September 9, 2025 • 65 mins
Last week, we took you through all the ways that cold can harm us and the harrowing history of humans perishing at its icy hands. Ending the story there would be skipping over the parts where cold gets to play the hero, rather than the villain. In the second installment of this frosty miniseries, we explore the situations in which we might use cold to protect us and how it actually works. We also delve into the surprisingly long (and unsurprisingly grim) history of therapeutic hypothermia, a journey that wouldn’t be complete without a debate over sea cloaks, a reconsideration of the plot of Titanic, and a brief jaunt into cryonics.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
In nineteen sixty seven, I was treated with hypothermia by
immersion in ice cold water as part of a local study,
and then developed subcutaneous fat necrosis. Both myself and one
other case were reported by the neonatal team who looked
after me to have had otherwise favorable short term outcomes,
but on the basis of this complication, these early studies
of hypothermia were stopped. I was born weighing three thousand,
(00:23):
nine hundred seventy grams at full term after an uncomplicated pregnancy,
labor and delivery. As reported, at one minute after birth,
I became apnic and did not respond to resuscitation. After
five minutes, I was placed in an ice water bath.
My breathing was reported to recover after twenty eight minutes
of hypothermia. At forty five minutes of life, my capillary
(00:44):
pH was six point nine but recovered steadily, and I
was discharged at day three. Subcutaneous fat necrosis developed between
two and four weeks of age. The calcium deposits were
largely cleared by six months. My serum calcium remained normal,
and my weight gain and in development were considered appropriate
at that age, but no further follow up was reported
(01:05):
fifty three years after these events. I have had a
very normal life. Although my mother tease me about my
skin in childhood, I never had any apparent skin problems
as a child or later. I was a keen sportsman
at school. My handwriting was never a strength, and so
I taught myself to touch type, which turned out to be
an advantage in the computer age. At the same time,
it is interesting to note that I can easily thread
(01:26):
a needle. Academically, I did very well throughout school and university.
I was awarded my PhD in nineteen ninety eight and
have served at my current institution as department chair and
faculty Senate president. In retrospect, I strongly believe that the
benefits of treatment clearly outweighed the costs, and that the
abrupt cessation of these early studies of therapeutic hypothermia represented
(01:46):
a missed opportunity. If the opinion of my parents had
been sought at the time, or subsequently my opinion, we
would have favored continued trialing of this promising treatment. Fascinating,
(02:43):
it's really an interesting I don't know that I've ever
read a report or like of someone who had been
a recipient of therapeutic hypothermia, like especially from so long ago,
Like it's really interesting. Yeah, it's really good. Fine, Darren,
thank you. I don't remember how I found it, but
(03:06):
well I can tell you where it's from.
Speaker 2 (03:10):
Do.
Speaker 1 (03:11):
That was by Robert Carlson in Pediatric Research from twenty
twenty one and article titled fifty three years of follow
up of an infant with neonatal encephalopathy treated with therapeutic hypothermia.
Speaker 3 (03:22):
It's fascinating and I feel like that, yeah, the first
hand account much much later because it's not like he
remembers this happening.
Speaker 1 (03:31):
Right, It's like he's clearly reading some of the like medical,
you know, records of his birth and treatment thereafter, and
then and then talking about his life since Like it's
so interesting.
Speaker 3 (03:42):
Yeah, and I'm I'm so curious to know how this
episode shakes out with like what you find. But like
the point I feel like, I feel like the thing
that stuck out to me when it comes to that
is that maybe it was a little bit of missed opportunity,
Maybe it was a little bit of you know, understandable
hesitation to pursue trials, but ultimately it's like, how do you,
(04:07):
how do you make scientific discoveries that do not harm
people or have the potential to harm people? And that's yeah.
You know, we've come a long way in the twentieth
century because of that. So yeah, anyway, Hi, I'm Aaron Welsh.
Speaker 1 (04:21):
And I'm Erin alman Updyke.
Speaker 3 (04:23):
And this is this podcast will kill You.
Speaker 1 (04:25):
And we're coming back with our second part on hypothermia,
as promised.
Speaker 3 (04:31):
As promised, this is hypothermia can be good, Cold can
be good.
Speaker 1 (04:36):
Cold is not always bad.
Speaker 3 (04:37):
Yeah, yeah, however you want to say it. Yes, it's
the history of therapeutic hypothermia. It's really so much to learn.
Speaker 1 (04:50):
I am thrilled. I know literally nothing about the history
prior to two thousand and two.
Speaker 3 (04:57):
Oh yep, oky dook. Well, I'll teach to some things
that I have discovered. Great, but we've got a few
a few things. This is off to a great start erin,
we've got a few things to tackle before we can
get into like the meat of the episode. It's quarantin
any time.
Speaker 1 (05:17):
It's quarantin any time. We're still we changed it. Yeah.
Speaker 3 (05:23):
Oh, uncommon cold, the uncommon cold.
Speaker 1 (05:25):
Yeah, that's what we're drinking. That's what we're drinking. Yep,
we should probably do that again though, right, Nah, Okay.
Speaker 3 (05:34):
This is gold erin, this is gold It's an uncommon cold.
It's a hobn arrow margarita, spicy margarita because it's blended.
It's cold, there's ice in it, but also there's like
a little bit of warmth, you know. Yeah, and also
(05:55):
alcohol does not make is not a treatment for hypothermia,
as we covered last episode as the Room. Yeah, it's
on our website, this podcast will kill You dot com.
It's on our social media channels, toy.
Speaker 1 (06:08):
This is going really well, really well.
Speaker 3 (06:11):
Our website has lots of good things. It's got transcripts,
it's got sources for all of our episodes, links to
merch links to Patreon, bookshop, dot Orgiphilia account, Goodreads list,
music by Bloodmobile. If I haven't already said that, contact
us form firsthand account form reach out, reach out. We
love to hear from you.
Speaker 1 (06:31):
We also love to hear when you have a great
rating or review to write about us, So if you
could leave us one of those, we'd really appreciate it.
I haven't done that already, Thank you if you have,
and subscribe on YouTube exactly right, channel. Can we get
into the episode.
Speaker 3 (06:52):
Certainly, but it's like a break. I left off last
week with the story of the amazing recovery of Anna Bagenholm,
(07:15):
whose body temperature dropped to thirteen point seven degrees celsius
or fifty six point six degrees fahrenheit. What I still
can't get over it.
Speaker 1 (07:26):
Yeah, it is that, like the is that in the
Guinness Book of World Records? Like is that the record?
Speaker 3 (07:31):
Or I don't trust the Guinness Book of World Records
anymore the g I ever did, but like, yeah, not
after a gallstone.
Speaker 1 (07:38):
Missaply hugely lost faith.
Speaker 3 (07:43):
But yeah, she might be in there.
Speaker 2 (07:44):
Wo.
Speaker 3 (07:45):
But in that episode Arin last week, you also took
us through all the ways that the cold can hurt
or even kill us, and how we can reverse or
halt some of that damage. But it would be unfair
to the cold for us to end the story there
just showing its villainous side, Because while the cold has
(08:05):
claimed many lives and fingers and toes and noses, it
has also saved many as harnessed by modern medicine. And
so this week I want to tell the story of
how humans have attempted to use cold, successfully or unsuccessfully,
to save or prolonged lives. We have long used cold
(08:26):
as a topical treatment for various aches and pains, swollen joints,
battle trauma, and fever. Ancient Egyptian, Greek, and Roman physicians
all called for cold to be used in various ailments.
You know, the oldest medical writing hailing the benefits of
cold comes from the Edwin Smith Scroll dating to sixteen
hundred BCE. It details a recipe to cool blisters, so
(08:50):
it's more about like a cooling sensation in the cold itself,
but still.
Speaker 1 (08:53):
Like still, yeah, cold can feel good.
Speaker 3 (08:56):
Cold can feel good. And Hippocrates, of course was a
big liver in cold, especially for those of a warmer temperament.
And he also wrote that this is yeah, infants left
out in winter like left out infants survived longer than
babies left out in the summer months.
Speaker 1 (09:16):
That's I'm sorry, I wrote, yeah, like, first of all,
what also second of all, I could miss this a
little bit, but you just said of a warmer temperament.
Speaker 3 (09:29):
Oh yeah, you know, like tempers or not tempers? Oh
like humors? Humors, Oh my god, you just did a whole.
Speaker 1 (09:36):
Episode, just did a whole episode on it.
Speaker 3 (09:38):
Honestly, this sweater is making me overheat.
Speaker 1 (09:41):
Well maybe you have a warm temperament and you need.
Speaker 3 (09:43):
Some cold next week hyperthermia. Just kidding, but no, so
I I have no idea.
Speaker 1 (09:49):
Was this experiment?
Speaker 3 (09:50):
Was this just like lore?
Speaker 1 (09:52):
You know?
Speaker 3 (09:53):
Yeah, I don't know.
Speaker 1 (09:55):
I mean so like babies can definitely overheat, yes, in
warmer temperatures, in many cases more quickly than they will.
But like we said last week, because of their body
surface area to volume ratio, they're also you know, going
to get be more susceptible to hype both roma too,
So it's it is both. And how about that both?
Speaker 3 (10:16):
And I mean really anything is possible with Hippocrates, Like
it's like I yeah, I don't know. But beginning in
the sixteen hundreds or so, there was a shift in
thinking like if a little localized cold was helpful to
relieve joint pain and whatnot, that a full body cold
soak would be even better. Right. Cold baths became all
(10:42):
the rage, and advocates claimed that they cured every ailment
under the sun, especially fevers, which honestly, maybe they did,
I don't know, But by the way, this made me
think I was I did a little digging in this
episode because I was like, oh, yeah, fevers that sometimes
can be adaptive, that sometimes can help us to fight
off infections. Can hypothermia ever be adaptive in that way?
(11:04):
Is there any reason that it would be protective? So
I did some digging, and yes, I did find that
a few people suggested that maybe a hypothermic response, like
sometimes people get hypothermic incepsis, for instance, could be a
last ditch effort to conserve energy and protect it gets
damage from inflammation. But I also see your face right now,
which is very questioning, and that's that's how I feel too,
(11:27):
because how do you disentangle that from the body just
not having the energy to maintain a fever or even
just like normal body temperature?
Speaker 1 (11:35):
Right And I will say, like, what is the what
is the driver of it? I don't know, but what
is the outcome of it? We do know that hypothermia
in case like unintentional hypothermia, We're going to talk later
and today about like intentionally reducing someone's body temperature. But
if someone is so sick with an infection and they
end up hypothermic, it's usually quite a bad sign that
(11:58):
things are not going well and they're usually poor outcomes.
Speaker 3 (12:00):
Yeah, so it's yeah, it's not like it seems to
me that we have no evidence to suggest or very
little and not none that I found that it's an
adaptive response and it's more just the body shutting down.
Speaker 1 (12:12):
Yeah, it's not like our It's not like a fever
where our hypothalmis is like, hey, let's raise the body temperature.
Our hypothemist doesn't go, hey let's lower the body temperature.
Speaker 2 (12:19):
Didn't.
Speaker 1 (12:19):
I didn't find any data that happens in humans and
other animals like you talked about, they're doing all the time.
Speaker 3 (12:25):
They're doing it for other reasons too. It's like not,
it's yeah, exactly. Yeah, okay, anyway, I love this one
of already. I'm glad, don't we love to just like
some easy swing and just bat down ideas. Yeah, hypotheses, No,
(12:45):
I got Okay. So, one of the biggest cheerleaders for
cold baths was this guy named James Curry, and I
mentioned him in our Fever episode last year as the
mastermind behind many enthusiastic cold water treatments, where he continually
doused people with freezing water, even past the point where
they were like no, please, no, no, more.
Speaker 1 (13:07):
Remember this.
Speaker 3 (13:09):
Well, I don't know. I don't remember if I got
into this in the episode. But one of the reasons
that he became so evangelical about cold water treatment is
because in the early seventeen seventies he observed a shipwreck
in the freezing waters of the North Channel. When rescue
finally came, the survivors tended to be those who stayed
in the water, while those who waited on top of
(13:31):
the ship more often perished. And that made me think
of Titanic and Jack and Rose, you know, because by
this logic, shouldn't Jack have survived.
Speaker 1 (13:43):
Spoilers, He doesn't.
Speaker 3 (13:46):
He doesn't spoilers. Sorry if that's a spoiler for it,
And it got spoiled for me by a neighborhood friend
in when it came out and it was trauma like that,
like has made me hate spoilers so much, you know
how I feel like would be I do like dealers, But.
Speaker 1 (14:01):
Yeah, it also I just want to say that that
does not make any sense because of what we talked
about last week with how water is a much better
conductor of heat than air, and so immersion in even
I mean, the water in Titanic was like below freezing,
very cold. But even immersion in like water that's like
sixty or seventy degrees can cause hypothermia in a number
(14:24):
of hours, where it would take a very very prolonged
exposure with no clothes at all to be hypothermic in
those temperatures in air.
Speaker 3 (14:32):
Yeah, I mean, you know, if only we had Curry
himself here to question only only bro.
Speaker 1 (14:39):
Yeah, what was your sample size?
Speaker 3 (14:41):
And I think he was watching from a distance, and
how he could even know were the people who were
on the shipwreck like or on the remains of the
boat where they also soaked in water? Did they fall
off occasionally?
Speaker 2 (14:52):
You know?
Speaker 1 (14:52):
Like right, was it that they were soaking wet and
then there was wind chill or something like that? Maybe
was the air temperature colder and the water temperture was
not that cold and then there was a winch maybe.
