What’s it all about? – Check out the introduction page linked above.
Dr Parnia was a guest speaker at a fairly recent 2018 resuscitation update seminar hosted by the European Resuscitation Council. YouTube link
In his presentation he covers the concept of the AWARE study, reconfirming the aims of analysing the flatline period of cardiac arrest. The key parameters of the monitoring are brain oxygenation levels alongside electrical activity (EEG). He presented a slide picture of the equipment designed into a portable unobtrusive all in one stand unit, including a mounted I Pad for image projection.
The data collection period is said to finish by the end of 2020, thus I suspect any report or release of findings will not likely appear before mid 2021. The data pool target is the recording of 1500 in hospital cardiac arrest patients. Concerns have been raised previously in this blog about data pool size, but inevitably resources and practicality must dictate limits.
The relationship of brain oxygenation levels with corresponding EEG measurement is still mooted as the key investigation of the study, with the noted proposition that better oxygenation during cardiac arrest resuscitation leads to not only better recovery but also increased likelihood of any experience recollection.
Oxygenation and these associated relationships are discussed in previous blog articles.
There is allusion and brief discussion of memory in the talk. In my opinion a relationship worthy of much discussion and analysis is indeed that of memory and the self, especially in the scenario of near/actual death experiences.
The other guest speakers in the session are also well worthy of a listen / watch, giving an insight into the past and future of resuscitation / life saving protocols.
Is the AWARE study starting all over again, or being expanded, or integrated into something else?
Thanks to one of the regular contributors for this reminder, but Dr Parnia tweeted for the first time in a very long time:
I use the word illusive since he doesn’t really clarify what this means. Is this AWARE II, surely not as that is well under way now. Are these sub-studies of AWARE II? Are they completely new studies, and if so how will they differ?
Anyway, hopefully we will learn more before long.
The Aware study team have set up a web portal for news and general project information on the Stony Brook University hospital website. (www.stonybrookmedicine.edu/sbuh)
Stony Brook is a New York teaching and research hospital, specialising in, among other fields, neurosciences, organ surgery and transplantation. It is a tertiary care and ‘Level 1’ trauma centre.
The resuscitation section (https://medicine.stonybrookmedicine.edu/medicine/sleep/resuscitation) is now the home of the AWARE study as it continues into the second phase, as part of the ‘Resuscitation Research Group’.
The copy content covers the aims of the study, summarised pretty much as Dr Parnia did in the “Dr Oz” interview discussed in the last article. It focuses heavily on the aim of improving resuscitation methodology and monitoring systems. To improve post cardiac arrest outcome, the group as a whole, including the study, is working on a standardisation of procedure that monitors oxygenation and CPR quality. The spreading or ‘education’ of this procedure so far is claimed to have had measurable success.
There is comparatively little description of the more esoteric aspect of AWARE, that being the probing of possible consciousness in cardiac arrest situations. There is an intriguing paragraph that raises similar thoughts that I have already mused upon in previous articles:
“we will be testing the hypothesis that by limiting ischemia during resuscitation, higher cerebral oxygenation leads to improved cortical function during CPR and is associated with improved survival as well as favourable neurological, functional and neuropsychological outcomes. We further hypothesize that mental and cognitive activity and awareness during CPR may reflect verifiable events and is associated with the quality of brain resuscitation.”
What is unclear here is, does this refer to the duration of ‘flatline’ EEG? If so, is this not a conflict of current medical understanding? Maybe the implication is rather that better recovery leads to better memory storage, but the wording as expressed could be taken to mean that the CPR quality is in fact itself directly enabling the possibility of awareness, rather than the memory of it.
Is it also then being suggested that verifiable memories, due to cognitive activity, will be based on functional human physiology, and thus any reported ‘out of body experiences’ are presumed to be illusional rather than actual external witness?
That latter point is quite crucial to the scope of the study, even if OBE verification is only presented as a lesser exploration.
I would like the study team to clarify their hypothesising in these regards.
The study has once again been publicly registered in the UK on the NHS research domain. (http://www.hra.nhs.uk/news/research-summaries/aware-ii)
As an extra, there is a good list of resource papers linked that are worth looking at.
Of particular note are the papers concerning oximetry during cardiac arrest, clinical outcomes, and consciousness and death experience.
It is good to see the study in full progress, and I among followers look forward to further updates.
Dr Sam Parnia, key organiser of the AWARE studies, is now on a Twitter account, of interest to those who wish to keep updated of his activities. (@SamParniaMDPhD). He indicates that there will be a web site or central portal of some sort to hold news and information on the AWARE II study, which is good news again for those following.
He has announced that the study will now go on until 2020, when a results presentation will be made to the Canadian Association of Emergency Physicians. This planned time extension can only be good for the study. It will be bring it in line to match the length, and hopefully breadth of the first AWARE. A larger data pool and more analysis means better observations and deductions. Many followers thought from the outset that a 2 year study was too ambitious.
