Extreme Medicine (3 page)

A Sea King helicopter had also been scrambled, but even traveling at over a hundred miles an hour, it would take more than sixty minutes to reach them and would take at least as long again to fly back to the nearest major hospital in Tromsø.

Forty minutes after becoming trapped, Anna's desperate thrashing stopped and her body went limp. The hypothermia, now profound enough to anesthetize her brain, would soon stop her heart.

Another forty minutes passed before rescuers from the bottom of the mountain arrived, carrying with them a more substantial shovel with a pointed tip that was finally able to break through the covering of ice.

Singstad, leading the mountain rescue team, was already deeply pessimistic, believing that their efforts now could only succeed in retrieving the body of a dead friend. Eighty minutes had passed since Anna had first fallen into the water, and her body was pulled clear of the stream limp and blue. She had stopped breathing and was without a pulse.

We call what follows
downtime
—the period from the moment of cardiac arrest until the point at which spontaneous circulation and breathing can be restored. In that interval, the process of dying begins.

Before that comes the
crash.
If your physiology has crashed, the processes that keep you alive have stopped working. When confronted with a patient in cardiac arrest, you, as a doctor, are staring at the wreckage of an individual, hoping desperately that something can be salvaged from the chaos. Frankly, it's a terrifying feeling.

In any emergency room, anyone suffering cardiac arrest who arrives with more than a few minutes of downtime almost invariably dies or is permanently disabled. My time as a newly qualified doctor is peppered with memories of pounding down hospital corridors in the middle of the night answering the crash call: that terrifying screech from your pager accompanied by a burst of static and a voice telling you where you instantly needed to be. The experience was always grim. Of the many thousands of people who suffer cardiac arrest each year, only a handful survive to leave the hospital. The odds always appeared so stacked against us and the outcomes so poor that over time I became deeply pessimistic about crash calls. I remember a registrar, seeing my distress at the end of yet another failed resuscitation, putting a comforting arm around me. “It's not really resuscitation, you know,” he said. “It's just a funny dance we do around the dying.”

So as the resuscitation effort began on Anna's body in the shadow of those Norwegian mountains, the challenge she faced looked insurmountable. She had already been without a pulse for far longer than any of the patients I'd ever rushed to attend on hospital wards. Her core temperature was now perhaps more than 20°C. (36°F.) lower than it should have been.

Torvind insisted that they continue their resuscitation attempts. Just before eight
P.M
., more than an hour and a half after first falling into the stream, Anna was winched onto the Sea King. Aboard the helicopter, moving at speed across the Norwegian landscape, the struggle to save Anna's life became a desperate scramble. The art of resuscitation, if you can call it that, is difficult even under ideal circumstances. Helicopters, with their cramped conditions, deafening noise, and vibration, are among the most difficult places in which to try to work.

Once, when transferring an unstable, critically ill patient by air, I asked the pilot what the aircraft protocols were if the patient needed resuscitating midflight. “Just mind the doors,” he said. “It's usually bad if you fall out.”

The key to good resuscitation is to keep the blood supplied with oxygen and moving around the body. This is achieved by breathing for the patients, ventilating them artificially—literally pumping oxygen into their lungs—and then compressing the chest rhythmically to provide something approximating a circulation. None of this is anything like as efficient or effective as the body's native heartbeat and breathing, but it buys time. In principle, it sounds pretty straightforward; in practice, there is perhaps nothing that adequately describes the sickening, repetitive crunch of ribs beneath the heel of your hand or the rising sense of desperation you feel as the minutes tick by.

—

W
HEN THEY TOUCHED DOWN
at Tromsø University Hospital, Anna's heart had not beaten for at least two hours. Her core temperature was measured at 13.7°C. (56.7°F.)—23°C. (42°F.) below normal, and lower at that point than any surviving patient in recorded medical history. This was genuine terra incognita. Any further attempt to resuscitate Anna could proceed only in the knowledge that in similar situations past medical teams had always failed.