Speaker 3 (15:02):
I mean the bottom line is that he was like
convinced cold water is where it is at.
Speaker 1 (15:09):
Well, we know you can't change their minds, you can't.
Speaker 3 (15:12):
Yeah. And oh, by the way, speaking of Titanic, so
of the nearly fifteen hundred deaths from the Titanic, from
that Titanic, I mean, I don't need to say, anymore
were classified as drowning when in fact they were probably hypothermia. Yeah,
makes just an interesting I think that kind of but
(15:33):
it shows to me it demonstrates sort of the public's
understanding of hypothermia and what was happening in that situation. Yeah, okay.
So the other reason that Curry was psyched about cold
baths was reading about the experience of this guy, doctor
William Wright, who used cold water to treat a fever
that he had, which was likely typhoid fever. All right,
(15:53):
quote September ninth. Having given the necessary directions, about three
o'clock in the afternoon, I stripped off all my clothes
and threw a sea cloak loosely about me till I
got upon deck. When the cloak was also laid aside.
Three buckets full of cold salt water were then thrown
at once on me. The shock was great, but I
(16:14):
felt immediate relief. The headache and other pains instantly abated,
and a fine glow and diaphoresis succeeded. Towards evening, however,
the febrile symptoms threatened return, and I had recourse again
to the same method as before, with the same good effect.
I now took food with an appetite and for the
first time had a sound night's rest en.
Speaker 1 (16:36):
I love that image. What is a sea cloak? Can
I have one?
Speaker 3 (16:41):
I'm assuming towel. No, I'm picturing.
Speaker 1 (16:50):
I'm picturing something quite much more majestic than a towel.
Speaker 3 (16:53):
I'm calling my towel sea cloak. From this point forward,
can you help me fold the sea clad folks? Please?
Speaker 1 (17:01):
Do you know that never in a million years would
I assumed that it's a towel.
Speaker 3 (17:06):
I have no idea. Somebody, we need to look this up.
Speaker 1 (17:13):
Of course it's a towel, but I never.
Speaker 3 (17:15):
Know it might not be. It's just a branding opportunity.
It really is.
Speaker 1 (17:21):
Someone make a seat cloak, Okay, but also like that's
a hih so that is the account that made this
guy Curry be like cold baths, cold bass for everyone,
cold bass for everything.
Speaker 3 (17:34):
Yeah, I mean it's it's not that much different than
like watching a TikTok video today and being like cold baths.
Speaker 1 (17:42):
I think you can find a lot of those videos
on tiktoks. People are really into cold baths.
Speaker 3 (17:47):
Yeah, yes, yeah, yep, uh and so, but this like
really took many different places by storm spas sprung up
where you could alternate between hot and cold waters, which
is quite delightful, and the benefits of cold water plunges
widely hailed even before the TikTok bros you know, came
on the scene. But cold treatments weren't always used with consent.
(18:08):
In the sixteen hundreds, cold water dunking was occasionally employed
as a cure for mental illness, where it proved not
only ineffective but also cruel, torturous, and even deadly. In
some cases, there were dunking stations built on the grounds
of some asylums.
Speaker 1 (18:26):
Oh my gosh, that's awful.
Speaker 3 (18:29):
The logic behind this was that, okay, well, if mental
illness is caused by a fevered brain, you need to
cool it by any means necessary. So as an example,
in seventeen twenty five, a woman who was accused of
neglecting her husband was forced, while restrained, to stand under
a torrent fifteen tons of freezing water for ninety minutes
(18:53):
until she promised she would become a loving and obedient wife. Torture.
That's like, I mean, what else do you call this?
Speaker 2 (19:00):
Really?
Speaker 1 (19:00):
Torture? Just actual torture? Yeah, yeah.
Speaker 3 (19:02):
What uh, and not to mention ineffective on medical grounds,
but even if it were effective, it's not like that
would justify its use.
Speaker 1 (19:11):
Also, it's not a mental disorder to not be nice
to your husband.
Speaker 2 (19:17):
I know.
Speaker 3 (19:18):
I I told my husband this, and he was like,
what is neglectful? Like what what does that? What does
that mean?
Speaker 2 (19:25):
Right?
Speaker 3 (19:25):
Yeah?
Speaker 1 (19:25):
Right, so many questions. Sandwich wasn't made crispy enough, or
like it was too crispy and it you know when
it scratches the.
Speaker 3 (19:33):
Top, Yeah, the Captain crunch syndrome. Yeah, just shreds the
roof of your mouth.
Speaker 1 (19:39):
She made his sandwich like that?
Speaker 3 (19:40):
Mm hmm. I mean, well, yeah, I still don't think
it deserves fifteen tons of freezing water. But you know
that's just my opinion, just.
Speaker 1 (19:47):
Our opinion, just our opinion, Okay.
Speaker 3 (19:50):
But yeah, And so as as much as I would
like to tell you that this type of thing fell
out of favor and was never used again by anyone
in medicine, unfortunately I I cannot. In fact, it was
the tortuous use of cold on non consenting individuals that
led to cold therapy being dismissed as an illegitimate and
groundless therapy, even when one doctor showed evidence to the contrary.
(20:17):
While in medical school in the early twentieth century, Temple
Fay was stumped by a question on a quiz, why
does metastatic cancer rarely appear in the limbs? He had
no idea. He was like, I don't know what to
put here. So he asked his professor, like, hey, what's
the answer to this? And his professor was like, I
(20:39):
don't know either.
Speaker 1 (20:39):
Actually, why did they put it on the quiz?
Speaker 3 (20:45):
I don't know, I don't know.
Speaker 1 (20:47):
Okay, yep.
Speaker 3 (20:48):
But the puzzles stuck with him, and so in the
nineteen thirties, Fay decided that he wanted to try to
solve it. His primary hypothesis had to do with temperature,
so he figured that parts of the body with higher
temperatures were more likely to promote cancer growth, while cooler
parts the extremities discouraged growth. It would stand to reason, then,
(21:11):
that if you cooled a metastatic growth, you could arrest
cancer development. So, operating under this logic, Fay devised a
few local refrigeration experiments, first in chicken embryos than tissue culture,
and then in humans. His first patient was a woman
who was experiencing extreme pain from a cervical carcinoma. He
(21:32):
inserted a device of his own making into the mass,
like a hollow metal capsule through which water flowed in
a closed system, and he set it to cooling. Forty
eight hours later, the patient was pain free, and within
five days the tumor had actually shrunk a fair bit
around the edges of wow. The results encouraged Fay to
(21:54):
invent more cooling instruments and setups rubber bags, tubing ice baths,
and he tested out his hypothesis on other cancer patients.
His results suggested he was onto something. Ninety five percent
of his patients reported an alleviation in pain, and twenty
to twenty five percent reported that their tumors shrank or
(22:14):
grew more slowly. I mean, this was the nineteen thirties,
so keep in mind that, like other treatment options for
cancer were really limited. Yeah, and when he presented his results,
the broader medical community was stunned. They had dismissed his
ideas initially as just quackery, Like what do you mean,
(22:35):
You're just going to refrigerate that body part and suddenly
you're all healed. And now they're like, hey, actually, maybe
there is something to therapeutic cooling. What other applications can
we find for this? And Fay himself would have likely
gone on to develop his cold therapy further if a
couple of things had not happened. The first was a
(22:56):
series of cold therapy programs that began in the nineteen
forties at a few hospitals in the US, notably McLain
Hospital in Belmont, Massachusetts. Doctors would administer barbiturates to the
patients of theirs who were the most seriously debilitated by
mental illness, and then place them in cold water for
periods ranging from ten to thirty eight hours. Oh jeez. Yeah,
(23:20):
and yes there were warming blankets on hand and the
patients were being monitored.
Speaker 1 (23:24):
But still, this is this is patients with mental illness. Yes,
these like this is these are not consented. This is
not a correct correct this is not an institutional review
board which doesn't exist approved done.
Speaker 3 (23:39):
Right, Yeah, body temperature would drop into the seventies fahrenheit
twenties celsius. Outcomes were allegedly positive, but it's not clear
who's making the assessment, right, Like, is it the doctor
who's like bio to think, Oh, I want this therapy
(24:01):
to work, you know, is it the person's self reporting, right,
And it's also not clear how long any you know,
positive effects, if they did exist, how long they lasted,
But they were encouraging enough for scientific American to rave
about them quote for the first time. This new therapy,
popularly known as human hibernation and technically as hypothermia, has
(24:24):
apparently found a definite, valuable application in treating insanity, particularly
schizophrenia or dementia praecox. Results in the case of study
have been remarkable, so that more extensive investigation of the
possibilities and limitations of this treatment will surely be forthcoming
at the war's end, if not before end.
Speaker 4 (24:44):
Quote Okay, Yeah, a little bit of unchecked enthusiasm there
that went a bit too far, as it often does.
Speaker 3 (24:57):
And as more hospitals started cold therapy program to treat
mental illness, there was several of them that got started. Illnesses, injuries,
and deaths, even deaths occurred. So for example, at the
University of Cincinnati in nineteen forty three, sixteen people were
put into refrigerators for forty eight hours, Two died, and
(25:18):
others suffered permanent brain damage. Yeah, jeez, this, This had
the understandable effect of halting interest in therapeutic hypothermia for
any reason or for any condition. But it was it
wasn't the only thing to do, so it wasn't the
only thing to kind of pump the brake. So I
mentioned that it was a couple of things that prevented
(25:40):
therapeutic hypothermia from being like more investigated. The first being
these US based programs, and the second was Nazis.
Speaker 1 (25:50):
Yeah, so that's what I knew about.
Speaker 3 (25:52):
Yeah. In nineteen thirty nine, temple Fay submitted a manuscript
to a publisher in Belgium, and somehow the Nazis, who
had captured Belgium in nineteen forty came across it. They
were already interested in hypothermia because their pilots often died
in frigid waters after being shot down, and they wanted
to better understand how long come someone could survive, at
(26:15):
what temperatures, which revival methods worked best, and when the
point of no return was there, like what that point
looked like, what it was? And they took inspiration from
phase paper to set up cold water immersion tanks at
Dochau concentration camp, where they held people in the tanks
at varying temperatures ranging from thirty six point five degrees fahrenheit,
(26:39):
which is two and a half degrees celsius, to fifty
four degrees fahrenheit or twelve degrees celsius. Sometimes they gave
people pilot suits or flotation devices. Other times they stripped
them and held them there naked for up to fourteen hours,
and over the course of the war, three hundred and
sixty to four hundred experimental sefts were carried out, involving
(27:01):
three hundred individuals. It's yeah, there are many, many more
horrifying details of this torture that emerged after the war
during the Nuremberg Trials, and the news of these trials
really poisoned any remaining interest in therapeutic hypothermia. For almost
(27:22):
two decades, no one wanted to be seen doing what
had become characterized as Nazi science. Eventually, though, that characterization
faded as people realized that cold therapy may still hold
some promise, and as World War two became more distant,
some researchers grew more comfortable with using the data generated
(27:43):
by these torture sessions, believing that it could quote advance
contemporary research on hypothermia and save lives end quote. And
it became and really still is quite a controversial topic.
Some people advocate for free, unrestricted use of this type
of data, and others saying that a ban is actually
more appropriate. No one, no one should be able to
(28:06):
use this data.
Speaker 1 (28:08):
I mean you're essentially benefiting from torture, torture in one way,
in one way or another.
Speaker 3 (28:17):
By nineteen eighty four, though over forty five publications had
cited the hypothermia experiments at Dacau implicitly or explicitly endorsing
the use of such data. And I found a paper
published in the New England Journal of Medicine in nineteen
ninety that discusses these hypothermia experiments specifically and the controversy
(28:37):
surrounding them, and the author concludes with this quote on analysis,
the Dacou hypothermia study has all the ingredients of a
scientific fraud, and rejection of the data on purely scientific
grounds is inevitable. If the shortcomings of the Dacou hypothermia
study had been fully appreciated, the ethical dialogue probably would
(28:59):
never have begun. Continuing it runs the risk of implying
that these grotesque Nazi medical exercises yielded results worthy of
consideration and possibly of benefit to humanity. The present analysis
clearly shows that nothing could be further from the truth. Basically,
like the author, I feel like he is saying that
(29:20):
if it's a question of using the data, first of all,
the data is worthless scientific, right. But even if it
was you know, had even if the experiments were done
in a way were quote unquote experiences were done in
a way that was controlled and all the variables, it
doesn't mean that it's okay to use.
Speaker 1 (29:38):
Yeah.
Speaker 2 (29:39):
So.
Speaker 1 (29:39):
And also and also on top of that, it's trash data.
Speaker 3 (29:42):
It's trash. Yeah, it's just yeah yeah, so yeah, there's
it is a really interesting paper.
Speaker 4 (29:49):
Yeah.
Speaker 3 (29:50):
So, therapeutic hyperthermia joins the ranks of so many other
scientific advancements that have been built on the backs of
those who did not have the power to say no
or have their no heard. And hopefully it's somewhat of
a consolation that overall, very few papers exploring the use
of therapeutic hypothermia make reference to Dacau, at least like
(30:13):
directly from data. They may mention this is where things
you know, this is what YEP was done, but they
don't say, and this is how we know.
Speaker 1 (30:21):
Is where we've got our data right right.
Speaker 3 (30:24):
And the therapy came crawling back slowly with a few
papers here and there in the mid to late nineteen fifties,
first the discovery by Hubert, Rossumov and Duncan holiday that
when a person is hypothermic, their brain consumes less oxygen.
