Horizon (1964–…): Season 47, Episode 1 - Back from the Dead - full transcript
I'm Kevin Fong, and I'm a
consultant anaesthetist
here at
University College London Hospital.
I've experienced the havoc
that the cold can wreak upon
our fragile physiology.
Even the smallest drop in
temperature has profound
effects on the human body.
Pass that... Bloody hurts, actually.
I wasn't quite prepared for
how much that was going to
hurt in my feet and hands.
Just one degree of cooling is
enough to cause a lot of pain.
Is it normal for it to hurt
that much when you go in?
I wasn't expecting that.
'And another ten would
almost certainly kill you.'
But scientists have found a way
to make the cold work for them,
learning lessons from accidental
events and turning this usually
lethal foe into a life-saving ally.
By the time they'd called
the rescue helicopter for Anna,
her heart hadn't beaten for
well over an hour and a half.
Extreme cooling is used in
operating theatres across the world.
It's the most fascinating
technique to which I've ever
been exposed in medicine.
And each time, to me it
seems a miracle that it works.
It's redrawing the line
between life and death.
The body is essentially in true,
real-life suspended animation,
with no pulse, no blood pressure,
no electrical waves
in the brain or EEG.
There's no room for error
or failure, really.
That would be catastrophic.
If you look at the monitors,
all of those the flat lines,
he is indistinguishable
from someone who's actually dead.
Cooling has the potential
to revolutionise everything,
from trauma surgery
to resuscitation medicine.
We find ourselves in this
very uncomfortable time period
where, while we used to know when a
patient was dead or alive,
there are
patients that are simply in-between.
And we must be really cautious
as we change our very ideas about
what is alive and what is dead.
FLATLINE TONE
Medical breakthroughs
often begin with an accident.
These are the Kjolen
mountains of northern Norway,
in the Arctic Circle.
They're popular with extreme skiers.
'11 years ago, a young doctor called
Anna Bagenholm suffered an accident
'that would change her life
and propel her into the
medical history books.'
It was a very, very nice weather day.
It was, like, 15 degrees in the sun,
and a lot of melting water and
very good skiing conditions.
Skiing just ahead of her
was her colleague, Torvind.
I skied first, stopped and looked
up again, and so Anna started skiing
and she was doing all right, and
then suddenly she started skidding.
I hit a rock and turned round so that
I, like,
turned round on my back,
and started to slide on the back.
And all of a sudden, she broke
through the ice,
um, and hit an ice ledge and went in
under the ice ledge into the water.
And the water filled the clothes and
then I was, like, suddenly dragged
under the ice very slowly.
Anna was trapped hopelessly beneath
the ice, and was slowly but surely
freezing to death.
Anna was moving inch by
inch in under the ice.
And in the end, we were just holding
on to Anna's legs to just stop her
from disappearing under the ice.
Far away from help in the icy
wilderness, Torvind and his friend
struggled for 40 minutes to pull
Anna out from underneath the ice,
but it was impossible.
And then, still trapped,
Anna's body went completely limp,
and shortly after this
her heart stopped beating.
Normally when your heart stops
beating, death will inevitably
follow a few hundred seconds later.
By the time they'd called the
rescue helicopter for Anna,
her heart hadn't beaten for well
over an hour and a half.
Now, I live and
work in London, where
you're never more than a few minutes
from healthcare, but this is Norway.
Just look at it. There
are great, huge distances between
the mountains and the hospitals.
And then were waiting for almost an
hour from the accident happened
till the first rescue team
got there.
40 minutes after Anna
had stopped moving,
they were finally able to pull
her out from underneath the ice.
Despite the best efforts of the
paramedic team on board
the helicopter that day,
Anna arrived at the hospital
in Tromso without a heartbeat.
Her heart had been at a
standstill for well over two hours.
Now, when you hear a story
like that,
you are not expecting the
patient to survive.
Frankly, this girl should have
been dead.
Two hours after Anna's heart
had stopped,
the helicopter carrying her body
landed at the
University Hospital in Tromso.
I landed here... Uh-huh.
..sliding out the door. I jumped in
and talked to the doctor on board.
'Anaesthetist Mads Gilbert
led the resuscitation team.'
So we had her on one
of these stretchers,
one of these trolleys, and we
were doing CPR continuously.
Where were you?
Were you on the trolley?
I was sort of
kneeling on the trolley,
to all the time make sure that the
two most important things
were maintained.
Ventilation, air in and
out of the lungs,
and good chest compression
to maintain the
blood circulation to her cold frame.
She looked dead, completely dead.
She was white,
ash white, waxy white, wet.
Dilated pupils and on the ECG,
no signs of life,.
The challenge for doctors now
was to find a way of dragging this
lifeless 29-year-old woman
back from the dead.
And it would be the extreme cold
that she'd experienced that would
hold the key to her survival.
'I've come to the sports
science department at the
University of Portsmouth
'to see how the human body reacts to
even tiny changes in temperature.'
OK, comfortable?
Let's get that out your way.
'Even the slightest change can have
powerful effects on our physiology.
'But when you sink as low as the
temperatures that Anna experienced,
the effects can be catastrophic.'
As human beings, we're engineered
to function at 37 degrees.
Any lower than that, and our
physiology rapidly begins to fail.
Now, I'm going to show you what
happens when my core temperature
drops by just one or two degrees.
But that small difference, that
small drop in temperature will show
you how poorly we tolerate the cold,
and what a double-edged
sword hypothermia really is.
The first thing that's going
to happen is, I'm suddenly
going to feel very, very cold.
37.45, starting temperature.
It's looking good. Well done.
30 seconds gone. In five,
three, two, one... That's a minute.
If you pass that to...
Bloody hurts, actually.
In the extremities? Yeah, I wasn't
quite prepared for how much that was
going to hurt in my feet and hands.
Number one, we're a tropical animal,
so this is about
one of the worst things you can to
do a human, put them in cold water.
The body will fight vigorously to try
and defend its deep body temperature,
and in so doing, it's prepared to
cut off blood supply and, if you
like, sacrifice the extremities.
I really wasn't enjoying this,
and my fight or flight reflexes
were running at full tilt.
My body was trying to protect
itself, knowing that if temperatures
continued to drop at this rate,
it could prove lethal.
So, I mean, right now it's just a
bit of shutdown, a bit of shivering,
bit of pain.
If I was to get any lower, what sort
of things would we start to see?
Well, around about
33 degrees Celsius, the first major
organ to be affected is the brain.
That starts to affect things
like central nervous system
function, so we see amnesia.
Somewhere between 30 and 33 Celsius,
it's normal for people to become
semi-conscious or unconscious.
It's very easy
to mistake somebody for being dead at
those kind of temperatures.
This is what was happening to Anna
in that freezing ravine,
her body shutting down as her
temperature dropped further
and further.
But the hypothermia, the thing
that was killing her,
would also
hold the key to her survival.
We've been hearing the story of
Anna Bagenholm, who...managed
to get her core temperature down
to 13.7 degrees, which is... Gosh,
I can barely do the maths right now,
but, er, you know,
23-odd degrees below my core.
We see the other side, we
see hypothermia cooling the brain,
reducing its requirement for oxygen.
So at the same time as
hypothermia is causing other
vital organs to fail, it is actually
also starting to protect the brain.
So essentially, you've got
somebody who is in major arrest,
but with a viable brain.
It's good to finally get out.
It's hard not to feel
like a bit of a wimp.
I've got you. Thank you.
Good stuff.
I think the thing that's impressed
me most about all of this is
how profound
your physiological responses are
to such a small fraction of cooling,
and how...fiercely your body fights
against being cooled down.
It doesn't want to be cooled
down, it doesn't work
at less than 37 degrees.
And it does everything it
can to stop that happening.
It tells you to get out of
the water, it tells you
to do something sensible.
And this is, like, one degree,
less than a fraction of a degree,
and then you think about Anna
getting down, you know,
23-odd degrees lower than that,
23 degrees lower than that, so cold
that her heart has stopped and her
brain has no electrical activity.
Even though Anna looked dead,
the doctors knew that
the hypothermia,
the very thing that had stopped her
heart, might also
have preserved her brain.
And so despite the incredible
duration of this cardiac arrest,
the team took the decision to carry
on the resuscitation and
warm her up.
Once she was on full bypass,
we all sort of put our hands together
and we waited.
And slowly,
the blood temperature increased.
We had an echo probe down
her oesophagus.
We saw the heart
still, standing like this, shivering
a little bit and suddenly, phoo!
HEART BEATS
And I had to maintain my control
not to start crying,
because it
was a very emotional moment.
And the heart continued to beat and
we were all very, sort of thrilled.
"Yes! Yes! The heart is beating,
she's starting up again."
Three weeks later, Anna opened her
eyes for the first time, and very
gradually, she began to recover.
I'm on my way to meet Anna
in the very town where she was
treated and now lives and works.
It's not one of the easiest
places to drive around.
I'm going to run these people over.
What am I meant to do here? Sorry!
I'm about to run over
a bunch of nurses,
playing drums.
This is... I'm in some
David Lynch movie.
Um...OK, concentrate.
When you see people who've had
cardiac arrests
where their hearts have stopped for
even just a few minutes,
they very often don't survive.
If they survive, they're very
often left with really severe
neurological disabilities.
So I am absolutely fascinated,
absolutely fascinated
to find out if she recovered, how
completely she managed to recover.
Hi, Anna. 'Anna now works as a
doctor specialising in radiology
'at the same hospital
in which her life was saved.'
I'm sure those first
few weeks must have been a haze,
but when you finally
realised what had happened, I mean,
what were your first thoughts?
I gathered all the information
and I ended up thinking
"This is something really special."
I hadn't heard about
anybody who has been so cold before.
Like, I had almost three
hours with heart standstill.
But because I was so cold,
the CPR is enough for giving
my brain enough oxygen.
'It took nearly six years for Anna
to fully recover, but she did.'
So now I'm back to work
as a normal doctor.
