Mostly dead is slightly alive

When bringing people to the edge of death is your day job. Guest: Adam Richman, perfusionist at the Mayo Clinic⁠ and Unexplainable listener. For show transcripts, go to ⁠⁠⁠⁠⁠⁠⁠⁠vox.com/unxtranscripts⁠⁠⁠⁠⁠⁠⁠⁠ For more, go to ⁠⁠⁠⁠⁠⁠⁠⁠vox.com/unexplainable⁠⁠⁠⁠⁠⁠⁠⁠ And please email us! ⁠⁠[email protected]⁠⁠ We read every email. Support Unexplainable (and get ad-free episodes) by becoming a Vox Member today: ⁠⁠⁠⁠⁠⁠⁠⁠vox.com/members⁠⁠⁠ Help us plan for the future of Unexplainable by filling out a brief survey: ⁠⁠⁠⁠⁠voxmedia.com/survey⁠⁠⁠⁠⁠. Thank you! Learn more about your ad choices. Visit podcastchoices.com/adchoices

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:01Speaker 00

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• 1:18Speaker 02

  Are there different ways that humans might be dead?

• 1:22Speaker 00

  I've been thinking about this question, right? Are there different ways to be dead? For years at this point. Basically, ever since Bob Trug, this bioethicist, asked it. I spoke to him for an episode that we did a while back called "Redefining Death," and he told me, essentially, that death used to be relatively simple.

• 1:46Speaker 02

  Up until about the 1950s, there was no confusion about what death meant.

• 1:51Speaker 00

  You just kind of knew it when you saw it.

• 1:54Speaker 02

  Your heart had stopped.

• 1:55Speaker 00

  You had no breathing, stiff body.

• 1:57Speaker 02

  And you were, you know, blue or gray.

• 2:00Speaker 00

  You were probably dead. But then, in the 20th century, as we started inventing new technology, the line started to blur more.

• 2:12Speaker 00

  You had things like ventilators, which kept patients alive even if their brains were too injured to tell their lungs to breathe.

• 2:19Speaker 02

  But when the ventilator was was used and you could breathe for them, they went on and lived and lived and lived.

• 2:25Speaker 00

  Their hearts were still pumping blood through their bodies, but their brains weren't working right. Eventually, the medical community had to define a new kind of death, not just the "your heart has stopped and you're cold and stiff" version, but something else.

• 2:41Speaker 02

  What we call brain death.

• 2:44Speaker 00

  Irreversible brain damage, where a brain and a brainstem stop functioning and stop sending signals.

• 2:50Speaker 02

  The person will never regain consciousness and will never breathe on their own again.

• 2:56Speaker 00

  That might seem straightforward, but as we showed in the episode we made a while back, there's a lot of nuance to it.

• 3:03Speaker 03

  Yeah, that's why I reached out. You know, this is just one big gray area.

• 3:10Speaker 00

  Adam Richman is one of my favorite kinds of people, the people who listen to Unexplainable and then write in about episodes. He heard this episode about redefining death, and he emailed us to share his very specific perspective on both medical technology and the definition of death.

• 3:28Speaker 03

  Death is unfortunately part of cardiac surgery.

• 3:32Speaker 00

  Adam is a perfusionist at the Mayo Clinic in Minnesota.

• 3:36Speaker 03

  So as a perfusionist, we run the heart-lung machine during cardiac surgery.

• 3:42Speaker 00

  This heart-lung machine lets doctors operate on parts of the heart by basically stopping the heart and rerouting the blood through a machine. It oxygenates the blood and it pumps it back through the body.

• 3:56Speaker 00

  But it also made him think long and hard about what it means to be dead. This is Unexplainable. I'm Byrd Pinkerton. And on today's show, hundreds of you, unexplainable listeners, you have written in over the years. So for this episode, we are handing over the mic to one of you, Adam Richman. And he will bring us to the edge of death and then back again.

• 4:40Speaker 00

  You're gonna be part of, uh, see, really see how the sausage is made.

• 4:45Speaker 03

  Yeah.

• 4:45Speaker 00

  Cause we, um, we're up to antics over here.

• 4:50Speaker 00

  Yeah. So you reached out to the show back in like 2022 because we, we made this episode, right? Called redefining death. And I'm curious, kind of given your day to day, what was it about that episode that kind of like struck a chord with you?

• 5:08Speaker 03

  So it reminded me of a lot of the surgeries and procedures that we do with the aorta specifically.

• 5:17Speaker 00

  That's like the big artery in the heart, right?

• 5:19Speaker 03

  Yep. That's the big artery coming straight out of the heart to carry all the oxygenated blood to the rest of the body. And if there is disease of the aorta, then that kind of presents a challenge because, you know, there's blood flowing up there, but that's also the area where they need to fix. So in order to do that, we use a technique called deep hypothermic circulatory arrest.

