Shocked

by David Casarett

  Jason is more open to the idea. “I wouldn’t like having to make that call either, but I’d do it if I could. And for sure I’d listen to the family, if there’s time. At least we should be able to give them a chance to call it off. If the family says stop . . .”

  “But that tomato lady’s husband wouldn’t have told us to stop.” Garrett raises the obvious objection. “And today? Her husband? Never. Even if we could ask them, most families wouldn’t.”

  That’s probably true. Especially when the paramedics are already there, in the house. Let’s face it, Jason and Garrett look like pros. They look like they know what they’re doing, and they inspire confidence. It would take a strong personality to tell them to stop.

  And Garrett and Jason and thousands of paramedics like them can’t make the decision to stop. They operate under a central medical control, with strict protocols to follow. They’re obligated to attempt resuscitation on all patients, unless there is clear evidence, like rigor mortis, that a patient has been dead for an extended period of time.

  “Families don’t want to give up,” Garrett says. “Even if a patient’s ready to go, that doesn’t mean the family’s ready to let him. They’ll call 911 and then cut the bracelet off.”

  I ask if that’s ever happened and Garrett and Jason shrug in unison.

  “Hell,” Jason says. “Maybe it just happened. We’ll never know.”

  Several days later, I visit Florence in the ICU, where she is still unconscious and on a ventilator. I notice a picture of a much younger Florence taped to the wall above her head. Dressed in white, and wearing a complicated hat, she looks like she might have been at a summer wedding. Carla told me later that it had been taken at Carla’s wedding, twenty years ago.

  Richard says they put that picture up to remind the doctors and nurses of who Florence had been, and who she really was. Carla adds that it’s partly for them, too. “I don’t want my last memory of her to be in this bed, like this,” she tells me. “But I hope we did the right thing,” she says, reaching over to squeeze her father’s hand.

  Richard did the only thing he could have done. He picked up the phone and dialed 911. Maybe it was inevitable.

  There are many costs to what Florence and her family went through, but Carla is wrestling with one that we tend to ignore. The lingering uncertainty that is going to haunt them for years. Maybe Richard shouldn’t have called 911. Or maybe he and Carla shouldn’t have agreed so readily to aggressive treatment once she reached the ER. Each time the question arises, they’ll feel guilty for doing too much.

  They’ll also have to live with the memories of Florence as she is now. No matter how intently they focus on it, that picture above her bed isn’t going to eclipse the very real Florence right in front of them, with a tube down her throat and the wheeze of the ventilator in the background. Just like their feelings of guilt about maybe making the “wrong” decisions, that image will be with them for a long, long time.

  Finally, there are the financial costs of Florence’s care. Conservatively speaking, the price tag for the ambulance ride, the ER treatment, and a week in an ICU is probably more than $100,000. Most of those costs will be paid by Medicare, but they are costs nonetheless.

  And they incurred all these costs—financial and psychological—for . . . what? Florence so far hasn’t had any additional meaningful time with Carla or Richard or her grandchildren. She has yet to do, or say, anything. All of that treatment hasn’t bought her any real time. Sitting here in the ICU with Carla and Richard, I’m thinking that it’s as if Florence really had died a week ago but is condemned to live in some half-dead state until her family lets her go.

  A week after I saw them for the last time, I heard that Richard and Carla decided that enough was enough, and that they should stop aggressive treatment. They had different reasons, apparently. Richard had decided that Florence wouldn’t survive. On the other hand, Carla was worried that Florence would survive, but in a state that she would have found unacceptable. From those very different fears, the two of them came to a shared decision to let her go.

  So the medical team turned off the ventilator and removed the tubes and wires that had been keeping Florence alive. She breathed on her own for a few brief minutes. Then her heart rhythm faltered and her heart stopped for the last time.

  7

  When Is “Dead” Really Dead? Listen for the Violins.