It was a major breakthrough. It opened the door for
new avenues to protect the brain during times where oxygen
(30:45):
might be restricted like stroke, heart attack, aneurism, certain surgeries.
By just reducing the brain's oxygen demands with hypothermia, you're
protecting the brain from long term injury. And shortly after
a few physicians started playing around with us hypothermia after
cardiac arrest others during cardiac surgery, although the routine use
(31:07):
of therapeutic hypothermia wouldn't happen for a long time, especially
as physicians grew aware and wary of certain complications with
the practice. In the nineteen fifties and nineteen sixties, again
the therapy was used in a few small studies for
infants that had trouble breathing shortly after birth, like Apgar
scores of one this is our first hand account. Animal
(31:29):
studies had shown promise in this regard, so doctors tried
it out on humans. And also it has a deeper history,
like there are some reports from the sixteen hundreds using
cold water immersion for infant For infants, it seems successful.
So when one of the studies, nine out of ten
of the infants survived and none showed any developmental delay.
(31:50):
And I couldn't find any indication that the baby that
did not survive died because of hypothermia. But I, yeah,
I don't think that that was the case. But these
studies were really small and they weren't well controlled, and
so combine that with the potential for complications, and you've
got another decades long delay in this becoming a standard
(32:10):
of care.
Speaker 1 (32:11):
Interesting.
Speaker 3 (32:12):
Yeah, And ultimately in two thousand and five, I believe
it did become a routine and has since saved lives
and prevented injuries. But what about prolonging lives. So someday, Aaron,
we should do an entire episode on cryonics. As a teaser.
(32:35):
For now, let's just say that while researchers were trying
to figure out how to use the cold to protect
the body from injury. Other folks were wondering whether we
could use hypothermia to put the body in a suspended state.
The space race had begun, after all, so like, who
was going to be the first to traverse light year's
worth of distances exactly? So a bunch of cryonics come
(33:00):
and he sprung up in the nineteen sixties, with the
first volunteer dying on January twelfth, nineteen sixty seven, and
which was a little bit earlier than the company that
he had. The Life Extension Society it was called, had
thought that they were going he was going ready for dot. Yeah,
they were not ready at all. Like his doctor was like,
(33:22):
he's on ice. You got to get him now. And
they didn't have anything set up. They were still in
building the pods or whatever. And so they stored this
person in one of the Life Extension Society guy's garages
in his station wagon and then was like, don't tell
my wife. And then his wife went into the garage
(33:44):
and was like, what, get this out of here. So
he found a couple of friends who would store the
body for a few days. But yeah, cry on.
Speaker 1 (33:56):
Sorry, all I can do is blinga sorry, this is
a this is a I just so, I'm so I understand. Sure,
this was a person who died, yes, of some other cause,
some cause cancer, Yes, I believe cancer. And then they
(34:18):
made him cold and stored him in a hatchback.
Speaker 3 (34:23):
There was some profusion of various substances. I forget what
got Yeah it might have been dmso sounds familiar.
Speaker 1 (34:33):
Yeah okay in the sixties, in nineteen sixty seven, yeah cool, okay, but.
Speaker 3 (34:38):
They didn't have the pods ready for like long term storage,
so the station wagon.
Speaker 1 (34:43):
Was the thing pod. Yeah, okay, yep.
Speaker 3 (34:50):
But this came out, like the news of this came out,
and cryonics never quite recovered from this first mishap, And
really it was like, over the years, it seems like
our way to extort money from grieving people who don't
know how to accept that their loved one died or
(35:11):
that they themselves are mortal.
Speaker 1 (35:14):
Going to die. Yeah.
Speaker 3 (35:16):
So there you have it, Aaron, the history of cold,
the good, the bad, and the weird. So, okay, tell
me how therapeutic hypothermia works. Does it work?
Speaker 1 (35:31):
I love that that's what you're leaving me with. Yeah,
I also have to tell you I am not going
to talk about cryonics at all.
Speaker 3 (35:40):
I didn't think, so that's okay.
Speaker 1 (35:42):
Literally, as you were like, as you were even starting,
I was like, gosh, I wonder if I should have
looked into like I didn't. So, if that's what you're
expecting from this episode, listeners, you're about to be disappointed.
I'm going to talk about real life and not science fiction. Yeah,
maybe it will be science reality someday. Right now, it's
science fiction.
Speaker 2 (36:02):
Okay.
Speaker 1 (36:02):
Wouldn't it be nice if we could wake up in
the morning anyways, so.
Speaker 3 (36:08):
The Salm Beach boys, Oh, didn't it be nice?
Speaker 2 (36:12):
Okay.
Speaker 1 (36:40):
What I am going to actually focus on today, not cryonics,
is how we use therapeutic hypothermia. I'm putting it in
air quotes because we don't call it that anymore. Oh,
there's there's been a multiple evolutions of this term for
a while, and a kind of depends on the like
(37:01):
what scenario you're looking at, So sometimes it still is
induced hypothermia or therapeutic hypothermia, but more commonly targeted temperature
management is used.
Speaker 3 (37:14):
Okay, this might explain why I could find so few
papers on the history of therapeutic hypothermia.
Speaker 1 (37:19):
Yes, it's why it took me so long to find
the papers that I finally found about how we do it.
It's because targeted temperature management and now newly just temperature control.
Why the change in rhetoric erin let me tell you. Oh,
I'm going to tell you, but it's going to take
me a while to get there because I'm verbose, and
(37:40):
I'm going to focus mostly on the broad strokes of
like what are the contexts in which we use therapeutic hypothermia,
how do we do it, and things like that. The
point of it, really big picture is what you mentioned, Aaron.
It is to reduce the risk of ischemic injury, meaning
(38:01):
reduce the risk that a lack of oxygen to our
tissues causes actual and irreversible damage because of the theoretical fact,
which is like, it's not just theoretical, it is true,
but because of the fact that as our body temperature cools,
(38:24):
our metabolic rate decreases, our need for oxygen in our
tissues decreases. That is the theory by which therapeutic hypothermia works.
But how does it end up working in practice? Like
what is it really doing to protect our tissues? We
(38:47):
think that in the brain, this decrease in our metabolic
rate decreases blood flow to the brain, which can also
decrease intra cranial pressure, which is something that often goes
up during damage in our heart because of changes to
(39:11):
the heart muscle and the heart tissues itself, as well
as the changes that we see in our blood vessels.
With cold. Right, we're vaso constricting a lot of our
blood vessels. We see a decrease in our heart rate,
but you can maintain blood pressure to a certain degree.
Speaker 3 (39:32):
Okay.
Speaker 1 (39:33):
And these are two of our organs, our heart and
our brain that we are wanting to protect the most
with therapeutic hypothermia, because our heart and our brain are
two organs that a are going to be impacted first
due to aeschemic damage. Right, lack of oxygen is going
(39:54):
to end up damaging those tissues irrevocably, and if we
we can protect those, then we could potentially recover from
any other insult to other organs or other tissues.
Speaker 3 (40:07):
So we're still in the hypothetical thing, the thought of
how this should go and why we think that that
recooling a body a core temperature is going to be beneficial, Okay,
got it.
Speaker 1 (40:22):
So to understand the specific situations where we might use
therapeutic hypothermia or targeted temperature management or whatever. We also
have to think about the ways in which this lack
of oxygen ends up causing damage. Okay, because what that
tells us is there's different time periods at which you
(40:46):
could potentially use hypothermia to try and reverse or prevent
this damage.
Speaker 3 (40:53):
Right, So tell we ah elaborate.
Speaker 1 (40:57):
Okay, let me elaborate, and we can use if we want,
we can use an example. Let's say your heart stops. Okay, Okay,
this is one possible situation. If your heart stops beating,
you're not pumping blood, so your tissues are not going
to get oxygen. That's all of your tissues, your brain,
your heart, all of your tissues are going to not
(41:19):
get oxygen. There's three phases to the damage that that
is going to cause. The first is when that heart stops,
you're going to have the lack of oxygen, right because
our cells require oxygen for metabolism. Without oxygen, your cells
start to become damaged. Okay, step one. But then if
(41:42):
we are in medicine and we're like trying to bring
somebody back and you can restart their heart after a
cardiac arrest, you're going to all of a sudden reperfuse
that area, yep, okay, which means you're going to have
a flow of oxygen to the area. You're doing CPR,
you're using a defibrillator, whatever it is you're now reperfusing.
(42:05):
That process actually causes its own sort of damage, because
as our cells start working again, they end up creating
reactive oxygen species. The way that I think of it
is like you know, if you turn your water off
in your house for a while, yeah, and then when
you turn it back on, it's like grody, like sputtery
(42:26):
and like brown water at first before it runs clear.
Speaker 3 (42:29):
Thank you.
Speaker 1 (42:30):
That's my analogy. That's like the immediate reperfusion injury that
you can get okay, okay, and then after that there's
a final stage that you can also get, like a
delayed reperfusion injury. Think of it like a few hours
after you start to get blood flow back, there's inflammation.
(42:52):
There's our body reacting to this insult that it just received,
so you can get additional damage to that time as well.
Speaker 3 (42:58):
I don't have a Sealskis analogy. How does the what
about pipes in the house water.
Speaker 1 (43:02):
It doesn't. Yeah, it doesn't. I don't have an equivalent there. Sorry, okay, okay, sorry, okay.
So that so that's that's the example with cardiac arrest.
But it's true in any scenario where you are have
lack of blood flow, right if you think of a stroke,
all of those same scenarios are going to happen. You
have blocking blood flow to a part of the brain
(43:23):
that causes tissue damage in the brain. Then if you're
able to reperfuse that area by say breaking up that
clot or something like that, you're going to get reperfusion injury,
and then you'll have delayed reperfusion injury as well. So
it is that's the ways that damage are caused. So
you could potentially, in theory use hypothermia at any of
(43:47):
those stages to decrease the risk of injury, depending on
when you can initiate it, how long you initiate it for.
Because in addition to decreasing our over a metabolism, this
hypothermia also just like attenuates all of our cellular responses.
It's going to reduce the inflammatory response. You'll have vaso constriction,
(44:11):
so you're not going to have as much edema or
fluid like collection outside of our vascular system. And there
is a lot of animal data to support the use
of therapeutic hypothermia in a really wide variety of situations.
Speaker 3 (44:28):
Okay, real quick though, So if someone has their heart stops,
then there already will be damaged because of the reperfusion
and then the second reperfusion situation whatever. So then when
is hypothermia? When when do you target the use of hypothermia?
(44:49):
And also how realistic is that from like a hospital situation.
Speaker 1 (44:55):
So that is why this gets so complicated. Okay, right,
because that's the exact right question. But if you think
about the survival story that you told last episode, Darren, Oh,
because her he hair just stopped, her heart stopped, right,
but she was already cold at that point. Yes, she
(45:16):
was cold and her heart stopped because of that cold.
So there was already a decrease. So you potentially in
that case, because she recovered so well, you already had
protection against anoxic injury, You had protection against lack of
oxygen because the tissues were already cold before that initial insult. Right,
(45:39):
in most realistic scenarios, that's not going to happen. Right.
Speaker 3 (45:44):
Yeah, So the cases.
Speaker 1 (45:45):
That we are going to potentially be able to use
therapeutic hypothermia were probably not going to be able to
do it before that initial injury, before the onset of
the lack of oxygen. Okay, so it's the second two
scenarios that were thinking about targeting. Can we use it
to reduce the risk of that initial reperfusion injury? Well,
(46:05):
to do that, you would have to cool the body
before you reperfuse it, right right, Okay, so before you
restart the heart. That's not a thing that people do
because if someone's heart stops, your first thought is to
restart it, restart us. Yeah. Right, So the way that
therapeutic hypothermia, or the way that targeted temperature management often
(46:27):
ends up being used is in that third phase to
try and reduce the risk of that delayed reperfusion injury
after the heart or whatever it is gets restarted or
things like that, Can we can we reduce the risk
of that further damage by cooling the body, slowing down
the metabolism, slowing down the need for oxygen.
Speaker 3 (46:49):
Does that make sense? It does? And so like, because
I feel like there are two main well, I mean
obviously you're going to tell me more. But like in
an emergency situation, there's it's like the use of therapeutic
kypothermia or whatever. We're good temperature control, yeah whatever, Yeah,
(47:09):
the thermostat in an emergency situation, And like we need
to decide, right now, what do we do versus a
we're going into surgery type of situation, Like is that
you know, like a more planned right use?
Speaker 1 (47:23):
So when do we when do we actually use it? Right?
What are the situations that we actually use it today?
And do we have data that it's actually helpful? Because
that was all like the theory of like this is
how it should work, we should be able to use
it in these scenarios. Can we actually use it in
these scenarios? Surgeries? So, in a surgical situation, you could,
because you're in total control there, you could cool the
(47:47):
body before any kind of a schemic insult. Right, Yeah,
you can do that. And if we are talking about
a heart surgery, you might need to actually stop the
heart in order to do a surgery on the heart. Right,
In those situations, a person is put on cardiopulmonary bypass,
(48:09):
so their blood is still being pumped. It's being oxygenated outside.
Speaker 3 (48:12):
Of the body.
Speaker 1 (48:13):
But could we by reducing their body temperature also decrease
the risk that if we're not oxygenating it quite well enough,
or just you know that the heart itself which is stopped,
it's not going to be as injured. That is something
that is sometimes used, but there is much more mixed
data on whether or not it's truly protective, both for
(48:36):
like neuroprotection as well as just like generally protective against dschemia.
