"If we do get to somebody in time after they've reached that traditional threshold of death, we can bring them back." – Dr Sam Parnia, intensive care physician.
JENNY BROCKIE: Hi, I'm Jenny Brockie, welcome everybody, good to have you with us tonight. Cassandra, in December last year, you effectively died, didn't you?
CASSANDRA SCOTT: That's right.
JENNY BROCKIE: What do you remember of what happened leading up to that?
CASSANDRA SCOTT: What I remember? I was at Coogee Beach going for a daily swim and I was swimming out the back and I went under the waves and that's actually all I remember.
JENNY BROCKIE: So the last thing you remember was going"¦
CASSANDRA SCOTT: Was diving under the waves, going under water.
JENNY BROCKIE: Now Neil, you saw Cassandra, you were swimming that day too?
NEIL CLUGSTON: I was indeed, yes.
JENNY BROCKIE: You saw her with her face in the water. What did you think at first?
NEIL CLUGSTON: I thought she was looking at fish. She had goggles on and I thought she was just having a look under water.
JENNY BROCKIE: So what did you do?
NEIL CLUGSTON: I waited. It's, it's a funny thing, I felt there was something wrong but I didn't act straight away.
JENNY BROCKIE: Now there were a few reasons you didn't act, weren't there?
NEIL CLUGSTON: Well, you don't go grabbing a woman whose, you know, in a bikini floating around in the water minding her own business, not since the '80's at least when it was considered okay, so you hesitate Jenny. I did hesitate and I watched her and tried to figure out what she was doing.
JENNY BROCKIE: How long did you wait?
NEIL CLUGSTON: Look, I'd love to know exactly but it would have been a couple of minutes. Because I was making my way towards her, she was about 20 metres out.
JENNY BROCKIE: So a couple of minutes that her face was in the water at least?
NEIL CLUGSTON: Absolutely, absolutely, well I wanted to be certain that she wasn't just holding her breath.
JENNY BROCKIE: And what happened when you realised that something was wrong? How did you realise?
NEIL CLUGSTON: I saw her actually, I saw a wave, there weren't big waves that day but there was a fairly substantial wave and she floated over it and her body was completely limp and it just flowed with the wave. There was no muscle tension whatsoever and that looked very wrong and so I got over to her and I actually leant over and I screamed: "Are you okay?" Which seemed rather strange but it was the best thing I thought I could do at that point and as soon as she did not respond, I flipped her over.
JENNY BROCKIE: And what did she look like?
NEIL CLUGSTON: She was, I'm not a medical practitioner, I know we've got a lot of people here tonight who are, but I know that she was dead. I know that she was, her lips were purple and her face was completely grey and there was no signs of life. There was no movement, there was no breathing. She was very bloated. I think she'd swallowed a lot of water.
JENNY BROCKIE: How long did it take to get her in?
NEIL CLUGSTON: Oh, about, probably about a minute and a half, two minutes to actually get her from the position she was once I'd grabbed her. I knew that was an urgent"¦
JENNY BROCKIE: We're talking at least four minutes then?
NEIL CLUGSTON: Absolutely.
JENNY BROCKIE: Between when you first spotted her and goodness knows how long she'd been there before you spotted her?
NEIL CLUGSTON: Well, that is the big question - that is the big question how long she was there.
JENNY BROCKIE: Matthew Oliver in LA, thanks so much for joining us. Now you're an emergency doctor based in Sydney and you just happened to be on the beach that day. What shape was Cassandra in when she got to the shore and when you got to her?
DR MATTHEW OLIVER, TRAUMA AND EMERGENCY SPECIALIST: Well, by the time I got to Cassandra she was, she was lifeless and there was no signs of life whatsoever. But again by the time I got to her there was a large crowd around and the life guards were actually already there starting CPR. I kind of went straight into a, a medical mode and there are a number of steps that occurred that saved her life and that was one that the life guards did early CPR. They were straight in action doing really good chest compressions.
The second thing they did was put the defibrillator pads on and that actually helped me enormously because by putting those pads on we could, it told me that the heart wasn't in a shockable rhythm so that effectively gave me the information that the primary problem for her heart to stop wasn't the heart itself, something else was going on.
JENNY BROCKIE: What did you do next?
DR MATTHEW OLIVER: So, then I guess the most important thing for me was to provide ventilation and oxygenation and that's kind of going away from the standard CPR type protocols that are commenced in the community and so I was using the life guards and we'd managed to piece together bits of equipment that enabled me to provide quite vigorous ventilation and pretty much within, I'd say a minute or two of doing that, we actually started getting a good response. So we actually started feeling a pulse and then a short time after that her breathing came back and then really it was a task of supporting her breathing with positive pressure and the ventilation and oxygenation and within a very short period again after that she started moving and by the time the ambulance arrived, she was actually awake and she was moving all arms and legs and her eyes were open. So she actually had a really good response and I knew from that point when she was being loaded into the ambulance that she would most likely have a fairly good recovery.
JENNY BROCKIE: Cassandra, piecing all these bits of your story together later, have you got any sense of how long you were out in this process?
CASSANDRA SCOTT: No, no, I don't. I mean I've heard from people that it was fifteen minutes but I was, I was pretty dead so I don't know.
JENNY BROCKIE: You were pretty dead?
CASSANDRA SCOTT: Yeah, a bit dead.
JENNY BROCKIE: And do you remember anything of that time?
CASSANDRA SCOTT: Looking back, it was just like being asleep but with no dreams. It was that sort of same sensation and"¦
JENNY BROCKIE: When you say like being asleep, you mean just a complete blackout"¦
CASSANDRA SCOTT: Complete.
