Cheating Death

by Sanjay Gupta

  To be fair, the box used to cool and pump the iced slurry solution costs about $25,000. But even if $25,000 sounds like a lot of money, when compared to therapies like dialysis, it’s cheap. Cost-benefit studies showed the box would actually save money. Merchant told me, “If you cool even one patient and avoid complications, you save more than the cost of dozens of boxes. It’s cheaper to cool than not to cool.” And even the box isn’t absolutely necessary. Ice bags will do the trick, although it’s harder to control the temperature. According to Lance Becker, for years, heart surgeons in Russia would pack a patient’s chest cavity with ice until it was cold enough to stop the heart. Fritz Sterz, the Austrian physician who pioneered the use of hypothermia in Europe, tells of a case where he used bags of frozen vegetables from a grocery freezer to cool a patient who had collapsed in a grocery aisle.

  In other words, it is a recommended, rather cost-effective therapy. I had to ask: “What am I missing here?” In Merchant’s view, the biggest hurdle to widespread use of hypothermia is a psychological one. Her colleague in the University of Pennsylvania emergency department, Dr. Ben Abella, explained, “It’s a paradigm shift. We’re using this for people whose eyes are yellow, they’re not moving, and you’re telling doctors to cool these people for twenty-four hours—then warm them up for a day, then take them to the cath lab. You’re doing all these things for people who look dead, sound dead, and act dead. It’s asking a lot.”

  Abella sees a parallel to the resistance that met the first groundbreaking chemotherapy treatments in the 1930s. At that time, cancer was a truly hopeless diagnosis, and many doctors were defeatist about it. “There was a certain sense of ‘everyone is going to die, so why waste all this money and time?’ ” he said.

  It may be that lack of hope leads to inertia and apathy, but as I dug deeper, I found even more reasons therapeutic hypothermia has been slow to catch on. Here’s one that will probably make you angry: using hypothermia might be inexpensive and effective, but it isn’t nearly as simple as rolling out a new miracle drug. In this case, being inexpensive is not necessarily an asset, but a potential liability. For example, let’s say you’ve invented this new medication. You run studies comparing the new pill to a placebo, publish the results, and then—assuming it works—you send the sales team to tell physicians about it. If they’re convinced, the doctors start writing prescriptions. There is no doubt money to be made.

  By contrast, a single doctor, no matter how motivated, can’t just start writing prescriptions for hypothermia. He or she has to convince a hospital to buy the equipment; it might not be terribly expensive as medical equipment goes, but it’s enough that a purchasing committee needs to get involved. It gets even more complicated. A cardiac arrest patient is as likely to be treated as a neurology patient as a cardiology patient, and in either case, he or she almost certainly starts in the emergency department. All three of those departments have to not only agree that hypothermia is useful, they have to agree on where to get the money to buy the gear. Then they have to figure out a protocol for identifying patients who would be helped by the treatment—and train people to do it properly. This would be hard enough in a single hospital department; with two or three departments involved, it can be a bit like herding cats. Even a good idea, without the millions of dollars that are often backing a new drug, has a hard time getting off the ground. There is a sometimes ugly underbelly of medical progress, and this is just one example of it.

  On the Penn Medicine website, Becker and his colleagues have posted the hypothermia protocols from more than two dozen medical centers. 27 There’s no special qualification; someone just has to be willing to e-mail their institution’s guidelines. Since setting up the website, the Center for Resuscitation Science has received thousands of e-mails from hospitals who want to set up their own hypothermia programs. The hope is that by making the details easily and publicly available, Becker and his team will inspire others to start—and will take away the excuse that hypothermia programs are all too complicated.

  Raina Merchant found that the most common reason hospitals start using hypothermia is because there’s a doctor or even a nurse who knows about hypothermia and talks it up among their colleagues. If there’s no local champion, no one gets cooled. Like a lot of things in medicine, it boils down to word of mouth, the squeaky wheel. Simply put, despite all the technology and years of studies, hypothermia still needs champions like Stephan Mayer.

