SEPTEMBER 11, 2008, WAS an important day in New York. It was hard to escape the somber memory of the devastating events that had shaken the city and the world seven years earlier. While many commemorations were taking place at Ground Zero, where the lives of all those who had passed away were being celebrated, another important event was also taking place not far from Ground Zero. A symposium entitled “Beyond the Mind-Body Problem: New Paradigms in the Science of Consciousness” was being held at the United Nations Headquarters in New York. The daylong program was sponsored by the NGO Section of the United Nations Department of Economic and Social Affairs (DESA), the Nour Foundation, and the University of Montreal. In many ways, this symposium represented the antithesis of all that had led to the events of 9/11, and it mirrored the mission of the Nour Foundation—to establish a universal platform upon which to draw human beings from all walks of life together in a greater spirit of unity, tolerance, and understanding. The symposium was also an acknowledgment that understanding the complex relationship between mind, brain, and consciousness has widespread ramifications for us all, regardless of our color, creed, or gender. And along those same lines, it made clear that at the heart of the matter, at the core of all human beings and all human actions, lies human thought and consciousness—however ethically or morally developed—and it is this thought that shapes all human ideas and actions, from the destruction witnessed on 9/11 to the solidarity, generosity, and unity that ensued in the following weeks and months.
Among a number of distinguished speakers, I had been invited to speak in front of an international audience, and this opportunity was both a tremendous honor and the culmination of years of work and thought—yet it was also just the beginning. During this symposium, whose main focus was the nature of the “self” and the phenomenon of consciousness, we were also announcing the launch of the AWARE study. The AWARE study—AWAreness during REsuscitation—would be an international collaboration of scientists and physicians joining forces to study the human brain and consciousness during clinical death. It reflected my professional interest and work, which has been driven by two parallel avenues of investigation that are intricately linked. The first is improving the quality of resuscitation in order to save more lives and prevent brain damage. The second is understanding what happens to the human mind and consciousness during death, for cardiac arrest is perhaps the only circumstance in which we can study human consciousness at a time when the brain has naturally shut down and flatlined. This thus enables us to determine its relationship with brain function, while also not losing sight of the fact that when trying to save a life, we are not dealing with a medical process alone but rather a human being. Even if we can’t see the human mind, consciousness, or soul, because the neural circuitry that modulates consciousness and awareness is down, a person is in there somewhere, and we must never ignore or forget that.
After successfully completing an eighteen-month pilot phase at selected hospitals in the United Kingdom, which had been established with the help of my colleagues Dr. Peter Fenwick and Ken Spearpoint, we were expanding the study through other medical centers in the United Kingdom, Europe, and the United States.
FOR YEARS, EVIDENCE HAD been building that people who had been resuscitated and brought back from death recalled certain experiences, as well as in many instances specific details of what had happened to them while watching doctors and nurses working on them from above. Could these so-called actual-death and out-of-body experiences be real? Was this why people claimed to be able to see events taking place below while watching from above? Alternatively, perhaps these experiences were simply a reflection of better-quality resuscitation of the brain? Maybe some people were able to recall specific memories because physicians had achieved better blood and oxygen delivery to the brain without realizing it. This was a possibility that had to be considered. Although previous research had indicated that, in general, during cardiac arrest, doctors cannot get enough blood into the patient’s brain, there was no way to rule out the possibility that some individuals who had recalled specific experiences had not somehow received better resuscitation. Maybe there were exceptions to the rule. This would be highly significant because it would indicate a potential avenue for further scientific exploration in the quest to identify improved quality brain resuscitation. At that time, no specific real-time brain monitoring system had been identified that could provide physicians with information regarding the quality of oxygen delivery to the brain during CPR, which was vitally important in the quest to reduce brain injury and improve overall survival. The first line of thought was to therefore try and identify a system that could remedy this very important and significant deficiency in our system of CPR care that had been highlighted by survivors with ADEs. Clearly, if we could identify a marker, some sort of gauge and tool that would give doctors real-time second-by-second immediate feedback regarding the quality of their resuscitation efforts and its impact on the brain during CPR, this would potentially help save many more lives and also prevent people from suffering with brain injury. Doctors would be able to potentially quickly recognize circumstances in which oxygen delivery to the brain had been inadequate and then attempt to remedy the situation before it became too late. An additional benefit of such a system would be to provide doctors with the ability to recognize when their resuscitation efforts may be futile and hence when they need to stop CPR, since the call to stop resuscitation in general is somewhat subjective. If after the recognition of poor-quality oxygen delivery to the brain, satisfactory oxygen delivery cannot be established in spite of all efforts, then continuation of CPR would clearly be futile. Thus, a major thrust of the study was focused on identifying a novel mechanism that would enable physicians to evaluate the quality of the resuscitation of the brain during CPR, with the hope that identifying a gauge that reflected quality would ultimately lead to improved resuscitation methods.
Although at first glance, many doctors, including me, would have considered the experiences recalled by people during their period of death to potentially reflect some sort of hallucination, this no longer seemed such a viable explanation. By the time my colleagues and I began the AWARE study, we had come to realize that millions of people all over the world had reported so-called ADEs, including many anecdotal reports of the ability to see and hear accurately during cardiac arrest and resuscitation. This suggested that this was an area we had to investigate further, since ultimately we as physicians are dealing with human beings with real lives, who also have unique mental and cognitive lives, rather than just numbers and statistics. From a scientific perspective, it was becoming clear that it was unlikely the entity we refer to as human consciousness is “lost” in the true sense of the word in the initial phase after death has taken place. Human consciousness could potentially continue to exist in some capacity at least for some time after death, even though it may disappear immediately from sight with respect to the outside world after the heart stops. This is because no (or inadequate) blood flow is getting into the brain during cardiac arrest and the ensuing resuscitation process, which is insufficient to enable brain circuits to function (including the circuits that modulate consciousness and awareness of the outside world). Perhaps these ADE reports were in some way similar to the recently discovered reports of consciousness in people who had been suffering with persistent vegetative states. They too had been deemed not to have any consciousness at all, since the areas that modulate consciousness in their brains had been irreversibly damaged. Yet studies had now demonstrated the entity we call consciousness had not been lost forever in this group of patients in spite of extensive brain damage. It had simply appeared to be “out of sight.” Similarly, perhaps people who could also demonstrate conscious awareness even after the process of death had started were the same, particularly since biologically speaking, death shares the same biology as those who have suffered with terrible and progressive irreversible anoxic brain injury.
