Cheating Death (3 page)

T
HE HALF-FROZEN PATIENTS
who made it to Tromso were given the standard medications used in resuscitation, such as norepinephrine to stimulate the
heart and saline solution to try and maintain normal blood pressure. The problem was, all those infusions meant even more
fluid in the body and more pressure on the damaged tissues, including the brain. For Gilbert and his Tromso team, an important
and lifesaving lesson had been learned: strictly limit the use of drugs and control the amount of fluid given to a patient
in hypothermia, and they are more likely to be saved.

Under normal circumstances, giving fluid to control blood pressure is a staple of emergency medicine, but Gilbert was on to
something. He thought this normally lifesaving fluid was also killing his hypothermic patients. “As long as you’re a monk,
you keep ringing the bell—keep doing the same thing, and you don’t look back,” he said.

The next time would be different. Gilbert told his team to forget about the fluids when the next patient came in. They would
withhold saline and any other medication unless the patient’s clinical condition began to sharply deteriorate. Gilbert said,
“On this next one, I’m going to keep it so dry, so restrictive—I’m going to err on the side of not giving fluids unless I’m
absolutely forced to.”

It was a gamble, but Gilbert was philosophical, saying, “We generate new knowledge and new medical practice in several ways.
One is the perspective of controlled clinical trials. Another is taking the problem to the lab, where you do some basic research
and then try to apply it.” But it was only the third way that could potentially help Anna Bagenholm. That is to
generate
new knowledge through clinical practice.

After landing, Bagenholm was wheeled through the swinging doors of the emergency department and onto an elevator straight
to the operating room, where cardiac surgeons ran tubes into Bagenholm’s femoral artery and vein and attached her to a heart-lung
machine. The machine would slowly rewarm her blood as it maintained circulation. It was approximately 9:50 p.m., and Bagenholm’s
core body temperature was still just 56 degrees Fahrenheit (13.7 degrees Celsius). As the machine warmed her blood, her heart
was still not beating and the team kept up CPR to keep at least some bit of oxygen flowing to her tissues. By 10 p.m., the
team saw an encouraging sign. Bagenholm’s heart showed a burst of electrical activity on its own. Within another fifteen minutes,
the once-still heart had settled into a regular pumping rhythm.

As Gilbert told the story, he paused for a second, then told a story he’s not made public before. All of these efforts were
nearly derailed by a simple missed detail—that the lifesaving medical team nearly killed their patient that night. While trying
to insert a central intravenous line into Bagenholm’s chest, a young assistant tore a hole in Bagenholm’s subclavian artery.
Worse, in the chaos around Bagenholm, no one realized it. Since Bagenholm was virtually dead, her blood pressure was almost
nonexistent and there was little blood leaking from the cut.

In a warm, healthy patient such a mistake would be devastating, and the victim would likely bleed to death in minutes. When
Bagenholm’s heartbeat finally returned, the doctors could see her blood pressure dropping. It was only then that they realized
the gravity of the situation. When they put in a chest tube, they watched, horrified, as a full liter of blood poured out.
Under pulse-pounding pressure, they raced to open Bagenholm’s chest, sawing through bone to find the source of the problem.
They were able to suture the artery closed just in time. I couldn’t help but marvel at how seemingly simple mishaps like this
could derail what would otherwise be striking scientific progress.

As the resuscitation dragged on, Bagenholm developed yet another deadly complication: a breathing problem known as ARDS, in
which the lungs are not capable of normal gas exchange. Gilbert’s team connected her to a device called ECMO that acts as
an artificial lung. She now had a beating heart that produced blood pressure, kidneys that produced urine, and lungs supported
by both ventilator and the ECMO-machine. At last they could leave the operating room.

