Nurses and other health professionals can have a great impact on patients in a state of perceived unconsciousness. Twenty-five percent of all unconscious patients can hear, understand, and emotionally respond to what is happening in their external environment. However, because of their medical condition, they are incapable of moving or communicating their awareness. This is a very common state, particularly when someone is just becoming unconscious, or is being physically moved.
It was not unusual for patients to say they heard doctors and nurses talking about their condition. "We're losing him", "Her blood pressure is dropping", were phrases they often heard. Some patients also reported feeling needle insertions and the charge from the defibrillator. In all of these reports, they said they had tried to communicate but could not move. Why they could not move is not clearly understood and needs further investigation.
Because these patients seemed to be in the traditionally accepted state of unconsciousness, many overheard negative comments about their condition. Understandably, these comments caused the patient more concern. One of the most distressing comments was to hear medical personnel say the patient would "probably be a vegetable." One man overheard his doctor tell his brother that "if he survived he would probably be a vegetable." The man tried to communicate and tell his brother he felt fine, and in fact could hear everything that was being said.
Patients often reported hearing what was being said when they were being transferred from stretcher to a bed or moved in some other way. Somehow this movement triggered an increase in awareness. This is a report from a radiology department manager from when she was working as a technician.
Late one Friday afternoon they sent me a patient for a series of head x-rays. The man had had a stroke and was on a stretcher completely out. He did not move. There was no response to anything I said or did. After I finished the 11 pictures, the orderly came down to get him. I said something to him like, 'Why do they waste time sending down these zonked out patients?' He just kind of shrugged and took the patient back upstairs. About a week later, my boss called me into the conference room and said a patient wanted to see me. The patient had checked to see who had taken his head x-rays and told me he heard me say he was zonked out. He had heard every word I said (Lawrence, 1995).
After this experience, this radiology department manager instructed all staff to monitor carefully what they say to all unconscious patient, especially when they are being moved from a stretcher to an x-ray table.
Proprioception and the vestibular system
What we know is that we all have knowledge of where parts of our body are located at any time without looking at them. We call this ability proprioception. The vestibular system also alerts us to changes in our orientation body. The end of the complex system of this proprioceptive ability is stimulus of the RAS, which we have already described as being the seat of consciousness. It is possible that movement stimulates the RAS, not only to help us recognize we are moving, but also to increase awareness. Again, exactly how this happens is not clearly understood, but it's obvious that a good time to try and communicate with a patient is when they are being moved.
Movement has no
effect on consciousness.
Patients also reported feeling needle sticks and the jolt from the defibrillator during resuscitation efforts. Again, because they could not move, they could not communicate this discomfort. Subjects who were going into shock or being defibrillated because of ventricular tachycardia, versus those with ventricular fibrillation or asystole, were more likely to feel these procedures.
Patients in this state were also aware of the feelings staff and visitors had toward them. They reported feeling positive and negative emotions. Some reported feeling love and caring from the nurses who were taking care of them. One patient said a nurse was so concerned about her well being, it increased her will to live. Other patients said they felt they were just an object. No one talked to them and "just rolled them like a log".
Not all visitors had a positive affect on the patients. When one patient's abusive husband visited, she would retreat into unconsciousness. She could not handle the anger and hostility she sensed from him. Other visitors, who were more positive, were reported as giving the patients energy. One man said he could feel the "positive energy" from his friend and it gave him strength.
Lawrence, M., (1995). The Unconscious Experience. American Journal of Critical Care, 4 (3) 227-232.