• 5:45Speaker 00

  Okay. Deep?

• 5:46Speaker 03

  Yeah.

• 5:47Speaker 00

  Hypo?

• 5:48Speaker 03

  Thermic.

• 5:49Speaker 00

  Deep hypothermic?

• 5:51Speaker 03

  Circulatory arrest.

• 5:52Speaker 00

  Circulatory arrest. So like very cold hypothermia is like being cold, very, very cold blood stop.

• 6:00Speaker 03

  Exactly. That's exactly what it is.

• 6:02Speaker 00

  Okay.

• 6:03Speaker 03

  You, you know, for instance, hear about a child that's fallen through the ice in the winter and their heart stops and everything. And, you know, they're brought to the hospital and warmed up again. They're essentially reanimated. So it's very similar to that.

• 6:20Speaker 03

  So as we change the temperature of the blood, that changes the temperature of the patient as a whole.

• 6:28Speaker 00

  So you're using the machine basically to like pump frigid blood, not freezing, obviously, but like pump frigid blood through their body to, to cool them all the way down?

• 6:40Speaker 03

  Yep. That's exactly it.

• 6:42Speaker 00

  Okay. And what does that do?

• 6:44Speaker 03

  So we know about a process called the Q10 effect. Essentially what that is, is that as our body temperature decreases.

• 6:53Speaker 03

  Our metabolism also decreases.

• 6:55Speaker 00

  Okay, so you're just literally slowing down.

• 6:58Speaker 03

  Exactly. You're slowing down every single metabolic process in the body.

• 7:03Speaker 00

  Oh, that's great. So, so how cold do they get? Like, like, how much slower is their body going?

• 7:13Speaker 03

  So, and this is why I reached out to you guys because we'll actually monitor their EEG, their brain activity, the electrical activity in the brain. And it will actually flatline and stop.

• 7:31Speaker 00

  Oh, my God. So are you temporarily killing them? Or are they like temporarily dead?

• 7:42Speaker 03

  I can't say yes for sure. Their body's still functioning. It's just extremely slow, but yeah, there's no brain activity. There's no cardiac activity. So the only reason that they're actually still alive is because we're actively pumping blood.

• 8:03Speaker 00

  After the break, how to bring someone back to life after you have turned their brain off.

• 8:13Noam Hassenfeld?

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• 11:50Speaker 06

  Are you brain dead? I'm not going in there with two Jedi.

• 11:55Speaker 00

  How long can a person stay in this sort of like interstitial zone? This gray, this little gray area, I guess.

• 12:04Speaker 03

  So ideally, under an hour.

• 12:08Speaker 00

  Okay.

• 12:08Speaker 03

  But, you know, depending on the surgery, sometimes we do have to go over an hour. And that's more of the extreme case. Like typically it's 20 minutes or so.

• 12:20Speaker 00

  Do we know what effect it has on the brain to just be flatlining for an hour?

• 12:26Speaker 03

  So not well, not understood well.

• 12:31Speaker 00

  Incredible. What are you thinking at this point in the surgery? Like, what's going through your mind?

• 12:36Speaker 03

  Just, it's still so surreal.

• 12:41Speaker 00

  Mm hmm.

• 12:42Speaker 03

  But, you know, that's a person and I want to do what I can to ensure that they're being taken care of as best as I can.

• 12:51Speaker 00

  I'm sorry, this is so, it feels like something out of science fiction. That kind of melding of, of person and machine and you're, you're turning people off and turning them on again, like, how has this job, how has it kind of changed the way, I guess, that you, that you think about life and death?

• 13:16Speaker 03

  Yeah, it's

• 13:19Speaker 03

  it's definitely raised more questions than answers, you know? You know, you think about

• 13:25Speaker 03

  no brain activity, no heart activity. It's like, well, yeah, our patient is dead, but they still have blood flowing. So are they actually dead?

• 13:39Speaker 03

  But yeah, if we were to stop the machine, then they would for sure die.

• 13:45Speaker 00

  Right.

• 13:46Speaker 03

  Because that's their only means of of support. It's pretty mind boggling to think about still.

• 13:52Speaker 00

  Right. I'm trying to think about like this in between state that our definition is blurry enough to allow for sort of 20 minutes of undefined.

• 14:05Speaker 03

  Yeah.

• 14:05Speaker 00

  Feels. I don't know. I just, I think when I was reporting out the episode, I kept on being like, but surely we should just surely we should know whether someone's I'm like, that feels like the most basic question is like, are we alive? Is this person alive or are they dead?

