Brain Death and Basketball

In reference to the recent unfortunate events regarding basketball player Lamar Odom, I have heard many inconsistent reports, from declarations that he is “brain dead” to reports that he woke up and spoke. This got me to thinking about how brain death, death, cardiac arrest, and altered levels of consciousness are often inaccurately portrayed in the media, and I wanted to clarify a few misconceptions 

First of all, when someone is brain dead, they are, for all intents and purposes, dead. Death is defined as brain death and/or cardiopulmonary death. If Odom were brain dead, he could not wake up. If he really woke up, he was never brain dead. Brain death = legal and biological death. Brain death means that the person has no function in their cortex (upper brain, which produces consciousness) OR in their brainstem (the “rudimentary” brain, so to speak, which controls functions such as breathing). When someone is brain dead, their entire brain is permanently functionally damaged and can never return to a functioning state in any way.

brain2

The way that we as doctors assess for brain function is first by clinical exam. First, we make sure to minimize factors confounding the exam (for example, turning off medications, or warming someone who had been hypothermic).

If someone is awake, alert, and conscious, they are demonstrating that they have at least some cortical (upper brain) function. When someone has altered levels of consciousness (for example, they are somnolent) The exam then aims to answer “how good is their cortical function?” — can they speak? Can they interact or express themselves in some way? Can they visually track? Can they follow simple commands?

People who are unconscious can sometimes have spontaneous movements (such as abnormal posturing), but they will not have purposeful movements or meaningful interaction with their surroundings.
When someone is unconscious, we want to see if they have some “lower brain,” or brainstem function. We start by examining cranial nerve reflexes. Cranial nerves are peripheral nerves that have their roots in the brainstem, and they control head and neck functions such as facial expressions, facial sensation, and pupil dilation and constriction. Reflexes mediated by cranial nerves include pupil constriction upon stimulation with light, blinking upon touching the cornea, and gagging when the back of the throat is stimulated (such as with a q-tip). Someone without brainstem function (i.e. a brain dead person, or equivalently a dead person) has fixed dilated pupils, will not react to stimulation of their corneas or throat, and cannot breath on their own, as the brainstem controls the respiratory drive.
What does it mean to “pull the plug” or remove “life support” from a brain dead person? Often, brain death is declared on a person who is intubated and on a ventilator—they have a tube (an endotracheal tube, named because of its position within the trachea) down their throats, and this tube is connected to a machine called a ventilator that moves air in and out of the lungs using positive pressure. The drive to breathe is located in the brainstem, so a brain dead person will not breathe on their own if the breathing tube is removed (if they are extubated). Once they experience respiratory arrest, their heart will soon stop beating and pumping because it is not being supplied with oxygen (the heart’s drive to beat is actually independent of the brain, but without oxygen the cardiac muscle will stop functioning). So, someone who has experience brain death will, inevitably, if left untouched by medical devices, swiftly experience cardiopulmonary death.

ventilator

Keeping a brain dead person on a ventilator is not “keeping someone alive”—it is oxygenating and perfusing a corpse. The medically appropriate next step after someone is declared brain dead is to extubate them within a reasonable amount of time (eg. sometimes a few hours to a day, to give the family time to process). There are situations, however, where a person is  NOT brain dead, but they are breathing with the help of a ventilator. Sometimes, based on the patient’s prior wishes, his or her durable power of attorney (often a spouse, a parent, an adult child) makes the decision to extubate them and let nature take its course.

Why does the heart keep pumping if the brain is dead? That is because the heart beats independently of the brain. The heart has its own pacemaker, and the heart will continue to function (if it is a viable organ) for as long as it continues to receive oxygen. A viable heart removed from the body would continue to pump if it received adequate tissue oxygenation. When a person dies naturally (i.e., when they are not intubated and on a ventilator), however, both brain death and cardiopulmonary death occur (the heart stops once breathing stops, and breathing stops once the brain dies. Sometimes, the heart dies first, and then the brain dies because it is not getting oxygenated blood flow).

Cardiac arrest occurs when your heart suddenly stops. Cardiac arrest is not the same as a “heart attack,” or myocardial infarction, which is when a coronary artery (vessel that brings oxygenated blood to the heart) gets blocked, such as by a clot that gets stuck in a plaque (plaques often form on vessels, narrowing of the vessel). A heart attack COULD lead to cardiac arrest, but there are several other events that can also cause a cardiac arrest. Also, the majority of heart attacks do not cause cardiac arrest.