The evidence so far seems to suggest that the occurrence of consciousness in relation to cardiac arrest is somewhat of a scientific paradox that cannot be easily explained using our current neuroscientific models. This is because consciousness (or the soul) seems to continue to exist and function during cardiac arrest and death, as evidenced by the ability of people to have well-structured thought processes, complete with reasoning and memory recall, when the brain circuits that modulate consciousness are down and consciousness appears lost to the outside world. People can recall specific conversations, details, and events that could only be done with a normally functioning brain. Throughout the years that I have been working in this field, I have come across numerous examples recalled by various physicians who have resuscitated patients back to life.
In September 2012, I was invited to give a lecture regarding the subject of near-death experiences at a conference entitled “Emergency Cardiovascular Care Update,” which focused on the topic of cardiac arrest. At the end of my talk, Dr. Tom Aufderheide, a prominent figure in the field of resuscitation science who had been sitting in the audience, volunteered to tell the audience about his own recollection of the first patient he had resuscitated back to life as a new medical intern. He said:
I was a brand-new doctor.... I had in fact been a doctor for just five days and had never treated a patient with a cardiac arrest. I was told [by my superiors] to go and see a patient who was having a heart attack on the CCU. I walked into the room and introduced myself, and the gentleman introduced himself back. Then at that point his eyes suddenly rolled back in his head, and he fell back into his bed. Being a doctor for just five days, I figured there were probably only two options to account for what had just happened—either he had fainted, or he had suffered a cardiac arrest. I knew it was the latter, as I suddenly saw five nurses run into the room with terrified faces! At that moment my own worst fears had been realized. I was all alone. I had no one to collaborate with, and I had never taken care of a cardiac arrest patient before. A thought directed to my seniors who had sent me to the room alone rushed through my head: “How could you do this to me?”
But I got over that really quickly and started CPR. In those days there was no cath lab. There was no therapy for a heart attack. You would just leave the person to finish his heart attack, and if he had a cardiac arrest you would shock him quickly [give an electrical shock using a defibrillator]. Finally after ten minutes of CPR, many more people came into the room, but he just kept on rearresting [having cardiac arrests]. This process went on for quite some time, and the doctors who were in the room had other things to attend to—so what did they do? They left the intern to stand by and deliver the shock treatment when he needed it again. So I remained at this man’s bedside from 5:00 A.M. to 1:00 P.M. in the afternoon, shocking him repeatedly when he went into ventricular fibrillation. He had a prolonged cardiac arrest. At this point the housekeeping staff came into his room to serve his lunch. I was hungry. So I ate his lunch! I certainly couldn’t leave his room, and he wasn’t going to eat it!
We finally stabilized him after many hours, and he ended up having a long and complicated hospital course. Then some thirty days later, on his last day before discharge, he said to me, “Can you please shut the door and come and sit down?” I thought that was kind of funny, so I went and shut the door and sat down. He said, “I want to tell you something. I have been meaning to tell someone, and you are really my doctor. You have been here the most, and I felt I can share this with you.” He then went on to describe a complete near-death experience. He went down a tunnel. He saw the light. He talked to his dead relatives. He talked to a higher being and was ultimately told he needed to come back. This was a really detailed and prolonged near-death experience, but at the end of it he said, “You know, I thought it was awfully funny … here I was dying in front of you, and you were thinking to yourself, ‘How could you do this to me?’ And then you ate my lunch!”
So that certainly got my attention in the first five days of being a physician! I have been fascinated by the experience ever since, and I often ask my patients about their experiences. It seems to be recalled by about 10 percent of them.
Later on somebody in the audience asked him whether he had vocalized or expressed to the nurses his thoughts, fears, and frustrations about being left alone by his seniors to deal with this very complicated medical emergency. He said, “No, I just thought it to myself and hadn’t said a word to anyone else. The thought just glanced past my mind for an instant.”
During the question-and-answer session after my lecture, Edward Stapleton, another prominent resuscitation expert who had a background working as an ambulance paramedic, also told everyone in the audience about a person he had resuscitated who had shared his own detailed experience with him afterward. These cases were similar to others recounted to me by other physician colleagues in the United Kingdom, including Dr. Douglas Chamberlain and Dr. Richard Mansfield.* The one common feature among all these accounts was that patients with cardiac arrests had come back and recalled incredibly detailed accounts of conversations and events relating to the period when they were seemingly “dead” to their physicians. Specifically, they all claimed to have been able to see the events relating to their own cardiac arrests while watching from a point above at the ceiling, and their physicians agreed with their accounts, yet found them scientifically inexplicable.
Thus, the key to determining what was really happening would be to have some sort of impartial yet objective test to determine whether or not consciousness could really be present and whether in particular the visual recollections that were being reported were really happening, and if so, when they were happening. Was it during the period of cardiac arrest and resuscitation or some time later when perhaps the brain had started to come back online after people had survived? To objectively test the claims that people had during out-of-body experiences and based on an adaptation of a previous study, we installed images on the top of shelves specially attached to the wall near the ceiling by us. The shelves were the size of a piece of copy paper and were attached approximately six feet, five inches above the ground so that an image that was placed on the surface of the shelf could only be seen by someone looking down from above and not by anyone looking upward from the ground level. The idea was simple: if these recollections and reports of consciousness of being at the ceiling and looking down were correct, then people should also be able to see the images that had been placed near the ceiling. If they were not, then they should not be able to see the images. So if we had one hundred or two hundred people who all claimed to be able to see themselves and doctors and nurses working on them from above and they all saw these pictures, then their experiences would potentially have to be considered real, whereas if none of them saw the images, then they would have to be considered as being less likely to be real—and perhaps were an illusion that had formed after the brain had recovered. Such a study would of course have many obstacles, but at least it was an idea worth pursuing.
