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Lethal Conventional Wisdom on Brain-Injured Patients Constantly Changing

by | Dec 8, 2011

By Dave Andrusko

Some of you may be personally familiar with this scenario.  When faced with a patient who has suffered serious brain injuries, many doctors almost reflexively conclude that the prognosis is hopelessly bleak and suggest to that the family “pull the plug.”

Why? Perhaps because they “knew” that a diagnosis of permanent could be affixed to anyone  in a so-called persistent vegetative state  if the patient has not come out after three months (if the injury was caused by oxygen deprivation), or one year (if it resulted from blunt trauma). Those diagnosed to be in what is known as a “minimally conscious” condition “did not fare much better than those who were vegetative, [so] most doctors did not bother to draw the distinction,” according to Jeneen Interlandi writing in last Sunday’s New York Times magazine  (www.nytimes.com/2011/12/04/magazine/can-ambien-wake-minimally-conscious.html?_r=1&scp=1&sq=Jeneen%20Interlandi%20&st=cse).

But all that conventional wisdom is now up for grabs. Interlandi’s fascinating story in last Sunday’s magazine focuses on the pharmaceutical sleeping drug Ambien which paradoxically has the effect in some patients of “wakening” them up. That was the case with Chris Cox in 2008. The narrative weaves the story of Chris and his parents, Judy and Warren Cox, into recent medical research to illustrate how much what physicians thought they knew about patients with severe brain injuries has been disapproved.

After Chris accidently took too much Oxycontin (taken for debilitating back pain), he collapsed. His brain was without oxygen for 30 minutes, and physicians (understandably) painted a nightmarish scenario, trying first to get the parents to “pull the plug” and then “sign a do-not-resuscitate order,” according to Mrs. Cox. They refused. Wayne and Judy refused to sign. “This is not some dog we’re talking about putting down,” Wayne shouted. “This is our son.”

When Chris not only survived but the horror stories did not take place, doctors decided Chris was in a less severe condition—“minimally conscious.” (Some studies have concluded that up to 40% of patients who are minimally conscious have been misdiagnosed as in a PVS.)

Convinced “that the son they know and love is still ‘in there,’ Chris’s parents have spent the past three years searching for a way to bring him back out. So far, their best hope has come from an unlikely source: Ambien,” Interlandi writes.

A growing body of case reports suggests that the popular sleep aid can have a profound — and paradoxical — effect on patients like Chris. Rather than put them to sleep, both Ambien and its generic twin, zolpidem, appear to awaken at least some of them. The early reports were so pronounced that until recently, doctors had a hard time believing them. Only now, more than a decade after the initial discovery, are they taking a closer look.

Ambien is not a miracle drug in the sense that it works all of the time on all patients with severe brain injuries. It doesn’t. But in Chris’s case the improvement is obvious, if limited, and in other patients the improvements have been nothing short of radical.

Early on the family had to fight with doctors who were convinced every behavior Chris made was entirely reflexive, produced by his brainstem. Only when they literally pulled him over and made a doctor watch Chris respond to requests did the light turn on: “The doctor’s jaw dropped.”

The most important conclusion in the story—most important for families with brain-injured kin—is that doctors often see their duty as “helping loved ones face reality”—aka assume the worse and advise family early on to withdraw care.

But Dr. Joseph J. Fins, chief of medical ethics at Weill Cornell, argues this is a “cop out,” according to Interlandi.

“It’s glossing over all the unknowns for the sake of a quicker, cleaner solution,” he says. “It’s wrong to be so uniformly fatalistic so early on, especially with all the data emerging about the prospects for later-stage recovery.”

A great and encouraging story of love, loyalty, and utter determination. Set aside 15 minutes of your day and go to www.nytimes.com/2011/12/04/magazine/can-ambien-wake-minimally-conscious.html?_r=1&scp=1&sq=Jeneen%20Interlandi%20&st=cse

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