It is often hard to know how to act in the best interests of your patients, even when they can talk to you and tell you what they want. In the midst of resuscitation, faced with an unconscious, dying patient, you have to try to imagine what the person in front of you would say if she could. It is a horribly difficult call to make. Your instinct as a human being is to carry on for as long as there's a chance of survival, however slim. But your thoughts as a medical professional are different; there are harsh realities to face. Under ordinary circumstances, the prognosis is horribly bleak. Even patients whose hearts are successfully resuscitated can have permanent and disabling damage to their brains because of oxygen starvation.

But the team at Tromsø decided to continue. Despite the amount of time that had passed since Anna's heart had stopped, there was still the glimmer of a hope that the terrible cold might also have protected and preserved her brain.

Mads Gilbert, the anesthetist leading the resuscitation effort, moved Anna directly to the operating room. He knew that raising her temperature at this point was going to be a massive challenge. Warm blankets and heated rooms alone wouldn't be anything like enough. Raising the whole body through all those missing degrees would take an enormous amount of energy—equivalent to the boiling of dozens of kettles of water. To do this quickly and without harming Anna in the process, Mads knew she would have to be established on a heart-lung bypass machine, the sort of device normally reserved for open-heart surgery. By removing her chilled blood, circulating it in the bypass machine, heating and then returning it to Anna's lifeless body, they could raise her core temperature rapidly. At least that was the theory.

They wasted no time. Thirty minutes after being established on the heart-lung bypass machine, Anna's core temperature had more than doubled, reaching 31°C. (87.8°F.). The heart itself, its molecular machinery now warm enough to work again, stuttered at first, unable to regain its own essential rhythm. But eventually electricity once again began to flow through the muscle of her heart, and this was followed by waves of contraction.

A little after ten
P.M.
, it started to beat independently for the first time in at least three hours. That first explosive beat was captured on film in an echocardiogram.

During the resuscitation, the team had to place a central line, a thin tube inserted into a major blood vessel, allowing them to give fluid and drugs more easily. To do this, they first had to pass a needle into her chest, aiming for a target vein whose diameter was no more than a fraction of an inch. It is a tricky feat to pull off at the best of times. You rely upon your knowledge of anatomy and a steady hand. But lying next to that vein is a large pulsating artery that, as they tell you in medical school with a wry smile, is always best avoided.

But the fight was far from over. During the scramble to save Anna's life, the team had damaged that artery and, hidden just behind her collarbone on the right side of her chest, it began to bleed. Here again the cold conspired to kill her. The hemorrhage that followed was made far worse by Anna's hypothermic state because blood loses much of its ability to clot at low temperatures. Having labored so hard to save her life, the team now faced the possibility that she would bleed to death.

They transfused blood, platelets, and clotting factors in an effort to replace what had been lost and encourage her blood to coagulate once more. Cardiothoracic surgeons then decided to open her chest, finally allowing them to isolate the bleeding artery and stop the hemorrhage. After hours of work by dozens of people, she was finally stable enough to be transferred to the intensive-care unit.

Once there, her lungs failed, and to maintain the levels of oxygen in her bloodstream, the team was forced to take the drastic step of establishing her on a device that could oxygenate her blood outside her body, which functioned like a bypass circuit for her lungs. Her kidneys also failed, and their function too was replaced artificially by yet another machine.

Miraculously, Anna survived even this, opening her eyes for the first time after just twelve days. But she found herself paralyzed from the neck down, waking alive but quadriplegic. Later she grew angry, asking the doctors at Tromsø why they had been so determined to keep her alive. Together the costs of her helicopter rescue, resuscitation, and admission to the intensive-care unit added up to many tens of thousands of dollars. All of this was done for a woman who awoke alive but with a body that no longer appeared to work. This was the best that anyone might have dared hope for, given how cold she'd been and how long she'd gone without a pulse. Had their endeavors truly been worth it? Should they have proceeded with the resuscitation at all?

