A12 SUNDAY, AUGUST 25, 2019 S LATIMES.COM
Jan. 18, 2016, about three months
after his accident, and one day
after he turned 22. He was living in
a special unit for people on life
support, most of whom have feed-
ing and breathing tubes.
Salgado had defied the odds.
Not only had he lived, he was
emerging from his semiconscious
state. But his is not a story about a
miracle — it’s a story about medi-
cine’s inability to accurately diag-
nose consciousness and treat
those who do wake up but linger in
a purgatory between wakefulness
and nothingness.
About 40% of the people diag-
nosed as being in a vegetative
state — a neurological condition in
which patients are awake but
show no signs of being aware of
themselves or their environment
— are conscious at least some of
the time, according to a growing
body of research. But, like Sal-
gado, they have no way of indicat-
ing they’re aware.
Salgado couldn’t speak. Ac-
cording to his medical file, no one
had ever seen him willingly move
any part of his body. It was just
luck that I happened to see him
turn his head that day.
Doctors have long relied on
behavior to measure conscious-
ness — in other words, they ask
patients to respond to commands,
such as lift your right hand or
move your left toe.
But that method is flawed, said
Martin Monti, an associate profes-
sor in UCLA’s Department of
Psychology and Department of
Neurosurgery.
How can a patient who can’t
move tell you he’s there? Monti
asked.
What’s more, once conscious-
ness is established, there is little or
no therapy offered to patients to
treat their condition or accelerate
their awakening, he said.
But Monti and his co-
researcher, Caroline Schnakers,
who is also his wife, are hoping to
change that. They are partnering
on a research project that uses an
ultrasound device the size of a
hockey puck to shake neurons in
the brain back into action.
They’ve used the technique on
several brain-injured people in
Southern California, and all but
one showed signs of increased
awareness, including one man who
fully recovered consciousness.
“It is a simple idea,” Monti said,
“but it’s not any simpler than
giving a medicine.”
b
On the night of Nov. 2, 2015,
Salgado was riding his bike in the
median of a four-lane highway. It
was dark on that stretch of State
Route 76 near Oceanside.
A car was making a left turn
where the highway intersects with
another four-lane roadway. The
driver, a man in his 20s, swerved
when he saw Salgado, but it was
too late. Salgado was airborne. His
bike landed on the shoulder and
he landed on the highway. He
wasn’t wearing a helmet. Another
car, traveling 55 mph, ran over
him.
“Based on what he went
through, I would not have ex-
pected him to live,” said Det. Bry-
an Hendrix, the Oceanside police
officer who was first on the scene.
Salgado had no drugs or alco-
hol in his system. He was uncon-
scious and had no identification
with him. Police ran his finger-
prints and learned he’d been in
trouble with the law before, mostly
for minor offenses like being drunk
in public.
I showed Hendrix a video I’d
taken of Salgado in the nursing
home. He was attached to tubes,
his skin stretched across bone. He
looked like a corpse.
“I told my wife to pull the plug if
I ever end up like that,” Hendrix
said. He’d investigated enough
accidents to know that people who
suffered injuries as severe as Sal-
gado’s might live but never really
recover.
In his mug shot, Salgado was a
5-foot-6, 120-pound troubled-
looking kid. In the nursing home,
he was a fragile young man whose
body constantly shivered; who was
dangerously thin (he weighed 96
pounds) because his body was
mysteriously shedding weight;
whose brown eyes seemed to grow
in size as the hollows of his sockets
became more pronounced.
He looked scared.
At the time of the accident,
Salgado was homeless — es-
tranged from an aunt and uncle
who raised him. They visited him
in the ICU at Scripps Memorial
Hospital in San Diego as he lay
unconscious for weeks. They met
with doctors to discuss withdraw-
ing life support when it appeared
their nephew had no hope of ever
waking up.
But one day, a nurse noticed
that Salgado was following her
movements with his eyes. In the
medical world, this is called track-
ing, and it’s an indicator that
Salgado was emerging from a
vegetative state.
