A joint British and Belgian group has published new findings with fMRI evaluating consciousness in patient’s previously meeting clinical classification for persistent wakeful unconscious states.
We used functional magnetic resonance imaging (MRI) to assess each patient’s ability to generate willful, neuroanatomically specific, blood-oxygenation-level–dependent responses during two established mental-imagery tasks. A technique was then developed to determine whether such tasks could be used to communicate yes-or-no answers to simple questions.
Of the 54 patients enrolled in the study, 5 were able to willfully modulate their brain activity. In three of these patients, additional bedside testing revealed some sign of awareness, but in the other two patients, no voluntary behavior could be detected by means of clinical assessment. One patient was able to use our technique to answer yes or no to questions during functional MRI; however, it remained impossible to establish any form of communication at the bedside.
Functional MRI has been front and center in the news the past several years with claims of scans that can predict people’s responses and actions before they make them and decipher people’s motives or tell us when they’re lying or telling the truth.
And it’s true studies such as those by Monti, et al raise important and serious questions about the right to life and the right to die. In an editorial to accompany NEJM’s publication Dr. Allan Ropper says,
Even in a preselected population, brain activation was infrequent, but it occurred often enough that it will now be difficult for physicians to tell families confidently that their unresponsive loved ones are not “in there somewhere.”
Indeed, the MRC and Belgian group’s efforts are game changers certainly. It, and future studies along the same lines, have made and will make the main stream news and will no doubt be commonly quoteb by anyone faced with a loved one who is awake but seemingly not there by any measure short of fMRI. And they should be. For all the reassurance the medical community gives family and friends the misdiagnosis of persistent vegetative states is a problem. Now further uncertainty is thrown on it.
But as much as the preservation of life and function is an important goal, arguably secondary only to primum non nocere, I still think caution is in order when using information as Monti et al have provided. Dr. Ropper likely says it better than I can,
First, in this study, brain activation was detected in very few patients. Second, activation was found only in some patients with traumatic brain injury, not in patients with global ischemia and anoxia. Third, cortical activation does not provide evidence of an internal “stream of thought” (William James’s term), memory, self-awareness, reflection, synthesis of experience, symbolic representations, or — just as important — anxiety, despair, or awareness of one’s predicament. Without judging the quality of any person’s inner life, we cannot be certain whether we are interacting with a sentient, much less a competent, person. Moreover, persons who look to this study to justify continued and unqualified life support in all unresponsive patients are missing the focus of the findings.
The presence of some rudimentary preserved cognition that is indicated by means of functional MRI will no longer be in question, but its meaning will continue to be subject to interpretation.
Be gentle in how we use these new resources to define consciousness; how we use these new resources to define who is still is with us.
New Scientist profiles the Wellcome Collection’s Exquisite Bodies exhibit looking at the portrayal of human anatomy in the Victorian era. I can almost guarantee that the next time I’m in London I will be at the Wellcome Collection; looks very interesting.
I once had a pharm professor, during my first two years of medical school, predict that we’d see the death of antibiotics during my practice career. The idea being that the antibiotics in the pipeline, the drive for new therapies against pathogenic bacteria was limited compared to the speed at which resistance was growing. Well Kary Mullis has some ideas about that and about the future of the battle against infection.
I know Mullins is a controversial figure and a strange bird at that. He is one of the most unique, choosing that adjective over others, Noble laureates I can remember. In spite of all that the talk, as most TED talks are, is very interesting.
Lexington, a pseudonymous columnist for my favorite magazine The Economist, had the following to say about efforts to reform American health care,
We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean? Should doctors seek to save the largest number of lives, or the largest number of years of life? Even in America, resources are finite. No one doubts that $1,000 to save the life of a child is money well spent. But what about $1m to prolong a terminally ill patient’s painful life by a week? Also, who should pay?
I couldn’t agree more. I’ve long been a proponent of the idea that expectations of healthcare in the United States are something else, more demanding as compared to the rest of the world. We try everything here in America for a patient, cost not prohibiting, before the plug is pulled. This trend is especially prominent in acute care situations. Situations of immediacy, of life and death.
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Consider I’m at a major trauma center for training right now. I know I’m not seeing unique scenarios and I, with some frequency, am witness to scenarios like the following. An 80 year old man comes in following a motor vehicle crash. He was the restrained driver. There was a death at the scene.
He had a prolonged extracation from the vehicle
On the scene he had a Glasgow Coma Scale of 9 and was combative and was intubated for such. En route to the emergency room his hemodynamics become a little marginal and he starts with progressive fluid requirements. On arrival to the emergency room a FAST scan is inconclusive and his pressures, while marginal, are stable enough for him to make a quick run through the scanner. His injuries are documented by imaging as bilateral femurs, open pelvis with active extravisation, splenic and liver injuries with active extravisation, a subdural hematoma on the right with marginal shift and bifrontal contusions.
Coming out of the scanner his pressures collapse as he’s being rolled emergently to the operating room. At this point his TRISS score predicts a mortality approaching 95%.
Intraoperatively he loses close to 20 liters and requires massive resuscitation. Resuscitation includes more than 50 units of packed red blood cells and corresponding fresh frozen plasma and cryo and platelets. He is transported to the SICU status post a splenectomy with an open packed abdomen. He requires continued resuscitation with another 10 of pRBCs and 10 of FFP. He requires ACLS overnight although a pulse is returned. He is not stable enough to make a trip back to the operating room as planned through the whole of the next week. At one point he has a reexploration of his abdominal wound at bedside under sterile conditions because he is too unstable to be transported to the OR.
He continues like this for a week despite the clear non-survivability of his injuries, until finally made comfort care and allowed to peacefully expire.
I love lacrosse. It’s my favorite sport on the field; my favorite to play. My favorite stick is still sitting next to my bed despite the fact I haven’t stepped competitively on a field in four years.
Although the overall mortality rate of lacrosse was similar to other major sports, the rate of sudden death attributed to commotio cordis (0.63 per 100,000 person-years) was significantly higher for lacrosse than baseball (0.24, P=0.017), football (0.043, P<0.0001), and other sports, except for hockey (0.53, P=0.73).
Don’t freak out too much. Despite that increase in blunt cardiac injuries with lacrosse, the incidence of sudden death amongst lacrosse players as compared to players of other major sports is essentially the same. Sudden death in young athletes gets a lot of attention, as it should, but it is exceedingly rare. Amongst sudden deaths in athletes, the most common etiology is not commotio cordis (or other blunt trauma) but congenital cardiac abnormalities.
I gained a lot more from lacrosse than any risk of commotio cordis I took when stepping out on the field.
GlaxoKlineSmith has teamed up with a non-profit for work on one of their AIDs vaccines.
The first AIDs vaccine will appear in the next decade. It’s effectiveness may be in question, however.
I’ve started work at an ophthalmology clinic until school starts. It explains my posting frequency recently.
It is actually cooler than I thought it could be. I’m working with the ophthalmologic photographer who takes pictures of patient’s eyes (inside and outside). I can pick out obvious cholesterol deposits, melanomas, ulcers, some glaucoma complications after only a week. That part of the work is actually pretty fun.
