Advances in Care

Mind Seeker: Exploring the Recovery of Consciousness

Mind Seeker: Exploring the Recovery of Consciousness
Mind Seeker: Exploring the Recovery of Consciousness

In this episode, critical care neurologist at NewYork-Presbyterian/Columbia, Dr. Jan Claassen sits down with Catherine Price to discuss his groundbreaking work on Cognitive Motor Dissociation and its astounding implications for the prognosis of patients with disorders of consciousness. Dr. Claassen explains how he is intentionally designing his studies so that they can be replicated by as many hospitals as possible, using diagnostic tools that are available in any ICU, in any corner of the world.

Whether a patient will ultimately recover from an unconscious state after brain injury isn’t easy to predict– yet. But Dr. Jan Claassen is working to change that. He describes the staggering revelations of his study on Cognitive Motor Dissociation, and how his team used a combination of widely available diagnostic tools and open source machine learning algorithms, to detect signs of consciousness in seemingly unconscious patients. Dr. Claassen also discusses his ongoing RECONFIG study, in which he hopes to refine tools that could predict the likelihood of recovery in patients following brain injury.

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Catherine: One day a patient was admitted into neurologist Dr. Jan Claassen’s care in the ICU. A young woman who’d suffered a sudden brain hemorrhage. 

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She seemed completely unresponsive. But her family had a gut feeling. They thought: she’s in there. Now, this kind of wishful thinking is common for families of people who suffer sudden brain trauma, and so for a lot of physicians, it’d be easy to brush off. But Dr. Claassen did not. And it turns out, the family was right. 

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I’m Catherine Price and this is Advances in Care.

Dr. Claassen is Chief of the Division of Critical Care & Hospitalist Neurology at NewYork-Presbyterian/Columbia. He’s leading the way in detecting a phenomenon called “covert consciousness” in the ICU, helping physicians and families to reimagine what patient care should look like

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in the early days after a brain trauma. 

Today on Advances in Care, Dr. Claassen tells us the story of his groundbreaking study on cognitive motor dissociation, and his hopes for how we’ll communicate with these patients in the future. 

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Catherine Price: I'm so excited to speak with you today.

Dr. Jan Claassen: Yeah, me too.

Catherine Price: I'm always really curious about how people got to do what they do today, so can you tell me a bit about your personal background and how this interest began? 

Dr. Jan Claassen: Uh, towards sort of the second part of, uh, my medical school training, there was an opportunity to get involved in research and I was looking around for a research project and I had this long standing interest in understanding human consciousness. And by coincidence, I stumbled across this investigator that wanted to do a study in patients with traumatic brain injury, that wanted to find better ways to predict how they would do long-term wise. 

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So, who would recover and who wouldn’t. And so I was this young medical student, got very eager and interested, got in first day in the ICU and they told me end of the hallway is your patient. You can do your study. A week later, part of the study was you, we followed up with the patient and wanted to see how they did and so I came back to the ICU and I asked them, where's this, this young patient, this was a 20 year old patient that had a rollerblading accident, fell on the back of his head and had a big hemorrhage and big trauma. And so I asked them where, where is he? And in my mind it was like, the patient isn't here anymore, he died. This is all a waste. What am I doing here? And they said, ‘actually, no, you have to go one floor up and he's actually on the regular floor.’ And so I went upstairs and this patient was actually in the common room playing cards with, um, other patients.

Catherine Price: Oh, wow. 

Dr. Jan Claassen: And he had fully recovered. And when I, when I saw that, that just triggered this response in me where I was like, this is what I want to dedicate my life to.

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I really want to figure out about recovery of consciousness, about recovery and of these sickest patients that, that you can imagine.

Catherine Price: What was it about that particular moment that made you realize, ‘oh my goodness, this is actually what I want to study?’

Dr. Jan Claassen: I think part of it was that I sort of was so surprised myself that I really honestly didn't believe that this patient had a chance of recovery. If he had a chance of recovery, he would recover in a very, very poor state, and the opposite was true. He was basically back to normal, and to see this differential in between complete hopelessness and then somebody where you can give them back to their family, back into a normal life was just incredibly inspiring to me.

