Speaker 1: In nineteen sixty seven, I was treated with hypothermia by
Speaker 1: immersion in ice cold water as part of a local study,
Speaker 1: and then developed subcutaneous fat necrosis. Both myself and one
Speaker 1: other case were reported by the neonatal team who looked
Speaker 1: after me to have had otherwise favorable short term outcomes,
Speaker 1: but on the basis of this complication, these early studies
Speaker 1: of hypothermia were stopped. I was born weighing three thousand,
Speaker 1: nine hundred seventy grams at full term after an uncomplicated pregnancy,
Speaker 1: labor and delivery. As reported, at one minute after birth,
Speaker 1: I became apnic and did not respond to resuscitation. After
Speaker 1: five minutes, I was placed in an ice water bath.
Speaker 1: My breathing was reported to recover after twenty eight minutes
Speaker 1: of hypothermia. At forty five minutes of life, my capillary
Speaker 1: pH was six point nine but recovered steadily, and I
Speaker 1: was discharged at day three. Subcutaneous fat necrosis developed between
Speaker 1: two and four weeks of age. The calcium deposits were
Speaker 1: largely cleared by six months. My serum calcium remained normal,
Speaker 1: and my weight gain and in development were considered appropriate
Speaker 1: at that age, but no further follow up was reported
Speaker 1: fifty three years after these events. I have had a
Speaker 1: very normal life. Although my mother tease me about my
Speaker 1: skin in childhood, I never had any apparent skin problems
Speaker 1: as a child or later. I was a keen sportsman
Speaker 1: at school. My handwriting was never a strength, and so
Speaker 1: I taught myself to touch type, which turned out to be
Speaker 1: an advantage in the computer age. At the same time,
Speaker 1: it is interesting to note that I can easily thread
Speaker 1: a needle. Academically, I did very well throughout school and university.
Speaker 1: I was awarded my PhD in nineteen ninety eight and
Speaker 1: have served at my current institution as department chair and
Speaker 1: faculty Senate president. In retrospect, I strongly believe that the
Speaker 1: benefits of treatment clearly outweighed the costs, and that the
Speaker 1: abrupt cessation of these early studies of therapeutic hypothermia represented
Speaker 1: a missed opportunity. If the opinion of my parents had
Speaker 1: been sought at the time, or subsequently my opinion, we
Speaker 1: would have favored continued trialing of this promising treatment. Fascinating,
Speaker 1: it's really an interesting I don't know that I've ever
Speaker 1: read a report or like of someone who had been
Speaker 1: a recipient of therapeutic hypothermia, like especially from so long ago,
Speaker 1: Like it's really interesting. Yeah, it's really good. Fine, Darren,
Speaker 1: thank you. I don't remember how I found it, but
Speaker 1: well I can tell you where it's from.
Speaker 2: Do.
Speaker 1: That was by Robert Carlson in Pediatric Research from twenty
Speaker 1: twenty one and article titled fifty three years of follow
Speaker 1: up of an infant with neonatal encephalopathy treated with therapeutic hypothermia.
Speaker 3: It's fascinating and I feel like that, yeah, the first
Speaker 3: hand account much much later because it's not like he
Speaker 3: remembers this happening.
Speaker 1: Right, It's like he's clearly reading some of the like medical,
Speaker 1: you know, records of his birth and treatment thereafter, and
Speaker 1: then and then talking about his life since Like it's
Speaker 1: so interesting.
Speaker 3: Yeah, and I'm I'm so curious to know how this
Speaker 3: episode shakes out with like what you find. But like
Speaker 3: the point I feel like, I feel like the thing
Speaker 3: that stuck out to me when it comes to that
Speaker 3: is that maybe it was a little bit of missed opportunity,
Speaker 3: Maybe it was a little bit of you know, understandable
Speaker 3: hesitation to pursue trials, but ultimately it's like, how do you,
Speaker 3: how do you make scientific discoveries that do not harm
Speaker 3: people or have the potential to harm people? And that's yeah.
Speaker 3: You know, we've come a long way in the twentieth
Speaker 3: century because of that. So yeah, anyway, Hi, I'm Aaron Welsh.
Speaker 1: And I'm Erin alman Updyke.
Speaker 3: And this is this podcast will kill You.
Speaker 1: And we're coming back with our second part on hypothermia,
Speaker 1: as promised.
Speaker 3: As promised, this is hypothermia can be good, Cold can
Speaker 3: be good.
Speaker 1: Cold is not always bad.
Speaker 3: Yeah, yeah, however you want to say it. Yes, it's
Speaker 3: the history of therapeutic hypothermia. It's really so much to learn.
Speaker 1: I am thrilled. I know literally nothing about the history
Speaker 1: prior to two thousand and two.
Speaker 3: Oh yep, oky dook. Well, I'll teach to some things
Speaker 3: that I have discovered. Great, but we've got a few
Speaker 3: a few things. This is off to a great start erin,
Speaker 3: we've got a few things to tackle before we can
Speaker 3: get into like the meat of the episode. It's quarantin
Speaker 3: any time.
Speaker 1: It's quarantin any time. We're still we changed it. Yeah.
Speaker 3: Oh, uncommon cold, the uncommon cold.
Speaker 1: Yeah, that's what we're drinking. That's what we're drinking. Yep,
Speaker 1: we should probably do that again though, right, Nah, Okay.
Speaker 3: This is gold erin, this is gold It's an uncommon cold.
Speaker 3: It's a hobn arrow margarita, spicy margarita because it's blended.
Speaker 3: It's cold, there's ice in it, but also there's like
Speaker 3: a little bit of warmth, you know. Yeah, and also
Speaker 3: alcohol does not make is not a treatment for hypothermia,
Speaker 3: as we covered last episode as the Room. Yeah, it's
Speaker 3: on our website, this podcast will kill You dot com.
Speaker 3: It's on our social media channels, toy.
Speaker 1: This is going really well, really well.
Speaker 3: Our website has lots of good things. It's got transcripts,
Speaker 3: it's got sources for all of our episodes, links to
Speaker 3: merch links to Patreon, bookshop, dot Orgiphilia account, Goodreads list,
Speaker 3: music by Bloodmobile. If I haven't already said that, contact
Speaker 3: us form firsthand account form reach out, reach out. We
Speaker 3: love to hear from you.
Speaker 1: We also love to hear when you have a great
Speaker 1: rating or review to write about us, So if you
Speaker 1: could leave us one of those, we'd really appreciate it.
Speaker 1: I haven't done that already, Thank you if you have,
Speaker 1: and subscribe on YouTube exactly right, channel. Can we get
Speaker 1: into the episode.
Speaker 3: Certainly, but it's like a break. I left off last
Speaker 3: week with the story of the amazing recovery of Anna Bagenholm,
Speaker 3: whose body temperature dropped to thirteen point seven degrees celsius
Speaker 3: or fifty six point six degrees fahrenheit. What I still
Speaker 3: can't get over it.
Speaker 1: Yeah, it is that, like the is that in the
Speaker 1: Guinness Book of World Records? Like is that the record?
Speaker 3: Or I don't trust the Guinness Book of World Records
Speaker 3: anymore the g I ever did, but like, yeah, not
Speaker 3: after a gallstone.
Speaker 1: Missaply hugely lost faith.
Speaker 3: But yeah, she might be in there.
Speaker 2: Wo.
Speaker 3: But in that episode Arin last week, you also took
Speaker 3: us through all the ways that the cold can hurt
Speaker 3: or even kill us, and how we can reverse or
Speaker 3: halt some of that damage. But it would be unfair
Speaker 3: to the cold for us to end the story there
Speaker 3: just showing its villainous side, Because while the cold has
Speaker 3: claimed many lives and fingers and toes and noses, it
Speaker 3: has also saved many as harnessed by modern medicine. And
Speaker 3: so this week I want to tell the story of
Speaker 3: how humans have attempted to use cold, successfully or unsuccessfully,
Speaker 3: to save or prolonged lives. We have long used cold
Speaker 3: as a topical treatment for various aches and pains, swollen joints,
Speaker 3: battle trauma, and fever. Ancient Egyptian, Greek, and Roman physicians
Speaker 3: all called for cold to be used in various ailments.
