Doctors thousands of miles apart were looking for signs of neurological activity yesterday as two men - a world leader and a coal miner - slowly emerged from medically induced comas.
The doctors had similar reasons to place Israeli Prime Minister Ariel Sharon and West Virginia miner Randal McCloy in states of deep sleep: to give their brains a rest from injuries that nearly killed them.
FOR THE RECORD - An article yesterday about medically induced comas misspelled the surname of Dr. Thomas Scalea, physician in chief of the Maryland Shock Trauma Center.
Sharon suffered a massive brain hemorrhage requiring three operations, and McCloy suffered carbon monoxide poisoning while trapped in a West Virginia mine.
In the days ahead, physicians will be looking for signals that the rest did some good: Can the patients move, respond to pain, recognize loved ones, speak or understand what is being said?
Physicians treating Sharon and McCloy said they have moved when poked and prodded, an encouraging sign that their brains perceive pain.
Yesterday, Dr. Shlomo Mor-Yosef of Hadassah University Medical Center said the Israeli prime minister had begun to breathe on his own, though he was still connected to a ventilator. His pulse, breathing, blood pressure and intracranial pressure were stable.
Sharon responded to pain stimuli with slight movements of his right hand or leg. "In response to administered pain, his blood pressure rose, another positive sign," Mor-Yosef said in a statement.
Similarly, McCloy reached up to grab someone's hand during a pain test, the Associated Press reported.
Experts watching the two cases from afar said it could be several days more, perhaps a week, before the patients shed the residual effects of the anesthesia used to induce a coma.
"If the five- or six-day mark comes around and there is no response or minimal neurologic function such as a gag reflex or speech, then it becomes more ominous," said Dr. Hassan Makhzoumi, an intensive care specialist at St. Joseph Medical Center in Towson.
For decades, doctors treating victims of brain injury have induced comas to slow down the body's activities, including the demands placed on the brain.
"The real thought behind the medically induced coma is that if you drop the brain's metabolism, you let it rest," said Dr. Thomas M. Scalia, physician in chief at Maryland Shock Trauma Center.
"It's like your mom said, if you rest you get better. It's a little more complicated in the brain, but you're essentially letting the brain recover through rest."
The technique is commonly used for people suffering from traumatic brain injuries and continual epileptic seizures, as well as severe strokes and carbon monoxide poisoning.
Dr. Daniel F. Hanley, a neurologist at the Johns Hopkins School of Medicine, said doctors often use barbiturates, long-acting sedatives, to render the patient unconscious. The drugs also have the effect of reducing intracranial pressure, a problem that causes much of the brain damage in astroke.
"The problem is that when you stop [the sedatives], it takes days and sometimes even a week to leave the body," Hanley said. "Impaired neurologic performance may be the drug or the disease."
As a result, some doctors prefer short-acting sedatives whose effects disappear within an hour after their use is stopped. Either way, patients are placed on intravenous fluids, feeding tubes and breathing machines while unconscious because the drugs have shut down many bodily functions.
The coma carries risks, such as lung infections that can occur when someone lacks the ability to cough or gag. The drugs can also overly suppress blood pressure and breathing.
Removing a patient from a coma is usually just a matter of stopping the intravenous drip that supplies the drugs.
"That's usually relatively benign," Scalia said of the withdrawal. "It just tends to wear off over some hours or days."
Hanley said doctors have to make sure that pressure inside the brain, held down by the anesthetics, doesn't rebound to dangerous levels once the drugs are stopped.
How a patient responds to the environment without being poked is a truer test of neurologic health, Makhzoumi said.
Both patients have suffered severe brain injuries that could leave irreversible deficits, doctors said. Though some patients can make significant recoveries, progress is often slow and requires months of therapy.
"Is it out of the question that some of Mr. Sharon's mental faculties will survive this assault? No, it's not," Hanley said. But he added that it's a safe bet Sharon won't be able to resume his duties as prime minister.
"And I think there's a very high likelihood that he's going to die from this," he said.
jonathan.bor@baltsun.com
