Part III: The Hand of God?—Brain Death, Coma, & The Will To Live
By Edison McDaniels, MD | surgeonwriter.com
You might want to read the other articles in this nonfiction series first. [Click Here]
Keywords: nonfiction, brain death, coma, persistent vegetative state, vigilant coma, miracle
If you google ‘brain death miracle’ you will get something on the order of 340,000 hits. That’s mind boggling.
Can it really be that a person without a functioning brain long enough to be declared brain dead can return to the world of the living and defy all the experts? And not once but over and over and over again?
Before we conjure images of a world populated by The Walking Dead, we need to ask ourselves this simple question:
What is more likely, a patient recovering from full on brain death, or a patient recovering who was never brain dead in the first place?
That’s right folks. These patients, every last one of them, were never brain dead in the first place.
To put it simply, dead is dead. A person who is truly brain dead is legally, clinically, and in every other sense imaginable, dead.
So what about these miracles?
The answer, of course, is coma. To the neurologically unsophisticated, coma can look a lot like brain death. Coma, at least as a first approximation, can be thought of as a substantial loss of the ability to respond to outward (and in some cases inward) stimuli. The key word here is substantial, as in significant but not total. In the presence of coma, there is life. And where there is life, there is—oftentimes—hope.
A patient in coma looks to be sleeping, at least to the uninitiated. They will respond to some stimuli and not others. Some patients in coma do recover significantly, others do not. As the length of coma lingers, patients often develop stereotypic responses. One of them is eye opening. Loved ones and caregivers may even note a sort of sleep wake cycle—that is, periods when the patient seems predictably more awake than at other times.
Such cycles can confuse families, and the uninitiated care givers. It gives the illusion of recovery, that the patient is waking up and if only enough time is granted a substantial recovery is possible. This situation is variously termed ‘vigilant coma,’ ‘persistent vegetative state,’ or less precisely, simply ‘coma.’ While a very few patients do recover to a significant extent from this condition, the vast majority never will. And the longer the vigilant coma persists, the less likely recovery is to occur.
The informed reader will point to a few prominent cases in the lexicon wherein recovery appears to have occurred after many years. That’s the trouble—or the hope—with vigilant coma. It’s life, and, as mentioned above, where there’s life there’s hope. That hope is small, minuscule even, in most cases of prolonged coma.
But without life—in brain death, to be clear—there is no hope of recovery. Death is death.
The mistake that places a comatose patient among the dead for even a brief time has many sources. One of the more common is that of the sedated patient, or even the pharmacologically paralyzed patient, who is declared brain dead by the neurologically unsophisticated medical professional. Occasionally a patient may appear to meet all of the clinical bedside criteria—no eye movement, no response to pain, no attempt to breath on an apnea test—because of hypothermia. This usually happens in very cold climates. Sometimes the temperature is normal but the apnea test isn’t carried on long enough for the carbon dioxide to rise sufficiently (carbon dioxide, not oxygen, controls the impetus to breathe—a believe it or not fact worthy of Ripley).
Remember, in all of this, the important thing is function. What is the brain doing or not doing? The brain is an organ like any other, with a so-called end organ function. The end organ function of the kidneys is to produce urine. The heart circulates blood. The lungs exchange oxygen and carbon dioxide. The end organ function of the brain is to ultimately coordinate every outward response a human produces (except for those coming from the GI tract, a fascinating fact in itself) and a myriad of inward responses as well (mundane things like coordinating walking and raising and lowering blood pressure, heart rate, and breathing, as well as deciding when it is socially acceptable to deficate or urinate).
If the kidneys fail, there is no urine—and no excretion of waste products. Without dialysis, the patient will die. If the heart fails, there is no pumping of blood. Just as often, the heart fails to pump effectively, which results in congestive heart failure. If the lungs fail, the patient suffocates, or suffers from oxygen hunger as in a bad pneumonia.
If the brain fails, the outward responses it coordinates cease. However, because the functions of the brain are compartmentalized, when it fails (as in a stroke) usually only some of the outward responses cease (for example, the patient stops talking—aphasia, or stops moving on the left side—hemiplegia, or develops blindness—amaurosis, or can’t coordinate movements and looks clumsy—ataxia, or…you get the idea).
If the brain fails to such an extent that most of these outward functions cease (we might call this partial or congestive brain failure in an analogy to congestive heart failure), the patient is in a coma.
But what about when the brain fails so massively that all outward—and inward—responses cease?
That is brain death folks, and it’s irreversible. Death by another name is still death.
One more thing, and it follows naturally from the above but may not be intuitive to the lay reader. If all outward and inward responses to stimuli fail in brain death, the body itself must fail eventually. Why? Because like an airliner deprived of its pilots, there is no master at the helm.
Such a plane may keep flying initially, but sooner or later (I’m guessing sooner) it will encounter an updraft or downdraft it doesn’t know what to do with. Hell, the plane doesn’t even know it’s flying. It has no awareness—and no ability to respond to its surroundings. And, as the second law of thermodynamics tells us, it will tend toward entropy and chaos. So it falls out of the sky.
A body without a brain is just as clueless. The heart may keep beating, but it has no awareness it is doing so. It can’t measure blood pressure, let alone adjust it up or down to the needs of the moment. The kidneys will still filter the blood and produce urine, but without the brain to tell them how much potassium to excrete or how much sodium to hang on to, their mission is doomed to failure. Even the lungs, seemingly nothing more than a bellows, will begin to collapse on itself without the brain to instruct it to take a deeper breath than normal several times a minute to clear any building secretions that might otherwise clog up its vital passages. You do this and swallow the result hundreds of times a day; when was the last time you swallowed? Did you think about swallowing? Were you even conscious of the fact you swallowed? Of course not. But your brain was, and is. Your brain keeps track of such things and a million other little tidbits you can’t consciously be bothered with as well.
A body without a functioning brain is a system tending toward chaos and will fail in a matter of days, a week maybe. It might last a little longer with close attention from both the medical and nursing staff attending to things like hydration, careful positioning to help the lungs, and drugs to maintain blood pressure etc., but not much longer. A few days at most. Certainly not months or years.
But a body in a vigilant coma—partial brain failure—can go on for years. Just google Karen Ann Quinlan. No hand of God miracle there, unfortunately.
Next time at Neurosurgery101—TheBlog: The most amazing thing—a miracle maybe, a Ripley’s Believe It or Not moment for sure—I have seen in twenty plus years as a brain surgeon.