either work in a foreign country, or with international students at a local university, would be insightful.

Well?

In Search Of, a tdaxp series
1. Educational Psychology
2. Load and Behavior
3. Experiments
4. Conclusions
5. Bibliography