Coronary artery anatomy
Coronary artery anatomy

Sometimes, however, a person can have serious brain damage and can be in a coma for days, but can still have brain function and a chance for some sort of meaningful recovery. I recently saw two patients around the same time who had experienced cardiac arrests. One died, and one is alive and interactive. Both received CPR at the scene, and both were brought to the hospital and their bodies were cooled (therapeutic hypothermia). Both were intubated and on ventilators, and unresponsive for several days. Bill had his eyes open, was at first not visually tracking, but was withdrawing to pain, and was moving his arms on the bed spontaneously. Tim was completely unawake, with eyes closed, not moving, not responding to pain; however, he did have cranial nerve reflexes. We did a test called somatosensory evoked potentials (SSEPs), which showed that Bill had some cortical activity, while Tim had only brainstem function. Neither was brain dead, but Tim had a very poor prognosis based on clinical exam and SSEP; Bill’s prognosis was at that point unclear. After a few days, however, Bill started tracking our faces with his eyes. He started following simple commands (at first, he would blink and shut his eyes on command. Next, he would squeeze hands on command. Then he became able to give a thumbs up, lift his legs). Soon Bill passed spontaneous breathing trials and he was extubated. He was very disoriented, not knowing where he was or what year it was, but he could verbalize, and he could tell me his name, his wife’s name, his hometown. Day after day, he continued to get better. He still has serious neurologic deficits, but he is awake and alive. Tim, on the other hand, did not get better. Each day, he looked the same as the day before. His family decided to extubate him, and he eventually passed.

Cardiac arrest is a serious event, and most who experience it die. However, like my patient Bill, there are some who do survive. However, most who survive a cardiac arrest are left with serious permanent neurologic deficits. Only a very small fraction, however, return to their baseline functioning. Someone might return to baseline–for example, if he or she were were young and healthy at baseline and received effective CPR right away.

How Your “Natural” Supplements Could Kill You.

Today during our “morbidity and mortality” lecture, we discussed a case of a woman who suffered a devastating stroke because she was taking naturopathic dietary supplements. She had a list of 70 different homeopathic supplements that she was taking, one of which contained thyroid hormone from animal organs. She presented to the hospital with a heart arrhythmia called atrial fibrillation as a result of the off the charts thyroid hormone levels in her body. Soon after arriving to the hospital she suffered a major stroke which left her permanently disabled (new-onset atrial fibrillation can put patients at risk of forming clots in the heart which can travel to the brain and cause ischemia, or inadequate blood supply, leading to cerebral infarction–commonly known as stroke).

Earlier this month I took care of a patient who died of metastatic breast cancer because she refused conventional treatment. She was diagnosed with breast cancer in her 40s, 7 years prior to her death. At that time, she had a very good chance of being cured with surgery and local radiation alone. However, she was a firm believer in naturopathic medicine, which essentially teaches that the body can heal itself, and she refused conventional or allopathic treatment. She was an educated person, and she had received a doctorate in a branch of alternative medicine. Eventually, her cancer became metastatic, infiltrating her liver, her bones, a diffusely throughout her tissues (known as “carcinomatosis”). She did agree to some chemotherapy towards the end of her life, but by that point it was too late. When I met her, she was bed bound, in severe pain all over her body, with chest tubes in place draining up to 2 liters per day of pleural fluid (fluid from around her lungs). The morning I met her I assisted her husband in draining her chest tubes, a task he meticulously completed every day. They were a very loving couple, speaking gently and kindly to each other in the most frustrating of circumstances, and she was a very sweet lady. After she died, after I left her room, I went somewhere private to cry. I had bonded with her. After some time passed, I also felt ashamed that she had died a preventable death. Somehow, we as allopathic doctors had failed her by not doing a good enough job of convincing her to allow us to treat her with evidence-based medicine. Maybe we hadn’t pushed hard enough, because we thought it was a losing battle.

Last week I met a patient with gastroesophageal reflux disease (GERD) who did not believe in taking medications and refused to take her Nexium (omeprazole, a proton pump inhibitor which decreases the acid content of the stomach). She experienced an uncomfortable feeling in the back of her throat after eating, and she was convinced that she had food allergies. A naturopathic doctor had diagnosed her with a whole slew of food allergies. In clinic, skin testing to the common food allergies, including the ones diagnosed by the naturopath, were all negative. The one treatment that would make her feel better was the proton pump inhibitor; however, due to misinformation and her mistrust of conventional or allopathic medicine, she would continue to feel lousy.

