Author Question: Medical Condition for Elderly Man to become Comatose

Amanda Asks:

I have an elderly character who is about 90-years-old. As things stand, he is very sharp mentally and physically and fairly strong for his age. The story needs are for him to be in a coma, whether natural or medically induced, for several weeks.

My question is, is there a cause or condition that would make this plausible at his age, that he could still awake from when it’s time for him to re-enter the story? I did some preliminary poking around and it seems like medically-induced comas are less common in the elderly. What might happen to him to put him in such a state (naturally or medically), that he could still awake from?

It could be anything at all for the story. I just don’t know what’s feasible and what’s not. And how long can he be in the unconscious state before it becomes too unrealistic?

Jordyn Says:

Lots of things can cause someone to be in a coma caused by direct injury to the brain or something that would cause lack of oxygen to the brain.

One thing that is quite common in the elderly is a subdural hemotoma. Sometimes, if the clot is big enough, it will cause pressure and swelling on the brain enough to induce a coma. Usually, surgery would be used to drain a blood collection like this. One of the most common causes of a subdural hematoma in the elderly is a fall where they strike their head. As we age, our blood vessels become more fragile. If your character was also on a blood thinner for any reason— this would increase his risk for bleeding and potentially the size of the blood clot.

Any significant, direct injury to the brain can cause coma. A serious car accident. Falling off a ladder onto your head. Etc.

More medical causes, particularly in his age group, could be a stroke or a heart attack. A stroke causing a coma might be hard to write. In real life, it has a high mortality rate. Not to say it’s impossible but any direct injury in the brain (either through blood bleeding where it shouldn’t or the brain dying because of lack of oxygen causing death of brain tissue) is going to be hard to overcome with a mentally intact patient on the other end.

A heart attack, where he was deprived of oxygen for a period of time, could cause coma. Generally, over four minutes of down time without resusitative efforts is getting into the brain death arena. Even patients who are revived after four minutes will typically have brain death or proceed there. Of course, there are always outliers.

However, even a patient who gets immediate resuscitation (CPR at the least) can still proceed to coma once a pulse and good blood pressure are reestablished.

If I were you, I would pick either a subdural hematoma or a heart attack. I think this will be more likely to preserve the mental state of your character. If the heart attack, I would have it be a very short down time before he is treated and gets his pulse back.

Comas are very hard to write into stories. The length of time is up to you— that happens in real life. A coma of 1-2 weeks for these situations might be a little on the outside but possible.

The problem with a character in a coma for a lengthy period is that normal bodily functions must be tended to. We have to maintain the body functioning as close to how it does when we’re awake. So, the patient must be fed (either through a nasal, oral, or surgically implanted feeding tube). The character will still need to pee and poop— so a catheter can be placed to drain urine. We generally don’t like catheters to stay in long term because it increases the risk of infection for the patient and the elderly are more at risk for this.

Also, a patient in a coma is likely going to need ventilatory assistance and if they are on a vent over 7-10 days then generally there will be talk of putting in a trach.

The longer the coma, the more rehab a person will need. Even if in a coma for 1-2 weeks, the amount of generalized muscle atrophy will be significant. A character who is a 90 y/o who awakens from a coma after being bedridden for 1-2 weeks would probably go to inpatient rehab for several weeks/months and then outpatient rehab for a couple of months– and that might be underestimating. It’s just hard to recover from these types of injures as we age.

Hope this helps and best of luck with your story!

Reverie: Not so Medically Dreamy

NBC has launched a new summer show titled Reverie.  In it, Mara (ex traumatized cop, maybe psychologist) is recruited by a company specializing in making-your-dreams-come-true via a hyper advanced virtual reality program. The participants receive an implant that allows them to interact virtually with a program partly of their design.

Problem becomes, some of the clients don’t want to leave. Hence, our heroine, Mara, is recruited to go in after them and pull them back to reality.

In the first episode, it’s noted that the client has been in his dream world for two weeks and it’s commented by the staff that he’s essentially comatose. The man is lying on a bed connected to an ECG monitor and some oxygen via nasal cannula as pictured below. They give the man two days left to live providing a time pressure for the heroine.

However, medically, this man would have already been dead because they are not providing for either hydration or nutrition. This could be solved simply medically by inserting a feeding tube via his nose and providing free water interspersed with bolus liquid feeds. After all, thousands of people live in comatose states for years if their basic medical needs are met such as oxygen (if needed) and nutrition.

The heroine, Mara, is psychologically damaged. She’s had a significant personal trauma she hasn’t quite worked through. There is also a concern expressed by the designers of the program that something might not be quite right with it. When Mara enters the virtual reality program for the first time to retrieve a voluntarily trapped client they run an EEG on her which measures brain waves.