Even then, Gilbert knew they were not out of the woods. “When we took her out of the OR, it was morning. There was sun coming
through the windows into the room, and I realized we were in the very same room as the young student,” said Gilbert. (The
student who had died after the avalanche a few months earlier.) “I said to myself, ‘This is not over yet. This is where the
struggle starts.’ ”

This time, the team at Tromso took a more patient approach. They made sure to keep Bagenholm dry (little hydration) and continued
to slowly rewarm her. They gave limited drugs and no extra intravenous fluids. For a time, her blood pressure was extremely
low, which meant her tissues were not getting as much oxygen as a healthy person requires, but Gilbert guessed that someone
in Bagenholm’s condition would not need as much oxygen. Otherwise, he reasoned, she could not have survived nearly ninety
minutes under the ice.

The road back wasn’t easy. For five days Bagenholm remained connected to a machine that helped oxygenate her blood, and she
spent another several weeks attached to a respirator, or breathing machine. “She [almost] died two or three times from complications,”
says Gilbert. “It was a hell of a struggle.” But in the end, the all-out effort paid off. A woman who most doctors in the
world would have left for dead was alive and breathing, all on her own.

She was paralyzed from the neck down for five months, and yet eighteen months later, Bagenholm was back at work, albeit without
full function of her hands, where some of the nerves had been badly damaged. She had to give up being a surgeon, but today
she is a full-fledged, successful physician, a radiologist at the University of North Norway Hospital, the same place where
she returned from the dead. Interestingly, she says that testing over the years has found that her nerves continue to regrow,
ten years after the accident. Her companions from that day work at the same hospital; Marie Falkenberg accomplished her goal
of treating children, and Torvind Næsheim now works side by side with Gilbert, riding the ambulance helicopter and aiding
in open-heart surgeries as a cardiothoracic anesthesiologist. He has been part of the team that’s successfully rewarmed several
people in cardiac arrest and with severe hypothermia.

O
N THE OTHER
side of the world, Zeyad Barazanji was also in need of a doctor who was willing to take a chance. After hearing his story,
I went back to the place where his life was truly saved—not the Bronx gym where he collapsed in cardiac arrest and was revived,
not the ambulance that raced him to the hospital, but the room where he slowly but surely fought for his life.

While there, I heard a buzzer sounding and a voice calling over the loudspeakers: “Dermatology Floor. Arrest. Stat. Dermatology.
Arrest. Stat. Dermatology.” The voice is muffled, but the message is urgent: Cardiac arrest. Stat. Dermatology. A patient
on another floor has had something go horribly wrong. Her heart has stopped, and it will take all the efforts of modern medicine
to keep her from the grave.

If this were a television show, doctors would scramble down the hall, white coats flying, toward the scene of the emergency.
There would be a sense of barely controlled chaos. Here, on the eighth floor of New York-Presbyterian Hospital/Columbia University
Medical Center, it barely registers that a life-and-death message is being broadcast through the building.

I am in the neurointensive care unit, an incongruously friendly and easygoing place. A right turn off the elevators, then
a left, and without going through a door, you find yourself smack in the middle of a coffee break. The walls are yellow, the
floor covered with large square tiles of orange and white. Everything is too new to be coated with the haze of gray that seems
to fill most big city hospitals or the grit that permeates the outside of these grand old buildings on the far Upper West
Side of New York City.

Nurses talk among themselves at one station, and a group of young people in white coats—mostly men—are huddled, like a football
team, around two computer monitors at the other end of the rectangular corridor. Smiles flash, greetings are exchanged, and
it takes a few minutes to register what seems to be missing: the patients.

The patients are here, of course, but you could say that’s a matter of interpretation. “If you need to be admitted to a neurointensive
care unit, it’s the worst thing that’s ever happened to you in your life,” says Dr. Stephan Mayer, the head of the unit. “All
of the patients are in varying degrees of coma. For the most part, they’re being kept alive artificially.”

This morning, a constantly shifting group—a mix of senior physicians, residents in training, and medical students—is huddled
around a tiny counter in the middle of the room, framed by two sleek computer monitors. They’re staring at a screen displaying
data from the Sunrise Clinical Manager, where detailed patient records are stored. Nearly everyone is dressed in a white coat,
their specialties etched in blue cursive over the left breast: “Intracranial Monitoring,” “Stroke Fellow,” “Pediatric Neurology.”