Catherine Price: Huh. And so you were saying you've always been interested in consciousness. I'm wondering if you can tell me a bit more about what you mean by that?

Dr. Jan Claassen: It's a really great question. So what is consciousness, right? Actually, honestly, when, if you really think about it, it's very, very difficult to define.

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And if you read philosophers, everybody actually talks about something different. And some say it's just too complicated to even define it or you know, it's like, it's like maybe it's all an illusion. And I mean, maybe that's true, right? When, when I think when I talk about consciousness, it's something much more practical. I mean, I talk to you and I, we have a conversation. You respond and I assume that you're conscious and that's how consciousness typically in very practical, in a practical sense, is conceptualized.

Catherine Price: So you mean basically that having like an understanding coupled with a reaction is how you're kind of pragmatically defining it?

Dr. Jan Claassen: And typically by a motor reaction, right?

Catherine Price: Oh, okay. 

Dr. Jan Claassen: By a motor response. So typically you ask in, in a very clinical sense, you ask somebody to do something, you know, in the ICU, for example, we ask a patient stick out your tongue or show us two fingers. If they do it, we assume that they're conscious. If they don't, we don't think that they're conscious. 

Catherine Price: Gotcha. So can you, can you

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tell me a little bit about how consciousness has been understood within medicine historically?

Dr. Jan Claassen: So disorders of consciousness have been known for a long, long time that the word coma is a, is a Greek word. And so they describe this state of a deep sleep that somebody could not be awakened up from. 

Catherine Price: Okay. 

Dr. Jan Claassen: I think a big sort of impetus for development of coma science has been really from the polio epidemic where a lot of people lost the ability to breathe on their own and, um, so that actually started the development of, uh, ventilators. And before that, patients in an unresponsive state just didn't survive. 

Catherine Price: Oh. 

Dr. Jan Claassen: So you, there was actually very little known about, um, uh, survival in an unconscious state. And then I would say in the sixties, there were critical care advancements that came around

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: that allowed sort of the, the application of ventilators also for other patients.

Catherine Price: Hmm. 

Dr. Jan Claassen: And what some very, very 

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astute, uh, neurologists and neurosurgeons observed in the 1960s, like in Plum and Posner, for example, um, who are, um, here at Cornell was this state where if you supported these patients for a while, some of them actually started to open their eyes, but they were unresponsive. So this was called the vegetative state. So the heart rate was functioning, the respiration, but they opened their eyes, but there was no consciousness, no interaction with the examiner. 

Catherine Price: I see.

Dr. Jan Claassen: And locked in syndrome is a, um, state that was also first sort of really clearly defined by Plum and Posner. Basically, it's a state where patients have lost much of their motor function, but they're fully conscious. 

Catherine Price: Ohhh.

Dr. Jan Claassen: And so many times those patients are actually misdiagnosed as being in a coma because if you, unless you do a very careful exam, you don't detect this blinking or the eye movement, the vertical eye movement. 

Catherine Price: Oh, I see. 

Dr. Jan Claassen: But if you go 

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back in the literature, probably a state like that was already described by Alexandre Dumas in The Count of Monte Cristo.

Catherine Price: Really! 

Dr. Jan Claassen: Where he basically describes a, um, a character that looked like a corpse, but, but with living eyes. These states are not new. Just our ways of describing them, our, our ways of ability to detect them has changed. 

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: And thereby we can, we can clearly potentially study them and, um, see how those patients do long-termwise.

Catherine Price: So speaking of our ability to detect these states, I was wondering if you could tell me a bit about the Adrian Owen study that I believe was very inspirational to you. 

Dr. Jan Claassen: Yeah, so Adrian Owen, um, is a psychologist and, um, he did a study, he published it in Science in 2006 and he studied, um, a young woman and she had had a traumatic brain injury, car accident. And this was months and months before, like six months or so. And she was in a 

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vegetative state, so she was in this state where she opened her eyes, but she had no interaction with the, uh, with the examiners. 

Catherine Price: Okay.

