A person’s vegetative state, or in other words, apallic syndrome, is a prolonged and non-sleeping specific state that occurs when leaving a coma. Due to the preservation of the functions of the diencephalon, a person has the whole set of conditioned reflexes, including the preservation of sleep and wake cycles. It is believed that while in a vegetative state, a person does not realize himself and the surrounding events, but is this really so and what do large medical specialists think about this?
Appalgic syndrome
Often you can even hear in scientific circles the expression that “a person came to himself from a protracted (severe) coma”, but this formulation of the question is incorrect in the root, because a person from a prolonged coma can only get into a vegetative state and nowhere else. Coma is the deep hibernation of the brain, but it cannot be a constant factor, it necessarily ends.
With minor head injuries or non-traumatic situations, exit from a coma is really possible without any additional intermediate phases. But the harder and more serious the event that led to the loss of consciousness, the correspondingly thornier the return path will be.
The phases of the vegetative state
The conditionally vegetative state of a person after a coma (which means - after the transition from an acute period to a wait period) is divided into two successive phases:
- persistent - when the appal form lasts less than 30 days and the doctors give the most optimistic forecasts;
- permanent - the term of being in a vegetable-like position for more than a month.
If we compare a person’s vegetative state with a coma, then, of course, this position can be called relative consciousness, but is the quality of consciousness “vegetative” always the same? It turns out, no.
Types of vegetative state
The heterogeneity of that intermediate stage, in which a helpless person finds himself, also has its own classification, which cannot be brought completely within the framework of one article. Here are just the main cases described in medicine:
- periods of sleep-wakefulness - all the life activity of the patient is enclosed in basic reflexes that are not related to an understanding of the surrounding reality;
- akinetic or hypokinetic mutism - the patient fully understands every word of those addressed to him, but is not able to express it externally;
- total aphasia - in the patient’s brain his own images and events are created that are not related to reality, he lives with them; reactions to the outside world are absent;
- locked-in is one of the most difficult situations for a patient when he is fully conscious and even tries to communicate by moving his eyes, but this happens almost imperceptibly to others.
We will talk more about the latter case of a person’s vegetative state later.
Life after a coma - what is a "small consciousness"
The intermediate state between the coma and the return of consciousness is not determined by any time frame. This period can last for months, and then doctors talk about a “stable” vegetative process, and can end only with the death of the patient, and then we will talk about the “chronic” form. True, recently this classification of post-coma conditions has been supplemented by another, called “small consciousness”, when the patient begins to “wake up”, but with flashes that are difficult to separate from the motor reflex movements characteristic of the apalic syndrome.
The transition to the "small consciousness" is the third link in the chain, which is extremely important to determine, since it literally means whether a person will be given a chance to survive or not. According to the standards of modern medicine, a person’s stay in a coma or vegetative state for more than a year (after a traumatic brain injury) or more than 3 months (if the cause of loss of consciousness was a stroke or heart attack) means the complete death of all the functions responsible for returning to normal life. That is, maintaining the life support of the heart is recognized as unjustified, and the patient is disconnected from the devices.
Separating the "small consciousness" from the reflexive "vegetative" and to this day is not possible. For example, we give the statistics of medical errors at the time of separation of the two conditions - this is 50%, that is, half of all cases of the diagnosis. Such shocking statistics cannot become an admissible error of medicine, therefore, at the moment, many scientific works have been devoted to the development of a methodology for accurately determining the transition phases of the patient’s consciousness after a coma.
Causes
Among the reasons that provoke coma, and subsequently vegetative "hibernation", traumatic and non-traumatic are distinguished. The first always include open or closed head injuries from a stroke or a fall, while the second etiological list is much wider:
- stroke;
- toxic poisoning;
- a consequence of an allergy to anesthesia or a medical error when administering an anesthetic drug;
- infectious pathogens that have invaded the brain;
- oxygen starvation (asphyxia);
- internal bleeding of the brain;
- cardiac arrest, heart attack.
