COMA: When a Person Has Brain Injury by Ron Savage, Ed.D and Marilyn Lash-Cluett, M.S.W.

Written by Ron Savage, Ed.D. and Marilyn Lash-Cluett, M.S.W.

This article helps family members, friends and visitors to understand what “coma” means and to respond and give comfort to the person with brain injury.

What Does Coma Mean?

Brain Injury and coma-an interruption in living

Being told that your family member, friend or relative is in a coma can be confusing and frightening. Seeing the person unconscious for the first time usually is an emotional shock. The first questions asked are often, “What is a coma? How long will it last? Can he hear me?” Watching and waiting for your relative to respond and become more alert can be emotionally and physically exhausting.

A coma is a state of unresponsiveness that can last for hours, days, weeks, or even months. It affects the person’s response to sound and light, ability to follow commands, speech, and awareness of surroundings. Movies and television often show a person in a coma lying very still and quiet as if sleeping and then suddenly waking up and becoming alert. This is not accurate.

No one really knows how much sound, information and activity filter through while a person is in a coma. A person may move or groan and respond to sounds, touch or pain. Family members often believe that the person hears and responds to their voices. These signs may be reflexes – like squeezing a hand or sucking in response to touch. It is hard for families to sort out which responses are reflexive or automatic actions and which are planned or intentional.

A brain injury is usually described as mild, moderate or severe. The length of time that a person is in a coma is one of many factors that determines the severity of an injury.

Brain Injury Length of coma

Mild none or very brief
Moderate up to 24 hours
Severe more than 24 hours

The length of a coma varies for each person because each brain injury is different. Professionals can not predict precisely how long a coma will last. This is frustrating for many families, but the brain is very complicated. Much is still unknown about what happens after it is injured.

Measuring the depth of a coma is complicated because there are many levels of awareness and response. It is not as simple as being asleep or awake. The depth of a coma can even vary during the day. Examiners can differ in how they evaluate a person’s responses to sound, light, touch and commands. Two scales are often used in hospitals and rehabilitation.

Glasgow Coma Scale

This scale helps medical staff evaluate the person’s level of consciousness. It is based on three measures that each have numbered scores:

eye opening
verbal or spoken responses
motor or physical responses

The overall score has a high of 15. When the score is 13-15, the brain injury is considered mild; 9-12 indicates a moderate brain injury; 8 or less reflects a severe brain injury.

The Glasgow Coma Scale is used with children (ages 4+) and adults. There is a modified scale for younger children.

Rancho Los Amigos Scale

This is a more detailed scale that describes the behaviors and abilities of a person who is gradually coming out of a coma. It is often referred to as the Rancho Scale. It includes 8 levels of response that describe a person’s awareness and response to light, sound, touch and commands.

The basic Rancho Scale is for children (age 14 years +) and for adults. Although this scale has been adapted for younger children, it is not as widely used with them.

Understanding the scales

Ask a doctor or nurse if the Glasgow or Rancho scale has been used to evaluate your relative. If the answer is yes, ask staff:

to explain what the numbers mean
if this score has changed since the injury
what may happen next

Early Stages of Coma Recovery

Noise, touch, light, and movement may either calm or upset the person. Post-traumatic amnesia is common as the person(s) regains consciousness. This means that the person may not remember being hurt or what happened after injury.

A person does not just “wake up” from a coma. It is a gradual process of becoming more responsive and aware of people and surroundings. Rarely do individuals progress directly through the different levels of consciousness. There is usually some overlap, or back and forth between stages.

Your relative may become confused, not recognize you, talk and behave strangely, swear, become angry, and even be violent. This is a normal stage of coma recovery and it is usually temporary.