In medical school I took care of a patient who went into liver failure because she was taking Herbalife. Here, a local police officer lost his job because he was taking a weight loss supplement that contained amphetamines.

There are countless stories like this. In the US, about half of the adult population uses dietary supplements. The US Food and Drug Administration (FDA) defines dietary supplements as “vitamins, minerals, herbs or other botanicals… amino acids, enzymes, organ tissues, glandulars, and metabolites… extracts or concentrates” and may be found in many forms such as “tablets, capsules, softgels, gelcaps, liquids, or powders.” Dietary supplements are a $34 billion per year industry. These supplements are marketed as “natural” and they are sold at “health food stores,” GNC, Whole Foods, etc.

The reality is that dietary supplements are not categorized by the FDA in the same way that drugs made by pharmaceutical companies are, and thus they are not held to the same rigid standards and regulations. Dietary supplements do not even need approval from the FDA before they are marketed to consumers. Under current law, the responsibility of monitoring safety and effectiveness falls not on the government, but on the manufacturer. In other words, I can bottle a concoction of sugar and rosehips and write on the label that my product cures cancer, diabetes, and heart disease, and the government will not stop me.

Though regulations were created in 2007 to “ensure the identity, purity, quality, strength and composition” of supplement products (in other words, to make it more likely that the bottle labeled as Vitamin C actually contains Vitamin C), the government does NOT enforce these regulations. Straight from FDA.gov: “Unlike drug products that must be proven safe and effective for their intended use before marketing, there are no provisions in the law for FDA to ‘approve’ dietary supplements for safety or effectiveness before they reach the consumer.” Under the DSHEA law signed in 1994 by President Clinton, dietary supplements are regulated retroactively; manufacturers are supposed to report adverse effects of their products to the FDA. In other words, the onus of regulating supplements falls on the manufacturers of these products, who have a vested interest in selling them and making money.

Furthermore, the dosing is completely unregulated. As mentioned on FDA.gov’s Q&A section, “Other than the manufacturer’s responsibility to ensure safety, there are no rules that limit a serving size or the amount of a nutrient in any form of dietary supplements. This decision is made by the manufacturer and does not require FDA review or approval.” A supplement may contain very high levels of a compound, or they can contain such a minimal amount that a person would have to take thousands of pills to have any kind of effect.

Many supplements are manufactured abroad, and often contain dangerous contaminants, including lead.

There is one reason alone to take vitamins or supplements: when your allopathic healthcare provider (board-certified MD or DO, or ARNP/PA working under the supervision of one) prescribes it. Notable examples include

  • When you have certain types of anemia that require supplementation with Vitamin B12, Folic acid, and/or iron.
  • When you have been diagnosed with Vitamin D insufficiency or deficiency
  • When you are trying to become pregnant, and prenatal vitamins are prescribed.
  • Or when studies have otherwise shown that taking that supplement is 1) safe and 2) effective in treating your problem.

Why is there a demand for dietary supplements? Now, this is just my personal conjecture… But perhaps we buy supplements because, in spite of the best evidence-based conventional medicine, people still get sick and die every day. The big bad pharmaceutical companies have big bad reputations, and conventional doctors make mistakes every day that hurt and kill people (“iatrogenic” events). We place unreasonably high expectations on medicine, and by proxy on doctors, to be perfect and Godly, Almighty Fathers and Mothers who keep us safe and take away our ailments. And conventional medicine very often fails to accomplish either. So, in rebellion, or perhaps with our last ounce of hope, we buy magical potions sold with impossible promises. Because we need to believe that something will fix us. Because illness is scary. Because death is scary.

My suggestions to the reader are:

  1. Know what you are ingesting.
  2. Do not waste money on products that are at best ineffective, and at worst dangerous.
  3. Put your faith in scientific evidence, not in false promises.

[PS This post is in no way implying that all alternative and complementary practices are harmful. The stipulation is that they be evidence-based–meditation and other stress-relieving techniques, for example, have some proven benefits. Otherwise, that they be low-risk and have subjective benefits–for example, massage therapy makes me feel great. In any case, alternative and complementary practices are not adequate substitutes for conventional medical therapy. The purpose of this post is to make the point that certain active compounds found in dietary supplements can be very harmful.]