  “DEAD” VERSUS SINCERELY DEAD

  I set out a year ago to learn about the science of resuscitation from the other side of the fence. That is, from the patient side instead of the doctor side. When I began, I’d seen many of my own patients—too many—reach the end of the proverbial road. These were people whose hearts had stopped working permanently.

  Some of those people had been through hell, like Joe, one of the first patients I met as a medical student and to whom you were introduced in chapter 1. He spent eighteen unconscious days in an ICU thanks to my efforts at CPR, and his family endured eighteen days of miserable watching and waiting because of me. I looked back at their histories, and at what they and their families had been through, and I became convinced that much of what they endured was futile.

  But there were others—people like Michelle Funk—who were alive against all odds. These were people who had bounced back after their hearts stopped. In short, people who had benefited from a miracle.

  I wondered what the future for all of us is going to be like. Are we all destined to die the way that Joe did, slowly, and in stages? Or can we look forward to miracles like the one that saved Michelle’s life?

  Those were the questions I started with a year ago. So what have I learned? Well, first, I’ve learned that death isn’t what it used to be.

  A man is shot multiple times and lies dying on the ground. His girlfriend is at his side to comfort him in his last minutes, and they say their tearful farewells. Weeping violins fade in. Then a bystander breaks the spell by asking how the man is doing. The girlfriend, annoyed, replies: “He’s dead! Can’t you hear the music?”

  Some version of that scene (in this case from the spoof I’m Gonna Git You Sucka) has been reprised countless times on stage and screen. A character dies and there are vivid, unmistakable cues. Most obviously, there’s the swell of music in the background (Samuel Barber’s “Adagio for Strings” is a favorite: see, for example, Platoon).

  But there isn’t always an orchestra on call for these events. In that case, we need to rely on someone who can announce the person’s death. Arguably the most famous authority in that role is Star Trek’s Dr. Leonard McCoy, who seems to relish the opportunity to announce, “He’s dead, Jim.”

  If Dr. McCoy is off in another galaxy and can’t be reached for comment, there are other cues that are subtler but still unmistakable. The victim’s eyes stare blankly (Dead Man Walking) or, for a more high-tech cue, the lights in Dr. Octavius’s arms die out (Spider-Man 2). Or a hand goes limp and an object falls to the floor (a snow globe in Citizen Kane). Or, in what has to be the most unmistakable death scene in the history of cinema, when Jimmy Durante’s character dies in It’s a Mad, Mad, Mad, Mad World, he kicks a bucket. Literally.

  Yet the paradigmatic example of this trope, at least in my book, occurs in The Wizard of Oz. The Munchkin coroner leaves no room for uncertainty in viewers’ minds regarding the fate of the Wicked Witch of the East. He proclaims:

  “As Coroner, I must aver

  I’ve thoroughly examined her

  And she’s not only merely dead

  She’s really most sincerely dead.”

  And there you have it. Not just dead. But sincerely dead. Which is pretty darn dead.

  In all of these scenes, death is unmistakable. Moreover, the point at which death occurs is unmistakable. There is a clear, bright line. And once a character crosses that line, there’s a cue for lights and music and McCoy’s famous line.

  A hundred
years ago, maybe, those scenes might have been a pretty good representation of how deaths played out. Someone was alive and then—suddenly, clearly, and unmistakably—they weren’t. Bystanders noted this fact and then moved on. Maybe sad music played in the background. But even without the score of “Adagio for Strings” playing in their heads, people knew that the person in front of them was dead.

  But now? Now, it’s not that simple. Now that line between alive and dead is getting increasingly blurry precisely because of the sorts of advances we’ve seen.

  Remember Michelle Funk? She was lucky that her rescuers were blissfully deaf to the sound of violins. But she’s hardly the only person we’ve met who was saved because no one stopped to listen. What about Anna Bågenholm, the “ice woman” who survived for hours? Or Mitsutaka Uchikoshi, the human bear who figured out all by himself how to hibernate? Or Thomas, the mushroom farm worker whose brain was put on ice for surgery? Or the dozens of bodies (and heads) stacked in that Alcor warehouse in Scottsdale, all of whom have completed their first life spans but who, we’re told, will be back? Someday.