Dr. Jan Claassen: So when you asked her, um, you know, do something, she wouldn't, wouldn't do anything at all. And so he put her in a functional MRI scanner and in a functional MRI scanner, you can actually visualize brain function. So you ask somebody, ‘tap your finger,’ and then you, say, ‘stop tapping your finger.’ By contrasting these two states, you can visualize the brain area that's engaged when you're tapping the finger. 

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: So he said ‘imagine playing tennis.’ And then he said, ‘imagine walking through your apartment.’

Catherine Price: Hmm. 

Dr. Jan Claassen: And you have to, to understand that playing tennis activates a very different part of the brain, so it activates, it's a lot of hand and arm move movement are involved, and so a lateral part of the motor homunculus is engaged, whereas walking through your apartment requires a lot of engagement of, 

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of spatial um, orientation.

Catherine Price: Okay. 

Dr. Jan Claassen: And so he asked the patient, ‘imagine playing tennis, imagine walking through the apartment’ and did the same with a group of healthy volunteers. And to everybody’s surprise, this patient that had been unresponsive to any commands, not doing anything at all, activated almost the same areas as the healthy volunteers.

Catherine Price: Wow. That's amazing. 

Dr. Jan Claassen: Yeah. So basically that's, that's this state, he called it covert consciousness back then. 

Catherine Price: Okay. 

Dr. Jan Claassen: And it basically indicates that there's some consciousness that was sort of hidden from the surface, and I think cognitive motor dissociation, um, is probably the term that is most widely used now.

Catherine Price: Okay. 

Dr. Jan Claassen: Basically signifying that the cognition is better than what you by just examining the patient that the motor response would suggest.

Catherine Price: I see. 

Dr. Jan Claassen: But clearly she was able to willfully modulate her brain activity to these commands.

Catherine Price: Hmm. And so tell me about your 

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personal response to this, uh, paper. Do you remember where you were when you first heard of it or read it or what your reaction was?

Dr. Jan Claassen: Yeah, I, I, I remember this practicing as a, a young, uh, neurointensivist or even in training as a neurologist, that, um, sometimes you go to the bedside and you had this gut feeling there's, there's more there. I don't know, I can't, couldn't really put it into words. And sometimes, you know, you talk to the family and they, they're like, ‘no, we think Grandma is in there,’ or, you know, ‘my wife, I think she's actually there.’ And so you're asking me what did– do I remember when I read that paper and I, I remember that I was reading it and I was like, wouldn't it be great if we could tell whether those patients in the ICU were in this state of cognitive motor dissociation? 

Catherine Price: Oh. 

Dr. Jan Claassen: Maybe that's actually what the families described. Maybe that's actually this gut feeling that I'm, I'm feeling myself, right? 

Catherine Price: Hmm. 

Dr. Jan Claassen: And I thought, we should think about a study where we study patients that have acute brain injury. 

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: Um, and are un, 

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unconscious, and, um, see whether we can identify any patient with cognitive motor dissociation.

Catherine Price: So why did you specifically want to study these patients who are in the "acute" early phase of injury? 

Dr. Jan Claassen: So when you're in the acute phase of injury, you can still modify the course. 

Catherine Price: Mm. 

Dr. Jan Claassen: So you can potentially change your treatment. If you look at how patients with traumatic brain injury that are unconscious, so many of them, uh, can recover. But if you look at the patients that die from acute brain injury, 75% of them die because of withdrawal of life sustaining therapies.

Catherine Price: Wow. 75%.

Dr. Jan Claassen: Yeah. 

Catherine Price: Wow.

Dr. Jan Claassen: So how does that happen? Typically, after set amount of time, like after a week, the physicians sit down with the family and they talk about the prognosis and the likely outcome, 

Catherine Price: Uh huh. 

Dr. Jan Claassen: and then a decision is being made based on the assumption of what the patient would want to do. Not what the family wants to do, not what the physician wants to do, but what the patient

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would want to do.

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: Obviously we can't ask the ask the patient, so I, I thought that it would be fundamentally important to try to find out whether we can become, become better and more precise at predicting the ultimate outcome of these patients,

Catherine Price: Uh huh.

