This remains our best example, thus far, of recreating the Lazarus Syndrome.
Great Success… Has Gone Nowhere
The initial experiences in our 14 patients appeared in the Journal of Thoracic and Cardiovascular Surgery.52 I received further feedback of its success during my travels to national and international conferences, as surgeons informed me of similar results after treating their post-operative cardiac arrest patients.
By 2006, we reported the 34 additional patients who had been successfully treated for sudden death with our methods by close colleagues.53 This time I wanted the cardiology and resuscitation community to learn of this innovative and dramatically successful approach, since they generate the guidelines for treatment protocols of sudden death victims.
This did not happen. Our manuscript summarizing these never-before-seen international results was rejected by the two major cardiology journals.
“The pitfalls are unknown” was the reason they cited for rejection, though I suspect the truth was that we had incited an uneasiness. We had challenged the status quo by criticizing the limitations of current treatment. Perhaps their ire was raised by our asserting that “conventional approaches deal with the symptom of sudden death, but disregard its underlying cardiac cause.”
We simply could not find a good source to publish our information in the cardiology journals. We ultimately did publish in the journal Resuscitation,53 but it was not customarily read by the cardiology and cardiac surgical community. Frankly, it doesn’t mean anything if one publishes… and nobody reads it.
So the death rate from sudden death remains at over 85% (minor improvement over the 90% observed in 1961 when CPR was developed), with brain damage still developing in 50% of rare survivors. Opposition to our innovative approach continues, despite these harrowing numbers.
In fact, the only improved methodology that’s been embraced has been the induced topical cooling of the body — hypothermia — to lower the ventricle’s and brain’s energy requirements. The ability to decrease brain damage by cooling exists, yet this technique can only be used in the rare survivor (less than 10% of patients), and devastating brain injury still persists.54
In a sense, this focus on cooling reflects a step backward in the development of more advanced techniques for sudden death. Our prior research of heart damage showed that hypothermia is only one little part of the process, and that much more is needed to be done,55 which is what motivated our use of controlled reperfusion.19
This large gulf between the understanding that others have, and the actions that must be taken… must somehow be bridged in order to make current treatment of sudden death successful.
Imagining a Better Tomorrow
The future seemed bright — because we had found and proved the solution. Yet new ideas must be turned into practice. The medical community must change its thinking by welcoming the freedom to adopt innovative and effective treatments that have been tested experimentally and proven in sudden death patients.
The approach remains three-pronged. CPR is first used to maintain brain blood flow. The heart-lung machine is then employed to stabilize the circulation and diagnose the underlying heart issue. Finally, the cardiac problem is corrected and controlled reperfusion is administered to remedy the reason behind development of sudden death. The tools to achieve all this are now available.
With present technologies, EMTs and other emergency personnel performing CPR can monitor blood pressure levels to make sure they are protecting the brain during retrieval and transportation of the body, allowing for much longer time periods than previously thought possible.
Portable heart-lung machines that are now available can be utilized by simply puncturing the skin with a needle to access the blood vessel — something that emergency personnel are also capable of doing, even while in the ambulance, and en route to the hospital!
The cardiac catheterization lab is capable of diagnosing the underlying cardiac problem, and must either learn to do the corrective treatment there, or send the patient to the operating room. Use of the heart-lung machine to protect the heart and brain can be done in either location, with controlled reperfusion given for heart recovery.
These are not new ideas. Our innovative approach exactly parallels techniques already used to treat patients sustaining heart attacks. The only difference is that heart attack patients have not died. CPR is not needed because they are alive. But most everything else done for the sudden death victim exactly mimics the way we treat heart attacks. Of great significance is that this approach adds a new dual treatment goal: save the heart and the brain.
The answers are here, as our 80% survival rate from sudden death, and the avoidance of nearly all brain damage, has been confirmed in patients treated at other major international centers.53
While such a positive future is within our grasps, the seeds for this change have not grown, as there is only marginal funding for sudden death by the National Institutes of Health (NIH), the chief U.S. agency devoted to health research. This inequitable deficiency is shown dramatically in a recent survey of NIH allocation of funds — that compares the number of deaths from a particular illness with the funding that NIH provides “per death” for that disease. For example, 750,000 patients with cancer died in one year, with NIH spending the equivalent of about $7,000 per deceased patient on research. Cardiovascular disease resulted in 500,000 patient deaths (except stroke), with approximately $4,000 spent per each of those patients by the NIH on research in cardiovascular disease.
Sudden death (cardiac arrest) occurred in 400,000 patients and the per-patient expenditure was $75. (Figure 1)
Figure 1: Funding from NIH to treat disease / patient deaths. Note comparisons between cancer, heart disease (excluding stroke), and sudden death. (Funding totals for 2013; downloaded from NIH August 4, 2014)
Amazingly, the situation has only gotten worse. The recent AHA update shows further reduction in allocations: 2017 funding for cardiac arrest (a disease with 85 to 90% mortality) is expected to fall to $63 per deceased patient!