Speaker 3: You know, the oldest medical writing hailing the benefits of
Speaker 3: cold comes from the Edwin Smith Scroll dating to sixteen
Speaker 3: hundred BCE. It details a recipe to cool blisters, so
Speaker 3: it's more about like a cooling sensation in the cold itself,
Speaker 3: but still.
Speaker 1: Like still, yeah, cold can feel good.
Speaker 3: Cold can feel good. And Hippocrates, of course was a
Speaker 3: big liver in cold, especially for those of a warmer temperament.
Speaker 3: And he also wrote that this is yeah, infants left
Speaker 3: out in winter like left out infants survived longer than
Speaker 3: babies left out in the summer months.
Speaker 1: That's I'm sorry, I wrote, yeah, like, first of all,
Speaker 1: what also second of all, I could miss this a
Speaker 1: little bit, but you just said of a warmer temperament.
Speaker 3: Oh yeah, you know, like tempers or not tempers? Oh
Speaker 3: like humors? Humors, Oh my god, you just did a whole.
Speaker 1: Episode, just did a whole episode on it.
Speaker 3: Honestly, this sweater is making me overheat.
Speaker 1: Well maybe you have a warm temperament and you need.
Speaker 3: Some cold next week hyperthermia. Just kidding, but no, so
Speaker 3: I I have no idea.
Speaker 1: Was this experiment?
Speaker 3: Was this just like lore?
Speaker 1: You know?
Speaker 3: Yeah, I don't know.
Speaker 1: I mean so like babies can definitely overheat, yes, in
Speaker 1: warmer temperatures, in many cases more quickly than they will.
Speaker 1: But like we said last week, because of their body
Speaker 1: surface area to volume ratio, they're also you know, going
Speaker 1: to get be more susceptible to hype both roma too,
Speaker 1: So it's it is both. And how about that both?
Speaker 3: And I mean really anything is possible with Hippocrates, Like
Speaker 3: it's like I yeah, I don't know. But beginning in
Speaker 3: the sixteen hundreds or so, there was a shift in
Speaker 3: thinking like if a little localized cold was helpful to
Speaker 3: relieve joint pain and whatnot, that a full body cold
Speaker 3: soak would be even better. Right. Cold baths became all
Speaker 3: the rage, and advocates claimed that they cured every ailment
Speaker 3: under the sun, especially fevers, which honestly, maybe they did,
Speaker 3: I don't know, But by the way, this made me
Speaker 3: think I was I did a little digging in this
Speaker 3: episode because I was like, oh, yeah, fevers that sometimes
Speaker 3: can be adaptive, that sometimes can help us to fight
Speaker 3: off infections. Can hypothermia ever be adaptive in that way?
Speaker 3: Is there any reason that it would be protective? So
Speaker 3: I did some digging, and yes, I did find that
Speaker 3: a few people suggested that maybe a hypothermic response, like
Speaker 3: sometimes people get hypothermic incepsis, for instance, could be a
Speaker 3: last ditch effort to conserve energy and protect it gets
Speaker 3: damage from inflammation. But I also see your face right now,
Speaker 3: which is very questioning, and that's that's how I feel too,
Speaker 3: because how do you disentangle that from the body just
Speaker 3: not having the energy to maintain a fever or even
Speaker 3: just like normal body temperature?
Speaker 1: Right And I will say, like, what is the what
Speaker 1: is the driver of it? I don't know, but what
Speaker 1: is the outcome of it? We do know that hypothermia
Speaker 1: in case like unintentional hypothermia, We're going to talk later
Speaker 1: and today about like intentionally reducing someone's body temperature. But
Speaker 1: if someone is so sick with an infection and they
Speaker 1: end up hypothermic, it's usually quite a bad sign that
Speaker 1: things are not going well and they're usually poor outcomes.
Speaker 3: Yeah, so it's yeah, it's not like it seems to
Speaker 3: me that we have no evidence to suggest or very
Speaker 3: little and not none that I found that it's an
Speaker 3: adaptive response and it's more just the body shutting down.
Speaker 1: Yeah, it's not like our It's not like a fever
Speaker 1: where our hypothalmis is like, hey, let's raise the body temperature.
Speaker 1: Our hypothemist doesn't go, hey let's lower the body temperature.
Speaker 2: Didn't.
Speaker 1: I didn't find any data that happens in humans and
Speaker 1: other animals like you talked about, they're doing all the time.
Speaker 3: They're doing it for other reasons too. It's like not,
Speaker 3: it's yeah, exactly. Yeah, okay, anyway, I love this one
Speaker 3: of already. I'm glad, don't we love to just like
Speaker 3: some easy swing and just bat down ideas. Yeah, hypotheses, No,
Speaker 3: I got Okay. So, one of the biggest cheerleaders for
Speaker 3: cold baths was this guy named James Curry, and I
Speaker 3: mentioned him in our Fever episode last year as the
Speaker 3: mastermind behind many enthusiastic cold water treatments, where he continually
Speaker 3: doused people with freezing water, even past the point where
Speaker 3: they were like no, please, no, no, more.
Speaker 1: Remember this.
Speaker 3: Well, I don't know. I don't remember if I got
Speaker 3: into this in the episode. But one of the reasons
Speaker 3: that he became so evangelical about cold water treatment is
Speaker 3: because in the early seventeen seventies he observed a shipwreck
Speaker 3: in the freezing waters of the North Channel. When rescue
Speaker 3: finally came, the survivors tended to be those who stayed
Speaker 3: in the water, while those who waited on top of
Speaker 3: the ship more often perished. And that made me think
Speaker 3: of Titanic and Jack and Rose, you know, because by
Speaker 3: this logic, shouldn't Jack have survived.
Speaker 1: Spoilers, He doesn't.
Speaker 3: He doesn't spoilers. Sorry if that's a spoiler for it,
Speaker 3: And it got spoiled for me by a neighborhood friend
Speaker 3: in when it came out and it was trauma like that,
Speaker 3: like has made me hate spoilers so much, you know
Speaker 3: how I feel like would be I do like dealers, But.
Speaker 1: Yeah, it also I just want to say that that
Speaker 1: does not make any sense because of what we talked
Speaker 1: about last week with how water is a much better
Speaker 1: conductor of heat than air, and so immersion in even
Speaker 1: I mean, the water in Titanic was like below freezing,
Speaker 1: very cold. But even immersion in like water that's like
Speaker 1: sixty or seventy degrees can cause hypothermia in a number
Speaker 1: of hours, where it would take a very very prolonged
Speaker 1: exposure with no clothes at all to be hypothermic in
Speaker 1: those temperatures in air.
Speaker 3: Yeah, I mean, you know, if only we had Curry
Speaker 3: himself here to question only only bro.
Speaker 1: Yeah, what was your sample size?
Speaker 3: And I think he was watching from a distance, and
Speaker 3: how he could even know were the people who were
Speaker 3: on the shipwreck like or on the remains of the
Speaker 3: boat where they also soaked in water? Did they fall
Speaker 3: off occasionally?
Speaker 2: You know?
Speaker 1: Like right, was it that they were soaking wet and
Speaker 1: then there was wind chill or something like that? Maybe
Speaker 1: was the air temperature colder and the water temperture was
Speaker 1: not that cold and then there was a winch maybe.
Speaker 3: I mean the bottom line is that he was like
Speaker 3: convinced cold water is where it is at.
Speaker 1: Well, we know you can't change their minds, you can't.
Speaker 3: Yeah. And oh, by the way, speaking of Titanic, so
Speaker 3: of the nearly fifteen hundred deaths from the Titanic, from
Speaker 3: that Titanic, I mean, I don't need to say, anymore
Speaker 3: were classified as drowning when in fact they were probably hypothermia. Yeah,
Speaker 3: makes just an interesting I think that kind of but
Speaker 3: it shows to me it demonstrates sort of the public's
Speaker 3: understanding of hypothermia and what was happening in that situation. Yeah, okay.
