Explaining A Coma

Explaining A Coma

Several questions have been emerging since Chelsie's recent progress. Now she is performing several commands like walking, talking, and eating. Many want to know how she can still be in a coma when she is doing such amazing things. I am going to make an attempt to explain it as best as I can.

All comas are based on the Rancho Los Amigos Scale. This scale contains eight levels, eight being the highest. Right now, Chelsie is in level seven. In each level, it explains certain characteristics a coma patient will have and tasks they can perform. When a patient reaches the end of level eight, he/she will be "officially" out of his/her coma. Here are a few quotes from the Rancho Los Amigos Scale website that may help to the understanding of this process:

"Many people are surprised that all stages of coma do not resemble what we have been taught to expect; a deep sleep. The person in the coma may exhibit movement, make sounds, and experience agitation."

"The progress of coma is measured by the patient's increasing awareness of external stimuli. There are many levels of coma which the patient will pass through as functionality increases."

You can find the link to the Rancho Los Amigos Scale on the main page
or you can click here.

Here are a few comments taken from an e-mail sent by Dr. Vikki Stefans. She is head of the Progressive Rehab Unit at Children's Hospital.

As a rehabilitation specialist, it means a lot to me to see "real" information about brain injury getting out there to the world. Most people do not at all realize what is involved in brain injury or the rehabilitation for it. The old Hollywood movie concept of it still lingers on- that people get hit on the head, act goofy and can't remember their loved ones, and then just all of a sudden wake up and everything is fine. They don't realize that the old and familiar memories are the ones they can fall back on first, that family and friends are a big help, but that the real effort comes in becoming oriented to the day and the time and the place, and remembering daily events. They don't realize that a severe injury means being unable to care for yourself or get around on your own, and having to regain or relearn the most basic of skills. People also do not realize that driving or riding in a motor vehicle is the most dangerous thing any of us do on a day to day basis and that injuries can happen to anyone; still too many people do not do the simple things like buckling up and wearing helmets that can reduce their risks.

This website presents the hard reality of injury with great accuracy, but also with great dignity and hope, and a little humor on the side. It truly reflects what rehabilitation is all about, and above all the critical role of family, friends, and support in the recovery process.

Please keep these things in mind and also help educate others about comas. This incident has ultimately made many people more aware about comas, and we have all had a learning experience through the proces.

Here is a research paper that Laura Roush, Chelsie's cousin, wrote about comas:

    In the blink of an eye, the lives of a family and an entire town were turned upside-down as the news spread like wildfire from person to person. Lonoke High School senior Chelsie McManus was in a vehicle accident late in the night on October 25 and was hospitalized in Baptist Memorial Hospital in North Little Rock, in a coma that showed little sign of improvement. The people of Lonoke and Chelsie�s family were in total shock and asked themselves why this tragic event had to happen to someone so young and full of life. Chelsie�s vehicle flipped, and unfortunately, she was not wearing her seatbelt and suffered head injuries. The impact she received when her head hit the rearview mirror caused her to go into a coma. Chelsie�s sinuses were crushed along with the bone around her right eye, which would be fixed later. Doctors felt that she would not need brain surgery to relieve the excess pressure on the brain. After her accident, the school was filled with silence and sadness; no one knew what was going to happen to her. The week after her accident, students waited for daily updates and phone calls with reports about Chelsie�s test. Not knowing what was going to happen to her was a frightening situation. People thought back on a girl with whom they had grown up. They hoped to create many new memories instead of having to look back on the past memories. All anyone could do at this time was to pray and hope for Chelsie to show signs of improvement. Even a local newspaper reported that no one knew when she would wake up from the coma (Galucki, Hope 2-3). �A coma is a prolonged period of unconsciousness,� according to experts (Johnson, Understanding 1). There may be movement, but the majority of the time it is just muscle contracting. Chelsie at the beginning, would squeeze people�s hands when they said, �I love you, or Good-bye.� Little things like these are not known to be voluntary but make others feel that she is reaching out or trying to respond. Comas are life-changing events that affect the patient, family, and community.

     When in a coma, a person goes from walking, talking, and fulfilling everyday activities to lying in a bed not responding. The brain is the controlling factor for the movement of the body. When there is brain damage, the person has a good deal of change to cope with (Senelick and Dougherty 27). When a person is said to be in a coma, she is thought to be at the period before death. Being unconscious is where the coma patient does not respond to people and noises in her surroundings (Filloux 1). A person in a coma can suffer from any of these three types of brain injuries: tearing, bleeding, or swelling.

     � Tearing is when information cannot be sent through the nerves because the tissues are torn.
     � Bleeding is where the blood is not able to be sent to all parts of the body; blood vessels are torn, which can result in dying of brain cells.
     � Swelling of the brain, is where the brain expands so much that pressure builds up because there is not enough room, causing the brain not to function.

