Neuro was not one of my favorite courses in nursing school, but one lesson stayed with me throughout my approach to unresponsive patients and that was to talk with them. It didn't matter if they were comatose, obtunded, catatonic, or my favorite term, hypovigilant. If the auditory cortex found within the temporal lobe was intact patients could at least hear to some degree. Even if they could not understand the speech, a nurse's rhythm and timbre could still be detected and communicate caring and concern.
There were quite a few nonresponsive patients I encountered while working at Downey V.A. hospital, a long-ago shuttered facility devoted to the long-term care or in more pejorative vernacular, warehousing of schizophrenics. Crude treatments of the day including lobotomies, insulin shock, and massive doses of major tranquilizers were enough to silence just about anyone including a gentle old soul named Ireno who rarely spoke.
Ireno was a massive bull of a man who had been confined to the forlorn pastures of Downey VA hospital for decades. Standing in line for medications he towered over the other patients, despite his threatening size a HumpteyDumpteyish aura surrounded him. He was mute and acted as if the slightest action could break him apart.
Ireno had been on massive doses of Thorazine which works by blocking dopamine receptors in the brain and as a result more dopamine is released systemically in the synaptic clefts. There is more dopamine around the peripheral nerves and more receptors to respond to it resulting in uncontrolled tremors and movement disorders.
One evening I noticed Ireno reclined on the floor of the day room which was his usual habitat before the dorms were opened. I frequently opened the dorms early, but had to wait until the nursing coordinator made her rounds. The VA had many rigid rules and one dictum stated the dorms were to be locked until 10PM.
I noticed Ireno busy at work with a pencil and paper while wearing heavy winter gloves to attenuate his shaking hands. He also was applying counter traction to his tremoring arm by attaching a sleeve of an old tee shirt to a valve on the radiator with the other sleeve wrapped around his elbow. Whatever endeavor he was up to required great effort and concentration When I walked over to him, he quickly covered his paper, but looked up at me with kindness in his eyes. I told him the dorms would soon be open so he could hit the sack and rest in comfort.
