A Question from a Screenwriter

[Brightlights87]

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(Mods, my apologies if this isn't the correct forum. Please move it as you see fit.)

Hello, my name is Misty and I'm currently working on a screenplay. It's a mystery involving a teenage girl who is attacked and goes into a coma for ten years. Since my medical knowledge is supremely limited, I thought that I might come here and pick a few brains (pun mostly intended.) My questions run along the lines of:
- Can blunt force trauma be enough to cause ten years of a minimal consciousness state without causing brain damage?
- If everything goes "right" medically, (no brain damage, plenty of phsyciotherapy,) is it possible for recovery time to be short and side effects to be minimal?
- Would this circumstance be rare enough to be notable or even considered a "miracle?"
- Would there be any notable considerations for a body going through puberty in a coma?

I don't want my mystery to be bogged down by details, but I also want it to be believable by people who would know. Any info (or links) that you could provide would be greatly appreciated. Thanks!

 

[typhoonegator]

We don't typically use the term coma for states lasting that amount of time, but you can be minimally conscious or in a permanent vegetative state for many years. Very few recover after that amount of time.

Blunt trauma can cause PVS and minimally conscious states, but by their very definition these constitute "brain damage". The odds of improving from these depressed states of consciousness diminish rapidly over the first year, and are extremely rare thereafter.

There have been a few "miraculous" recoveries after prolonged minimally conscious states, including people who just started talking again one day after 10-40 years. The general consensus is that people in PVS never recover, and those that have been reported were really in minimally conscious states mislabeled as PVS (a bit of a self fulfilling prophecy but whatever). However, even these amazing stories often have bad endings, as in the few recorded cases the subjects tend to regress again for unclear reasons.

The idea that someone could suffer a severe enough injury to put them in a minimally conscious state for 10 years and then one day wake up and walk and talk like nothing happened is more of a Lifetime movie thing. Even if they had a truly singular brain that rewired itself after 10 years with no lasting sequelae (exceedingly doubtful), the body wouldn't have done anything meaningful for that amount of time. Even with top shelf physical and occupational therapy on a daily basis, there is going to be muscle wasting, contractures, frozen joints, etc. to some degree. Also, people in these depressed states of consciousness can't participate fully in their rehabilitation, so things like speech and language therapy, gait and balance therapy, etc. can't really happen to a meaningful degree.

I've taken care of many young patients that suffered severe TBI and were in my ICU for weeks to months, then went to a coma-stim program in a minimally conscious state. Many of these people do improve to some degree, and some can even feed themselves and communicate after a year or two of rehab. I've seen a few really dramatic improvements, particularly in young people, where they walk back into the ICU a year or two later and thank us for what we did for them. That's rare, and even then they're never as good as they would have been if nothing had happened to them.

Provided that the pituitary gland and hypothalamus are not severely damaged by the trauma, the body would continue to move through puberty if the subject was young at the time of injury. Caretakers of people in these settings sometimes pursue chemical or surgical supression of sex hormone activity to prevent menstruation. The subject would probably be of very short stature, as the lack of gravitational load-bearing on the long bones would likely lead to early epiphyseal plate fusion.

Would love to hear what others think. The PM&R folks see a lot more long-term TBI than we do, so they might have some more insight for you as well.

 

[neglect]

Would love to hear what others think.

I think coma recovery stories in the media and, even worse, in TV adn movies do a disservice to the public. They mis-educate the viewers even more thoroughly than Fox news. In these shows, the girlfriend in a coma wakes up after months/years with none of the terrible residua we see. It simply is not reality based. So in talking to families about coma and brain death, one has to undo all the stupidity they "learned" from 90210 and Kill Bill. And that's hard.

And that's fine. This is fiction. I don't watch "Walking Dead" with a neurologic eye as to what sort of encephalitis the zombies have. (I do have to say that I found that Avatar/Pandora movie to be stupid on a neurologic basis)

No, the problem with these recoveries is that they reflect lazy and stupid writers (or whoever writes movies these days - some committee I suppose), who are unable to incorporate the real world into their fictions and need to rely on these inanities.

 

[neglect]

This is highly germane to this thread.

http://thesocietypages.org/socimages/2013/06/24/how-do-physicians-and-non-physicians-want-to-die/

In short, the fictions that our patients watch while NOT exercising or engaging with life keep them in a deep state of ignorance and might contribute to their unrealistic medical decision making.