Surviving the Extremes: A Doctor's Journey to the Limits of Human Endurance (36 page)

When Rob was told by radio that the Sherpas couldn’t reach him, he asked to be patched through to his pregnant wife who was home in New Zealand. He said good-bye and then turned off his radio. He did what he could to protect himself. He crawled into a depression in the ice to block the wind, partly covering himself with snow as insulation against the cold. He took his metal crampons off to slow the conduction of heat away from his body.

That night came the most violent winds I have ever experienced. Our tents at Camp III were anchored to the side of the slope by ice screws. We were sure the screws would pull out at any second or else the tent would shred, sending us tumbling 3,000 feet down the face. We spent the night fully dressed with our boots on, splayed out over the tent floor, trying to hold the tent down to lessen the pull on the ice screws.

In the morning came word that Beck and Makalu had survived the night and would be brought down to me at Camp II. The New
Zealand team, what was left of them, would be able to come down under their own power. We were all grimly aware, though, that it was impossible for Rob to have survived a second night so high and so exposed. The storm had passed and taken Rob’s life with it, though the real cause of death was altruism.

Todd and Pete and the group of Sherpas at Camp IV were also responding to the instinct to save their species as they prepared to lead Beck and Makalu down the mountain. I asked Pete to give Beck some dexamethasone before they started. He would first have to melt and warm the frozen ampoules before he could inject one, and then place the other inside his jacket for later use on the road. Beck would need all the help he could get. He couldn’t hold the rope in his frozen hands and could hardly even see it, due to what I presumed was snow blindness. They climbed down bunched together, with Pete in front acting as Beck’s seeing-eye dog and Todd behind holding Beck’s harness to prevent a fall. The Sherpas had left earlier with Makalu. Both convoys were making good progress. It was time for me to start down. As I left the camp I passed Dave Breashears, the IMAX director, and Ed Viesturs, his superclimber film star, on their way up to take the relay from Todd and Pete. I climbed down the 3,000 feet to Camp II and prepared to receive my patients, who really belonged in an ICU. I would be treating them at 21,000 feet, trying to work out complex medical problems at an altitude where tying your shoes can be confusing.

I commandeered the largest tent in the camp, the New Zealand mess tent, and took an inventory of available supplies. Everything I had requested the previous day had been brought up that morning, including a heavy propane heater. I also had plenty of help. Henrik Hansen, a Danish climber who was also a doctor, had come up from base camp. Sherpas were eager to do what they could, as were those climbers who still had some energy left. We cleared out the folding tables and chairs, laid foam mats and sleeping bags on the floor, hooked carabiners into the tent frame to hang IV bags, and laid out oxygen cylinders and regulators, presetting them for maximum flow. Climbers gathered together two complete sets of dry clothes, and Sherpas went to the kitchen to heat as much water as they could. I systematically
arranged my medications and bandages and verified that my medical instruments hadn’t been damaged or frozen during the trip up from base camp. Only the IV bags were frozen. The Sherpas took them to the kitchen, thawed them out in the boiling water, and returned them to me with a cup of tea drawn from the same water. I hung two IV bags, connected the tubing, and left the ends dangling above the sleeping bags. I sipped my tea and waited.

Makalu arrived first, bursting through the door in a bulky hooded down suit, an oxygen mask over his face. He was escorted by a group of Sherpas who immediately laid him down on one of the sleeping bags and began taking off layer after layer of wet clothes. He was wet down to his underwear. His feet had swollen tightly inside his boots and swelled even more once we worked them off. We would have to find a larger pair of boots to put back on him later. He was coherent and only mildly hypothermic, but his appearance was terrifying. He was missing his nose. In its place was a brittle black crust that spread onto his cheeks up to his eyes, which were swollen shut. All his fingers were dark gray plump sausages. His toes and heels were also frozen and gray. There were weak pulses in his wrists and ankles. I marked them with a pen to keep track of his circulation, and prepared to treat the worst case of frostbite I had ever seen.

