by Sanjay Gupta
Hibernation seems to be caused by different factors, depending on the animal, but cold weather is a common trigger. Take ground squirrels, for example. As soon as temperatures dip below freezing on a regular basis, ground squirrels go into a near-complete torpor. Their heart rate, usually around two hundred beats per minute, slows to less than ten. The squirrel’s body temperature will drop from a warm-blooded 37 degrees Celsius to just one or two degrees above the outside temperature. They stay in that state, using just a bare minimum of energy, for at least six months. 5
True, humans aren’t squirrels, but believe it or not, we have some of the same adaptive ability. For example, immersion in cold water triggers something called the mammalian diving reflex. You could think of it as throwing the body into a state of semi-hibernation. Blood flow is shunted from the extremities to the heart and lungs, breathing slows, and the heart and brain use less than half of the oxygen they normally require. Survival time is stretched out.
BAGENHOLM COULDN’T HAVE known it at the time, but as the helicopter prepared to land, her life was about to intersect with a doctor who in one way or another had been preparing for this moment all his professional life. The director of emergency services at the University Hospital in Tromso was Dr. Mads Gilbert. Like his patient, Gilbert is a daredevil, a risk taker, enjoying off-piste skiing and trekking through the wilderness. He loves action; he loves riding the emergency helicopters that serve as ambulances for much of the far-flung, mountainous stretch of coastal Norway that surrounds his home base. In fact he had taken off in the rescue chopper to treat Bagenholm in the field, and only turned back when he learned that a larger, better-equipped helicopter was closer to the scene.
Gilbert spends his vacation time in places like Burma and Kurdistan, teaching emergency medical techniques to people who don’t live anywhere near a hospital and doctors who have to treat battlefield wounds with only the barest medical kits. He had a brush with worldwide fame in 2008, during Israel’s offensive in the Gaza Strip. Gilbert was interviewed inside a Gaza hospital, where he helped to treat wounded fighters and civilians. He accused Israel of deliberately killing civilians and in turn was denounced by conservative critics who called him a “Hamas apologist” and a “shill for terrorism.” 6
In other words, Gilbert is not a man who shies from controversy, whether the debate is over politics or medicine. That was true long before he started turning up in global hot spots. Some might consider his risk taking dangerous, even reckless, but in Bagenholm’s case, it was exactly what she needed. Many other doctors would have given up, and for good reason. Taking stock of his new patient, Gilbert told me he knew that she didn’t look good. “I saw this very, very athletic young girl. But she looked like a corpse.” By the time Anna Bagenholm was wheeled into the operating room, she had been clinically dead for three hours.
When I first read about the Bagenholm case, I imagined a daring physician, attempting extravagant new measures on behalf of his beautiful, hopeless patient. I imagined only sheer desperation would drive someone to that brink of attempting the impossible. As it turns out, only some of this is true. The effort to save Bagenholm did in fact stem from desperation, but it was not so much a matter of luck as careful guesswork and experience.
Before the Bagenholm rescue, Gilbert says his team had made at least fifteen previous attempts to resuscitate patients with no pulse and severe accidental hypothermia. 7 They were fishermen or skiers or hikers who had fallen in the sea or through ice, or gotten trapped under snow, or simply become drunk and lost in the woods until they nearly froze to death. When I asked Gilbert how many of those patients had survived, he looked away for a second and then replied thoughtfully, “We hadn’t succeeded with a single survivor, but we were getting closer and closer.” He told me, “In fact, the person just before Anna was in some ways an even more dramatic story.”
Just a few months earlier, Gilbert had flown a risky helicopter mission to the scene of an avalanche that had buried another skier, a young university student. The student and a companion had set off the avalanche while telemarking down a pristine snowfield near the base of Ullstinden, a popular ski mountain just north of Tromso. The student’s companion managed to avoid the collapse and made it down to the road to seek help. In the meantime, two young skiers who had seen the accident from above made it down to the scene and began to dig.
Gilbert’s rescue chopper arrived within the hour, but the side of the valley was too steep for it to land, so the helicopter touched down on a ridge several hundred yards above. Gilbert, a nurse, and a local police officer clambered down the side of the valley. By the time they reached the victim, only his ski pole and one of his arms were visible. It took some time to set him free and then start CPR. A long time had passed; perhaps too long.
The situation was dire. The young man had no pulse, and they would have to wait for a rescue; the snow was too deep and unstable to carry out the victim on a pallet. For three hours in the bitter mountainside cold, Gilbert’s team pressed ahead with resuscitation efforts. While Gilbert adjusted the breathing tube and pumped the young man’s chest, a colleague lit the emergency stove from the camping set and boiled tea to keep them warm. The patient, on the other hand, was kept cold. Every five minutes, the team members would switch places.
When the helicopter was finally able to land, they got the unconscious student up the steep mountainside on a sledge, stumbling through the dark while shivering at the thought of another avalanche. Once on board, they continued CPR, all the while taking care not to raise the patient’s temperature. Only after arriving at the hospital did they hook him to a bypass machine to warm him up. Miraculously, the student’s heart regained a beat. What’s more, his kidneys and lungs had started to function, and his pupils once again shrank in response to light, a sign that his brain was not irreparably damaged. “We were so completely excited,” recalls Gilbert. “Very, very, very excited. We thought, ‘We finally did it!’ ”
The young man continued to do well for about two days, but then he took a sudden turn for the worse. In a matter of hours, his brain was crushed by an overload of fluid. In the cramped space of his skull, the pressure was too much, and he died. Gilbert and his team were devastated. They had been so close to a miraculous success, only to have it end the way others had. “I was crazy. I just thought, what did we do wrong? Why were we unable to prevent swelling of the brain?” he said.
As they did after every intensive effort, his team gathered to compare notes on similar cases. Looking back at fifteen similar cases, Gilbert saw that edema, or swelling, was a common problem; the young man had survived longer, but he was not the first to suffer fatal brain swelling after getting back a heartbeat. Gilbert suspected that these half-frozen patients were particularly susceptible. For one thing, hypothermia essentially acts as a blood thinner, so the patients were prone to internal bleeding. But something else was happening that was even more critical. These patients had all suffered cardiac arrest due to hypothermia or been partially suffocated by avalanches or submerged under ice. One way or another, their brains and bodies had been starved of oxygen.
This is where it gets a little tricky and maybe counterintuitive. In effect, these patients were probably all suffering from varying degrees of something known as reperfusion injury. Reperfusion injury is the name for the damage that takes place when oxygen is reintroduced to oxygen-starved tissue. Normally, reintroducing oxygen is good, but with reperfusion injury it seems to set off a complex chain of damaging chemical reactions. The exact mechanism isn’t clear, but Gilbert says that cell membranes throughout the body tend to become more permeable—in other words, they start to leak fluid—and that is the major cause of swelling.
THE 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 d
amaged 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.
ON 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!’ ”
