X-Message-Number: 6003
Date: 29 Mar 96 17:59:24 EST
From: Michael Darwin <>
Subject: SCI.CRYONICS Dead while alive

Brian Wowk asserts that people are routinely pronounced dead in Canada and the

US while "still conscious" in the sense that CPR is stopped while the patient is
still conscious and death then occurs.


I wish to add my own considerable experience to this statement, and to expand on
it.

First, what Brian says is true.  I have seen the same thing in hospital several
times in the ICU during my career as a hemodialysis technician.  We had a

patient who could squeeeze our hand in response to commands, but was in asystole
(no cardiac electrical activity) and could not be cardioverted.  The situation
was handled differently in this case from what Brian describes with the M.D.
standing at the end of the bed, holding his finger to his lips indicating
silence and then using the baseball time out hand sign followed by running his
finger across his neck indicating stop CPR but not to distress the patient by
telling her or letting her know.


Such situations are not common, but they occur several times in anyone's carreer
if they work in critical care medicine.

However, there are other situations that Mr. Sharman might find even more

unbelieveable and which happen in Western countries (Including the UK) everyday.
These are situations where someone is on cardiopulmonary bypass for heart
surgery; valve replacement, emergent coronary artery bypass (CABG), electective
CABG on a very sick heart, etc.  Sometimes, when it comes time to restart the
heart it will either: 

1) Not restart at all.

2) Resume beating but with too low an ejection fraction to sustain life and
allow weaning from the heart-lung machine.

3) Develop intractable "non-perfusing" rythms that will not sustain life.

I personally have seen pump time run onto to 5 hours (for what was to be a

1-hour surgery!) while desperate efforts are made to get a perfusing rythm and a
tolerable mean arterial pressure: to no avail.  In such situations, all you can
do is:

1) Switch off the pump.

2) Hope a donor heart is lying around somewhere that has the same ABO blood
group and is available.

Mostly what happens is #1 above.  The pump is switched off and the patient is

pronounced the second  the perfusionist shuts the pump down; probably 60 seconds
to a minute before the EEG goes isoelectric (flat); the patient is cooled to
30-34 C for bypass so it takes a little longer for the EEG to flatten out.  Of

course, they aren't monitoring EEG in the OR, so cardiac arrest is the benchmark
used.


I have seen real heroics go on to try to save young people, especially teenagers
or children who end up in this kind of fix.  One kid was kept on bypass for 9

hours at UCLA while a desperate search for a heart was launched (it worked).  In
another situation which I'm familiar with, the surgeon screwed up during bypass
and destroyed the patient's heart by failing to administer cardioplegia

properly.  The patient was taken off the bubble oxygenator and put on a membrane

oxygenator, the chest wound was approximated and covered, and a desperate search
for a heart was launched.  It lasted 3 days and was unsuccessful; they had to
turn the pump off; in this case the patient was kept "snowed" with opiates and
did not know what was going on.

My final story in this vein is that of an LA firefighter in his early 20's who
suffered smoke inhalation and heated gas injury to his lungs.  He was put on
femoral-femoral extracorporeal membrane oxygenation (ECMO) (blood pump and

membrane oxygenator)  to support his oxygenation needs while his lungs "healed."
This was in the early days of adult ECMO before there was much experience with
type of injury.  21 days later he was still on ECMO and could not be weaned.

His chest film showed bilateral complete fibrosis of the lung.  Lung transplants
were not very successful at that time, and in any event, there were none

available.  The MD and family went in and explained to this healthy, fully alert

young man that they would have to stop ECMO.  At several $K a day (1981 dollars)
just for ECMO plus about 3K a day for support services it was cost-prohibitive
and manpower-prohibitive (the perfusionists were exhausted from round the clock

care and other patients' lives were being jeopardized).  Additionally, infection
would soon set in at the groin incision where the cannula exited the body.

He took it pretty well, although he was terrified.  They gave him lots of

diazepam (Valium) and morphine and slowly turned the pump off over several hours
so he would die from CO2 narcosis and hypoxia with gradual loss of
consciousness.

I just returned from the ELSO ECMO conference in Ann Arbor a few weeks ago.
This kind of thing still happens all the time, although every effort is made to
NOT put adults on ECMO who do not have a reasonable chance of recovering
lung/heart function.

So, Mr. Sharman, you should be aware that your view of the world is quite a
sheltered one and that life is full of shades of gray.  Death, like everything
else, is never as  simple as it seems.  As your countryman Oscar Wilde said in
"The Importance of Being Earnest:"   "The truth is rarely pure, and never
simple." Or maybe it was the other way around?

Mike Darwin


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