Speaker 3: So the other reason that Curry was psyched about cold
Speaker 3: baths was reading about the experience of this guy, doctor
Speaker 3: William Wright, who used cold water to treat a fever
Speaker 3: that he had, which was likely typhoid fever. All right,
Speaker 3: quote September ninth. Having given the necessary directions, about three
Speaker 3: o'clock in the afternoon, I stripped off all my clothes
Speaker 3: and threw a sea cloak loosely about me till I
Speaker 3: got upon deck. When the cloak was also laid aside.
Speaker 3: Three buckets full of cold salt water were then thrown
Speaker 3: at once on me. The shock was great, but I
Speaker 3: felt immediate relief. The headache and other pains instantly abated,
Speaker 3: and a fine glow and diaphoresis succeeded. Towards evening, however,
Speaker 3: the febrile symptoms threatened return, and I had recourse again
Speaker 3: to the same method as before, with the same good effect.
Speaker 3: I now took food with an appetite and for the
Speaker 3: first time had a sound night's rest en.
Speaker 1: I love that image. What is a sea cloak? Can
Speaker 1: I have one?
Speaker 3: I'm assuming towel. No, I'm picturing.
Speaker 1: I'm picturing something quite much more majestic than a towel.
Speaker 3: I'm calling my towel sea cloak. From this point forward,
Speaker 3: can you help me fold the sea clad folks? Please?
Speaker 1: Do you know that never in a million years would
Speaker 1: I assumed that it's a towel.
Speaker 3: I have no idea. Somebody, we need to look this up.
Speaker 1: Of course it's a towel, but I never.
Speaker 3: Know it might not be. It's just a branding opportunity.
Speaker 3: It really is.
Speaker 1: Someone make a seat cloak, Okay, but also like that's
Speaker 1: a hih so that is the account that made this
Speaker 1: guy Curry be like cold baths, cold bass for everyone,
Speaker 1: cold bass for everything.
Speaker 3: Yeah, I mean it's it's not that much different than
Speaker 3: like watching a TikTok video today and being like cold baths.
Speaker 1: I think you can find a lot of those videos
Speaker 1: on tiktoks. People are really into cold baths.
Speaker 3: Yeah, yes, yeah, yep, uh and so, but this like
Speaker 3: really took many different places by storm spas sprung up
Speaker 3: where you could alternate between hot and cold waters, which
Speaker 3: is quite delightful, and the benefits of cold water plunges
Speaker 3: widely hailed even before the TikTok bros you know, came
Speaker 3: on the scene. But cold treatments weren't always used with consent.
Speaker 3: In the sixteen hundreds, cold water dunking was occasionally employed
Speaker 3: as a cure for mental illness, where it proved not
Speaker 3: only ineffective but also cruel, torturous, and even deadly. In
Speaker 3: some cases, there were dunking stations built on the grounds
Speaker 3: of some asylums.
Speaker 1: Oh my gosh, that's awful.
Speaker 3: The logic behind this was that, okay, well, if mental
Speaker 3: illness is caused by a fevered brain, you need to
Speaker 3: cool it by any means necessary. So as an example,
Speaker 3: in seventeen twenty five, a woman who was accused of
Speaker 3: neglecting her husband was forced, while restrained, to stand under
Speaker 3: a torrent fifteen tons of freezing water for ninety minutes
Speaker 3: until she promised she would become a loving and obedient wife. Torture.
Speaker 3: That's like, I mean, what else do you call this?
Speaker 2: Really?
Speaker 1: Torture? Just actual torture? Yeah, yeah.
Speaker 3: What uh, and not to mention ineffective on medical grounds,
Speaker 3: but even if it were effective, it's not like that
Speaker 3: would justify its use.
Speaker 1: Also, it's not a mental disorder to not be nice
Speaker 1: to your husband.
Speaker 2: I know.
Speaker 3: I I told my husband this, and he was like,
Speaker 3: what is neglectful? Like what what does that? What does
Speaker 3: that mean?
Speaker 2: Right?
Speaker 3: Yeah?
Speaker 1: Right, so many questions. Sandwich wasn't made crispy enough, or
Speaker 1: like it was too crispy and it you know when
Speaker 1: it scratches the.
Speaker 3: Top, Yeah, the Captain crunch syndrome. Yeah, just shreds the
Speaker 3: roof of your mouth.
Speaker 1: She made his sandwich like that?
Speaker 3: Mm hmm. I mean, well, yeah, I still don't think
Speaker 3: it deserves fifteen tons of freezing water. But you know
Speaker 3: that's just my opinion, just.
Speaker 1: Our opinion, just our opinion, Okay.
Speaker 3: But yeah, And so as as much as I would
Speaker 3: like to tell you that this type of thing fell
Speaker 3: out of favor and was never used again by anyone
Speaker 3: in medicine, unfortunately I I cannot. In fact, it was
Speaker 3: the tortuous use of cold on non consenting individuals that
Speaker 3: led to cold therapy being dismissed as an illegitimate and
Speaker 3: groundless therapy, even when one doctor showed evidence to the contrary.
Speaker 3: While in medical school in the early twentieth century, Temple
Speaker 3: Fay was stumped by a question on a quiz, why
Speaker 3: does metastatic cancer rarely appear in the limbs? He had
Speaker 3: no idea. He was like, I don't know what to
Speaker 3: put here. So he asked his professor, like, hey, what's
Speaker 3: the answer to this? And his professor was like, I
Speaker 3: don't know either.
Speaker 1: Actually, why did they put it on the quiz?
Speaker 3: I don't know, I don't know.
Speaker 1: Okay, yep.
Speaker 3: But the puzzles stuck with him, and so in the
Speaker 3: nineteen thirties, Fay decided that he wanted to try to
Speaker 3: solve it. His primary hypothesis had to do with temperature,
Speaker 3: so he figured that parts of the body with higher
Speaker 3: temperatures were more likely to promote cancer growth, while cooler
Speaker 3: parts the extremities discouraged growth. It would stand to reason, then,
Speaker 3: that if you cooled a metastatic growth, you could arrest
Speaker 3: cancer development. So, operating under this logic, Fay devised a
Speaker 3: few local refrigeration experiments, first in chicken embryos than tissue culture,
Speaker 3: and then in humans. His first patient was a woman
Speaker 3: who was experiencing extreme pain from a cervical carcinoma. He
Speaker 3: inserted a device of his own making into the mass,
Speaker 3: like a hollow metal capsule through which water flowed in
Speaker 3: a closed system, and he set it to cooling. Forty
Speaker 3: eight hours later, the patient was pain free, and within
Speaker 3: five days the tumor had actually shrunk a fair bit
Speaker 3: around the edges of wow. The results encouraged Fay to
Speaker 3: invent more cooling instruments and setups rubber bags, tubing ice baths,
Speaker 3: and he tested out his hypothesis on other cancer patients.
Speaker 3: His results suggested he was onto something. Ninety five percent
Speaker 3: of his patients reported an alleviation in pain, and twenty
Speaker 3: to twenty five percent reported that their tumors shrank or
Speaker 3: grew more slowly. I mean, this was the nineteen thirties,
Speaker 3: so keep in mind that, like other treatment options for
Speaker 3: cancer were really limited. Yeah, and when he presented his results,
Speaker 3: the broader medical community was stunned. They had dismissed his
Speaker 3: ideas initially as just quackery, Like what do you mean,
Speaker 3: You're just going to refrigerate that body part and suddenly
Speaker 3: you're all healed. And now they're like, hey, actually, maybe
Speaker 3: there is something to therapeutic cooling. What other applications can
Speaker 3: we find for this? And Fay himself would have likely
Speaker 3: gone on to develop his cold therapy further if a
Speaker 3: couple of things had not happened. The first was a
Speaker 3: series of cold therapy programs that began in the nineteen
Speaker 3: forties at a few hospitals in the US, notably McLain
Speaker 3: Hospital in Belmont, Massachusetts. Doctors would administer barbiturates to the
Speaker 3: patients of theirs who were the most seriously debilitated by
Speaker 3: mental illness, and then place them in cold water for
Speaker 3: periods ranging from ten to thirty eight hours. Oh jeez. Yeah,
Speaker 3: and yes there were warming blankets on hand and the
Speaker 3: patients were being monitored.