Instead of discontinuing medi-
cal treatment and allowing Sal-
gado to die, doctors transferred
him to the nursing home. His aunt
and uncle stopped visiting after
that, according to nursing home
staff. For nearly three years, no
one from Salgado’s family came to
see him.b
Salgado occupied the middle
bed in Room 20, with an old man
the staff called Papa to his right,
and the man I was reporting on —
known only as Sixty-Six Garage —
to his left. I largely ignored Sal-
gado, making the occasional note
about him on my laptop. I noticed
his scar first. It extended from the
corner of his left eye to his hairline.
Unlike the cuts on his hands and
feet, which still appeared fresh
from his accident, the scar looked
old, embedded in Salgado’s olive
skin like a birthmark.
The “new roommate looks
exactly how he looked when I left
three days ago ... eyes open, star-
ing up at the ceiling,” I wrote on
Christmas Day 2015. There were
times Salgado’s face dripped with
sweat, even though he shivered
uncontrollably. He had stage four
bedsores (a wound that may “ex-
pose muscle, bone or tendons,”
according to the Mayo Clinic) on
his buttocks. They had merged to
form one large hole that was per-
petually infected.
I usually had my back to Sal-
gado, my chair pulled up beside
Sixty-Six Garage’s bed. I don’t
know why on that late Januaryafternoon I changed my routine
and placed my chair so I could see
both men.
If Salgado’s movement had
been less deliberate, if his head
had dropped or jerked to the side
as if he’d fallen asleep sitting up, it
might have passed for a reflex. But
this was different.
“Must show you something,” I
texted to Ed Kirkpatrick, the
nursing home’s director.
Kirkpatrick was used to getting
text messages like these. I’d been
reporting in the nursing home for
nearly two years and often shared
my observations.
While I waited for Kirkpatrick
to arrive, I kept asking Salgado
questions because I was afraid
he’d slip away if I stopped talking.
“Blink once if you know you’re
in the hospital.”
He blinked.
“Blink if you know you were in
an accident.”
He blinked again.
I told Salgado he was being
taken care of and that he was
going to get better. But if you’d
been there to see him, you would
know I was lying.
Watching his body wither away
all those weeks, I was afraid to ask
the obvious question: Did he want
to live or die? When Kirkpatrick
arrived, he held up three fingers
and asked Salgado to blink twice if
he saw three fingers. He blinkedtwice. Kirkpatrick asked him to
squeeze his hand. Nothing.
“Blink twice if you’re trying to
squeeze my hand,” Kirkpatrick
said.
Salgado blinked twice.
But Kirkpatrick seemed unim-
pressed.
“What does it matter?” he
asked.
Salgado will never be able to
walk, tie his shoes, go to the bath-
room on his own — he’ll never
speak because his brain injury has
left him mute, Kirkpatrick said.
“There is no money for rehabili-
tation once they get to this place.
Medi-Cal only pays to keep them
alive,” he said.
After Kirkpatrick left the room,
I returned to Salgado’s bedside.
“Blink twice if you want the TV
on,” I said.
He blinked twice.
“Should I read to you the next
time I come?”
He blinked again.b
Caroline Schnakers was a
neuropsychologist in Belgium
when studies began appearing
that showed doctors were misdi-
agnosing consciousness: People
who were conscious were being
diagnosed as being in a vegetative
state. The news hit Schnakers
especially hard because in Bel-gium, euthanasia is legal and
families may have made end-of-life
decisions based on a misdiagnosis.
“The first thing I thought, and I
know a lot of clinicians thought
the same thing as me, is how many
patients did I miss?” she said.
Schnakers, assistant director
of research at the Casa Colina
Hospital and Centers for Health-
care in Pomona, went on to con-
duct her own studies. She found
that about 40% of the people who
are diagnosed in a vegetative state
are minimally conscious, meaning
they drift in and out of conscious-
ness.
Schnakers is also an expert on
diagnosing consciousness using
the JFK Coma Recovery Scale
Revised. It’s a scoring system that
can detect nuanced signs of
awareness, like object recognition.
For example, when adminis-
tering the test, Schnakers will hold
a cup in one hand and a pen in the
other. She’ll then ask patients to
look at the cup. If they fix their
eyes on the cup, and repeatedly do
so, they score points in the visual
function category.