JENNY BROCKIE: "¦.. that you remember nothing or are there things that you remember?
CASSANDRA SCOTT: There were no lights, no tunnels, there were no guys with long grey beards and white robes. It wasn't hot. So no, I think there's a few things, there are very few things that I would agree with Kerry Packer about but there was a big fat nothing there.
JENNY BROCKIE: Pretty much nothing there?
CASSANDRA SCOTT: Yeah.
JENNY BROCKIE: Do you remember coming to?
CASSANDRA SCOTT: Um, patches of it. I re, it was sort of like the flash lights, like having photographs sort of flicked between your eyes. I remember coming to and having a sea of faces, complete strangers around me very, very close to my face and peering at me, that was one memory that I have of coming to.
JENNY BROCKIE: Neil, what happened when she came back? You were on the beach there, you were beside her?
NEIL CLUGSTON: Yes, I was to Matthew's right and I was holding her wrist doing an attempt at feeling a pulse and"¦.
JENNY BROCKIE: Did you feel anything?
NEIL CLUGSTON: I did eventually, when the guys Matthew and Luke who was giving cardiac massage managed to actually get Cassandra back, I felt the hard hit. One really good hard hit pulse.
JENNY BROCKIE: From her?
NEIL CLUGSTON: Yeah, and I'm going oh, I felt something, I felt something, and then all of a sudden she fought her way back, you know, you could really feel it. It was like Wham, wham, wham.
JENNY BROCKIE: In what way could you feel it?
NEIL CLUGSTON: Just the pulse, just the pulse, it was like she came back really hard and really strong and she felt like she wanted to come back. I think she was so lucky that, that, that, Matthew was there and that Luke was there and particularly Luke who was beating the hell out of her.
JENNY BROCKIE: Luke was the life guard, yeah?
NEIL CLUGSTON: Luke was the life guard, that's right, and he was really not giving up. He was on a mission and I think everyone was, Matthew was ventilating her and I was talking to her at the time going, you know, come on.
JENNY BROCKIE: Matthew, when you said you sort of broke the protocols by giving her oxygen, what do you mean?
DR MATTHEW OLIVER: Because normally people in the community collapse because of heart attacks, so lack of blood supply to the heart. So the main principal there is to get early good chest compressions and get the defibrillator pads on. However, in Cassandra's situation, which is a very rare situation, her problem wasn't actually a lack of blood supply to the heart, or actually anything to do with the heart. So that in other words, her lungs were full of water and she wasn't getting oxygen into the blood. The main goal for her in this instance was ventilation, and the only way that I knew that is really through my training. There's no other way.
JENNY BROCKIE: So Cassandra, you chose the right beach on the right day with the right guy very nearby?
CASSANDRA SCOTT: Of course it was pre-planned, yes.
JENNY BROCKIE: But incredibly lucky he was there presumably?
CASSANDRA SCOTT: There is luck on every front. It was, it was, it's so lucky it's almost not true.
JENNY BROCKIE: Ron, you're Cassandra's neurologist, what sort of state was she in by the time she got to you in intensive care?
DR RON GRANOT, NEUROLOGIST: I have to say I was very impressed. When I first saw her in intensive care she was already up, sitting in the bed, and having known her from before she already had her usual sort of slightly dark sense of humour back. I've got to say she looked fairly normal.
JENNY BROCKIE: How did you know her from before?
DR RON GRANOT: Because she was my patient earlier for her epilepsy.
JENNY BROCKIE: And you'd had an epileptic fit in the water, is that what had happened?
CASSANDRA SCOTT: That's the theory.
JENNY BROCKIE: That's the theory but no one really knows?
CASSANDRA SCOTT: No.
JENNY BROCKIE: Sorry, go on.
DR RON GRANOT: And basically, you could see that basically the fundamentals of her personality were there and a lot of the higher order functioning was there. The major issue was with some memory and attention issues and that sort of played itself out over the next few weeks.
JENNY BROCKIE: Colin, in June last year you had a cardiac arrest. How long did your heart stop beating for?
COLIN FEIDLER: Apparently 46 minutes is what I've been told.
JENNY BROCKIE: So you were effectively dead for all of that time?
COLIN FEIDLER: Mm-mmm.
JENNY BROCKIE: And let's backtrack here a little bit. When did you first think something was wrong, tell us about the moment when you first thought something was wrong, where were you?
COLIN FEIDLER: I was just sitting on the couch. Yeah, I just got a bit of like a heavy sensation in my chest. It was, that was it really.
JENNY BROCKIE: And did you immediately think to call an ambulance or call a doctor?
COLIN FEIDLER: Not really. Not really. It was - I knew something was wrong and obviously my first thought was to talk to Shinade and get her to,
JENNY BROCKIE: Shinade, what you were you thinking?
SHINADE ROGERS: Um, it was, I mean you do a lot of reading on heart attacks and so forth and just trying to go through the different, what was happening to him at the time and not all signs were there so we weren't quite sure.
JENNY BROCKIE: So at this stage he's conscious, he's just got pains in his chest?
SHINADE ROGERS: Yeah, yeah, he was quite pale.
JENNY BROCKIE: And how long did you wait before you called an ambulance?
SHINADE ROGERS: We called Nurse On Call at first and they were on the phone for about ten minutes and they talked us through a lot and then Colin kind of said oh, I think I'm okay, just hang up, so we hung up, and then he continued on that he still wasn't well so I said no, I think we need to speak to them and they actually called the ambulance.
