05/24/2013 // Concord, CA, USA // LifeCare123 // Greg Vigna, M.D., J.D. // (press release)

Medical Perspective:

Brain injuries that are the result of an acute deprivation of oxygen are termed anoxic brain injury. This type of brain injury is most commonly the result of acute cardiac events such as a heart attack, near drowning, and shock (inadequate blood perfusion to the brain) from major trauma. ‘Successful’ resuscitation in the field are those patients who have no pulse on initial presentation but with acute management by bystanders or train medical providers become a “viable” survivor in an intensive care unit often in coma which is a state of “unarousable unresponsiveness.”‘ When the patient opens their eyes and has a Glasgow Coma Scale of eight or more, they will be out of coma. The mechanism of coma in anoxic brain injury is a diffuse injury to the cerebral hemispheres of the brain because of a lack of oxygen.

During the first week following the anoxic event patients will be in the ICU where there will be a variety of specialist managing the various aspects of the care. Families will find themselves asking the treating physicians, the nurses, the therapist issues regarding prognosis such as death, survival, and functional outcomes. Medical providers are saddled with the burden of both needing to be honest with the patient’s family but not being perceived as callus and negative. In this situation medical providers will often dodge the difficult questions and cling to the generally accepted tenets held by the medical community and simply tell the family that the longer the coma the worse the prognosis. This article will discuss clinical findings that the family can themselves see when they visit their loved one so they will have a better understanding of the patient’s prognosis and “break the ice” with the treating physicians and hopefully will lead to a more frank discussion about the prognosis and future care needed in the care of the anoxic patient. From my fifteen years of experience in managing patients and dealing with anoxic brain injured patients it is important to discuss with the family issues regarding outcome and prognosis in the context of what needs to be done for the patient now and in the future to improve the patient’s lives and decrease the social stress on the family unit. Hopefully this article will allow families an opportunity at having more frank discussion with providers of medical care.

During the first week following an anoxic event families are most concerned with the question of whether they’re loved one will have a chance at being independent in the future. There are certain findings on clinical exam that a layperson can do and understand. It is important for families to understand that both the depth of coma and findings on physical exam may be blunted or changed by medications that are required to sustain the anoxic patient on life support. Therefore, the patient may appear to be in coma, but for reasons related to the necessary medical management they are in a drug-induced state of unconsciousness that doesn’t reflex the patient’s actual neurologic status.

There are certain findings on physical exam at key time periods following the event that caused the anoxic brain damage that directly correlate with chances that the patient will regain function that they can be independent.

Initial Presentation:

Patients with intact pupillary reflex have a much better chance of independent living than those who don’t. An intact pupillary reflex is when the pupil gets smaller when a ‘pen light’ shown into the eye.

At 24 Hours:

Patients who move their body away from painful stimuli and those who spontaneously open their eyes or open their eyes in response to noise have a much better chance of independent living than those who don’t. Patients who respond by simply flexing both arms and wrist and holding their legs stiff like a board (decorticate posturing) have a worse prognosis.

At 72 Hours:

Patients who move their body away from painful stimuli or purposefully in response to visual, verbal, or tactile stimuli and have normal spontaneous eye movements have a much better chance of independent living than those who don’t. In patients who response with nothing better than a decorticate posture have worse prognosis

At 1 Week:

Patients who obey commands have a much better chance of independent living compared to those who do not.

From my experience from providing consultation services during my training at a Level 1 Trauma center the significance of the physical findings can be explained to families which will give them a greater understanding of the prognosis that will lead to more constructive discussions regarding future needs of both the patient and the family. By allowing the family to understand what the experienced clinician is observing will increase the trust of the family regarding the care that the team of health care professionals are providing which will decrease anxiety and confusion of the family.

What is a life care plan?

It is a life care planner’s role to provide a road map for the care of these patients to maximize function, reduce or eliminate complications, and improve the individual’s quality of life going forward. All recommendations must be medically necessary and must be appropriate. Individuals and families of a severely brain injured patient will benefit from a life care plan because it is a concise summary of current and future needs and their associated costs. It is essential evidence for the court for damages related to injuries from a negligent act or a product liability case. A medical profession who is a Certified Life Care Planner best devises a life care plan in a brain-injured patient. It is best to obtain a life care plan from an experienced professional with extensive experience caring for patients with brain injury who communicates with the treating physicians and other medical providers to develop a comprehensive plan that will provide all the care to the expected life expectancy of the patient.

It would be unusual for a life care planner to be involved in a patient at this stage of injury, but generally the earlier a life care planner is involved the better. A life care planner will be familiar with the most appropriate rehabilitation facility that can meet the needs of the patient. A life care planner will understand the needs of the families and will seek out help psychologist who can assist with the stress on the family unit. A life care planner will look at available indicators of prognosis to gain some insight regarding necessary care and future needs of the patient and family going forward. An anoxic brain injured physical findings within the first seven days has proven reliable regarding future outcomes.

Lawyer Prospective:

At this early stage medical and family support will take precedent over lawsuit related issues. It is necessary for a patient and their family to do the following to preserve their rights going forward: 1) Avoid any potentially damaging admissions, 2) Preserve evidence (such as crash scene evidence) for further evaluation, 3) Verify the accuracy of police reports, and 4) Obtain contact information from witnesses, and 4) Discuss your situation with an attorney who is capable of dealing with the complexity of the medical diagnosis and can provide competent representation in the matter. It is unfortunate that a severe brain injury may have catastrophic financial impact on a family’s future. It is important for the family to seek services of an attorney to discuss the situation and investigate the insurance issues, the negligent parties resources, and the potential for adding a defective product to the claim that may have contributed to the cause of the brain injury which would provide a ‘very deep pocket’. Further, an attorney who can identify breaches in the standard of care, which may have contributed to the severity of the injury, may also provide for another ‘very deep pocket’. It is important to secure your rights and protect the interest of the injured family.

Media Information:

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