Into the Void

UPenn’s Center for Resuscitation Science

Interesting web site. It’s about how we define the moment of death. They are turning Emergency Medicine on its head.

If you have advance directives, a living will or a DNR order, it’s because you don’t want to wind up a vegetable after a medical emergency or because you have an incurable, fatal condition. Advanced directives are NOT intended to force the ER doctors to let you die when medical treatment can easily fix you right up. With the exception, of course, of folks whose religion forbids medical treatment.

When I was a whitewater rafting guide I had to be certified in Advanced First Aid and Life Support. This program took four weekends to complete. It was hard for me to put in that kind of sustained effort, now that I think about it, but it really helped my confidence on the job. The point of the course was to enable the guides to stabilize someone injured on the river until we could get real medical help. And it wasn’t a far stretch to consider CPR in case a guest had a heart attack on the river.

Read the UPenn web site. Look at the powerpoint presentations. Read the doctors’ curriculum vitae.

Again: it’s about how we define the moment of death.

So.

Google “cellular reperfusion injury” and read a few of the articles that come up.

Your cells don’t die right away when you die. When oxygen-deprived they go into a kind of stasis and even after several hours a doctor can still extract undamaged, living cells. They haven’t stopped, they’ve just slowed down. You don’t fade out in that first magic 5 minutes. You fall into a deep coma, then actual cell death takes hours – or longer.

This is completely different than what the public and most of the medical profession believes at this time. The current belief is that no pulse equals death. Which really sucks for a few folks who have temporary a artificial heart that whirrrrrs instead of beating. But I digress.

So if you want to define death in terms of brain activity as monitored on an Electroencephalogram (EEG), well, the EEG can only measure down to about 0.5 Hz. This is a limitation of our technology. As you fall asleep brainwaves slow from 30Hz maximum down to around 4Hz. If you go into a deep coma, they slow down even more. No brainwave equals death, then. Except that our technology has serious limitations. Well, it turns out that brain cells go into stasis too.

Now here’s where it gets weird.

Think about what they do in the ER. It’s all about reperfusion, getting oxygen back into the brain as quickly as possible. Jump-start the heart, pump oxygen into the lungs, get a cold patient warm. Well, it turns out that if you pump too much oxygen into a cell that’s in stasis, it self-destructs. That magic 5 minutes isn’t the time that it takes the cells to die. The magic 5 minutes is the time it takes for some of the cells to go into stasis, that is, enough that the self-destruction, or apoptosis, causes wide-spread damage to the body on reperfusion. The heart seems to be the most susceptable organ.

The gist of the web page I linked to is that if someone is brought into the ER suffering from cardiac arrest, they have a better chance at survival if the ER doctors immediately cool them down and add some chemicals to prevent apoptosis before beginning slow reperfusion. The Resuscitation Medicine department at the U of P is working on establishing a new set of protocols.

Where it gets scary is here:

If they bring you in after the magic 5 minutes, present ER protocols can’t save you. Not without massive, permanent damage to the heart and to the brain. They declare you, and that’s it. The body is sent to a funeral home and cremated or injected with preservatives, sometimes long before the several-hour deadline (so to speak) is up.

No wonder the Irish hold wakes. The British, after discovering that an unsettling number of people had been buried alive – used to attach bell cords to the wrists of folks they buried. Saved by the bell.

IRL your family can decide to keep your brain-dead corpse alive despite anything you said in life. Witness what poor Terri Schaivo’s parents did to keep her mindless body alive long after her spirit was gone.

I’ll be watching the Rescusitation Medicine story with great interest.