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Na Spiegel Online de 29 de Julho de 2013.
Raising the dead may soon become medical reality. According to
critical care physician Sam Parnia, modern resuscitation science will
soon allow doctors to reanimate people up to 24 hours after their death.
At some point, everyone's heart will stop. For most, this is when they
begin to die. Doctors succeed in very few cases at bringing the
clinically dead back to life. However, more patients could be saved if
medical professionals put existing knowledge about the treatment of
cardiac arrest to better use, argues critical care physician Sam Parnia,
41, who is leading a revival of research in this field at the Stony
Brook University School of Medicine in New York.
When Parnia was a student some 20 years ago, a patient he knew well died
under his care. It was a key moment for the young doctor, who has since
sought to understand and fight the process of death.
SPIEGEL: Dr. Parnia, in your new book on resuscitation science,
"Erasing Death," you state: "We may soon be rescuing people from death's
clutches hours, or even longer, after they have actually died." That
sounds a lot like resurrection. Is this a serious claim?
Parnia: In the past decade we have seen tremendous progress. With today's
medicine,
we can bring people back to life up to one, maybe two hours, sometimes
even longer, after their heart stopped beating and they have thus died
by circulatory failure. In the future, we will likely get better at
reversing death. We may have injectable drugs that slow the process of
cell death in the brain and other organs. It is possible that in 20
years, we may be able to restore people to life 12 hours or maybe even
24 hours after they have died. You could call that resurrection, if you
will. But I still call it resuscitation science.
SPIEGEL: With all due respect, this discipline has a dismal
record. Survival rates for out-of-hospital cardiac arrests continue to
be poor and have barely improved from what they were 25 years ago.
Parnia: Sadly, that's correct. There is no generally enforced
standard of care. In some communities in the United States, survival
rates after resuscitation are as low as close to 0 percent. In general,
we are better at rescuing people who suffer cardiac arrest in hospitals.
But even in this group the average now in the US is 18 percent. The
United Kingdom has 16 percent and I assume German hospitals have a
similar rate.
SPIEGEL: That's shockingly bad.
Parnia: Here in Stony Brook we had a 21 percent survival rate
when I first arrived. Now, two years later, we are at 33 percent. In the
first quarter of this year, our latest available data shows that we
reached 38 percent, which likely puts us among the top hospitals in the
US. Most, but not all of our patients, get discharged with no
neurological damage whatsoever.
SPIEGEL: Are you some sort of a magician?
Parnia: Not at all. We work strictly according to the
recommendations of ILCOR, the International Liaison Committee on
Resuscitation. We have taken some things even a bit further. ILCOR
publishes their consensus findings every five years, most recently 2010.
But the problem is: Most hospitals have not fully implemented all their
findings.
SPIEGEL: Why not?
Parnia. That's exactly why I have written this book. I want to
shine a light on the fact that resuscitation science has advanced
tremendously over the last 20 years, yet the implementation of this
knowledge remains very poor. This is costing us many lives every year.
SPIEGEL: Is this due to a lack of understanding on the part of doctors?
Parnia: Apparently. A recent study found that the optimal length
of resuscitation to yield higher survival is at least 40 minutes. Yet
most doctors will stop within 20 minutes. They don't try as hard because
they wrongly think the brain will be damaged by then or that it will be
pointless to continue.
SPIEGEL: Why are the findings of such studies not put into practice?
Parnia: Resuscitation has gone from something every doctor does
every now and then to a highly specialized and complicated field, much
like cardiology. Yet that is not generally recognized. As long as
hospitals don't require their resuscitation doctors to implement all the
nuances required to save brains and lives after cardiac arrest through
fully trained specialists, survival rates in general will not improve. I
think we need more regulation by state or medical authorities. That's
the only way to reach higher standards. We can't go on with a situation
where hospital or individual physicians decide for themselves what part
of the guidelines they implement or not.
SPIEGEL: Basic first aid teaches us that the brain is very
fragile. Three to five minutes after the heart stops, the brain incurs
permanent damage due to lack of oxygen.
Parnia: This is a widely-held misconception, even among doctors.
It's mostly based on research done in the 1940s, 1950s and 1960s. In
those days, doctors concluded that brain cell death was inevitable in
such a short time. Now we know that if treatment is correct, it really
can take hours for brain cells to die. And only if all the treatments
that we know today are not implemented, the damage can become apparent
after as little as five minutes without blood flow. Part of the problem
is that we all live in the past -- patients, doctors, nurses and
legislatures. We have preconceived ideas about death. For thousands of
years, death was a clear, precise moment: The heart stopped beating, and
that was it. Nothing could be done from then on. You either were alive
or not. But since the arrival of CPR (cardiopulmonary resuscitation)
more than 50 years ago, we know that this view is no longer correct.
Death is not a fixed moment anymore. From a cellular perspective, it is a
process that proceeds at various speeds in the different tissues of the
body after the heart stops.
SPIEGEL: And that process is, in your words, fully reversible?