Most of the damage was irreversible. Makalu had been exposed to high winds and subzero temperatures for over twenty-four hours. With wet clothes, no shelter, and no energy left, his body was desperate to retain what little heat it still had. Severe constriction of blood vessels in his arms, legs, and face—the worst heat-leaking body parts—had reduced blood flow to nearly zero. With no incoming heat to counteract the environment, the sacrificed parts rapidly cooled to the ambient temperature—far below freezing. The water inside the tissues formed ice crystals, which grew by extracting water from the individual cells. In other words, Makalu’s hands, feet, and nose were freeze-dried. At this point, frostbite is still reversible. Adding heat melts the water, and, like freeze-dried food, the tissues can be reconstituted. With prolonged exposure, however, cells begin to break down. Ice forms within the shrunken individual cells, and as the ice expands, the cells rupture. Endothelial cells, which make up the smooth lining of
blood vessels, are especially susceptible to injury. When their surfaces break, the result resembles what occurs when the vessel is cut from the outside. The damage is misread by circulating blood proteins called fibrin, which activate as if responding to a bleeding vessel. The fibrin forms into clots to plug holes that aren’t actually there. As the endothelial damage spreads, clots are deposited everywhere, obstructing flow within all the vessels. Even if the body part is warmed, the clots are permanent and flow remains blocked.

It was too late for Makalu’s nose, but parts of his hands and feet might still be saved if they were rewarmed rapidly. The decision to thaw him out, however, was not as obvious as it might at first appear. Once thawed, the hands and feet, as well as the rest of Makalu, would have to be kept continuously warm. Blood would be flowing again, through tissues that had been damaged but hadn’t fully clotted off. If those parts froze again, they would quickly clot off completely, adding a second layer of dead tissue to the first and leaving Makalu worse off than if his hands and feet had never defrosted. It might be a lot safer, and it would certainly be easier, to preserve them frozen, since the temperature inside the tent was well below zero, and we didn’t yet know how we were going to get him down. Thawed-out feet are fragile and will crumble if they have to bear weight. If Makalu had to walk, frozen feet would support him a whole lot better. In treating frostbite at 21,000 feet, the problems are all in the logistics, but I had a lot of help, the right medical supplies, enough fuel, and more than enough snow to melt. We could manage the logistics. I would thaw him out.

Into the IV that Henrik had already started, I injected nifedipine, the drug that dilates blood vessels in the extremities. This would bring more blood to the hands and feet but take it from the center of the body. Given that Makalu was already severely dehydrated, I was afraid that it might cause a precipitous drop in blood pressure, so, having no pressure cuff to monitor him, I periodically placed my fingers over the carotid artery in his neck to make sure the pulsations remained strong. Any weakening and I would have opened wide the IV line and pumped his pressure back up with more fluid. Defrosting Makalu required three tubs of warm water—one for each hand and one for
the feet. The Sherpas filled the tubs with water heated in the kitchen tent, and I measured the temperature by dropping a little plastic bubble thermometer card into each one. The water was initially far too hot, but the temperature in the freezing tent quickly dropped it to the ideal temperature of 104°F. Any cooler and it wouldn’t be effective. Any hotter and it would burn the skin. Frostbitten hands and feet are incapable of feeling pain because nerves shut down quickly when exposed to cold. The ensuing numbness explains why applying ice is a good pain reliever, but it makes rewarming dangerous. I’ve seen cases of second-degree burns on top of frostbitten skin because the heating was done too energetically and detected only when the victim smelled his own skin burning. Maintaining the ideal water temperature takes work when the air surrounding it is below zero. As the water in the tubs cooled, it was canted off into empty bottles to make room for the hot water, which had to be added almost constantly. The Sherpas were eager assistants, and though most of them had never used a thermometer before, they quickly got the hang of it, reading the temperature in each tub and deciding on their own when to add water.

Just as we were getting Makalu under control, Beck arrived, led in by Dave and Ed, who had taken the relay from Todd and Pete. I had expected a disoriented, uncoordinated, half-blind, frozen shell of a human, but as he was being eased to the floor, he looked at me and said casually, “Hi, Ken. Where should I sit?”

Makalu had had the worst frostbite I had ever seen—but that was before I saw Beck. His entire right hand and a third of his forearm, as well as his left hand, were deep purple and frozen solid. They radiated a cold that I could feel against my face even in the subzero tent. They had no pulses, felt no sensation or pain. They didn’t even have any blisters, an automatic body response that requires a minimum of coordinated activity between nerves and blood vessels. They were the hands of a dead man, yet bizarrely, Beck could still move them. Hands are designed for both delicate and strong motion and thus are powered by a large array of both fine and bulky muscles. They are such compact machines, though, that most of the muscle mass must be placed outside, in the forearm, connected to the bones in the hand by ropelike tendons. Beck’s forearm muscles were still alive, so the
tendons were able to pull on his dead bones and produce motion, in the same way strings move a marionette.