Speaker 1: But still, this is this is patients with mental illness. Yes,
Speaker 1: these like this is these are not consented. This is
Speaker 1: not a correct correct this is not an institutional review
Speaker 1: board which doesn't exist approved done.
Speaker 3: Right, Yeah, body temperature would drop into the seventies fahrenheit
Speaker 3: twenties celsius. Outcomes were allegedly positive, but it's not clear
Speaker 3: who's making the assessment, right, Like, is it the doctor
Speaker 3: who's like bio to think, Oh, I want this therapy
Speaker 3: to work, you know, is it the person's self reporting, right,
Speaker 3: And it's also not clear how long any you know,
Speaker 3: positive effects, if they did exist, how long they lasted,
Speaker 3: But they were encouraging enough for scientific American to rave
Speaker 3: about them quote for the first time. This new therapy,
Speaker 3: popularly known as human hibernation and technically as hypothermia, has
Speaker 3: apparently found a definite, valuable application in treating insanity, particularly
Speaker 3: schizophrenia or dementia praecox. Results in the case of study
Speaker 3: have been remarkable, so that more extensive investigation of the
Speaker 3: possibilities and limitations of this treatment will surely be forthcoming
Speaker 3: at the war's end, if not before end.
Speaker 4: Quote Okay, Yeah, a little bit of unchecked enthusiasm there
Speaker 4: that went a bit too far, as it often does.
Speaker 3: And as more hospitals started cold therapy program to treat
Speaker 3: mental illness, there was several of them that got started. Illnesses, injuries,
Speaker 3: and deaths, even deaths occurred. So for example, at the
Speaker 3: University of Cincinnati in nineteen forty three, sixteen people were
Speaker 3: put into refrigerators for forty eight hours, Two died, and
Speaker 3: others suffered permanent brain damage. Yeah, jeez, this, This had
Speaker 3: the understandable effect of halting interest in therapeutic hypothermia for
Speaker 3: any reason or for any condition. But it was it
Speaker 3: wasn't the only thing to do, so it wasn't the
Speaker 3: only thing to kind of pump the brake. So I
Speaker 3: mentioned that it was a couple of things that prevented
Speaker 3: therapeutic hypothermia from being like more investigated. The first being
Speaker 3: these US based programs, and the second was Nazis.
Speaker 1: Yeah, so that's what I knew about.
Speaker 3: Yeah. In nineteen thirty nine, temple Fay submitted a manuscript
Speaker 3: to a publisher in Belgium, and somehow the Nazis, who
Speaker 3: had captured Belgium in nineteen forty came across it. They
Speaker 3: were already interested in hypothermia because their pilots often died
Speaker 3: in frigid waters after being shot down, and they wanted
Speaker 3: to better understand how long come someone could survive, at
Speaker 3: what temperatures, which revival methods worked best, and when the
Speaker 3: point of no return was there, like what that point
Speaker 3: looked like, what it was? And they took inspiration from
Speaker 3: phase paper to set up cold water immersion tanks at
Speaker 3: Dochau concentration camp, where they held people in the tanks
Speaker 3: at varying temperatures ranging from thirty six point five degrees fahrenheit,
Speaker 3: which is two and a half degrees celsius, to fifty
Speaker 3: four degrees fahrenheit or twelve degrees celsius. Sometimes they gave
Speaker 3: people pilot suits or flotation devices. Other times they stripped
Speaker 3: them and held them there naked for up to fourteen hours,
Speaker 3: and over the course of the war, three hundred and
Speaker 3: sixty to four hundred experimental sefts were carried out, involving
Speaker 3: three hundred individuals. It's yeah, there are many, many more
Speaker 3: horrifying details of this torture that emerged after the war
Speaker 3: during the Nuremberg Trials, and the news of these trials
Speaker 3: really poisoned any remaining interest in therapeutic hypothermia. For almost
Speaker 3: two decades, no one wanted to be seen doing what
Speaker 3: had become characterized as Nazi science. Eventually, though, that characterization
Speaker 3: faded as people realized that cold therapy may still hold
Speaker 3: some promise, and as World War two became more distant,
Speaker 3: some researchers grew more comfortable with using the data generated
Speaker 3: by these torture sessions, believing that it could quote advance
Speaker 3: contemporary research on hypothermia and save lives end quote. And
Speaker 3: it became and really still is quite a controversial topic.
Speaker 3: Some people advocate for free, unrestricted use of this type
Speaker 3: of data, and others saying that a ban is actually
Speaker 3: more appropriate. No one, no one should be able to
Speaker 3: use this data.
Speaker 1: I mean you're essentially benefiting from torture, torture in one way,
Speaker 1: in one way or another.
Speaker 3: By nineteen eighty four, though over forty five publications had
Speaker 3: cited the hypothermia experiments at Dacau implicitly or explicitly endorsing
Speaker 3: the use of such data. And I found a paper
Speaker 3: published in the New England Journal of Medicine in nineteen
Speaker 3: ninety that discusses these hypothermia experiments specifically and the controversy
Speaker 3: surrounding them, and the author concludes with this quote on analysis,
Speaker 3: the Dacou hypothermia study has all the ingredients of a
Speaker 3: scientific fraud, and rejection of the data on purely scientific
Speaker 3: grounds is inevitable. If the shortcomings of the Dacou hypothermia
Speaker 3: study had been fully appreciated, the ethical dialogue probably would
Speaker 3: never have begun. Continuing it runs the risk of implying
Speaker 3: that these grotesque Nazi medical exercises yielded results worthy of
Speaker 3: consideration and possibly of benefit to humanity. The present analysis
Speaker 3: clearly shows that nothing could be further from the truth. Basically,
Speaker 3: like the author, I feel like he is saying that
Speaker 3: if it's a question of using the data, first of all,
Speaker 3: the data is worthless scientific, right. But even if it
Speaker 3: was you know, had even if the experiments were done
Speaker 3: in a way were quote unquote experiences were done in
Speaker 3: a way that was controlled and all the variables, it
Speaker 3: doesn't mean that it's okay to use.
Speaker 1: Yeah.
Speaker 2: So.
Speaker 1: And also and also on top of that, it's trash data.
Speaker 3: It's trash. Yeah, it's just yeah yeah, so yeah, there's
Speaker 3: it is a really interesting paper.
Speaker 4: Yeah.
Speaker 3: So, therapeutic hyperthermia joins the ranks of so many other
Speaker 3: scientific advancements that have been built on the backs of
Speaker 3: those who did not have the power to say no
Speaker 3: or have their no heard. And hopefully it's somewhat of
Speaker 3: a consolation that overall, very few papers exploring the use
Speaker 3: of therapeutic hypothermia make reference to Dacau, at least like
Speaker 3: directly from data. They may mention this is where things
Speaker 3: you know, this is what YEP was done, but they
Speaker 3: don't say, and this is how we know.
Speaker 1: Is where we've got our data right right.
Speaker 3: And the therapy came crawling back slowly with a few
Speaker 3: papers here and there in the mid to late nineteen fifties,
Speaker 3: first the discovery by Hubert, Rossumov and Duncan holiday that
Speaker 3: when a person is hypothermic, their brain consumes less oxygen.
Speaker 3: It was a major breakthrough. It opened the door for
Speaker 3: new avenues to protect the brain during times where oxygen
Speaker 3: might be restricted like stroke, heart attack, aneurism, certain surgeries.
Speaker 3: By just reducing the brain's oxygen demands with hypothermia, you're
Speaker 3: protecting the brain from long term injury. And shortly after
Speaker 3: a few physicians started playing around with us hypothermia after
Speaker 3: cardiac arrest others during cardiac surgery, although the routine use
Speaker 3: of therapeutic hypothermia wouldn't happen for a long time, especially
Speaker 3: as physicians grew aware and wary of certain complications with
Speaker 3: the practice. In the nineteen fifties and nineteen sixties, again
Speaker 3: the therapy was used in a few small studies for
Speaker 3: infants that had trouble breathing shortly after birth, like Apgar
Speaker 3: scores of one this is our first hand account. Animal
Speaker 3: studies had shown promise in this regard, so doctors tried
Speaker 3: it out on humans. And also it has a deeper history,
Speaker 3: like there are some reports from the sixteen hundreds using
Speaker 3: cold water immersion for infant For infants, it seems successful.