Tips for families to help your relative:

Keep things simple. Do only one activity at a time. Too much talking, noise, touching or activity can confuse the person even more.
Assure your relative that he or she is safe. Tell her what happened and where she is. Repeat this many times. It may be hard for your relative to understand and remember new information.
- “You were in an accident. You are in the hospital.”
Tell the person the time of the day. He or she needs reassurance about whether it is morning, afternoon or evening. This helps orient your relative to time, but keep it simple.
- “It is morning,” rather than, “It is eight o’clock.”
Identify People Present. Let the person know who you are and who is with you.
- “This is your wife, Ann. Your Dad is here too.”
Touch the person when you speak. This helps your relative figure out where you are, who you are and what you are doing.
- “This is your sister, Kate. I am holding your hand.”
Do the same thing(s) each time.
- “I am going to put some lotion on your legs.”
Bring in a favorite item from home. Your relative needs to hear and touch things that are familiar. But again, keep it simple.
- “I’m playing your favorite CD.”
- “I’m going to read your favorite story.”
- “Here’s your favorite stuffed animal.”
- “I am putting the afghan your mother made over you.”
Avoid arguing. Change the direction of conversation or the topic. Your relative may quickly become frustrated and angry, especially when still confused and irritable. Instead of:
- “That’s not right…,” suggest doing something a different way.
Avoid negative or uncomfortable topics. No one knows how much the person hears or understands. Instead of discussing your relative’s condition or upsetting topics by the bedside, go to a private area or separate room.
Avoid asking questions. Describe what is happening or give specific directions. Instead of,
- “Can you see me?” say, “I can see you. Your eyes are open.”
- “Can you move your arm?” say, “Try to move your arm.”
Give your relative specific information. Avoid asking open-ended questions like,
- “Do you remember anything.” Instead, ask: “Do you remember the car crash?” Or say,
- “You were driving on the highway and another car hit you. You have been in the hospital for three days.”
Help orient your relative with visual information. Post a calendar and mark off each passing day. Bring in family photos or hang favorite pictures on the walls.
Write a short note. It will be something about your relative, easily readable, which you will then hang over the bed on the wall. This will help nurses, doctors and others know the person better. Describe personal likes and dislikes and include a picture of your relative.

Tips for helping children…

Too often children with a parent or sibling in a coma feel left out and receive little information. Efforts to protect them may increase their fears and anxiety about what has happened to their mother or father, brother or sister.

Ask medical staff for advice on explaining coma to your children.
Use language that your children can understand.
Encourage them to ask questions.
Describe how their parent or sibling looks.
Don’t force them to visit until they feel ready -let it be their choice if hospital rules allow it.
Encourage children to send messages by cards, drawings, pictures, or audiotapes.
Call home regularly each day if you are away from home to touch base with your children and to reassure them.

Tips for family members…

Waiting and watching are the two words most often used by family members to describe what this time was like for them. The stress, worry and anxiety may feel overwhelming at times. It may be hard to concentrate or do even the simplest things. This period of coma is among the most difficult for family members because of its seriousness and uncertainty.

Each person in a family reacts differently to stress but these are suggestions offered by families who have gone through this experience.

Write down information in a journal, notebook, or laptop.
- Record questions for medical and nursing staff.
- Write down changes you have seen.
Set up a phone tree.
- Identify one person for family and friends to call for information and updates.
Use the Internet to keep others informed
- Create a website on programs such as Caring Bridge caringbridge.org
- Use social networking sites (i.e.,FACEBOOK, TWITTER, PINTEREST, etc.) to keep in touch.
Allow others to help.
- Say “yes” when someone offers to help.
- Be specific about what help you need.
- Talk about your feelings.
Be kind to yourself.
- Try to eat and get some sleep.
- Take breaks from the bedside and hospital.

Conclusion

This is a difficult time for everyone in the family. Patience, support, information and help from staff, relatives and friends will help you through this uncertain time.

Reference

Hammond, F. & Guerrier, T. (2010). Brain Injury: It is a Journey. Wake Forest, NC: Lash & Associates Publishing/Training, Inc.

This ARTICLE was part of a Tip Card series on brain injury among children, adults and veterans. For MORE INFORMATION, contact Lash & Associates Tel: (919) 556-0300 or visit our web site www.lapublishing.com

This ARTICLE is not intended as a substitute for the medical advice of your physician. Consult your doctor regularly about matters concerning your health, particularly regarding symptoms that require diagnosis or immediate medical attention.

This material is copyrighted by Lash & Associates and cannot be reproduced in any form without permission.

Published by: Lash &Associates Publishing/Training Inc.

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