And so right now, the guidelines for you know, if
someone is doing a heart surgery and is going to
be on cardiopulmonary bypass, do you do intentional hypothermia or
do you not? It depends on the situation.
Speaker 3 (48:55):
In what and like in what way.
Speaker 1 (48:57):
It might depend on that particular person, how high of
risk are they for eschemia to begin with. It might
depend on the capabilities of where you're doing the surgery.
Do you have the ability to cool somebody or not.
But the data is not like a clear cut like
you need to do it in order to improve outcomes
and it's okay if you don't do it. Essentially, in
(49:20):
most other surgeries, the data is more clear that hypothermia
should actually be avoided, okay, because your body is going
to be under more stress trying to warm itself up,
and surgery is already a very stressful situation. So it's
really only like heart surgeries. There also was like there's
(49:43):
been trials on using it for brain surgeries, especially like
aneurism clips and things like that. There's not really data
that hypothermia is beneficial necessarily in those scenarios.
Speaker 3 (49:54):
It's so interesting because I feel like, I mean, and
maybe this just speaks to the papers that I found
that were you know, out of date, but how so
many how it is talked about in terms of like
this is a really promising thing. It's case by case,
but like it does, it does really work. And I
think also just the fact it's the human body, Like
(50:19):
we have these controls. These these are are homeostasis or whatever.
We're trying to maintain temperature for our benefit, even if
that does end up hurting us, And so I see, yeah,
causing more stress by trying to override those controls. That
makes sense.
Speaker 1 (50:34):
Yeah, yeah, So that's really from what I could find,
at least, that's the only scenario where if you could
do therapeutic hypothermia, you would be trying to prevent that
initial injury. Everything else that we use it for is
kind of post injury. Can we prevent you know, worse
Sequele When it comes to neurologic stuff, because there's a
(50:57):
lot of interest in like protecting our brain using hypothermia,
the data is much more mixed and not as strong
as I kind of expected. So after stroke, after traumatic
brain injury, after you know, hemorrhagic aneurism or aneurism, rupture,
any of these things, the data is unclear and guidelines
right now do not support universal therapeutic hypothermia. Okay, they
(51:24):
do support avoiding fever, and that is part of why,
and I'll get into it even more, but that is
part of why the kind of naming of this has
changed more to let's not think as much about you know,
intentionally cooling the body, but to like a degree lower
(51:44):
than a typical body temperature of thirty seven, but let
us do make sure that we don't go above thirty
seven point five, because then we do see that there's
more damage.
Speaker 3 (51:54):
That makes sense. What about babies?
Speaker 1 (51:58):
Okay, I was going to talk about cardiac arrest next.
You can do a basory No, I love it. Those
are the two. Those are the two big areas. So
that's all the things that we maybe sometimes kind of
use it for. There's two areas that at least for
a while, Oh spoilers, this therapeutic hypothermia actually cooling the
body to around thirty two thirty three thirty four degrees.
(52:21):
So mild hypothermia was considered standard of care for almost
twenty years for out of hospital cardiac arrest. Okay, so
if somebody heart stops outside of the hospital and you're
doing CPR or you have access to a diffibrillator and
(52:43):
they have a shockable rhythm, so you can different relate them.
There was a big paper that came out in two
thousand and two that showed big benefit to once you
get circulation back, once you have rosc which is return
of spontaneous circulation, once you bring that person back to life,
if you cool them for at least twenty four hours
(53:05):
I think it was twelve to twenty four hours at first,
you have improved outcomes, better survival.
Speaker 3 (53:10):
Okay, survival, that's the outcome, got it.
Speaker 1 (53:12):
Survival is the outcome, because that's yeah, And so that
became standard of care. And then there was other papers
that came out later that showed even if the person
initially did not have a shockable rhythm, meaning if their
heart stopped, but it was because of other things. It
could be because of substance use, it could be because
(53:33):
of a pulmonary issue, it could be like just so
many different things. But their initial rhythm wasn't one that
you could differ relate like they do on er.
Speaker 2 (53:42):
Huh.
Speaker 3 (53:42):
Yep, they've moved past the Oh that's good. The paddles, Yeah,
that's good.
Speaker 1 (53:48):
Yeah. But so there were other papers that came out
in like the early two thousands that showed even in
those situations there was some benefit to therapeutic hypothermia, so
that was the standard of care. However, since very recently,
like a paper came out in twenty twenty one that
(54:09):
looked at a pretty big swath of people regardless of
their initial rhythm out of hospital cardiac arrest and did
not find that therapeutic hypothermia was beneficial compared to just
ensuring that they don't have a fever. So targeting thirty
seven point five and not allowing it to go higher
(54:30):
than that but not necessarily lowering it wasn't any more beneficial.
There were a couple of other papers that came out
since then that were similar that kind of just showed
maybe this because there were papers that looked at, okay, well,
if lowering the body temperature is beneficial, what's the ideal temperature?
Is it thirty two? Is it thirty three? Could it
be thirty six? How low do we need to go?
(54:51):
And those papers found that like thirty six and thirty three, Eh,
no big difference, And so that led to more and
more of these papers looking at how cold do we
need to get people to have a benefit to try
and keep them alive with minimal neurologic damage once we
bring them back after their heart stops.
Speaker 3 (55:11):
Okay, so this is once you bring them back after
their heart stops, administer therapeutic hypothermia, but you don't anymore.
It's just make sure they don't have a fever.
Speaker 1 (55:20):
So right now, as of twenty twenty three, the guidelines
is to pick a temperature somewhere between thirty two and
thirty seven point five and keep them there, so temperature
control but not necessarily therapeutic hypothermia.
Speaker 3 (55:34):
I have a question, how do we do that? Ooh,
such a good question.
Speaker 1 (55:42):
There's a lot of different ways. It all does have
to be very tightly monitored, especially during the induction and
maintenance phase, so as you're cooling that body down and
then once you get to that temperature that you're targeting,
one of the things you have to do is avoid shivering,
right because that's an automatic response that's going to rewarm
(56:04):
the body and increase metabolic demand. You also have to
keep very close eye on like their blood counts, making
sure that all of the things that can go wrong
during hypothermia, getting increased blood clotting, electrolyte abnormalities, diarrhasis, acid
base disorders, from things shifting in and out of cells.
You have to monitor all of those things. But how
(56:24):
do you actually do it. You can do it almost
the opposite of how we can warm your body, So
you can externally cool with like water baths or these
fancy gel pads that like circulate temperature controlled water. You
can do internal cooling like the opposite of what we
would do to warm it up. You can infuse cold
ivy fluids or cold like peritoneal or levage. You can
(56:48):
also I know you can also do have you ever
donated plasma only blood? If you ever donate plasma they
take out circulate, yeah, yeah, and so when it goes
back into you, it is a little it's not cooled,
but it is just colder than your body temperature usually,
and it does it makes you feel cold. But you
(57:08):
can also do that. You can do extra corporeal blood cooling,
so you can take someone's blood out, cool it down
and then and then infuse it back in. So there's
a number of different ways. And like I mentioned, it's
usually a very mild hypothermia that is targeted, so like
thirty two to thirty four degrees celsius, right, okay, pascinating, Okay,
I know. And then there is babies, you asked, Aaron,
(57:32):
And this is the area that I think therapeutic hypothermia
is truly still the correct term because it is the
area that is still used Okay, whole body cooling or
sometimes just head cooling, so just cooling of the head
is used and is considered standard of care for full
(57:56):
term newborns that are born and suspected of having hypoxic
ischemic encephalopathy or HIE. And this is suspected brain damage
that's due to lack of oxygen to the brain in
a newborn okay, and that can happen. I'm not going
to go into a lot of deep detail on this
because I think it deserves its whole own episode. But
(58:19):
this can happen in a variety of different contexts, either
just before delivery or kind of during delivery, or shortly
after delivery. Right, There's a lot of situations. Whether it's
placental abruption when like the placenta comes off of the
uterus before the baby is delivered, that is going to
disrupt oxygen flow to the fetus, other cord issues like
(58:42):
the cord getting compressed or prolapsing, uterine rupture, the heart
rate of the fetus just dropping and then not recovering,
or even during or after delivery. Anything that causes the
baby to stop breathing or not have access to oxygen
is going to lead to potentially hypoxic a ischemic encephalopathy.
(59:03):
And we use that Appgar score that you mentioned, which
is a composite score of like how well they're breathing,
their skin color, Turger reflexes all of these things to
give a sense of how a baby is doing. And
it's usually at that ten minute mark if a baby's
heart rate is still really low or if it's not
there at all, and if they're not breathing or they're
(59:24):
requiring continued ventilation support, there is good data that cooling
these babies can help prevent severe disability or death. Okay,
and I specifically mentioned full term infants. Yes, because a
relatively recent study from I think it was actually published
(59:45):
this year in twenty twenty five, was actually one of
the first ones that looked at preterm infants and did
not find any statistically significant improvement in outcomes for preterm
infants by using therapeutic hypothermia.
Speaker 3 (01:00:02):
Why why do you think that is?
Speaker 1 (01:00:05):
I mean, babies, newborn babies are so different in their physiology,
and so like a premature newborn has different physiology than
a non premature like a full term newborn, and so
we don't know, I mean the short answers, we just
don't know. But that's why it was so important that
(01:00:25):
this study was actually done, because there certainly were all
of the studies previously had only used full term infants,
and yet therapeutic hypothermia I think was often maybe used
in some situations in preterm infants just based on the
data of full term infants. Right, But because we know
they're so different. It was important that this data actually
came out and it doesn't show improvement in outcome.
Speaker 3 (01:00:49):
So okay, and what is like the the effect size,
I guess or like what you know, it's a good question.
Speaker 1 (01:00:58):
A meta analysis from twenty one found for full term
infants a pooled reduction in risk of mortality of about
twenty six percent in infants who were cooled compared to
ones who weren't. And this was similar whether it was
whole body cooling or just head cooling that was used. Okay, yeah,
it's not nothing.
Speaker 3 (01:01:19):
It's not nothing, and it's pretty amazing that, yeah, that
there are there is I don't know there are uses
for this because it does seem like fairly, I know,
it's not straightforward that there are many different home approaches
that you can use to do this and administer this
and monitor this, and that it's about the degree and
all this stuff. But it's like it's just I don't know,
(01:01:42):
it's it's fascinating to me that it's like we use
temperature in this way.
Speaker 1 (01:01:46):
Also, what you had mentioned, Aaron about the use in
cancer is so interesting because I didn't find anything about
it's you. I mean, I know you know, people do
sometimes like ice on the head to try and reduce
hair loss during chemo therapy or things like that. The
mechanism that's going to be very different than what you
had mentioned, but someone using it to try and reduce
cancer growth. I think probably because we have better options
(01:02:10):
today is why there's not really a lot of data
that I could find, at least on modern uses of that.
We do use a different kind of crowd therapy like
liquid nitrogen to kill small skin cancers or other growths
all the time. Yeah, I forgot about that after the fact.
I also did find a paper on cold plunges and
(01:02:33):
that kind of crowd therapy for muscle recovery have to
work out by the way, there's not really good data
to support it, but I can give you a paper
if you want to read about it.
Speaker 3 (01:02:40):
Well, And you know, I'm not against cold plunges. If
you enjoy jumping into an icy lake or tub or
whatever it, do it safely, have a buddy whatever you know.
Speaker 1 (01:02:52):
No, but there's not like for like the muscle recovery stuff, like,
there's not a lot of data that it's really beneficial.
But you can read about it if you want to
know more. We have so many sources for you.
Speaker 3 (01:03:03):
We do okay again, I'm going to shout out that
book by Phil Jakol called out Cold Chilling Descent into
the macabre, controversial, life saving History of Hypothermia. And then
a paper about doctor temple Fay called Breaking the Thermal
Barrier Doctor temple Fay by al Saga at All from
(01:03:24):
two thousand and six and then by Gunn from twenty
seventeen Therapeutic Hyperthermia Translates from Ancient History into Practice and
more papers.
Speaker 1 (01:03:34):
I had a couple of older papers, one from twenty
fourteen that old but called Clinical Applications of Targeted Temperature
Management by Perman at All and another one from two
thousand and eight that was just called Therapeutic Hypothermia by
Varren and Acosta. And then the two papers two biggest
(01:03:56):
papers that I had on hypothermia in infants. One of
them is Whole Body Hypothermia for Neo nail and Cephalopathy
and Preterm Infants thirty three to thirty five weeks in
GEMI Pediatrics, and the other one was from PLUS one.
And it was that twenty twenty one paper that was
the systematic review and meta analysis. But then what's fun
is I have guidelines. So many of the guidelines, like
(01:04:17):
the two thousand and two paper that led to the
guidelines initially of being yes, do therapeutic hypothermia for out
of hospital kardiac arrest, and then all the subsequent papers
that were like, yes, it's beneficial. No wait, maybe it isn't.
Maybe it's not as good to be thought. Now Here
are the new guidelines. So many guideline papers. You can
find them all on our website, This podcast will kill
You dot com.
Speaker 3 (01:04:38):
You can thank you to Bloodmobile for providing the music
for this episode and all of our episodes.
Speaker 1 (01:04:44):
And thank you to Leanna and Tom and Brent and
Pete and Jessica and Mike and everyone else at Exactly
Right Network for all that you do.
Speaker 3 (01:04:51):
Thank you, thank you, and thank you to you listeners
and watchers and anyone who enjoys this podcast in any way.
It means the world to us, and as does the
support of our patrons.