There are currently 8 participating hospitals in the study, with an option to extend to 25. Dr Parnia is on the look out for more participants, presumably with a view to recruiting towards the higher number. This could be what the discovered PowerPoint slides in the ‘intervention presentation’ as discussed in the last article were about.
Again, this is encouraging. It would seem there is ongoing enthusiasm and support from the medical community at large, especially from the emergency resuscitation field. The study is accepted as a viable project with worthy aims.
Last year, October 2016, Dr Parnia made an appearance on the American television show Dr Oz, in a feature about the experience of dying. It can still be viewed at – http://www.doctoroz.com/episode/oz-investigates-final-7-minutes-death-what-does-it-really-feel-die?video_id=5170234436001
He spoke enthusiastically of the study and it’s aims, which in short, he says are:
1) Improve resuscitation techniques to achieve a better outcome for cardiac arrest patients.
2) Learn more of the subjective experience patients go through in such situations, with a view to educate at large possible expectations to have of the dying process.
3) Explore the relationship between consciousness and the dying brain, examining further the details of memories in near death experience.
Dr Parnia believes that the experiences are a universal phenomenon which everyone undergoes through the dying process. Depending on the quality of resuscitation, and thus the recovery speed of the patient post cardiac arrest, there is a ‘spectrum’ of recollection. The spectrum would start from remembering absolutely nothing at all at one end, to a full vivid account of apparent witness at the other.
The suggestion is that the post arrest ‘tsunami’ of brain cell inflammation and chemical shock quite often destroys any memory of experience, unless mitigated by better oxygenation throughout the arrest, thus reducing post event damage.
It is a proposed relationship that the study is geared to explore.
Analysis of these variables at the end of the study will certainly give insight and open debate on the states of physiological functionality during cardiac arrest, as well as question the relationship between consciousness and memory, and indeed memory storage, physiological or otherwise.
At what point do these experiences and the memorising of them occur? I feel this will have to be discussed and conjectured upon if the idea of better recovery contributing to recollection is going to become the focus.
There is of course still the holy grail as far followers of AWARE are concerned, will there be a confirmed veridical visual out of body experience? Can there be?
We watch with interest, and wish the practitioners and indeed the patients the best in their endeavours.
Towards the end of last year 2016 the details of the second aware study, and its ongoing recruitment progress, were removed from the public database at UKCRN. This led to some worry and speculation among followers as to what was going on with the study. An interesting piece was put up by fellow blogger and clinician Ben Williams.
There is reference made to some discovered PowerPoint / presentation slides that appear to infer a necessary intervention in the study to improve the patient recruitment.
Without official news or statements, we can only wait for the original published study end date to pass, considered to be May. I expect some form of update in the summer.
It is worth noting that in October, Dr Sam Parnia (chief clinical coordinator in the study) was interviewed on American talk show “The Dr Oz show”.
Dr Parnia’s demeanour and enthusiasm would suggest that he is buoyed by the AWARE study progress so far. There are interesting points put across by Parnia in this show, not least his belief that all people entering clinical death have similar special experiences with only some actually remembering.
More on the implications of this another time….
Our experience of the world is as for every different animal species, unique, not just due to our brain complexity, but also due to the nature of our sensory detection equipment. How we experience the world is down to the presentation given to us by our mental processing ability of all the sensory data from our senses and their range of detection.
The data starts as physical interaction between the atomic nature of our surroundings and the biological construct of our sensory equipment. Scientific understanding has an extremely good grasp of our bodily interactions with the atoms, photons and electromagnetic waves that make up our environment. Our sensors take in a bombardment from the physical world that is in essence (at a quantum level) an interaction of electrical forces.
The data feeds to our brain from our sensory organs as electrical impulses producing a picture for us to monitor and interact with.
Our world is the way it is to us because of (a) it’s construct, (b) our own biological construct to sense it, and (c) our brain’s processing ability to create a mental sensory picture of it.
Our body is part of the physical world it inhabits and follows the same rules of construct, producing the mental sensory picture. This picture is reasonably conjectured to be different for different species of animal based on varying sensory equipment and processing ability.
So what of consciousness?
Perhaps our consciousness can be described as the entity that is looking, hearing, and feeling this picture. Our personality and sense of who we are is built on the development of this consciousness through experience and memory. We are our own history. The accumulation of experience and memory makes us, even if the essential consciousness itself can arguably be separated from these.
Out of body experiences
When considering an out of body experience, or in other words a consciousness without the physical sensory equipment, how and why would a physical world still be pictured? Furthermore, if then the consciousness is free from the physical brain, why does the picture still build as a physical construct? How is the physical world still seemingly interacting with consciousness, even if only in an observation / perception manner?