Together, Schnakers and Monti
are trying to determine whether
the ultrasonic device, Monti’s
hockey puck, can reignite brain
function by exciting neurons in the
thalamus, the control center for
the brain and integral for con-
sciousness.
“So we try to reignite that by
literally massaging the thalamus
with the ultrasound,” Monti said.
In 2016, Monti’s work made
headlines when a 25-year-old
brain-injured man regained con-
sciousness just days after being
treated with his device.
Bradley Crehan had been hit by
a car in Santa Monica, and part of
his skull was removed to relieve
pressure on his brain. He was
placed in a medically induced
coma, and when he woke 19 days
later, he showed few signs of being
able to communicate or respond
to commands.
Monti placed the ultrasonic
device at the right side of Crehan’s
brain, aimed it at his thalamus,
and pulsed 10 times at 30-second
intervals. The next day, Crehan
could reach toward objects and
make sounds on command. Three
days later he could nod his head
for “yes” and shake it for “no.”
“So Bradley came back six
months later and we asked him,
‘How are you feeling?’ And he said,
‘I feel just about 80% of what I was
before,’ ” Monti said.
But there’s no way of knowing
whether the ultrasound caused
Crehan to suddenly awake, or
whether he would have sponta-
neously recovered on his own.
“That’s the biggest question.
We could have sung a song with my
beautiful singing voice and he
would have recovered anyway,”
Monti joked. Now, Monti and
Schnakers want to use their tech-
nique on chronically brain-injured
people — those who’ve been in a
vegetative or minimally conscious
state for years or even decades.
If they have success with those
patients, whose chances of spon-
taneous recovery are almost nil,
they’ll know with more certainty
that the ultrasonic device is work-
ing.
So far, they’ve had positive
results.
When Schnakers discussed
using the experimental treatment
on a middle-aged man who’d been
minimally conscious for more than
three years, she cautioned his wife
not to get her hopes up. He’d suf-
fered a stroke and his brain had
been deprived of oxygen. Chances
of recovery in this type of brain
injury are not as good as in a trau-
matic injury where a specific part
of the brain is damaged.
“I don’t expect anything,”
Schnakers told the wife.
The woman agreed to let Monti
attach the device to her husband’s
head and “sonic” his brain 10 times
for 30 seconds, each interval 30
seconds apart. The man got two
treatments, one week apart.
His wife saw a dramatic im-
provement after the first week.
He began responding to “yes”
and “no” questions by turning his
head side to side and up and down.
The couple spent one evening
looking at pictures, Monti said.
The man began laughing at jokes.
“I just remember [the wife]
saying for the first time, ‘I had a
conversation with my husband,’
which is pretty powerful,” Monti
said.
Another woman, in her 40s and
also minimally conscious, was able
to look at her mother on command
after the treatment.
But one patient, who was in a
vegetative state, did not appear to
respond to the device, Monti said.
Monti and Schnakers are writ-
ing up their findings. They need a
much larger sample to know
whether their treatment is effec-
tive and whether the positive
effects last over time. They’re
recruiting 15 patients for a small
clinical trial. If they get good re-
sults from that study, they’ll move
on to a large scale double-blind
trial.
Schnakers said part of the
challenge is finding patients to
participate in their experiments,
even though California has about
125 subacute units housing more
than 4,000 people on life support.A brain-injured man’s awakening
OMAR SALGADOreads a Spider-Man comic book, one of the goals he set for himself after
his awakening. Others included eating pizza and going outside. He learned to use an iPad and
started a Facebook account, which helped him track down a sister he hadn’t seen in years.Joanne FaryonFor The TimesRESEARCHERSCaroline Schnakers and Martin Monti are partnering on a project that
uses an ultrasound device the size of a hockey puck to shake neurons in the brain back into
action. They’ve used the technique on several brain-injured people in Southern California.Marcus YamLos Angeles Times‘Unfortunately, the way you heard it — that Medi-Cal
pays for us to keep him alive — that’s really true and
really challenging. For every one of [these patients]
I would like to do more than I’m doing.’
—DR. KENWARM,Omar Salgado’s physician[Awakening,from A1]