I do exactly the same
things as everyone else.
And you're out skiing,
I understand, so you're
doing everything you were before?
Yeah. I take a bit more care. Yeah.
'I can see why amongst doctors,
this is still such an iconic case.'
I mean, I'm the living proof
that it's possible.
It's important to start the CPR, call
for help and get the persons to
the right hospital where they can
re-warm and then wait and see.
This is without doubt the most
amazing story of survival I have
ever heard.
What Anna's incredible tale
tells us
is that there is this sort of no
man's land between life and death
that we might be able to manipulate.
I think it got medics all over the
world thinking again
about death not as
a moment in time, but as a process,
and one that they might
be able to stretch out
and give themselves
a chance to intervene.
I'm on my way to one of the most
prestigious medical centres in the
world, Yale-New Haven Hospital.
They've applied the knowledge we've
gained through accidental
discoveries,
and made use of it
in heart surgery.
Dr John Elefteriades and his team
use extreme hypothermia to make
heroic feats of surgery possible.
It's the most fascinating
technique to which I've ever
been exposed in medicine,
and each time, to me it
seems a miracle that it works.
One person who is hoping to benefit
from this life saving technique
is 59- year-old Esmail Dezhbod.
I had a stomach pain,
and it was a terrible stomach pain.
I came home, she took me to hospital
and they had a scan about.
They found something in my stomach.
And doctor came back and said,
"You know, anyone said to
you you have an aneurysm?"
Esmail needs urgent
life-saving surgery.
His thoracic aneurysm could
rupture and kill him at any time.
How are you? Hot day?
Yeah, it's really hot.
I'm concerned about my children.
They're so worried.
They ask me questions.
I cannot mention reality,
because it hurts them.
This morning,
I kind of hugged them and kissed them
and mentioned everything will be OK,
but it...it will be a risk too.
Esmail will undergo an
operation which will take him
to the very edge of death.
His aneurysm
is in his aorta, high in his chest.
To repair it, the surgeons
will have to cut off
the blood supply to his brain, and
in doing so, starve it of oxygen.
You can't
be clamping in that region because
you would devitalise the brain.
You would
deprive the brain of blood flow.
And that's wherein arises the need
for alternate techniques.
Our preferred technique here at
Yale is what we call deep
hypothermic circulatory arrest.
I just wanted to talk a little about
why we need to cool to such
extreme temperatures.
For these operations, we drop
the temperature from 36 degrees
centigrade to 18 degrees centigrade.
So the metabolic
requirement is about 12.5%
of what our needs are now.
Now, that's not zero, Kevin,
but that's pretty darn low.
So that provides us with
a safe window
of about 45-60 minutes
to work on this aortic arch.
Beyond that point,
there are dangers of
death of cells in the brain.
It's Esmail's big day.
It's 7.30 in the morning, and he's
being prepared for the operation.
The body is essentially in true,
real-life suspended animation,
with no pulse, no blood pressure,
no electrical waves
in the brain or EEG,
no signs of activity.
Today, in order to save Esmail's
life, they're going to have
to very nearly kill him.
I am intrigued to see how this
extraordinary operation is
going to unfold.
So this is the anaesthetic
monitoring suite, and it's this
that tells you that the patient
is alive and well.
It's not just the heartbeat,
the ECG,
it's also
everything from the amount of oxygen
in the bloodstream to the pressures
in the different chambers of the
heart here, all the way down to
a measure of the metabolic rate in
terms of the carbon dioxide being
exhaled with every breath.
Esmail's core body temperature is
going to be lowered to 18 degrees,
just five degrees more
than Anna was
when she was dragged out
of that freezing ravine.
His temperature already is a little
bit lower than it normally would
be at 35 degrees.
That's about 1.5, 2 degrees below
what you'd normally be.
Later on, we're going to see
that drop precipitously to
around about 20 degrees.
It's that huge drop in temperature
which will slow down
the dying process
while his entire system is shut down
and starved of oxygen.
The surgeons have finally
got down to the aneurysm.
It's every bit as impressive
in the flesh as it is on
the scans, isn't it?
Impressive for you.
It's intimidating for us.
At around 28 degrees,
the effects of the extreme cold
will make Esmail's heart
stop beating.
We cool the heart extra low,
and we use cold fluid
for that purpose.
We'll be putting some forward here
through the aorta to cool the heart
extra low in temperature.
Go ahead on the pump, please, Tim.
Take all the flow,
cool us to 18 degrees.
To get his body temperature down
low enough to protect his brain,
Esmail's warm blood is drained
from his body, cooled through the
bypass machine and then pumped back
around his veins and arteries.
So we're fully established
on the heart-lung bypass now,
and we're beginning to cool down,
trying to bring
this temperature down
to that very-low 18 degrees or so
that's needed to protect the brain.
But not all of the methods
are so hi-tech.
So you know
that Dr Rafferty and his team are
placing ice around the head.
Although we're able to cool very
well with the heart-lung machine,
we are not above simple measures
like ice, like in a beer cooler,
because that cold will get through
the cranium and cool the brain
a couple of extra degrees.
The colder Esmail's brain,
the more time the surgeons buy
for this very tricky operation.
Can you see that ulcer crater?
Yeah.
That was the impending rupture.
You see that change in colour,
the blue discoloration
in the ulcer crater?
And then you see the hole
where it ruptured.
This was a procedure just in time.
The repair begins, and as Esmail's
body temperature drops even further,
Dr Elefteriades prepares to put him
into suspended animation.
There's no room for error
or failure, really.
That would be catastrophic.
It's all about the brain.
Its vital cells and tissues
are amongst
the most metabolically-active
and fragile in the human body.
We're down at 20 degrees centigrade
now,
extremely low temperature, the sort
of temperatures we saw with Anna
out in the mountains of Norway.
We're still on the bypass,
but when we come off
the heart-lung bypass machine,
it's that temperature
that's going to protect Mr Dezhbod.
The key to all of this
is cooling Esmail's brain down
low enough to be preserved
before his circulation is arrested.
This was what saved Anna's life
on the frozen mountains of Norway.
Her temperature dropped low enough
to protect her brain
BEFORE her heart stopped beating.
Now, Tim, where do you stand
with your temperatures?
We're at 18-and-a-half.
Fully? Fully, yes.
And how long have you been cooling?
Cooling...40 minutes.
OK, so you're ready? We are ready.
So now it's all in place.
Everyone is in position and it's
time for everything supporting
Esmail's life to be switched off.
This is not a time of death,
but it is a time of dying.
We're now into
deep hypothermic arrest.
Everything has stopped.
His heart is at a standstill.
The heart-lung bypass machine
has stopped.
We've now got to race the clock
to get this repair done.
His heart has stopped, his blood's
stationary in the bypass machine,
and all brain activity has ceased.
Well, they're halfway through
the deep hypothermic arrest.
It's a kind of eerie time. There is
nothing supporting that patient
at the moment,
no drugs, no machinery.
It's just him in there
in that freezing-cold room,
with the surgical team
racing the clock,
trying to get that repair done
before irreversible damage happens.
If you look at the monitors,
the anaesthetists' monitors
with all of those flat lines,
he is indistinguishable
from someone who's actually dead.
Dr Elefteriades knows
that if the repair is not complete
in 45 minutes,
there's a significant risk
of permanent brain damage.
Everything about Esmail
is flatlining now.
Time is fast running out.
So that's it, that's coming to the
end of the deep hypothermic arrest.
Tim's now re-establishing
the heart-lung bypass.
Flow is coming back into the body.
Mr Dezhbod's cells are seeing
a fresh supply of blood and oxygen
for the first time in, well,
30 minutes and 10 seconds.
They're rapidly
bringing up the flows and getting
back to some level of support.
We're not out of the woods yet,
but there's a significant step.
They now need to warm Esmail up
and bring him back
to the land of the living.
And now the heart is
receiving blood flow again.
The clamp is off, and every part
is receiving blood flow.
The team are about to try
and defibrillate the heart here.
And...a peculiarity of
this particular procedure
is that they're going to have to use
external paddles. There they go.
So after those electric shocks,
those direct current shocks,
the heart has returned
to its normal rhythm,
sinus rhythm, and it's beating
and looks pretty good.
Esmail is alive, but until he wakes,
it will be impossible to tell
whether or not his brain has
suffered any damage. We're all done,
and Mr Dezhbod is in ICU.
The aneurysm was very large,
and it had an area that
was ready to rupture.
It would have ruptured,
I would say, in the near future.
Now, of course, it doesn't
mean that he's out of the woods.
The next two days or so
are a very important time.
It's a huge operation,
a very serious operation,
and we'll be watching him closely.
Thank you. I don't know how to
thank you. You're very welcome.
Probably we'll see you around.
You will, yes.
Nice to meet you, ma'am.
Thank you very much.
The real risk of this procedure,
feared by surgeon and patient alike,
is that of permanent brain damage.
It's this that I was really
keen to ask Dr Elefteriades about
once it was all over.
Looking at that technique,
I think it's fascinating that we
can cool people to such extremes,
but what's even more interesting is
that they seem to return to almost
a normal functioning of the brain.
I understand you've done a little
research in that area yourself?
First, we looked at
all the patients, and then from
them, we selected a subgroup
of truly challenging occupations,
and then we focused on them with a
microscope with very detailed tests,
looking for any evidence
of functional impairment,
and we really didn't find it.
The writers were writing,
the musicians were playing
and we really were able to document
an absolutely equal level of
performance after this dramatic
period of deep hypothermic arrest.
This really has been one of
the most remarkable days I've spent
in an operating theatre.
The thing that you have trouble
getting your head around is that
what we're doing here
is not just taking the heart out of
the circuit and letting machines
replace it all.
We're arresting the whole system,
the whole circulation and the brain.
We're cooling down to the point at
which you can't measure the activity
of the neurons and the cells of
the brain, electrically or
otherwise.
There is no evidence during
this whole period that he's alive.
He is indistinguishable entirely
from somebody who is dead
in that period.
