Mostly dead is slightly alive

Summary

Podcast Title: Unexplainable
Host/Author: Vox
Episode: Mostly Dead is Slightly Alive
Release Date: June 16, 2025

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Introduction

In the episode titled "Mostly Dead is Slightly Alive," the Vox team delves into the intricate and often perplexing definitions of death in the modern medical landscape. Hosted by Bird Pinkerton, the episode explores how advancements in medical technology have blurred the traditional lines between life and death, raising profound ethical and philosophical questions. This episode features insights from Adam Richman, a perfusionist at the Mayo Clinic, who provides a firsthand perspective on the challenges and ambiguities faced by medical professionals in defining and managing death.

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Evolution of the Definition of Death

Bird Pinkerton opens the discussion by posing a fundamental question: "Are there different ways that humans might be dead?" (00:58). This inquiry stems from a long-standing debate initiated by bioethicist Bob Troog, who highlighted the complexities in defining death beyond the traditional markers.

Originally, death was a clear-cut concept marked by the cessation of the heart, breathing, and muscle stiffness (rigor mortis). As Pinkerton explains, "You just kind of knew it when you saw it. Your heart had stopped, you had no breathing, stiff body, and you were, you" (01:26). However, the advent of technologies like ventilators in the 20th century introduced scenarios where the body could maintain essential functions despite the failure of vital organs like the brain.

This technological intervention led to the recognition of brain death, a condition where the brain and brain stem cease functioning irreversibly, even though other bodily functions are artificially maintained. Pinkerton notes, "Not just the your heart stopped and your cold and still version that we're all more familiar with, but also another version, what we call brain death, irreversible brain damage, where a brain and a brain stem stop functioning and stop sending signals" (02:05).

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Insights from Adam Richman

Enter Adam Richman, a perfusionist whose role is critical during cardiac surgeries. Richman provides an insider's view on how his work intersects with the evolving definitions of death. He recounts, "Death is, unfortunately, part of cardiac surgery" (03:15), highlighting the delicate balance medical professionals must maintain between life-sustaining interventions and the finality of death.

Richman explains the process of deep hypothermic circulatory arrest (DHCA), a technique used during complex heart surgeries. "That's exactly what it is. You know, for instance, hear about a child that's fallen through the ice in the winter, and their heart stops, and everything and, you know, they're brought to the hospital and warmed up again. They're essentially reanimated." (05:08). This method involves cooling the patient's body to drastically reduce metabolic rates, effectively slowing down bodily functions to pause life processes temporarily.

He elaborates on the challenges posed by DHCA: "We don't understand very well neurologically what's going on." (07:02). The application of this technique raises critical questions about the state of the patient during surgery—are they truly dead, or merely in a suspended state of life?

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The Gray Area Between Life and Death

The conversation delves deeper into the ethical and medical ambiguities of circulatory arrest. Pinkerton probes, "Oh, my God. So are you, by our medical definition of brain death, are you temporarily killing them or are they, like, temporarily dead?" (07:20). Richman responds thoughtfully, acknowledging the complexity: "I can't say. Yes, for sure. Their body's still functioning. It's just extremely slow. But there's no brain activity, there's no cardiac activity. So the only reason that they're actually still alive is because we're actively pumping blood." (07:39).

This revelation underscores the "interstitial zone"—a liminal state where a patient exhibits signs of both life and death. Richman mentions, "I guess so ideally under an hour. But you know, depending on the surgery, sometimes we do have to go over an hour." (10:30). The uncertainty surrounding the patient's status during this period highlights the need for clearer definitions and ethical guidelines.

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Reversing Circulatory Arrest

A critical aspect of DHCA is the process of rewarming the patient and restoring normal bodily functions. Richman describes the meticulous procedure: "But we have to do it very gradually, because when you're at such a deep hypothermic level, if you warm the blood up too fast, what can happen is you can create microscopic bubbles." (13:26). This cautious approach ensures that the patient regains consciousness without adverse effects, such as the formation of blood bubbles, which can lead to complications akin to "the bends."

The gradual rewarming process can take up to an hour and a half, during which sporadic bursts of brain activity are monitored: "As we warm closer and closer to normal body temperature, we're starting to get bursts of activity back from the brain." (14:00). This intermittent revival of brain function serves as a beacon of life, bridging the gap between life and death.

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Ethical and Philosophical Implications

The episode poignantly captures the moral dilemmas faced by medical practitioners. Richman reflects, "Yeah, it's definitely raised more questions than answers, you know? You know, you think about no brain activity, no heart activity. It's like, well, yeah, our patient is dead. They still have blood flowing. So are they actually dead?" (11:55). This introspection reveals the profound responsibility borne by those who operate at the intersection of life-sustaining technology and the finality of death.

