Ms Shanthini is part of a multi-disciplinary team providing specialised, round-the-clock care for patients at the NTFGH ICU, many of whom are in a coma (prolonged state of unconsciousness). 

There is one nurse for every two patients in the ICU, enabling Ms Shanthini and her colleagues to provide individualised and intensive care. They work in close collaboration with critical care physicians and allied health professionals to comprehensively address the multifaceted needs of coma patients. This includes constantly monitoring their vital signs, performing basic caregiving duties, managing complex medical equipment such as dialysis machines, and responding swiftly to medical emergencies.

Common causes of a coma include traumatic brain injury, stroke, and cardiac arrest or abrupt loss of heart function.

“We determine this based on the patient’s clinical history, physical examination, and tests such as blood investigations and brain imaging,” said Dr Seth Ting, Consultant, Intensive Care Medicine, NTFGH. “Our arsenal of diagnostic tests includes CT and MRI scans, electroencephalography or EEG (which measures electrical brain activity), and lumbar puncture (spinal fluid analysis).”

About half of the coma cases are medically induced, meaning patients receive a controlled dose of an anaesthetic drug to place them under temporary sedation. An induced coma allows doctors to perform critical care interventions, such as putting a patient on a mechanical ventilator (breathing machine), without causing pain or discomfort.

If the coma is caused by a traumatic brain injury, treatment options include surgery and medication to lower intracranial pressure (pressure inside the skull) and protect the brain from further damage.

Other causes are managed differently. For example, brain infections are treated with antibiotics or antiviral drugs.

Continuous observation of patients is achieved through frequent bedside checks and real-time patient monitoring systems. Besides tracking vital signs, doctors assess their neurological status by checking for changes in pupil size, reaction to light or responsiveness to painful stimuli. Automatic alarms go off if a patient’s condition suddenly changes, facilitating a quick medical response.

“Bowel movements and urination still occur in coma patients through reflexes controlled by the spinal cord and brainstem,” added Dr Ting. “These basic functions do not stop even when higher brain regions are impaired.”

Coma patients are wholly dependent on the ICU team for the management of all physical processes, not just bodily waste. Nurses handle the lion’s share of duties, such as regularly emptying urine collection bags and inspecting the patient’s skin. They also collaborate with allied health professionals to provide holistic care, day and night.

Once intubated, the patient’s breathing status is continuously assessed so that their airway remains clear and optimal gas exchange can occur. Respiratory therapists analyse blood samples to measure oxygen and carbon dioxide levels, adjusting ventilator settings based on the patient’s needs.

Respiratory therapists also train ICU nurses on proper airway suctioning techniques. Frequent suctioning, or removal of mucus and other secretions from a patient’s airway, is important to prevent airway obstruction and reduce infection risk.

In emergencies where a patient goes into cardiac arrest or stops breathing, respiratory therapists form part of the Code Blue team and work together with doctors and nurses to perform life-saving resuscitation.

“Every time we connect or remove oxygen supply is an emotionally charged moment,” said Mr Montero. “There’s joy and relief when patients can breathe on their own again. Other times, we did all we could and have to say goodbye. It reminds us how unpredictable life can be.”

“My role is to assess nutritional needs, select appropriate formulas and determine the optimal dose,” explained Ms Chong. “I work with the multi-disciplinary team, including doctors and nurses, to ensure the provision of nutritional support to improve clinical outcomes.”

Dietitians prescribe an individualised nutritional plan for each patient, which involves determining the right formula and feeding rate. Patients are fed enterally (via a feeding tube placed into the gastrointestinal tract) or, if their digestive system is not functioning well, parenterally (via an intravenous catheter placed into a vein).

Through regular monitoring and consultation with the ICU team, dietitians then adapt the feeding regimen according to changes in a patient’s condition, laboratory values or tolerance.

“I use passive range-of-motion exercises to gently move the patient’s limbs, from shoulders to ankles. This helps maintain joint integrity and mobility,” Mr Farrock elaborated.

Technology enhances these efforts, with bedside ergonomic bicycles for lower limb movement and electrical stimulation devices to activate muscles.

Warding off chest infections in coma patients is also a priority, he added. “I apply chest physiotherapy techniques like percussion to clear mucus buildup in the lungs.”

While patients are in a coma, support is offered to their caregivers and loved ones who understandably feel anxious. “We look out for the emotional well-being of family members or bring in a medical social worker for counselling,” said Ms Shanthini. “If a family has difficulty understanding the patient’s prognosis or care plan, we go over it with them.”

Unfortunately, sometimes patients do not regain consciousness and remain in a permanent coma. This leads to tough conversations between the family and the medical staff about whether or when to withdraw treatment.

The good news is these instances tend to be the exception rather than the rule. Most patients wake up from their coma and embark on the journey of rehabilitation. While the extent of recovery is highly variable and differs from case to case, the unwavering care delivered by the ICU team offers hope that they can make a full recovery.

In consultation with Dr Seth Ting, Consultant, Intensive Care Medicine, NTFGH; Ms Shanthini Shanmugam, Senior Staff Nurse, Intensive Care Unit, NTFGH; Mr Rodel Montero, Respiratory Therapist, Respiratory Therapy, NTFGH; Ms Chong Shu Han, Senior Dietitian, Dietetics and Nutrition¸ NTFGH; and Mr Emmanuel Farrock, Senior Physiotherapist, Physiotherapy, NTFGH.