Tag Archives: coma

Surgery, and the Rancho Los Amigos Levels of Cognitive Awareness

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.

Looking for Hope

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.

A Better Place

Schiavo Finale,” by TM Lutas, Flit(tm), 17 June 2005, http://www.snappingturtle.net/jmc/tmblog/archives/005443.html.

TM Lutas on the resolution of the case
Schiavo Finale

I owe myself (and my readers) an honest bit of closure on Teri Schiavo. I was wrong, and the autopsy results (pdf) seems to have closed the book, on the level of damage Teri Schiavo had. I still can’t understand Michael Schiavo and why he chose to act the way he acted. Seeking the additional tests the parents sought prior to letting go would have cost less, salvaged his reputation in an awful lot of people’s eyes and perhaps saved us all from a national circus that should never have happened. His stand against testing and willingness to spend money on lawyers but not on medical tests was the strongest bit of evidence on the parents’ side.

At this point, I hope that she is in a better place and at peace. I hope that the family will look to their own souls as they pray for hers.

Well said.

Derbyshire on Schiavo

RE: Schiavo,” by John Derbyshire, The Corner, 15 June 2005, http://corner.nationalreview.com/05_06_12_corner-archive.asp#066242.

Great post by John Derbyshire in reaction to the latest Schiavo fuss. Emphasis mine

Some comments on that e-mail that seemed right to you, Kathryn:

Regardless of the severity of brain damage, it seems to me the moral principle still abides...”

Regardless? Regardless? So all those things we heard about Mrs. Schiavo’s condition not really being as bad as the husband & the doctors said, was just cynical propaganda? In fact, however bad her condition actually was, the right-to-life side would have held the same position? Then wasn’t it dishonest of them to raise the issue of Mrs. Schiavo’s actual neurological status? Even if she had had no functioning cerebral cortex at all (which seems, in fact, to have been pretty nearly the case) the right-to-lifers wouldn’t have budged — “regardless”? Which right-to-lifers — names, please — made this clear at the time? It sure wasn’t clear to me.

“1. No human life should be contingent as to whether or not another person gives it credibility or not.””

So if anyone, in any condition, has a metabolism that can be kept functioning somehow, that ought to be done, regardless (!) of what any person — spouse, parent, eminent neurosurgeon, judge — thinks? Start building some real big warehouses — you’re going to need them.

“2. If a family member wants to terminate a human life where the human in question is not able to speak for him or herself, and another family member wants to sustain that life, defer to the family member that wants to keep the human in question alive.””

This is not currently the law in the state of Florida. If the people of Florida, in their collective wisdom, would like it to be the law, get lobbying. It seems like a fair principle to me… provided you can iron out a definition of the term “family member” that will not produce results just as rancorous as the Schiavo case (which I doubt — see next point).

And what if ALL family members wish to terminate a Schiavo-type life? Should that life then be terminated, even in violation of our reader’s point (1)?

“3. A fortiori should this be the case where the family member wanting to keep the human in question alive is willing to care for that human in question. (in this case, the parents).””

What if the parents are both 90 years old? Prisoners in the state penitentiary? Only doubtfully of sound mind? Stand to gain financially from their caring? Etc., etc.

“4. It remains true, no matter how many different circumstances one raises, the only direct cause of Schiavo’s death was government action, i.e., a court order.””

At least two of the governments (if you mean, executive administrations) involved — the Florida govt. and the Feds — were trying every way they could to find some way around the laws — laws written and approved through elected representatives, according to state and federal constitutions. The laws won. May they ever do so. And may we ever remain free to change the laws when they no longer satisfy we, the people.

Schiavo Case Leads Conservatives to Support Euthanasia

Re: Schiavo,” by John Derbyshire, The Corner, 15 June 2005, http://corner.nationalreview.com/05_06_12_corner-archive.asp#066258.

More Derb

At the Atlanta bash last month, an audience member asked the panel whether the Schiavo case had caused any of us to change our minds about the underlying issues.

I piped up & said yes, the case had changed my mind in one respect. It had made me realise, a thing I never realised before, that I do favor euthanasia.