Speaker 3: So when one of the studies, nine out of ten
Speaker 3: of the infants survived and none showed any developmental delay.
Speaker 3: And I couldn't find any indication that the baby that
Speaker 3: did not survive died because of hypothermia. But I, yeah,
Speaker 3: I don't think that that was the case. But these
Speaker 3: studies were really small and they weren't well controlled, and
Speaker 3: so combine that with the potential for complications, and you've
Speaker 3: got another decades long delay in this becoming a standard
Speaker 3: of care.
Speaker 1: Interesting.
Speaker 3: Yeah, And ultimately in two thousand and five, I believe
Speaker 3: it did become a routine and has since saved lives
Speaker 3: and prevented injuries. But what about prolonging lives. So someday, Aaron,
Speaker 3: we should do an entire episode on cryonics. As a teaser.
Speaker 3: For now, let's just say that while researchers were trying
Speaker 3: to figure out how to use the cold to protect
Speaker 3: the body from injury. Other folks were wondering whether we
Speaker 3: could use hypothermia to put the body in a suspended state.
Speaker 3: The space race had begun, after all, so like, who
Speaker 3: was going to be the first to traverse light year's
Speaker 3: worth of distances exactly? So a bunch of cryonics come
Speaker 3: and he sprung up in the nineteen sixties, with the
Speaker 3: first volunteer dying on January twelfth, nineteen sixty seven, and
Speaker 3: which was a little bit earlier than the company that
Speaker 3: he had. The Life Extension Society it was called, had
Speaker 3: thought that they were going he was going ready for dot. Yeah,
Speaker 3: they were not ready at all. Like his doctor was like,
Speaker 3: he's on ice. You got to get him now. And
Speaker 3: they didn't have anything set up. They were still in
Speaker 3: building the pods or whatever. And so they stored this
Speaker 3: person in one of the Life Extension Society guy's garages
Speaker 3: in his station wagon and then was like, don't tell
Speaker 3: my wife. And then his wife went into the garage
Speaker 3: and was like, what, get this out of here. So
Speaker 3: he found a couple of friends who would store the
Speaker 3: body for a few days. But yeah, cry on.
Speaker 1: Sorry, all I can do is blinga sorry, this is
Speaker 1: a this is a I just so, I'm so I understand. Sure,
Speaker 1: this was a person who died, yes, of some other cause,
Speaker 1: some cause cancer, Yes, I believe cancer. And then they
Speaker 1: made him cold and stored him in a hatchback.
Speaker 3: There was some profusion of various substances. I forget what
Speaker 3: got Yeah it might have been dmso sounds familiar.
Speaker 1: Yeah okay in the sixties, in nineteen sixty seven, yeah cool, okay, but.
Speaker 3: They didn't have the pods ready for like long term storage,
Speaker 3: so the station wagon.
Speaker 1: Was the thing pod. Yeah, okay, yep.
Speaker 3: But this came out, like the news of this came out,
Speaker 3: and cryonics never quite recovered from this first mishap, And
Speaker 3: really it was like, over the years, it seems like
Speaker 3: our way to extort money from grieving people who don't
Speaker 3: know how to accept that their loved one died or
Speaker 3: that they themselves are mortal.
Speaker 1: Going to die. Yeah.
Speaker 3: So there you have it, Aaron, the history of cold,
Speaker 3: the good, the bad, and the weird. So, okay, tell
Speaker 3: me how therapeutic hypothermia works. Does it work?
Speaker 1: I love that that's what you're leaving me with. Yeah,
Speaker 1: I also have to tell you I am not going
Speaker 1: to talk about cryonics at all.
Speaker 3: I didn't think, so that's okay.
Speaker 1: Literally, as you were like, as you were even starting,
Speaker 1: I was like, gosh, I wonder if I should have
Speaker 1: looked into like I didn't. So, if that's what you're
Speaker 1: expecting from this episode, listeners, you're about to be disappointed.
Speaker 1: I'm going to talk about real life and not science fiction. Yeah,
Speaker 1: maybe it will be science reality someday. Right now, it's
Speaker 1: science fiction.
Speaker 2: Okay.
Speaker 1: Wouldn't it be nice if we could wake up in
Speaker 1: the morning anyways, so.
Speaker 3: The Salm Beach boys, Oh, didn't it be nice?
Speaker 2: Okay.
Speaker 1: What I am going to actually focus on today, not cryonics,
Speaker 1: is how we use therapeutic hypothermia. I'm putting it in
Speaker 1: air quotes because we don't call it that anymore. Oh,
Speaker 1: there's there's been a multiple evolutions of this term for
Speaker 1: a while, and a kind of depends on the like
Speaker 1: what scenario you're looking at, So sometimes it still is
Speaker 1: induced hypothermia or therapeutic hypothermia, but more commonly targeted temperature
Speaker 1: management is used.
Speaker 3: Okay, this might explain why I could find so few
Speaker 3: papers on the history of therapeutic hypothermia.
Speaker 1: Yes, it's why it took me so long to find
Speaker 1: the papers that I finally found about how we do it.
Speaker 1: It's because targeted temperature management and now newly just temperature control.
Speaker 1: Why the change in rhetoric erin let me tell you. Oh,
Speaker 1: I'm going to tell you, but it's going to take
Speaker 1: me a while to get there because I'm verbose, and
Speaker 1: I'm going to focus mostly on the broad strokes of
Speaker 1: like what are the contexts in which we use therapeutic hypothermia,
Speaker 1: how do we do it, and things like that. The
Speaker 1: point of it, really big picture is what you mentioned, Aaron.
Speaker 1: It is to reduce the risk of ischemic injury, meaning
Speaker 1: reduce the risk that a lack of oxygen to our
Speaker 1: tissues causes actual and irreversible damage because of the theoretical fact,
Speaker 1: which is like, it's not just theoretical, it is true,
Speaker 1: but because of the fact that as our body temperature cools,
Speaker 1: our metabolic rate decreases, our need for oxygen in our
Speaker 1: tissues decreases. That is the theory by which therapeutic hypothermia works.
Speaker 1: But how does it end up working in practice? Like
Speaker 1: what is it really doing to protect our tissues? We
Speaker 1: think that in the brain, this decrease in our metabolic
Speaker 1: rate decreases blood flow to the brain, which can also
Speaker 1: decrease intra cranial pressure, which is something that often goes
Speaker 1: up during damage in our heart because of changes to
Speaker 1: the heart muscle and the heart tissues itself, as well
Speaker 1: as the changes that we see in our blood vessels.
Speaker 1: With cold. Right, we're vaso constricting a lot of our
Speaker 1: blood vessels. We see a decrease in our heart rate,
Speaker 1: but you can maintain blood pressure to a certain degree.
Speaker 3: Okay.
Speaker 1: And these are two of our organs, our heart and
Speaker 1: our brain that we are wanting to protect the most
Speaker 1: with therapeutic hypothermia, because our heart and our brain are
Speaker 1: two organs that a are going to be impacted first
Speaker 1: due to aeschemic damage. Right, lack of oxygen is going
Speaker 1: to end up damaging those tissues irrevocably, and if we
Speaker 1: we can protect those, then we could potentially recover from
Speaker 1: any other insult to other organs or other tissues.
Speaker 3: So we're still in the hypothetical thing, the thought of
Speaker 3: how this should go and why we think that that
Speaker 3: recooling a body a core temperature is going to be beneficial, Okay,
Speaker 3: got it.
Speaker 1: So to understand the specific situations where we might use
Speaker 1: therapeutic hypothermia or targeted temperature management or whatever. We also
Speaker 1: have to think about the ways in which this lack
Speaker 1: of oxygen ends up causing damage. Okay, because what that
Speaker 1: tells us is there's different time periods at which you
Speaker 1: could potentially use hypothermia to try and reverse or prevent
Speaker 1: this damage.
