Life is resilient; life strives to
be. To give up on life too readily is a betrayal of life.
Life deserves our
every effort to provide what support we are able to muster.
Where There Is Life There Is Life
Yahle's near-death experience started at 4 a.m. that day, when his wife, Melissa Yahle, woke up and realized his breathing didn't sound right. Melissa, who has been a nurse for seven years, said she tried unsuccessfully to wake him up.
Melissa and Lawrence performed CPR until an ambulance could arrive, and first responders found a heartbeat after shocking Yahle several times.
At the hospital, doctors expected Yahle's arteries to be clogged, but they were clear. Things were looking positive until later that afternoon, when Yahle's heart stopped.
He "coded" for 45 minutes as doctors tried to revive him, but eventually Nazir realized it was time to call the time of death.
"We looked at each other," Nazir said. "We'd given him all the medicine we had in our code cart. At some point, you have to call it off."
Nazir said he wasn't sure exactly how long Yahle was "dead," before Lawrence ran down the hall to tell his father he couldn't die that day.
"Suddenly that trickle of a thing came back," Nazir said. "We were lucky we saw and reacted to it, and that brought him back."
Nazir said it was "mind boggling." Melissa said she, Lawrence and the people from their church who were praying with them witnessed a miracle.
Yahle was transferred to Ohio State University, and he returned home to West Carrollton on Aug. 10 with a defibrillator in his chest. He doesn't remember any of the experience after he went to bed on Aug. 4.
"He doesn't have one broken rib," Melissa said. "He's not sore. These are things that just clinically don't happen."
Yahle is set to go back to work on Monday, and doctors may do a heart biopsy to find out more about what happened.
"Modo liceat
vivere, est spes." - Terence (190 - 159 BC)
Ubi non est spes ulla spe!
Lorina Naci has a communication brainwave -
JAMA Network Author Video Interviews
Author Lorina Naci, PhD, discusses Making Every Word Count for Nonresponsive Patients
This is JAMA Network Neurology -
Our understanding of the pathophysiology of chronic disorders of consciousness continues to be illuminated by creative functional neuroimaging studies, yet the diagnosis and classification of these disorders remain based on clinical examination findings.1 Naci and Owen2 supplement the growing evidence that functional magnetic resonance imaging (fMRI) can uncover cognitive functioning that cannot be elicited by neurological examination. They show that selective auditory attention and the capacity to follow commands and communicate can be detected in a few patients in a minimally conscious state (MCS) or a vegetative state (VS) who are otherwise utterly unresponsive. Their convincing data raise the more general question that I consider here of how these findings impact the nosology and diagnostic criteria of chronic disorders of consciousness. [James L. Bernat, MD]
Making Every Word Count for Nonresponsive Patients
ABSTRACT
Importance Despite the apparent absence of external signs of consciousness, a significant small proportion of patients with disorders of consciousness can respond to commands by willfully modulating their brain activity, even respond to yes or no questions, by performing mental imagery tasks. However, little is known about the mental life of such responsive patients, for example, with regard to whether they can have coherent thoughts or selectively maintain attention to specific events in their environment. The ability to selectively pay attention would provide evidence of a patient’s preserved cognition and a method for brain-based communication, thus far untested with functional magnetic resonance imaging in this patient group.
Objective To test whether selective auditory attention can be used to detect conscious awareness and communicate with behaviorally nonresponsive patients.
Design, Setting, and Participants Case study performed in 3 patients with severe brain injury, 2 diagnosed as being in a minimally conscious state and 1 as being in a vegetative state. The patients constituted a convenience sample.
Main Outcomes and Measures Functional magnetic resonance imaging data were acquired as the patients were asked to selectively attend to auditory stimuli, thereby conveying their ability to follow commands and communicate.
Results All patients demonstrated command following according to instructions. Two patients (1 in a minimally conscious state and 1 in a vegetative state) were also able to guide their attention to repeatedly communicate correct answers to binary (yes or no) questions.