JENNY BROCKIE: Now when the ambulance arrived you made a very crucial decision about where you wanted to go when you were asked which hospital you wanted to go to. Tell us which one you chose and why?
COLIN FEIDLER: I chose the Alfred and I really don't know why. There was"¦
JENNY BROCKIE: This is the Alfred in Melbourne?
COLIN FEIDLER: Alfred Hospital in Melbourne, yes. I think looking back, maybe it was because I'd heard a bit about their trauma units and the stuff they do in there.
JENNY BROCKIE: But for some reason you just asked for the Alfred?
COLIN FEIDLER: Yeah. It's unlikely that even getting in an ambulance you would normally get a decision or a choice where you want to go. They just sort of cart you off and that’s it.
JENNY BROCKIE: Yeah, I wondered about that. But they asked you, right?
COLLIN FEIDLER: Yeah.
JENNY BROCKIE: Now Stephen Philpot in Melbourne, you're an intensive care specialist and you just happened to be at the Alfred late that night. What was the first thing the doctors at the Alfred did once Colin's heart stopped beating?
DR STEPHEN PHILPOT, INTENSIVE CARE, ALFRED HOSPITAL: Well Colin was lucky enough that he was in the Emergency Department when his heart stopped beating. He was already attached to a heart monitor. The first thing that the emergency doctors did was commence cardio pulmonary resuscitation, chest compressions, and it was about five or six minutes after they'd started chest compressions that I was walking through the department with a colleague of mine and we poked our heads into the cubicle to find out exactly what was going on.
What we did was attach Colin to a machine called an ECMO machine which basically draws blood out of the circulation using a large tube inserted into the major vein of the body, puts oxygen into the blood and returns it through another tube inserted into the main artery of the body, and by doing this we can maintain the circulation, we could maintain Colin's circulation even though his heart wasn't beating.
JENNY BROCKIE: And what did you do after that, you cooled him as well. Can you explain how cooling works, what did you do?
DR STEPHEN PHILPOT: Well cooling the body temperature is thought to protect the brain during a period where it's not receiving enough oxygen. It's becoming quite a critical part of resuscitation, we're becoming more and more aware that it's very important to preserve brain function. So what we did was while Colin was receiving his chest compressions and while we were inserting the ECMO cannulars we were infusing a large volume of ice cold saline into Colin's veins and backing his groins and his neck with ice to try and lower his body temperature.
JENNY BROCKIE: Now if Colin had gone to any other hospital in Australia, would this have happened?
DR STEPHEN PHILPOT: I think it's unlikely, there are very few hospitals that would have the capacity to do this in an emergency. I should point out that it was 11 o'clock at night and he made a very good choice in his hospital on that night.
JENNY BROCKIE: And why is it just being done at the Alfred?
DR STEPHEN PHILPOT: We are running a trial which means that we are constantly ready to insert ECMO cannulars at very short notice, including during chest compressions.
JENNY BROCKIE: But usually it has to be during business hours, is that right?
DR STEPHEN PHILPOT: That's correct. And ironically the reason that we were in the hospital at 11 o'clock at night was because we'd spent the day putting a patient on ECMO at another hospital in Victoria and we just happened to be returning to the hospital wheeling the patient up to the intensive care as it happens with all of our ECMO equipment and we walked past Colin's bay what he had his cardiac arrest.
JENNY BROCKIE: What is it about you two? How did you both manage to pull this off? Were you aware of any of this going on Colin?
COLIN FEIDLER: Not in the hospital, no.
JENNY BROCKIE: Any memory of what happened in the hospital?
COLIN FEIDLER: No. The first memory I"¦
JENNY BROCKIE: Any memories from when you were gone, when you were dead for that time?
COLIN FEIDLER: I don't recall anything.
JENNY BROCKIE: Shinade, were you aware that this was a kind of really unusual procedure to have?
SHINADE ROGERS: Well I didn't, no, I didn't know a lot at all actually. The last I saw Colin went away in the ambulance and I was on my way to pick him up, not knowing that what had happened in the interim.
JENNY BROCKIE: Sam Parnia in New York you've been using this same technique in Long Island for more than three years. Why?
DR SAM PARNIA, INTENSIVE CARE, STONY BROOK HOSPITAL: One of the goals that we have to have is to try to preserve brain cells and other cells after a person has died because we now understand that it's only after a person's heart has stopped that the cells inside their body start to undergo their own process of death and that actually contrary to our views, which was that we thought we only had six to ten minutes before brain cells become permanently damaged, we now know that we have a lot longer period of time.
And therefore, ECMO is a fantastic way to essentially deliver oxygen to the brain and the heart and other organs and prevent the cells from undergoing their own process of death or slowing it down while buying time for physicians to go and fix the underlying problem that has caused the person to die in the first place. And when that's combined with cooling and the hypothermia treatment, then this really gives us a very prolonged and extended period of time to go back and fix, for instance, a heart attack.
JENNY BROCKIE: And you go so far as to claim that death is reversible?
DR SAM PARNIA: Well, it's not a claim that I make, it's just a fact, because if you think about it, we have a very fixed perception of death that really goes back centuries, if not millennia, because only until a few decades ago when a person's heart stopped there was nothing that you could do to reverse that. Now obviously if you have been left dead for a very long period of time, then the cells in the brain and other organs have undergone their own process of death and at some point they reach irreversible and irretrievable damage such that no matter what we do, we cannot bring them back.
However, the key discovery in the last ten years is that it's not just six to ten minutes, that we have hours of time after a person has turned into a corpse whereby, with the right medical care, we cannot only halt the process of cell death but also restart the heart and bring back a whole person fully intact without brain damage and that really is the revolution of resuscitation science.