Speaker 3: Right, So tell we ah elaborate.
Speaker 1: Okay, let me elaborate, and we can use if we want,
Speaker 1: we can use an example. Let's say your heart stops. Okay, Okay,
Speaker 1: this is one possible situation. If your heart stops beating,
Speaker 1: you're not pumping blood, so your tissues are not going
Speaker 1: to get oxygen. That's all of your tissues, your brain,
Speaker 1: your heart, all of your tissues are going to not
Speaker 1: get oxygen. There's three phases to the damage that that
Speaker 1: is going to cause. The first is when that heart stops,
Speaker 1: you're going to have the lack of oxygen, right because
Speaker 1: our cells require oxygen for metabolism. Without oxygen, your cells
Speaker 1: start to become damaged. Okay, step one. But then if
Speaker 1: we are in medicine and we're like trying to bring
Speaker 1: somebody back and you can restart their heart after a
Speaker 1: cardiac arrest, you're going to all of a sudden reperfuse
Speaker 1: that area, yep, okay, which means you're going to have
Speaker 1: a flow of oxygen to the area. You're doing CPR,
Speaker 1: you're using a defibrillator, whatever it is you're now reperfusing.
Speaker 1: That process actually causes its own sort of damage, because
Speaker 1: as our cells start working again, they end up creating
Speaker 1: reactive oxygen species. The way that I think of it
Speaker 1: is like you know, if you turn your water off
Speaker 1: in your house for a while, yeah, and then when
Speaker 1: you turn it back on, it's like grody, like sputtery
Speaker 1: and like brown water at first before it runs clear.
Speaker 3: Thank you.
Speaker 1: That's my analogy. That's like the immediate reperfusion injury that
Speaker 1: you can get okay, okay, and then after that there's
Speaker 1: a final stage that you can also get, like a
Speaker 1: delayed reperfusion injury. Think of it like a few hours
Speaker 1: after you start to get blood flow back, there's inflammation.
Speaker 1: There's our body reacting to this insult that it just received,
Speaker 1: so you can get additional damage to that time as well.
Speaker 3: I don't have a Sealskis analogy. How does the what
Speaker 3: about pipes in the house water.
Speaker 1: It doesn't. Yeah, it doesn't. I don't have an equivalent there. Sorry, okay, okay, sorry, okay.
Speaker 1: So that so that's that's the example with cardiac arrest.
Speaker 1: But it's true in any scenario where you are have
Speaker 1: lack of blood flow, right if you think of a stroke,
Speaker 1: all of those same scenarios are going to happen. You
Speaker 1: have blocking blood flow to a part of the brain
Speaker 1: that causes tissue damage in the brain. Then if you're
Speaker 1: able to reperfuse that area by say breaking up that
Speaker 1: clot or something like that, you're going to get reperfusion injury,
Speaker 1: and then you'll have delayed reperfusion injury as well. So
Speaker 1: it is that's the ways that damage are caused. So
Speaker 1: you could potentially, in theory use hypothermia at any of
Speaker 1: those stages to decrease the risk of injury, depending on
Speaker 1: when you can initiate it, how long you initiate it for.
Speaker 1: Because in addition to decreasing our over a metabolism, this
Speaker 1: hypothermia also just like attenuates all of our cellular responses.
Speaker 1: It's going to reduce the inflammatory response. You'll have vaso constriction,
Speaker 1: so you're not going to have as much edema or
Speaker 1: fluid like collection outside of our vascular system. And there
Speaker 1: is a lot of animal data to support the use
Speaker 1: of therapeutic hypothermia in a really wide variety of situations.
Speaker 3: Okay, real quick though, So if someone has their heart stops,
Speaker 3: then there already will be damaged because of the reperfusion
Speaker 3: and then the second reperfusion situation whatever. So then when
Speaker 3: is hypothermia? When when do you target the use of hypothermia?
Speaker 3: And also how realistic is that from like a hospital situation.
Speaker 1: So that is why this gets so complicated. Okay, right,
Speaker 1: because that's the exact right question. But if you think
Speaker 1: about the survival story that you told last episode, Darren, Oh,
Speaker 1: because her he hair just stopped, her heart stopped, right,
Speaker 1: but she was already cold at that point. Yes, she
Speaker 1: was cold and her heart stopped because of that cold.
Speaker 1: So there was already a decrease. So you potentially in
Speaker 1: that case, because she recovered so well, you already had
Speaker 1: protection against anoxic injury, You had protection against lack of
Speaker 1: oxygen because the tissues were already cold before that initial insult. Right,
Speaker 1: in most realistic scenarios, that's not going to happen. Right.
Speaker 3: Yeah, So the cases.
Speaker 1: That we are going to potentially be able to use
Speaker 1: therapeutic hypothermia were probably not going to be able to
Speaker 1: do it before that initial injury, before the onset of
Speaker 1: the lack of oxygen. Okay, so it's the second two
Speaker 1: scenarios that were thinking about targeting. Can we use it
Speaker 1: to reduce the risk of that initial reperfusion injury? Well,
Speaker 1: to do that, you would have to cool the body
Speaker 1: before you reperfuse it, right right, Okay, so before you
Speaker 1: restart the heart. That's not a thing that people do
Speaker 1: because if someone's heart stops, your first thought is to
Speaker 1: restart it, restart us. Yeah. Right, So the way that
Speaker 1: therapeutic hypothermia, or the way that targeted temperature management often
Speaker 1: ends up being used is in that third phase to
Speaker 1: try and reduce the risk of that delayed reperfusion injury
Speaker 1: after the heart or whatever it is gets restarted or
Speaker 1: things like that, Can we can we reduce the risk
Speaker 1: of that further damage by cooling the body, slowing down
Speaker 1: the metabolism, slowing down the need for oxygen.
Speaker 3: Does that make sense? It does? And so like, because
Speaker 3: I feel like there are two main well, I mean
Speaker 3: obviously you're going to tell me more. But like in
Speaker 3: an emergency situation, there's it's like the use of therapeutic
Speaker 3: kypothermia or whatever. We're good temperature control, yeah whatever, Yeah,
Speaker 3: the thermostat in an emergency situation, And like we need
Speaker 3: to decide, right now, what do we do versus a
Speaker 3: we're going into surgery type of situation, Like is that
Speaker 3: you know, like a more planned right use?
Speaker 1: So when do we when do we actually use it? Right?
Speaker 1: What are the situations that we actually use it today?
Speaker 1: And do we have data that it's actually helpful? Because
Speaker 1: that was all like the theory of like this is
Speaker 1: how it should work, we should be able to use
Speaker 1: it in these scenarios. Can we actually use it in
Speaker 1: these scenarios? Surgeries? So, in a surgical situation, you could,
Speaker 1: because you're in total control there, you could cool the
Speaker 1: body before any kind of a schemic insult. Right, Yeah,
Speaker 1: you can do that. And if we are talking about
Speaker 1: a heart surgery, you might need to actually stop the
Speaker 1: heart in order to do a surgery on the heart. Right,
Speaker 1: In those situations, a person is put on cardiopulmonary bypass,
Speaker 1: so their blood is still being pumped. It's being oxygenated outside.
Speaker 3: Of the body.
Speaker 1: But could we by reducing their body temperature also decrease
Speaker 1: the risk that if we're not oxygenating it quite well enough,
Speaker 1: or just you know that the heart itself which is stopped,
Speaker 1: it's not going to be as injured. That is something
Speaker 1: that is sometimes used, but there is much more mixed
Speaker 1: data on whether or not it's truly protective, both for
Speaker 1: like neuroprotection as well as just like generally protective against dschemia.
Speaker 1: And so right now, the guidelines for you know, if
Speaker 1: someone is doing a heart surgery and is going to
Speaker 1: be on cardiopulmonary bypass, do you do intentional hypothermia or
Speaker 1: do you not? It depends on the situation.
Speaker 3: In what and like in what way.
Speaker 1: It might depend on that particular person, how high of
Speaker 1: risk are they for eschemia to begin with. It might
Speaker 1: depend on the capabilities of where you're doing the surgery.
Speaker 1: Do you have the ability to cool somebody or not.