In the study, in addition to investigating consciousness and recollections, we sought to examine the processes involved with optimization of brain and organ resuscitation in order to save brains and lives and to study mental and cognitive processes, realizing they are closely linked. It was clear that there is a thinking, conscious person inside the body, and this is what we are trying to save even if the person seems to be absent when we are working actively on them. We would thus study the recollections of those who had survived and would also assess the impact of the quality of resuscitation care, to try to determine if consciousness was simply a reflection of differences in the quality of care with respect to the brain or something more.
To measure the changes in oxygen levels in the brain during cardiac arrest, we obtained a highly sophisticated brain monitoring device, called a cerebral oximeter, that could measure oxygen levels in the brain continuously and record the levels every few seconds during a cardiac arrest and allow us to see if any relationship exists. Cerebral oximetry is a noninvasive system that can be placed on the forehead to give doctors a clear indication of how much oxygen is getting into the brain during and after resuscitation. By measuring the levels of oxygen in the brain during resuscitation of those people who survived and had experiences, we could determine if they were related to the quality of resuscitation as well as identifying a real-time system to inform doctors of the quality of care being delivered to the brain. Although cerebral oximetry had been around since the mid-1990s, it had not been used to track the quality of the delivery of oxygen to the brain during CPR. There had been a few occasional instances in which it had been used during CPR, particularly in the case of certain people who had suffered an unexpected cardiac arrest while being monitored using this technology during surgery for another purpose. It had shown promise but had not been systematically investigated during cardiac arrest resuscitation. Perhaps the people who had experiences simply had higher levels of blood flowing into the brain and hence oxygen delivery. Either way, by studying this technology in a novel manner, we would potentially be able to change the way that doctors manage cardiac arrest by developing a new application for this already existent technology during cardiac arrest and hence ultimately reduce brain injury.
Such an endeavor aimed at studying people’s experiences from a period of cardiac arrest would of course have huge challenges. The biggest challenge would be that, unlike other research projects where researchers could enroll patients from clinics or elsewhere, we were dealing with cardiac arrest, an event that can happen randomly at any time of the day and anywhere in a given hospital. The second major challenge (as I have explained) was that most patients who suffer a cardiac arrest by virtue of having died once are unlikely to survive long enough to be interviewed so that we can determine if they had any experiences or not. So we would be dealing with an event that could happen anytime, anywhere and would give us a roughly 15 to 18 percent chance of survival to a point where the person could even be interviewed. Of course, many of the 15 to 18 percent of people who survive will end up with permanent neurological and cognitive damage and so would therefore not be in a physical state to be interviewed. On top of all these challenges, we would have to account for the fact that most of the people who do survive and are in a state to speak will of course have memory loss resulting from the cardiac arrest itself and the impact of all the changes in the brain that take place both during cardiac arrest and in the postresuscitation period. Finally, we would have to address the question of why people having out-of-body experiences (assuming they are even real) would even look at the images we put up (rather than focusing on the doctors working on them).
So what type of images should we choose, and where should they be placed? The ideal position would be on the patient’s bed, but of course, that would mean that everyone would see them; we couldn’t then be sure that, if a patient recalled the images, it hadn’t been because somebody else who had been part of the resuscitation had told the patient about the images after the event. We decided to place the images directly above the head of the bed, just below the ceiling so that they would be in the line of vision of patients looking at themselves. We would also use images that would be potentially interesting and eye-catching to people. For example, if we felt the people were very nationalistic, we could use symbols that reflected their country, whereas if they were religious, we could use imagery that reflected those beliefs, and so on.
Our initial goal was to recruit twenty-five hospitals with the objective of recruiting at least fifteen hundred cardiac arrest survivors. By 2008, we had reached agreement with investigators from twenty-five different hospitals to take part. Large numbers of hospitals were needed because the low survival rates meant that we would need ten thousand actual cardiac arrest events to have fifteen hundred survivors. But then again, at best 10 percent would be expected to have any memories (ADEs), and only 2 percent would be expected to have an out-of-body experience that would enable us to determine if what they claimed to see was correct. Although many people have an ineffable experience that includes feeling peaceful, seeing a luminous being that guides them, or entering a beautiful place, these experiences were very subjective and could not be independently tested. The only component that would be amenable to testing would be an out-of-body experience, because it was only during this time that people recalled specific potentially verifiable events that had taken place relating to their own cardiac arrests. Based on these numbers, if we followed ten thousand cardiac arrest events, we would perhaps expect to end up with about 150 people with mental and cognitive experiences and perhaps only thirty people with an out-of-body experience.
Reflecting on that day in 2008, it was clear that many professional factors had led to the announcement of the AWARE study. On a personal level, my speech at the United Nations returned me to events during my own childhood and early adult life where I experienced firsthand what it means to live with someone with severe brain injury. This early life experience had brought home and made very clear to me the importance of trying to save “brains” while studying the nature of human consciousness. When I was nine years old, my father, then thirty-seven, was diagnosed with a progressive and devastating neurological disorder. In eighteen short months, he was in a wheelchair, and the crippling effects of this neurological disorder continued relentlessly until he became figuratively like a “vegetable” within just a few years. He endured this condition for seventeen years, and for the majority of that time, he was just barely alive and unable to communicate at all. As a teenager I would spend time with him, not understanding what had happened to my father, the man who had been so strong and powerful in my eyes when I was a small boy, but now had become just a shell, a husk of his former self. We couldn’t communicate in any way other than being in the same room together, and he couldn’t reminisce about the things we had done together or even enjoy life’s simplest pleasures. Later, when I graduated from medical school, I couldn’t even tell if he was aware that I had become a doctor—something he had always wanted me to aspire to when I was a young boy. He was trapped in a body that could no longer convey his wishes, his feelings, or his thoughts to the outside world. We all felt he was there—but often wondered where and what was really left of his self. As he lay propped up by cushions in his bed day after day, I often wondered what was happening to this man’s consciousness, to his sense of self—that entity that made up his unique personality. As sad as death is, it was a great relief for all of us when he finally passed away at the age of fifty-four, because he had endured such suffering.
