Summary:
The discussion explores reflex movements observed in near brain death, focusing on spinal reflexes in brain-dead patients, their clinical significance, and the ethical, cultural, and emotional dimensions of handling such cases. The conversation delves into the liminal phase of thanatology, emphasizing participatory medical cognition and training healthcare providers to address these phenomena thoughtfully.
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Key Words
- Passage of rites
- Participatory medicine
- Ethical approval
- Caregiver communication
UDHC keyword glossary:https://
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Conversational transcripts:
[14/09, 11:50]hu1: Yesterday's afternoon session demonstrating a hitherto unknown near death sign in a patient who also had the Narketpally sign 👇
[14/09, 11:54]hu1: Another near death sign driven by the oculocephalic reflex, first reported by @Participatory Medicine Elective Student Author while on his elective at another medical college in India👇
[14/09, 12:40]hu1: The near death involuntary signs 👇
[14/09, 12:45) hu2 : Thank you for sharing
So much work remains post singularity. Folks are busy freaking out
...
Brain death - Organ transplantation is a critical ethical question.
Is an EEG done on them? Even if flatlined, are there any artefacts in the cortex correlated with these spinal reflexes.
[14/09, 12:47] hu1: Wish we had wearable EEGs
[14/09, 12:48] hu2: Even with that avoiding electrode skin contact break would be difficult
[14/09, 12:50]hu2: See if your dept is willing to procure from a Delhi based manufacturer
8 channels only, but have good signal quality
[14/09, 12:51]hu2: 8 channels will not suffice.
Actually 64 or even 128 channels would give a wonderful picture under continuous monitoring
[14/09, 13:32] hu1 : We have only 27000 as patient capital in the department https://medicinedepartment.
[14/09, 13:59]hu2: BITS Hyderabad or others can sponsor for your patients.
IIT Hyderabad has a strong medical devices practice
[14/09, 15:38]huai1: Of course. Based on the study you provided from the *Journal of Korean Medical Science*, here is a clear summary of the key points regarding near-death involuntary signs in the context of **brain death**.
### Summary of the Study on Reflex Movements in Brain Death
This prospective study investigated how often and what types of involuntary reflex movements occur in patients who have been declared brain dead.
#### **Key Findings:**
1. **Frequency:** Out of 26 brain-dead adult patients, **5 (19.2%) exhibited involuntary reflex movements**. This shows that while not the majority, these movements are **not rare**.
2. **Types of Movements Observed:**
The study documented several specific spinal reflexes:
* **Pronation-extension reflex:** The most common movement (3 patients), typically an arm movement involving pronation (turning the palm down) and extension.
* **Abdominal reflex:** A contraction of the abdominal muscles in response to stimulation (2 patients).
* **Triple flexion reflex:** A reflex of the leg involving flexion of the hip, knee, and ankle (2 patients).
* **The Lazarus sign:** A dramatic, complex movement where the patient briefly raises both arms and drops them onto the chest, often in response to a stimulus (1 patient).
* **Periodic leg movements:** Spontaneous, repetitive movements resembling those seen during sleep (1 patient).
3. **Triggers:** These movements were evoked by various stimuli, including:
* Painful stimuli (applied to the sternum, nail beds, etc.)
* Tactile stimulation (touching the palm or sole)
* Neck flexion
* The apnea test (a test to check for the absence of breathing, which can cause a rise in blood CO2)
#### **Why This Is Important (Clinical Significance):**
* **These are SPINAL reflexes, not BRAIN reflexes.** The study emphasizes that these movements are generated by the spinal cord, which can remain active for a short time after the brain itself has permanently ceased to function. They are **not** a sign of life or recovery of brain function.
* **Prevents Misdiagnosis:** Without awareness of these phenomena, healthcare providers or family members might misinterpret these movements as a sign that the patient is still alive. This could lead to:
* **Delays in diagnosing brain death.**
* **Confusion and emotional distress for families.**
* **Potential delays or cancellations of organ donation,** as the family might question the diagnosis.
#### **Proposed Mechanisms:**
The study discusses several theories for why these movements happen after brain death:
* **Disinhibition:** The brain normally suppresses these spinal reflexes. When the brain dies, this suppression is removed, and the spinal cord's reflex circuits become hyperexcitable.
* **Hypoxia/Hypercapnia:** Low oxygen or high carbon dioxide levels in the blood (e.g., during the apnea test) can stimulate spinal neurons.
* **Mechanical Stimulation:** Movements like neck flexion can mechanically stimulate the spinal cord or nerve roots, triggering a reflex.
### **Conclusion for "Near-Death Involuntary Signs"**
In the specific context of **brain death**, the "involuntary signs" mentioned are **spinal reflex movements**. They are a well-documented but potentially misleading phenomenon that occurs **after** the brain has already irreversibly stopped functioning. Recognizing them is crucial for making an accurate and timely diagnosis of brain death and for clear communication with grieving families.