Speaker 1: But the data is not like a clear cut like
Speaker 1: you need to do it in order to improve outcomes
Speaker 1: and it's okay if you don't do it. Essentially, in
Speaker 1: most other surgeries, the data is more clear that hypothermia
Speaker 1: should actually be avoided, okay, because your body is going
Speaker 1: to be under more stress trying to warm itself up,
Speaker 1: and surgery is already a very stressful situation. So it's
Speaker 1: really only like heart surgeries. There also was like there's
Speaker 1: been trials on using it for brain surgeries, especially like
Speaker 1: aneurism clips and things like that. There's not really data
Speaker 1: that hypothermia is beneficial necessarily in those scenarios.
Speaker 3: It's so interesting because I feel like, I mean, and
Speaker 3: maybe this just speaks to the papers that I found
Speaker 3: that were you know, out of date, but how so
Speaker 3: many how it is talked about in terms of like
Speaker 3: this is a really promising thing. It's case by case,
Speaker 3: but like it does, it does really work. And I
Speaker 3: think also just the fact it's the human body, Like
Speaker 3: we have these controls. These these are are homeostasis or whatever.
Speaker 3: We're trying to maintain temperature for our benefit, even if
Speaker 3: that does end up hurting us, And so I see, yeah,
Speaker 3: causing more stress by trying to override those controls. That
Speaker 3: makes sense.
Speaker 1: Yeah, yeah, So that's really from what I could find,
Speaker 1: at least, that's the only scenario where if you could
Speaker 1: do therapeutic hypothermia, you would be trying to prevent that
Speaker 1: initial injury. Everything else that we use it for is
Speaker 1: kind of post injury. Can we prevent you know, worse
Speaker 1: Sequele When it comes to neurologic stuff, because there's a
Speaker 1: lot of interest in like protecting our brain using hypothermia,
Speaker 1: the data is much more mixed and not as strong
Speaker 1: as I kind of expected. So after stroke, after traumatic
Speaker 1: brain injury, after you know, hemorrhagic aneurism or aneurism, rupture,
Speaker 1: any of these things, the data is unclear and guidelines
Speaker 1: right now do not support universal therapeutic hypothermia. Okay, they
Speaker 1: do support avoiding fever, and that is part of why,
Speaker 1: and I'll get into it even more, but that is
Speaker 1: part of why the kind of naming of this has
Speaker 1: changed more to let's not think as much about you know,
Speaker 1: intentionally cooling the body, but to like a degree lower
Speaker 1: than a typical body temperature of thirty seven, but let
Speaker 1: us do make sure that we don't go above thirty
Speaker 1: seven point five, because then we do see that there's
Speaker 1: more damage.
Speaker 3: That makes sense. What about babies?
Speaker 1: Okay, I was going to talk about cardiac arrest next.
Speaker 1: You can do a basory No, I love it. Those
Speaker 1: are the two. Those are the two big areas. So
Speaker 1: that's all the things that we maybe sometimes kind of
Speaker 1: use it for. There's two areas that at least for
Speaker 1: a while, Oh spoilers, this therapeutic hypothermia actually cooling the
Speaker 1: body to around thirty two thirty three thirty four degrees.
Speaker 1: So mild hypothermia was considered standard of care for almost
Speaker 1: twenty years for out of hospital cardiac arrest. Okay, so
Speaker 1: if somebody heart stops outside of the hospital and you're
Speaker 1: doing CPR or you have access to a diffibrillator and
Speaker 1: they have a shockable rhythm, so you can different relate them.
Speaker 1: There was a big paper that came out in two
Speaker 1: thousand and two that showed big benefit to once you
Speaker 1: get circulation back, once you have rosc which is return
Speaker 1: of spontaneous circulation, once you bring that person back to life,
Speaker 1: if you cool them for at least twenty four hours
Speaker 1: I think it was twelve to twenty four hours at first,
Speaker 1: you have improved outcomes, better survival.
Speaker 3: Okay, survival, that's the outcome, got it.
Speaker 1: Survival is the outcome, because that's yeah, And so that
Speaker 1: became standard of care. And then there was other papers
Speaker 1: that came out later that showed even if the person
Speaker 1: initially did not have a shockable rhythm, meaning if their
Speaker 1: heart stopped, but it was because of other things. It
Speaker 1: could be because of substance use, it could be because
Speaker 1: of a pulmonary issue, it could be like just so
Speaker 1: many different things. But their initial rhythm wasn't one that
Speaker 1: you could differ relate like they do on er.
Speaker 2: Huh.
Speaker 3: Yep, they've moved past the Oh that's good. The paddles, Yeah,
Speaker 3: that's good.
Speaker 1: Yeah. But so there were other papers that came out
Speaker 1: in like the early two thousands that showed even in
Speaker 1: those situations there was some benefit to therapeutic hypothermia, so
Speaker 1: that was the standard of care. However, since very recently,
Speaker 1: like a paper came out in twenty twenty one that
Speaker 1: looked at a pretty big swath of people regardless of
Speaker 1: their initial rhythm out of hospital cardiac arrest and did
Speaker 1: not find that therapeutic hypothermia was beneficial compared to just
Speaker 1: ensuring that they don't have a fever. So targeting thirty
Speaker 1: seven point five and not allowing it to go higher
Speaker 1: than that but not necessarily lowering it wasn't any more beneficial.
Speaker 1: There were a couple of other papers that came out
Speaker 1: since then that were similar that kind of just showed
Speaker 1: maybe this because there were papers that looked at, okay, well,
Speaker 1: if lowering the body temperature is beneficial, what's the ideal temperature?
Speaker 1: Is it thirty two? Is it thirty three? Could it
Speaker 1: be thirty six? How low do we need to go?
Speaker 1: And those papers found that like thirty six and thirty three, Eh,
Speaker 1: no big difference, And so that led to more and
Speaker 1: more of these papers looking at how cold do we
Speaker 1: need to get people to have a benefit to try
Speaker 1: and keep them alive with minimal neurologic damage once we
Speaker 1: bring them back after their heart stops.
Speaker 3: Okay, so this is once you bring them back after
Speaker 3: their heart stops, administer therapeutic hypothermia, but you don't anymore.
Speaker 3: It's just make sure they don't have a fever.
Speaker 1: So right now, as of twenty twenty three, the guidelines
Speaker 1: is to pick a temperature somewhere between thirty two and
Speaker 1: thirty seven point five and keep them there, so temperature
Speaker 1: control but not necessarily therapeutic hypothermia.
Speaker 3: I have a question, how do we do that? Ooh,
Speaker 3: such a good question.
Speaker 1: There's a lot of different ways. It all does have
Speaker 1: to be very tightly monitored, especially during the induction and
Speaker 1: maintenance phase, so as you're cooling that body down and
Speaker 1: then once you get to that temperature that you're targeting,
Speaker 1: one of the things you have to do is avoid shivering,
Speaker 1: right because that's an automatic response that's going to rewarm
Speaker 1: the body and increase metabolic demand. You also have to
Speaker 1: keep very close eye on like their blood counts, making
Speaker 1: sure that all of the things that can go wrong
Speaker 1: during hypothermia, getting increased blood clotting, electrolyte abnormalities, diarrhasis, acid
Speaker 1: base disorders, from things shifting in and out of cells.