Speaker 1 (01:05:03):
Thank you, thank you, thank you, thank you. Wow.
Speaker 3 (01:05:06):
Until next time, wash your hands
Speaker 1 (01:05:08):
You filthy animals.
In nineteen sixty seven, I was treated with hypothermia by
immersion in ice cold water as part of a local study,
and then developed subcutaneous fat necrosis. Both myself and one
other case were reported by the neonatal team who looked
after me to have had otherwise favorable short term outcomes,
but on the basis of this complication, these early studies
of hypothermia were stopped. I was born weighing three thousand,
(00:23):
nine hundred seventy grams at full term after an uncomplicated pregnancy,
labor and delivery. As reported, at one minute after birth,
I became apnic and did not respond to resuscitation. After
five minutes, I was placed in an ice water bath.
My breathing was reported to recover after twenty eight minutes
of hypothermia. At forty five minutes of life, my capillary
(00:44):
pH was six point nine but recovered steadily, and I
was discharged at day three. Subcutaneous fat necrosis developed between
two and four weeks of age. The calcium deposits were
largely cleared by six months. My serum calcium remained normal,
and my weight gain and in development were considered appropriate
at that age, but no further follow up was reported
(01:05):
fifty three years after these events. I have had a
very normal life. Although my mother tease me about my
skin in childhood, I never had any apparent skin problems
as a child or later. I was a keen sportsman
at school. My handwriting was never a strength, and so
I taught myself to touch type, which turned out to be
an advantage in the computer age. At the same time,
it is interesting to note that I can easily thread
(01:26):
a needle. Academically, I did very well throughout school and university.
I was awarded my PhD in nineteen ninety eight and
have served at my current institution as department chair and
faculty Senate president. In retrospect, I strongly believe that the
benefits of treatment clearly outweighed the costs, and that the
abrupt cessation of these early studies of therapeutic hypothermia represented
(01:46):
a missed opportunity. If the opinion of my parents had
been sought at the time, or subsequently my opinion, we
would have favored continued trialing of this promising treatment. Fascinating,
(02:43):
it's really an interesting I don't know that I've ever
read a report or like of someone who had been
a recipient of therapeutic hypothermia, like especially from so long ago,
Like it's really interesting. Yeah, it's really good. Fine, Darren,
thank you. I don't remember how I found it, but
(03:06):
well I can tell you where it's from.
Speaker 2 (03:10):
Do.
Speaker 1 (03:11):
That was by Robert Carlson in Pediatric Research from twenty
twenty one and article titled fifty three years of follow
up of an infant with neonatal encephalopathy treated with therapeutic hypothermia.
Speaker 3 (03:22):
It's fascinating and I feel like that, yeah, the first
hand account much much later because it's not like he
remembers this happening.
Speaker 1 (03:31):
Right, It's like he's clearly reading some of the like medical,
you know, records of his birth and treatment thereafter, and
then and then talking about his life since Like it's
so interesting.
Speaker 3 (03:42):
Yeah, and I'm I'm so curious to know how this
episode shakes out with like what you find. But like
the point I feel like, I feel like the thing
that stuck out to me when it comes to that
is that maybe it was a little bit of missed opportunity,
Maybe it was a little bit of you know, understandable
hesitation to pursue trials, but ultimately it's like, how do you,
(04:07):
how do you make scientific discoveries that do not harm
people or have the potential to harm people? And that's yeah.
You know, we've come a long way in the twentieth
century because of that. So yeah, anyway, Hi, I'm Aaron Welsh.
Speaker 1 (04:21):
And I'm Erin alman Updyke.
Speaker 3 (04:23):
And this is this podcast will kill You.
Speaker 1 (04:25):
And we're coming back with our second part on hypothermia,
as promised.
Speaker 3 (04:31):
As promised, this is hypothermia can be good, Cold can
be good.
Speaker 1 (04:36):
Cold is not always bad.
Speaker 3 (04:37):
Yeah, yeah, however you want to say it. Yes, it's
the history of therapeutic hypothermia. It's really so much to learn.
Speaker 1 (04:50):
I am thrilled. I know literally nothing about the history
prior to two thousand and two.
Speaker 3 (04:57):
Oh yep, oky dook. Well, I'll teach to some things
that I have discovered. Great, but we've got a few
a few things. This is off to a great start erin,
we've got a few things to tackle before we can
get into like the meat of the episode. It's quarantin
any time.
Speaker 1 (05:17):
It's quarantin any time. We're still we changed it. Yeah.
Speaker 3 (05:23):
Oh, uncommon cold, the uncommon cold.
Speaker 1 (05:25):
Yeah, that's what we're drinking. That's what we're drinking. Yep,
we should probably do that again though, right, Nah, Okay.
Speaker 3 (05:34):
This is gold erin, this is gold It's an uncommon cold.
It's a hobn arrow margarita, spicy margarita because it's blended.
It's cold, there's ice in it, but also there's like
a little bit of warmth, you know. Yeah, and also
(05:55):
alcohol does not make is not a treatment for hypothermia,
as we covered last episode as the Room. Yeah, it's
on our website, this podcast will kill You dot com.
It's on our social media channels, toy.
Speaker 1 (06:08):
This is going really well, really well.
Speaker 3 (06:11):
Our website has lots of good things. It's got transcripts,
it's got sources for all of our episodes, links to
merch links to Patreon, bookshop, dot Orgiphilia account, Goodreads list,
music by Bloodmobile. If I haven't already said that, contact
us form firsthand account form reach out, reach out. We
love to hear from you.
Speaker 1 (06:31):
We also love to hear when you have a great
rating or review to write about us, So if you
could leave us one of those, we'd really appreciate it.
I haven't done that already, Thank you if you have,
and subscribe on YouTube exactly right, channel. Can we get
into the episode.
Speaker 3 (06:52):
Certainly, but it's like a break. I left off last
week with the story of the amazing recovery of Anna Bagenholm,
(07:15):
whose body temperature dropped to thirteen point seven degrees celsius
or fifty six point six degrees fahrenheit. What I still
can't get over it.
Speaker 1 (07:26):
Yeah, it is that, like the is that in the
Guinness Book of World Records? Like is that the record?
Speaker 3 (07:31):
Or I don't trust the Guinness Book of World Records
anymore the g I ever did, but like, yeah, not
after a gallstone.
Speaker 1 (07:38):
Missaply hugely lost faith.
Speaker 3 (07:43):
But yeah, she might be in there.
Speaker 2 (07:44):
Wo.
Speaker 3 (07:45):
But in that episode Arin last week, you also took
us through all the ways that the cold can hurt
or even kill us, and how we can reverse or
halt some of that damage. But it would be unfair
to the cold for us to end the story there
just showing its villainous side, Because while the cold has
(08:05):
claimed many lives and fingers and toes and noses, it
has also saved many as harnessed by modern medicine. And
so this week I want to tell the story of
how humans have attempted to use cold, successfully or unsuccessfully,
to save or prolonged lives. We have long used cold
(08:26):
as a topical treatment for various aches and pains, swollen joints,
battle trauma, and fever. Ancient Egyptian, Greek, and Roman physicians
all called for cold to be used in various ailments.
You know, the oldest medical writing hailing the benefits of
cold comes from the Edwin Smith Scroll dating to sixteen
hundred BCE. It details a recipe to cool blisters, so
(08:50):
it's more about like a cooling sensation in the cold itself,
but still.
Speaker 1 (08:53):
Like still, yeah, cold can feel good.
Speaker 3 (08:56):
Cold can feel good. And Hippocrates, of course was a
big liver in cold, especially for those of a warmer temperament.
And he also wrote that this is yeah, infants left
out in winter like left out infants survived longer than
babies left out in the summer months.
Speaker 1 (09:16):
That's I'm sorry, I wrote, yeah, like, first of all,
what also second of all, I could miss this a
little bit, but you just said of a warmer temperament.
Speaker 3 (09:29):
Oh yeah, you know, like tempers or not tempers? Oh
like humors? Humors, Oh my god, you just did a whole.
Speaker 1 (09:36):
Episode, just did a whole episode on it.
Speaker 3 (09:38):
Honestly, this sweater is making me overheat.
Speaker 1 (09:41):
Well maybe you have a warm temperament and you need.
Speaker 3 (09:43):
Some cold next week hyperthermia. Just kidding, but no, so
I I have no idea.
Speaker 1 (09:49):
Was this experiment?
Speaker 3 (09:50):
Was this just like lore?
Speaker 1 (09:52):
You know?
Speaker 3 (09:53):
Yeah, I don't know.
Speaker 1 (09:55):
I mean so like babies can definitely overheat, yes, in
warmer temperatures, in many cases more quickly than they will.
But like we said last week, because of their body
surface area to volume ratio, they're also you know, going
to get be more susceptible to hype both roma too,
So it's it is both. And how about that both?
Speaker 3 (10:16):
And I mean really anything is possible with Hippocrates, Like
it's like I yeah, I don't know. But beginning in
the sixteen hundreds or so, there was a shift in
thinking like if a little localized cold was helpful to
relieve joint pain and whatnot, that a full body cold
soak would be even better. Right. Cold baths became all
(10:42):
the rage, and advocates claimed that they cured every ailment
under the sun, especially fevers, which honestly, maybe they did,
I don't know, But by the way, this made me
think I was I did a little digging in this
episode because I was like, oh, yeah, fevers that sometimes
can be adaptive, that sometimes can help us to fight
off infections. Can hypothermia ever be adaptive in that way?
(11:04):
Is there any reason that it would be protective? So
I did some digging, and yes, I did find that
a few people suggested that maybe a hypothermic response, like
sometimes people get hypothermic incepsis, for instance, could be a
last ditch effort to conserve energy and protect it gets
damage from inflammation. But I also see your face right now,
which is very questioning, and that's that's how I feel too,
(11:27):
because how do you disentangle that from the body just
not having the energy to maintain a fever or even
just like normal body temperature?
Speaker 1 (11:35):
Right And I will say, like, what is the what
is the driver of it? I don't know, but what
is the outcome of it? We do know that hypothermia
in case like unintentional hypothermia, We're going to talk later
and today about like intentionally reducing someone's body temperature. But
if someone is so sick with an infection and they
end up hypothermic, it's usually quite a bad sign that
(11:58):
things are not going well and they're usually poor outcomes.
Speaker 3 (12:00):
Yeah, so it's yeah, it's not like it seems to
me that we have no evidence to suggest or very
little and not none that I found that it's an
adaptive response and it's more just the body shutting down.
Speaker 1 (12:12):
Yeah, it's not like our It's not like a fever
where our hypothalmis is like, hey, let's raise the body temperature.
Our hypothemist doesn't go, hey let's lower the body temperature.
Speaker 2 (12:19):
Didn't.
Speaker 1 (12:19):
I didn't find any data that happens in humans and
other animals like you talked about, they're doing all the time.
Speaker 3 (12:25):
They're doing it for other reasons too. It's like not,
it's yeah, exactly. Yeah, okay, anyway, I love this one
of already. I'm glad, don't we love to just like
some easy swing and just bat down ideas. Yeah, hypotheses, No,
(12:45):
I got Okay. So, one of the biggest cheerleaders for
cold baths was this guy named James Curry, and I
mentioned him in our Fever episode last year as the
mastermind behind many enthusiastic cold water treatments, where he continually
doused people with freezing water, even past the point where
they were like no, please, no, no, more.
Speaker 1 (13:07):
Remember this.
Speaker 3 (13:09):
Well, I don't know. I don't remember if I got
into this in the episode. But one of the reasons
that he became so evangelical about cold water treatment is
because in the early seventeen seventies he observed a shipwreck
in the freezing waters of the North Channel. When rescue
finally came, the survivors tended to be those who stayed
in the water, while those who waited on top of
(13:31):
the ship more often perished. And that made me think
of Titanic and Jack and Rose, you know, because by
this logic, shouldn't Jack have survived.
Speaker 1 (13:43):
Spoilers, He doesn't.
Speaker 3 (13:46):
He doesn't spoilers. Sorry if that's a spoiler for it,
And it got spoiled for me by a neighborhood friend
in when it came out and it was trauma like that,
like has made me hate spoilers so much, you know
how I feel like would be I do like dealers, But.
Speaker 1 (14:01):
Yeah, it also I just want to say that that
does not make any sense because of what we talked
about last week with how water is a much better
conductor of heat than air, and so immersion in even
I mean, the water in Titanic was like below freezing,
very cold. But even immersion in like water that's like
sixty or seventy degrees can cause hypothermia in a number
(14:24):
of hours, where it would take a very very prolonged
exposure with no clothes at all to be hypothermic in
those temperatures in air.
Speaker 3 (14:32):
Yeah, I mean, you know, if only we had Curry
himself here to question only only bro.
Speaker 1 (14:39):
Yeah, what was your sample size?
Speaker 3 (14:41):
And I think he was watching from a distance, and
how he could even know were the people who were
on the shipwreck like or on the remains of the
boat where they also soaked in water? Did they fall
off occasionally?
Speaker 2 (14:52):
You know?
Speaker 1 (14:52):
Like right, was it that they were soaking wet and
then there was wind chill or something like that? Maybe
was the air temperature colder and the water temperture was
not that cold and then there was a winch maybe.
Speaker 3 (15:02):
I mean the bottom line is that he was like
convinced cold water is where it is at.
Speaker 1 (15:09):
Well, we know you can't change their minds, you can't.
