Just because someone with brain injury is not awake does not mean that he is brain dead

CAN you read my mind?

That used to be a magician’s trick.

But medical research now shows that doctors can sometimes read the minds of people who have suffered brain damage.

A Belgian man who suffered brain damage in a traffic accident seven years ago was asked a series of questions.

He was able to communicate “yes” and “no” using just his thoughts by altering his brain activity. The answers were decoded through brain scans using a technique called functional magnetic resonance imaging
(fMRI).

This technique relies on changes in blood flow and oxygenation to the braindue to brain activity.

But it doesn’t workall the time.

Only four out of 23 vegetative state patients responded in this way (including the Belgian man).

The findings were reported in the New England Journal of Medicine this month. The research, carried out in the UK and Belgium, involved fMRI.

With fMRI, scientists could reach into the mind of a brain-damaged man and communicate with him.

The scans could detect signs of awareness in patients thought to be closed off from the world.

But there is a difference between being brain damaged and brain dead.

Brain death equals death and there is no way back. Organs are removed only when a person is declared brain dead.

Brain damage is a more complex issue.

Patients with brain damage are very much alive. Those whose damage is mild may even recover.

But those who are severely brain-damaged are considered to be in a vegetative state and cannot communicate with others. The recent report shows there are exceptions.

Brain dead?

So why is this an issue?
 
The New Paper had reported in November that Mr Thomas Yap Lam Choon’s family thought he was brain dead and so was surprised when he continued to breathe on his own when he was taken off the life
support machine on 13 Nov last year.

But doctors at Tan Tock Seng Hospital (TTSH) and the National Neuroscience Institute (NNI) have clarified that such a scenario is not possible.

Said Dr Tan Hui Ling, a senior consultant at the department of anaesthesiology at TTSH: “At no point was Mr Yap diagnosed to be brain dead nor was brain-death certification ever carried out on him.”

Medically speaking, he can’t be brain dead if he can breathe on his own.

Mr Yap suffered brain damage when a lorry hit him while he was walking along Cambridge Road on his way home around 10pm on 8 Nov. He suffered serious injuries and has been unconscious since then.

But even with brain damage, there are various degrees of injury.

Doctors here said the damage needs to be qualified by the type and extent of injury as well as the potential for recovery, whether temporary or permanent.

An example of a milder type of damage is a mild stroke, said Dr Tan.

The patient may suffer from numbness and weakness of the limbs on one side and recovers fully or partially.

In severe brain damage cases, the patients have permanent loss of awareness and diminished ability to respond.

Such patients are totally dependent on others and often require specialised methods of feeding.

But even in extremely severe brain damage, where the patients have permanent loss of consciousness, they will exhibit attempts to breathe spontaneously, said Dr Tan.

She added: “While he remains unconscious, his breathing function recovers to sustain adequate spontaneous breathing and he is able to come off breathing machine support.”

Unlike patients with various degrees of brain damage, brain dead patients are not capable of spontaneous breathing and their heart would stop within minutes of being removed from machine-assisted breathing support, she said.

For example, when someone has extensive brain injury from a severe stroke (spontaneous bleeding in the brain) or when trauma (accident) happens.

Said Dr Pang Boon Chuan, associate consultant neurosurgeon at NNI: “Emergency life support and treatment for the brain are instituted. For example, medication to prevent worsening of the bleeding, medication to reduce the brain pressure, surgery to remove the blood clot or reduce brain pressure.”

But the person’s condition may continue to deteriorate and brain pressure remains persistently high and unresponsive to treatment. The person then loses all brain function.

Said Dr Pang: “Only then will tests be carried out to confirm the diagnosis of brain death.”

There is another type of brain damage where the patient is unable to communicate using conventional means. However, he is fully aware of what is going on.

Mr Rom Houben, a 46-year-old Belgian man, was one such patient.

He was presumed comatose and in a vegetative state for 23 years after a near-fatal vehicle accident.

Recent news reports said he was actually conscious and understood everything that was going on around him during his entire hospital stay.

He was finally diagnosed with locked-in syndrome by Belgian neurologist Steven Laureys in 2006 with the help of modern brain-imaging techniques and equipment.

Dr Tan said that in the locked-in syndrome, the patient is alert and awake. Furthermore, the patient can obey commands to look up and down and blink.

“In Singapore, we will always look out for this condition and test patients to see if they have it,” she said.

In case you are still worried, according to Dr Tan, there has not been any case here of a patient diagnosed and certified to be brain dead by internationally accepted criteria who has subsequently woken up.

Diagnosis misunderstood
By: Bryna Sim

SHE thought her brother was brain dead but she has since learnt that she had misunderstood the diagnosis.

Perhaps it was her layman understanding of the situation, but Tan Tock Seng Hospital (TTSH) said that storeman Thomas Yap Lam Choon, 51, was not brain dead after all.

He was knocked down by a lorry on 8 Nov and suffered serious injuries.

His half-sister, Miss Catherine Ee, 55, told The New Paper his family was told on 9 Nov last year that he might not survive for long because he had blood clots in his brain.

The family decided to take him off life support on 13 Nov.

On 17 Nov, Miss Ee said that his ventilator and breathing tubes were also removed. She said she was surprised when his lungs and heart were still functioning weeks later.

Miss Ee believes that the reason for his “hanging on to life” was because he wanted to see his daughter one last time.

Mr Yap divorced seven years ago and his ex-wife has custody of their daughter, Xian Wen, who will turn 10 this year.

Miss Ee said it had been years since her brother last saw his daughter, so she wanted to help them meet.

Initially, he was in an intensive care unit but was moved to a step-down unit last December.

He is now in a nursing home, but Miss Ee declined to say which one.

She also declined to elaborate on her brother’s condition.

Organs can be removed only after brain death
IN Singapore, under the Human Organ Transplant Act (Hota), the organs for transplant are only removed after brain death has been certified by two senior specialist doctors.

They are independent and must not have been involved in the care or treatment of the patient being certified nor can they be in the transplant team of doctors.

The certification of brain death is based on accepted international standards that follows a well-defined set of stringent clinical criteria.

No preparation for organ recovery or transplantation takes place until death has been certified in this manner.

Brain death is widely accepted as a definition of death by international medical communities, said a Ministry of Health spokesman.

The possibility of recovery of any brain function is excluded.

“Brain death equals death,” said Dr Pang Boon Chuan, an associate consultant neurosurgeon at National Neuroscience Institute.