Levels of Consciousness

INTRODUCTION

"Coma is the total absence of awareness of self and environment even when the subject is externally stimulated" - Baker, Jacqueline (1988)

My interest in the levels of consciousness in comatose patients which led me to make this the topic of my research, stems from the interest that was kindled in the aftermath of my hearing a news item in May 2008, over the airwaves of the BBC about Elizabeth Fritzl who woke up from an induced coma, 7 weeks after she was artificially sent into one by doctors who did so in order to give her failed organs time to recover.

Wishing to explore Coma with an aroused interest in “Consciousness levels” during a Comatose state, I chose this particular subject as my research topic.

The focus of my paper would be to survey the Topic of Consciousness Levels During
Comatose States with an attempt at exploring the Coma within the context of the
Research Question which is – what levels of consciousness exist in comatose patients?

My focus is to gain some idea of whether patients are more conscious than we attribute them to be in a comatose situation which is deemed to be one in which alertness to one’s surroundings is at its minimal. And my focus is on researching further into levels of consciousness or unconsciousness in patients who have been in comas as well as interviewing a few chosen research subjects who would be able to enlighten me on the realms of consciousness when patients have slipped into comas.

LITERATURE REVIEW

Induced Coma - A temporary coma or deep state of unconsciousness brought on by a controlled dose of a barbiturate drug, usually pentobarbital or thiopental.

The Glasgow Coma Scale - a neurological scale which aims to give a reliable, objective way of recording the conscious state of a person, for continuing assessment that gives a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale).

Tracheotomy - surgical procedure on the neck to open a direct airway through an
incision in the trachea (the windpipe).

Brain Stem Contusion - A form of traumatic brain injury and bruise of the brain tissue which occurs in 20–30% of severe head injuries

Consciousness - a quality of the mind generally regarded to comprise qualities such as subjectivity, self-awareness, sentience, sapience, and the ability to perceive the relationship between oneself and one's environment.

MRI Magnetic resonance imaging (MRI) - a medical imaging technique provides detailed images making it especially useful in neurological (brain) imaging.

Stupor - the lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain.

Vegetative State - condition of patients with severe brain damage in whom coma has
progressed to a state of wakefulness without detectable awareness.

Locked-in-Sydrome - a condition in which a patient is aware, awake, but cannot move
or communicate due to complete paralysis of nearly all voluntary muscles in the body

Brain Death - The irreversible end of all brain activity (including involuntary activity necessary to sustain life) due to total shut down of the cerebral neurons following loss of blood flow and oxygenation

METHODOLOGY

The Methodology involved in exploring my Research Topic consisted of

- Interviewing someone who has been in a coma,

- Interviewing a doctor who has treated coma and thirdly,

- Interviewing someone whose family member has been in a coma (someone whose been

by their side during their state of Comotose)


With extensive exploration via Internet sources as cited within this text and Research Questions which revolved around how conscious or unconscious the coma patient really is, my mode of inquiry was in actual face-to-face interview form as I prepared the interview questions that were open ended questions that inquired into what levels of Consciousness were in existence within the period of coma as treated, as observed and as experienced first hand. With a familiarity with the concept of a Coma and the data possessed on the topic in hand which involved inquiring into what levels of consciousness are apparent, how conscious or unconscious the coma patient is in terms of observable and medical evidence, what is believed to be heard, experienced, absorbed of the world around the coma patient and in its most informal form, the question of what really goes on within the comatose patients realm of consciousness were questions directed at the doctor.

A difficulty I encountered was the need for sensitivity with regards to the family member whose loved one had been in a state of comatose (before passing away) whilst the coma patient himself required that a pre-prepared quota of questions be laid aside in favour of discretion while interviewing, this causing the research questions to rely on the lines of what observable and personal experience could be recounted of the Research Subject’s exposure to the event of “Coma”


FINDINGS AND DISCUSSION

Coma - During this time, the patient cannot be woken; the patient's eyes are closed, and brain patterns reveal a type of sleep similar to that induced by anesthesia, with no dreaming. (Wanjek 2007)

Dr. Madhri Senanayake, a practising surgeon at the General Hospital in Colombo when
interviewed, explained that from a medical point of view, the severity of coma has a
bearing on what realms of consciousness may be observable as the mind diminishes in its capacity to react to external stimuli.

Explaining that Stupor, Vegetative State, Locked-in-Sydrome, Brain Death and Coma
are different stages of abnormal conscious states, she said that a Coma is the lowest level of consciousnesss a person can be at. Measuring the realms of consciousness she said, brain activity differed from case to case although the outward signs were the same – that of a deeply sleeping patient. She stated that if patient response to stimuli was very poor in cases of extreme neurological damage in the brain of the coma patient, the patient would then have difficulty in responsing with non-existence of motor activity, zero response to pain (as she explained that patients are touched and pressed at certain points to ascertain response levels) going down to a score of 3 on the “Glasgow Coma Scale” which she said, was the measuring scale of consciousness in como patients. She explained that while hearing is the last sense to go, there is no really conclusive way in which to determine what exactly goes on within the thought patterns or unconscious realms of a comatose person can here. In instances of lesser brain damage, patients asleep, heard and responded to such as simple commands like squeezing a hand or opening eyes.