The Aware study led by Dr Sam Parnia and others is putting out of body experience anecdotes to the test, using controlled monitoring and observation environments. A truly verified experience of this nature is yet to be discovered, but it would be wrong to assume that this is the sole objective of the study. There appears to be a direction in questioning the assumptions from measurements of when a brain is capable of conscious activity, and in what state.
Apparent evidence of consciousness in a ‘dead’ brain does not automatically infer the separation of consciousness. Exploration of possible activity in hitherto considered ‘impossible’ states would have to be exhausted. Only more convincing evidence, such as the verified veridical visual experience would suggest a separation.
How would separation fit in our understanding of the universe?
How is our understanding of our place in the universe now, without separation? We are biological matter with complex brains that process inputs to then direct function of our bodies within environments. As alluded to at the beginning of this article, physically this can be reduced to the interaction and exchange of electricity, as can all physicality. In quantum field theory all matter is the ‘excitation’ or movement of energy within fields of fundamental forces.
Perception of the universe is a picture, assembled with electricity. It is a picture because our consciousness makes it so, we ‘see’ it and interact with it, but the picture itself is produced by our brain through its electrochemistry.
If consciousness is removed from normal physical inputs, would it still be possible to ‘see’ a picture? In the debate of what consciousness actually is, most conjectures still put it in the realm of physical existence, albeit in a yet to be understood manner.
The brain based point of view would say that a picture can still be created, with compensations made for the lack of sensory data. The picture may not be veridically accurate, but will still be based on whatever input is available, including memory.
A separation conjecture could argue that a picture can still be created independent of the brain or any bodily sensors, by using inputs on a level deeper than atomic contact. That is, perhaps, the electrical interaction that goes on within the brain and between the body and the environment, could still happen at a smaller quantum level, without the bigger manifestations of body matter. The picture could then still be built in a similar way as though the bodily senses were still there.
Modern science at a microcosmic level puts all existence, or all matter at least, down to a consequence of electromagnetic forces and energy. It is not that far fetched then to suggest that the phenomenon of consciousness, however linked to brain matter itself, is likely to be of the same. What it is the consequence of, is the big question.
The exploration of possible consciousness separation from the brain could lead to three major paradigm shifts:
Is our understanding of brain functionality in ‘dead’ states shortcoming?
Does our existence, through our consciousness, go beyond manifest biology?’
Is our understanding of the fundamental forces of the universe in need of revision?
As of writing Jan 2016, the UKCRN website (http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=17129) states that 3% of the study data pool has been achieved, or in the exact wording “global recruitment to date”. (EDIT: Please note as of late 2016 the details of this study outline have been removed and the link is no longer valid. There is a new official briefing page on the NHS Research portal http://www.hra.nhs.uk/news/research-summaries/aware-ii). The study start appears to have been started in May 2015, meaning that if the proposed time duration has to be adhered to, as stated ending May 2017, the likely final pool will only be 12% of what was hoped for, or approximately 180 patients recruited. I take this to infer the number of survivors of cardiac arrest through resuscitation under the controlled conditions of the study.
This may seem disheartening, especially in the light of statistical probabilities of patient recall, but there may well be good reason for optimism.
One aspect of this study, much discussed on this blog, is the monitoring of oxygen during resuscitation to better assist CPR efforts and give more survivable outcomes. A correlation between better oxygen and NDE recall is part of the research. This should mean that better resuscitation is implemented in the pool of this study, thus hopefully producing better patient outcomes, and maybe then, if the oxygen / recall correlation does exist, a richer rate of experiences is recorded.
So whereas the study from it’s outset is small, the useful data return could still be substantial.
The possible pattern of higher oxygen producing more recall experiences is good for this and future studies, but in itself will have to at some point be questioned and explored for any causality factors. It could be postulated that better recovery and less post arrest damage allows an experience to be imbedded in memory at an earlier stage in recovery, when it is less likely to be lost. But then some of the wording from Dr Parnia and the AWARE team could be read as somewhat leading down a physiological understanding.
“Perhaps the people who had experiences simply had higher oxygen levels of blood flowing into the brain and hence oxygen delivery.” (Erasing Death)
“It is possible that patients who are able to recount these experiences may have better patient outcomes in terms of reduced brain damage, improved functional ability and better psychological adjustment to the event. We think that these patients may have had better blood flow to the brain during cardiac arrest, leading to consciousness and activity of the mind.” (UKCRN study outline)
Of course what will help steer this quandary is what could be seen as the holy grail of the whole AWARE project, that is, an experimentally verified visually veridical experience recall. Such a result will have to lead to more than physiological hypotheses. At the very least it would question our understanding of measurable brain activity in relation to actual conscious activity. Indeed, a specifically external visual recall would question the convention of consciousness as a physiological phenomenon entirely.
Having started in May 2015, the current phase of study should finish data collection in May 2017.
Then we wait…..