During those seventeen years, I witnessed up close and personal the devastating effects of a destructive brain disease. The end result of my father’s neurological condition and his state of being was largely the same as what happens to people who suffer catastrophic brain damage after anoxic brain injury from cardiac arrest. In truth, part of what motivates my work and drives me is the realization that through the establishment of higher standards of care, we can all work together in unity to ensure that many of the people who have suffered cardiac arrests and have been resuscitated not only come back to life again but also do not end up neurologically in a state similar to Don Herbert, George Melendez, or even my own father. Professionally, I’ve resuscitated hundreds of people and taken care of hundreds more who could not be revived. I also unfortunately have seen people on the other end—those who have been resuscitated and ended up with the devastating consequences of brain injuries after cardiac arrests. It saddens me to feel that people may be dying or getting brain damaged unnecessarily, because with better systems many cases could potentially be avoided. This, of course (as I have tried to highlight in this book), is a complex problem that requires changing old perceptions while introducing a systemwide change regarding how medical treatment in this area is administered both in the community and in hospitals, much like what has been done in the aviation industry.
At the time of launching AWARE, my colleagues and I had spent nearly ten years searching for the funding required to enable us to perform this study on a large scale. It was clear that this work was needed now, if only to enable us to design better studies. If we didn’t take the first step, then we wouldn’t be able to take the second and the third. The study received funding from the Resuscitation Council in the United Kingdom and later additional support from the Nour Foundation to develop the study in the United States. For the European arm of the study, we also received funding from the Bial Foundation, a Portuguese nonprofit organization. Although ideally we wanted to have fully funded positions of independent staff in each hospital doing the work, that would prove far too costly when considered in the context of twenty-five hospitals, and it would be too complicated since no one could predict when or where a cardiac arrest would take place. Most cardiac arrests actually happen at nights and on weekends, so even funding the position would not guarantee having someone there when we needed that person the most. We knew we needed to start somewhere. So we agreed that staff at the twenty-five hospitals working with us would use their own time to identify cardiac arrest patients, interview them, and study their charts for various markers that would show the quality of care they received; staff would then forward the data to us. We realized we would probably capture fewer people that way, but at least it was a practical way to go forward. Because of the enormity of the project at hand and the number of beds at each hospital (average 500 beds, multiplied by 25 would total roughly 12,500), combined with funding constraints, we also couldn’t install a shelf in every room in every hospital, so we worked with our investigators to determine historically where patients were more likely to have cardiac arrests, such as in the emergency room or the coronary care unit. We knew there would be cases where someone would have a cardiac arrest in a room without a shelf, but again for the sake of being practical and ensuring the study would be manageable, we had to compromise. Clearly, although the study would be more complete with more resources, we needed to take this first step. In all, we installed about one thousand shelves to begin with, which was itself quite a lot, but still covered only 10 percent of the total hospital beds.
Obviously, we didn’t know what to expect at the time, but nevertheless, we proceeded with the study.
NOW IN SEPTEMBER 2012, it has been four years since we started our research collaboration. This period has enabled us to test many of our systems with a view to building on our findings.
The results so far have been very promising and have demonstrated that almost all the patients in our study who have suffered with cardiac arrests start out with very low brain oxygen levels. Normally brain oxygen levels should be between 60 percent and 80 percent; however, in our experience during cardiac arrest, the levels are often well below 20 percent and on many occasions below 10 percent and even sometimes zero! Importantly, we have found that if quality resuscitation efforts are instigated during this time, the level of oxygen to the brain can gradually be increased with sustained effort. Nevertheless, it has become very clear that if the levels are less than 30 percent, the heart will almost never restart and the person cannot be revived. On the other hand, when doctors have successfully elevated the oxygen level through quality resuscitation efforts in the brain to approximately 45 to 50 percent and maintained these levels for approximately five minutes, then in almost all instances the heart will restart. The key is thus to elevate the oxygen levels in the brain to at least this important threshold level.
This was a significant yet unexpected finding, and it led to a very interesting question. What does brain oxygen level have to do with the heart? In other words, if this machine is measuring oxygen delivery to the brain, how is it that it seems to clearly predict whether the heart will restart and the person will be saved, at least in the immediate sense? The answer seems to be that if we can clearly improve oxygen delivery to the brain, then it means that we have also been able to improve oxygen delivery all over the body, including the heart. Oxygen levels as measured by cerebral oximetry thus not only provide data regarding the state of brain resuscitation but also are a surrogate marker of the level of oxygen that is being delivered to the entire body, including the heart. If the levels that are being delivered to the heart are below a certain threshold (30 percent), then the heart will simply not have sufficient oxygen to be able to allow the heart muscles to pump again, and the person remains dead and cannot be revived.
Although this early data is extremely important because it helps us predict when immediate survival can be achieved, it doesn’t tell us the brain oxygen levels that may predict longer-term survival and also reduced brain injury. At this point we are thus concentrating our efforts on trying to identify the optimal oxygen level in the brain that would potentially lead to better longer-term survival and also reduced long-term brain injury. It is clear that while a level of about 45 to 50 percent may perhaps be sufficient to restart the heart in the immediate phase, it may not be sufficient to reduce the post-cardiac-arrest tsunami effect that inflames the brain and other organs with a toxic fury leading to brain swelling and generalized organ injury after the heart has been restarted and the patient has been revived initially. This is the main reason people die in the subsequent hours to days. Our preliminary data suggest that we may have to strive to achieve a higher level of brain oxygen level to not only start the heart but also, and more important, preserve the brain and minimize the toxic tsunami effect that ensues when there has been a prolonged period of lack of oxygen to the brain during cardiac arrest.
Interestingly, roughly at the same time that we started doing this work, another group (Dr. Noritashi Ito and his colleagues at Osaka Saiseikai Senri Hospital) in Japan had also started to study the role of cerebral oximetry during cardiac arrest. They specifically looked at this technology in patients who had been taken to their hospitals by ambulance after suffering with cardiac arrests. Their data indicated that if a patient arrives at the hospital with a particularly low level of brain oxygen (less than 25 percent), then the person would invariably have a poor outcome. The results of our work, however, complement the work carried out by the Japanese group. We have demonstrated that after measuring a low brain oxygen saturation level, specific steps may be taken to actually improve this and hence lead to the restoration of the heartbeat and potentially improve longer-term brain and survival outcomes. Thus, measuring a brain oxygen level that is very low while using a cerebral oximeter as a form of “spot check” does not necessarily lead to poor outcomes, since the oxygen level can be improved with dedicated effort. At this time, we have integrated the routine use of cerebral oximetry into all our cardiac arrests at my own particular medical establishment. As far as we are aware, we are one of the first medical centers (if not the first) to do so. We have also published the results of our studies in reputable scientific journals and have presented our findings at national and international scientific meetings, including the annual American Heart Association meeting. Interestingly, however, none of the patients in whom cerebral oximetry was used reported any mental and cognitive recollections from their periods of cardiac arrest. Nevertheless, the component of our work that focuses on cognitive and mental experiences and the ADE has also been ongoing and has provided us with a lot of interesting information that we are currently analyzing.