  At Columbia, when it comes to hypothermia, it’s full speed ahead. After receiving the midnight call from Nobl Barazangi, Mayer called the hospital that was treating her uncle and arranged a transfer. Thirty minutes later, Zeyad Barazanji was in Mayer’s ICU, being strapped to the cooling pads and blankets. 28 His temperature was falling. Mayer could only hope that it would hold down the chaos bubbling up in the professor’s wounded, oxygen-deprived brain cells.

  Watching over Barazanji was a nurse, Mary Grace Savage, who had her own story to tell. That spring, her husband, a senior official with the New York Fire Department, suffered a cardiac arrest at his gym in Brooklyn. Two fellow firefighters performed CPR to get his heart going again, but he was still unconscious when he was taken to the local hospital. When Savage found out, she had him transferred to Columbia immediately. She believes that if it had been just another hour or two longer, he might not have made it. As it is, he was out of the hospital in eight days and back at work within six months. 29

  As these success stories start to percolate, the tide has lately been turning. In early 2009, the New York Fire Department announced bold new plans to cool cardiac arrest patients in the field, and to only take them to hospitals that practice cooling. “The plan is to make therapeutic hypothermia the first thing out of the bag, right after defibrillation,” says FDNY Medical Director John Freese. “Once we get the breathing tube and an IV placed, we’ll just give everyone two liters of cooled saline.” 30

  In preparation, Freese has had to identify which hospitals are able to efficiently cool patients coming in from the field. After all, it would make no sense to cool a cardiac arrest victim in their home, only to let them warm up thirty minutes later when they reach the hospital. The process has not been tension free. There was shouting at one meeting, when the head of a major hospital group said he didn’t want to publicly compare survival rates at different hospitals—it might embarrass someone. Similar efforts are underway in Arizona, Wisconsin, and Seattle.

  Lance Becker insists that doubters are missing the forest for the trees; whatever side effects exist are minimal in contrast to the life-preserving power of cold. “No matter which direction you go, whether you’re conservative or aggressive, we know it will save people’s lives,” said Becker. “How many lives have been lost, because we delayed implementing this for a year or two? I have to think that we’ve lost lives, because we’ve failed to move aggressively.”

  The practice of medicine is changing constantly. The innovation isn’t always for the better—ask one of the women who took thalidomide in the 1960s to ward off morning sickness. And innovation is never easy—most of the first heart transplant patients died within hours or days of their transplant. But the next round of transplants went better, and then better, and today thousands of heart transplant patients live rich lives because of the bold pioneers of the 1950s and 1960s and their brave subjects. What I have learned is that this cycle—desperation, desperate measure, apparent miracle, insight, common practice—shifts the line in the sand. That’s how medicine moves forward. When Mads Gilbert saw his lifeless, near-frozen patient, what if he had thrown his hands in the air, and said, “We’ve done all we can do”? Would he have been unreasonable?

  Hypothermia is no antidote to death, no cure for cardiac arrest. What it does is buy time. Today, minutes, or hours, but some scientists have more dramatic goals. The European Space Agency, the counterpart to NASA, reportedly has studied extreme hypothermia—cryonics—as a way to preserve astronauts for distant journeys through the solar system, trips too long
to bring sufficient food or water. Some people say extended preservation using extreme cold could someday be part of routine medical care. The British futurist Aubrey de Grey, whose scientific foundation is seeking ways to radically increase longevity, predicts that in the future virtually any ailment will be reversible, anything short of total physical destruction. 31 The trick is to somehow preserve our bodies until such technology exists. Grey says cryonics is an extremely promising technique: “This is not bringing people back from the dead. This is a form of critical care.”