Pinkerton adds, "It feels like something out of science fiction. That kind of melding of person and machine and you're turning people off and turning them on again." (11:30). This sentiment underscores the unsettling reality of medical advancements that can both preserve and obscure the essence of human life.

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Conclusion

"Mostly Dead is Slightly Alive" masterfully navigates the complex terrain of modern definitions of death, illuminated by the experiences of medical professionals like Adam Richman. The episode challenges listeners to reconsider preconceived notions about life and death, emphasizing the need for ongoing dialogue and ethical consideration as technology continues to evolve. By highlighting the gray areas and ethical quandaries inherent in contemporary medicine, the podcast fosters a deeper understanding of what it means to be alive or dead in an age where the lines are increasingly blurred.

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Listener Engagement

Towards the end of the episode, Pinkerton encourages listeners to engage by sharing their own experiences and questions, emphasizing the podcast's commitment to exploring the unknown through audience participation. She invites listeners to reach out via email or voice memos to contribute to future episodes, fostering a collaborative exploration of unexplainable phenomena.

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Notable Quotes:

• "Are there different ways that humans might be dead?" — Unknown Speaker (00:58)
• "Death is, unfortunately, part of cardiac surgery." — Adam Richman (03:15)
• "We don't understand very well neurologically what's going on." — Adam Richman (07:02)
• "I can't say. Yes, for sure. Their body's still functioning. It's just extremely slow..." — Adam Richman (07:39)
• "It feels like something out of science fiction. That kind of melding of person and machine..." — Bird Pinkerton (11:30)

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This episode not only sheds light on the medical intricacies surrounding death but also invites listeners to ponder the profound implications of technological advancements on our understanding of life itself.

Transcript

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[Unknown Speaker 1]

Are there different ways that humans might be dead?

[Bird Pinkerton]

I've been thinking about this question, right Are there different ways to be dead? For years at this point, basically ever since Bob Troog, this bioethicist, asked it. I spoke to him for an episode that we did a while back called Redefining Death, and he told me essentially that death used to be relatively simple.

[Unknown Speaker 1]

Up until about the 1950s, there was no confusion about what death meant.

[Bird Pinkerton]

You just kind of knew it when you saw it. Your heart had stopped, you had no breathing, stiff body, and you were, you.

[Unknown Speaker 1]

Know, blue or gray.

[Bird Pinkerton]

You were probably dead. But then in the 20th century, as we started inventing new technology, the line started to blur more. You had stuff like ventilators, which kept patients alive even if their lungs and brains failed.

[Unknown Speaker 1]

But when the ventilator was used and you could breathe for them, they went on and lived and lived and lived.

[Bird Pinkerton]

Their hearts were still pumping oxygenated blood through their bodies and their bodies were still functioning, but their brains weren't working. Eventually, this forced the medical community to define a new kind of death. Not just the your heart stopped and your cold and still version that we're all more familiar with, but also another version, what we call brain death, irreversible brain damage, where a brain and a brain stem stop functioning and stop sending signals.

[Unknown Speaker 1]

The person will never regain consciousness and will never breathe on their own again.

[Bird Pinkerton]

That might seem straightforward, but as we showed in the episode we made a while back, there's a lot of nuance to it.

[Adam Richman]

Yeah, that's why I Reached out. You know, this is just one big gray area.

[Bird Pinkerton]

Adam Richman is one of my favorite kinds of people, the people who listen to Unexplainable and then write in about episodes. He heard this episode about Redefining Death, and. And he emailed us to share his very specific perspective on both medical technology and the definition of death.

[Adam Richman]

Death is, unfortunately, part of cardiac surgery.

[Bird Pinkerton]

Adam is a perfusionist at the Mayo Clinic in Minnesota.

[Adam Richman]

So as a perfusionist, we run the heart lung machine during cardiac surgery.

[Bird Pinkerton]

This heart lung machine lets doctors operate on parts of the heart by basically stopping the heart and rerouting the blood through a machine. It oxygenates the blood, and it pumps it back through the body. But as Adam told me, it also made him think long and hard about what it means to be brain dead.

[Adam Richman]

We don't understand very well neurologically what's going on.

[Bird Pinkerton]

This is unexplainable. I'm Bird Pinkerton, and on today's show, hundreds of you unexplainable listeners you have written in over the years. So for this episode, we are handing over the mic to one of you, Adam Richman, and he will bring us to the edge of death and then back again. You're gonna be part of. Really See how the sausage is made.

[Adam Richman]

Yeah.

[Bird Pinkerton]

Cause we're up to antics over here. Yeah. So you reached out to the show back in 2022, because we made this episode. Right. Called Redefining Death. And I'm curious, kind of given your day to day, what was it about that episode that kind of, like, struck a chord with you?