And you find it amazing that you can
do that and have someone survive at
the end, let alone someone be so
completely themselves in addition.
The success of hypothermia
in operating theatres
has led doctors to wonder
where else it might be applied.
Cooling the brain down before
cardiac arrest occurs is one thing.
What I want to know is, can we cheat
death in true emergencies
away from the operating theatre,
when the heart stops before the
brain has a chance to cool down?
For people of my age, the greatest
threat to life comes from trauma.
Now amongst those trauma deaths,
the vast majority
are due to major haemorrhaging
from torrential bleeding.
I guess the question we have to
ask ourselves is, can this trick
of cooling, this hypothermia, get
doctors a much-needed edge even in
this wildly-uncontrolled situation?
In America,
more people under the age of 44 die
from traumatic injuries than
all diseases put together.
Tell me all about your
experience of trauma in this city.
Annually, we see about 1,700
priority-one trauma patients.
That's shooting, stabbing,
pedestrians struck in a severe way.
We're in the emergency department
at Mass Gen.
Just tell me a bit about
this place and what you do here.
So this is our 11-bay trauma area.
This is where all of
the traumas would come in.
Gunshot wounds, stabbings,
anybody who's haemorrhaging.
150 miles from Yale,
Boston's number-one trauma unit
has a constant stream of cases
where the patients
are literally bleeding to death.
Trauma bleeding is
always a huge problem.
It's probably the second thing
on our list of concerns,
and one of the things
that's sometimes obvious
from external injuries,
but not always, if there's some sort
of internal bleeding.
If your heart stops because
of trauma and blood loss,
surgeons have only minutes
to repair the injury and resuscitate
you before irreversible damage
or death occur.
Most of the time, this kind
of injury is unsurvivable.
But I'm going to meet someone with
a transforming vision of the future.
Hypothermia or cooling
offers organ protection,
and depending on how deep
the hypothermia is,
the longer and the more measurable
the protection is.
Dr Hasan Alam believes
hypothermia could save many patients
who would otherwise be declared dead
shortly after arrival.
If you drop the core body
temperature, the brain temperature,
down to 10 or 15 degrees Celsius,
then we're talking about 60 minutes,
maybe up to 90 or 120 minutes of
protection time.
To get this clear,
you're talking about
dropping these temperatures down
to ten degrees, core temperature?
That's pretty impressive.
Yes, that's a huge drop.
This is something that's never
happened in a trauma unit before,
and it presents some
very difficult practical issues.
How are you going to drop
them down to ten degrees?
That's another...
very practical issue.
Today if somebody comes in and
they've been stabbed and they arrest,
we end up opening the chest up
to do open cardiac massage.
By opening the chest, it also
provides you access to all the
big blood vessels
that are present in the chest.
Infusing cold saline rapidly
into the circulation using a pump,
directing it
towards the head, preferentially,
to cool the brain down rapidly.
We're talking about dropping
the temperature
by about two degrees centigrade
per minute.
So far, Hasan has only trialled
this technique in animals.
It's quite incredible.
I mean, you talk about challenge,
but you're saying that
these are people who would otherwise
die - 100% chance of dying.
By cooling them rapidly in this
fashion, we can convert
that almost-certain death
into almost-certain survival.
We're talking about 90%-plus
survival, with normal
cognitive function,
normal brain activity,
normal other organ function.
It's challenging, but it's doable.
You have to understand the scale
of Hasan's ambition. He's talking
about repairing the unrepairable.
This is something that, as a doctor,
is routinely fatal, and he's
talking about making it survivable.
To do that, he's talking about
getting people in,
opening their chests,
shoving them on bypass,
cooling them down within seconds
of them having bled out
and had a cardiac arrest.
It's an enormous intervention,
but if he can make it work,
it's going to save lives.
Before I move on, I want to find out
if Esmail's operation
has truly been a success.
I love you, honey. How are you?
I'm fine.
I love you, Daddy.
I love you.
How are you feeling?
How's it all going?
OK. I have pain.
It's not easy.
But I know it will be a good end,
and I know that my problem
has been solved.
I cannot worry about it.
You've been, you've had...
been through
a heavy bit of surgery there.
So how do you think he's doing?
I think he's doing good.
Half the tubes that were attached to
him yesterday came out and the chest
tube came out today. He looked good.
You look fantastic,
and I'm very pleased to see you
looking this well so soon after.
And I don't want
to hold you up any longer.
I'll let you get on with your
afternoon. Lovely to see you.
Well done. Thank you so much.
What people like Dr Elefteriades
and Dr Alam are doing with
hypothermia holds great promise.
Everywhere else I've encountered
profound hypothermia at temperatures
less than 32 degrees centigrade,
it's always, always been an enemy,
always been something that
threatens the life of your patient.
And yet...
here, you keep going,
getting down to less than half
what your normal core should be,
and it gives you this advantage that
lets you do these amazing things.
We understand very little,
I think, truly, fundamentally,
about what the process of this
profound hypothermia is doing to the
body, but particularly to the brain.
I think it's just another thing that
tells us that the brain is the last
dark continent of physiology
and biological science that is
truly unexplored, poorly understood.
What we do know is that life,
your life, is a property distributed
across the many trillions
of cells of your body.
Hypothermia works
because at some level,
it is able to protect those cells.
And so I want to know whether
a deeper understanding of the cell
can give us more control over the
events surrounding life and death.
You know, ultimately this isn't
a morbid story about death,
it's actually about life.
It's about what it means to
be alive, it's about living.
It's about the intricacy and
complexity that makes life possible,
and it's a story about doctors
and scientists who are searching for
something in amongst all of that
that they might get hold of,
that they might manipulate.
If we're going to understand that,
we'll have to examine the very
machinery that drives our cells.
The next part of this
scientific quest has brought me to
an unassuming building,
deep in the heart of Philadelphia.
There's a man here
who's spent his career
looking for
the Holy Grail of medicine,
something that controls death,
and therefore life, in our cells.
I'd like to hear a bit
about the story
of how you got started
along this route.
You know, having to pronounce
someone dead on a regular basis
is a terrible problem,
and I do that on a regular basis.
and that's a strong motivator
every day to get me to,
you know, think of one more thing
that can be done.
That's what led me to the basic
science of beginning to think about,
"Well, gee-whiz, if I'm trying to
bring someone back to life,
"what do I know about
bringing cells back to life?
"What do I know about how cells die?"
In his search for an
understanding how and why cells die,
Becker did a simple experiment,
in which he took healthy cells
and starved them of oxygen.
What we all expected is,
"You're going to
"deprive them of oxygen
and after a while,
they're going to begin to die."
So I did the experiment and,
by golly,
I sat there and looked through
the microscope...
and when they were
without oxygen for one hour,
there was almost zero cell death.
It was so minimal,
we could barely detect it.
And the minute we would reperfuse,
the cell death would just take off.
It was only when the damaged cells
were reperfused,
when the oxygen was reintroduced,
that they started to die.
What we figured out was that the
cells were not actually dying during
this period of time without oxygen.
Now, they weren't happy.
They weren't happy cells.
They were clearly being
altered by being without oxygen.
But they weren't dead.
And so it was clear that death was
being accelerated by reperfusion.
If you deprive cells of
oxygen for long enough,
they will eventually die.
But what Becker discovered
was that reintroducing oxygen was
also fraught with danger, because
this could trigger cell suicide.
He wanted to know why
this was happening
and what he could do about it.
I began to query, is there a
centre for death in the cell?
And that's when I realised a
number of very new breakthroughs
in the basic science world.
We're beginning to recognise
that the mitochondria,
sort of the power plant
within the cell,
was also the controller of death.
So what is this controller of death?
What are the mitochondria?
Invisible to the naked eye
and difficult to photograph,
they are nevertheless beautiful.
These tiny organelles that
are hidden within almost every
single cell of your body
are incredible pieces of evolution.
As a piece of biological
engineering, they're almost perfect.
We call them the powerhouses
of our cell. That kind of
understates what they do.
These inner membranes here thrown
into folds allow electrons to
flow across them.
They take the oxygen that
you breathe and they convert it
into the chemical energy
that powers everything that you do
and everything that you are.
Mitochondria are way more
complicated than we thought.
But the fundamental thing that turns
out to be so critical is that they
have the ability to kill the cell.
It's almost like a switch
inside the cellular machinery.
And that the cell has the ability
to go,
"Let's die."
It's almost as if the cell
is booby-trapped in such a way
that it will do one or the other.
It doesn't like to be
in between those two.
It's either, "I want to make energy,
I want to create energy for you",
or "I'm not good at creating energy
or I'm not good at something I'm
doing - it's time for me to die."
So far, Becker has been
using cooling as a method
to slow down cell death.
It seems to be stopping some
cells committing suicide,
but it's not effective enough.
Would you say that with our efforts
at cooling, in a very gross way,
we've learnt how to throttle down,
but that there may be a
way of manipulating those
switches in a more subtle way?
Absolutely. Who would make a
nuclear reactor without control rods,
right, without the ability to
sort of get it hotter, cool it down?
We have that same sort of ability,
if you will, at the subcellular
level in our mitochondria.
We want the cell to take a
serious chill pill.
And whether it's done with
hypothermia or with some sort
of mitochondrial medicine...
I don't think it'll matter.
But we want that cell to take
that chill pill and to cool out
and to not do the work that it was
doing previously for a period of time
while it sort of reorganises itself.
I do believe that's possible, and I
do believe we're moving towards that.
So Becker's started to understand
the process of death as a property
of the cells, with the mitochondria
as a target we might aim for
in our efforts to cheat death.
If he really can find a drug to
manipulate the mitochondria,
the consequences are enormous.
His research is a long
way off finding a solution.
But it's people like him
who persevere in scientific research
who change the course
of medical history.
Becker's about making a difference.
Becker is about
taking on those big problems
and not letting someone
tell him they can't be addressed.