After she successfully retrieves the client, there is a conversation between the designer and lead dream architect that something is wrong with Mara’s EEG— something that indicates she could have a mental illness.

An EEG cannot diagnose a mental health disorder. Its use might be to determine if a patient has a medical cause that may be masked by some psychiatric like complaints such as a seizure disorder or sleep disturbance.

In episode 2, the producers must have gotten some feedback that they needed some actual medical equipment if they were concerned about these clients suffering medical complications. This time, a woman’s heart is going into erratic rhythms, specifically V-tach, because of the stress she’s under in her dream scape. But the medical equipment must make sense. What’s pictured in the photo to the right is what we call a rapid fluid infuser. It delivers IV fluids very quickly. Typically, it would be used in a trauma patient or one who is suffering from overwhelming sepsis where rapid delivery of IV fluids can be lifesaving. It is not appropriate for this patient who is suffering from a heart arrhythmia— much better to park a defibrillator at her bedside.

Have you watched Reverie? What do you think of the show’s premise?

Author Question: Long Term Coma

Tina Asks:

I’m a self-published author who has written two books from a YA fantasy series (The Arid Kingdom) and am now working now on a modern fantasy action novel.

I’d be really grateful if you could help me with some medical advice regarding this scene:

There is an accident during a concert. A girl who was singing on the stage has her head hit by a stage lamp. She falls unconscious and remains so for eight months.

1. Some other character with an open injury (a dagger injury) will be in the same hospital. Will they be in the same ward?
2. After she wakes up, will she have some memory problems?
3. I expect her to have some mobility issues after staying in a lying position for such a long time, like she’ll have to learn to walk again. Will her arms present similar issues?
4. How long does the recovery stage last and how is that done?

Jordyn Says:

Let’s first tackle the character who is in a coma for eight months.

What a lot of authors don’t consider is that humans eat, poop, and pee so all of these things need to be provided for in the unconscious person. If she has perpetual unconsciousness, she would need to be fed by a tube. Also, she’ll still need to poop and pee and since she can’t walk to the bathroom then she’d be placed in an adult diaper (or a catheter placed for urine drainage especially in the beginning). There are other things medically we consider in a perpetually unconscious person– most importantly– can they breathe adequately. Some can, but most end up with a trach.

When she wakes up, will she have some memory problems? You have some latitude here as a writer. Could go either way. She’ll probably be fuzzy until she figures out what happened but as far as her retaining her past experiences/memories you can decide.

This character would have whole body muscle atrophy from being bedridden for eight months. So yes, arms will be weak as well. She would be easily fatigued. Even something basic like brushing her teeth will be taxing.

Once she does wake up and is considered stable, she would be transferred to a rehab center and then transitioned to outpatient therapy. How fast and well a person does in rehab can be largely up to them. If she works hard, has a positive spirit, etc she could progress quickly if she has no other injuries. However, considering her length of unconsciousness, I’d imagine rehab would take months. Maybe eight weeks on the short side. I consulted with a physical therapist on this and he agrees. Could easily be longer. Two to four months as a range.

The character with the dagger injury would likely not be on the same ward. The unconscious person would likely initially be admitted to the ICU. The dagger injury, could even go home if not surgical. If surgical– then a regular surgical floor unless extenuating circumstances required ICU admission. Depending on the hospital, some ICU’s are split between medical and surgical.

Hope this helps and best of luck with your novel.

Treatment of Car Accident Victim with a Brain Injury

Leslie Asks:

My character has been in a car accident and sustained head damage (swelling to the brain)— is there a medical term for that? Also, the swelling becomes so bad the doctors have to remove part of her skull— is there a name for that? How long does that swelling usually take before it goes down so they can replace the skull? Does the character regain consciousness? I have her in an induced coma which I want her in for a while.

Jordyn Says:

Upon further clarification of this question from the author, she says there is not a significant description of the motor vehicle collision in the manuscript and the scene is being told from the POV of a nurse.

The brain swelling is called cerebral edema. Usually, if it’s a significant car accident then there is usually bleeding as well. This is why I ask about the car accident. It should be pretty serious.

A nurse will use language that a family can understand. So, I might actually avoid a lot of medical terminology when speaking to the family unless I also clarify what the words mean.

I might say something like, “Your mother (or whatever relation) has a lot of swelling in her brain as a result of the car accident. We call this cerebral edema.”

A craniectomy is where they remove a portion of the skull.

Peak brain swelling is generally 48-72 from the time of injury and diminishes from there. Induced coma is a reasonable medical scenario here.

Whether or not this patient regains consciousness is up to you as the writer. Statically, the odds are pretty low for her to be the same person she was before. If she does wake up, she’ll have extensive rehab needs for sure– but you could write it either way.

Best of luck with your story!