  Each one of these examples has blurred the line between life and death a little more. The result is that it’s often no longer possible to say with the certainty of a Munchkin coroner that someone is “sincerely dead.” Because as soon as you do, a second later you’ll think about those people like Michelle Funk or Anna Bågenholm who were also “sincerely dead” until, all of a sudden, they weren’t.

  WHAT’S POSSIBLE?

  If the line between life and death is blurry now, what is it going to look like in five years? Or ten? Or fifty?

  From everything I’ve learned in the past year, I’m betting that the science we’ve seen up until now is just the warm-up act. I think the pace of advances is going to pick up, and I wouldn’t be surprised to see the field grow exponentially over the next ten years. A year immersed in the science of resuscitation hardly qualifies me to predict the future, but I’ll offer a couple of guesses.

  First, I’m betting that we can look forward to a huge bump in survival rates after cardiac arrest. How huge? Probably in the next five years, patients will be able to expect a better than 50 percent chance of a good neurologic outcome. Overall survival, too, will go way up. That’s partly because of the science I’ve seen in my travels, of course. But also because of relatively low-tech innovations like AEDs on every corner. They’re not fancy, and the technology that makes them possible has been around for decades. But they save lives, and the more of them are out there, the more lives will be saved.

  That’s the next five or ten years. But what can we expect in twenty or thirty? Once we learn how to bring people back to life, and once we get good at it, what’s the next big thing?

  Honestly—and I’m going out on a limb here—I’m optimistic about suspended animation. Not the crazy space travel version. But short-term suspensions that keep people alive for hours or maybe days.

  I’m not taking any sides in the squirrel-lemur showdown, and I’m open to the possibility that there are other examples out there that we don’t know about yet. Maybe that’s Dr. Cheng’s AMP, or maybe it’s something else entirely. But someone, somewhere, is going to figure out how to place people in a state of reduced metabolism that’s a small fraction of normal. And when they do, that’s going to be huge.

  HAPPY FAILURES

  If it sounds like I’m optimistic, I am. In part, my optimism comes from the rapid progress that has been made in the past ten or twenty years. That is, I’m optimistic because of our successes.

  But I’m also optimistic because of our failures. And there have been a lot of those, most of which I’ve left out of this book. For every day that I spent with people like Cheng Chi Lee and his mouse #0011 that entered a state of suspended animation, I spent weeks tracking down advances that didn’t pan out.

  Hydrogen sulfide (H2S), for instance, was the next big thing, until, all of a sudden, it wasn’t. H2S was first studied in detail by a biologist named Mark Roth, gaining him instant fame and, not coincidentally, a MacArthur “genius” award. Apparently this stuff—the gas that’s emitted from rotten eggs and sewage-treatment plants—induces a state of hibernation in mice. This would be the new wonder drug, everyone thought.

  In an experiment that received a blizzard of publicity, Roth exposed mice for six hours to H2S at a concentration of 80 parts per million. His team observed an average drop in temperature of 13 degrees Celsius and a 90 percent drop in metabolism. Impressive.

  Roth’s results inspired a wave of follow-up studies, but those studies, alas, produced results that were not so inspiring. Pigs, apparently, don’t respond very well to H2S. Nor do sheep.

  However, humans are not sheep, or pigs. So, undeterred, Roth brought H2S to clinical trials in people. That created challenges, because H2S is a gas, and you can’t use gas safely without the risk of poisoning everyone nearby. So Roth needed a form of H2S that could be administered intravenously.

  An early study used sodium sulfide (Na2S). Exposed to water and oxygen (for example, in humid air or in the bloodstream), Na2S generates H2S. It’s not without risks, though. Na2S is strongly alkaline in solution, like sodium hydroxide, also known as Drano. OK, so this isn’t sounding like something you want to get anywhere near, right?