He's about, you know... I was really
taken with something he said today,
where he said "Look,
I looked at what we do
"and I looked at what might be done,
"and I realised that in the
difference were people's lives".
And that's a very dramatic,
but you know, very positive
and inspiring way
to think about your path,
his path in scientific research.
But you'd be wrong to think
that all the cutting-edge science
happens in America.
Some of the most exciting
work taking place right now
in this area of science,
where researchers are looking at how
to protect and prevent cell suicide,
is happening here in Britain.
We discovered hypothermia by
accident, literally in accidents.
And we started using it
before we really understood
how it was working.
In fact, I remain to be convinced
that we fundamentally understand
the mechanism by which
cooling people down gets you
an advantage even today.
But that, I guess, is
sometimes how medicine progresses.
It pushes at the boundaries
with incomplete knowledge
using something,
knowing only that it works,
and leaving the whys
and the wherefores and the how
the thing works till later.
Now, hypothermia has some very real,
very lethal hazards,
and those remain to be negotiated.
Researchers are looking for anything
that can augment that therapy,
make it better or reduce the risk.
Here at St Michael's,
researchers have discovered
a new weapon to add to the arsenal
in the fight for survival.
It's happening in the neo-natal
intensive care unit at a time
when life has only just begun.
It's pioneering and risky work.
It's quite stressful
to, you know, to do something
to somebody's very sick baby.
This is not in the lab,
this is somebody's baby,
the most precious thing in the
world, and it just can't go wrong.
Here in the neo-natal unit,
the stakes couldn't be higher.
Hypoxic brain injury caused by
oxygen starvation at birth is a
real threat to newborn children.
For the last 14 years,
Professor Marianne Thoresen has been
using cooling, and it's worked well.
But there's a group of children who
it doesn't help, and it fired up her
interest to add something to cooling
which could help prevent cell death.
It's not good enough, is it?
We have improved it from 70%
to 50%, but I really want to
do something with those 50% that
has not been helped by cooling only.
Her research led her to xenon,
a simple elemental gas plucked
from the very air that we breathe.
Xenon is a remarkable atom.
It is a rare noble gas
present in only trace amounts in all
of the atmosphere that we breathe.
For every ten million parts, perhaps
only one or two is an atom of xenon.
Now, for something so rare and
unreactive, you might think that
it would be utterly useless.
But in fact, it has some
extraordinary and very valuable
biological properties.
In medicine, we've come to think of
it as the ideal anaesthetic agent.
And when you give it,
it's very rapid in onset.
It has very few side-effects,
and when you stop giving it, it
leaves the body extremely quickly.
But it's its property
as a neuro-protective agent,
as something that might protect the
brain when breathed as a gas, that
makes it of interest and great value
to researchers working in the
field of hypoxic brain injury.
And here it is.
This precious gas, xenon.
I'm fascinated that something
which is inert actually
can have a biological effect.
And I think it's very...
interesting also that the effect
is much stronger when you're cold.
I'm hoping Marianne can explain
how this combination of xenon and
cooling might actually save lives.
It's a very exotic drug.
We're not sure how it works.
It seems to protect cells
against cell suicide, doesn't it?
Yeah, it reduces the degree of
apoptosis very significantly,
so this is a delayed cell death.
The real test came in March this
year, when Marianne was given
permission to try xenon
on her first human baby.
You hope that it will all go well,
but you can't be absolutely sure
and you can't say that
to the parents either,
that we are absolutely sure
there won't be a problem.
Riley Joyce was born by emergency
caesarean section on March 28th
this year, after what had
been a perfectly normal
healthy pregnancy for Sarah.
It wasn't until they took him away
as soon as he was born and, you know,
they didn't bring him over for me to
see him and you didn't hear him cry.
It was then that I started to think
"Actually, something's really wrong".
Riley was born unable to breathe
and without a heartbeat.
No-one knew how long his
brain had been starved of oxygen,
but he was critically unwell
and the processes of cell damage
and cell suicide
were at risk of progressing.
It must have been a pretty
anxiety-producing time?
It was so frightening.
I think, although I realised, you
know, it was serious, until they came
and said "We need to take him to
Bristol for special treatment",
that's when it really hit home for
me that actually, we could lose him.
Baby Riley was Marianne's
first opportunity to see
if xenon would work.
So you've arrived at Bristol,
and Marianne Thoresen is explaining
this new treatment to you.
Just tell me about
what that was like?
I felt very...not sure about
going for it, really, to be honest.
You know, Riley's our little baby
and it was like "Do I want him to be
this experiment?"
My initial reaction was "No way".
You know, my little boy was so sick.
I'd only seen him
for about 30 seconds.
Riley's brain was at risk of
damage from the oxygen deprivation.
He was already benefiting from the
cooling, but there was still a real
chance of brain damage or death.
Sarah and Dave now had to decide
whether to let him be the first baby
to receive xenon.
It was just so frightening seeing him
completely wired up, you know,
to so many machines
and looking so fragile.
The xenon was given
without incident.
But it was another ten days
before they would find out
what its effects had been.
When he was ten days old, we did
an MRI scan, a picture of his brain
which showed that the brain was
normal on the scan, which is a very
good sign of a normal outcome.
You can never
predict 100% what the baby will
be like long term, but I think
I'm quite confident he will do well.
Five days after he was born,
Sarah held him properly
for the first time.
Actually to hear him cry
as well was just amazing.
Most parents go,
"Oh, no, a crying baby," but it
was actually an amazing sound.
We waited so long, didn't we,
to hear him cry, so yeah.
You get really touched.
You get tears in your eyes,
actually, because you think "Oh, I
can look into your eyes now, baby,"
and you remember how sick he was.
And that it all went well,
it is such a pleasure.
Riley left hospital two weeks later,
and as you can see, he's thriving.
Stretch, stretch!
"Oh, dear.
Who's this stranger person?"
Tell me about Riley
and what's he like now.
He's generally a happy little boy,
isn't he? He's just starting
to find his giggle.
Certainly deciding to go for his
daily exercise.
He smiles at lots of different
people out and about, don't he?
He's a happy little chappy, really.
He's four months old now,
and although it's early days,
the paediatricians think
he's indistinguishable from
any other healthy baby.
So you've still got quite a
long way to go with all of this?
Oh, yes. This is, from a clinical
point of view, absolutely the
beginning, and he will...although
he's the first baby,
we're planning to do another
12 babies in this feasibility study.
It's only when you randomise, you
have a huge number of babies, maybe
200 or something, and you see how
they are doing, those who have
got xenon and those who haven't,
that's when you can say whether
it really works in babies as well as
experimentally, and that will take
another six years.
You don't often see researchers
who are taking their work from
the lab and translating it into real
patients in the clinical setting.
You almost never see
the direct results of that.
So it was lovely to see Riley,
lovely to see the fruits
of Marianne and
Marianne's team's labours.
And he has certainly
benefited from cooling.
He may have benefited from xenon,
it's a bit too early to say.
But you have to admit,
it looks pretty good,
and that is what it's all about.
I'm back at my job at UCLH.
This has been a fantastic
opportunity for me to get out there
to see what's going on.
The world of resuscitation and
critical care is so full of
appalling outcomes that sometimes
it's difficult to
see a way forwards.
And yet we've met people
who are doing exactly that,
who are pushing the boundaries,
who are making progress.
I've met people who are living proof
that death can sometimes be cheated.
That's the main thing -
don't declare people dead
before they are really dead.
The man who I saw so very nearly
dead on the operating table at Yale
is now back with his family
alive and well, and clearly
with a new lease of life.
Those technology help me
to be a part of my family.
To still be alive,
that's a reality.
What's really struck me is that the
line between life and death becomes
more blurred with every year,
opening up real possibilities
that could affect us all.
We're in a different era
where survival is expected
even in the most high-risk cases, so
it is indeed a very different world.
We find ourselves in this very
uncomfortable time period where,
while we used to know when a patient
was dead or alive, there are
patients that are simply in between.
Every Friday,
our anaesthetic department at UCLH
gathers to share information and
news of new discoveries in an effort
to put theory into practice.
I wanted to talk about this concept
of cooling in resuscitation,
something familiar to us,
but so often overlooked.
I'd like to start
with a case history.
This is a story of a doctor
who was out with two other
registrars in Norway, skiing.
And she goes down a ravine and goes
through the ice into a hole here,
and this is 6.20 in the evening.
This is her rescue team. They arrive
at 19.56, so that's fully about an
hour and a half downstream
from the event where she goes
through the ice.
They need to fly to Tromso. Now,
Tromso is 250 nautical miles away.
And...I would have stopped.
Hands up, anyone who
wouldn't have stopped?
That looks like a dead person,
biochemically.
But that's her,
a year after the event.
Even though resuscitation and
critical illness present formidable
challenges, for the right people
in the right circumstances,
we can still make important
differences to real people.
We moved on from her
to the deep hypothermic arrests.
We went to Yale and we saw this guy,
who's Dr John Elefteriades.
The case he had us go
and film him doing was this guy.
You know, we're taught that all our
memories and all our neurocognitive
stuff is all about little circuits
that continue to fire.
And yet in this guy's case, you've
pressed the hard reset button,
and all of that stopped.
And yet that's him
about a week after surgery.
'What I've witnessed is science and
medical practice coming together,
'giving us the hope that we can
continue in our efforts to blur
the line between life and death.'
A sick baby, you can see that. You
don't need to be a neonatologist.
Sick, sick, sick baby.
And the trick here, apparently,
is to try with cooling and the
adjunct of xenon to switch that off.
And that's what it appears to do.
It's not clear that
the xenon did this.
But it could.
It will change the survival rate
by a good fraction, 50-60%.
That's kind of it.
We should be doing more of this
because... these people,
who are all doing well,
are all evidence that you can have
extreme physiological insults
and get through it.
And all of them,
I've met all of them.
We don't get to meet them
afterwards very often.
And that, I guess,
is how medicine works.
You know, it's accidental.
Sometimes, it looks
like a complete mess.