Ramesh asked me at some point why, if I were willing to see Mrs Schiavo have her feeding withdrawn so that she dehydrated to death over several days, I wasn’t willing to just have her given a lethal injection. I couldn’t think of any satisfactory answer to this, and haven’t been able to since; so in all honesty, I am bound to say I favor the lethal injection, in at least some cases.

Good point.

This is why federalism is important. So when one state legalizes something, an uninformed majority doesn’t snuff it out.

Right Bolsheviks and Terri Schiavo

Theocracy in America,” by Collounsbury, Lounsbury on MENA, 29 March 2005, http://www.livejournal.com/users/collounsbury/304891.html.

Are “defenders” or Republican Lenninists? Col thinks so:

However, returning to the subject of Theocracy in America and the “God Botherers” – I confess one of my favorite memories of my father, otherwise … well a model for my personality, was his reducing some Mormon missionaries to tears, quite inspirational that – I find myself appalled in a real sense by this case. More in the sense in which these so called “Conservatives” in the American government lost their hypocritical attachment to local rights, family and whatnot to use the power of the State to intervene and even try to override the courts. These are the policies of Right Bolsheviks, not classic liberals by either instinct or nature. They are the actions of theocrats (in the wide sense the very same people often use in regards to the Islamists (who are not so far away from them in their thinking)), with this talk of “God’s Law” and the like. To take Central Government action to rip a case from its proper context and place it into another sphere, into the Federal court system in this case, is an abuse of power worthy of any theocracy.

The “theocrat” charge is exaggerated, but the rest isn’t

  1. The Schiavo Actists are not Conservatives. They are attempting to break family law, break the courts, and break local control.
  2. The Schiavo Activists are attacking marriage. The entire argument rests on the inability of Schiavo’s lawful husband to determine her medical treatment. If marriage is so weak, why would these activists bother defending it against homosexualists?
  3. Allowing for hyperbole. the Schiavo Activsts are like Bolsheviks. Some popular pundits are alreading justifying extreme means with the ends. Ann Coulter adocated executive nullification (the Andrew Jakcon Option), for goodness sake!

The Schiavo case has a wider context, and I will blog that once it is over. But the extremism of my friends on the right is still alarming.

Conspiracy of the Informed (Judge Refuses Shiavo Motion)

Federal Judge Denies Request to Reinsert Schiavo’s Feeding Tube,” by Abby Goodnough, New York Times, 22 March 2005, http://www.nytimes.com/2005/03/22/national/22cnd-schiavo.html.

A federal judge here today refused to order the reinsertion of a feeding tube for the brain-damaged Terri Schiavo, denying an emergency request from the woman’s parents and despite the intervention of Congress and President Bush in the case, The Associated Press reported.

Judge Dames D. Whittemore of Federal District Court said the 41-year-old woman’s parents had not established a “substantial likelihood of success” at trial on the merits of their arguments, the agency said.

I guess this makes him “legally blind” too. I mean, where does this “substantial likelihood” talk come from?

Judge Whittemore asked Mr. Gibbs to cite case law that would bolster the claim that Ms. Schiavo’s Fourteenth Amendment rights to due process had been violated, adding, “because we haven’t found any.” Without proof that the state court’s handling of the case violated precedent, Judge Whittemore said, “I think you would be hard pressed to convince me that you have substantial likelihood” of succeeding on the merits of the case.

To win a temporary restraining order, a plaintiff must prove such likelihood.

Oh. Something called “the law.”

The most interesting part of the case are dueling freedoms. Would Mrs. Shiavo have the freedom to refuse the treatment for herself, or does Mr. Shiavo have the freedom to refuse the same treatment on behalf of his wife?

Mr. Felos, representing Mr. Schiavo, sought to focus Judge Whittemore on the question of whether the Congressional act passed in the early morning hours was constitutional. He argued that Congress did not have the authority to allow a federal review of the case because the Constitution says it is up to a state to decide whether due process rights have been violated.

“Yes, life is sacred,” Mr. Felos said, “but so is liberty, your honor, especially in this country.”