Beck had lost his vision on summit day, and I had expected to treat him for snow blindness, which is a common condition in climbers who either lose their goggles or remove them when the vapor from breathing warm oxygen fogs them over. High on a mountain, ultraviolet rays are undiminished by the thin air. When they reflect off ice and snow into the eyes of an unprotected climber, the cornea—the transparent skin window over the lens—gets an intense sunburn and becomes opaque. Light is blocked from entering the eye, and total, though temporary, blindness results. Like any other sunburn, it is very painful, but it will heal. That healing, however, takes a few days. I was puzzled that Beck was experiencing no eye pain and was able to see me clearly as soon as he entered the tent. Examining his corneas with my ophthalmoscope, I found them surprisingly clear. Each cornea had four scars radiating out from the center, like the spokes of a wheel. I didn’t understand then that they were the reason—not snow blindness—for Beck’s temporary loss of vision. He had had a radial keratotomy, an operation in which relaxing incisions are made to modify the shape of the lens so that glasses are no longer necessary. The result of the operation had never been tested at extreme altitude. Corneas get their oxygen supply directly from the air rather than from blood vessels because they have to be transparent. Beck had been breathing supplemental oxygen on summit day. However, since that oxygen reaches tissues only through blood vessels, it didn’t help his corneas. Unable to absorb enough oxygen from the air, the corneas swelled, but the scars unevenly restricted their expansion, creating an irregular surface that distorted the entering light. With increasing altitude, Beck’s vision became blurrier and blurrier until he could barely see. Now, with the reduction in altitude, his eyes were curing themselves.

We followed the same routine for Beck as we had for Makalu except that Beck’s feet weren’t frostbitten so a third tub wasn’t required. By now the Sherpas had become masters of rewarming, but even with only two tubs to maintain, they were scarcely able to keep up. Beck’s hands were blocks of ice and they cooled the water with incredible speed.

Beck was coordinated and fully oriented. As we worked, he talked easily about what had happened to him. He said his vision had progressively deteriorated on summit day, and by the time he reached the southeast ridge he knew he had to turn back. He was overtaken by the storm and, in the whiteout, couldn’t find his way back to camp. Realizing that his hands were numb, he tried to warm them by putting them inside his jacket. He removed his right glove to unzip the jacket, but the glove blew away. Though he got his jacket open, he never managed to get his hand inside. Exhausted, he collapsed in the snow.

He said he entered a timeless, dreamlike state, aware of his surroundings but unable to move. A voice intruded into his consciousness when someone leaned over him and said, “He’s dead.” Images and sounds of his home and family floated through his mind, growing more and more vivid and real until they became powerful enough to stir him into action. He got up out of the snow. Reasoning that he would have to face into the wind to get back, since it had been behind him when he set out, he staggered ahead through the whiteout until he became the apparition Todd had seen outside his tent.

Though he recounted all this in a quiet, straightforward way, the story left me awestruck. The windchill factor above Camp IV could only be found on a chart for Mars. Already oxygen-deprived, dehydrated, and exhausted, a human body cannot withstand an onslaught of this magnitude for a day, a night, and a second day. It was impossible for Beck to have survived. As his temperature dropped, slow nerve impulses and stiff muscles would have left him unable to shiver, dropping his temperature even more. He would have lost the ability to coordinate the large muscles necessary to keep moving, and with it, the heat those muscles would have generated. Too weak to remain upright, he collapsed in the snow, helpless to counteract heat loss while his body temperature began its downward slide toward matching the outside temperature. He would burn the last of his fuel to try to produce heat, but the cold-stiffened muscles of his heart and lungs would be increasingly hard to propel. As his metabolic fire dimmed, his body would begin to shut down. Heart contraction and lung expansion would occur probably only once or twice a minute, their motion so reduced that movement of the chest wall would be almost
imperceptible. So little oxygen would circulate that even his brain, the priority user, would barely have enough to maintain its most elemental electrical circuits. When those few remaining sparks went out, vital functions would stop. That was the sequence that should have begun as soon as Beck collapsed in the snow. Looking at Beck now—alive and talking to me—I felt I was witness to a supernatural event. The contrast between the powerful story and the casual way in which he told it made his testimony all the more stunning.