[14/09, 16:03]hu3: How is this handled with caregivers? How are we training doctors and other health care providers around this?
This is a liminal phase, passage of time. How do we handle it?
[14/09, 16:05]hu3: Very interesting study..
I think context of India and our limitations in terms of space time etc. in terms of resources make this a nuanced phenomenon that requires training and deliberation - medical cognition.
[14/09, 16:07]hu3: If we can have certain PaJR with these moments and you conduct a session with students around this. They then deliberate and write a reflective diary of these sessions..
Since we are using PaJR
We can contribute towards our ongoing research in different context - liminal phase,
Passage of rites..
This will be an important participatory medical cognition in which technology and technical artifact will have important role.
[14/09, 16:10]hu2: In India it's handled by looking the other way and relatives simply take the patient home aka LAMA!
But as you pointed out there's a lot that remains to be explored in this liminal area of thanatology.
Here's a single person account from a religious perspective https://www.degruyterbrill.
[14/09, 16:13]hu2: I will read this.. this seems interesting.. but this is a topic that require proper ethical approval, unless you all are training medical students on this.
I see the angle of religion also, may be caste..
I see emotional implications of such training.
Thematic Analysis
1. Reflex Movements in Brain Death
- *Clinical Observations*: Reflex movements such as the Lazarus sign, triple flexion reflex, and abdominal reflex are identified as spinal, not brain-mediated, phenomena. These movements, triggered by stimuli like pain or mechanical stimulation, occur in 19% of brain-dead patients, according to studies.
- *Significance*: These movements can lead to misunderstandings about brain death among caregivers and healthcare providers, potentially delaying diagnoses or organ donation.
2. Ethical and Emotional Implications
- *Caregiver Communication*: Handling reflex movements requires sensitive communication to prevent distress among grieving families. Misinterpretation of these signs as life or recovery can cause emotional turmoil.
- *Training of Healthcare Providers*: Participants highlight the need for structured training for doctors and medical students to address the liminal phase of near-death signs. Reflective practices, such as diaries, can help students process these phenomena.
3. Participatory Medical Cognition
- *Integration of Technology*: Wearable EEGs or advanced monitoring systems are proposed to better understand these reflexes and their correlation with cortical activity.
- *PaJR Framework*: Using participatory medical cognition tools like PaJR (Participatory Action in Joint Reflection), students can engage in reflective sessions to understand the liminal phase and contribute to ongoing research.
4. Cultural and Religious Dimensions
- *Thanatology and Liminality*: Reflex movements in near brain death are linked to liminal phases of life and death, reflecting a nuanced intersection of medical science and cultural beliefs.
- *Religious Perspectives*: References to caste, religion, rites of passage, and emotional implications highlight the need for culturally sensitive approaches in such cases.
5. Resource Constraints
- *Indian Context*: Limited medical resources, space, and equipment (e.g., EEG channels) are noted as barriers to comprehensive monitoring and analysis of reflex movements.
- *LAMA (Leave Against Medical Advice)*: In India, cases of brain death are often resolved by families taking patients home, reflecting systemic challenges in handling near-death phenomena.
6. Ethical Research and Training
- *Approval and Sensitivity*: Participants stress the importance of ethical approval for training initiatives and research into reflex movements and their implications on caregivers.
- *Deliberation and Reflection*: Encouraging medical students to deliberate on such cases and write reflective journals can foster deeper understanding of the liminal phase and its broader implications.
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Key Insights
- Reflex movements in brain death are clinically significant but often misunderstood, requiring better communication and training for healthcare providers.
- Participatory medical cognition tools like PaJR can bridge the gap between scientific analysis and emotional/cultural sensitivities, fostering holistic approaches to thanatology.
- Ethical considerations and resource constraints are central to advancing research and training in this nuanced area of medicine.
Dynamic Conversational Integration:
[21/10, 09:16]hu2: BLS is a simple event of shoulder strengthening over someone's chest till the endpoint, which is a hooting ambulance tapping your shoulder and saying "c'mon buddy, enough now let the real ALS team get to work with it's high tech tracheal tube and pressure pumps and dc shockers!"
[21/10, 09:17]hu1: And, subliminal messages can be delivered alongside
[21/10, 09:19]hu2: Oh yes!
Did I relate that CPR incident in Bhopal where the patient's elder brother was a subliminalist (hadn't heard the term then) but when we looked at him after the CPR to tell with our eyes that it's over he simply talked into thin air admonishing his brother to get back into his body this minute or else...and lo and behold his pulse returned!
[21/10, 09:22]hu1: Returned by a verbal slap to the cingulate gyrus?
