Neuro Note #1 Coma

Coma: HBO Documentary 

For my first neuro note, I decided to watch a documentary called Coma. I actually decided to do my neuro note on coma following our time in class we spent studying the subject. I became very interested in learning more about comas because they are in and of themselves somewhat of a mystery. I decided on the documentary coma because I had seen it pop up on the HBO account I mooch off of while I was trying to watch the new episode of Big Little Lies. I decided that I would go ahead and watch this as my interest was peaked. Coma is a HBO documentary film that follows a year in the life of four different patients who are at JFK Medical Center’s Center for Head Injuries. The Center for Head Injuries at JFK Medical Center is one of America’s premiere institutions for the studying and rehabilitation of patients with brain injuries. The film begins in the Summer of 2005. The four patients in the film emerge over the year from their comas into either a persistent vegetative state, a minimally conscious state, and beyond. The film follows Tom, Al’Khan, Roxy, and Sean, as they are all in varying levels of coma and have sustained brain injuries to differing degrees. The film makes a point of stating that for the vast majority of patients, the first year is the most important time for recovery of consciousness, after this one year chances for recovery dwindle. For the purpose of clarity, I am going to report on each individual at JFK’s story and group them separately. 

Tom

Summer 2005

Tom Segars is the first patient we meet, Tom is 31 and works as a sales manager, he sustained a brain injury in a fall from a balcony. Tom emerged from his coma 3 weeks prior to filming and is in a minimally conscious state. He was then enrolled in an fMRI study that was designed to measure the level of consciousness in his brain. Tom’s location of his injury occurred in the left side of his frontal lobe. Tom eventually begins showing improvements, and the neuropsychologist says that he has crossed the threshold and is no longer in the minimally conscious state. He is communicating reliantly and showing intentional behaviors that could only be possible if he knew what was going on around him. Tom, however, cannot speak. This is concerning considering where his injury occurred (left side of frontal lobe) as this is a primary language area. 

Fall 2005

It’s now been four months since Tom’s injury. He is still having a lot of trouble talking but he can understand what is being said to him indicative of Broca’s aphasia. Tom’s fiancé is showing hopefulness for his condition, but a neuropsychologist says that this is almost a harder time for the family because they saw all of this headway being made in the past four months and now he is getting more stagnant in his recovery and they just want to see more and more improvement like they saw immediately post-injury. Tom himself is also growing more frustrated with his lack of improvement and is seen growing agitated while in group rehab. They decide to call in a neuro consultant for Tom to try and figure out a more functional treatment plan for his therapists to put in place. They find that his hearing is a major problem and that he understands when instructions are written out for him. The neuro consultant comes to the conclusion that Tom has anosognosia. Anosognosia is a loss of awareness of ones self or ones acquired deficits. In Tom’s case, he goes through interactions as if he can hear, but he cannot. This is his anosognosia coming into play as he is not aware of his lack of hearing. This is a big deal because this could be a big player in a lot of his problems he has been having and his frustrations. 

Winter 2005

Tom is fitted for hearing aids by an audiologist. The hearing aids are shown not to be working on Tom during this time. The audiologist says that the hearing aids are working, his ear is hearing sound, but the brain injury is not letting him process or understand the sound. She says that this is due to central deafness. It’s now been 8 months since Tom’s injury. He is shown getting frustrated during his therapy session and has no motivation to do his therapy and curses out his therapist. His mother is struggling and just wants to bring him home, but knows that he needs his therapy. Brain scans on Tom show that his hearing loss is due to brain injury and he has central and peripheral deafness. Tom is showing behavioral changes at this point and is growing increasingly hostile. 

Follow Ups

A year later, Tom is discharged from the center and into an assisted living program. He and his fiancé bought an apartment and planned to marry in 2008. 

Roxy

Summer 2005

 Roxy is the next patient, she is a 19-year-old college study who sustained a brain injury in a car accident 8 weeks prior to the filming. Roxy’s eyes did not open for one month. A neuropsychologist in the film says the hallmark sign of a minimally conscious state is inconsistency, where your consciousness comes and goes. This is the state that Roxy is in. Roxy demonstrates a little bit of tracking and can respond to instruction further proving that she is not in the vegetative state. Roxy was then able to say mom in a subvocalized manner, which is another good sign that she is on a good track. Roxy eventually begins to speak more clearly and intentionally. Roxy, then claims that she is 13 years old when she is 19 years old. She then mistakes a hammer for a screwdriver. Roxy is also pronounced out of the minimally conscious state, but the neuropsychologist now says they must tackle to possible cognitive deficits Roxy may face. 