  Cryonics is already starting to find its way into the lay public. At least two private companies, including the Arizona-based Alcor Life Extension Foundation, are already using cryonics to preserve paying customers at extremely low temperatures. Alcor says that its process—called vitrification—uses organ preservation fluid that enables rapid cooling without creating ice crystals that would damage individual cells. The bodies are stored in gleaming metal tanks at the bottom of a bubbling pool of liquid nitrogen; it looks like water, but it’s no hot tub: the temperature is minus-196 degrees Celsius. Despite a price tag of $150,000 (with a bargain rate of $80,000 for neuropreservation—i.e., just having your head frozen), Alcor says it has already chilled more than eighty people and signed up nearly nine hundred members to follow in their footsteps. 32 Lest it be seen as an out-of-reach luxury, Alcor Executive Director Jennifer Chapman notes that most customers pay using proceeds of their life insurance.

  According to Alcor’s website, cryonic preservation needs to begin within fifteen minutes of the heart stopping, and ideally within just a minute or two. Otherwise, too much damage is done to cells in the process of death. Along those same lines, Mads Gilbert believes it was the suddenness of Anna Bagenholm’s plunge through the ice that may have saved her. “If you’re suffocated while you’re still warm, it’s like hanging or drowning,” he explains. “You can probably forget it.”

  That pessimism largely stems from an experience Gilbert had in 1989, helping to rescue Norwegian soldiers trapped in an avalanche during NATO’s winter training exercise: thirty-one troops were trapped; sixteen of them died—most from hypothermia, as their body temperature slowly dropped inside their snowy prison. It is true that as the body cools, every organ needs less oxygen. But when that cooling process is dragged out, it means an extended time where oxygen demand is high, even as supply—the ability to breathe—stays low. That means irreversible damage. Had the soldiers fallen into frozen water causing a sudden and dramatic drop in body temperature, says Gilbert, it could have turned out differently. “If you fall in through the ice, you’re cool before you even stop breathing,” he said. “That’s Anna.”

  Bagenholm herself remembers nothing of the accident, only waking up to find herself in critical care. In an interview a year later, she said she’s as surprised as anyone to still be here. “When you’re a patient, you’re not thinking you are going to die. You think, I’m going to make it,” said Bagenholm. “But as a medical person, I think it’s amazing that I’m alive.” 33

  She told my team she never despaired, even in the darkest days when she was still paralyzed in intensive care. “As a doctor, I understood a lot of things that were happening. I knew there was no spinal cord damage. I just waited to see what would happen. I focused on slowly getting better, trying do to the things I could. I never thought about not going back to work.”

  Gilbert maintains that the rescue was no miracle: “It’s the simple things, not the complicated things.” Success came not from any high-tech solution, but from fifteen years of hard work and intuition honed by trial and error. “It was the whole system, from the way we interact with local resources to the way we include the hospital at the end,” said Gilbert. “We’d had mistakes with other patients. We nearly succeeded, but lost them. By the time Anna came in, we’d adjusted some of the treatment… . The team on call that very night was a very well-geared team, tightly woven, with a strong spirit and optimism.”

  Bagenholm still goes hiking and skiing on a near daily basis. She and Gilbert are friends. In fact, the day he finally shared the full details of Bagenholm’s case, he had just spent the weekend with her and a close friend, skiing on the same slopes that sparked the frustration and inspiration for his most famous rescue.

  CHAPTER TWO

  A Heart-Stopping Moment

  And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands: and stretched himself upon the child; and the flesh of the child waxed warm.

  —2 Kings 4:34, KJV

  MIKE MERTZ WAS driving home, an hour after finishing his run as a school bus driver in Glendale, Arizona. He told me he doesn’t remember why he didn’t come straight home from work that day. He thinks that maybe he went for a jog. A trim fifty-nine years old, Mertz enjoyed a two- or three-mile run several days a week. Maybe he was looking for a cheaper gas station than the one on his usual route or was just trying to avoid taking his Saturn over a nasty set of new speed bumps. Whatever the reason, whatever route he wandered, it brought Mertz not to the usual entrance of his townhome complex, but the back driveway. 1 The change in routine may have saved his life.