Parnia: Of course, it is of paramount importance to protect the
brain. CPR as early as possible after cardiac arrest is essential. But
the really dangerous period for brain is only after you restart the
heart and get the person back to life. It is then that you start getting
major brain damage. One of the reasons for this is that when you
restart blood flow to the brain, which hasn't seen any blood for a
while, the oxygen itself becomes toxic. The brain can become very
swollen and inflamed and at the same time, blood flow to the brain drops
to dangerously low levels. The brain also becomes perilously starved of
oxygen and nutrients. Consequently, most brain damage after
resuscitation occurs not within the first few minutes of death, but in
the hours up to the first 72 hours after resuscitation. But with proper
post resuscitation care, we can minimize that.
SPIEGEL: What exactly happens once the heart stops?
Parnia: A person immediately loses consciousness, breathing stops
as well, and within seconds, the brain ceases working, even at the very
basic level of the brain stem. The pupils become fixed and dilated. The
EEG shows a flatline. This person is now dead, yet in what we may call
the early stages of death. He is a corpse, and in a hospital setting
might now be certified dead and sent to the mortuary.
SPIEGEL: Unnecessarily?
Parnia: That depends on what caused the person to die, what caused his cardiac arrest.
SPIEGEL: What can you do to potentially bring him back to life?
Parnia: It is a chain of interventions, and everything we do
counts. One error somewhere along the line, and he will stay dead or
live with brain damage. We start with chest compressions as early as
possible, first by hand, then by a machine, because in general human
beings cannot administer this to the required standards for more that
just a few minutes. At the same time we provide breaths via an ambu bag
-- not more than 8 breaths per minute. Even this simple exercise is
often done wrong in many cases. Once you pump too much air into the
body, it squeezes the heart, and it won't start again. This itself can
kill people -- or in this case, keep them dead.
SPIEGEL: What are some of the newer interventions that you'd recommend?
Parnia: We cool the body down, from 37 degrees to somewhere
between 32 and 34 degrees. I usually go to 32 degrees. Patients stay at
this temperature for 24 hours or so. Cooling has a lot of positive
effects. It reduces the amount of oxygen the brain needs, it prevents
dangerous chemicals like hydrogen peroxyde from forming and it slows
down the process of cell death. Even this really critical part of
resuscitation is not done routinely, not even in places where its
benefits are known, including Germany. At times it has been reported to
be used by less than 50-60 percent of hospitals.
SPIEGEL: How do you cool a body?
Parnia: We use pads that get attached to the thighs and the upper
body. In a matter of hours, the cooling machine brings the body
temperature down to the desired level. But you could also do this at
home, if you found someone there in cardiac arrest. Call an ambulance,
administer CPR and place a bag of frozen peas or other frozen vegetables
on the patient. It helps to protect the brain.
SPIEGEL: What do you do that is not regularly done?
Parnia: Among other things, we check continuously how much blood
and oxygen gets to the brain. If we have at least 80 percent of normal
levels, the person tends to do better. If his condition doesn't improve,
we follow steps that includes the use of an automatic machine to give
compressions and breathing and eventually put him on ECMO. These are two
catheters, one at the groin, one at the neck. It is basically a
shortcut for the heart: The blood gets oxygenated outside of the body
and pumped back in. It is more widely used in Japan and South Korea, and
doctors there have found that their survival rates have increased when
ECMO is used with the right patients. But most ICUs in the world still
don't use it.
Part 2: A New Understanding of Human Consciousness
SPIEGEL: If it's so easy, why don't doctors all over the world just follow suit? Are they ill-informed?
Parnia: No, it's not that they are ill-informed. The reality is
that preserving the brain requires brain experts with specialization in
this field, as it is very complicated. Saving lives also requires
experts in ventilator management, together with cardiac experts. No
physician can be expected to be a specialist in three different areas of
medicine so each does the best they can from their own perspective.
With such a complicated condition the solution is to have national and
professional responsible bodies to enforce and train specialists to deal
with resuscitation based on 21st century standards and not 20th century
ones. Rightly used, reanimation could play a major role in the therapy
for many life threatening conditions and thousands more will be saved.
SPIEGEL: In what way, exactly?
Parnia: In my view, young, otherwise healthy people shouldn't die
from heart attacks anymore. Remember James Gandolfini, the actor from
"The Sopranos" who died last month at age 51 in Rome? I believe if he
died here, he could still be alive. We'd cool him down, put him on ECMO,
so oxygen gets to the tissues and prevents them from dying. Clinically
dead, he could then be cared for by the cardiologist. He would make an
angiogram, find the clot, take it out, put in a stent and we would
restart the heart.
SPIEGEL: Is this truly a realistic scenario?
Parnia: Of course we can't rescue everybody, and many people with
heart attacks have other major problems. But I will say that if all the
latest medical technologies and training had been implemented, which
clearly hasn't been done, then in principle the only people who should
die and stay dead are those that have an underlying condition that is
untreatable. A heart attack is treatable. Blood loss as well. A terminal
cancer isn't, neither are many infections with multiresistant
pathogens. In these cases, even if we'd restart the heart, it would stop
again and again.