Speaker 3 (15:12):
Yeah. And oh, by the way, speaking of Titanic, so
of the nearly fifteen hundred deaths from the Titanic, from
that Titanic, I mean, I don't need to say, anymore
were classified as drowning when in fact they were probably hypothermia. Yeah,
makes just an interesting I think that kind of but
(15:33):
it shows to me it demonstrates sort of the public's
understanding of hypothermia and what was happening in that situation. Yeah, okay.
So the other reason that Curry was psyched about cold
baths was reading about the experience of this guy, doctor
William Wright, who used cold water to treat a fever
that he had, which was likely typhoid fever. All right,
(15:53):
quote September ninth. Having given the necessary directions, about three
o'clock in the afternoon, I stripped off all my clothes
and threw a sea cloak loosely about me till I
got upon deck. When the cloak was also laid aside.
Three buckets full of cold salt water were then thrown
at once on me. The shock was great, but I
(16:14):
felt immediate relief. The headache and other pains instantly abated,
and a fine glow and diaphoresis succeeded. Towards evening, however,
the febrile symptoms threatened return, and I had recourse again
to the same method as before, with the same good effect.
I now took food with an appetite and for the
first time had a sound night's rest en.
Speaker 1 (16:36):
I love that image. What is a sea cloak? Can
I have one?
Speaker 3 (16:41):
I'm assuming towel. No, I'm picturing.
Speaker 1 (16:50):
I'm picturing something quite much more majestic than a towel.
Speaker 3 (16:53):
I'm calling my towel sea cloak. From this point forward,
can you help me fold the sea clad folks? Please?
Speaker 1 (17:01):
Do you know that never in a million years would
I assumed that it's a towel.
Speaker 3 (17:06):
I have no idea. Somebody, we need to look this up.
Speaker 1 (17:13):
Of course it's a towel, but I never.
Speaker 3 (17:15):
Know it might not be. It's just a branding opportunity.
It really is.
Speaker 1 (17:21):
Someone make a seat cloak, Okay, but also like that's
a hih so that is the account that made this
guy Curry be like cold baths, cold bass for everyone,
cold bass for everything.
Speaker 3 (17:34):
Yeah, I mean it's it's not that much different than
like watching a TikTok video today and being like cold baths.
Speaker 1 (17:42):
I think you can find a lot of those videos
on tiktoks. People are really into cold baths.
Speaker 3 (17:47):
Yeah, yes, yeah, yep, uh and so, but this like
really took many different places by storm spas sprung up
where you could alternate between hot and cold waters, which
is quite delightful, and the benefits of cold water plunges
widely hailed even before the TikTok bros you know, came
on the scene. But cold treatments weren't always used with consent.
(18:08):
In the sixteen hundreds, cold water dunking was occasionally employed
as a cure for mental illness, where it proved not
only ineffective but also cruel, torturous, and even deadly. In
some cases, there were dunking stations built on the grounds
of some asylums.
Speaker 1 (18:26):
Oh my gosh, that's awful.
Speaker 3 (18:29):
The logic behind this was that, okay, well, if mental
illness is caused by a fevered brain, you need to
cool it by any means necessary. So as an example,
in seventeen twenty five, a woman who was accused of
neglecting her husband was forced, while restrained, to stand under
a torrent fifteen tons of freezing water for ninety minutes
(18:53):
until she promised she would become a loving and obedient wife. Torture.
That's like, I mean, what else do you call this?
Speaker 2 (19:00):
Really?
Speaker 1 (19:00):
Torture? Just actual torture? Yeah, yeah.
Speaker 3 (19:02):
What uh, and not to mention ineffective on medical grounds,
but even if it were effective, it's not like that
would justify its use.
Speaker 1 (19:11):
Also, it's not a mental disorder to not be nice
to your husband.
Speaker 2 (19:17):
I know.
Speaker 3 (19:18):
I I told my husband this, and he was like,
what is neglectful? Like what what does that? What does
that mean?
Speaker 2 (19:25):
Right?
Speaker 3 (19:25):
Yeah?
Speaker 1 (19:25):
Right, so many questions. Sandwich wasn't made crispy enough, or
like it was too crispy and it you know when
it scratches the.
Speaker 3 (19:33):
Top, Yeah, the Captain crunch syndrome. Yeah, just shreds the
roof of your mouth.
Speaker 1 (19:39):
She made his sandwich like that?
Speaker 3 (19:40):
Mm hmm. I mean, well, yeah, I still don't think
it deserves fifteen tons of freezing water. But you know
that's just my opinion, just.
Speaker 1 (19:47):
Our opinion, just our opinion, Okay.
Speaker 3 (19:50):
But yeah, And so as as much as I would
like to tell you that this type of thing fell
out of favor and was never used again by anyone
in medicine, unfortunately I I cannot. In fact, it was
the tortuous use of cold on non consenting individuals that
led to cold therapy being dismissed as an illegitimate and
groundless therapy, even when one doctor showed evidence to the contrary.
(20:17):
While in medical school in the early twentieth century, Temple
Fay was stumped by a question on a quiz, why
does metastatic cancer rarely appear in the limbs? He had
no idea. He was like, I don't know what to
put here. So he asked his professor, like, hey, what's
the answer to this? And his professor was like, I
(20:39):
don't know either.
Speaker 1 (20:39):
Actually, why did they put it on the quiz?
Speaker 3 (20:45):
I don't know, I don't know.
Speaker 1 (20:47):
Okay, yep.
Speaker 3 (20:48):
But the puzzles stuck with him, and so in the
nineteen thirties, Fay decided that he wanted to try to
solve it. His primary hypothesis had to do with temperature,
so he figured that parts of the body with higher
temperatures were more likely to promote cancer growth, while cooler
parts the extremities discouraged growth. It would stand to reason, then,
(21:11):
that if you cooled a metastatic growth, you could arrest
cancer development. So, operating under this logic, Fay devised a
few local refrigeration experiments, first in chicken embryos than tissue culture,
and then in humans. His first patient was a woman
who was experiencing extreme pain from a cervical carcinoma. He
(21:32):
inserted a device of his own making into the mass,
like a hollow metal capsule through which water flowed in
a closed system, and he set it to cooling. Forty
eight hours later, the patient was pain free, and within
five days the tumor had actually shrunk a fair bit
around the edges of wow. The results encouraged Fay to
(21:54):
invent more cooling instruments and setups rubber bags, tubing ice baths,
and he tested out his hypothesis on other cancer patients.
His results suggested he was onto something. Ninety five percent
of his patients reported an alleviation in pain, and twenty
to twenty five percent reported that their tumors shrank or
(22:14):
grew more slowly. I mean, this was the nineteen thirties,
so keep in mind that, like other treatment options for
cancer were really limited. Yeah, and when he presented his results,
the broader medical community was stunned. They had dismissed his
ideas initially as just quackery, Like what do you mean,
(22:35):
You're just going to refrigerate that body part and suddenly
you're all healed. And now they're like, hey, actually, maybe
there is something to therapeutic cooling. What other applications can
we find for this? And Fay himself would have likely
gone on to develop his cold therapy further if a
couple of things had not happened. The first was a
(22:56):
series of cold therapy programs that began in the nineteen
forties at a few hospitals in the US, notably McLain
Hospital in Belmont, Massachusetts. Doctors would administer barbiturates to the
patients of theirs who were the most seriously debilitated by
mental illness, and then place them in cold water for
periods ranging from ten to thirty eight hours. Oh jeez. Yeah,
(23:20):
and yes there were warming blankets on hand and the
patients were being monitored.
Speaker 1 (23:24):
But still, this is this is patients with mental illness. Yes,
these like this is these are not consented. This is
not a correct correct this is not an institutional review
board which doesn't exist approved done.
Speaker 3 (23:39):
Right, Yeah, body temperature would drop into the seventies fahrenheit
twenties celsius. Outcomes were allegedly positive, but it's not clear
who's making the assessment, right, Like, is it the doctor
who's like bio to think, Oh, I want this therapy
(24:01):
to work, you know, is it the person's self reporting, right,
And it's also not clear how long any you know,
positive effects, if they did exist, how long they lasted,
But they were encouraging enough for scientific American to rave
about them quote for the first time. This new therapy,
popularly known as human hibernation and technically as hypothermia, has
(24:24):
apparently found a definite, valuable application in treating insanity, particularly
schizophrenia or dementia praecox. Results in the case of study
have been remarkable, so that more extensive investigation of the
possibilities and limitations of this treatment will surely be forthcoming
at the war's end, if not before end.
Speaker 4 (24:44):
Quote Okay, Yeah, a little bit of unchecked enthusiasm there
that went a bit too far, as it often does.
Speaker 3 (24:57):
And as more hospitals started cold therapy program to treat
mental illness, there was several of them that got started. Illnesses, injuries,
and deaths, even deaths occurred. So for example, at the
University of Cincinnati in nineteen forty three, sixteen people were
put into refrigerators for forty eight hours, Two died, and
(25:18):
others suffered permanent brain damage. Yeah, jeez, this, This had
the understandable effect of halting interest in therapeutic hypothermia for
any reason or for any condition. But it was it
wasn't the only thing to do, so it wasn't the
only thing to kind of pump the brake. So I
mentioned that it was a couple of things that prevented
(25:40):
therapeutic hypothermia from being like more investigated. The first being
these US based programs, and the second was Nazis.
Speaker 1 (25:50):
Yeah, so that's what I knew about.
Speaker 3 (25:52):
Yeah. In nineteen thirty nine, temple Fay submitted a manuscript
to a publisher in Belgium, and somehow the Nazis, who
had captured Belgium in nineteen forty came across it. They
were already interested in hypothermia because their pilots often died
in frigid waters after being shot down, and they wanted
to better understand how long come someone could survive, at
(26:15):
what temperatures, which revival methods worked best, and when the
point of no return was there, like what that point
looked like, what it was? And they took inspiration from
phase paper to set up cold water immersion tanks at
Dochau concentration camp, where they held people in the tanks
at varying temperatures ranging from thirty six point five degrees fahrenheit,
(26:39):
which is two and a half degrees celsius, to fifty
four degrees fahrenheit or twelve degrees celsius. Sometimes they gave
people pilot suits or flotation devices. Other times they stripped
them and held them there naked for up to fourteen hours,
and over the course of the war, three hundred and
sixty to four hundred experimental sefts were carried out, involving
(27:01):
three hundred individuals. It's yeah, there are many, many more
horrifying details of this torture that emerged after the war
during the Nuremberg Trials, and the news of these trials
really poisoned any remaining interest in therapeutic hypothermia. For almost
(27:22):
two decades, no one wanted to be seen doing what
had become characterized as Nazi science. Eventually, though, that characterization
faded as people realized that cold therapy may still hold
some promise, and as World War two became more distant,
some researchers grew more comfortable with using the data generated
(27:43):
by these torture sessions, believing that it could quote advance
contemporary research on hypothermia and save lives end quote. And
it became and really still is quite a controversial topic.
Some people advocate for free, unrestricted use of this type
of data, and others saying that a ban is actually
more appropriate. No one, no one should be able to
(28:06):
use this data.
Speaker 1 (28:08):
I mean you're essentially benefiting from torture, torture in one way,
in one way or another.
Speaker 3 (28:17):
By nineteen eighty four, though over forty five publications had
cited the hypothermia experiments at Dacau implicitly or explicitly endorsing
the use of such data. And I found a paper
published in the New England Journal of Medicine in nineteen
ninety that discusses these hypothermia experiments specifically and the controversy
(28:37):
surrounding them, and the author concludes with this quote on analysis,
the Dacou hypothermia study has all the ingredients of a
scientific fraud, and rejection of the data on purely scientific
grounds is inevitable. If the shortcomings of the Dacou hypothermia
study had been fully appreciated, the ethical dialogue probably would
(28:59):
never have begun. Continuing it runs the risk of implying
that these grotesque Nazi medical exercises yielded results worthy of
consideration and possibly of benefit to humanity. The present analysis
clearly shows that nothing could be further from the truth. Basically,
like the author, I feel like he is saying that
(29:20):
if it's a question of using the data, first of all,
the data is worthless scientific, right. But even if it
was you know, had even if the experiments were done
in a way were quote unquote experiences were done in
a way that was controlled and all the variables, it
doesn't mean that it's okay to use.
Speaker 1 (29:38):
Yeah.
Speaker 2 (29:39):
So.
Speaker 1 (29:39):
And also and also on top of that, it's trash data.
Speaker 3 (29:42):
It's trash. Yeah, it's just yeah yeah, so yeah, there's
it is a really interesting paper.
Speaker 4 (29:49):
Yeah.
Speaker 3 (29:50):
So, therapeutic hyperthermia joins the ranks of so many other
scientific advancements that have been built on the backs of
those who did not have the power to say no
or have their no heard. And hopefully it's somewhat of
a consolation that overall, very few papers exploring the use
of therapeutic hypothermia make reference to Dacau, at least like
(30:13):
directly from data. They may mention this is where things
you know, this is what YEP was done, but they
don't say, and this is how we know.
Speaker 1 (30:21):
Is where we've got our data right right.
Speaker 3 (30:24):
And the therapy came crawling back slowly with a few
papers here and there in the mid to late nineteen fifties,
first the discovery by Hubert, Rossumov and Duncan holiday that
when a person is hypothermic, their brain consumes less oxygen.
It was a major breakthrough. It opened the door for
new avenues to protect the brain during times where oxygen
(30:45):
might be restricted like stroke, heart attack, aneurism, certain surgeries.