DURING THE FOUR YEARS since the study started, our collaborators in the different medical centers who have been participating in the AWARE study have reported a total of more than four thousand cardiac arrest events. Of these, it was found that on average in approximately 32 percent of cases the heart had been restarted by doctors and nurses resuscitating the patient but that only about 50 percent of these initial survivors had remained alive to a point where they could be interviewed (thus about 16 percent of the total cardiac arrest events), with many unfortunately dying in the subsequent hours to days after their hearts had initially been restarted. As mentioned, during this period we installed in the participating hospitals approximately one thousand shelves high up with images that were only visible from the ceiling. We did not have the means to be able to put a shelf above every single bed in each hospital because of the vast numbers of shelves that would have been required.
During our initial assessment we had estimated that if we covered the most critical areas of the hospitals, we would hope to be able to capture at least 80 percent of all cardiac arrest events, since we know that most cardiac arrest events happen in the same locations in hospitals. These are usually the coronary care units, the emergency wards, as well as specific wards where more critically ill patients are kept, such as the intensive care units.
The evaluation of these initial approximately four thousand cardiac arrest events actually indicated to us that despite all our best efforts, placing the one thousand shelves had enabled us to capture no more than 50 percent of all cardiac arrests in the hospitals. This meant that in at least half of the cases where a cardiac arrest had occurred, it was possible a person who had recalled a specific ADE, and had provided us with recollections of what had actually happened while seemingly watching from the ceiling, was not able to have his or her case tested and examined in a more objective fashion with the use of these image boards.
In this initial phase, a total of approximately a hundred interviews were carried out with cardiac arrest survivors, and we found that ADEs seem to have occurred in only approximately 5 percent of our study group. It was therefore possible that we would have had more patients with specific recollections but they had been lost to follow-up.* Those whose experiences were documented seemed to follow what we had already come to understand of what happens during a cardiac arrest. Although few and far between, the experiences were nevertheless interesting. My colleague Ken Spearpoint described one patient’s experience. He wrote:
His journey commenced by travelling through a tunnel towards a very strong light, which didn’t dazzle him or hurt his eyes. Interestingly, he said that there were other people in the tunnel, whom he did not recognize. When he emerged he described a very beautiful crystal city and I quote “I have seen nothing more beautiful.” He said there was a river that ran through. There were many people, without faces, who were washing in the waters. He said that when the people were washing it made their clothes very bright and shiny. He said the people were very beautiful and I asked him if he recalled hearing anything—he said that there was the most beautiful singing, which he described as a choral—as he described this he was very powerfully moved to tears. His next recollection was looking up at a doctor doing chest compressions!
For the patient this was a profound spiritual experience, and certainly powerful for me too … unfortunately the event was not in a research area [an area with a board].
For a long time, nobody in the first phase of the study reported the ability to “see” themselves from the ceiling and watch doctors and nurses working on them. We had one “near miss” in 2009 when everyone thought they had had a “hit,” which led to a frenzy of excitement at the participating hospitals in the United Kingdom. A patient who had suffered with a cardiac arrest at St. Peter’s Hospital located just outside London had been sent to another participating hospital in London (St. George’s) for cardiac testing. The team at St. Peter’s had asked the team at St. George’s to conduct the interview on their behalf since the patient had left their hospital. During the interview it transpired that the patient had recalled an ADE, and as part of this he had seen a vision of a green light. His experience was not very detailed; however, the staff at St. Peter’s were curious. They went back to the ward where he had suffered a cardiac arrest and removed the board that contained the image that had been above his bed. The image on the board was essentially the front cover of a UK newspaper showing smoke coming out of a New York apartment block after a small airplane flown by a famous baseball player had lost control and crashed into the building. At first, it seemed there was nothing to correspond with the patient’s recollection, but when they looked more carefully at the bottom of the newspaper cutting, they spotted an image that caught their attention. This was a picture of a group of doctors standing in a circle round an operating room light wearing green scrub caps on their heads. The team thought this corresponded with the green light the patient had recalled. I received a very excited call, but on closer questioning the patient had not recalled seeing anything from above at all.
Then finally in 2011 we had our first real out-of-body experience claim. A fifty-seven-year-old man had suffered a cardiac arrest in the cardiac catheterization laboratory in Southampton General Hospital in the United Kingdom. The patient specifically recalled feeling that he had been above his own body and had been looking down. He said he had seen people in the room around him and that they had given his heart electrical shock treatment (defibrillation) twice. He said he had a bird’s-eye view, while looking from above himself, of all that was happening to him below. However, the cardiac arrest did not take place in an area of the hospital where there had been a board present, so the staff were unable to confirm the details of what the patient had recalled; specifically, they couldn’t ask him whether he had “seen” an independent objective image. I did, however, interview him later and found his experience to be remarkable. I have transcribed our conversation here (with my questions and comments in italics):
Before I tell you about my experience, I want to tell you about a couple of things that will put it into perspective. In terms of me, I come from a really, very, very large family. I know that directly after I told them about my experience they said, “It was the drugs,” and things like that.
After the experience?
Yes, they all said it wasn’t real and things like that. But there are a couple of things about it that stuck with me and made me want to repeat [my story], directly to people who would listen to me.
So you felt you wanted to tell people.
Yes, because it was totally alien to whatever I had had before in my life, and I felt it was important and basically it went like this:
Apparently I didn’t know I was having a heart attack, doctor. I was at work, I went to work normally, I didn’t feel 100 percent, and that is not unusual, because one of the other things I have is diabetes and I have had that for over thirty years now, but I felt a little bit different. Because I felt different, I immediately tested my blood, because when you have had diabetes for a time you get used to things all the time and one of the first things I do is test my blood just to make sure that I haven’t eaten something or taken something that I shouldn’t have, and my blood was fine—no problem whatsoever. The day went on, I had a coffee and had a meeting, and my boss said, “Let’s go down to the pub and we will have a sandwich and a coffee.”