Dr. Jan Claassen: because that would then feed into this goals of care discussion, um, in, in the long term.

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: And so actually, honestly, the, the time when this switched into something that could be actionable was when, uh, when a study came out that showed that you could potentially do this with EEG as well.

Catherine Price: So why was the ability to use EEG to monitor brain activity such a game changer in terms, uh, of your ability to do this study in the ICU?  

Dr. Jan Claassen: And so EEG has the advantage. It's at the bedside. It can be done without transporting the patient. You know, there's, there's EEGs that are very research oriented. They're called high density EEG. They have hundreds of EEG electrodes. Intentionally, I wanted to use the sort of standard setup

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that we have available in any ICU, and so I thought the scalability would be much larger. When I, even when I first thought about this, I thought you have to develop something that's scalable, because if you can only do this in one center, the impact the public health impact is not gonna be big. 

Catherine Price: I see. So pretty basic EEG. 

Dr. Jan Claassen: Very basic. So the EEG is able to have repeated assessments, and it is important because behavioral states, um, after acute brain injury, brain injury fluctuate. The recovery from the acute brain injury and the secondary worsening from complications, be it strokes, be it sepsis, be it pneumonia, urinary tract infection, all of that can affect your, your brain function. And so these complex interactions, if you just have one snapshot in time, it's going to be impossible to even know where you are there. Whereas if you have a repeated assessment and it goes boom, boom, boom, boom up, 

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then you know then you can sort of put that into the context.

Catherine Price: Gotcha, so how did you design and carry out your study?

Dr. Jan Claassen: So basically what, what what we did is we used the EEG, we asked the patient, ‘keep moving your right hand and just keep opening and closing your right hand.’ And then we said, ‘stop opening and closing your right hand.’ 

Catherine Price: Oh. 

Dr. Jan Claassen: and then we did the same with the left hand. Obviously if they do open their hand, then they're not unconscious, right?

Catherine Price: That's pretty easy. 

Dr. Jan Claassen: And they were out of the study. 

Catherine Price: Right, exactly. 

Dr. Jan Claassen: That was, that's not, that's not what we're testing here. But while they are engaging, or not engaging, in trying to do this, we were recording the EEG–

Catherine Price: I see...

Dr. Jan Claassen: Sort of time synced to that. And we did this over and over again. Uh,’ keep opening and closing your right hand, stop opening and closing your right hand.’ And then basically what you do is you take the EEG that's recorded and you analyze the power in specific frequencies. 

So what does that mean? You have fast and slow waves in the EEG and 

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you look at the power, the amplitude in specific frequency spectra. So how much power is there of slow waves? How much power is there of fast waves? And you look at that at each electrode 

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: that you have on the head, and that generates a dataset., and then basically this dataset is analyzed with a machine learning algorithm. And the idea is very simple. The algorithm basically creates a line between these data sets and looks at whether the response to a move command compared to a stop moving command is systematically different. 

Catherine Price: Hmm. 

Dr. Jan Claassen: And if it's systematically different, that means the brain reacted in a way to the move command differently to the stop moving command.

Catherine Price: Wow. So you’re saying if the patient's response to the two commands was discernibly different, then it meant that the patient had some level of consciousness?

Dr. Jan Claassen: That's exactly right. That's exactly right, yeah.

Catherine Price: Okay, so tell me what happened! What were the results of this study? 

Dr. Jan Claassen: Yeah. It, it was, I, I 

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remember this very, very, um, very well. It was a big surprise. I think we, we did this for at least five, six years. 

Catherine Price: Oh, wow.

Dr. Jan Claassen: And, um, you know, the whole time we kept ourselves completely blinded to the results. So we certainly didn't tell the families, we didn't tell the physicians taking care of the patients, making any decisions, and we didn't know ourselves. 

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: And so when we had collected the first one hundred patients, we said ‘we're gonna look, uh, is there anybody that has cognitive motor dissociation?’ And to our big surprise, actually 15% of the patients had cognitive motor dissociation.

Catherine Price: What! 