JENNY BROCKIE: You talk about hours?
DR SAM PARNIA: There’s a grey zone in which a person has died but the cells are still viable can go on for hours. There's lots of research that demonstrates brain cells can be viable this was done and published ten years ago in Nature Medicine, where they biopsied brain tissue from cadavers who were in a mortuary and they managed to grow brain cells in the laboratory up to 21 hours after a person had died. There are also incredible case reports of patients who have been found literally dead hours after their heart has stopped and who are then brought back to life.
For instance, the longest case that I have seen that's published in the medical literature is a Japanese woman who was found at least four to ten hours after her heart had stopped in a forest by a passerby and she received six hours of resuscitation using ECMO after she was found and she left the hospital three weeks later and I've been in touch with her physician, she had a baby in the last year.
JENNY BROCKIE: Tonight we're talking about bringing people back from the dead, new techniques and the ethics around making decisions to revive people. Wendy, your brother Trevor was revived after he suffered a heart attack at the football. How long did his heart stop for?
WENDY VEITCH: We've been told a few different things but about 45 minutes. All I know is that someone started CPR pretty quickly and then they had to get him down because he was at the top, one of the top tiers at Etihad Stadium so had to clear people away and put him on a board and strap him up and take him downstairs before they could do a lot of stuff. But people have said that he had defibrillation and all that sort of thing there so.
JENNY BROCKIE: And what happened after that?
WENDY VEITCH: Um, he was in ICU for quite a long time. They couldn't get him out of the induced coma. They had lowered his temperature and then when they tried to bring it back up and bring him out of the coma, it took a long time and they weren't getting any responses from him.
JENNY BROCKIE: And did he get this ECMO machine?
WENDY VEITCH: No.
JENNY BROCKIE: No, but he got the other things, the cooling of his body and so on?
WENDY VEITCH: Yes.
JENNY BROCKIE: What sort of person was he before all this happened?
WENDY VEITCH: Um, he liked to associate with people younger than him, he was a very handsome man, he was a bit of a chick magnet. He sort of would go out and all of the girls would like to, you know, talk to him – a very social butterfly, not a stay at home person at all.
JENNY BROCKIE: And now?
WENDY VEITCH: Well now he's in an old age nursing home so he doesn't do any of those things any more.
JENNY BROCKIE: We've got some footage of him here that is taken quite recently.
WENDY VEITCH: Yes.
JENNY BROCKIE: What sort of damage did he have?
WENDY VEITCH: Um, well, he can't speak, he's got aphasia, he is incontinent.
JENNY BROCKIE: He's motioning there about his heart and his head.
WENDY VEITCH: Telling people I had a heart attack, I've got brain damage now but that's his life now living with people who are 80 plus.
JENNY BROCKIE: You were explaining what sort of damage he sustained?
WENDY VEITCH: Oh, okay, he's got aphasia, he's incontinent, both. He, when he first went into, came out of hospital he was able to dress himself and look after himself a little bit. I remember him learning to tie his shoe laces up and things like that, but then he developed complications and that's made him much worse now.
JENNY BROCKIE: So how do you feel about him being resuscitated?
WENDY VEITCH: At the time I thought, you know, do anything to save my brother but as time has gone on and I've seen his condition worsen and where he's living now, well if it was me I'd be saying don't do it.
JENNY BROCKIE: And how have you felt listening to these other stories?
WENDY VEITCH: I feel guilty saying that after meeting you two, and I knew I would because I see how wonderful they are but my, in my position, I see my brother and that's not for me and I was just saying, I've said to my husband if you come home and you see me having a heart attack, go outside and don't come back. Come back in a few hours time and I know that's an awful thing to say but that's how I feel.
JENNY BROCKIE: Okay, anyone like to comment on what Wendy's had to say?
PROFESSOR PAUL MIDDLETON, AUSTRALIAN RESUSCITATION COUNCIL: I think the discussion shouldn't get derailed by talking about the incredible technology and all the things can be done at the far end of the process because what's most important is actually what's done at the very beginning of the process. The definition of cardiac arrest now worldwide is that somebody is not responsive and is not breathing normally. There's actually not even a check for pulse in the current definition because we recognise that people feel for a pulse and often feel it when it's not there, and sometimes when it is there they miss it. So the definition is very, very simple.
What's been shown to work incontrovertibly is immediate high quality CPR which we've just seen be a success. Done the very moment somebody drops, if possible. The other thing that's incontrovertibly successful is putting a defibrillator on, and if it's a shockable rhythm, as Matthew pointed out, to actually apply the shock as soon as possible. Those two things have more success than anything else.
JENNY BROCKIE: How consistent are the systems in Australia for resuscitating people?
PROFESSOR PAUL MIDDLETON: Every five years the guidelines are developed and published based on the very best evidence from research over the preceding five years. Now the actual implementation of those guidelines, so who teaches CPR to bystanders and lay people, varies because sometimes it might be an Ambulance Service, sometimes it might be a provider like surf lifesaving or St John's.
JENNY BROCKIE: But there are inconsistencies, aren't there? I mean if Colin hadn't been at Alfred in Melbourne he wouldn't have had access to the ECMO machine, for example?
PROFESSOR PAUL MIDDLETON: That's true, but the inconsistencies, the further into the system you go there's undoubtedly inconsistencies and the variability will be huge. But on the level of the things we know saves lives much more than anything else, which is immediate CPR and defibrillation, the consistency is a lot better than it is if you think about where there is an ECMO machine or not.