The researcher was of the view that a patient’s awareness to the environment is possibly yet to be critically and infinitely measurable from a psychological point of view in Sri Lanka as the practical medical requirement of treating seemed to superceed that of researching into the infinite workings of the unconscious mind of the patient on a case-by-case basis.

Traveena Jesudasan when interviewed about what she observed in her cousin who was in
a coma for 3 weeks, said that she felt that the doctors were right in explaining to her that the patient’s sense of hearing would be the last sense to leave the patient. She recounted that the patient was very still in a state of deep unconsciousness and was of the view that the positive talking was what kept her cousin who was severely brain damaged alive for longer than was intitally expected. She went on to state that while every other function remained static, the pulse rate of the patient increased whenever the patient’s sister was in the room.

This provided some explanation into the belief the researcher found that doctors held that regardless of the prognosis, family members and friends should keep talking positively to the patient whose consciousness then, seemed to extent to some awarness, of who was in the room and what was being said, contrary to what was visible to the lay visitor.

Jith de Fonseka – the third research subject, experienced Coma first hand when he
was thrown out of a sports car in an accident which bent his neck abnormally and
stretched his spinal chord beyond normal extremity. When asked to describe his
experience of consciousness, he explained that he was fully unconscious for 6 weeks with a diagnosis of Coma caused by “Brain Stem Contusion”. He regaining consciousness in the 7th week. He recalls shutting his eyes at the scene of the accident when he lost consciousness as he hit his head on the the ground. and opening them in a blink, long enough for it to register in his mind that he was in a hospital. Again he realls shutting his eyes and falling fast asleep after looking around in seconds, feeling as if he were in a dream, seeing a clock before him and yet not being able to speak or make sense of his world.

Describing the realms of consciousness he felt through out his coma, he stated that he would categotegorise it as fully unconscious, regaining consciousness, semi-cnsciousness and consciousness. When asked the difference in realms of consciousness he experienced, an interesting fact he stated was that the fact that in his semi-conscious stage, he was able to slowly connect a person he saw with some association which faded away in his mind within seconds and open his eyes again. His family ascribed it to be regaining consciousness but in his experiecne he said, was that it was yet a comotose stage as far as he was concerened. He was not conscious. He explained that when in coma, his consciousness levels were poor, yet fading, yet returning to fade again. The day he completely awoke from his coma was the day he said to himself, “today I’m fully conscious”. He said he was neither conscious of the fact that he was after an accident, nor that the right end of his body was completely paralysed and hardly aware of any sensation to his body caused by the
Tracheotomy.

The subject stating that he was not aware of his family members being near yet had a
“sense” of what went around him audibly from the ticking of the clock to eternal sounds that he could not make sense of as he lapsed into days of what he said, felt like a dream, complimented the medical explanation of the sense of hearing lingering to the last. The researcher noted that while he described the incident as traumatic and even said that most of what he recalls is what people say happened to him, he affirmed that he remembered the sound of soft voices as being vivid through the long period of silence of even in his “deepest unconscious sleep”

CONCLUSION

Based on what was ascertained through the results I obtained whilst exploring
this Topic of Coma in relation to the field of Consciousness, the findings within articles and the three conducted interviews when perused within the scope of original analysis, led me to realize that there was indeed some level of consciousness in which there was a susceptibility to hear external stimuli from the environment.

Moreover it left me pondering on the need for a more efficient means of measuring or
probing into consciousness levels in comatose patients in the country in which my
research was conducted. Sri Lanka I realized through this research, required a sophisticated MRI and Pet Scan equipment that would give a more detailed account of
the frequency, intensity and duration of environmental stimuli that the patient receives which in turn would give a clearer insight into the realms of consciousness on a case by case basis of all comatose patients which would enable more in-depth research to be fruitful in the said topic of exploration of consciousness levels.

Finally, my own analysis of this research topic was one which discerned a gap between the monitoring of levels of consciousness in coma patients in Sri Lanka as
opposed to the West. Encountering the story of Terry Wallis who made a recovery after 19 years of being in a Vegetative State which led to a team of US/New Zealand
researchers who scanned his brain with a technique called diffusion tensor imaging (DTI) even as Voss explained (as cited in Journal of Clinical Investigation study, 2006) that the emergence of conscious activity was due a very slow and ongoing self-healing process in the brain, I realized through inquiry that this method is yet unavailable in Sri Lanka, which helped me understand perhaps the levels at which research into close monitoring of consciousness levels in coma patients in Sri Lanka lie which had its own bearing on the research outcome in terms of in-depth explanation.

© Slow Chills