Fall 2005

Roxanne is also showing hostility. She is shown pushing and slapping at her therapists and cursing at them. Roxy is now in a post-traumatic confused state. This is hard on her mother as she is seen trying to get her to apologize to her therapists.

Spring 2006

Roxy’s mother has decided to take her home. In preparation for this Roxy’s therapist has brought her mother and other family members in for training. Roxy’s mother has stopped working to take care of Roxy full-time at home, but says she can only do this for 5-6 months. This is not necessarily the best idea as Roxy cannot get the full intensity of therapy at home. Roxy is seen at home and can hold a conversation well. She is shown to be doing a lot better. 

Follow Ups:

Roxy’s mother readmitted her back into the center 4 months after she went home. One year later, Roxy was discharged again and began auditing a college course and is beginning to walk.

Sean

Summer 2005

 The next patient we see is Sean, Sean is 20 years old and a college student. He sustained a TBI while studying in Europe when he was assaulted and thrown off a bridge. Ever since Sean’s injury the year before filming, his medical team has been trying to determine whether he is in a minimally conscious state or a vegetative state. Sean’s OT can be seen trying to get him to bring his hand towards his face to no avail. Sean’s doctors describe him as an enigma, it is hard to figure out where he lands on the coma scale. They are hoping that they can get some clarity on Sean once he passes his one year mark. 

Fall 2005

Sean hasn’t really seen much improvement. Sean begins crying during a visit with his mom and brother. Sean’s team of therapists and a neuro consultant are seen communicating with his parent to try and come up with a plan for Tom. The therapists at this point are feeling as though what they are doing is not doing anything. The Father wishes for them to up the therapy, but the therapists are trying to explain that upping the therapy could just frustrate Sean more. It has been 20 months since Sean’s injury and the fact that he still has shown no improvement or any indication of coming out of the vegetative state is not optimal. The Father is shown upset and wishes for them to continue 5 days a week while they are wanting to go down to 3 days a week. 

Winter 2005 

Sean’s therapy has been cut down, to the frustration of Sean’s parents. He has not shown improvement. His mom describes him as stuck in the middle of nowhere and that she doesn’t know what to do because he hasn’t gotten any better or any worse.

Spring 2006

It has now been 2 years since Sean’s injury. His parents have requested that Sean be included in the fMRI study, to see if they can detect consciousness in Sean. Sean has a very damaged left hemisphere. His temporal lobes have been damaged and are not activating when listening to voices. Therefore, Sean does not have activation in his language areas and the right remains a mystery. The neuro consultant believes that this is further indicative that Sean is in a vegetative state. It has been a long time without any evidence of conscious behavior and Sean’s neuro consultant believes Sean is nearing the end of the line. 

Follow Ups:

Sean’s parents are paying for additional services. Doctors diagnose Sean as being in a permanently vegetative state. 

Al’Khan

Summer 2005

The next patient we are introduced to is Al’Khan. Al’Khan is 26 year old father and works in a restaurant, he sustained a TBI in a car accident ten months prior to filming. Al’Khan has been in the minimally conscious state for the past 8 months. Al’Khan can tell you his last name and tell you his sons name and demonstrates good tracking. 

Fall 2005

Al’Khan has started bleed internally and is transferred to the Critical Care Unit. Al’Khan can blink twice for yes and once for no, but is not able to talk. He shows purposeful reactions and the ability to understand.

Winter 2005

Al’Khan is now on a ventilator. He is not showing responses to stimuli and is not opening his eyes. His mother thought that he had been sedated, but he has now slipped into a vegetative state. Al’Khan is also having seizures and his EEG is not showing brain functioning. Al’Khan’s doctor recommends to his mother that he needs a DNR and should possibly be taken off the ventilator as at this point, he really is not showing any chance of being able to recover. 

Spring 2006

Al’Khan’s neurologist is seen going to his wake. She expresses concern that she instilled too much hope in the beginning stages to his family and feels guilty about how things ended. 

My takeaways: 

Despite how many times I cried while watching this documentary, I really feel like I gained a lot of insight into the daily lives of individuals who have sustained a brain injury. It was really neat seeing the things I have learned at school be talked about in this documentary. I would recommend anyone to watch this documentary no matter their background as I feel like it helped me gain a lot of empathy for the individuals and the family members of the individuals who are going through this life-changing event not only as a future healthcare professional, but also as a fellow human being. 

Tom and Roxy pictured at the NYC premiere of COMA 

Reference:

Motion picture. (2007). United States: HBO. Retrieved July 17, 2019, from https://play.hbogo.com/feature/urn:hbo:feature:GVU3T5wTXyoNJjhsJAXsL