The patient can have the symptoms or suffer from one or more of the types of brain injury (�The Body�s Control Center� 4). Chelsie had bruising of the brain, which is the same as swelling, and possible bleeding. Her brain was swelling, but not bleeding, so she did not have to undergo brain surgery (Galucki, Hope 2). A coma is as if the patient is asleep and cannot be awakened, no matter how hard family and doctors try. One question is if she can hear what is being said around her. No one knows if she hears noises, because often no response is made (Dimancescu 1-2). Doctors do not even know what Chelsie McManus is capable of doing. Everyone has to wait for her to start doing things (Galucki, Hope 3).

     Chelsie�s coma is scaled on the Ranch Los Amigos, a scale from 1 to 8 (8 being the last level). The patient is not completely over the coma until all levels have been completed, meaning she has past level eight. The levels of a coma are as follows:

     1. No Response
     2. Generalized Response
     3. Localized Response
     4. Confused-Agitated
     5. Confused-Inappropriate-Non-agitated
     6. Confused-Appropriate
     7. Automatic-Appropriate
     8. Purposeful-Appropriate (Johnson, Rancho 1-2)

The patient has to overcome many �Behavioral Problems.� She can suffer from depression, get violent, and have rapid mood changes (Senelick and Dougherty 4). The patient might yell, �Get out of my room!� or think, �Who am I?� A coma patient has to overcome many personalities and asks those around her all kinds of questions. She does not understand the feelings that she endures. To express these feelings she has verbal and physical outburst towards others (Senelick and Dougherty 101,106).

     Recovery is vital for the patient to get back into the world and it�s daily functions. A scheduled routine or a day-to-day activity schedule is important for the patient to progress efficiently. A person needs to learn to follow a day-to-day constant routine (Levels of Cognitive Functions 3). Goals are set in which the patient is taught to try to accomplish the following:

     � Feeding �using utensils
     � Taking care of one�s self-learning grooming and dressing skills
     � Paying attention to tasks-building motor skills and playing simple games
     � Visual discrimination tasks-matching similarities/differences
     � Memory retention span-visual/auditory
     � Orientation-time, place, treatment program (Levels of Cognitive Functions 8-9)

There are therapists who help the patient learn the daily functions. The respiratory therapist is involved in helping the patient breath, when she is at the critical point of recovery. The therapist works with the patient on coughing, so that she can keep the fluid off the lungs (Senelick and Dougherty 12). The speech therapist works with the communication skills. Reading, writing, and talking are a few skills that are retaught to the patient (Senelick and Dougherty 122). Therapists teach her to write down what she does in a memory book. In addition, writing events on a calendar is helpful in remembering things (Senelick and Dougherty 146-147). The occupational therapist builds the hand-eye coordination skills. The patient learns how to cut food and interact with others (Senelick and Dougherty 122). Recreational therapy gets the patient ready for everyday life. She does things such as planting gardens and pretending to do work (Senelick and Dougherty 149). Feeding, dressing, and grooming are three of the main daily routine activities in which a person participates. When feeding herself, she has to sit correctly so she can swallow properly. The setup of the patient�s room is important when getting dressed. She has to be able to find clothes and then help in putting them on. The therapist is cleaning her and having her to help groom herself. The patient has to pay attention so that she will know what to do later when she is on her own (Senelick and Dougherty 128).

     In many instances, the family is told that their loved one who is in a coma does not have a good chance for recovery. At the point they are told, a feeling of shock and loss overwhelms them. The International Coma Recovery Institute considers that recovery is possible; anything is worth trying (DeYoung and Grass 2). For Chelsie McManus�s parents, finding out that she had been in a car accident and is now in a coma, was their worst nightmare. They have to stay hopeful to stay strong. Little things that Chelsie is able to overcome give them bits of hope. Things such as opening her eyes or moving her fingers and toes are what give them hope that she will get better (Galucki, Hope 1-2). Not knowing what will happen next makes the family feel sad and helpless. Chelsie�s family has to take one day at a time. They do not know what she will be able to do, and waiting is all they can do (Galucki, LHS 3). Many questions are asked when the patient�s family first finds out about their loved one�s state.

     � Will my loved on ever be the same?
     � How long will the healing process take?
     � Can�t the doctor make the person I love wake up from a coma?
     � Is my loved one malingering?
     � Do people in comas feel pain?
     � My loved one�s CT scan was normal, why is he in a coma (Senelick and Dougherty 180-182)?

The family has to change their daily life and routine. Mentioning the patient�s problems is not acceptable. The patient does not need negative feedback; a positive atmosphere will keep the patient strong and determined (Levels of Cognitive Functions12). The family needs support from others, but being educated on what is going on is good for the family. Being able to ask questions and understand what is going on helps the family adjust. New burdens on their lives range from behavioral problems to money issues. When the patient comes home, the family loses their freedom (Senelick and Dougherty 166-168).