What do you do, sir?
I am a social worker.
So do you work for the hospital?
No, I don’t. I work for a charity. So that’s what I did. We went for lunch. Came back from lunch. We were only gone half an hour and I didn’t feel well again. I work in an open office and it’s really difficult to …
You are visible?
Yes, very visible. You can’t talk on the phone privately or anything like that. So I went to the loo, and I felt really unwell. I came back into the office and said to one of the people there, “Can you go and get me a chair, just so I can sit.” It felt like I wanted to get some air and I couldn’t. So they went and got me a chair and—anyway, cut a long story short—they phoned an ambulance.
What time was this, roughly?
This was about 2:30 in the afternoon. I felt well again, the ambulance eventually arrived, and two paramedics came up. I said, “Look, I feel well now,” and they said, “Would you please come down to the ambulance.” Halfway down I felt unwell again. Anyway, I got into the ambulance and they put something on me, a wire or something, and then the whole mood changed.
When they got your ECG?
It sort of all changed then, and they wanted to whisk me off and not talk to me and just do it. Do you know what I mean, doctor? That unnerved me a little bit because I am not used to anything like that, so I said, “Hang on, what are you doing?” They said, “We need to get you to hospital.” Anyway, they did.
So based on the ECG, they said, “We have to get you into hospital,” right? You had changes that said you had had a heart attack. But you didn’t have any symptoms.
No pain, no nothing, no pain whatsoever. I can remember coming into the [hospital bay] … and a nurse came on board. [The paramedics] had told me a nurse called Sarah would come to meet me when I arrived.
Getting on board the ambulance?
She came on board the ambulance like they said she would and then she said, “Mr. A, I am the most important person in your life at the moment. I am going to ask you some questions and I want you to answer every one of them.” I said yes. I can remember that I wanted to sleep all the time at that stage and all she kept trying to do, it felt like, was to keep me awake and talk with her. Do you understand what I mean? And that’s how it was with her.
But you were sleepy?
Yes, I felt sleepy then, very much so. Anyway, she was asking me all these questions, have I got pain, have I got this, and I can remember 100 percent. I can remember her asking me one question and because I didn’t answer it quick enough or was still tired, she asked me again and I bit back at her, as if to say, don’t keep onto me. I can remember doing it. Anyway, they got me into hospital. I can remember lying on a trolley or a bed but I couldn’t see any further. I couldn’t see what they were doing down below me.
At this point he described that while he was in the catheterization laboratory, the team had placed a sterile drape over him and he was lying flat. The nurses had placed the drape as a form of partition approximately at the level of his upper body so that the doctors and nurses could work around his groin without him being able to see what was happening. He hadn’t seen the doctor come into the room, and he was just lying there. Typically the team then gives injections in the groin area to numb the patient and then push a wire firmly into the main blood vessel in the groin and feed it all the way up to the heart.
So you were awake still?
Yes.
You were lying there?
100 percent.
They were getting you ready to do the procedure, the cardiac catheterization?
Yes, to put a stent in.
That’s right.
Yes, and she was still talking to me.
Sarah was?
Yes, and I was answering her, but I could also feel a real hard pressure on my groin. I could feel the pressure, couldn’t feel the pain or anything like that, just real hard pressure, like someone was really pushing down on me. And I was still talking to her and then all of a sudden, I wasn’t.
The medical records from the hospital indicate that at this time Mr. A had gone into cardiac arrest with his heart showing a specific electrical abnormality called ventricular fibrillation (VF). This is a fatal condition in which instead of beating, the heart fibrillates but cannot create a contraction, and hence, there is no heartbeat. The heart immediately stops, and the person receives no blood to the brain and dies immediately. It is a well-known complication of a heart attack and is usually what kills people instantly after the attack. VF is universally incompatible with a beating heart and hence life. There have been many scientific studies that have examined what happens to the brain immediately after the heart goes into VF and stops. These studies have all demonstrated that brain electrical activity stops and the brain itself flatlines.
In the cardiac catheterization laboratory of Southampton General Hospital, the medical and nursing staff had attached a specific type of device that can shock the heart, called an automated external defibrillator (AED), to the patient’s chest. This is the same type of defibrillator that is installed in many airports, train stations, and other public places. The difference between this defibrillator and others routinely used in many hospital wards or emergency areas is that the AED is designed to be used by laypeople (but can also be used by health-care professionals), whereas other defibrillators are designed only for professionals. The AED assumes the person using it has no medical knowledge and thus would not be able to recognize VF and know when to deliver the necessary shock treatment. The AED is designed to be very simple to use and can detect VF itself. Once VF is detected, the AED provides verbal feedback to the users. The device would say something like “shock advised” and then enable the delivery of the shock treatment. Standard hospital defibrillators leave the recognition of VF to trained nursing and medical staff and therefore do not have a verbal output. I went on to ask Mr. A what happened.
You blanked out?
I must have done. I didn’t know at the time, but then I can remember vividly an automated voice saying, “Shock the patient, shock the patient,” and with that, up in that corner of the room [he pointed to the far corner of the room], there was a person beckoning me. I can see her now, and I can remember thinking (but not saying) to myself, “I can’t get up there.” The next second I was up there and I was looking down at me, the nurse Sarah, and another man who had a bald head. I can remember doing that. I can remember seeing them whilst I was up there watching them do that.
What did Sarah look like?
Sarah who?
Sarah the nurse.
She had blond hair. She was quite tall.
And you could see her from …?
Up in the corner, right up in the corner I was, with this other person beside me.
So let’s say this is the room. Where were you lying before this happened? Where was your head?
On the bed here, and that’s the corner. [He again pointed to the far corner where his legs would have been pointing had he been lying down. There was a bed in the hospital interview room.]
Where was Sarah standing relative to the corner?
[Before this happened] I couldn’t see down here. [He showed the end of the bed where his legs and groin area would have been.] I couldn’t see her and I didn’t even know there was another man standing there. I hadn’t seen him. Not until I went up in that corner—then I saw them. You understand what I am saying?