But it moves forwards,
and it makes yesterday's impossible
tomorrow's survival.
consultant anaesthetist
here at
University College London Hospital.
I've experienced the havoc
that the cold can wreak upon
our fragile physiology.
Even the smallest drop in
temperature has profound
effects on the human body.
Pass that... Bloody hurts, actually.
I wasn't quite prepared for
how much that was going to
hurt in my feet and hands.
Just one degree of cooling is
enough to cause a lot of pain.
Is it normal for it to hurt
that much when you go in?
I wasn't expecting that.
'And another ten would
almost certainly kill you.'
But scientists have found a way
to make the cold work for them,
learning lessons from accidental
events and turning this usually
lethal foe into a life-saving ally.
By the time they'd called
the rescue helicopter for Anna,
her heart hadn't beaten for
well over an hour and a half.
Extreme cooling is used in
operating theatres across the world.
It's the most fascinating
technique to which I've ever
been exposed in medicine.
And each time, to me it
seems a miracle that it works.
It's redrawing the line
between life and death.
The body is essentially in true,
real-life suspended animation,
with no pulse, no blood pressure,
no electrical waves
in the brain or EEG.
There's no room for error
or failure, really.
That would be catastrophic.
If you look at the monitors,
all of those the flat lines,
he is indistinguishable
from someone who's actually dead.
Cooling has the potential
to revolutionise everything,
from trauma surgery
to resuscitation medicine.
We find ourselves in this
very uncomfortable time period
where, while we used to know when a
patient was dead or alive,
there are
patients that are simply in-between.
And we must be really cautious
as we change our very ideas about
what is alive and what is dead.
FLATLINE TONE
Medical breakthroughs
often begin with an accident.
These are the Kjolen
mountains of northern Norway,
in the Arctic Circle.
They're popular with extreme skiers.
'11 years ago, a young doctor called
Anna Bagenholm suffered an accident
'that would change her life
and propel her into the
medical history books.'
It was a very, very nice weather day.
It was, like, 15 degrees in the sun,
and a lot of melting water and
very good skiing conditions.
Skiing just ahead of her
was her colleague, Torvind.
I skied first, stopped and looked
up again, and so Anna started skiing
and she was doing all right, and
then suddenly she started skidding.
I hit a rock and turned round so that
I, like,
turned round on my back,
and started to slide on the back.
And all of a sudden, she broke
through the ice,
um, and hit an ice ledge and went in
under the ice ledge into the water.
And the water filled the clothes and
then I was, like, suddenly dragged
under the ice very slowly.
Anna was trapped hopelessly beneath
the ice, and was slowly but surely
freezing to death.
Anna was moving inch by
inch in under the ice.
And in the end, we were just holding
on to Anna's legs to just stop her
from disappearing under the ice.
Far away from help in the icy
wilderness, Torvind and his friend
struggled for 40 minutes to pull
Anna out from underneath the ice,
but it was impossible.
And then, still trapped,
Anna's body went completely limp,
and shortly after this
her heart stopped beating.
Normally when your heart stops
beating, death will inevitably
follow a few hundred seconds later.
By the time they'd called the
rescue helicopter for Anna,
her heart hadn't beaten for well
over an hour and a half.
Now, I live and
work in London, where
you're never more than a few minutes
from healthcare, but this is Norway.
Just look at it. There
are great, huge distances between
the mountains and the hospitals.
And then were waiting for almost an
hour from the accident happened
till the first rescue team
got there.
40 minutes after Anna
had stopped moving,
they were finally able to pull
her out from underneath the ice.
Despite the best efforts of the
paramedic team on board
the helicopter that day,
Anna arrived at the hospital
in Tromso without a heartbeat.
Her heart had been at a
standstill for well over two hours.
Now, when you hear a story
like that,
you are not expecting the
patient to survive.
Frankly, this girl should have
been dead.
Two hours after Anna's heart
had stopped,
the helicopter carrying her body
landed at the
University Hospital in Tromso.
I landed here... Uh-huh.
..sliding out the door. I jumped in
and talked to the doctor on board.
'Anaesthetist Mads Gilbert
led the resuscitation team.'
So we had her on one
of these stretchers,
one of these trolleys, and we
were doing CPR continuously.
Where were you?
Were you on the trolley?
I was sort of
kneeling on the trolley,
to all the time make sure that the
two most important things
were maintained.
Ventilation, air in and
out of the lungs,
and good chest compression
to maintain the
blood circulation to her cold frame.
She looked dead, completely dead.
She was white,
ash white, waxy white, wet.
Dilated pupils and on the ECG,
no signs of life,.
The challenge for doctors now
was to find a way of dragging this
lifeless 29-year-old woman
back from the dead.
And it would be the extreme cold
that she'd experienced that would
hold the key to her survival.
'I've come to the sports
science department at the
University of Portsmouth
'to see how the human body reacts to
even tiny changes in temperature.'
OK, comfortable?
Let's get that out your way.
'Even the slightest change can have
powerful effects on our physiology.
'But when you sink as low as the
temperatures that Anna experienced,
the effects can be catastrophic.'
As human beings, we're engineered
to function at 37 degrees.
Any lower than that, and our
physiology rapidly begins to fail.
Now, I'm going to show you what
happens when my core temperature
drops by just one or two degrees.
But that small difference, that
small drop in temperature will show
you how poorly we tolerate the cold,
and what a double-edged
sword hypothermia really is.
The first thing that's going
to happen is, I'm suddenly
going to feel very, very cold.
37.45, starting temperature.
It's looking good. Well done.
30 seconds gone. In five,
three, two, one... That's a minute.
If you pass that to...
Bloody hurts, actually.
In the extremities? Yeah, I wasn't
quite prepared for how much that was
going to hurt in my feet and hands.
Number one, we're a tropical animal,
so this is about
one of the worst things you can to
do a human, put them in cold water.
The body will fight vigorously to try
and defend its deep body temperature,
and in so doing, it's prepared to
cut off blood supply and, if you
like, sacrifice the extremities.
I really wasn't enjoying this,
and my fight or flight reflexes
were running at full tilt.
My body was trying to protect
itself, knowing that if temperatures
continued to drop at this rate,
it could prove lethal.
So, I mean, right now it's just a
bit of shutdown, a bit of shivering,
bit of pain.
If I was to get any lower, what sort
of things would we start to see?
Well, around about
33 degrees Celsius, the first major
organ to be affected is the brain.
That starts to affect things
like central nervous system
function, so we see amnesia.
Somewhere between 30 and 33 Celsius,
it's normal for people to become
semi-conscious or unconscious.
It's very easy
to mistake somebody for being dead at
those kind of temperatures.
This is what was happening to Anna
in that freezing ravine,
her body shutting down as her
temperature dropped further
and further.
But the hypothermia, the thing
that was killing her,
would also
hold the key to her survival.
We've been hearing the story of
Anna Bagenholm, who...managed
to get her core temperature down
to 13.7 degrees, which is... Gosh,
I can barely do the maths right now,
but, er, you know,
23-odd degrees below my core.
We see the other side, we
see hypothermia cooling the brain,
reducing its requirement for oxygen.
So at the same time as
hypothermia is causing other
vital organs to fail, it is actually
also starting to protect the brain.
So essentially, you've got
somebody who is in major arrest,
but with a viable brain.
It's good to finally get out.
It's hard not to feel
like a bit of a wimp.
I've got you. Thank you.
Good stuff.
I think the thing that's impressed
me most about all of this is
how profound
your physiological responses are
to such a small fraction of cooling,
and how...fiercely your body fights
against being cooled down.
It doesn't want to be cooled
down, it doesn't work
at less than 37 degrees.
And it does everything it
can to stop that happening.
It tells you to get out of
the water, it tells you
to do something sensible.
And this is, like, one degree,
less than a fraction of a degree,
and then you think about Anna
getting down, you know,
23-odd degrees lower than that,
23 degrees lower than that, so cold
that her heart has stopped and her
brain has no electrical activity.
Even though Anna looked dead,
the doctors knew that
the hypothermia,
the very thing that had stopped her
heart, might also
have preserved her brain.
And so despite the incredible
duration of this cardiac arrest,
the team took the decision to carry
on the resuscitation and
warm her up.
Once she was on full bypass,
we all sort of put our hands together
and we waited.
And slowly,
the blood temperature increased.
We had an echo probe down
her oesophagus.
We saw the heart
still, standing like this, shivering
a little bit and suddenly, phoo!
HEART BEATS
And I had to maintain my control
not to start crying,
because it
was a very emotional moment.
And the heart continued to beat and
we were all very, sort of thrilled.
"Yes! Yes! The heart is beating,
she's starting up again."
Three weeks later, Anna opened her
eyes for the first time, and very
gradually, she began to recover.
I'm on my way to meet Anna
in the very town where she was
treated and now lives and works.
It's not one of the easiest
places to drive around.
I'm going to run these people over.
What am I meant to do here? Sorry!
I'm about to run over
a bunch of nurses,
playing drums.
This is... I'm in some
David Lynch movie.
Um...OK, concentrate.
When you see people who've had
cardiac arrests
where their hearts have stopped for
even just a few minutes,
they very often don't survive.
If they survive, they're very
often left with really severe
neurological disabilities.
So I am absolutely fascinated,
absolutely fascinated
to find out if she recovered, how
completely she managed to recover.
Hi, Anna. 'Anna now works as a
doctor specialising in radiology
'at the same hospital
in which her life was saved.'
I'm sure those first
few weeks must have been a haze,
but when you finally
realised what had happened, I mean,
what were your first thoughts?
I gathered all the information
and I ended up thinking
"This is something really special."
I hadn't heard about
anybody who has been so cold before.
Like, I had almost three
hours with heart standstill.
But because I was so cold,
the CPR is enough for giving
my brain enough oxygen.
'It took nearly six years for Anna
to fully recover, but she did.'
So now I'm back to work
as a normal doctor.
I do exactly the same
things as everyone else.