[Adam Richman]

So it reminded me of a lot of the surgeries and procedures that we do with the aorta specifically.

[Bird Pinkerton]

That's like the big artery in the heart, right?

[Adam Richman]

Yep. That's the big artery coming straight out of the heart to carry all the oxygenated blood to the rest of the body. And if there is disease of the aorta, then that kind of presents a challenge because, you know, there's blood flying up there, but that's also the area where they need to fix. So in order to do that, we use a technique called deep hypothermic circulatory arrest.

[Bird Pinkerton]

Okay.

[Adam Richman]

Deep hypothermic.

[Bird Pinkerton]

Deep hypothermic circulatory arrest, Circulatory arrest. So, like, very cold hypothermia is like being cold. Very, very cold blood. Stop.

[Adam Richman]

Exactly. That's exactly what it is.

[Bird Pinkerton]

Okay.

[Adam Richman]

You, you know, for instance, hear about a child that's fallen through the ice in the winter, and their heart stops, and everything and, you know, they're brought to the hospital and warmed up again. They're essentially reanimated. So it's very similar to that. So as we change the temperature of the blood, that changes the temperature of the patient as a whole.

[Bird Pinkerton]

So you're using the machine basically to, like, pump frigid blood, not freezing, obviously, but, like, pump frigid blood through their body to. To cool them all the way down?

[Adam Richman]

Yep, that's exactly it.

[Bird Pinkerton]

Okay, and what does that do?

[Adam Richman]

So we know about a process called the Q10 effect. Essentially, what that is is that as our body temperature decreases, our metabolism also decreases.

[Bird Pinkerton]

Okay, so you're just literally slowing down.

[Adam Richman]

Exactly. You're slowing down every single metabolic process in the body.

[Bird Pinkerton]

Oh, that's great. So how cold do they get? Like, how much slower is their body going?

[Adam Richman]

So, and this is why I reached out to you guys, because we'll actually monitor their eeg, their brain activity, the electrical activity in the brain, and it will actually flatline and stop.

[Bird Pinkerton]

Oh, my God. So are you, by our medical definition of brain death, are you temporarily killing them or are they, like, temporarily dead?

[Adam Richman]

I can't say. Yes, for sure. Their body's still functioning. It's just extremely slow. But there's no brain activity, there's no cardiac activity. So the only reason that they're actually still alive is because we're actively pumping blood.

[Bird Pinkerton]

After the break. How to bring someone back to life after you have turned their brain off?

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Generation out of the water, I looked down.

[Unknown Speaker 2]

There was this great big head, these big white teeth.

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[Adam Richman]

Are you brain dead?

[Bird Pinkerton]

I'm not going in there with two Jedi. How long can a person stay in this sort of like interstitial zone, this little gray area?

[Adam Richman]

I guess so ideally under an hour.

[Bird Pinkerton]

Okay.

[Adam Richman]

But you know, depending on the surgery, sometimes we do have to go over an hour. And that's more the extreme case. Like typically it's 20 minutes or so.

[Bird Pinkerton]

Do we know what effect it has on the brain to just be flatlining for an hour?

[Adam Richman]

So not. Well, not understood. Well.

[Bird Pinkerton]

Incredible. What are you thinking at this point in the surgery? Like, what's going through your mind?

[Adam Richman]

Just, it's still so surreal.

[Radiolab]

Mm.

[Adam Richman]

But, you know, that's a person and I wanna do what I can to ensure that they're being taken care of as best as I can.

[Bird Pinkerton]

I'm sorry. This is so. It feels like something out of science fiction. That kind of melding of person and machine and you're turning people off and turning them on again. Like, how has this job, how has it kind of changed the way, I guess, that you, that you think about life and death?

[Adam Richman]

Yeah, it's definitely raised more questions than answers, you know? You know, you think about no brain activity, no heart activity. It's like, well, yeah, our patient is dead. They still have blood flowing. So are they actually dead? But yeah, if we were to stop the machine, then they would for sure die.

[Radiolab]

Right.

[Adam Richman]

Because that's their only means of support. It's pretty mind boggling to think about still.

[Bird Pinkerton]

Right. I'm trying to think about like this in between state that our definition is blurry enough to allow for sort of 20 minutes of undefined.

[Adam Richman]

Yeah.

[Bird Pinkerton]

Feels. I don't know, I just, I think when I was reporting out the episode, I kept on being like, but surely we should just, surely we should know whether someone's like that Feels like the most basic question is, like, are we. Is this person alive or are they dead?

[Adam Richman]

Right. And like the doctor that you talked with in that Redefining Death episode, you know, you think of cardiopulmonary death, so you're not breathing and your heart's not beating. Or you think of brain death, you know, where the brain's unresponsive. And in these circulatory arrest cases, we have both of those.