  And indeed it turns out that you don’t. That trial began in May 2009 and was terminated in April 2010 after only six subjects had been enrolled. As is often the case when trials are stopped, available information is sparse. A query to Ikaria, Roth’s company, received only this terse reply: “Unfortunately, I’m not able to provide any further details other than our development of this asset has been terminated.”

  So hydrogen sulfide, apparently, is not coming to an emergency room near you anytime soon. And who knows? Maybe Cheng’s AMP will suffer the same fate. Indeed, it seems like many innovations that look exciting now will be doomed.

  Failures like this are cause for optimism because they mean that science is taking risks. People are asking questions that have a very small chance of turning up answers that will lead to new treatments. And when there are a lot of scientists trying new things—and taking nosedives—it’s a comforting indication that we’re exploring new avenues and that, eventually, we’ll learn something.

  And the reason these risks are possible is the last reason I’m optimistic. Over the past year I’ve spent nosing around and talking to scientists, I’ve been amazed at how many receive funding from the private sector. I’m even more amazed that many have started their own companies. And these aren’t businesspeople. They’re scientists, backed by venture capital. So someone out there—many someones, with hundreds of millions of dollars to spend—is betting that resuscitation science is a good investment opportunity. And if you follow the money, it’s safe to say that the science of resuscitation is going places.

  SO YOU WANT TO BE A CRYONAUT

  If the science of resuscitation is going to be increasingly characterized by risk taking and frequent failures, then some of the ideas I’ve seen in the past year are going to end up in the wastebasket of science. But which ones? Well, at the top of my list of likely failures, at least in our lifetimes, is cryonics.

  The biggest challenge facing cryonics is the enormous gap that exists between what can be done in a laboratory and what cryonauts are currently attempting on people. In the laboratory, we’ve gotten to the point where we can freeze eggs and sperm and bits of tissue, like corneas and heart valves. What cryonauts are doing—with fingers crossed—is freezing whole people or sometimes just their heads. Contrast that with the pace of other advances we’ve seen, which have moved carefully, methodically, and with many stops and starts, from animals to people. The work on suspended animation, for instance, has been slow but steady.

  The problem isn’t only that cryonauts are trying things in people that haven’t been tried in animals. The real issue is that there’s none of the usual back-and-f
orth of failures and successes that will help us learn. There have been no whole animal successes at all yet, anywhere. There’s no process of perfecting a technique in animals and trying it out in humans—and failing—so we can go back to the drawing board. Hydrogen sulfide was both a miracle and a bust in the space of ten years. We learned something, and then science picked itself up and moved on.

  But in cryonics, they’re freezing cryonauts first, and hoping that science catches up, not just in terms of thawing out the cryonauts, but also in curing what was killing them in the first place. It’s a little like tickling dead people with feathers and hoping that, someday, science will come along and prove that feathers really are a good strategy for life preservation.

  Then there’s the quackery quotient. For the most part, and with a few exceptions, the science just isn’t there. Most of the work in cryonics is self-funded or supported by small foundations. Little of it is peer-reviewed, and hardly any ends up in mainstream scientific publications.

  Of course I understand that mainstream science is often risk-averse and resistant to new ideas. And I’ll also admit that some of the most impressive advances in other areas of science have been made without following the usual pathways of funding that flows from the National Institutes of Health to top-tier research universities. Craig Venter’s effort to sequence the human genome, for instance, was a private end-run around mainstream science.

  But Venter was a respected scientist who used techniques that were widely accepted. Moreover, the premise of his work—sequencing the human genome—had already gained wide support. So Venter’s foray into private science was really just a way of advancing the goals of mainstream science more quickly and efficiently. Cryonics, on the other hand, represents an entirely new direction based on new ideas and assumptions.