Dr. Jan Claassen: So 15% doesn't sound a lot, but if you think about the number of patients that are in an unconscious state worldwide, it is millions actually, and 15% of that is a huge number. 

Catherine Price: So you're saying that of people who seem totally unresponsive, that in the past might have had their life support pulled–I mean, perhaps even did in this circumstance–but might have just been thought to be hopeless. There 

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actually were 15% showing some sign that they were conscious? 

Dr. Jan Claassen: Yeah, exactly. Only not behaviorally, right? 

Catherine Price: Right. 

Dr. Jan Claassen: So none of them showed any behavioral sign of consciousness, you know, and we don't know what their fate would've been, but I, uh, what we were surprised by is that, that this was such a high rate.

Catherine Price: So tell me about the moment when you unblinded yourself. I mean, where were you? What did you feel like, how did you respond?

Dr. Jan Claassen: So first we didn't believe it. We did a number of tests to assure that this was a real finding. There's a number of plausibility approaches that you, uh, that you apply to the data and the data stood. It, it actually remained. But what we wanted to see was, we wanted to see does this have any meaning in predicting, um, the outcome of these patients.

Catherine Price: I mean that makes sense cause I guess, even if you know they’re in there it doesn't necessarily mean they'll be able to come back. So how did you go about figuring that out?

Dr. Jan Claassen: We had actually prospectively assessed this because that was, uh, 

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part of the study so that everybody was assessed at the same time. 

Catherine Price: Oh, okay. 

Dr. Jan Claassen: So we looked at 3, 6 month, 12 months, and then 3 years. And what we found, first of all, which was shocking, that patients that had had covert consciousness had a much higher chance to recover behavioral features of consciousness before, um, hospital discharge. And then even more important, when we looked a year after the injury, 44% of the patients with covert consciousness had, uh, functional recovery. 

Catherine Price: Wow. 

Dr. Jan Claassen: Yeah, so we were able to show that independent of each of the neurological deficits on admission to the hospital and the brain injury that they had, independent of that, we were able to predict time to recovery. 

Catherine Price: Hmm. 

Dr. Jan Claassen: So the patients with cognitive motor dissociation recover earlier than the ones without cognitive motor dissociation. So is this a transitory state that

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we detect there that then predicts the recovery? Or is it a defined state that just associates with recovery?

Catherine Price: I understand you're saying this is not yet possible, but it seems like in the future, perhaps you would be able to identify the people who were the most likely to recover, and that might be a life or death piece of knowledge, right? 

Dr. Jan Claassen: Yeah. 

Catherine Price: In terms of, as you were saying, 75% of the people who die from these states is because we withdraw care. 

Dr. Jan Claassen: Yeah. Yeah. What we're trying to do right now is to, uh, take it to the next step and see whether we can scale this. Right now we have a, uh, study, uh, the RECONFIG study where we are actually studying patients with brain hemorrhages. 

Catherine Price: Yeah, tell me about that. 

Dr. Jan Claassen: So RECONFIG is um, uh, is an acronym that stands for Recovery of Consciousness Following Intracerebral Hemorrhage. Um, the reason I focused on that was that these patients have focal lesions where the injury is, but also diffuse injury. So it's a good sort of patient population to study 

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the impact of brain injury on the ability to detect, uh, covert consciousness, and we are studying this with regular and advanced MRI, um, study. 

So basically what we're looking at is getting an exact idea about the injury, where it occurs, and then also on the network effect. And by that, understand more about the mechanisms of what underlies covert consciousness. I think the idea is if we understand the mechanisms underlying covert consciousness, then we can better integrate it into our prognostic and therapeutic, um, uh, approaches of treating these patients. 

Catherine Price: Hmm.

Dr. Jan Claassen: And we, uh, are enrolling not only here at, at uh, NYP/Columbia, but also in Miami… 

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: And we are having them upload the EEG to our server and analyze it here. So basically to go towards a, um, a setup where you can actually scale this better. And then to make this, um, as sort of scalable as 

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possible we also shared all of our protocols, we shared our code basically that we use to analyze these data immediately with the publication of the papers so that, you know, we can, you know, multiply this and potentially, um, have a bigger impact.