According to medical statistics, people who have left the vegetative state after ischemic brain damage, in only 4% of all cases can return to the lifestyle that they led to a coma. After traumatic brain injuries, ischemia is the most common cause of a person's transition to an appal form of consciousness.
Clinical picture
Physical diagnosis of the patient, allowing to draw conclusions about the finding of the latter in a vegetative state, should identify the following factors:
- the patient does not respond to speech addressed to him, but responds to pain or touch with reflex movements of the limbs, groans;
- a complete lack of speech, including meaningful sounds that have a purpose;
- even at the moment when the patient’s eyes are open, the gaze does not focus on people around him or on objects;
- defecation and urination occur in a patient involuntarily.
At the same time, the following body functions are noted and evaluated by doctors as remaining unchanged:
- activity of the heart and blood vessels;
- digestive organs;
- respiratory activity.
Physical diagnostics also contain elements of testing motor functions - it analyzes how the patient eats, chewing and swallowing food, moves his limbs in response to pain stimuli. Normally, in the case of the appal syndrome, such actions as twitching for centuries, blinking, opening the eyes to light flashes or loud sounds, eyelid contraction, yawning, are present. The reflex of the capture of the object is kept, which is used to touch the patient’s open palm, legs are pressed to touch the feet.
"Closed man"
The locked-in syndrome is one of the most mysterious phenomena of a person’s vegetative state. What the patient feels, what he hears, and how the world perceives, the patient, who fell into the trap of his own body, was told to the whole world by the Belgian Rum Houben. The young man was immobilized after a car accident and spent more than 23 years connected to the equipment as a hopeless “vegetative”, obliged by the continuation of his life to the same person who gave it to his mother.
The woman all this time struggled to ensure that her son was recognized as a viable organism, however, professor of medicine Stephen Loris managed to prove more - that for all these years the patient’s consciousness remained completely clear. According to the unfortunate, for 23 years he tried to reach out to others, giving them signs that he hears and understands everything, but no one noticed them.
The locked-in syndrome is visually even more like a coma than the standard vegetative state, and how many people can live in this position - no one can tell, barely retaining the ability to move eyeballs, but rather, until the council and relatives are a decision was made to disconnect him from the life support apparatus. And another monstrous fact cited by medical statistics - it turns out that about 40% of all coma, who cannot even swallow food on their own and eat through a tube, understand everything that was said with them. So is it true that almost half of those who seem hopelessly lost to us are actually desperate to reach out to those around us from that layer of life that we call a vegetative state? Where is the soul of a person locked in himself, and how to understand that this is not a coma?
Diagnostics
Despite the large percentage of permissible errors, diagnostics to clarify the condition in which a person is suspected of having someone is carried out very carefully. First of all, the cause of pathological loss of consciousness is thoroughly investigated, then the verification of the preserved functions of the body and reflexes is studied.
Hardware diagnostics is performed using MRI equipment or CT, which allows you to consider the level of brain damage and evaluate the incoming electrical impulses from various parts of the brain. By the time the final diagnosis is made, a neurosurgeon and resuscitator are often involved. If the appalistic syndrome is confirmed, the patient is fully admitted to the department of the resuscitator, who is engaged in further treatment of a person in a vegetative state.
Treatment
Any treatment implies the patient’s return to the initial position preceding the disease, but in the case of “vegetatics” this is possible only at the very early stages of the extinction of brain activity. Otherwise, even if the patient manages to "put on his feet", he will not be able to lead a full life and will have to put up with the loss of many body functions.
The drug treatment of the patient consists in taking general supportive and stimulating agents:
- nootropics;
- vitamins;
- blood circulation improving drugs;
- neuroprotective agents.
The traditional recovery course also includes massages to prevent the formation of pressure sores and to maintain the quality of motor functions, physiotherapy. A more modern approach, practiced in some clinics, involves magnetic-wave stimulation and brain electrical stimulation. Side effects are not significant enough to rely on them, denying a person the opportunity to return to normal life.