Being buried alive is a primal fear for some people. This almost never happens. An extremely rare but feared phenomenon.
It’s a scary idea: you are first pronounced dead, only to wake up on the autopsy table a short time later. The so-called Lazarus phenomenon almost never occurs, but it is very rare. It is named after the biblical Lazarus, who is said to have been raised from the dead by Jesus.
How can this be achieved?
The phenomenon can occur in people with cardiovascular arrest who are declared clinically dead after unsuccessful emergency medical interventions based on uncertain signs of death – cooling of the body, cadaverous pallor, no longer detectable pulse – and a zero line in the electrocardiogram (ECG) and the their circulation and breathing suddenly resume.
In this extremely rare phenomenon “the heart must have stopped for some time”, explains Klaus Püschel, director of the institute at the University Hospital Hamburg-Eppendorf (UKE). In exceptional cases, however, he could still start beating.
It is therefore important for the mortuary examination routine that a person’s death is first determined on the basis of certain signs of death such as corpse stains, rigor mortis, corpse rot and lesions not compatible with life, says Püschel.
«The first 20 minutes after cardiac arrest are an uncertain time; when in doubt you must always resuscitate”, underlines the specialist in forensic medicine. Only when it is certain that resuscitation will not be successful can the process be stopped. However, Püschel emphasizes: “What definitely means failure, there are no very strict criteria.”
Study: 65 cases worldwide since 1982
It is still not entirely clear why people who have actually been unsuccessfully resuscitated show signs of life again. A study published in 2020 provides information on the frequency of the phenomenon: For this study, a four-member international research team searched the medical literature for known cases since 1982, i.e. since the phenomenon was first described.
Scientists have found only 65 cases worldwide, about a third of whom (22 people) survived cardiac arrest, 18 of them without permanent neurological damage. “Even if they seem few, the consequences are significant when you think about the medical personnel involved, the relatives, the legal consequences and the daily number of patients requiring resuscitation measures”, explained the two authors and doctors Hermann Brugger and Peter Paal in a statement about the study at the time.
“The fact that the majority of survivors suffered no consequences is of the utmost importance,” added co-author Mathieu Pasquier. Based on their findings, the four researchers made a series of recommendations, most notably that of observing and monitoring a patient using an ECG for at least ten minutes after the end of cardiopulmonary resuscitation.
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Apparent death versus the Lazarus phenomenon
A slightly different case occurred this summer in South America. Last June, a woman mistakenly declared dead in Ecuador showed signs of life again during her wake, according to media reports. Her relatives were about to move the alleged body into the coffin for burial when they noticed that the elderly woman was still breathing. In this case, according to Püschel, we are talking about apparent death.
The difference with the Lazarus phenomenon is that doctors do not adequately examine an apparent death and do not look for sure signs of death. “There are many or relatively more cases in which the sure signs of death have not been identified correctly and someone is declared dead prematurely,” says Püschel. “Then he can actually stay in a deep coma for hours and then wake up again.” In extreme cases this phenomenon could even occur in a mortuary, says Püschel. “In ancient literature, cases of apparent death were even described in which someone scratched the coffin.”
Stories of this kind give rise to a specific fear in some people: the fear of being buried alive, also known as taphephobia. Thus a very special bestseller was born in the 19th century: the safety coffin. This gave the buried people the opportunity to survive in the coffin. “When you woke up, you could pull a string and it would ring upstairs, including the air supply,” explains the UKE director. Nowadays such coffins no longer exist, but the fear of apparent death certainly exists.
Hamburg, 2005: The case warranted clear guidelines for resuscitation
Püschel has examined thousands of deaths in his career and to this day has not forgotten one case that he also published in the German journal “Emergency + Rescue Medicine” in 2005: At that moment, an 83-year-old woman collapsed at a bus stop near to the clinic. Paramedics and an emergency doctor arrived on scene within minutes to revive her. “The emergency doctor also said that she had taken an ECG for a long period of time and that it was a zero line,” Püschel says.
Less than half an hour passed from the completion of resuscitation measures to the woman’s arrival at the Institute of Forensic Medicine. In the anteroom of the cold room, the woman’s heart suddenly started beating again. “I was the doctor on duty and then I revived her. We called the anesthesiologists at the hospital and they actually took the woman to the intensive care unit with her circulation still stable.” But she died there after six hours. Püschel discovered that the cause of the resumption of heart activity was the so-called Lazarus phenomenon: if the heart has stopped, it can start beating again when the oxygen-rich blood reaches the so-called sinoatrial node.
After the accident a clear guideline was agreed for the Hamburg rescue system: the death of a patient must be determined after unsuccessful resuscitation measures by deriving and recording a reference ECG for at least ten minutes – similar to the recommendation of the study of 2020 “This is about the time it takes to put away all your emergency medical supplies again, so as not to limit your readiness for action,” explains Püschel.
Problem: An accurate test is only possible with an ECG device
If you reliably get a zero line on the EKG over ten minutes, the chance of anyone waking up is zero, according to the medical examiner. The problem: It is usually not possible to reliably derive a zero line to determine death. “This can be done during a rescue operation if you have an ECG machine with you. But when a family doctor or the public health insurance company goes to the apartment of the deceased, he usually does not bring an ECG with him,” he explains the specialist.
When attempting resuscitation, patience is a crucial factor. “Lazarus phenomena mostly occur during resuscitation. That’s why I always say: you should never give up too soon,” emphasizes Bernd Böttiger, director of the Anesthesia and Operational Intensive Care Clinic at Cologne University Hospital. It is better for him to relive for a longer time than for a shorter time. In fact, you can still be successfully revived after two or even three hours. “However, it becomes increasingly unlikely that someone has not stabilized after 20 or 30 minutes,” emphasizes Böttiger. However, unlikely does not mean impossible. (Serhat Koçak, dpa/mak)
Numerous accidents occur every day: at work, at home or on the street. Then you need quick help. Everyone should be able to master resuscitation measures. (Photo: Michael Trampert)
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