And you're out skiing,
I understand, so you're
doing everything you were before?
Yeah. I take a bit more care. Yeah.
'I can see why amongst doctors,
this is still such an iconic case.'
I mean, I'm the living proof
that it's possible.
It's important to start the CPR, call
for help and get the persons to
the right hospital where they can
re-warm and then wait and see.
This is without doubt the most
amazing story of survival I have
ever heard.
What Anna's incredible tale
tells us
is that there is this sort of no
man's land between life and death
that we might be able to manipulate.
I think it got medics all over the
world thinking again
about death not as
a moment in time, but as a process,
and one that they might
be able to stretch out
and give themselves
a chance to intervene.
I'm on my way to one of the most
prestigious medical centres in the
world, Yale-New Haven Hospital.
They've applied the knowledge we've
gained through accidental
discoveries,
and made use of it
in heart surgery.
Dr John Elefteriades and his team
use extreme hypothermia to make
heroic feats of surgery possible.
It's the most fascinating
technique to which I've ever
been exposed in medicine,
and each time, to me it
seems a miracle that it works.
One person who is hoping to benefit
from this life saving technique
is 59- year-old Esmail Dezhbod.
I had a stomach pain,
and it was a terrible stomach pain.
I came home, she took me to hospital
and they had a scan about.
They found something in my stomach.
And doctor came back and said,
"You know, anyone said to
you you have an aneurysm?"
Esmail needs urgent
life-saving surgery.
His thoracic aneurysm could
rupture and kill him at any time.
How are you? Hot day?
Yeah, it's really hot.
I'm concerned about my children.
They're so worried.
They ask me questions.
I cannot mention reality,
because it hurts them.
This morning,
I kind of hugged them and kissed them
and mentioned everything will be OK,
but it...it will be a risk too.
Esmail will undergo an
operation which will take him
to the very edge of death.
His aneurysm
is in his aorta, high in his chest.
To repair it, the surgeons
will have to cut off
the blood supply to his brain, and
in doing so, starve it of oxygen.
You can't
be clamping in that region because
you would devitalise the brain.
You would
deprive the brain of blood flow.
And that's wherein arises the need
for alternate techniques.
Our preferred technique here at
Yale is what we call deep
hypothermic circulatory arrest.
I just wanted to talk a little about
why we need to cool to such
extreme temperatures.
For these operations, we drop
the temperature from 36 degrees
centigrade to 18 degrees centigrade.
So the metabolic
requirement is about 12.5%
of what our needs are now.
Now, that's not zero, Kevin,
but that's pretty darn low.
So that provides us with
a safe window
of about 45-60 minutes
to work on this aortic arch.
Beyond that point,
there are dangers of
death of cells in the brain.
It's Esmail's big day.
It's 7.30 in the morning, and he's
being prepared for the operation.
The body is essentially in true,
real-life suspended animation,
with no pulse, no blood pressure,
no electrical waves
in the brain or EEG,
no signs of activity.
Today, in order to save Esmail's
life, they're going to have
to very nearly kill him.
I am intrigued to see how this
extraordinary operation is
going to unfold.
So this is the anaesthetic
monitoring suite, and it's this
that tells you that the patient
is alive and well.
It's not just the heartbeat,
the ECG,
it's also
everything from the amount of oxygen
in the bloodstream to the pressures
in the different chambers of the
heart here, all the way down to
a measure of the metabolic rate in
terms of the carbon dioxide being
exhaled with every breath.
Esmail's core body temperature is
going to be lowered to 18 degrees,
just five degrees more
than Anna was
when she was dragged out
of that freezing ravine.
His temperature already is a little
bit lower than it normally would
be at 35 degrees.
That's about 1.5, 2 degrees below
what you'd normally be.
Later on, we're going to see
that drop precipitously to
around about 20 degrees.
It's that huge drop in temperature
which will slow down
the dying process
while his entire system is shut down
and starved of oxygen.
The surgeons have finally
got down to the aneurysm.
It's every bit as impressive
in the flesh as it is on
the scans, isn't it?
Impressive for you.
It's intimidating for us.
At around 28 degrees,
the effects of the extreme cold
will make Esmail's heart
stop beating.
We cool the heart extra low,
and we use cold fluid
for that purpose.
We'll be putting some forward here
through the aorta to cool the heart
extra low in temperature.
Go ahead on the pump, please, Tim.
Take all the flow,
cool us to 18 degrees.
To get his body temperature down
low enough to protect his brain,
Esmail's warm blood is drained
from his body, cooled through the
bypass machine and then pumped back
around his veins and arteries.
So we're fully established
on the heart-lung bypass now,
and we're beginning to cool down,
trying to bring
this temperature down
to that very-low 18 degrees or so
that's needed to protect the brain.
But not all of the methods
are so hi-tech.
So you know
that Dr Rafferty and his team are
placing ice around the head.
Although we're able to cool very
well with the heart-lung machine,
we are not above simple measures
like ice, like in a beer cooler,
because that cold will get through
the cranium and cool the brain
a couple of extra degrees.
The colder Esmail's brain,
the more time the surgeons buy
for this very tricky operation.
Can you see that ulcer crater?
Yeah.
That was the impending rupture.
You see that change in colour,
the blue discoloration
in the ulcer crater?
And then you see the hole
where it ruptured.
This was a procedure just in time.
The repair begins, and as Esmail's
body temperature drops even further,
Dr Elefteriades prepares to put him
into suspended animation.
There's no room for error
or failure, really.
That would be catastrophic.
It's all about the brain.
Its vital cells and tissues
are amongst
the most metabolically-active
and fragile in the human body.
We're down at 20 degrees centigrade
now,
extremely low temperature, the sort
of temperatures we saw with Anna
out in the mountains of Norway.
We're still on the bypass,
but when we come off
the heart-lung bypass machine,
it's that temperature
that's going to protect Mr Dezhbod.
The key to all of this
is cooling Esmail's brain down
low enough to be preserved
before his circulation is arrested.
This was what saved Anna's life
on the frozen mountains of Norway.
Her temperature dropped low enough
to protect her brain
BEFORE her heart stopped beating.
Now, Tim, where do you stand
with your temperatures?
We're at 18-and-a-half.
Fully? Fully, yes.
And how long have you been cooling?
Cooling...40 minutes.
OK, so you're ready? We are ready.
So now it's all in place.
Everyone is in position and it's
time for everything supporting
Esmail's life to be switched off.
This is not a time of death,
but it is a time of dying.
We're now into
deep hypothermic arrest.
Everything has stopped.
His heart is at a standstill.
The heart-lung bypass machine
has stopped.
We've now got to race the clock
to get this repair done.
His heart has stopped, his blood's
stationary in the bypass machine,
and all brain activity has ceased.
Well, they're halfway through
the deep hypothermic arrest.
It's a kind of eerie time. There is
nothing supporting that patient
at the moment,
no drugs, no machinery.
It's just him in there
in that freezing-cold room,
with the surgical team
racing the clock,
trying to get that repair done
before irreversible damage happens.
If you look at the monitors,
the anaesthetists' monitors
with all of those flat lines,
he is indistinguishable
from someone who's actually dead.
Dr Elefteriades knows
that if the repair is not complete
in 45 minutes,
there's a significant risk
of permanent brain damage.
Everything about Esmail
is flatlining now.
Time is fast running out.
So that's it, that's coming to the
end of the deep hypothermic arrest.
Tim's now re-establishing
the heart-lung bypass.
Flow is coming back into the body.
Mr Dezhbod's cells are seeing
a fresh supply of blood and oxygen
for the first time in, well,
30 minutes and 10 seconds.
They're rapidly
bringing up the flows and getting
back to some level of support.
We're not out of the woods yet,
but there's a significant step.
They now need to warm Esmail up
and bring him back
to the land of the living.
And now the heart is
receiving blood flow again.
The clamp is off, and every part
is receiving blood flow.
The team are about to try
and defibrillate the heart here.
And...a peculiarity of
this particular procedure
is that they're going to have to use
external paddles. There they go.
So after those electric shocks,
those direct current shocks,
the heart has returned
to its normal rhythm,
sinus rhythm, and it's beating
and looks pretty good.
Esmail is alive, but until he wakes,
it will be impossible to tell
whether or not his brain has
suffered any damage. We're all done,
and Mr Dezhbod is in ICU.
The aneurysm was very large,
and it had an area that
was ready to rupture.
It would have ruptured,
I would say, in the near future.
Now, of course, it doesn't
mean that he's out of the woods.
The next two days or so
are a very important time.
It's a huge operation,
a very serious operation,
and we'll be watching him closely.
Thank you. I don't know how to
thank you. You're very welcome.
Probably we'll see you around.
You will, yes.
Nice to meet you, ma'am.
Thank you very much.
The real risk of this procedure,
feared by surgeon and patient alike,
is that of permanent brain damage.
It's this that I was really
keen to ask Dr Elefteriades about
once it was all over.
Looking at that technique,
I think it's fascinating that we
can cool people to such extremes,
but what's even more interesting is
that they seem to return to almost
a normal functioning of the brain.
I understand you've done a little
research in that area yourself?
First, we looked at
all the patients, and then from
them, we selected a subgroup
of truly challenging occupations,
and then we focused on them with a
microscope with very detailed tests,
looking for any evidence
of functional impairment,
and we really didn't find it.
The writers were writing,
the musicians were playing
and we really were able to document
an absolutely equal level of
performance after this dramatic
period of deep hypothermic arrest.
This really has been one of
the most remarkable days I've spent
in an operating theatre.
The thing that you have trouble
getting your head around is that
what we're doing here
is not just taking the heart out of
the circuit and letting machines
replace it all.
We're arresting the whole system,
the whole circulation and the brain.
We're cooling down to the point at
which you can't measure the activity
of the neurons and the cells of
the brain, electrically or
otherwise.
There is no evidence during
this whole period that he's alive.
He is indistinguishable entirely
from somebody who is dead
in that period.