By just reducing the brain's oxygen demands with hypothermia, you're
protecting the brain from long term injury. And shortly after
a few physicians started playing around with us hypothermia after
cardiac arrest others during cardiac surgery, although the routine use
(31:07):
of therapeutic hypothermia wouldn't happen for a long time, especially
as physicians grew aware and wary of certain complications with
the practice. In the nineteen fifties and nineteen sixties, again
the therapy was used in a few small studies for
infants that had trouble breathing shortly after birth, like Apgar
scores of one this is our first hand account. Animal
(31:29):
studies had shown promise in this regard, so doctors tried
it out on humans. And also it has a deeper history,
like there are some reports from the sixteen hundreds using
cold water immersion for infant For infants, it seems successful.
So when one of the studies, nine out of ten
of the infants survived and none showed any developmental delay.
(31:50):
And I couldn't find any indication that the baby that
did not survive died because of hypothermia. But I, yeah,
I don't think that that was the case. But these
studies were really small and they weren't well controlled, and
so combine that with the potential for complications, and you've
got another decades long delay in this becoming a standard
(32:10):
of care.
Speaker 1 (32:11):
Interesting.
Speaker 3 (32:12):
Yeah, And ultimately in two thousand and five, I believe
it did become a routine and has since saved lives
and prevented injuries. But what about prolonging lives. So someday, Aaron,
we should do an entire episode on cryonics. As a teaser.
(32:35):
For now, let's just say that while researchers were trying
to figure out how to use the cold to protect
the body from injury. Other folks were wondering whether we
could use hypothermia to put the body in a suspended state.
The space race had begun, after all, so like, who
was going to be the first to traverse light year's
worth of distances exactly? So a bunch of cryonics come
(33:00):
and he sprung up in the nineteen sixties, with the
first volunteer dying on January twelfth, nineteen sixty seven, and
which was a little bit earlier than the company that
he had. The Life Extension Society it was called, had
thought that they were going he was going ready for dot. Yeah,
they were not ready at all. Like his doctor was like,
(33:22):
he's on ice. You got to get him now. And
they didn't have anything set up. They were still in
building the pods or whatever. And so they stored this
person in one of the Life Extension Society guy's garages
in his station wagon and then was like, don't tell
my wife. And then his wife went into the garage
(33:44):
and was like, what, get this out of here. So
he found a couple of friends who would store the
body for a few days. But yeah, cry on.
Speaker 1 (33:56):
Sorry, all I can do is blinga sorry, this is
a this is a I just so, I'm so I understand. Sure,
this was a person who died, yes, of some other cause,
some cause cancer, Yes, I believe cancer. And then they
(34:18):
made him cold and stored him in a hatchback.
Speaker 3 (34:23):
There was some profusion of various substances. I forget what
got Yeah it might have been dmso sounds familiar.
Speaker 1 (34:33):
Yeah okay in the sixties, in nineteen sixty seven, yeah cool, okay, but.
Speaker 3 (34:38):
They didn't have the pods ready for like long term storage,
so the station wagon.
Speaker 1 (34:43):
Was the thing pod. Yeah, okay, yep.
Speaker 3 (34:50):
But this came out, like the news of this came out,
and cryonics never quite recovered from this first mishap, And
really it was like, over the years, it seems like
our way to extort money from grieving people who don't
know how to accept that their loved one died or
(35:11):
that they themselves are mortal.
Speaker 1 (35:14):
Going to die. Yeah.
Speaker 3 (35:16):
So there you have it, Aaron, the history of cold,
the good, the bad, and the weird. So, okay, tell
me how therapeutic hypothermia works. Does it work?
Speaker 1 (35:31):
I love that that's what you're leaving me with. Yeah,
I also have to tell you I am not going
to talk about cryonics at all.
Speaker 3 (35:40):
I didn't think, so that's okay.
Speaker 1 (35:42):
Literally, as you were like, as you were even starting,
I was like, gosh, I wonder if I should have
looked into like I didn't. So, if that's what you're
expecting from this episode, listeners, you're about to be disappointed.
I'm going to talk about real life and not science fiction. Yeah,
maybe it will be science reality someday. Right now, it's
science fiction.
Speaker 2 (36:02):
Okay.
Speaker 1 (36:02):
Wouldn't it be nice if we could wake up in
the morning anyways, so.
Speaker 3 (36:08):
The Salm Beach boys, Oh, didn't it be nice?
Speaker 2 (36:12):
Okay.
Speaker 1 (36:40):
What I am going to actually focus on today, not cryonics,
is how we use therapeutic hypothermia. I'm putting it in
air quotes because we don't call it that anymore. Oh,
there's there's been a multiple evolutions of this term for
a while, and a kind of depends on the like
(37:01):
what scenario you're looking at, So sometimes it still is
induced hypothermia or therapeutic hypothermia, but more commonly targeted temperature
management is used.
Speaker 3 (37:14):
Okay, this might explain why I could find so few
papers on the history of therapeutic hypothermia.
Speaker 1 (37:19):
Yes, it's why it took me so long to find
the papers that I finally found about how we do it.
It's because targeted temperature management and now newly just temperature control.
Why the change in rhetoric erin let me tell you. Oh,
I'm going to tell you, but it's going to take
me a while to get there because I'm verbose, and
(37:40):
I'm going to focus mostly on the broad strokes of
like what are the contexts in which we use therapeutic hypothermia,
how do we do it, and things like that. The
point of it, really big picture is what you mentioned, Aaron.
It is to reduce the risk of ischemic injury, meaning
(38:01):
reduce the risk that a lack of oxygen to our
tissues causes actual and irreversible damage because of the theoretical fact,
which is like, it's not just theoretical, it is true,
but because of the fact that as our body temperature cools,
(38:24):
our metabolic rate decreases, our need for oxygen in our
tissues decreases. That is the theory by which therapeutic hypothermia works.
But how does it end up working in practice? Like
what is it really doing to protect our tissues? We
(38:47):
think that in the brain, this decrease in our metabolic
rate decreases blood flow to the brain, which can also
decrease intra cranial pressure, which is something that often goes
up during damage in our heart because of changes to
(39:11):
the heart muscle and the heart tissues itself, as well
as the changes that we see in our blood vessels.
With cold. Right, we're vaso constricting a lot of our
blood vessels. We see a decrease in our heart rate,
but you can maintain blood pressure to a certain degree.
Speaker 3 (39:32):
Okay.
Speaker 1 (39:33):
And these are two of our organs, our heart and
our brain that we are wanting to protect the most
with therapeutic hypothermia, because our heart and our brain are
two organs that a are going to be impacted first
due to aeschemic damage. Right, lack of oxygen is going
(39:54):
to end up damaging those tissues irrevocably, and if we
we can protect those, then we could potentially recover from
any other insult to other organs or other tissues.
Speaker 3 (40:07):
So we're still in the hypothetical thing, the thought of
how this should go and why we think that that
recooling a body a core temperature is going to be beneficial, Okay,
got it.
Speaker 1 (40:22):
So to understand the specific situations where we might use
therapeutic hypothermia or targeted temperature management or whatever. We also
have to think about the ways in which this lack
of oxygen ends up causing damage. Okay, because what that
tells us is there's different time periods at which you
(40:46):
could potentially use hypothermia to try and reverse or prevent
this damage.
Speaker 3 (40:53):
Right, So tell we ah elaborate.
Speaker 1 (40:57):
Okay, let me elaborate, and we can use if we want,
we can use an example. Let's say your heart stops. Okay, Okay,
this is one possible situation. If your heart stops beating,
you're not pumping blood, so your tissues are not going
to get oxygen. That's all of your tissues, your brain,
your heart, all of your tissues are going to not
(41:19):
get oxygen. There's three phases to the damage that that
is going to cause. The first is when that heart stops,
you're going to have the lack of oxygen, right because
our cells require oxygen for metabolism. Without oxygen, your cells
start to become damaged. Okay, step one. But then if
(41:42):
we are in medicine and we're like trying to bring
somebody back and you can restart their heart after a
cardiac arrest, you're going to all of a sudden reperfuse
that area, yep, okay, which means you're going to have
a flow of oxygen to the area. You're doing CPR,
you're using a defibrillator, whatever it is you're now reperfusing.
(42:05):
That process actually causes its own sort of damage, because
as our cells start working again, they end up creating
reactive oxygen species. The way that I think of it
is like you know, if you turn your water off
in your house for a while, yeah, and then when
you turn it back on, it's like grody, like sputtery
(42:26):
and like brown water at first before it runs clear.
Speaker 3 (42:29):
Thank you.
Speaker 1 (42:30):
That's my analogy. That's like the immediate reperfusion injury that
you can get okay, okay, and then after that there's
a final stage that you can also get, like a
delayed reperfusion injury. Think of it like a few hours
after you start to get blood flow back, there's inflammation.
(42:52):
There's our body reacting to this insult that it just received,
so you can get additional damage to that time as well.
Speaker 3 (42:58):
I don't have a Sealskis analogy. How does the what
about pipes in the house water.
Speaker 1 (43:02):
It doesn't. Yeah, it doesn't. I don't have an equivalent there. Sorry, okay, okay, sorry, okay.
So that so that's that's the example with cardiac arrest.
But it's true in any scenario where you are have
lack of blood flow, right if you think of a stroke,
all of those same scenarios are going to happen. You
have blocking blood flow to a part of the brain
(43:23):
that causes tissue damage in the brain. Then if you're
able to reperfuse that area by say breaking up that
clot or something like that, you're going to get reperfusion injury,
and then you'll have delayed reperfusion injury as well. So
it is that's the ways that damage are caused. So
you could potentially, in theory use hypothermia at any of
(43:47):
those stages to decrease the risk of injury, depending on
when you can initiate it, how long you initiate it for.
Because in addition to decreasing our over a metabolism, this
hypothermia also just like attenuates all of our cellular responses.
It's going to reduce the inflammatory response. You'll have vaso constriction,
(44:11):
so you're not going to have as much edema or
fluid like collection outside of our vascular system. And there
is a lot of animal data to support the use
of therapeutic hypothermia in a really wide variety of situations.
Speaker 3 (44:28):
Okay, real quick though, So if someone has their heart stops,
then there already will be damaged because of the reperfusion
and then the second reperfusion situation whatever. So then when
is hypothermia? When when do you target the use of hypothermia?
(44:49):
And also how realistic is that from like a hospital situation.
Speaker 1 (44:55):
So that is why this gets so complicated. Okay, right,
because that's the exact right question. But if you think
about the survival story that you told last episode, Darren, Oh,
because her he hair just stopped, her heart stopped, right,
but she was already cold at that point. Yes, she
(45:16):
was cold and her heart stopped because of that cold.
So there was already a decrease. So you potentially in
that case, because she recovered so well, you already had
protection against anoxic injury, You had protection against lack of
oxygen because the tissues were already cold before that initial insult. Right,
(45:39):
in most realistic scenarios, that's not going to happen. Right.
Speaker 3 (45:44):
Yeah, So the cases.
Speaker 1 (45:45):
That we are going to potentially be able to use
therapeutic hypothermia were probably not going to be able to
do it before that initial injury, before the onset of
the lack of oxygen. Okay, so it's the second two
scenarios that were thinking about targeting. Can we use it
to reduce the risk of that initial reperfusion injury? Well,
(46:05):
to do that, you would have to cool the body
before you reperfuse it, right right, Okay, so before you
restart the heart. That's not a thing that people do
because if someone's heart stops, your first thought is to
restart it, restart us. Yeah. Right, So the way that
therapeutic hypothermia, or the way that targeted temperature management often
(46:27):
ends up being used is in that third phase to
try and reduce the risk of that delayed reperfusion injury
after the heart or whatever it is gets restarted or
things like that, Can we can we reduce the risk
of that further damage by cooling the body, slowing down
the metabolism, slowing down the need for oxygen.
Speaker 3 (46:49):
Does that make sense? It does? And so like, because
I feel like there are two main well, I mean
obviously you're going to tell me more. But like in
an emergency situation, there's it's like the use of therapeutic
kypothermia or whatever. We're good temperature control, yeah whatever, Yeah,
(47:09):
the thermostat in an emergency situation, And like we need
to decide, right now, what do we do versus a
we're going into surgery type of situation, Like is that
you know, like a more planned right use?
Speaker 1 (47:23):
So when do we when do we actually use it? Right?
What are the situations that we actually use it today?
And do we have data that it's actually helpful? Because
that was all like the theory of like this is
how it should work, we should be able to use
it in these scenarios. Can we actually use it in
these scenarios? Surgeries? So, in a surgical situation, you could,
because you're in total control there, you could cool the
(47:47):
body before any kind of a schemic insult. Right, Yeah,
you can do that. And if we are talking about
a heart surgery, you might need to actually stop the
heart in order to do a surgery on the heart. Right,
In those situations, a person is put on cardiopulmonary bypass,
(48:09):
so their blood is still being pumped. It's being oxygenated outside.
Speaker 3 (48:12):
Of the body.
Speaker 1 (48:13):
But could we by reducing their body temperature also decrease
the risk that if we're not oxygenating it quite well enough,
or just you know that the heart itself which is stopped,
it's not going to be as injured. That is something
that is sometimes used, but there is much more mixed
data on whether or not it's truly protective, both for
(48:36):
like neuroprotection as well as just like generally protective against dschemia.
And so right now, the guidelines for you know, if
someone is doing a heart surgery and is going to
be on cardiopulmonary bypass, do you do intentional hypothermia or
do you not? It depends on the situation.
Speaker 3 (48:55):
In what and like in what way.