Before this happened, before you lost consciousness, you didn’t see Sarah physically at that point, and you didn’t see this man with the bald head?
No.
When you were looking there, were you seeing her front, her face, her back, or what were you seeing?
[He pointed to the far corner of the room.] This was me, and she was here. [He pointed to the end of the bed.] And the other man was on the other side of me there. [He pointed to a position next to the nurse where his legs would have been.]
Which way were they facing?
Towards my head. Away from me while I was looking down from the ceiling.
You could see their backs?
I could see all this side of them. [He pointed to the back.] As clear as the day I could see that. [He pointed to an object.] The next thing I remember is waking up on that bed. And these are the words that Sarah said to me: “Oh you nodded off then, Mr. A. You are back with us now.” Whether she said those words, whether that automated voice really happened, I don’t know—only you would know those things. I don’t know how to be able to confirm that those things did happen. I am only telling you what happened with me and what I experienced.
In the medical records, the events had been independently documented. It read:
In cath lab recovery area … IV access obtained by cardiology registrar. [This is the senior cardiology trainee physician getting access to the blood vessel.]
Whilst repeat ECG taken—VF arrest. Shock x2 AED 150 joules. [“150” refers to the strength of electricity the AED device had given.]
Return of circulation 15:07 hours.
May I ask you something else? What else did you see in the room? What I mean is, did you pay attention to anything else or were you fixed on this? What were your feelings? If you remember any? What else if anything were you looking at? And what happened to the lady that you saw?
I don’t know what happened to that lady. I can still see her now if I want to. I want to say she was an angel.
Did you recognize her?
No.
What were the distinguishing features about her?
She had lovely curly hair. It wasn’t blond but it wasn’t dark, if you know what I mean. She just had lovely features about her. I would say she was an angel, but from what I perceive as an angel. I can remember that she beckoned me (I can remember thinking, and I know I didn’t say it, “But I can’t get up there”), and the next second I was up there.
You thought it?
Yes, 100 percent I thought it.
You thought, “I can’t get up there”?
Yes.
So, can I take you back to that thought—when you had that thought, where were you?
In my bed.
Right, but were you physically in the bed or just above yourself? How was it that you saw her? Were your eyes open? Do you know what I mean? How were you summoned?
Whilst I am lying down, when I have looked up there, she beckoned me like this. [He mimicked being beckoned.] I can remember thinking, “I can’t get up there.” You know, whether I said that with my face I don’t know, but that is how I felt. I can remember feeling it and the next second, I was up there, looking down on me.
In that split second, before you found yourself up there, did you see anything else around you in the room?
I can’t remember.
Okay, it was such a split second that you basically just shot up and you were there. And then when you went there, you didn’t notice her anymore—is that correct?
It felt like she was with me.
It felt like there was a presence there.
I didn’t say I couldn’t see her anymore, because I wasn’t looking to my left or right while in the corner. I was looking down at my body lying below.
Did she have any kind of presence? I mean, how would you describe her? Did she have any qualities, any personality?
I felt that she knew me, I felt that I could trust her, and I felt she was there for a reason and I didn’t know what that was.
So then, you were basically fixated on what was going on down below—it grabbed your attention?
I was up there looking down at me lying on the bed, and I couldn’t see my face because there was like a curtain here, and I didn’t know [before this happened] that there was a man on the other side of me [he pointed to where the drape had been placed that had prevented his seeing what the doctors and nurses were doing to him before his experience], and I could see Sarah on that side, and that’s all I can tell you.
What did the man look like? I mean, what did you see of him? Can you still picture him?
I couldn’t see his face but I could see the back of his body. He was quite a chunky fella, he was. He had blue scrubs on, and he had a blue hat, but I could tell he didn’t have any hair, because of where the hat was.
What did you see of his head that made you think about it?
Just very little. It looked like he was bald and he just had a hat on. I wear a hat because I like a hat. I am not bald.
I know who he is.
Who is he?
I don’t know his full name, but he is a professor now, and he was the man that I saw later, because the next day, when I was lying in bed on the ward, I saw this man [come to visit me] and I knew who I had seen the day before. I don’t know his name, Professor something. He is now a professor—he wasn’t at the time, but he is now. [The hospital staff correctly revealed his name and confirmed his promotion.]
Because this was 2011, wasn’t it?
Yes.
What was Sarah doing?
I don’t know what she was doing. All I know is that she was this side of me. [He pointed to where his legs would have been.]
What was she wearing?
Blue, well, like that color blue. It was a different blue to what he was wearing. Almost sure of that.
Slightly different blue?
Yes.
What was she doing?
I don’t know, something to me, but I don’t know exactly what they were doing.
Was she moving her arms?
She was doing some things and she was trying to … at one stage, I can remember, her face looking [toward the male doctor], almost in anticipation of his movements, checking to see whether he was going to do something or not. Do you know what I mean? That’s how it felt. Then within the next few seconds, I was back in my bed, and she was saying, “You nodded off for a little bit.”
What were your feelings like up there? Did you have any sensations, feelings, sentiments, anything?
The only time I realized that my heart had stopped was about twenty minutes later.
No, sorry, I meant when you were up at the ceiling, did you have any feelings then?
I can remember feeling quite euphoric in terms of, I am actually up here, I can see all of this. Do you understand what I mean?
In that split second, and you may have not had time to see or think of anything else, I am just curious, did you notice anything? Because obviously just before that you had this drape or curtain in front of you so you couldn’t see around, but then suddenly you were at the corner and you were able to see things. What did you see?
All I could see was a space in front of me and them working on me.
Anything else?
I just focused on myself. But I have thought about it and thought about it for a long time. I just wish that there was a way that I could prove to you what happened, and there isn’t a way but I think that I have thought of a couple of things that I think may help.
What would help?
If the doctor, or whoever is doing anything at that stage, picks up an envelope and in an envelope is a word, it could be any word, that is repeated three times between the two people or three people dealing with that procedure—whether I would have picked up on that one word or not, I don’t know.
The interview ended soon after, and he gave me permission to reveal his experience and look at his medical chart.