And you find it amazing that you can
do that and have someone survive at
the end, let alone someone be so
completely themselves in addition.
The success of hypothermia
in operating theatres
has led doctors to wonder
where else it might be applied.
Cooling the brain down before
cardiac arrest occurs is one thing.
What I want to know is, can we cheat
death in true emergencies
away from the operating theatre,
when the heart stops before the
brain has a chance to cool down?
For people of my age, the greatest
threat to life comes from trauma.
Now amongst those trauma deaths,
the vast majority
are due to major haemorrhaging
from torrential bleeding.
I guess the question we have to
ask ourselves is, can this trick
of cooling, this hypothermia, get
doctors a much-needed edge even in
this wildly-uncontrolled situation?
In America,
more people under the age of 44 die
from traumatic injuries than
all diseases put together.
Tell me all about your
experience of trauma in this city.
Annually, we see about 1,700
priority-one trauma patients.
That's shooting, stabbing,
pedestrians struck in a severe way.
We're in the emergency department
at Mass Gen.
Just tell me a bit about
this place and what you do here.
So this is our 11-bay trauma area.
This is where all of
the traumas would come in.
Gunshot wounds, stabbings,
anybody who's haemorrhaging.
150 miles from Yale,
Boston's number-one trauma unit
has a constant stream of cases
where the patients
are literally bleeding to death.
Trauma bleeding is
always a huge problem.
It's probably the second thing
on our list of concerns,
and one of the things
that's sometimes obvious
from external injuries,
but not always, if there's some sort
of internal bleeding.
If your heart stops because
of trauma and blood loss,
surgeons have only minutes
to repair the injury and resuscitate
you before irreversible damage
or death occur.
Most of the time, this kind
of injury is unsurvivable.
But I'm going to meet someone with
a transforming vision of the future.
Hypothermia or cooling
offers organ protection,
and depending on how deep
the hypothermia is,
the longer and the more measurable
the protection is.
Dr Hasan Alam believes
hypothermia could save many patients
who would otherwise be declared dead
shortly after arrival.
If you drop the core body
temperature, the brain temperature,
down to 10 or 15 degrees Celsius,
then we're talking about 60 minutes,
maybe up to 90 or 120 minutes of
protection time.
To get this clear,
you're talking about
dropping these temperatures down
to ten degrees, core temperature?
That's pretty impressive.
Yes, that's a huge drop.
This is something that's never
happened in a trauma unit before,
and it presents some
very difficult practical issues.
How are you going to drop
them down to ten degrees?
That's another...
very practical issue.
Today if somebody comes in and
they've been stabbed and they arrest,
we end up opening the chest up
to do open cardiac massage.
By opening the chest, it also
provides you access to all the
big blood vessels
that are present in the chest.
Infusing cold saline rapidly
into the circulation using a pump,
directing it
towards the head, preferentially,
to cool the brain down rapidly.
We're talking about dropping
the temperature
by about two degrees centigrade
per minute.
So far, Hasan has only trialled
this technique in animals.
It's quite incredible.
I mean, you talk about challenge,
but you're saying that
these are people who would otherwise
die - 100% chance of dying.
By cooling them rapidly in this
fashion, we can convert
that almost-certain death
into almost-certain survival.
We're talking about 90%-plus
survival, with normal
cognitive function,
normal brain activity,
normal other organ function.
It's challenging, but it's doable.
You have to understand the scale
of Hasan's ambition. He's talking
about repairing the unrepairable.
This is something that, as a doctor,
is routinely fatal, and he's
talking about making it survivable.
To do that, he's talking about
getting people in,
opening their chests,
shoving them on bypass,
cooling them down within seconds
of them having bled out
and had a cardiac arrest.
It's an enormous intervention,
but if he can make it work,
it's going to save lives.
Before I move on, I want to find out
if Esmail's operation
has truly been a success.
I love you, honey. How are you?
I'm fine.
I love you, Daddy.
I love you.
How are you feeling?
How's it all going?
OK. I have pain.
It's not easy.
But I know it will be a good end,
and I know that my problem
has been solved.
I cannot worry about it.
You've been, you've had...
been through
a heavy bit of surgery there.
So how do you think he's doing?
I think he's doing good.
Half the tubes that were attached to
him yesterday came out and the chest
tube came out today. He looked good.
You look fantastic,
and I'm very pleased to see you
looking this well so soon after.
And I don't want
to hold you up any longer.
I'll let you get on with your
afternoon. Lovely to see you.
Well done. Thank you so much.
What people like Dr Elefteriades
and Dr Alam are doing with
hypothermia holds great promise.
Everywhere else I've encountered
profound hypothermia at temperatures
less than 32 degrees centigrade,
it's always, always been an enemy,
always been something that
threatens the life of your patient.
And yet...
here, you keep going,
getting down to less than half
what your normal core should be,
and it gives you this advantage that
lets you do these amazing things.
We understand very little,
I think, truly, fundamentally,
about what the process of this
profound hypothermia is doing to the
body, but particularly to the brain.
I think it's just another thing that
tells us that the brain is the last
dark continent of physiology
and biological science that is
truly unexplored, poorly understood.
What we do know is that life,
your life, is a property distributed
across the many trillions
of cells of your body.
Hypothermia works
because at some level,
it is able to protect those cells.
And so I want to know whether
a deeper understanding of the cell
can give us more control over the
events surrounding life and death.
You know, ultimately this isn't
a morbid story about death,
it's actually about life.
It's about what it means to
be alive, it's about living.
It's about the intricacy and
complexity that makes life possible,
and it's a story about doctors
and scientists who are searching for
something in amongst all of that
that they might get hold of,
that they might manipulate.
If we're going to understand that,
we'll have to examine the very
machinery that drives our cells.
The next part of this
scientific quest has brought me to
an unassuming building,
deep in the heart of Philadelphia.
There's a man here
who's spent his career
looking for
the Holy Grail of medicine,
something that controls death,
and therefore life, in our cells.
I'd like to hear a bit
about the story
of how you got started
along this route.
You know, having to pronounce
someone dead on a regular basis
is a terrible problem,
and I do that on a regular basis.
and that's a strong motivator
every day to get me to,
you know, think of one more thing
that can be done.
That's what led me to the basic
science of beginning to think about,
"Well, gee-whiz, if I'm trying to
bring someone back to life,
"what do I know about
bringing cells back to life?
"What do I know about how cells die?"
In his search for an
understanding how and why cells die,
Becker did a simple experiment,
in which he took healthy cells
and starved them of oxygen.
What we all expected is,
"You're going to
"deprive them of oxygen
and after a while,
they're going to begin to die."
So I did the experiment and,
by golly,
I sat there and looked through
the microscope...
and when they were
without oxygen for one hour,
there was almost zero cell death.
It was so minimal,
we could barely detect it.
And the minute we would reperfuse,
the cell death would just take off.
It was only when the damaged cells
were reperfused,
when the oxygen was reintroduced,
that they started to die.
What we figured out was that the
cells were not actually dying during
this period of time without oxygen.
Now, they weren't happy.
They weren't happy cells.
They were clearly being
altered by being without oxygen.
But they weren't dead.
And so it was clear that death was
being accelerated by reperfusion.
If you deprive cells of
oxygen for long enough,
they will eventually die.
But what Becker discovered
was that reintroducing oxygen was
also fraught with danger, because
this could trigger cell suicide.
He wanted to know why
this was happening
and what he could do about it.
I began to query, is there a
centre for death in the cell?
And that's when I realised a
number of very new breakthroughs
in the basic science world.
We're beginning to recognise
that the mitochondria,
sort of the power plant
within the cell,
was also the controller of death.
So what is this controller of death?
What are the mitochondria?
Invisible to the naked eye
and difficult to photograph,
they are nevertheless beautiful.
These tiny organelles that
are hidden within almost every
single cell of your body
are incredible pieces of evolution.
As a piece of biological
engineering, they're almost perfect.
We call them the powerhouses
of our cell. That kind of
understates what they do.
These inner membranes here thrown
into folds allow electrons to
flow across them.
They take the oxygen that
you breathe and they convert it
into the chemical energy
that powers everything that you do
and everything that you are.
Mitochondria are way more
complicated than we thought.
But the fundamental thing that turns
out to be so critical is that they
have the ability to kill the cell.
It's almost like a switch
inside the cellular machinery.
And that the cell has the ability
to go,
"Let's die."
It's almost as if the cell
is booby-trapped in such a way
that it will do one or the other.
It doesn't like to be
in between those two.
It's either, "I want to make energy,
I want to create energy for you",
or "I'm not good at creating energy
or I'm not good at something I'm
doing - it's time for me to die."
So far, Becker has been
using cooling as a method
to slow down cell death.
It seems to be stopping some
cells committing suicide,
but it's not effective enough.
Would you say that with our efforts
at cooling, in a very gross way,
we've learnt how to throttle down,
but that there may be a
way of manipulating those
switches in a more subtle way?
Absolutely. Who would make a
nuclear reactor without control rods,
right, without the ability to
sort of get it hotter, cool it down?
We have that same sort of ability,
if you will, at the subcellular
level in our mitochondria.
We want the cell to take a
serious chill pill.
And whether it's done with
hypothermia or with some sort
of mitochondrial medicine...
I don't think it'll matter.
But we want that cell to take
that chill pill and to cool out
and to not do the work that it was
doing previously for a period of time
while it sort of reorganises itself.
I do believe that's possible, and I
do believe we're moving towards that.
So Becker's started to understand
the process of death as a property
of the cells, with the mitochondria
as a target we might aim for
in our efforts to cheat death.
If he really can find a drug to
manipulate the mitochondria,
the consequences are enormous.
His research is a long
way off finding a solution.
But it's people like him
who persevere in scientific research
who change the course
of medical history.
Becker's about making a difference.
Becker is about
taking on those big problems
and not letting someone
tell him they can't be addressed.
He's about, you know... I was really
taken with something he said today,
where he said "Look,
I looked at what we do
"and I looked at what might be done,
"and I realised that in the
difference were people's lives".