JENNY BROCKIE: Peter Saul, you're an intensive care specialist, what do you regard as a successful resuscitation?
DR PETER SAUL, INTENSIVE CARE, JOHN HUNTER HOSPITAL: Well I would dispute what Sam said about what death is, death isn't just when you're not breathing and your heart's not beating and your pupils don't work. It's when the doctor says you're dead which takes into account a whole lot of other stuff like how well you were, what you were like beforehand, what we know about you and how long we've already tried. So I do think that we have to take into account. We've bandied around the word death here like Colin death for 45 minutes. I'm very uncomfortable with that. I feel like he was in a state of cardiac arrest for 45 minutes but he wasn't dead because here he is. So death is philosophically and legally irreversible so I think we've got to be careful about how we use that term.
JENNY BROCKIE: I want to go back to the question you had for Sam.
DR PETER SAUL: The question is where's the systematic, if you like, randomised control trial for this? I would think it's anecdotal from the way you've described it so far?
DR SAM PARNIA: No, let me explain better perhaps. I think what I'm trying to explain is that after a person dies, right, the way that we define them as being dead, as opposed to having a cardiac arrest, is whether they had wanted to be resuscitated. For instance, if somebody is 90 years old and they have cancer and they did not want to be resuscitated, then when their heart stops they stop breathing and their brain shuts down and they have fixed and dilated pupils, they will be certified as being dead, that is the time of death that will go into the certificate.
Now that is biologically when death occurs, but my point is that that corpse, forget the fact that that person is elderly and they have cancer, the brain cells and other cells inside the body have not yet undergone irreversible irretrievable damage. We simply don't know when a corpse has reached that point and that's really the point that I was trying to make and this is well documented in the medical literature.
JENNY BROCKIE: Paul, what did you want to say?
PROFESSOR PAUL MIDDLETON: I think to be fair and with the greatest of respect, what you quoted earlier on was studies in Nature which showed you'd grown neurons in a Petrie dish, or whatever, several hours after death. Now there's a vast amount of difference between growing brain cells in a dish and having somebody go home, pay tax and look after their kids which is actually a definition of success that we'd prefer to use.
DR RON GRANOT: But there is, I have to say in neurology we started "¦.
JENNY BROCKIE: Hang on one second Sam, I'll come to you in a sec.
DR RON GRANOT: In neurology in the last few years we've started using clot busting drugs for stroke and originally we thought, there was a great deal of controversy after some initial negative studies but now we know that we can return the brain that was, a stroke is basically where a clot blocks the blood flow to a particular part of the brain and we know that if we apply a clot busting drug through the veins, the person may regain function of that part of the brain initially after, even if the therapy is given after three, and lately that's been pushed out to four and a half hours. So there certainly is increased viability of brain tissue that's receiving little or no blood flow after many hours.
JENNY BROCKIE: But as Paul's saying, viability of brain tissue is one thing. Going home and having a functioning life and"¦
DR RON GRANOT: Yeah, these are patients who received the clot busting drugs and have a good neurological outcome. In other words, have a significant reverse of their deficit. It doesn't mean zero deficit but certainly markedly improved.
JENNY BROCKIE: Wendy, you're listening to this, what you do think?
WENDY VEITCH: I just remember seeing some scans of my brother's brain and all these grey patches or white patches and being told that that was - they were areas of his brain that were damaged and couldn't be repaired. And you can see from the video what he's like. He can't speak and he can't toilet himself, he can't do any of those things and now he can barely feed himself as well, so.
JENNY BROCKIE: Sam, have you conducted a proper trial of your processes after the last three years?
DR SAM PARNIA: There are guidelines that are published that deal with the quality of care that parents should receive during cardiac arrest and then followed by quality of care for the first 24 to 72 hours in the intensive care unit. Over the last two years we have tried to implement a number of these measures. It's very difficult to get everything done immediately but through that we've managed to increase our survival to hospital discharge from a rate of 21 percent to 32 percent in 2012 and so far in 2013 our current rate of survival lies at 38 percent.
Most of our patients do not have brain damage. This is still a work in progress. We are anticipating writing up the results of our outcomes when we've reached the full two years of improved outcomes and follow-up of our patients.
JENNY BROCKIE: Are there people that you've revived that you wish you hadn't?
DR SAM PARNIA: If somebody has a condition that is untreatable, in my opinion, they should not receive any CPR whatsoever. I go out of my way on the intensive care unit to explain to family members that we should stop and not do any CPR for certain patients that we know we cannot treat the underlying problem, because even if we were to restart the heart, it's going to stop again and again.
JENNY BROCKIE: But can I ask you again, in your hospital are there patients you have revived using these procedures that you look back and, with the benefit of hindsight, wish you hadn't revived them?
DR SAM PARNIA: Well, first of all you have to realise I'm not a sole practitioner.
JENNY BROCKIE: But it's a personal question Sam. It's a personal question, it's just a question to you?
DR SAM PARNIA: I'm not aware of a patient that I have personally I'm not aware, I'm not aware of a patient that I have personally been involved in their resuscitation and that I have regretted having done that, if that's what you're asking me, because of bad outcomes.
JENNY BROCKIE: Okay. Stephen Bernard, you're running the trial at the Alfred which is similar procedures here and which Colin benefited from. What sort of results are you getting in terms of quality of life out of that trial for people?