Catherine Price: Is that one of the benefits of making the code open source, that it actually makes it more standardized if people are using the same code to analyze their data as you did for yours? 

Dr. Jan Claassen: Exactly, because otherwise they would try, try to copy, I mean, to come up with something similar. But then maybe we have different results and maybe it's because the code is different, so as, as much as you use the same technology, uh, the more that people do that, the more likely it is that they will get the same results.

Catherine Price: Tell me more about that, ‘cuz it seems you're very passionate about, you know, making things equitable and making sure that the research you're doing is scalable and not just available in an elite research setting, so. 

Dr. Jan Claassen: So I, I think it is as researchers, I think it's incredibly important to think about not just what you can do at your place, but what the bigger impact 

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can be. A huge number of patients worldwide have disorders of consciousness. Um, trauma is very prevalent no matter where you go in, in the world. So we, in 2019, after, um, the paper was published, um, I got together with, um, investigators, uh, through the Neurocritical Care Society and we, um, developed this Curing Coma campaign and it's a worldwide campaign now involving, um, scientists from all over the world. And, um, we are working one on, for example, doing a study like covert consciousness detection in a, in a broader scale. And so what I think is important that we think about innovative ways of using what we already have because we have a lot of technology. 

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: So you can, for example, um, analyze an, a CT image that somebody obtains in California in real time here in New York. You have to think about what is the 

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minimum technological need that that, that that is required 

Catherine Price: Hmm. 

Dr. Jan Claassen: to obtain your data, and then how can you democratize, um, your analytics and share that with everybody while at the same time, you assure quality of the data. So part of that can be then obtained with protocols that are rigorously developed, and for the acquisition, and then standardization of the analysis that can be potentially even done remotely.

Catherine Price: Gotcha. So it's been about four years. How do these findings affect the way you address either the patient or the family now that you suspect that up to 15% of these people may actually have some degree of consciousness?

Dr. Jan Claassen: So if you think about the, the, the most important thing is at the bedside, you should always assume that your patient is conscious. 

Catherine Price: Uh huh. 

Dr. Jan Claassen: Because you can't tell. I think that's a very, very important, um, uh, lesson from this that 

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I share always with, um, with my trainees, that you have to assume that the patient is conscious. When you go back to the bedside, very often families ask, ‘so what should we do when we're in the room?’ 

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: and I always tell them, ‘just assume that, you know, your loved one, uh, fully understands you.’ If, if the person enjoys music, play them some music. I always tell families, ‘tell them what's going on at home. Have them take part in, in, in your life. Obviously don't tell them something super stressful, ‘cause the last thing they need is another stressor, but share, share.’ You know, make them, make them feel that they haven't lost that connection. And that's, I think that is built on these quality of life assessments that we have from patients in locked in syndrome, which, which granted is a different condition, but, um, what ultimately what we would love to do is we would love to build a, um, communication bridge back to these patients. So they're basically, you have to imagine 

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they're locked in there. They're in this, in this state, they're in this state where they're in covert consciousness. They have no way of communicating with the outside environment, no way of sharing their feelings, their fears, their– even their pain, right? They can't even ask for pain medication. And so, um, so I think ultimately it would be fantastic if we could build some communication bridges with them. That is super, super difficult to do. The reason I think it's so important is from the locked in patients, we know that if they actually have ways of expressing themselves, their quality of life is much better, right? How can we sort of get to that communication strategy?

Catherine Price: So I think where you're going with this is the brain computer interface that you’re working on, right? Can you tell me about that? 

Dr. Jan Claassen: Yeah, so, so a brain computer inter interface, fundamentally, right? So you, you present the patient with a task.

Catherine Price: Okay. 

Dr. Jan Claassen: You can say, you know, uh, ‘move a bar up or down on a computer screen’ and you record a biological 

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signal, and then the machine learning algorithm learns and the computer, basically learns 

Catherine Price: I see. 

Dr. Jan Claassen: what your brain activity or some other biological signal looks like when you're trying to engage in this task. And once it's learned that, actually that biological signal alone is enough to drive the computer.

Catherine Price: Wow. 

