American Scientist

SHOCKED: Adventures in Bringing Back the Recently Dead. David Casarett. x + 262 pp. Current, 2014. $27.95.

Whether they’re prime-time dramas like House or Grey’s Anatomy, comedies like Scrubs or MASH, or afternoon soaps like General Hospital, medical shows hinge on a particular drama riveting to viewers: the heroic resuscitation of patients. The typical revival occurs in a busy emergency room, and the patient’s passage from death back to life is characteristically swift and decisive.

Author David Casarett, a practicing hospice physician, explains in his book Shocked: Adventures in Bringing Back the Recently Dead that his own early notions of medicine were shaped by such scenes. As a youth, having watched his share of medical drama cliffhangers, he believed physicians could usually revive patients in the span of a single commercial break, a conviction he dubs the “Big Mac rule of resuscitation”: “A perceptive watcher of these shows would conclude that the fate of a newly dead person is determined in the span of time that it takes to learn about the merits of cookies made by Keebler Elves or a sing-along of the McDonald’s Big Mac jingle. . . . By then, your victim is probably wide-awake and hugging the rescuers.”

With this early impression as his starting point, Casarett embarks on a journey to examine the boundaries of resuscitation in real life. His encounters along the way range from the clinical to the bizarre, and in the process he examines the historical, scientific, pseudoscientific, medical, and social aspects of reviving the dead or nearly dead—a transition zone that, contrary to popular belief, remains ill defined. Combining the insights of a physician with an accessible writing style, Shocked raises important social and ethical issues, particularly around resuscitating very old, profoundly ill patients in view of the high costs and the potential for patient harm.

Casarett’s personal evolution guides the book’s narrative. Initially he had planned to be an emergency room physician. As a student he was captivated by the story of a revived toddler whose heart had stopped after she had lain submerged for over an hour in a stream brimming with snowmelt. Over the years, however, following training in medical anthropology and ethics, he changed his focus to palliative care. Casarett covers territory familiar to him throughout the book, and he proves an apt, reassuring guide; he presents his findings as a kind of travelogue, narrating with wit and aplomb visits to historical sites and cutting-edge medical labs. In the process he also weaves in interviews with patients, witnesses, and practitioners from the spectrum of biomedical sciences.

The journey begins in Amsterdam, the city of canals, where drowning was once common—hence the city’s emergence as the earliest recorded venue for resuscitation research (dating back to 1767) with the formation of the curiously named Society in Favor of Drowned Persons, a group of volunteers who gathered information from rescues, aiming to develop better resuscitation treatments. Various methods emerged for reviving the near-dead. Among the techniques purported to have saved lives were rubbing the body with liniments and brandy, blowing tobacco smoke into the rectum, and tickling the back of the throat with a feather. In London, under the aegis of what later became the Royal Humane Society, similar methods were being developed contemporaneously to save drowning victims in the Hyde Park Serpentine, an elongated lake with an adjacent receiving house (essentially an emergency room that doubled as a research laboratory). The receiving house served as the proving ground for many novel methods of resuscitation. Some of the techniques developed there, although largely useless by modern standards, were precursors of ones used today, such as warming some victims who suffered severe hypothermia and chilling others for complicated surgeries.

From these 18th-century origin stories, Shocked moves on to notable recent successes, taking stock of research milestones along the way. Casarett discusses the much publicized resuscitation in 1999 of Anna Bagenholm, a young Swedish medical student who took a spill while skiing, plunging head-first into a frozen streambed. For hours she remained submerged in the cold water under the ice, suspended upside down by her skis. The story of her remarkable rescue and recovery after being “dead” for over 5 hours sets the next signpost for the author’s journey. He turns to the history of cardiac resuscitation, specifically the use of electricity for defibrillation, a tale that begins in 1774 and leads to the breakthrough discovery in 1947 that made the technique common. Yet “it’s one thing to restart a heart,” Casarett explains. “Protecting a brain and other organs until the heart starts beating again is a whole different problem.” Because of the loss of blood flow to the brain, the benefits of cardiac resuscitation are typically time limited; he attributes Bagenholm’s survival, as well as that of the toddler who inspired his career, to the brain being chilled. The hypothermia thus induced greatly slowed the damage compared to what happens at a normal body temperature.

