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Trapped in a coma but aware

Trapped ‘coma’ man: How was he misdiagnosed?
By Mark Tutton, CNN

STORY HIGHLIGHTS

.         Man diagnosed as being in vegetative state for 23 years was fully

conscious

.         Study found that 41 percent of patients in minimally-conscious
state were wrongly diagnosed
.         Lack of careful assessment can contribute to misdiagnosis

London, England (CNN) — A Belgian car crash victim who was misdiagnosed as
being in a vegetative state for 23 years was conscious the whole time, it
has emerged.

For years he listened to the conversations going on around him but he was
unable to communicate with his doctors or family.

Rom Houben was 23 at the time of the near-fatal car crash in 1983 that left
him paralyzed. Doctors presumed he was in a vegetative state following the
accident and they believed he could feel and hear nothing.

Neurologist Dr.Steven Laureys of the University of Liege, in Belgium carried

out a brain scan using state-of-the art scanning system and discovered that

Houben’s brain was fully functional.

In an interview with the UK’s ITV news Monday, Rom communicated by typing on
a special keyboard attached to his wheelchair, and aided by his carer.

He said: “At some moments it was terribly lonely but I knew my family was
believing in me.”

“I simply want to enjoy life,” he added. “I notice a big difference now I’m
back in contact with the world.”

The case has highlighted the difficulties doctors face when trying to
diagnose the level of consciousness of a patient in a coma-like state.

Watch Laureys explain how comas are assessed
<http://cnn.site.printthis.clickability.com/pt/cpt?action=cpt&title=Trapped+
%27coma%27+man%3A+How+was+he+misdiagnosed%3F+-+CNN.com&expire=&urlID=4154151
17&fb=Y&url=http%3A%2F%2Fwww.cnn.com%2F2009%2FHEALTH%2F11%2F24%2Fcoma.man.be
lgium%2Findex.html&partnerID=211911#expand1>

A study carried out last year on 103 patients by Laureys and his colleagues
at Liege’s Coma Science Group found that 41 percent of patients in a

Minimally Conscious State (MCS) were misdiagnosed as being in the much more

serious Vegetative State (VS).

Dr. Daniel Hanley, professor of neurology at Johns Hopkins Medicine, in
Maryland, told CNN that VS is a coma-like state in which patients have a

sleep and wake cycle, and can show reflex chewing, swallowing and blinking,

but don’t respond to language or stimulation.

Patients in MCS occasionally show they are aware of their environment, for
example moving to face a doctor when asked, but only infrequently.

Laureys said of his research, “Differentiating the vegetative from the

minimally conscious state is often one of the most challenging tasks facing

clinicians involved in the care of patients with disorders of consciousness.

“Misdiagnosis can lead to grave consequences, especially in end-of-life
decision-making.”

Watch one iReporter’s reaction to the situation
<http://www.ireport.com/docs/DOC-361212>

Caroline Schnakers, who carried out the research with Laureys, told CNN that
one probable reason for the high rate of misdiagnosis is that doctors often

base their diagnosis on observations of a patient’s behavior, rather than

assessing patients using standardized tests.

“Assessment is usually behavioral,” Schnakers told CNN. “For example, if you

come into a room and a patient’s eyes follow you, or if they smile when you
make a joke, they are conscious — but it doesn’t mean they will still be

able to do that one hour later.”

Schnakers said that using standardized tests could reduce incidents of
misdiagnosis.

The Glasgow Coma Scale is a standardized test that classifies a patient’s
motor, verbal and eye response on a graded scale. It was widely used until
about 2000 to classify a patient’s level of consciousness, but Schnakers
says it may contribute to misdiagnosis.

She told CNN, “In our study we used the JFK Coma Recovery Scale-Revised
(CRS-R), which is standardized for detecting signs of consciousness in
someone recovering from a coma. It’s very sensitive and avoided a lot more
misdiagnosis than the Glasgow Coma Scale.”

The CRS-R was developed at the JFK Johnson Rehabilitation Institute and
grades patients’ verbalization, communication, motor function, visual
function and response to sound.
Diagnosis can be further complicated by another condition, called Locked-In
Syndrome. Much less common than VS or MCS, patients in a locked-in state are

totally aware of their environment but have minimal reflexive movements,
typically only being able to blink their eyes. Hanley told CNN that Houben
may have been in a locked-in state.

But Houben’s diagnosis may have been made more difficult by the fact that he
was partly paralyzed, meaning he was unable to show a motor response.

“He was conscious for a long time, but it’s difficult to know for how long,”
said Schnakers. “Maybe he had a period of VS, but you wouldn’t know how long
it lasted, even if you ask a patient how long they were in VS or MCS.”

Hanley explained that diagnosis is also more difficult if a patient is being
treated with sedative drugs, which can cause severe neurological impairment
that can mimic VS. But even given those considerations, Hanley says
neurologists should easily be able to tell the difference between a patient
in VS and MCS.

Dr. Nicholas Schiff, of the Weill Cornell Medical Center, in New York, told
CNN that the risk of misdiagnosis is increased because a patient’s condition
can change over a long period and the transition from VS to MS often takes
place outside the time window of careful assessment.

“The ‘standard’ is probably transfer to nursing home from acute care at an
early stage, where an accurate diagnosis of VS gets replaced at the nursing
home with an inaccurate prognosis of permanent VS, explicitly or
implicitly,” Schiff said.

“Because there are no standards for reassessment or any access to
rehabilitation centers for many of these patients this is the status quo.”

CNN’s Caleb Hellerman contributed to this story.

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