[Bird Pinkerton]

Right.

[Adam Richman]

But the patient isn't actually dead somehow.

[Bird Pinkerton]

How do you. Like, how do you reverse the process? I guess. Is it just like turning the temperature knob back up to bring the patients back to life?

[Adam Richman]

That's exactly it. But we have to do it very gradually, because when you're at such a deep hypothermic level, if you warm the blood up too fast, what can happen is you can create microscopic bubbles.

[Bird Pinkerton]

What, like the bends?

[Adam Richman]

Yep.

[Bird Pinkerton]

But from temperature?

[Adam Richman]

Yep. Just literally microscopic bubbles coming out of the water, part of your blood.

[Bird Pinkerton]

So you're doing it very slowly. How long does it take to kind of warm people up again?

[Adam Richman]

It depends on the size of the patient, but on average, probably hour and a half or so.

[Bird Pinkerton]

Wow. Okay.

[Adam Richman]

As we warm closer and closer to normal body temperature, we're starting to get bursts of activity back from the brain.

[Bird Pinkerton]

So. So basically, the brain sort of like spits and spurts back into life, like an engine or something.

[Adam Richman]

Yep, yep. They'll get just little bursts every so often and then, yeah, eventually return to normal.

[Bird Pinkerton]

Honestly, any open heart surgery is kind of a miracle, Right. People like Adam and the surgeons he works with, they sort of have to get used to holding our lives in their hands.

[Adam Richman]

Yeah. It's still surreal just because this type of surgery especially is just one big nebulous area. I've been doing this over 12 years now, and it still just, you know, amazes me every day what we're able to do.

[Bird Pinkerton]

In some ways, it's kind of like death itself. It's both unbelievably complicated and mysterious and hard to pin down. And also, it happens a lot to everyone in ways that are both miraculous and routine.

[Adam Richman]

You know, 50 years ago, when heart surgery was still in its infancy, you know, these were things that were just dreamt of. And now it's just like, oh, we got a Cirque arrest case today. It's the slang term, I guess, for it. Just circ arrest. Like, oh, we got a circ arrest case today. You know, no big deal. It's just going to be a longer day, that's all. But I mean, I do remember learning about it and I was just like, wait, we do what now?

[Bird Pinkerton]

This conversation was a bit of an experiment because one of my favorite parts of my day is checking our inbox to read all of your emails. People will tell us everything they think we got right in an episode or wrong in the case of the posture episode that I did. People send in questions that I'd never considered before. They will ask us to look into the geopolitics of 17th century metallurgy, for example. Or a listener wrote to us from a research vessel in Antarctica to tell us how their eye movements are being used to to train a lander for a future mission to Europa. Another listener sent us proof of the comedy work that they did with Buzz Aldrin. And someone else sent pictures of whale sharks whose exposure to Cold War nuclear testing helped scientists figure out how old they are. All to say, we are here for that kind of email. Like we love your messages and there have been a lot that we wish that we could share with you, our audience. This episode where we called Adam back and talked to him about his job, this is how we've started. But we'd like to do more episodes like this to feature more listeners like Adam and maybe like you. The best way for that to happen is for you to send us either an email or or a voice memo. We love to read your messages. We especially love to hear your messages. Just tell us your own weird, wonderful take on any of our episodes. How you are connected to the question we asked or the answers we didn't find. What you know that we have not yet figured out. Tell us new things to check out. Ask us new questions that we ought to explore. Basically just let us know what you're thinking. We are@ unexplainableox.com and please just reach out. In the meantime, if you want to hear more about how complicated our medical ideas of death are and how scientists are even trying to someday reverse it, check out our episode Redefining Death. This episode was produced by Meredith Hotnot who who also runs the show and by me, Bird Pinkerton who does not run the show. We had editing from Julia Longoria with help from Jorge Just sound design and mixing from Christian Ayala, music from Noam Hassenfeld, production support from Thomas Liu and fact checking from the wonderful Melissa Hirsch. Thanks always, always, always to Brian Resnik for co creating the show. And if you don't want to email us but you do have thoughts, you can leave us a review or a rating wherever you listen. It really helps us to find new listeners and it's really nice to read your thoughts on various episodes. You can also support this show and all of Vox's journalism by joining our membership program. You can go to vox.commembers to sign up. If you do sign up, you get ad free podcasts, you get unlimited access to all of Vox's journalism, and you get the delightful sense of supporting a bunch of journalists who you hopefully enjoy. Right now we are running a limited time membership sale so a membership is 30% off. So you can get that lovely sense of having supported journalism for 30% off. What a bargain. Unexplainable is part of the Vox Media Podcast Network and we will see you on Wednesday.

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