Why The Medical Adage ‘You’re Not Dead Until You’re Warm And Dead’ Might Need A Rethink

I was at a BBQ a couple of weeks ago. Tina has the best BBQ parties on the island. The kids splash around in pools and run wild around her massive garden. The food is great and the company excellent.

At this particular BBQ I met her brother Kevin. Tall, bearded and with a quick wit and down to earth good sense he was very interesting to talk to. We got on to what we have done, and what we do now and somehow ended up talking about life support, CPR, that kind of stuff.

For decades medics have passed on the “You’re not dead until you’re warm and dead” in the hope of preventing patients waking up in mortuaries or even worse at autopsy or even their own funeral, all of which has been recorded.

These mishaps happen because when a body is exceptionally cold it can appear lifeless as respiration and brain activity is so slow that life is apparently extinct. Many times warming these patients has resulted in a return to consciousness and a complete recovery.

I told Kevin about a patient I had some years ago, who was warm and was definitely dead, his only cardiac output coming from me jumping up and down on his chest and his lungs only inflating due to the anaesthetist ‘bagging’ him via an endotrachael tube.

It was a huge shock when more than a decade later I met him again, and he recounted in detail the conversations going on around him whilst he was dead.

“You HAVE to write this up” Kevin said at least a dozen times. So Hear it is.

Some 20 years ago I was on call for a major accident and emergency department when the call came that a helicopter was bringing in a critically injured motorcyclist. I’ll call him Tom.

Tom was a 54 year old slightly overweight male in good general health prior to the accident. He was a life long biker who was also an instructor teaching those new to motor cycles how to ride safely. He was on his way home on a dark mid-winter night, it was pouring with rain, a car was travelling behind him, and all seemed well. He was familiar with the route and was according to the car driver behind him riding carefully with no excessive speed.

The car driver recalled a man walking along the side of the road waving his arms, neither Tom nor the car driver stopped thinking he was a hitch hiker.

He wasn’t. He was a truck driver, He had pulled out of a side road just past a blind bend, he had jackknifed the rig, and it was skewed across both sides of the road. He was trying to alert people. He’d walked to the other side of the bend to put up a warning triangle, but it had been too late for Tom.

He rounded the bend, saw the truck, knew he was going to hit it so threw the bike onto its side and aquaplaned along the road. It almost worked. Most of him went under the truck, through the gap between its massive wheel axles.

His helmet was smashed as he bounced under the truck, one leg severed below the knee as it hit the huge wheels.

Toms blood loss was massive, and he had only been in the air ambulance a few minutes when he went into cardiac arrest, the first of many such episodes over the next eight hours.

By the time I received him from the air ambulance crew he was only alive due to CPR the helicopter tech was giving him. He was a mess. They had brought in his severed leg but just looking at it said it was unlikely that there wound be an attempt to re-attach it. His face was a mashed mess, the visor had broken and shredded his face. He had other injuries, a skull fracture, broken pelvis, broken arm, punctured lung, and of course numerous cuts and lacerations.

Within minutes we had a chest drain in and continued our attempts to get him back. After an hour the resuscitation attempt was called off but someone objected. Here,we have the rule that if a qualified member of the team objects to stopping and has a valid reason why we should continue we will. The argument was that when we stopped CPR he maintained his own cardiac output for three minutes.

During the next hour he maintained his own output again, for a minute or so, then for several minutes and then for almost ten minutes before ‘going off’ again. It was decided to take him to the operating theatre. That saw me sitting astride him…I am small, he was big, sweating like a stuck pig doing CPR as we were wheeled towards the theatres. It’s a design fault here that the operating theatres are so far from accident and emergency.

My counting of compressions and how many rounds of compressions had been done had been taken over by a student nurse so I was talking to Tom.

“You will not die on my watch”

“Listen to me Tom, I will not ALLOW you to die on me. Do you hear me? ”

“You owe me a pint Tom, I haven’t worked this hard in years.”

We handed him  over to the theatre and left. Somehow he made it through surgery, survived a month in intensive care, another month on a general ward and went home to his wife.

FAST FORWARD 12 YEARS

Another hospital 100 miles away from where I first met Tom. A student is checking in an elderly gentleman for a routine procedure.

“Is that you’re signature?” She asked him.

“I have no idea, I’m blind” The man answered. I was furious. It was written on the board that the patient was blind. I tapped her on the shoulder, gave her ‘the glare’ and took the paperwork from her.

“I’m sorry to interrupt Mr smith but Student Nurse Jones has to go and deal with something for me. My name is Lizzie Bennett, and I’m going to be going through the check list, I’ll be taking you into theatre and then I’ll be staying with you afterwards until you’re ready to go back to the ward.”

I ran through the questions and a few more besides when he asked if he could touch my face. There was a slight delay in patient turnaround so after exploring my face we chatted. Mr Smith kept sniffing, moving his head and sniffing. He was smiling. He asked me if I remembered him. I apologised and said I did not.

He told me where I used to work, he told me I was working with a male colleague who had said:

“If I die I want you to promise me you will staddle me and jump up and down on my chest like that.”

This was swiftly followed by a tech at the head end staring down my top and commenting:

“When them puppies come up for sale can I have the one with the brown nose?”

There were not many women doing my job back then, and what is now called sexual harassment was then ‘the lads’ being idiots. It went with the territory.

“I came off my bike,” He said quietly. “They wanted to let me go, but the lad there said no, then you all carried on and they wanted to let me go again and you said no.”

He carried on telling me I said he owed me a drink. That he could hear and feel everything that was happening. He said although he was in great pain he wanted to open his eyes and see my ‘puppies’ but he couldn’t.

We spent three hours chatting after he came out of surgery. His recall was totally amazing. He had a blank spot until just before he came out of the helicopter but from that point on he has almost total recall. He said he wanted to scream when the doctor said ‘He’s gone, we’re done’. He wanted to let us know he was alive but he couldn’t. Medically he wasn’t alive, he was dead, no output except for that created artificially by chest compressions.

When you do CPR you don’t get anything like the output a normal beating heart would achieve. Ventilation keeps the tissues perfused and prevents brain damage and organ malfunction, but that’s all.

So, we have a man, gravely injured, who has lost well over half of his circulating blood volume, his heart is not beating, he has so little function he cannot even move a finger to tell us there’s life…and he’s hearing us pronounce him dead, warm and dead at that.

He remembers the smells, the sounds, the fear and the pain. Obviously he still had brain activity but to have enough to recount in such detail is astounding.

Having moved on from the hospital Tom was brought into after the accident I had no clue until we came together years later. He’d told the rest of the team before his discharge.

He lost his sight and a leg in that accident. He was about as smashed up as you can be, but he hung on. He literally clung to life that night.

Tom’s case has made me wonder how many times we have stopped the intervention, let someone go that was screaming inside for us to keep them alive. From the day I sat and talked to Tom I have refused to let any resuscitation attempt stop until we have scanned and proved brain activity has ceased. Only once have I been justified, sadly the rest of the patients were beyond help.

Talking to Tom makes you think, really think about life and death. Where one ends and the other begins. Of course without the equipment that allows us to test for brain activity there’s no way of knowing who has and who does not have brain function and therefore who has a reasonable chance of survival if we persist.

If we ever find ourselves in a situation where hospitals and equipment are not available we will have to return to “You’re not dead until you’re warm and dead” but until then I’d like to think that Tom has taught us all a lesson that no text books could ever teach us.

Take care

Liz