A wrinkle I cannot comment on is Mrs. Shiavo’s Catholocism

The lawyer, David Gibbs, also said Ms. Schiavo’s religious beliefs as a Roman Catholic were being infringed because Pope John Paul II has deemed it unacceptable for Catholics to refuse food and water.

(Aside: Why “Ms.” not “Mrs.”?)

It seems that David Gibbs is saying that, out of religious freedom, all non-responsive Catholics should be under Canon law, unless otherwise indicated in writing. Maybe this is what Juan Cole means by the Islamization of the Republican Party?

Let’s hope this tragedy is over soon.

Cross Debates

Two good trans-post debates:

Sites: CCK, tdaxp
Philosophies: tdaxp v. sodakdems
Chad, Seth, Charley, and I are debating jobs v. readiness in Box Elder, South Dakota’s Next Ghost Town?, Ellsworth Revisited, and South Dakotan War on Terrorism (CKK: Daschle is a Traitor)).

Sites: Red Side, tdaxp
Philosophies: tdaxp v. paleocon
Aaron, Adam, Belew, Theo, and I are discussing the Terri Shiavo Case. The posts? Evangelicals: Marriage Irrelevant, Rounds: South Dakota’s Abraham Lincoln, and Terri Shiavo Says She Wants to Live

Ruminations on Shiavo

Shiavo Case,” by John Derbyshire, The Corner, 21 March 2005, http://www.nationalreview.com/thecorner/05_03_20_corner-archive.asp#058815.

Terry Shiavo,” Michael Forbush, Dr. Forbush Thinks, 21 March 2005, http://drforbush.blogspirit.com/archive/2005/03/21/terri_schiavo.html.

Liberal scientist Forbush and paleocon Mathematician Derbyshire join the skeptics in the Shiavo case. It’s hard to tell which paragraph is from which. Two well written editorials.

But, politicians can’t know the medical truth because they are not doctors nor have they spent the time needed to study the case. Even Bill Frist puts his medical credibility at risk for diagnosing a patient via videotape. If he really wants to have a say, then he should go to Florida and read the brain scan data and view Terri in person. Medical Doctors are responsible for providing the facts, and the family is responsible for deciding whether she should be removed from life support. The problem in Florida is not with whether Terri is alive or not, it is with the law that says who is in charge, the Husband or the Parents.

I did grow up among medical chatter, though. My mother was a professional nurse — an exceptionally dedicated and conscientious one, from all I have seen since. I spent several hundred hours of my childhood sitting in rooms with Mum and her colleagues (a high proportion of whom, by the way, were Catholic women from the Republic of Ireland — that’s how the nursing profession in England was structured) listening to their nurse talk. A recurrent theme was some patient in a terminal condition being kept alive on tubes and drips by, as these nurses would say, some damn fool doctor. (The nurse-doctor relationship is a very fascinating one.) “Let the poor thing die!” one of the nurses would say, to sympathetic nods of agreement all round.

People who deal with the human frame and its ailments every working day develop an understanding of the rightness and natural-ness of death that isn’t often vouchsafed to the rest of us. I don’t know the fine details of the Schiavo case. Knowing nothing of Michael Schiavo’s motives, I am willing to give him the benefit of the doubt, and assume that he just wants his wife to be at peace rather than linger indefinitely in her present wretched state. There is nothing ipso fact ignoble or shameful about that. The guy might be operating from some ulterior motive, I suppose, but does anyone have actual evidence of this? Judging from the few quotes of his that I have read and heard, he doesn’t seem like a bad sort.

Evangelicals: Marriage Irrelevant

Congressional Republicans Declare:
State Interest Trumps Marital Interests

Christians Criticize Husband Deciding for Wife
(Wife Not Objecting)

Husband, Wife ‘Not One Body,’ Born Agains Maintain
Preachers: Genesis 2:24, Mark 10:8 ‘Just Stupid’

These are the headlines I see in the Terri Schiavo case. I think the Democrats must see the same thing, because few are criticizing Republicans for righists’ bizarre stand. When I see solid conservatives like Michelle Malkin and The Red Side of Belew join the statists I despair.