How Active Is the Brain in a Coma?
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New technology could help foster a primitive form of communication with patients who are minimally conscious.
June 28, 2012 --
Today the Supreme Court upheld the 2010 health care law in a dramatic victory for President Barack Obama. The lead up to today's decision has prompted debate between opponents and supporters of the Patient Protection and Affordable Care Act two years ago. Take a look at how we got to the health care system we have in place today.
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Prior to the 20th century, nothing even close to what could be called a health care system existed in the United States. Although the Civil War had led to some medical breakthroughs in terms of surgical techniques and pain management, medical knowledge, techniques and treatment availability at the time left little hope that patients would actually recover from severe ailments. As NPR's Alex Blumberg and Adam Davidson point out, medical treatments may have been downright medieval at the time, consisting of potions. But at least it was cheap. "In 1900, the average American spent $5 a year on health care ($100 in today's money)," they note in their report.
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In 1912, Theodore Roosevelt was the first presidential candidate to get behind the idea of a national health insurance plan. Roosevelt ultimately didn't win election that year. Proponents of government-provided health care tried to press the issue through state initiatives, only to see their efforts fail in 16 states. Roosevelt's plan may have certainly been ahead of its time, particularly since there weren't that many services that doctors could actually provide patients during that era.
At the same time, however, developments within the medical community changed the face of the industry. The horrors of World War I led to advances in the areas of wound care, sanitation, pain management and more, according to an article published in the Journal of the Royal Society of Medicine. Hospitals in the United States began to widely adopt the practice of using antiseptics to sanitize their facilities, preventing the possibility of medical personnel or patients becoming exposed to infection. That decade also saw the introduction of the first employer group insurance contracts (though not specifically for health insurance) as well as the first physician service and industrial health plans.
In 1928, Alexander Fleming made one of the most important discoveries in the history of medicine: penicillin, a life-saving drug used to treat countless millions. It would be decades, however, before penicillin would be mass-produced. Fleming's discovery was the signature achievement in an era that saw medical treatment become more effective, and, as a result, expensive. The Great Depression also fueled concerns about affordability of medical treatment as millions of Americans suddenly found themselves out of work. In 1929, Baylor Hospital provided the first group health insurance plan in the United States through an agreement with Dallas-area teachers. The plan was the forerunner of Blue Cross. The effort wasn't just meant to be in the best interests of patients, but also the hospitals. Patient facilities saw more empty beds as fewer patients during the Great Depression could afford treatment without participating in these collective prepaid health insurance plans.
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As part of his push to create a social safety net for Americans during the Great Depression, President Franklin D. Roosevelt advocated the passage of national health insurance. Roosevelt pushed ahead with efforts to pass Social Security first, a bill which intentionally omitted any mention of medical care to ensure its passage. Harry Truman attempted to carry on Roosevelt's legacy in 1945 by calling on Congress to create such a program. His efforts failed, partly due to criticism by the American Medical Association (AMA), who called the plan "socialized medicine." In this photo taken in 1937, First Lady Eleanor Roosevelt examines a chart of enrollment of health care insurance plans.
Like its predecessor, World War II would lead to new medical advancements, including the widespread adoption of antibiotics and the use of ultrasound. The war would also have a similar effect in terms of the spread of employer-sponsored health plans. Because the nation was in a state of emergency and had a legally mandated wage freeze as a result, employers had to attract workers to assist the war effort by providing them with benefits, including health insurance. Tax laws passed between 1943 and 1945 also gave breaks to employers who provided insurance to their employees, which gave businesses all the more incentive to offer coverage. Following the war, employer-sponsored health insurance became common. In 1951, around 77 million Americans had some kind of coverage, according to an insurance industry trade group. That era also saw one of the most celebrated medical achievements in history: Jonas Salk's polio vaccine.
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Although health insurance was widely available to employed Americans in the mid-20th century, the unemployed and the elderly were often excluded from these plans. President John F. Kennedy campaigned on the issue of insuring these groups. President Lyndon B. Johnson succeeded where Kennedy left off, securing the passage of a bill through Congress creating Medicare and Medicaid. At the bill-signing ceremony, shown here, Johnson presented former president Truman with the nation's first Medicare card. Within the medical industry itself, an increasing number of doctors began specializing in certain fields of medicine rather than acting as general physicians. By 1960, more than two-thirds of doctors reported themselves as full-time specialists, rather than general practitioners.