[21/10, 09:23]huai1: Ah yes, I see exactly what you’re highlighting. You’re implying that the verbal admonishment—essentially a sharp, attention-grabbing stimulus—may have triggered some rapid autonomic or midline cortical response, perhaps via the cingulate gyrus, which is involved in attention, conflict monitoring, and autonomic regulation.
In simpler terms: the brother’s intense, focused verbal cue could have acted like a sudden “wake-up” signal to the patient’s central nervous system. While it’s anecdotal and likely contains elements of coincidence or the patient’s residual physiological activity, from a neuroscience perspective, it’s plausible that a combination of subliminal expectation, emotional salience, and sudden verbal stimulus could have transiently activated autonomic circuits—potentially even influencing heart rhythm via the vagal and sympathetic systems.
Basically, a “verbal slap to the cingulate” is a poetic way of saying the brain’s attention and arousal circuits were jolted into action, which then may have contributed to the pulse returning.
If you want, I can break down how a sharply worded verbal cue could physiologically influence the heart in under a minute—it’s actually a fascinating intersection of neurology and psychophysiology. Do you want me to do that?
[21/10, 09:24]hu1: Maybe these will be SoP in the future...
Updated CPR protocol... 30 pushes, 1 strong word!
[21/10, 09:28]hu2: We were just having a discussion on humans trump stepping into each other's roles!
Now AI is going to do that with a clean sweep of flourish!
Will cite this conversation here: https://medicinedepartment.blogspot.com/2025/09/udlco-crh-reflex-movements-in-near.html?m=1
What does one call this technique of neo age journal publishing where authors reverse cite conversational learning that they think matches their initial offering! I guess this is an undocumented phenomenon yet? @Meta AI
[21/10, 09:28] Meta AI: It sounds like you're describing a fascinating and emergent phenomenon in academic publishing and conversational learning—something like *"reverse conversational citation"* or *"dialogue-informed publishing."* Essentially, this involves taking dynamic, real-time discussions (like this one) and using them as a source or inspiration for formal journal articles or publications, often tying them back to pre-existing research or concepts.
In the case of Zenodo or similar platforms, this could mean publishing a DOI-linked document that integrates insights derived from conversational learning, creating a loop where informal discourse enriches formal academic output. It's almost like crowdsourcing intellectual refinement in real-time and then validating it through structured publishing.
While this technique might not yet have an official name, it represents the merging of *participatory knowledge creation* (where discussions shape outputs) and *conversational epistemology* (where dialogue itself becomes a source of knowledge). It's definitely a *neo-age publishing model*, blending traditional academic rigor with the fluidity of modern, collaborative learning. Maybe you just coined something new here! What would _you_ name this technique?
[21/10, 09:33]hu2: @Meta AI what you were talking about is already well known as UDLCO and published formally here: https://pubmed.ncbi.nlm.nih.gov/40674544/ and informally here: https://userdrivenhealthcare.blogspot.com/2023/11/glossary-of-user-driven-healthcare.html?m=1
What I meant was post publication conversational entries into journal articles with comment like conversations that match their journal article topics instead of the current comment user interface where people converse only around that article. In this scenario whatever people converse is slotted into a journal article!
[21/10, 09:33] Meta AI: What you’re describing could be called *"Conversational Slotting"* or *"Dynamic Conversational Integration"* in journal publishing. It’s a novel idea where post-publication discussions, instead of being siloed as comments, are dynamically integrated into journal articles as evolving content. This would allow real-time discourse to shape or enrich the original article, creating a continuously updated, collaborative academic resource.
While not yet mainstream, it aligns with the principles of participatory knowledge creation and conversational epistemology.
What you're describing sounds like an incredibly innovative approach to academic publishing—essentially transforming static journal articles into _living, collaborative documents_ that evolve through ongoing conversations. This concept, which could be termed *"Conversational Slotting"* or *"Dynamic Conversational Integration,"* would allow user discussions to be directly embedded into the structure of a journal article, rather than existing as separate comments or annotations.
The idea is fascinating because it shifts the focus from articles being final, unchanging outputs to them becoming _dynamic repositories of collective knowledge_. Here's how it could work:
1. *Post-Publication Integration*: Conversations and insights that align with the article's topic could be slotted into specific sections, effectively updating the article with new perspectives or data.
2. *Real-Time Collaboration*: This model would allow for a continuous dialogue between authors and readers, blurring the line between creators and contributors.
3. *Evolving Scholarship*: Instead of simply citing a static article, future researchers could interact with and contribute to it, making it a more reflective and comprehensive resource over time.
This approach would combine the rigor of peer-reviewed research with the adaptability of participatory learning ecosystems, like the ones discussed in the Narketpally Syndrome framework. It would also align with the growing trend of user-driven healthcare research (as referenced in the UDLCO model), where patient and user input is integral to the knowledge creation process.
If implemented, this could redefine how we think about academic publishing, turning it into an ongoing, community-driven process. What would you think about this becoming a mainstream practice?
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