Speaker 1: You have to monitor all of those things. But how
Speaker 1: do you actually do it. You can do it almost
Speaker 1: the opposite of how we can warm your body, So
Speaker 1: you can externally cool with like water baths or these
Speaker 1: fancy gel pads that like circulate temperature controlled water. You
Speaker 1: can do internal cooling like the opposite of what we
Speaker 1: would do to warm it up. You can infuse cold
Speaker 1: ivy fluids or cold like peritoneal or levage. You can
Speaker 1: also I know you can also do have you ever
Speaker 1: donated plasma only blood? If you ever donate plasma they
Speaker 1: take out circulate, yeah, yeah, and so when it goes
Speaker 1: back into you, it is a little it's not cooled,
Speaker 1: but it is just colder than your body temperature usually,
Speaker 1: and it does it makes you feel cold. But you
Speaker 1: can also do that. You can do extra corporeal blood cooling,
Speaker 1: so you can take someone's blood out, cool it down
Speaker 1: and then and then infuse it back in. So there's
Speaker 1: a number of different ways. And like I mentioned, it's
Speaker 1: usually a very mild hypothermia that is targeted, so like
Speaker 1: thirty two to thirty four degrees celsius, right, okay, pascinating, Okay,
Speaker 1: I know. And then there is babies, you asked, Aaron,
Speaker 1: And this is the area that I think therapeutic hypothermia
Speaker 1: is truly still the correct term because it is the
Speaker 1: area that is still used Okay, whole body cooling or
Speaker 1: sometimes just head cooling, so just cooling of the head
Speaker 1: is used and is considered standard of care for full
Speaker 1: term newborns that are born and suspected of having hypoxic
Speaker 1: ischemic encephalopathy or HIE. And this is suspected brain damage
Speaker 1: that's due to lack of oxygen to the brain in
Speaker 1: a newborn okay, and that can happen. I'm not going
Speaker 1: to go into a lot of deep detail on this
Speaker 1: because I think it deserves its whole own episode. But
Speaker 1: this can happen in a variety of different contexts, either
Speaker 1: just before delivery or kind of during delivery, or shortly
Speaker 1: after delivery. Right, There's a lot of situations. Whether it's
Speaker 1: placental abruption when like the placenta comes off of the
Speaker 1: uterus before the baby is delivered, that is going to
Speaker 1: disrupt oxygen flow to the fetus, other cord issues like
Speaker 1: the cord getting compressed or prolapsing, uterine rupture, the heart
Speaker 1: rate of the fetus just dropping and then not recovering,
Speaker 1: or even during or after delivery. Anything that causes the
Speaker 1: baby to stop breathing or not have access to oxygen
Speaker 1: is going to lead to potentially hypoxic a ischemic encephalopathy.
Speaker 1: And we use that Appgar score that you mentioned, which
Speaker 1: is a composite score of like how well they're breathing,
Speaker 1: their skin color, Turger reflexes all of these things to
Speaker 1: give a sense of how a baby is doing. And
Speaker 1: it's usually at that ten minute mark if a baby's
Speaker 1: heart rate is still really low or if it's not
Speaker 1: there at all, and if they're not breathing or they're
Speaker 1: requiring continued ventilation support, there is good data that cooling
Speaker 1: these babies can help prevent severe disability or death. Okay,
Speaker 1: and I specifically mentioned full term infants. Yes, because a
Speaker 1: relatively recent study from I think it was actually published
Speaker 1: this year in twenty twenty five, was actually one of
Speaker 1: the first ones that looked at preterm infants and did
Speaker 1: not find any statistically significant improvement in outcomes for preterm
Speaker 1: infants by using therapeutic hypothermia.
Speaker 3: Why why do you think that is?
Speaker 1: I mean, babies, newborn babies are so different in their physiology,
Speaker 1: and so like a premature newborn has different physiology than
Speaker 1: a non premature like a full term newborn, and so
Speaker 1: we don't know, I mean the short answers, we just
Speaker 1: don't know. But that's why it was so important that
Speaker 1: this study was actually done, because there certainly were all
Speaker 1: of the studies previously had only used full term infants,
Speaker 1: and yet therapeutic hypothermia I think was often maybe used
Speaker 1: in some situations in preterm infants just based on the
Speaker 1: data of full term infants. Right, But because we know
Speaker 1: they're so different. It was important that this data actually
Speaker 1: came out and it doesn't show improvement in outcome.
Speaker 3: So okay, and what is like the the effect size,
Speaker 3: I guess or like what you know, it's a good question.
Speaker 1: A meta analysis from twenty one found for full term
Speaker 1: infants a pooled reduction in risk of mortality of about
Speaker 1: twenty six percent in infants who were cooled compared to
Speaker 1: ones who weren't. And this was similar whether it was
Speaker 1: whole body cooling or just head cooling that was used. Okay, yeah,
Speaker 1: it's not nothing.
Speaker 3: It's not nothing, and it's pretty amazing that, yeah, that
Speaker 3: there are there is I don't know there are uses
Speaker 3: for this because it does seem like fairly, I know,
Speaker 3: it's not straightforward that there are many different home approaches
Speaker 3: that you can use to do this and administer this
Speaker 3: and monitor this, and that it's about the degree and
Speaker 3: all this stuff. But it's like it's just I don't know,
Speaker 3: it's it's fascinating to me that it's like we use
Speaker 3: temperature in this way.
Speaker 1: Also, what you had mentioned, Aaron about the use in
Speaker 1: cancer is so interesting because I didn't find anything about
Speaker 1: it's you. I mean, I know you know, people do
Speaker 1: sometimes like ice on the head to try and reduce
Speaker 1: hair loss during chemo therapy or things like that. The
Speaker 1: mechanism that's going to be very different than what you
Speaker 1: had mentioned, but someone using it to try and reduce
Speaker 1: cancer growth. I think probably because we have better options
Speaker 1: today is why there's not really a lot of data
Speaker 1: that I could find, at least on modern uses of that.
Speaker 1: We do use a different kind of crowd therapy like
Speaker 1: liquid nitrogen to kill small skin cancers or other growths
Speaker 1: all the time. Yeah, I forgot about that after the fact.
Speaker 1: I also did find a paper on cold plunges and
Speaker 1: that kind of crowd therapy for muscle recovery have to
Speaker 1: work out by the way, there's not really good data
Speaker 1: to support it, but I can give you a paper
Speaker 1: if you want to read about it.
Speaker 3: Well, And you know, I'm not against cold plunges. If
Speaker 3: you enjoy jumping into an icy lake or tub or
Speaker 3: whatever it, do it safely, have a buddy whatever you know.
Speaker 1: No, but there's not like for like the muscle recovery stuff, like,
Speaker 1: there's not a lot of data that it's really beneficial.
Speaker 1: But you can read about it if you want to
Speaker 1: know more. We have so many sources for you.
Speaker 3: We do okay again, I'm going to shout out that
Speaker 3: book by Phil Jakol called out Cold Chilling Descent into
Speaker 3: the macabre, controversial, life saving History of Hypothermia. And then
Speaker 3: a paper about doctor temple Fay called Breaking the Thermal
Speaker 3: Barrier Doctor temple Fay by al Saga at All from
Speaker 3: two thousand and six and then by Gunn from twenty
Speaker 3: seventeen Therapeutic Hyperthermia Translates from Ancient History into Practice and
Speaker 3: more papers.
Speaker 1: I had a couple of older papers, one from twenty
Speaker 1: fourteen that old but called Clinical Applications of Targeted Temperature
Speaker 1: Management by Perman at All and another one from two
Speaker 1: thousand and eight that was just called Therapeutic Hypothermia by
Speaker 1: Varren and Acosta. And then the two papers two biggest
Speaker 1: papers that I had on hypothermia in infants. One of
Speaker 1: them is Whole Body Hypothermia for Neo nail and Cephalopathy
Speaker 1: and Preterm Infants thirty three to thirty five weeks in
Speaker 1: GEMI Pediatrics, and the other one was from PLUS one.
Speaker 1: And it was that twenty twenty one paper that was
Speaker 1: the systematic review and meta analysis. But then what's fun
Speaker 1: is I have guidelines. So many of the guidelines, like
Speaker 1: the two thousand and two paper that led to the
Speaker 1: guidelines initially of being yes, do therapeutic hypothermia for out
Speaker 1: of hospital kardiac arrest, and then all the subsequent papers
Speaker 1: that were like, yes, it's beneficial. No wait, maybe it isn't.
Speaker 1: Maybe it's not as good to be thought. Now Here
Speaker 1: are the new guidelines. So many guideline papers. You can
Speaker 1: find them all on our website, This podcast will kill
Speaker 1: You dot com.
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Speaker 1: And thank you to Leanna and Tom and Brent and
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Speaker 1: Thank you, thank you, thank you, thank you. Wow.
Speaker 3: Until next time, wash your hands
Speaker 1: You filthy animals.