SPIEGEL: Doesn't the idea of "bringing people back" imply that they weren't really dead in the first place?
Parnia: I think the state they are in corresponds to the cultural
concept we all have of death. We encounter it in movies and books all
the time. That is my basic message: The death we commonly perceive today
in 2013 is a death that can be reversed.
SPIEGEL: But not real brain death.
Parnia: No. When brain cells have decayed after a number of
hours, no intervention, neither now nor in a 1000 years, will bring them
back. That death is final. But up to that point, there is a gray zone.
Today, we simply do not know when someone transitions from potentially
reversible to irreversible. Tests used today to diagnose brain death are
tests of brain stem function -- not of actual cell death.
SPIEGEL: What does this finding mean for the diagnosis of brain death as a prerequisite for organ donation?
Parnia: Nobody knows exactly how long we should wait to be
absolutely certain the brain has died after it stops functioning. That's
why the criteria for the diagnosis of brain death vary from country to
country and, in the US, even from state to state. There are many
different recommendations regarding the tests and how long physicians
should wait before repeating them. But clearly: The longer the brain
doesn't function, the more likely it is that the brain has truly died.
Technically speaking, the brain may then not be really dead yet, as you
could take individual cells out of the brain and still grow them in a
lab. But it is safe to consider a person at this stage irreversibly dead
for the purpose of organ removal.
SPIEGEL: As a researcher, you not only work on resuscitation but
also on what people experience during the process. But these people are
clinically dead. They don't experience anything.
Parnia: At least, according to our perception of consciousness.
And yet, over the last 50 years since the arrival of CPR, literally
millions of people have gone beyond the threshold of death and come
back. Many of them tell us incredible stories of their experiences. I
myself have studied more than 500 people with NDEs (Near Death
Experiences).
SPIEGEL: What exactly do they tell you?
Parnia: Typically, they report being very peaceful. Some see a
bright light, others feel the presence of a warm, loving, compassionate
being. Many describe having a review of their lives, from childhood up
to that point. Others tell of encounters with family members who have
died. Others report out-of-body experiences. They feel they witnessed
the scene of their resuscitation from a position near the ceiling of the
room. Some even correctly describe conversations people had, clothes
people wore, events that went on 10 or 20 minutes into resuscitation.
One of the most fascinating NDE tales was published in 2001 in medical
journal
The Lancet. A man asked his nurse for his dentures, which he remembered he had put in a cupboard during his cardiac arrest.
SPIEGEL: There's no scientific proof for any of these stories. Do you believe them?
Parnia: These experiences feel very real to those who had them.
Why should we doubt the reality of their experience? NDEs occur
everywhere, in all cultures, in every country, in religious people and
atheists, even in children younger than three years old. It would be
wrong to see them as mere fabrications.
SPIEGEL: What's your personal take on them?
Parnia: It looks like people's consciousness does not get
annihilated just because they are in the early stages of death. It's a
medical paradox.
SPIEGEL: To say the least.
Parnia: From what the patients describe, we have to conclude that
death is a pleasant experience for most people. I think we have no
reason to be afraid of it.
SPIEGEL: Maybe NDEs are just tricks of the brain due to a lack of oxygen, as other scientists have claimed?
Parnia: I checked that and I don't think that lack of oxygen
leads to any of these experiences. I'm the principal investigator in the
AWARE study for a number of years now. We have installed shelves with
pictures on them near the ceiling in various ER rooms across the US and
Europe. We want to find out whether people who claim to be hovering
close to the ceiling can really perceive what's going on in the room. We
will publish our first set of data in November. But I won't reveal any
details yet.
SPIEGEL: You are a reputable researcher. But right now you sound more like a mystic.
Parnia: I'm neutral. I'm just a researcher. For many people, death has to do with religion and philosophy, not
science.
To me, that makes no sense. I deal with death every day in my life.
What we study is very scientific, there's nothing paranormal about it.
But of course I get criticized from all sides. Paranormal enthusiasts
think we are treading on their territory. Religious people accuse me of
blasphemy, skeptical scientists of leaning to the other side. And we
also get requests from people who ask us to kill them and get them back
for science. This is dangerous territory we're in.
SPIEGEL: You have experimented with putting pictures face up near
the ceiling in hospital emergency rooms to determine if a person having
an NDE will, upon regaining consciousness, report seeing the target
object. Isn't that going too far?
Parnia: Any new field of science inevitably meets with criticism
and incomprehension. Gene therapy was once seen as pure science fiction.
When string theory was first proposed, physicists made fun of it. And
everyone including Einstein laughed at quantum theory. This research
might well lead to a new understanding of human consciousness. Nobody
can yet explain how it works and how it interacts with brain cells.
Interview conducted by Marco Evers