Speaker 1 (48:57):
It might depend on that particular person, how high of
risk are they for eschemia to begin with. It might
depend on the capabilities of where you're doing the surgery.
Do you have the ability to cool somebody or not.
But the data is not like a clear cut like
you need to do it in order to improve outcomes
and it's okay if you don't do it. Essentially, in
(49:20):
most other surgeries, the data is more clear that hypothermia
should actually be avoided, okay, because your body is going
to be under more stress trying to warm itself up,
and surgery is already a very stressful situation. So it's
really only like heart surgeries. There also was like there's
(49:43):
been trials on using it for brain surgeries, especially like
aneurism clips and things like that. There's not really data
that hypothermia is beneficial necessarily in those scenarios.
Speaker 3 (49:54):
It's so interesting because I feel like, I mean, and
maybe this just speaks to the papers that I found
that were you know, out of date, but how so
many how it is talked about in terms of like
this is a really promising thing. It's case by case,
but like it does, it does really work. And I
think also just the fact it's the human body, Like
(50:19):
we have these controls. These these are are homeostasis or whatever.
We're trying to maintain temperature for our benefit, even if
that does end up hurting us, And so I see, yeah,
causing more stress by trying to override those controls. That
makes sense.
Speaker 1 (50:34):
Yeah, yeah, So that's really from what I could find,
at least, that's the only scenario where if you could
do therapeutic hypothermia, you would be trying to prevent that
initial injury. Everything else that we use it for is
kind of post injury. Can we prevent you know, worse
Sequele When it comes to neurologic stuff, because there's a
(50:57):
lot of interest in like protecting our brain using hypothermia,
the data is much more mixed and not as strong
as I kind of expected. So after stroke, after traumatic
brain injury, after you know, hemorrhagic aneurism or aneurism, rupture,
any of these things, the data is unclear and guidelines
right now do not support universal therapeutic hypothermia. Okay, they
(51:24):
do support avoiding fever, and that is part of why,
and I'll get into it even more, but that is
part of why the kind of naming of this has
changed more to let's not think as much about you know,
intentionally cooling the body, but to like a degree lower
(51:44):
than a typical body temperature of thirty seven, but let
us do make sure that we don't go above thirty
seven point five, because then we do see that there's
more damage.
Speaker 3 (51:54):
That makes sense. What about babies?
Speaker 1 (51:58):
Okay, I was going to talk about cardiac arrest next.
You can do a basory No, I love it. Those
are the two. Those are the two big areas. So
that's all the things that we maybe sometimes kind of
use it for. There's two areas that at least for
a while, Oh spoilers, this therapeutic hypothermia actually cooling the
body to around thirty two thirty three thirty four degrees.
(52:21):
So mild hypothermia was considered standard of care for almost
twenty years for out of hospital cardiac arrest. Okay, so
if somebody heart stops outside of the hospital and you're
doing CPR or you have access to a diffibrillator and
(52:43):
they have a shockable rhythm, so you can different relate them.
There was a big paper that came out in two
thousand and two that showed big benefit to once you
get circulation back, once you have rosc which is return
of spontaneous circulation, once you bring that person back to life,
if you cool them for at least twenty four hours
(53:05):
I think it was twelve to twenty four hours at first,
you have improved outcomes, better survival.
Speaker 3 (53:10):
Okay, survival, that's the outcome, got it.
Speaker 1 (53:12):
Survival is the outcome, because that's yeah, And so that
became standard of care. And then there was other papers
that came out later that showed even if the person
initially did not have a shockable rhythm, meaning if their
heart stopped, but it was because of other things. It
could be because of substance use, it could be because
(53:33):
of a pulmonary issue, it could be like just so
many different things. But their initial rhythm wasn't one that
you could differ relate like they do on er.
Speaker 2 (53:42):
Huh.
Speaker 3 (53:42):
Yep, they've moved past the Oh that's good. The paddles, Yeah,
that's good.
Speaker 1 (53:48):
Yeah. But so there were other papers that came out
in like the early two thousands that showed even in
those situations there was some benefit to therapeutic hypothermia, so
that was the standard of care. However, since very recently,
like a paper came out in twenty twenty one that
(54:09):
looked at a pretty big swath of people regardless of
their initial rhythm out of hospital cardiac arrest and did
not find that therapeutic hypothermia was beneficial compared to just
ensuring that they don't have a fever. So targeting thirty
seven point five and not allowing it to go higher
(54:30):
than that but not necessarily lowering it wasn't any more beneficial.
There were a couple of other papers that came out
since then that were similar that kind of just showed
maybe this because there were papers that looked at, okay, well,
if lowering the body temperature is beneficial, what's the ideal temperature?
Is it thirty two? Is it thirty three? Could it
be thirty six? How low do we need to go?
(54:51):
And those papers found that like thirty six and thirty three, Eh,
no big difference, And so that led to more and
more of these papers looking at how cold do we
need to get people to have a benefit to try
and keep them alive with minimal neurologic damage once we
bring them back after their heart stops.
Speaker 3 (55:11):
Okay, so this is once you bring them back after
their heart stops, administer therapeutic hypothermia, but you don't anymore.
It's just make sure they don't have a fever.
Speaker 1 (55:20):
So right now, as of twenty twenty three, the guidelines
is to pick a temperature somewhere between thirty two and
thirty seven point five and keep them there, so temperature
control but not necessarily therapeutic hypothermia.
Speaker 3 (55:34):
I have a question, how do we do that? Ooh,
such a good question.
Speaker 1 (55:42):
There's a lot of different ways. It all does have
to be very tightly monitored, especially during the induction and
maintenance phase, so as you're cooling that body down and
then once you get to that temperature that you're targeting,
one of the things you have to do is avoid shivering,
right because that's an automatic response that's going to rewarm
(56:04):
the body and increase metabolic demand. You also have to
keep very close eye on like their blood counts, making
sure that all of the things that can go wrong
during hypothermia, getting increased blood clotting, electrolyte abnormalities, diarrhasis, acid
base disorders, from things shifting in and out of cells.
You have to monitor all of those things. But how
(56:24):
do you actually do it. You can do it almost
the opposite of how we can warm your body, So
you can externally cool with like water baths or these
fancy gel pads that like circulate temperature controlled water. You
can do internal cooling like the opposite of what we
would do to warm it up. You can infuse cold
ivy fluids or cold like peritoneal or levage. You can
(56:48):
also I know you can also do have you ever
donated plasma only blood? If you ever donate plasma they
take out circulate, yeah, yeah, and so when it goes
back into you, it is a little it's not cooled,
but it is just colder than your body temperature usually,
and it does it makes you feel cold. But you
(57:08):
can also do that. You can do extra corporeal blood cooling,
so you can take someone's blood out, cool it down
and then and then infuse it back in. So there's
a number of different ways. And like I mentioned, it's
usually a very mild hypothermia that is targeted, so like
thirty two to thirty four degrees celsius, right, okay, pascinating, Okay,
I know. And then there is babies, you asked, Aaron,
(57:32):
And this is the area that I think therapeutic hypothermia
is truly still the correct term because it is the
area that is still used Okay, whole body cooling or
sometimes just head cooling, so just cooling of the head
is used and is considered standard of care for full
(57:56):
term newborns that are born and suspected of having hypoxic
ischemic encephalopathy or HIE. And this is suspected brain damage
that's due to lack of oxygen to the brain in
a newborn okay, and that can happen. I'm not going
to go into a lot of deep detail on this
because I think it deserves its whole own episode. But
(58:19):
this can happen in a variety of different contexts, either
just before delivery or kind of during delivery, or shortly
after delivery. Right, There's a lot of situations. Whether it's
placental abruption when like the placenta comes off of the
uterus before the baby is delivered, that is going to
disrupt oxygen flow to the fetus, other cord issues like
(58:42):
the cord getting compressed or prolapsing, uterine rupture, the heart
rate of the fetus just dropping and then not recovering,
or even during or after delivery. Anything that causes the
baby to stop breathing or not have access to oxygen
is going to lead to potentially hypoxic a ischemic encephalopathy.
(59:03):
And we use that Appgar score that you mentioned, which
is a composite score of like how well they're breathing,
their skin color, Turger reflexes all of these things to
give a sense of how a baby is doing. And
it's usually at that ten minute mark if a baby's
heart rate is still really low or if it's not
there at all, and if they're not breathing or they're
(59:24):
requiring continued ventilation support, there is good data that cooling
these babies can help prevent severe disability or death. Okay,
and I specifically mentioned full term infants. Yes, because a
relatively recent study from I think it was actually published
(59:45):
this year in twenty twenty five, was actually one of
the first ones that looked at preterm infants and did
not find any statistically significant improvement in outcomes for preterm
infants by using therapeutic hypothermia.
Speaker 3 (01:00:02):
Why why do you think that is?
Speaker 1 (01:00:05):
I mean, babies, newborn babies are so different in their physiology,
and so like a premature newborn has different physiology than
a non premature like a full term newborn, and so
we don't know, I mean the short answers, we just
don't know. But that's why it was so important that
(01:00:25):
this study was actually done, because there certainly were all
of the studies previously had only used full term infants,
and yet therapeutic hypothermia I think was often maybe used
in some situations in preterm infants just based on the
data of full term infants. Right, But because we know
they're so different. It was important that this data actually
came out and it doesn't show improvement in outcome.
Speaker 3 (01:00:49):
So okay, and what is like the the effect size,
I guess or like what you know, it's a good question.
Speaker 1 (01:00:58):
A meta analysis from twenty one found for full term
infants a pooled reduction in risk of mortality of about
twenty six percent in infants who were cooled compared to
ones who weren't. And this was similar whether it was
whole body cooling or just head cooling that was used. Okay, yeah,
it's not nothing.
Speaker 3 (01:01:19):
It's not nothing, and it's pretty amazing that, yeah, that
there are there is I don't know there are uses
for this because it does seem like fairly, I know,
it's not straightforward that there are many different home approaches
that you can use to do this and administer this
and monitor this, and that it's about the degree and
all this stuff. But it's like it's just I don't know,
(01:01:42):
it's it's fascinating to me that it's like we use
temperature in this way.
Speaker 1 (01:01:46):
Also, what you had mentioned, Aaron about the use in
cancer is so interesting because I didn't find anything about
it's you. I mean, I know you know, people do
sometimes like ice on the head to try and reduce
hair loss during chemo therapy or things like that. The
mechanism that's going to be very different than what you
had mentioned, but someone using it to try and reduce
cancer growth. I think probably because we have better options
(01:02:10):
today is why there's not really a lot of data
that I could find, at least on modern uses of that.
We do use a different kind of crowd therapy like
liquid nitrogen to kill small skin cancers or other growths
all the time. Yeah, I forgot about that after the fact.
I also did find a paper on cold plunges and
(01:02:33):
that kind of crowd therapy for muscle recovery have to
work out by the way, there's not really good data
to support it, but I can give you a paper
if you want to read about it.
Speaker 3 (01:02:40):
Well, And you know, I'm not against cold plunges. If
you enjoy jumping into an icy lake or tub or
whatever it, do it safely, have a buddy whatever you know.
Speaker 1 (01:02:52):
No, but there's not like for like the muscle recovery stuff, like,
there's not a lot of data that it's really beneficial.
But you can read about it if you want to
know more. We have so many sources for you.
Speaker 3 (01:03:03):
We do okay again, I'm going to shout out that
book by Phil Jakol called out Cold Chilling Descent into
the macabre, controversial, life saving History of Hypothermia. And then
a paper about doctor temple Fay called Breaking the Thermal
Barrier Doctor temple Fay by al Saga at All from
(01:03:24):
two thousand and six and then by Gunn from twenty
seventeen Therapeutic Hyperthermia Translates from Ancient History into Practice and
more papers.
Speaker 1 (01:03:34):
I had a couple of older papers, one from twenty
fourteen that old but called Clinical Applications of Targeted Temperature
Management by Perman at All and another one from two
thousand and eight that was just called Therapeutic Hypothermia by
Varren and Acosta. And then the two papers two biggest
(01:03:56):
papers that I had on hypothermia in infants. One of
them is Whole Body Hypothermia for Neo nail and Cephalopathy
and Preterm Infants thirty three to thirty five weeks in
GEMI Pediatrics, and the other one was from PLUS one.
And it was that twenty twenty one paper that was
the systematic review and meta analysis. But then what's fun
is I have guidelines. So many of the guidelines, like
(01:04:17):
the two thousand and two paper that led to the
guidelines initially of being yes, do therapeutic hypothermia for out
of hospital kardiac arrest, and then all the subsequent papers
that were like, yes, it's beneficial. No wait, maybe it isn't.
Maybe it's not as good to be thought. Now Here
are the new guidelines. So many guideline papers. You can
find them all on our website, This podcast will kill
You dot com.
Speaker 3 (01:04:38):
You can thank you to Bloodmobile for providing the music
for this episode and all of our episodes.
Speaker 1 (01:04:44):
And thank you to Leanna and Tom and Brent and
Pete and Jessica and Mike and everyone else at Exactly
Right Network for all that you do.
Speaker 3 (01:04:51):
Thank you, thank you, and thank you to you listeners
and watchers and anyone who enjoys this podcast in any way.
It means the world to us, and as does the
support of our patrons.
Speaker 1 (01:05:03):
Thank you, thank you, thank you, thank you. Wow.
Speaker 3 (01:05:06):
Until next time, wash your hands
Speaker 1 (01:05:08):
You filthy animals.
Hosts And Creators
Erin Welsh
Erin Allmann Updyke
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