    Finding a rehabilitation center is important, but complicated. There are many places in which the patient can undergo therapy. Hospitals, rehabs, and home are all places that therapy can be provided so that the patient can regain part of the lost functions. The family has to think of the patient�s interest and concerns. There are fifteen steps to finding a rehab:

     1. Evaluation and assessment of a patient�s needs
     2. Physical independence activities dealing with mobility, strength, and endurance
     3. Activities of daily living such as dressing, grooming, personal hygiene, and feeding
     4. Cognitive rehabilitation to compensate for deficits in attention, memory, judgment, initiation, and planning
     5. Treatment for swallowing disorders
     6. Speech and language therapy for communication disorder
     7. Behavioral management and modification
     8. Sexuality counseling and support
     9. Social skills groups
     10. Family counseling to deal with adjustment to a loved one�s disability
     11. Therapeutic recreation for teaching leisure skills
     12. Vocational assessment and retraining
     13. Re-entry into the community
     14. Patient and family education
     15. Alumni and support groups (Senelick and Dougherty 110-111)

The family in most cases feels that their loved one should be at home to recover, but rehab is better suited to recovery. It has specially trained people to take care of the coma patient. The family is taught how to take care of the patient when she finally gets to go home (Senelick and Dougherty 112). When finally choosing a rehab, researching and visiting the facilities will help to make the decision. The family should get second opinions and ask others who have had loved ones in the rehab, in order to see if the rehab will meet the needs of the patient. When interviewing the rehabs, families need to make sure that they will be updated on the patient�s daily progress (Senelick and Dougherty 114-115). The family is there to encourage and support the patient (Senelick and Dougherty 126). The McManus family has set a goal for Chelsie that she will be able to walk at graduation with her friends. Mike McManus, Chelsie�s father said, �Every little thing that she does is phenomenal. It�s been a real blessing, and she�s working hard.� Her determination and strong will should convince others that they should never give up. Family members are the ones who stay with the patient and keep her going in the right track (Tonsall 1).

    As the family supports the patient, so do community and friends support the family. On the night and first day of Chelsie�s accident, �More than 400 people came to the hospital,� Mike McManus said. People coming to visit kept the family�s minds off what was going on (Galucki, Hope 1). The community reached out through posters, ribbons, and many other gifts. People from school came to visit bringing cards to show their support for Chelsie. Lori Bevill, from Peppermint School where Chelsie worked, said Chelsie was, �A special girl, very rare.� Family members were still in shock, and keeping busy is what they needed at this point. The community, family, and friends missed Chelsie�s smile and hugs that she gave everyone. She was the �brightening� factor of the community. Chelsie�s accident caused many of her fellow students to think about how precious and delicate life is. They miss their friend and classmate giving them a smile and just conversing with them. This event has given students a better look at reality. Mike McManus said, �They realized that there are no guarantees, that bad things happen, and they need to better appreciate what they have� (Galucki, Hope 3-4). �The road to recovery has not been an easy one, but it has been made more bearable by the support the family has gotten from the community,� McManus said. People in the community reach out to the family for answers and give the family the support and comfort that they need to overcome such a tragedy (Galucki, LHS 2). Little Rock news station, KARK, came to Chelsie�s school to get the story on how the community feels a healing touch by one of her friends creating a web page for the world to see and read about a girl in Lonoke, AR. Lonoke senior, Amanda Harris, creator of the web page, said, � You shouldn�t have to see one of your best friends in a hospital bed�not able to talk to you, or know who you are�it was very, very hard.� People all over the world are writing to Chelsie. When something happens, many people are affected (Tonsall 1-2). The website has a message book for her friends and neighbors to talk to Chelsie and her family. Why have a web page? �It is our mission to have a place for people to share their thoughts from all over the state, nation, and globe concerning Chelsie�s health,� wrote Amanda Harris. A Chelsie McManus Rehab Fund was set up to help with rehab and further education at the First State Bank of Lonoke and Bank of England. The community is ready to help in any way possible (Harris 1-2).

    The story of Chelsie McManus is an example of how a coma can have a great impact on many lives. Dealing with change does not come easy; with change comes frustration and hardship. Family and friends cannot help think that they might lose a person who means so much to them, and this makes many think of how they could do things differently. For the patient, she is the one who suffers the most. She has to possibly live with some of the change for the rest of her life. When in a coma, the person will not ever be completely back to normal in most cases. The family is there to help their loved one cope with the change that she has to endure. The main thing to remember is that the only way to get through such a tragic misfortune is everyone has to look to each other for support and comfort. Support is just around the corner, because the family has the community and friends. Chelsie�s unfortunate accident brought many people closer together. A shoulder to cry on and people to talk to was what the community of Lonoke gave to the McManus family. Many felt that a part of their life was missing without such an inspirational person, one who gave everyone a great big smile. Prayers and hope to soon see her wonderful smile was what kept everyone�s drive for her to improve high. In the end, Chelsie was on her way to recovery with support from everyone around her.

Many Affects of a Coma