But Anna's paralyzed body did not remain that way. It wasn't an irreversible injury to her spinal cord that left her unable to move, as is so often the case after traumatic injuries. It was instead her peripheral nerves, damaged by the extremes of cold, which had failed. Slowly but surely these nerves and her flaccid muscles began to recover and regain their function.

The nerves recovered most slowly in her extremities. Initially she could not use her arms and legs at all. Though after six weeks she was ready for discharge from the hospital, she could not go home. Anna spent another four months in a rehabilitation unit, slowly growing in strength and learning how to move once more. It was a slow process, but eventually she was able to go home. Medicine had brought her this far, and where it stopped, her determination had to take over.

It would ultimately take six hard years of rehabilitation in all, but eventually Anna was well enough to ski again, well enough to return to complete her training as a doctor. Eventually she specialized in radiology and now works in Tromsø, at the hospital that had dared to save her life.

—

A
NNA
B
ÅGENHOLM IS
an extraordinary survivor. Doctors exploited her profound hypothermia to successfully resuscitate her against seemingly impossible odds. While her survival occurred in the context of an accident, others have benefited from hypothermia by design.

Esmail Dezhbod's symptoms had begun to worry him. He felt pressure in his chest; at times great pain. Visiting the doctor did nothing to allay those fears. After asking him some questions, his doctor gave him a physical examination and ordered a body scan to investigate the structures within his chest. The pictures didn't lie: Esmail was in trouble. He had developed an aneurysm of his thoracic aorta, a swelling of the main arterial tributary leading from his heart. Normally no more than 1.2 inches in diameter, this vessel had more than doubled in size, to the width of a can of Coke. With this swelling came the risk of rupture. The greater the diameter of the vessel, the greater the risk that its wall might suddenly tear. The consequences would be catastrophic. Esmail had a bomb in his chest that might go off at any moment. Aneurysms elsewhere in the body can usually be repaired with relative ease. But in this location, so close to the heart itself, there are no easy options. The thoracic aorta carries blood from the heart into the upper body, supplying, among other things, the brain. To repair it, the flow would have to be interrupted by stopping the heart. At normal body temperatures this and the accompanying oxygen starvation would damage the brain, leading to permanent disability or death within three or four minutes.

Yet for Esmail to survive, the repair had to be done. His surgeon, the leading cardiac specialist John Elefteriades, decided to carry out the procedure under conditions of deep hypothermic arrest. He used a heart-lung bypass machine to cool the body to a mere 18°C. (64.4°F.) before stopping the heart completely. Then, while the heart and circulation were at a standstill, Dr. Elefteriades performed the complicated repair, racing the clock while his patient lay dying on the operating table.

—

O
N THE DAY OF THE OPERATION,
I was there to watch this remarkable feat of surgery. Though Dr. Elefteriades is an old hand with the technique of deep hypothermic arrest, every time feels like a leap of faith. Once the circulation has come to a standstill, he has no more than about forty-five minutes to complete the repair before irreversible damage to the patient's brain occurs. Without the induced hypothermia, he'd have just four.

Standing in the operating room and marking the moment at which Esmail's circulation comes to a stop is a sobering experience. At this point, nothing is supporting him: no drugs, no machines, no bypass circuit. Esmail's physiology is crashing in slow motion. Up until now, the surgery has proceeded in a relaxed fashion. Knife in hand, paring away the tissues around the heart, John has chatted away as if he's doing nothing more taxing than driving to the supermarket. That demeanor changes at the moment of circulatory arrest. Now there's no time for small talk.

The hands of the clock on the wall swing around; the digital timer counts off the minutes and seconds. John lays down the stitches, elegantly and efficiently, making every movement count. He has to cut out the diseased section of aorta, a length of around six inches or so, and then replace it with an artificial graft. To this he must stitch other tributaries supplying the brain and upper body. And all the while Esmail is dying.