So you have a disease (cardiac arrest) that we can correct (80% survival and minimal brain damage) — and practically no money is allocated for it. While immense funding is directed toward two other disease categories they cannot correct.
Astoundingly, this shortsightedness continues despite our international report documenting the success of these innovative methods. I suspect commitment to reverse the extremely high death rate from sudden death has not taken hold because they still believe there is no solution. We have one, but they don’t want to hear it. That’s because the solution means one must accept failure, and recognize it is essential to change the traditional approach to treatment.
I realize our approach radically alters what has been the norm for decades. Significant modifications would be needed in both methods and facilities. Cardiologists must use a heart-lung machine and learn to insert tubes for its use through the skin. New teams will need to join the cath lab for the heart-lung machine to be used there, and cath labs would need to be re-equipped. Both of these hurdles must be overcome to allow controlled reperfusion to take place. Resistance to these initial increased costs and training must be quashed, when weighed against the vastly improved patient outcomes that can be expected.
The key motivator is that many lives can be saved. Not the 10 to 15% as is the case now, but the 80% that have very little accompanying brain damage. This stunning impact becomes clear when we consider how many of the 400,000 patients in the U.S. experiencing sudden death can be returned to normal fruitful lives.
Signs of Progress
Despite the disappointing lack of acceptance of these methods, there are encouraging signs.
Recent experiences in Japan for treating sudden death have included extended periods of CPR and a rapid set up of the heart-lung bypass using the skin puncturing method. But they didn’t follow all our protocols, as they used normal blood rather than controlled reperfusion in treating the underlyi
ng heart attack and did not decompress the heart… which led to only limited survival improvement (raising survival from 10% to 30%) and did not prevent brain injury.56
Yet this limitation does not diminish the enormous importance of their findings, as their promptly initiating a heart-lung bypass by skin puncturing methods can serve as a guidepost for others. These same methods were duplicated by medical teams in Korea and Taiwan, showing that rapid heart-lung bypass can be done in sudden death patients within just a 15-minute interval.57, 58 Such innovative efforts have not yet been undertaken by the leading centers in the United States and Europe.
Still, sporadic feedback of success continues, as with the surgeon who came up to introduce himself after I gave a lecture in Bakersfield, California, and said he’d heard me present my findings at an earlier conference.
“We’ve done your protocols on ten patients. It’s been unbelievable! Everything worked out just as you said it would. It all went beautifully.”
Truth Wins
Our efforts to educate are never ending, as we pass along our findings in written and oral presentations in journals and meetings… and now through this book. I want the huge numbers of people that could be affected by sudden death, as well as their loving families, to realize this tragedy can be avoided.
Regrettably, the failures of the past will persist until the Lazarus Syndrome is revisited. Yet I remain confident these protocols will find their way into mainstream cardiac care… hopefully sooner rather than later.
CHAPTER 12
Unwitnessed Arrest
Part I: The Never Taken Pathway
Conventional wisdom states that brain death happens after four to five minutes of no brain blood flow.
But is that true?
I was in my office during the late afternoon when I got the call from Brad Allen in the lab. I knew this was the day he was conducting the long-awaited procedure on our first test subject. His words were cryptic.
“You better get down here.”
“What’s wrong?” I asked.
“You just need to get down here.”
I hurried through the hall, to the elevator, and then down to where the procedure was done.
Upon entering the lab, I noticed how quiet it was. No usual bustle of activity. Everyone standing around, waiting for me.
I glanced past a lab table and onto the floor. There, a pig was walking and sniffing around.
“Is that the test subject?”
Brad’s reply was a big smile. The entire team broke into grins.
The impossible had been achieved. They had administered controlled reperfusion following 30 minutes of no blood flow to the brain — and this pig demonstrated full recovery.
It was absolutely unbelievable.
Previously, a brain without blood flow for just four to five minutes was thought to be irreversibly damaged. Yet here we had shown that an absence of blood flow for 30 minutes was remedied by our treatment protocol. The implications of this were far reaching and game-changing. We were thrilled!
But then… our next four test subjects did not have this same great recovery. In fact, each suffered significant brain damage.
We went from monumental and exhilarating success… to posing unexpected new questions: what could have gone wrong and where do we go from here?
A gauntlet had been dropped before us. It introduced a challenge we must meet. If we could.
Yet to fully appreciate where we were at this point, we need to go back to the beginning of this story….
New Outlook on Perpetual Problem
The previous chapter focused on sudden death under circumstances that we call “witnessed arrest.” When observers “witness” someone collapse as their heart stops, they quickly perform the traditional treatments of CPR and defibrillation, and blood flow to the brain is maintained as best as possible. It is a serious event that can occur in hospitals, airports, stores, homes, and many other locations. As pointed out, even with such conventional life-saving efforts, 85 to 90% of people do not survive and brain injury develops in half of the rare few that do.
The chapter also revealed how this problem is offset by using controlled reperfusion to protect the heart, while maintaining adequate brain blood flow during resuscitation.