  Corey Ash, a UPS driver, was making deliveries that Wednesday afternoon, when he heard a terrible engine noise. Thinking the sound was underneath his own hood, he pulled over. Hopping out, Ash immediately realized that it was coming from a Saturn almost directly across the street.

  It was an accident scene. The small silver car was piled up against a palm tree, the engine revving at top speed. The only thing keeping it in place was a stucco wall a few feet from the tree; the car was wedged between the two. Racing over, Ash could see that the driver had his eyes closed and seemed to be unconscious. The driver’s foot was wedged against the accelerator. Ignoring the chance that the car might break free and crush him, Ash reached across the slumped body and turned off the ignition. He dragged Mertz out of the car and laid him on the ground. After dialing 911, Ash started CPR the way he’d learned during an Air National Guard training exercise just two months before.

  As he listened to the ambulance siren, racing up the road from Glendale Fire Station 154 barely a mile away, Ash began to pump hard on Mertz’ chest. Studies show that when a bystander jumps in, the chances of survival in a cardiac arrest case increase exponentially. Even though it may not seem like you are accomplishing much, simply pushing the heart and circulating the blood can make a tremendous difference. Mertz had that going for him, but he was also fortunate to have collapsed in Glendale. Paramedics there are at the forefront of a revolution in emergency care. With a few simple measures—going against the grain of the medical establishment—they have found that they can radically improve the odds of surviving a cardiac arrest.

  The fire engine pulled up with a screech, and a brawny firefighter named Ruben Florez jumped to the curb. As fellow firefighters scrambled down, Florez thumped an urgent rhythm on Mertz’ chest, two hundred compressions over two minutes, before a medic stepped in and delivered an electric shock from the paddles of a defibrillator.

  Then came another two hundred compressions, then shock, two hundred compressions, then shock. Finally, after six hundred thumps and three defibrillator shocks, a weak pulse returned. Mertz was back from the dead. At no point was mouth-to-mouth resuscitation performed, and at no point did Mike Mertz get a breath. Surprisingly, that may be the real reason he survived.

  In reality, survival from cardiac arrest outside the hospital is rare. Until very recently, Arizona was in line with the rest of the country—only about 2 percent of the victims pulled through without long-term damage. 2 But in 2005, cities around Arizona began doing something new. It went against the guidelines of the American Medical Association and the teaching practices of major medical schools and hospitals. This new method didn’t look like the CPR that had been taught in every YMCA, firehouse, school, and church ever since the 1970s. In short, it was a radical experiment.

  The experime
nt sprang from two lines of thinking: animal studies aimed at modifying CPR technique and a public health effort to train more people in CPR. If your heart gives out while you’re walking down the street, the number-one thing that can save your life is to have a bystander who is not only trained in CPR, but willing to help. Unfortunately, such help is rare. Published studies put the rate of bystander CPR at around 20 percent. 3 If you dig deep, the number really has nothing to do with the lack of desire. Instead, study after study shows people are apprehensive about putting their mouth on someone else’s and maybe catching an infection from someone who’s on the ground dying.

  Now, the reluctance can be overcome. In Seattle, which has run massive training programs and public education campaigns since the 1970s, the rate of CPR assistance from bystanders is close to 50 percent. 4 That one fact gets much of the credit for the city’s high survival rate from cardiac arrest. In recent years, a driving goal of the American Heart Association has been to encourage more members of the public to jump in and help. But how? There was simply no getting around mouth-to-mouth resuscitation. Or was there?

  Cardiologist Dr. Gordon Ewy, and his team at the Sarver Heart Center in Tucson, had been doing CPR experiments for more than twenty years. Their focus was to try to understand the role that artificial breathing plays in emergency resuscitation, and for more than a decade, much to the consternation of the powers that be, Ewy had argued that breathing was nearly irrelevant.