Starting with Richard Nixon in 1970, presidents have offered successive plans for covering the nation's uninsured, but they have have stalled for different reasons. In 1974, Nixon put forward a plan to cover all Americans through private insurance, only to have the Watergate scandal force him out of office. An economic crisis prevented Jimmy Carter from pushing forward with a national health plan. Congress late in Reagan's second term attempted to expand Medicare, only to have the law repealed the following year. Bill Clinton had a 1,300-page health care reform bill that was never even taken up for a vote in Congress. Since Nixon's presidency, health care costs have continued to rise, often outpacing inflation. This increase is due to a number of factors, including the increased use of new medical technologies for diagnosis and treatment. The Patient Protection and Affordable Care Act signed by President Barack Obama was intended to cover the 30 million Americans who live without health insurance, according to the bill's authors. It has been the most far-reaching piece of health care legislation since Johnson's signed the legislation creating the Medicare and Medicaid health care programs.
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A new type of brain scan is giving neurologists insight into what is happening in the brains of patients who appear to be in comas.
When doctors recently tested former Israeli Prime Minister Ariel Sharon brain with a functional MRI, they found "robust" brain activity when he was shown pictures of his family and heard his son’s voice. A stroke and brain hemorrhage left Sharon in a coma seven years ago.
While the findings don’t change the prognosis of many patients, doctors are excited because the technology could foster a primitive form of communication with patients who are minimally conscious. It could also help prevent and correct misdiagnosis of patients who appear to be in comas, but are actually in a "locked-in" state.
"It’s like watching the top of the ocean and thinking you can understand what goes on under the waves," said Dr. Peter Nakaji, a neurosurgeon at the Barrow Neurological Institute in Phoenix, of the bedside techniques commonly used in clinics. He and others are hopeful that new techniques could provide a glimpse into the deeper realms of the brain.
The fMRI technology has been used in brain mapping research since the early 1990s, helping detect the onset of Alzheimer's and providing key information to brain surgeons about where to operate, but researchers in the United Kingdom and Belgium made a breakthrough discovery by applying the technology to patients who could not communicate at the bedside.
Knowing that 40 percent of patients with disorders of consciousness are misdiagnosed, the researchers designed an experiment to see if they could learn more about how their subjects’ brains were functioning. When 54 patients -- in vegetative or minimally conscious states -- were asked to imagine hitting a tennis ball, the appropriate area lit up on the image of the brains of five of them. One of the patients was able to use the technique to answer yes or no questions. The study was published in The New England Journal of Medicine in 2010.
What actually goes on in the brains of patients with disorders of consciousness depends on where they fall on the spectrum of unconsciousness, although there is some grey area in the terminology of coma vs. vegetative state vs. minimally conscious.
In a comatose patient, brain activity is "dampened and slowed."iStockPhoto
In a comatose patient, brain activity is "dampened and slowed," Nakaji said, and the "light switch of the brain" -- the reticular activating system -- is not on. While it might seem like the person is sleeping, the brain is in a much different mode. The brain activity of a sleeping person is much more active than that of someone in a coma.
"When you're asleep, you're actually much more active than you might think," Nakaji said. For example, if you poke a sleeping person, he or she might swat at your hand. Someone in a coma would not respond except with a reflex movement.
Most patients don’t remain in a true coma: they either die or move into a vegetative state. A patient is described as in a vegetative state when the arousal mode starts to kick in, but they are not able to interact with their environment. A vegetative patient's eyelids might flicker when someone walks in the room, for example.
"By definition, vegetative patients are not able to give any meaningful responses," said Dr. Romer Geocadin, associate professor of neurology at Johns Hopkins. "Vegetative patients are able to regain the ability to ‘wake’ up, but their brains are never able to interact with the environment or be aware. However, a vegetative patient can recover to a point that they can answer simple questions or follow simple commands. When they are able to do this, they are in a state known as minimally conscious ... at that time they are still severely incapacitated, but many may be able to respond to questions of prolonged life support."
And some patients who appear to be in comas actually have full brain capacity. Locked-in syndrome means that a patient cannot move except for blinking eyelids. When a patient in a locked-in state is diagnosed correctly, doctors and family can communicate through asking questions that can be answered by blinking yes and no responses. Twice, Geocadin and patients’ families have taken patients off of life support by using the method to understand their wishes. The primitive form of communication can also be used to make the person more comfortable.
So what does Sharon’s brain activity indicate?
"All we can tell from the report is that they are observing some brain activity in response to voice and images on the brain MRI," Geocadin said. "Given the extent of brain injury, it is extremely difficult to say where these observations of brain activity on MRI will lead in terms of recovery. Yes, this may bring some hope. But there is a very big gap between changes in brain activity to actually seeing a person regaining consciousness, enough to sit up and talk. Given the devastating stroke, this is unlikely to happen."