The only exception to the dress code is Mayer, who looks like a college freshman in khakis and a blue-and-white striped dress
shirt. Small, plain wire-rimmed glasses are perched on his nose, and he quizzes his charges in a friendly, if insistent, slightly
nasal voice.

“Can we remember her blood sugar values?”

No answer.

“Come on, people, I’m thinking it’s hypoglycemia,” he answers quickly himself.

On an especially cold November night in 2006, Mayer took a midnight call from an intense, dark-haired former medical student.
He barely knew her; she’d been in the unit the year before, finishing up her rotations. A few months later she had interviewed
for a job in the unit, but there was no money to hire her and she ended up in San Francisco. Just the usual comings and goings,
but when he took the late-night call he guessed it wasn’t to reminisce. When acquaintances called him late at night, they
usually had something else on their minds.

On the phone, Nobl Barazangi’s
⁸
voice was friendly but tense. An uncle, an elderly but otherwise healthy man, had suffered a cardiac arrest that afternoon,
and he was up in intensive care at another Columbia-affiliated hospital. She didn’t trust the doctor running the ICU—mainly
because he didn’t know anything about hypothermia—and was there an open bed down on 168th Street? “She knew to call here,
because she had seen what was happening with the patients here,” Mayer told me. “She said, ‘Hey, my uncle is thirty-four blocks
from you—can you cool him?’ And of course I said, ‘Sure!’ ”

When she talks about her uncle that night, Nobl Barazangi focuses on the clinical details, not the stress of being on the
other side of the country, desperately seeking help for her father’s beloved brother. Though a physician herself, she described
the sometimes heart-wrenching difficulty many of us have experienced with elderly parents living far away. She says the first
doctor who saw her uncle told her there really wasn’t much to be done. “He said they were planning to send him to their intensive
care unit for evaluation of his heart, and then just wait for him to either die or wake up,” said Barazangi. “I asked if he
had considered cooling therapy, and he said he wasn’t familiar with it—-that he didn’t think they did it at his hospital.”

It was the middle of the night, and she didn’t know exactly what number to call, so she rang up the neurointensive care unit,
where she found someone willing to give out Mayer’s cell phone number. As she waited on hold, she could feel the seconds ticking
away. At the University of California, San Francisco, she had been trained to start cooling patients within an hour of their
cardiac arrest. She had learned that with every hour that went by, the odds of survival dropped.

*   *   *

M
AYER, TOO, KNEW
those statistics well. Mayer is a crusader for therapeutic hypothermia, fretting about doctors who are reluctant to use it
as a treatment and the medical organizations who in his view don’t do enough to promote it. Mayer first encountered hypothermia
in a very different context, on the grounds of an ancient mental hospital in Westchester County, New York. In October 1986,
Mayer was a third-year medical student, and he spent most of that month looking after young men who had basically fallen apart
under the strain of their freshman year in college. “Depression, bipolar disorder, borderline personality disorder—they were
all these young guys who had gone off from home for the first time, and just decompensated under the pressure,” he said.

One night, a young man came into the unit in a straitjacket, clearly in the midst of a complete breakdown. “He was in this
psychotic rage,” says Mayer. “We were giving him doses, megadoses, of Thorazine, Haldol, you name it, and it wasn’t touching
him at all. He just kept going. And then someone said, ‘Get the cold sheets!’ And I’m like, ‘What’s that?’ ”

Next thing he knew, says Mayer, he was helping more than a dozen doctors and orderlies hold down the unruly patient, while
someone else soaked the sheets in ice water and rolled the patient up like a caterpillar in his cocoon. “It was amazing. He
immediately calmed down. It worked like nothing else. It was right away. [The young man] said something like, ‘Oh, I think
I feel okay now.’ ”

Curious, Mayer asked around and learned that cold sheets had been widely used in psychiatric hospitals in the early twentieth
century.
⁹
The practice had been widely abandoned, but not by the elderly psychiatrist who ran the institution where Mayer spent that
eventful fall. Mayer knew he didn’t really understand what he had witnessed, but something about it left a deep imprint.