Comatose when lightning strikes
“Mental”
Fox
June 9, 9 p.m.
Episode: “Book of Judges”
The premise
Dr. Jack Gallagher (Chris Vance) is the director of mental health services at a Los Angeles hospital. One of his patients is a famous writer, Gideon Graham (the late David Carradine), who was hit by lightning while on an excursion with his wife. His wife is killed, but Graham survives, sustaining burns and a traumatic injury that leaves him in a coma. He emerges from the coma but remains in a catatonic state, minimally responsive, occasionally jerking (he kicks off the slippers that his aide puts on) but not speaking. Gallagher attempts transcranial magnetic stimulation (TMS) to bring Graham out of the state, using an electromagnet to generate the same amount of current as in an MRI but in a more focused manner. The therapy has some effect, though Gallagher believes that Graham remains “lost inside himself” from the grief of losing his wife and guilt over an affair. Sleep studies are normal, seeming to confirm that Graham is in fact conscious. Gallagher postulates that the writer’s intelligence and imagination are creating a wall against reality and impeding his recovery. Gallagher considers using electroconvulsive therapy (ECT), thinking that the electricity may bring back the experience of the lightning and help Graham to move past it.
The medical questions
Could being struck by lightning lead to coma instead of death, and could the coma be replaced by a catatonic state of extreme immobility and stupor? Could this condition be treated by transcranial magnetic stimulation? Do responses vary based on a patient’s emotional burdens? Could reliving the experience of the lightning strike help a patient resolve the catatonia?
The reality
Electrocution can lead to coma, caused by insufficient blood flow to the brain (anoxic encephalopathy), says Dr. Gregory Fricchione, associate chief of psychiatry at Massachusetts General Hospital. And a patient emerging from a coma might become catatonic, but Fricchione points out that a patient with Gideon’s symptoms might be suffering from seizures instead of catatonia.
TMS, which is still experimental, has reportedly been helpful in case reports of catatonia but, according to Fricchione, the first line of treatment would be the sedative lorazepam. It can directly relieve catatonia, even without seizures, and overcome inhibition and immobility. “I would give him lorazepam but, when it worked, the show would be over before the first commercial,” Fricchione says. Lorazepam or the barbiturate amobarbital (sodium amytal) is effective in 60% to 80% of cases, says Dr. Andrew Francis, professor of psychiatry at State University of New York Stony Brook. And if the drugs are ineffective alone in relieving the catatonic state, they’re generally followed by ECT, which the show depicts. As with sedatives, ECT works on catatonia by an unknown mechanism, possibly by decreasing the brain excitability that led to the condition.
The patient’s recovery could be complicated by grief and depression, though lorazepam and ECT usually work despite this. Dr. Stanley Caroff, professor of psychiatry at the University of Pennsylvania School of Medicine, says that catatonia and response to treatment are physiological and are not based on “emotional burdens” or “creating a wall” to resolve conflicts. But Francis believes that primitive emotions may play a role. “One psychological theory of catatonia is that the patient is frozen with fright like when an animal freezes as a predator approaches,” he says. Caroff, Fricchione and Francis are coauthors of the book “Catatonia: From Psychopathology to Neurobiology.”
Finally, the show’s connection between ECT and reliving the lightning strike is misleading. In the real world, patients are anesthetized and unconscious during the procedure. “ECT would never be recommended to remind someone of being electrocuted,” Caroff says.
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Siegel is an associate professor of medicine at New York University’s School of Medicine. marc@doctorsiegel.com