Dr. Jan Claassen: So you can have patients like that, for example, play a game. Do you remember this Pong game? 

Catherine Price: Oh yeah.

Dr. Jan Claassen: Where you just  move the bar up and down, very like, I think that was the first computer game or so.

Catherine Price: Right. 

Dr. Jan Claassen: And so, um, patients can actually play that game with, just by thinking about it, right?

Catherine Price: Wow.

Dr. Jan Claassen: So, obviously it is what we would wanna do is now take this and use them in patients with covert consciousness, and we are very far away from that. And the question remains, even if we are able to connect to them, are they in a state that they can actually engage in any meaningful interaction with the environment?

Catherine Price: Mhmm.

Dr. Jan Claassen: And ideally they would be able to direct their pain medications.

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Could they even engage in, um, in any conversation or interaction with their loved ones? I think that would be probably the most meaningful, meaningful thing.

Catherine Price: Okay. 

Dr. Jan Claassen: Whether they can really learn to systematically activate your brain activity in a predictable way that the computer can learn it, is really an open question. We don't know that. We have some patients that we've studied that are behaviorally unresponsive that have shown responses that are more than just chance. That gives us hope that we can potentially, you know, dig into that and utilize that signal to, to, to, to move towards something where it becomes meaningful.

Catherine Price: I see. Okay! I mean, that makes me wonder about your vision for the future. Like, if you were able to look ahead 5 or 10 years, what would you hope we know about disorders of consciousness that we don't know right now, and then also what we might be able to do that we currently can't do?

Dr. Jan Claassen: One of the things, I would 

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hope that we become more precise and accurate in our predictions. In some ways, it's almost like personalized medicine, that every patient is different and you take into account all of the factors that influence outcome and that we could come up with a more precise, uh, long term prediction. I remember when I first started training my, uh, the senior physician said in patients with traumatic brain injury, that if somebody hadn't recovered within a day or two that there was no chance of recovery. 

Catherine Price: Hmm. 

Dr. Jan Claassen: We know now that patients recover beyond one year after the injury, right?

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: So there's, this scale is just completely off and so the, um, the expectations when some, somebody should show recovery needs to be reset. The other thing is that I hope that we, um, will be able to connect to those patients as we talked about the brain computer interface.

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: And then maybe most 

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importantly, that we will be able to actively support their recovery. And I think one important, um, aspect that I really enjoy a lot is also engaging with non-scientists about this. 

Catherine Price: Mm-hmm. 

Dr. Jan Claassen: Um, one, I, I’ll just tell you one experience that I had during the Covid pandemic. I, uh, gave a talk in my son's, um, high school philosophy class because they asked me to talk about consciousness. And I tell you sometimes from people that are, I wanna say not burdened by all the scientific knowledge, sometimes the best questions come from them.

Catherine Price: Do you remember any of those specific questions?

Dr. Jan Claassen: Um, they basically ask very fundamental questions about what consciousness is to begin with. 

Catherine Price: Uh huh. 

Dr. Jan Claassen: And, you know, in my mind that's like, it's such a big question. I mean, what, what are we doing here? So I think it's, it's very, very helpful and meaningful to, to sort of, to, to talk to people that don't have that much scientific knowledge yet. 

Catherine Price: Uh huh.

Dr. Jan Claassen:  And I, I just enjoy that a lot and I think that's, uh, that's also something 

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that I hope will, people will embrace and, um, integrate into their thinking.

Catherine Price: Wow. So much that we don't know. 

Dr. Jan Claassen: Yeah, exactly.

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Catherine Price: Great. Well, thank you so much. This is fascinating.

Dr. Jan Claassen: It's my pleasure. Thank you so much. Really enjoyed it.

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Catherine Price: So many thanks to Dr. Jan Claassen for taking the time to speak with us on this fascinating– and philosophical– topic. I’m Catherine Price. Advances in Care is a production of NewYork-Presbyterian hospital. As a reminder, the views expressed on this podcast solely reflect the expertise and experience of our guests. To find more amazing stories about the pioneering physicians at NewYork-Presbyterian, go to nyp.org/advances.

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