What is most remarkable about this experience is that while this man did not suffer with a prolonged cardiac arrest, the duration of his cardiac arrest would have nevertheless been at least three to five minutes. This is because after recognizing ventricular fibrillation and delivering the first shock treatment to a patient, the AED device will automatically recommend a two-minute period of chest compression before analyzing the heart rhythm again. If the patient is still in VF, the AED will recommend another electrical shock. Therefore the whole process of delivering two shock treatments and the subsequent analysis would take about three to five minutes, which is well beyond the time that it takes for the brain to stop functioning after the heart stops. As described earlier, the brain stops functioning immediately after the heart stops, which is why people lose consciousness instantly (and usually within ten seconds all electrical activity stops and the brain completely flatlines). This patient, however, maintained conscious awareness of his surroundings and was able to accurately describe events that he had not been aware of before his experience, such as seeing the balding male cardiologist in blue scrubs standing at the foot of the bed. He also correctly described “hearing” the AED give the two separate commands to deliver the shock treatment (which would have been at least two to three minutes apart). This provides some perspective in terms of how long after his cardiac arrest he was able to maintain conscious awareness while perceiving that his real self was at the ceiling. Although there had been no images placed on a shelf in his room, judging by the fact that this man was able to maintain consciousness at a time when his brain could not have been in a functioning state, this case supports the emerging scientific possibility that after death has begun, a person’s consciousness, psyche, or soul does not appear to be annihilated. It also supports the position taken by some scientists and physicians (such as professor’s Sir John Eccles and Bahram Elahi) that human consciousness (or the soul) could be a separate and independent entity to the brain and may continue to exist after death.
The final practical take-home message from this case is that placing an image above the head of the bed may not have been very useful in this case since he perceived his consciousness as looking from the other corner of the room. This is an important point in guiding any future research that may seek to use preinstalled images to independently test the claim that people are able to “see” from above.
Since that time we have amended the study and sought regulatory approval to contact and interview the patients who had been discharged home from the hospital before they could be interviewed. This aspect of our work is still ongoing, but we hope in the near future to be able to reach out to all the patients from the participating hospitals who are still alive, using a mailed questionnaire followed by a telephone call. So far, from these ongoing interviews we have had one more person claim to have had an out-of-body experience. This occurred in a fifty-one-year-old woman who suffered a brief cardiac arrest in one of the hospital wards. During her interview she had stated:
I felt scared. I was on the ceiling looking down. I saw a nurse that I did not know beforehand who I saw after the event. I could see my body and saw everything at once. I saw my blood pressure being taken whilst the doctor was putting something down my throat. I saw a nurse pumping on my chest, saying, “Come on Vanessa, come on Vanessa.” I saw blood gases and blood sugar levels being taken, but it did not hurt (it usually does when I am awake). At the beginning, I think, I heard the nurse say, “Dial 444 cardiac arrest.”
I became depressed after the event and later was frightened to get off the bed. I did not have a chance to talk to the nurse [mentioned above] but I did see her on the ward.
However, in this case, the cardiac arrest also had taken place in an area of the hospital where there had not been a board present. Not surprisingly, when the interviewer asked if the woman had seen anything unusual such as signs above the bed while she was looking down, she had said no. A board was not present in this particular location because it was one of the wards with a historically very low incidence of cardiac arrest. Therefore, at the beginning of the study it had not been identified as a potential hot spot, and thus no images were ever placed there.
Interestingly and perhaps disappointedly, both out-of-body experiences reported to us so far have occurred in areas without images placed on shelves attached to the walls. Therefore, we have not yet been able to objectively ascertain the accuracy of people’s claims to “see” events from above. However, we are still actively conducting interviews, and it is possible there may be more out-of-body experiences reported. Closer examination of the two cases has also demonstrated another very interesting observation. Both cardiac arrest cases had been relatively short in duration (less than ten minutes), which I believe may turn out to be very significant.* As explained previously, if a cardiac arrest event is relatively short, then the postresuscitation inflammation and disease that normally engulf the brain and cause widespread damage (including damage to the memory circuits) are also relatively mild by comparison to someone with a prolonged cardiac arrest. This suggests that people who report profound ADEs, including out-of-body experiences, may perhaps be able to better recall their experiences simply because they had suffered less damage to their brains and specifically the memory circuits in the days and weeks after the cardiac arrest. Maybe many others also experienced an ADE but couldn’t recall the details of the experience due to their memories being wiped away by the extensive postresuscitation inflammation and damage that occur in the brain after a cardiac arrest. This may explain why 90 percent of people who survive a cardiac arrest usually say they have no memory of their cardiac arrests, and the remaining 10 percent usually have very sketchy memories with only a very small proportion having detailed recollections. The main finding, though, has been that the out-of-body experience is even rarer than we thought and seems to occur in less than 1 percent of survivors (0.1 percent of total cardiac arrests). This suggests that our original calculations will need to be revised and the study expanded, since after four thousand cardiac arrests, we had only two out-of-body experiences.
FOR NOW WE ARE continuing with the data collection process, but once we manage to collect all the initial-phase data for the study, we plan to publish our results in a reputable medical journal and amend and alter the study based on the lessons we have learned. It is clear now that installing images on shelves above beds may not be sufficient, because it takes an enormous effort and in many cases cardiac arrests happen in areas without images. For the moment, the recollection of ADEs is quite rare, particularly when we look at the occurrence of an out-of-body experience. We would therefore need to expand our network of hospitals and, more important, provide funding for each center to dedicate a member of staff who can attend every single cardiac arrest and ensure that all patients at the staff member’s site are interviewed within a few days of their initial survival. We will therefore be looking at alternative means, such as the potential use of a tablet computer that may have a built-in image generator and timer device, which a dedicated member of staff at each hospital can take to the scene of a cardiac arrest; the staff person can then place the image generator at a point high above the patient’s head during cardiac arrest. The images would rotate sequentially and the data could hopefully be captured in one go and then be downloaded and analyzed by an independent member of staff.
Today, we are also continuing our efforts with respect to the use of cerebral oximetry, both in terms of the relationship that it may have with patients’ experiences and, more important, as a unique way to determine the quality of resuscitation; we hope to identify novel ways to improve oxygen delivery to the brain with a view to ensuring more people survive and have less brain injury. Thus this first stage of the AWARE study during the past four years has provided us with a lot of very interesting data, which we will use to establish our research network in the next four years and beyond.