• 14:20Speaker 03

  Right. And like the doctor that you talked with in that redefining death episode. You know, you think of cardiopulmonary death, so you're not breathing and your heart's not beating. Or you think of brain death. You know, where the brain's unresponsive. And in these circulatory arrest cases, we have both of those.

• 14:42Speaker 00

  Right.

• 14:42Speaker 03

  But the patient isn't actually dead. Somehow.

• 14:47Speaker 00

  How do you like? How do you reverse the process? I guess, is it just like turning the temperature knob back up to to bring the patients back to life?

• 14:58Speaker 03

  That's exactly it. But we have to do it very gradually. Because when you're at such a deep hypothermic level, if you warm the blood up too fast, what can happen is you can create microscopic bubbles.

• 15:12Speaker 00

  What, like the bends?

• 15:13Speaker 03

  Yep.

• 15:14Speaker 00

  But from temperature?

• 15:15Speaker 03

  Yep, just literally microscopic bubbles coming out of the water part of your blood.

• 15:21Speaker 00

  So you're doing it very slowly. How long does it take to kind of warm people up again?

• 15:26Speaker 03

  It depends on the size of the patient, but on average. Probably hour and a half or so.

• 15:34Speaker 00

  Oh, okay.

• 15:35Speaker 03

  As we warm closer and closer to normal body temperature, we're starting to get bursts of activity back from the brain.

• 15:43Speaker 00

  So, so basically, the brain sort of like spits and spurts back into life, like an engine or something?

• 15:49Speaker 03

  Yep. Yep. They'll get just little bursts every so often. And then, yeah, eventually return to normal.

• 15:58Speaker 00

  Honestly, any open heart surgery is kind of a miracle, right? People like Adam and the surgeons he works with, they sort of have to get used to holding our lives in their hands.

• 16:08Speaker 03

  Yeah, it's still surreal, just because this type of surgery especially is just one big nebulous area. But I've been doing this over 12 years now, and it's still just, you know, amazes me every day, what we're able to do.

• 16:27Speaker 00

  In some ways, it's kind of like death itself. It's both unbelievably complicated, mysterious, and hard to pin down. And also, it happens a lot to everyone in ways that are both miraculous and routine.

• 16:45Speaker 03

  You know, 50 years ago, when heart surgery was still in its infancy, you know, these were things that were just dreamt of. And now it's just like, oh, we got a cirrhorest case today. It's the slang term, I guess, for it, just cirrhorest. Like, oh, we got a cirrhorest case today, you know, no big deal. It's just gonna be a longer day, that's all. But, I mean, I do remember learning about it. And I was just like, wait, we do what now?

• 17:23Speaker 00

  This conversation was a bit of an experiment. Because one of my favorite parts of my day is checking our inbox to read all of your emails. People will tell us everything they think we got right in an episode or wrong. In the case of the posture episode that I did, people send in questions that I'd never considered before. They will ask us to look into the geopolitics of 17th century metallurgy, for example, or a listener wrote to us from a research vessel in Antarctica to tell us how their eye movements are being used to train a lander for a future mission to Europa. Another listener sent us proof of the comedy work that they did with Buzz

• 18:07Speaker 00

  Aldrin, and someone else sent pictures of whale sharks, whose exposure to Cold War nuclear testing helped scientists figure out how old they are. All to say, we are here for that kind of email. Like, we love your messages, and there have been a lot that we wish that we could share with you, our audience. This episode, where we called Adam back and talked to him about his job, this is how we've started, but we'd like to do more episodes like this, to feature more listeners like Adam and maybe like you. The best way for that to happen is for you to send us either an email or a voice memo.

• 18:52Speaker 00

  We love to read your messages. We especially love to hear your messages. Just tell us your own weird, wonderful take on any of our episodes, how you are connected to the question we asked, or the answers we didn't find, what you know that we have not yet figured out. Tell us new things to check out. Ask us new questions that we ought to explore. Basically, just let us know what you're thinking. We are at [email protected]. And please, just reach out. In the meantime, if you want to hear more about how complicated our medical ideas of death are and how scientists are even trying to someday reverse it, check out

• 19:37Speaker 00

  our episode, Redefining Death. This episode was produced by Meredith Hoddinott, who also runs the show, and by me, Bird Pinkerton, who does not run the show. We had editing from Julia Longoria, with help from Jorge Just. Sound design and mixing from Christian Ayala. Music from Noam Hassanfeld. Production support from Thomas Lu. And fact checking from the wonderful Melissa Hirsch. Thanks always, always, always to Brian Resnick for co-creating the show. And if you don't want to email us, but you do have thoughts, you can leave us a review or a rating wherever you listen. It really helps us to find new listeners, and it's really nice to read your thoughts on various episodes. You can also

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