Inspired by these case studies, medical researchers are actively exploring thermal manipulation to protect and preserve brain health in the cardiac clinic. Casarett examines in detail how techniques for sharply reducing the body temperature—by chilling the body, stopping the shivering response pharmacologically, or diluting and cooling the blood using a heart-lung machine—have permitted extraordinary surgeries, such as the repair of an aortal aneurysm that required stopping the heart for a longer period than normally permissible. From there he launches into a fascinating discussion of the biochemistry of hibernation (where the metabolic rate drops precipitously) among amphibians and mammals, especially for nonhuman primates like lemurs. Researchers in this field are currently attempting to locate key hibernation response–inducing biomolecules, such as D-alanine-D-leucine-enkephalin, ghrelin, or adenosine monophosphate (AMP). These molecules could potentially induce a condition in humans somewhat akin to states of suspended animation portrayed in science fiction movies to accommodate space travel. In fact, in anticipation of manned missions to Mars, NASA is currently funding research on the effects of inducing a state of deep sleep, called torpor, by chilling the body to 5 degrees Fahrenheit below normal and chemically suppressing the shiver response.

What NASA is contemplating for its astronauts pales in comparison to the extreme measures already being embraced by “cryonauts,” a group whose members want to have their bodies frozen at death. They hope that future doctors will revive and repair them once the cure for their cause of death has been discovered—hundreds, perhaps thousands of years from now. Casarett’s account of the Alcor Life Extension Foundation’s 40th anniversary conference, a gathering of the cryonauts, is at once intriguing, miserable, comical, and bizarre. It provides examples that powerfully testify to humanity’s craving for immortality against all costs and odds and its hubris in the face of death. Attempts at cryonic preservation began in the late 1960s. More recently, a biotech company, Suspended Animation, has partnered with Alcor to freeze the bodies of a few hopeful humans. Interestingly, some have chosen to freeze only their heads, anticipating that by the time the cryonauts can be revived, heads will be readily transplantable to donor bodies.

Resuscitation research emerged in Amsterdam, the city of canals, where drowning was once common.

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The bodies of some amphibians have adapted to survive cycles of freezing and thawing, as Casarett explains, which may account for some of the optimism. Unfortunately, there is not a single case of a human head or whole body being frozen and then revived functionally. The cryonauts’ futuristic fantasy is further complicated by logistical and bureaucratic obstacles: recovering the body after death in a timely manner, obtaining necessary medical clearances for preparing the body and freezing it, and ensuring the legal and technological safekeeping of the body far into the future. Despite the difficulties and long odds of success, there are enthusiastic takers willing to pay huge sums.

While companies like Alcor garner outsize media attention, Casarett notes that most people fail to appreciate how thoroughly the real forms of resuscitation technology have infiltrated Western society, even far outside of the hospital setting. Consider the proliferation of CPR classes; the Red Cross offers a wealth of courses, many so carefully tailored that babysitters and construction workers may find classes designed to suit their needs. Consider the number of airports, airplanes, shopping malls, and other public spaces where automatic external defibrillators are readily available, their robotic voices programmed to guide bystanders as they attempt to revive the stricken. In some cases the technology can now do the work entirely on its own, as with implantable cardiac defibrillators that protect patients from sudden cardiac arrhythmia and death, constantly monitoring the heart rhythm and delivering shocks as needed.

In the last stop of the book’s fascinating journey, the author tags along with paramedics to get a firsthand look at resuscitation technology as it is used to provide emergency treatment for aged, often feeble patients. Here the discussion turns reflective, raising questions about the value of resuscitation technologies for very aged patients with multiple chronic ailments—particularly in the face of an expensive, overburdened health care system and the incessant suffering patients may endure following extensive revival efforts.

Even if a patient has no wish for resuscitation, a crisis event typically results in a 911 call followed by the rapid appearance of paramedics whose training and medical ethics prepare them to save lives at all costs. Often unaware of patients’ wishes or written directives to the contrary—or disregarding them and acceding to pleas of the close family—emergency responders resuscitate and transport aged, profoundly ill patients, many of whom end up in the hospital ICU. Frequently they die there, away from home and hooked up to medical paraphernalia. Casarett does not provide any easy answers. Instead, he leaves the reader to reflect on the thorny socio-ethical issues surrounding the end of life.

Shocked is sobering and information laden, but Casarett eases the reader through with abundant good humor and an affable style. Enjoyable for the scientist and nonscientist alike, this tour of life and death should not be missed.

Ram Ramabhadran, PhD, is a pharmaceutical/biotechnology consultant working with biotech companies and nonprofit organizations in the global health sector. He holds an adjunct faculty position in the curriculum in toxicology at the University of North Carolina, Chapel Hill, and resides in Cary, North Carolina.