Coma

Jean asks:

I have a question related to cerebral hypoxia as a complication of old-style electro-convulsive therapy.

I’m plotting out a story that takes place in a psychiatric hospital. My protagonist is a patient at the hospital who was sane and healthy when he was forcibly admitted. He was formerly a thief, and escaped prison by being diagnosed with kleptomania, as a form of monomania. During the year he is incarcerated at the asylum and as a result of the treatments he undergoes, he gradually loses his sanity and his memory.

One of the anachronisms I have in the setting is the existence of electroconvulsive therapy, or ECT, which will be done using the early, more damaging methods. As such there will be no anesthetic, muscle relaxants, bilateral electrode placement or oxygen administered during the procedure. Other than the existence of ECT, the medical knowledge of the doctors at the hospital largely reflects the state of medical knowledge from about 1850 or thereabouts.

I’ve learned that one of the complications of ECT is the possibility of triggering a prolonged seizure or series of seizures that can last for many minutes during which the patient might be unable to breathe. Currently, doctors can prevent this by administering oxygen and using anticonvulsants to arrest a seizure that continues for too long. Neither of these options is available in a Victorian-based setting in which there were no effective treatments for seizures or coma.

In the plot, the ECT triggers a prolonged seizure and the protagonist is unable to breathe for several minutes. The resulting hypoxia puts him into a shallow coma for a short period of time. After he wakes again, the complications from the hypoxia produce symptoms in him that mimic the psychiatric symptoms that the doctors were expecting to see as a result of his “insanity”, such as memory loss, confusion, hallucinations, etc.

The research I’ve been able to do suggests to me that this is a plausible scenario, but I have no medical training and would greatly appreciate a more experienced opinion. Can hypoxia from a prolonged seizure triggered by old-style ECT send a patient into a coma if given no treatment? How long might be a realistic length of time for the coma to last? How severe could the resulting symptoms be?

Jordyn Says:

Thanks so much for sending me this question Jean and it is an interesting question!

I ran this by a physician friend of mine (thanks Liz!) and here are her thoughts and then I’ll add some of mine.

Liz Says:

I am sure with ECT “anything could be possible” but nowadays it is total disinhibition. These patients become very “frontal”—driven by the frontal lobe and lose their filter, become hypersexual, will say and do anything.

Some can become psychotic which can be accompanied by hallucinations. I don’t know if they could have hallucinations WITHOUT psychosis. But I don’t think anyone would argue the point since strange things happen in the brain with electricity especially in the setting as the early years of ECT. I’m sure hallucinations could also happen after the hypoxia and coma.

Jordyn Says:

The brain is one organ that we still know very little about. In the presence of hypoxia (or lack of oxygen) the length of coma and the severity of symptoms is largely up to the writer. There is a lot of leeway here. I’ve seen patients wake up from a coma that I would never thought should have survived and I’ve seen patients with more what seemed to be treatable head injuries progress to death.

Hope this helps and best of luck with your book!

I’ll be handling Christy’s question in two parts. Part one today.

Christy Asks:

A bullet grazes my hero’s brain. He’s taken to the hospital where he has an intracranial hematoma.Would he be in a medically induced coma after this? If so, for how long? When do doctors decide to take someone out of a medically induced coma? What would a victim be like after the fact? Sedated? When would they know the extent of the injuries?

Jordyn Says:

It depends. Let’s start from the top.

A bullet grazing someone’s brain. Okay—well in order for it to even hit the brain it has to come through the skull. So, it’s not going to be a minor injury considering that. Not like a bullet grazing your arm.

An intracranial hematoma means you have bleeding on the brain but you haven’t really specified the area. For instance, epidural hematomas occur between the dura (which is a tough membranous covering) and the skull. These are almost always taken to surgery.

In a subdural hematoma the bleeding occurs between the dura and the arachnoid layer. These are not always evacuated by surgery. It depends on their size. Intracranial bleeding can mean a lot of things—that the bleeding is just within skull (which includes the two things I’ve mentioned) or in the brain tissue itself. Bleeding within the brain tissue itself is much harder to deal with.

Would he be in a medically induced coma? It depends. The decision to put someone in a medically induced coma is more based on whether or not the doctors think the brain will swell as a result of the injury and not necessarily because there was a bleed. For instance—epidural hematomas are generally taken to surgery and evacuated without the patient needing to be put into a coma.

If they think they see a significant amount of swelling of the brain tissue then a medically induced coma is more likely. A patient is generally placed into a coma through the period of peak swelling which is generally 48-72 hours post injury. The patient gets a special monitor (a bolt) that monitors their brain pressure (or ICP—intracranial pressure).

After that peak period of swelling comes and goes a decision will be made to wean the patient off their sedation. The pressure may stay high. If the pressure stays high the patient may proceed to brain death (caused by herniation or hypoxia related to the pressure), or significant brain injury, or recover. It may not be known for several months what the outcome is though generally if a patient is going to suffer brain death they will do it in that 48-72 hr window. Past that, if they live but the pressures have been high—more a vegetative state or significant neurological impairment. If pressures have stayed lower—the patient may recover okay.

I have seen miracles, though, too so this is not cut and dried.

As far as knowing the extent of injures—they’ll know that pretty quickly based on CT imaging. However, what won’t be known is the affect on the patient. People can have the same exact brain injury—some die—some fully recover so there is a lot of writing leeway here. It may not be known for years how the patient will recover or what their lives post-injury will look like.

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Christy Barritt is an author, freelance writer and speaker who lives in Virginia. She’s married to her

Prince Charming, a man who thinks she’s hilarious–but only when she’s not trying to be. Christy’s a self-proclaimed klutz, an avid music lover who’s known for spontaneously bursting into song, and a road trip aficionado. She’s only won one contest in her life–and her prize was kissing a pig (okay, okay… actually she did win the Daphne du Maurier Award for Excellence in Suspense and Mystery for her book Suspicious Minds also).

Her current claim to fame is showing off her mother, who looks just like former First Lady Barbara Bush. When she’s not working or spending time with her family, she enjoys singing, playing the guitar, and exploring small, unsuspecting towns where people have no idea how accident prone she is. For more information, visit her website at: www.christybarritt.com.