Monday, October 22, 2012

Writing a Comatose Character On a Ventilator After a Stroke

Hi Kelly, My character is 70ish, and is hospitalized after a car accident, broken bones and head injury. While in the hospital, he has a stroke.

1. What would cause the stroke?
A couple of options. Strokes can be ischemic (lack of blood flow) or hemorrhagic (bleeding into the brain). Either would work for an older individual.

2. I'd like him fairly soon go into a comatose state. Could that happen?
Yes—and it can occur with whatever timing you wish, if you want it to coincide with the stroke.

2-A. If he has a stroke and is comatose and ventilated, could he have normal brain activity?
If he has a stroke and becomes comatose, the EEG (Brain wave activity measured by the pattern of electrical impulses coming from the brain) won't be normal. Diffuse slowing is usually noted with a diffuse brain injury, such as lack of oxygen after cardiac arrest.

More abnormal patterns are seen after severe trauma.
Two EEGs seventy-two hours apart are often used to get an idea of prognosis.

If the patient doesn't react to external noxious stimuli, like pain or cold water in the ears, chances are you're looking at a very poor prognosis.
Coma of any source has abnormal brain activity--after cardiac arrest, for example, where the brain can be damaged by lack of oxygen until circulation is restored.
The ventilator can be for many reasons: the patient who doesn't breathe on his/her own; sedation given for seizures or agitation; severe brain injury.
Sometimes in electing to withdraw life support the ventilator is removed. Some patients will breathe on their own as breathing is a brainstem function, not a cerebral "Gray Matter" function.

3. What would lead to a tracheotomy?
A tracheotomy (or tracheostomy) is a surgically created hole in the windpipe, generally used for longterm ventilator patients or in cases of head/neck cancer.)
Need for a ventilator beyond a few days. The breathing tube (endotracheal tube) is held in place by a balloon cuff, which puts pressure on the trachea. After a few days, that can injure the trachea, so a tracheostomy is done.

4. Could he have the ventilator and a tracheotomy?
Both. The trach would be done because of the continued need for mechanical ventilation.

5. What I'm really wanting to do is set him up so that he gets increasingly worse and the children have to debate whether to take him off life support. I'd like the doctor to say a few words that would convince one hesitant grown up child that his prognosis if futile and he should be taken off all life support and be allowed to die, but yet I'd like the patient be open for a miraculous recovery. What words would a doctor use to convince the person to stop treatments?
“No hope of meaningful recovery.” Or, “Severe brain damage.” Or, “His organs have shut down.” Kidneys and liver being biggies in this area and worsening the prognosis.

6. Is it possible to take off the feeding tube and if the patient breathes on his own, to continue giving nourishment, if a decision is made to let him die?
If the patient has enough brainstem function, he can breathe on his own. Nourishment is considered to be supportive care. There’s a lot of controversy about whether it equals life support. Starving a patient will make most medical personnel uncomfortable, and they will likely refuse to starve the patient. This can lead to an ethics inquiry within the hospital.

In these situations (no vent, nourishment given), it’s not uncommon for a secondary complication to lead to death, such as pneumonia or another infection.

7. Say the family all agrees that the vent should be removed, but if he breathes on his own, he should be given treatment. Is that doable?
Anything is doable. There are no absolutes when it comes to these situations.
You can decide not to resume the vent if the patient can’t breathe, decide not to use CPR for resuscitation and use only drugs, use no drugs or CPR.

Another thing you may want to keep in mind: if there is no wife and no medical care proxy, the oldest child is the legal next of kin and legal decision maker. That doesn't mean they won't take the wishes of the others into account, but legally that individual can call the shots.

Questions? Comments?
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at


  1. As always, a great post. Keep up the great work, and be sure to pace yourself. We don't want you to burn yourself out.

    SS Hampton, Sr., MIU Writer

    1. Thanks, SS.
      I pace as I can. Hoping to get permission for some cool pics in the near future.
      Cheers, Kelly