While we waited for the world to embrace our new life-saving approach (and I continued writing articles, letters, and having conversations to help forward that shift), we came to recognize there was another related and very serious challenge that needed to be considered.
Unwitnessed Sudden Death
We’ve all heard the classic philosophical query: “If a tree falls in a forest and no one is around to hear it, does it make a sound?”
While this question has no simple answer, it relates to another question that might: If someone suffers cardiac arrest (sudden death) and no one is immediately nearby — can they possibly survive it?
Such a grim scenario had been given a new term in cardiac medicine: “unwitnessed arrest.”
Unwitnessed arrest describes a sudden death event where there is a time lag before treatment can be started. It may be that sudden death is observed, as might happen when someone looks out of their window to see a person collapse in the distance, leading to a 5-to-15 minute delay before CPR is started while 911 is called. Similarly, someone in normal condition at home or in an office enters a room… and is later found dead when the closed door is reopened, perhaps after a similar 15-minute time frame.
As you might expect, the results for this are even more dreadful than with observed sudden death. The mortality rate for unwitnessed arrest is essentially 100%, with severe brain damage in the ultra-rare survivor.
Such circumstances create an almost inconceivable challenge to the arriving emergency medical team, who knows the bleak mortality rate for someone dead for 15 minutes without CPR administered. They may even ask, Why start? Gone is gone.
It is a desperate situation without a solution.
Or is it?
The Impossible Dream
Conventional knowledge accepts this tragedy as inescapable. As a result, no one attempts to solve it. But these appalling consequences were unacceptable to me. Instead, they became the ignition key to spark a new voyage for my research.
This endeavor made me think of the way Miguel de Cervantes described how Don Quixote confronted the windmills. Quixote’s intent was to bring justice to the world by reviving chivalry and undoing wrongs. While I don’t compare my own actions to the fanciful imaginations of Don Quixote, our pursuits do share an implausibility and boldness.
Quixote envisioned his opponents to be the solid, rigid, never-changing windmill structures. He reasoned that he had chosen a worthy foe as he imagined them to be giants. But instead, the spinning blades of the windmill proved to be his greatest obstacles. While they served a valued purpose by turning millstones to grind grain, they broke Quixote’s lance as he made his gallant charge on his opponents.
I could easily imagine these windmills to mirror the diseases we confronted. Solid, unyielding, and seemingly impossible to counteract. I would devote all my energy and resources to do battle with them. Yet an almost equal obstacle was the “whirling blades” of conventional medical beliefs. They were every bit as obstinate as the diseases themselves. They formed a shield that prevented the penetration of new ideas.
While the actions of those practicing modern medicine deliver enormous value, their prevailing rigid adherence to the past has thwarted the introduction of novel ways to overcome diseases we all confront.
Many would think it was irrational that I would even try to recover brain function after it had been absent a blood supply for an extended period. But most of my accomplishments — and those of many others before me — faced similar skepticism in their early phases. While these barriers make our pathway more arduous, the pursuit is never abandoned because of them. Our only chance to overcome certain death after unwitnessed arrest is to attack these windmills.
Our Past Opens
Doors to our Future
From my perspective, this clinical problem with unwitnessed arrest reflected the ischemic reperfusion injury that we had previously approached in the heart (restoring blood flow after it had been absent). Now, something similar was occurring in the brain. I believed this biologic response might happen in all body organs, not just one.
The next step was to test if this conviction was true.
But how could we adapt what we successfully learned in treating witnessed arrest — to the even greater challenging circumstances of unwitnessed arrest? Here the victim sustains severe damage — because no CPR is given during the 15 or more minutes before help arrives.
Nature taught us a significant biology lesson in allowing us to demonstrate that controlled reperfusion after a heart attack — will completely overturn the cell death that conventional thinking believes to be terminal. This principle now needed to be tested in a new way — as we switched the organ in question from the heart to the brain.
While the study and events cited in this and the next chapter took place from 2008 to 2011… I introduce them now because this concept’s presentation should follow sudden death, our previous chapter.
A Focus on the Brain
All organs suffer damage when deprived of blood supply. The extent of injury varies from organ to organ, and depends upon how long the blood flow is absent. The heart will still function without flow for 45 minutes, but it is damaged. Lungs show injury after two hours, as does the liver.
I recognized these adverse changes become more dramatic in the brain, where brain death is traditionally expected after as little as four to five minutes without oxygen nourishment. This belief sets the stage for an anticipated terminal brain injury if there is a delay of 15 or more minutes before restarting the circulation in sudden death patients.
This reminded me of another traditionally-presumed conclusion: that when a lack of blood flow has caused a heart attack, returning (normal) blood after a period as long as six hours was considered futile. Yet our controlled reperfusion (which uses a specific composition and delivery of reflow blood) prevented this predicted damage and provided recovery. We would test this concept again, as our first task would now be to determine if CPR — which, in effect, restarts flow with normal blood — would produce a similar injury to the brain. Then we’d need to find out if controlled reperfusion would once more prevent this tragedy.
Solving the Mysteries of Heart Disease Page 20