PROFESSOR STEPHEN BERNARD, INTENSIVE CARE, ALFRED HOSPITAL: Well in Victoria we've run a number of big trials looking at out of hospital cardiac arrest in the Victorian setting, and particularly the Melbourne setting, and for people like Colin who have this cardiac arrest at home, our paramedics are very highly trained and they have a drill that they go through but with the sort of condition that Colin had, about half the patients don't respond. The other half do and they go to hospital and of those patients, about a half die and of the other half, hardly any, maybe just a couple of percent, end up sadly like Trevor in a nursing home. So that's, that is an outcome I know that every doctor I know points to and says whatever you're doing with research you can't have that as an outcome, you've got to get people home and happy and having a great quality of life.
JENNY BROCKIE: And how do you make those decisions as a doctor? I mean how do you make those split second decisions about whether to persevere or not?
PROFESSOR STEPHEN BERNARD: In the hospital we are very careful. If the family indicate that someone would not have wanted resuscitation, we're always able to stop if it's a clear case. But for the most part, the really big difficulty for doctors is after, you have to let something like five days go by and then make some sort of judgment call using a series of tests and give the family a prognosis.
So doctors in intensive care, in particular, neurologists are often sought for a second opinion, often find this amongst the most difficult decisions to, well they don't make the decision, amongst the most opinions to form and then together with the family to make decisions about either continuing on with a prospect of the patient getting home, or the patient would receive palliative care and die, and as I say a dreadful outcome is someone who ends up, you know, with high dependency.
JENNY BROCKIE: Are there people you've revived you wished you hadn't?
PROFESSOR STEPHEN BERNARD: I certainly remember one patient and I met, incidentally, his widow some years later and we agonised over this decision. He was very young and she did tell me later on that he suffered a lot. Having said that, we would have given up on Colin and I guess there's a balance there, isn't there?
JENNY BROCKIE: Yes, and I guess the interesting thing is where you draw those lines. As a paramedic, what do you do, where do you draw those lines?
MICK STEPHENSON, INTENSIVE CARE PARAMEDIC: There are, as Steve described Jenny there are advance directives and there are guidelines that we use to determine whether or not we would start resuscitation or not. And if people are elderly or sick, or if their families don't want them resuscitated, then we don't. But I mean given we're talking about these three cases tonight, we would have gone flat out at all of them and you know, unfortunately, and Trevor is just the sort of guy that we would have given our all to and hoped desperately that he did well.
JENNY BROCKIE: How long do you persist with resuscitation before you stop though?
MICK STEPHENSON: Our mindset is changing but we've probably traditionally say about half an hour is enough. I have personally done resuscitations that are a lot longer and I know a lot of intensive care paramedics in Victoria have also done so.
JENNY BROCKIE: Paul?
PROFESSOR PAUL MIDDLETON: I've done resuscitations on people where the CPR has gone on for four or five hours. Usually that's somebody is hypothermic or something like that and, you know, we do sometimes resuscitate people for that length of time.
JENNY BROCKIE: Are the kind of discussions we're having about, you know, raising different areas, different techniques and so on pushing those boundaries out? Are they making them more blurred now?
PROFESSOR PAUL MIDDLETON: They are but think what you've also got to think about is bang for your buck. That if you buy an ECMO opinion and I've never bought one so I can't say but I'm led to believe they're about 60, $70,000. If you get the most basic mannequin to teach somebody CPR with it costs 35 bucks. Now that means in a quick calculation that I can buy almost 2000 of those for the price of an ECMO machine and if I can train 10, 20, 30 people to do immediate CPR on a patient on the beach, then I think the bang for the buck is with the early interventions.
JENNY BROCKIE: Okay Stephen, what do you think, given you're doing the trial?
PROFESSOR STEPHEN BERNARD: Well, I think there's room for both and we know that there are about 60 patients a year in Melbourne, like Colin, whose heart cannot be started by the paramedics and this is the sense that we're getting, is that the future is that we will be able to do something for those people. So that's the question of mechanical CPR which I think you'll be showing some vision of shortly. People teach chest compressions, we want to do all that and we also want to do more, the cooling which has I think been adopted widely now around the world, ECMO more a select number of patients.
JENNY BROCKIE: ECMO is effectively a heart lung machine?
PROFESSOR STEPHEN BERNARD: Yes, the heart lung machine.
JENNY BROCKIE: Now the big difference is that some hospitals have those machines but they don't have them in emergency, is that right?
PROFESSOR STEPHEN BERNARD: Well, most hospitals, well really the Alfred has this ability and in Japan they have been doing this for about thirteen years and publishing quite good results. Now quite good is for people that otherwise wouldn't have had any chance, around the low, around 20 percent of people going home.
JENNY BROCKIE: Peter, what did you want to say?
DR PETER SAUL: I was just going to make the point that Stephen is talking about Japan and using ECMO, but they've actually got the world's worst outcomes from out of hospital cardiac arrest at the same time and I think he's playing into the hands of what Paul's saying and what"¦.
JENNY BROCKIE: So you think all the efforts being put into what happens in the hospital but not outside?
DR PETER SAUL: And if you're putting the effort at that end and missing out and I guess what Stephen's saying, you've got to have both but if you're looking for bang for the buck, it really is in trying to get early intervention that - at the moment in Australia, between two out of three or at least over half the people would walk past a collapsed person on the street.
JENNY BROCKIE: Colin, what's your reaction to that debate about whether the money should be put into the machines?
COLIN FEIDLER: I can only go on my own experience. I know I'm here and I'm healthy and to me it's definitely worth it. That's all I could say, you know.
JENNY BROCKIE: Of course it is.
COLIN FEIDLER: I can see their point though, there is definitely merit in trying to teach people young how to do these procedures that do save lives.