Conclusions and Relevance To our knowledge, we show for the first time with functional magnetic resonance imaging that behaviorally nonresponsive patients can use selective auditory attention to convey their ability to follow commands and communicate. One patient in a minimally conscious state was able to use attention to establish functional communication in the scanner, despite his inability to produce any communication responses in repeated bedside examinations. More important, 1 patient, who had been in a vegetative state for 12 years before the scanning and subsequent to it, was able to use attention to correctly communicate answers to several binary questions. The technique may be useful in establishing basic communication with patients who appear unresponsive to bedside examinations and cannot respond with existing neuroimaging methods.
A proportion of patients who survive severe brain injury are rendered behaviorally nonresponsive or exhibit very limited responsivity to commands administered at the bedside by the clinical staff. At the most extreme end of this spectrum, patients appear to be awake but show no signs of awareness of themselves or of the environment in repeated clinical examinations. Patients with this behavioral profile, particularly signs of wakefulness (ie, periodic eye opening and closing) in the absence of signs of awareness of themselves or of the environment, are clinically diagnosed as being in a vegetative state. Some patients may remain indefinitely in a vegetative state. Other patients, as they recover their ability to demonstrate inconsistent but reproducible signs of awareness, are said to progress to a minimally conscious state.1 The clinical assessment of both patient groups is particularly difficult because of its reliance on the subjective interpretation of inconsistent behaviors, which are often limited by motor constraints.2- 3 It is well established that misdiagnosis occurs frequently in this patient group, with up to 40% of patients being diagnosed as in a vegetative state when they are, in fact, (minimally) aware.4- 6
Although a clinical vegetative state diagnosis implies lack of consciousness and cognition, this is not necessarily always the case. Several recent neuroimaging studies have demonstrated that, despite the apparent absence of external signs of consciousness, a significant small proportion of behaviorally nonresponsive patients with disorders of consciousness can respond to commands by willfully modulating their brain activity according to instruction.7- 11
Despite these advances, little is known about the mental life of such patients with regard to whether they can have any coherent thoughts. One fundamental mental function, critical for coherent thinking, is the ability to pay attention. Two different aspects of attention, selective attention (the ability to attend selectively to a stimulus while ignoring other potentially irrelevant ones) andsustained attention (the ability to maintain attention on a set of stimuli for prolonged periods), are often intertwined in the execution of everyday tasks. Attention fluctuates widely over time in patients with disorders of consciousness,12- 13 but to our knowledge, these 2 dimensions of attention have not been tested directly with functional magnetic resonance imaging (fMRI) in individual patients. More important, any given nonresponsive patient who can selectively sustain attention to events in his or her environment may be able to use it to convey conscious awareness and communicate answers to questions by simply attending to specific words (eg, yes or no), as has been shown for healthy controls.14
The most successful fMRI methods deployed to date to detect awareness in patients with disorders of consciousness have used mental imagery tasks (ie, motor and spatial navigation imagery) to elicit brain-based communication responses.7- 11 Patient cohort studies9- 10 have found that a small proportion (9%-19%) of nonresponsive patients were able to generate meaningful brain responses that confirmed that they were, in fact, performing the mental imagery task as requested. Apart from a genuine lack of awareness, other factors may explain the lack of response in some patients. Specifically, it is possible that some patients who are misdiagnosed as being in a vegetative state and are, in fact, conscious are nevertheless unable to perform the mental imagery tasks.10 Indeed, a proportion of the healthy population is not able to produce robust brain activity with motor imagery tasks.15 Another possibility is that, due to the brain injury, a patient may lose the ability to perform mental imagery and/or related precursory mental processes.10
In summary, although a large proportion (approximately 40%) of behaviorally nonresponsive patients are routinely misdiagnosed with bedside assessments,4- 6 only some of these patients have been shown to respond with existing neuroimaging methods. Thus, complementary tests that elicit volitional brain responses by recruiting alternate mental functions, such as attention, are needed to maximize the chances that any nonresponsive patient who retains covert awareness will be able to achieve brain-based communication. In this study, we tested whether selective auditory attention can be used as a proxy for behavior in nonresponsive brain-injured patients. As a proof of principle, we asked whether 2 patients in a minimally conscious state and 1 patient in a vegetative state could selectively pay attention, thereby conveying their ability to follow commands and communicate answers to binary (yes or no) questions.
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