And that's a very dramatic,
but you know, very positive
and inspiring way
to think about your path,
his path in scientific research.
But you'd be wrong to think
that all the cutting-edge science
happens in America.
Some of the most exciting
work taking place right now
in this area of science,
where researchers are looking at how
to protect and prevent cell suicide,
is happening here in Britain.
We discovered hypothermia by
accident, literally in accidents.
And we started using it
before we really understood
how it was working.
In fact, I remain to be convinced
that we fundamentally understand
the mechanism by which
cooling people down gets you
an advantage even today.
But that, I guess, is
sometimes how medicine progresses.
It pushes at the boundaries
with incomplete knowledge
using something,
knowing only that it works,
and leaving the whys
and the wherefores and the how
the thing works till later.
Now, hypothermia has some very real,
very lethal hazards,
and those remain to be negotiated.
Researchers are looking for anything
that can augment that therapy,
make it better or reduce the risk.
Here at St Michael's,
researchers have discovered
a new weapon to add to the arsenal
in the fight for survival.
It's happening in the neo-natal
intensive care unit at a time
when life has only just begun.
It's pioneering and risky work.
It's quite stressful
to, you know, to do something
to somebody's very sick baby.
This is not in the lab,
this is somebody's baby,
the most precious thing in the
world, and it just can't go wrong.
Here in the neo-natal unit,
the stakes couldn't be higher.
Hypoxic brain injury caused by
oxygen starvation at birth is a
real threat to newborn children.
For the last 14 years,
Professor Marianne Thoresen has been
using cooling, and it's worked well.
But there's a group of children who
it doesn't help, and it fired up her
interest to add something to cooling
which could help prevent cell death.
It's not good enough, is it?
We have improved it from 70%
to 50%, but I really want to
do something with those 50% that
has not been helped by cooling only.
Her research led her to xenon,
a simple elemental gas plucked
from the very air that we breathe.
Xenon is a remarkable atom.
It is a rare noble gas
present in only trace amounts in all
of the atmosphere that we breathe.
For every ten million parts, perhaps
only one or two is an atom of xenon.
Now, for something so rare and
unreactive, you might think that
it would be utterly useless.
But in fact, it has some
extraordinary and very valuable
biological properties.
In medicine, we've come to think of
it as the ideal anaesthetic agent.
And when you give it,
it's very rapid in onset.
It has very few side-effects,
and when you stop giving it, it
leaves the body extremely quickly.
But it's its property
as a neuro-protective agent,
as something that might protect the
brain when breathed as a gas, that
makes it of interest and great value
to researchers working in the
field of hypoxic brain injury.
And here it is.
This precious gas, xenon.
I'm fascinated that something
which is inert actually
can have a biological effect.
And I think it's very...
interesting also that the effect
is much stronger when you're cold.
I'm hoping Marianne can explain
how this combination of xenon and
cooling might actually save lives.
It's a very exotic drug.
We're not sure how it works.
It seems to protect cells
against cell suicide, doesn't it?
Yeah, it reduces the degree of
apoptosis very significantly,
so this is a delayed cell death.
The real test came in March this
year, when Marianne was given
permission to try xenon
on her first human baby.
You hope that it will all go well,
but you can't be absolutely sure
and you can't say that
to the parents either,
that we are absolutely sure
there won't be a problem.
Riley Joyce was born by emergency
caesarean section on March 28th
this year, after what had
been a perfectly normal
healthy pregnancy for Sarah.
It wasn't until they took him away
as soon as he was born and, you know,
they didn't bring him over for me to
see him and you didn't hear him cry.
It was then that I started to think
"Actually, something's really wrong".
Riley was born unable to breathe
and without a heartbeat.
No-one knew how long his
brain had been starved of oxygen,
but he was critically unwell
and the processes of cell damage
and cell suicide
were at risk of progressing.
It must have been a pretty
anxiety-producing time?
It was so frightening.
I think, although I realised, you
know, it was serious, until they came
and said "We need to take him to
Bristol for special treatment",
that's when it really hit home for
me that actually, we could lose him.
Baby Riley was Marianne's
first opportunity to see
if xenon would work.
So you've arrived at Bristol,
and Marianne Thoresen is explaining
this new treatment to you.
Just tell me about
what that was like?
I felt very...not sure about
going for it, really, to be honest.
You know, Riley's our little baby
and it was like "Do I want him to be
this experiment?"
My initial reaction was "No way".
You know, my little boy was so sick.
I'd only seen him
for about 30 seconds.
Riley's brain was at risk of
damage from the oxygen deprivation.
He was already benefiting from the
cooling, but there was still a real
chance of brain damage or death.
Sarah and Dave now had to decide
whether to let him be the first baby
to receive xenon.
It was just so frightening seeing him
completely wired up, you know,
to so many machines
and looking so fragile.
The xenon was given
without incident.
But it was another ten days
before they would find out
what its effects had been.
When he was ten days old, we did
an MRI scan, a picture of his brain
which showed that the brain was
normal on the scan, which is a very
good sign of a normal outcome.
You can never
predict 100% what the baby will
be like long term, but I think
I'm quite confident he will do well.
Five days after he was born,
Sarah held him properly
for the first time.
Actually to hear him cry
as well was just amazing.
Most parents go,
"Oh, no, a crying baby," but it
was actually an amazing sound.
We waited so long, didn't we,
to hear him cry, so yeah.
You get really touched.
You get tears in your eyes,
actually, because you think "Oh, I
can look into your eyes now, baby,"
and you remember how sick he was.
And that it all went well,
it is such a pleasure.
Riley left hospital two weeks later,
and as you can see, he's thriving.
Stretch, stretch!
"Oh, dear.
Who's this stranger person?"
Tell me about Riley
and what's he like now.
He's generally a happy little boy,
isn't he? He's just starting
to find his giggle.
Certainly deciding to go for his
daily exercise.
He smiles at lots of different
people out and about, don't he?
He's a happy little chappy, really.
He's four months old now,
and although it's early days,
the paediatricians think
he's indistinguishable from
any other healthy baby.
So you've still got quite a
long way to go with all of this?
Oh, yes. This is, from a clinical
point of view, absolutely the
beginning, and he will...although
he's the first baby,
we're planning to do another
12 babies in this feasibility study.
It's only when you randomise, you
have a huge number of babies, maybe
200 or something, and you see how
they are doing, those who have
got xenon and those who haven't,
that's when you can say whether
it really works in babies as well as
experimentally, and that will take
another six years.
You don't often see researchers
who are taking their work from
the lab and translating it into real
patients in the clinical setting.
You almost never see
the direct results of that.
So it was lovely to see Riley,
lovely to see the fruits
of Marianne and
Marianne's team's labours.
And he has certainly
benefited from cooling.
He may have benefited from xenon,
it's a bit too early to say.
But you have to admit,
it looks pretty good,
and that is what it's all about.
I'm back at my job at UCLH.
This has been a fantastic
opportunity for me to get out there
to see what's going on.
The world of resuscitation and
critical care is so full of
appalling outcomes that sometimes
it's difficult to
see a way forwards.
And yet we've met people
who are doing exactly that,
who are pushing the boundaries,
who are making progress.
I've met people who are living proof
that death can sometimes be cheated.
That's the main thing -
don't declare people dead
before they are really dead.
The man who I saw so very nearly
dead on the operating table at Yale
is now back with his family
alive and well, and clearly
with a new lease of life.
Those technology help me
to be a part of my family.
To still be alive,
that's a reality.
What's really struck me is that the
line between life and death becomes
more blurred with every year,
opening up real possibilities
that could affect us all.
We're in a different era
where survival is expected
even in the most high-risk cases, so
it is indeed a very different world.
We find ourselves in this very
uncomfortable time period where,
while we used to know when a patient
was dead or alive, there are
patients that are simply in between.
Every Friday,
our anaesthetic department at UCLH
gathers to share information and
news of new discoveries in an effort
to put theory into practice.
I wanted to talk about this concept
of cooling in resuscitation,
something familiar to us,
but so often overlooked.
I'd like to start
with a case history.
This is a story of a doctor
who was out with two other
registrars in Norway, skiing.
And she goes down a ravine and goes
through the ice into a hole here,
and this is 6.20 in the evening.
This is her rescue team. They arrive
at 19.56, so that's fully about an
hour and a half downstream
from the event where she goes
through the ice.
They need to fly to Tromso. Now,
Tromso is 250 nautical miles away.
And...I would have stopped.
Hands up, anyone who
wouldn't have stopped?
That looks like a dead person,
biochemically.
But that's her,
a year after the event.
Even though resuscitation and
critical illness present formidable
challenges, for the right people
in the right circumstances,
we can still make important
differences to real people.
We moved on from her
to the deep hypothermic arrests.
We went to Yale and we saw this guy,
who's Dr John Elefteriades.
The case he had us go
and film him doing was this guy.
You know, we're taught that all our
memories and all our neurocognitive
stuff is all about little circuits
that continue to fire.
And yet in this guy's case, you've
pressed the hard reset button,
and all of that stopped.
And yet that's him
about a week after surgery.
'What I've witnessed is science and
medical practice coming together,
'giving us the hope that we can
continue in our efforts to blur
the line between life and death.'
A sick baby, you can see that. You
don't need to be a neonatologist.
Sick, sick, sick baby.
And the trick here, apparently,
is to try with cooling and the
adjunct of xenon to switch that off.
And that's what it appears to do.
It's not clear that
the xenon did this.
But it could.
It will change the survival rate
by a good fraction, 50-60%.
That's kind of it.
We should be doing more of this
because... these people,
who are all doing well,
are all evidence that you can have
extreme physiological insults
and get through it.
And all of them,
I've met all of them.
We don't get to meet them
afterwards very often.
And that, I guess,
is how medicine works.
You know, it's accidental.
Sometimes, it looks
like a complete mess.
But it moves forwards,
and it makes yesterday's impossible
tomorrow's survival.