JENNY BROCKIE: Neil, you've been listening to all this, what do you make of all this kind of discussion about the theory as opposed to being in the water with somebody who's face down?
NEIL CLUGSTON: I actually spent three days where I didn't know whether Cassandra would come through without any long term problems and I actually had a couple of people say to me, and they were actually doctors said I wonder if you did the right thing? I wonder if, you know, they should have let her go because by the circumstance she was pretty, pretty bad, you know? And I think we sometimes forget when we're talking, you know, on a clinical level that we're talking about someone's mum and someone's brother and someone's partner. And I think we need to respond and we need to respond well.
JENNY BROCKIE: Cassandra, what do you think, having listened to all the medical debate?
CASSANDRA SCOTT: Um, I think that the privilege of coming back to life or staying alive, no matter what your definition happens to be, is that I've had thirty years younger than most been confronted with what are your life lessons and to me it's been, um, at the end of it all it's not your house, it's not the job title, it's not any of that. It's who do you love and who loves you? And I'm fortunate in that Neil had a big enough heart to say there's a stranger, I'm going to see whether she's okay.
JENNY BROCKIE: Colin, has your health suffered at all since you were revived?
COLIN FEIDLER: I had a bit of an issue with a blocked artery in my leg for a while but it was nothing that couldn't be repaired and, yeah, now I'm probably fitter than I was for a long time before.
JENNY BROCKIE: And any brain damage at all?
COLIN FEIDLER: Not that I've seen.
JENNY BROCKIE: Shinade, do you think he's been affected?
SHINADE ROGERS: Dare I say - Maybe very slight short term memory but, yeah, nothing significant.
JENNY BROCKIE: And other changes, is he different now?
SHINADE ROGERS: No, sharp as ever, extremely lucky.
JENNY BROCKIE: Have your priorities changed do you think?
COLIN FEIDLER: I probably don't just stress as much about things that I would normally get stressed about. It's just not worth it.
JENNY BROCKIE: Cassandra, what about you, any lasting effects from what happened?
CASSANDRA SCOTT: No, I don't believe so. At the time when, sort of a month after I certainly did notice there were a couple of things that weren't up to scratch. I'm a writer and communicator by trade and I knew that my reading out loud, as I was reading to my son was not as good as it should have been and my spelling and my grammar had suffered a little. But I'm very fortunate in that my son has autism and we've spent seven, eight years going through an enormous amount of therapies and a lot of that has been learning about how to remember because a lot of autistic children find it difficult to remember things that are said to them. So I was, it was great because I had the tools already, that I knew them, that I'd been using on my son and it validated that for me because I used them on myself. And as a consequence it's all coming back, it's fantastic, so.
JENNY BROCKIE: So do you still have trouble reading to your son?
CASSANDRA SCOTT: No, and the great thing is we've been working our way through one of the thick Harry Potter books and I remember it was about January when we were starting this epic journey of Harry and his friends and I did find it quite hard and that was when I knew something was wrong. But now it's fine, no problems at all.
JENNY BROCKIE: Ron, how do you consider Cassandra's going?
DR RON GRANOT: I think she's done a brilliant job. As she mentioned, she almost rehabilitated herself. We did have the involvement of brain injury specialists initially but they felt that there was essentially not much they could offer that was necessary. So she certainly returned to a, she was extremely high functioning before and is certainly back to that level as well now.
JENNY BROCKIE: Does she have brain damage?
DR RON GRANOT: No, she doesn't.
JENNY BROCKIE: No, so did she have it and has it repaired or"¦
DR RON GRANOT: I mean essentially she had deficits in brain function to start with. It's difficult to say what's brain damage and how much of the brain can sort of bypass deficits and sort of - we know that brains are able to reassign functions elsewhere which is called plasticity so the brain is able to recover from what otherwise would appear to be permanent insults and work around them to return essentially to a normal function.
JENNY BROCKIE: How much do we know about human consciousness in these situations?
DR PETER SAUL: I've certainly had people report what you didn't report, the spiritual experience, the out of body. I'm not sure about the other professionals here who have seen that. I've had reported to me, we've had the whole thing, the lights, the tunnels, people do say it. I mean"¦
JENNY BROCKIE: Have other medical professionals here had that? Stephen- no?
DR STEPHEN PHILPOT: For a lot of these patients I'm afraid to say not one has ever reported seeing anything at the end of the tunnel.
JENNY BROCKIE: Sam, you're actually studying this, what are you finding out?
DR SAM PARNIA: Well we've been undertaking a separate study which is interviewing patients after they've been resuscitated. This is a large multi-centre study carried out in the US, the UK and in Austria but in essence, actually far more people than we thought have recollections of some sort of consciousness when you interview them. But most people don't volunteer the information and that's why I'm not surprised that some of medical members in the audience mention that they haven't come across it and what people describe is a feeling of feeling incredibly peaceful.
So for instance, if they were in pain let's say due to a heart attack or some other process, that they suddenly switch out of it. They feel immense peace, they feel that there is, they see a bright warm welcoming light. And interestingly of course, one of the most interesting aspects is when they describe a sensation of looking down at doctors, nurses resuscitating them, recalling conversations, clothing and various details that they really should not have known about.
Well if you think about it the brain cells have not yet become irreversibly damaged and consciousness as an entity does not appear to become annihilated just because you reach beyond that threshold of death. Whether it continues, you know, for how long of course we don't know but certainly in the first tens of minutes to first couple of hours of time it appears not to be annihilated.
JENNY BROCKIE: Do either of you want to comment on that?
CASSANDRA SCOTT: I think the memory is really interesting. There's a very interesting part of this because it is what got jumbled up. I was at a concert a couple of weeks ago and it was this Mahler concerto and I was listening to it and I closed my eyes and it was like my entire life memory was swiping before my eyes, like an Ipad, and it was pushing through really, really quickly of events I hadn't recalled ever actively before. But it was very, very intense and I feel that my memories are just, are being like sorted and catalogued and it's been very intense and actually fantastic because there's all these lovely things that happened when I was a child that I'd never thought of before and it's all being put back together.
JENNY BROCKIE: Ron, what do you make of this with your patient?
DR RON GRANOT: It's interesting. I mean we certainly know from a memory point of view that the part of the brain that really handles the laying down of memory, the hypo-campus, is the part that's very sensitive to low oxygen.
JENNY BROCKIE: Is there any way of measuring consciousness?
DR RON GRANOT: Apart from, apart from interacting with people, no. There is certainly ways of measuring brain responsiveness to stimuli and we can certainly shine lights and observe how brains respond to that. We can certainly put electrical impulses into limbs and see how the brain responds to that.
JENNY BROCKIE: But you can't monitor consciousness?
DR RON GRANOT: No.
JENNY BROCKIE: And if you can't do that, how do you know when someone's gone?
DR RON GRANOT: Therein lies the difficulty.
JENNY BROCKIE: Cassandra, what do you think about death now?
CASSANDRA SCOTT: I'm not afraid of it but I was very lucky in that I was confronted with death earlier on in my life. My best friend died which is certainly very unlucky but I had had death presented to me in my early 30s and I think that death is not an avoidable condition but it's a very taboo subject.
JENNY BROCKIE: So it's made you more open to it, to think about?
CASSANDRA SCOTT: I'm happy to talk about. I've written, I do on the side weirdly I'm a funeral celebrant as well and that was way before me dying, okay?
JENNY BROCKIE: That is such a great line. I was a celebrant way before I died.
CASSANDRA SCOTT: So yeah, I think it's probably going a bit far for the sort of customary experience but, um, but I have given funerals. I have hosted them, I've written eulogies, I've delivered the entire service from end to end so I've been with families, a lot of them when they are just in the process of dealing with someone dying in their family, and we don't emotionally address death very well at all. When you die, it's the people that notice that you're going to care about.
JENNY BROCKIE: And you got the chance to see who cared of course because you came back?
CASSANDRA SCOTT: I did and I have to say it was hands down the most emotionally confronting thing I think that's ever happened to me because it was, it was so moving to have not just family and immediate friends but people I hadn't heard from in years and then strangers as well. I mean the relationship that I have with Neil and with Luke the life guard, we just sort of sat down and held hands and cried and it's, it's really profound.
JENNY BROCKIE: Neil, how is what happened that day changed you?
NEIL CLUGSTON: Um, I think I should point out for a start that Luke is on a world discovery tour.
JENNY BROCKIE: And that's why he's not here?
NEIL CLUGSTON: Yes, that's why he not with us tonight and I'm probably to blame for that because I told him to get out there and live his life because it's so incredibly fragile. I went off with my daughter to Hong Kong and Japan on very little notice early this year and then decided to stay out and went to Fiji and all over the place. I think it impresses upon you the importance of your family, your friends, but also the fragility of your life and how important it is to just live it and to be happy. You know, the things that are important.
JENNY BROCKIE: Colin, what about you, what do you think about death now?
COLIN FEIDLER: I was going to say exactly what he said. I think just get out there and enjoy it.
JENNY BROCKIE: Are you frightened of dying now?
COLIN FEIDLER: No, not at all. I'm quite peaceful with it to be honest. Obviously I haven't done something I'm meant to do yet and you know, luckily a group of people and a machine was able to give me a little bit of extra time to maybe do the things that I have to get done before it's my time to go.
JENNY BROCKIE: Thank you so much for joining us tonight, all of you, thank you very, very much indeed and thanks everyone. Cassandra wants to have a quick word with you I think.
CASSANDRA SCOTT: It’s just that it is the first time I have seen him.
JENNY BROCKIE: The first time you have seen him since it happened?
CASSANDRA SCOTT: Yes, we have spoken on email.
DR MATTHEW OLIVER: Like wise
JENNY BROCKIE: Oh, I didn't know that. I wish I had known that. This is the first time have you actually seen one another since it happened?
CASSANDRA SCOTT: Yeah.
JENNY BROCKIE: Wow.
DR MATTHEW OLIVER: You were in a lot worse state then. You look a lot better.
JENNY BROCKIE: Do you mind if we record this? It's amazing.
CASSANDRA SCOTT: Fine.
JENNY BROCKIE: So this is the first time you have seen one another?
CASSANDRA SCOTT: It is. It is. It's been great to hear him and I hadn't realised what an integral part he played. The criticality of Matthew being there as really dawned on me and what a privilege and what a top bloke.
JENNY BROCKIE: Matthew, how does she look to you?
DR MATTHEW OLIVER: It's just incredible seeing how well she looks now. Because normally in my job I don't really get to see the outcome sometimes of how people look.
JENNY BROCKIE: How does that make you feel about what you do professionally?
DR MATTHEW OLIVER: Well, um, I guess it just reaffirms how much I love my job.
CASSANDRA SCOTT: I have had a lot to do with hospitals obviously as a consequence of this experience. It's full of people who do this. That's what makes it sing. We're really lucky.
JENNY BROCKIE: Terrific. You two keep talking for a little bit if you want to. Thanks, everybody. Terrific.