by Sanjay Gupta
But it was no relief. Struggling against a heavy weight, he felt a pain deep inside his chest. “I was twenty-seven years old at the time, and my first thought was, ‘what the hell would I be having a heart attack for?’ ” recalls Ragucci. “So I waited about forty-five minutes in the locker room until the pain went away. Then I went home. I know that’s probably not the smartest thing to do,” said Ragucci.
“Once I got home, I called my mom—that’s what you do in these kinds of situations.” He paused to smile. “She said to call 911.” It was January, and Chicago was digging out from a blizzard; still, Ragucci decided to walk to the hospital. He tells us he climbed over snowbanks higher than his head to reach the emergency room entrance. He found it inconceivable that he could be anything but healthy. “Going over the snow, I remember thinking, ‘Hey, I’m fine,’ ” he said.
But inside, an EKG test was abnormal enough to alarm the attending physician. The next test, an echocardiogram, or “echo,” uses ultrasound to detect abnormalities in the heart’s structure. Ragucci recalls a growing sense of dread as he waited for the news—a feeling that was soon justified by the results.
“I don’t really know how to read an echocardiogram, but I could see that wasn’t good at all,” recalls Ragucci. “My aortic valve was floppy.” The aortic valve separates the left ventricle, the chamber where blood first enters the heart, from the aorta, the exit chamber. Many patients with the condition show no symptoms or just a bit of fatigue. Many live happily without ever knowing that something is amiss, but if the valve is more deformed, it can cause irregular heart rhythms or even sudden death. Ragucci’s test results were so alarming, the cardiologist at Cook County recommended immediate surgery.
Ragucci is not prone to outer turmoil or emotional displays. He doesn’t smile much. His curly hair is cropped short and graying at the temples, and though he looks to be in excellent physical condition, his serious aspect comes across as older than his thirty-six years. Even as he described what was probably the most frightening day of his life, his tone was flat, almost clinical.
“I think I’d just stressed my body too much,” he said. Between lack of sleep, the rigors of medical training, and his insomniac gym workout, he had literally pushed himself to the brink of death. Of course, while many people keep crazy hours, Ragucci had something else working against him, genetic susceptibility. An uncle had died suddenly in his mid-thirties, presumably of heart trouble, although no autopsy was performed and the cause of death was never determined.
Fortunately, the open-heart surgery was a success, and Ragucci returned to work just six weeks later. Driven as ever, he pushed ahead with his medical training. He made no concessions to his new status as a heart patient, except for regular checkups by a cardiologist. It was nearly four years later when that cardiologist once again gave him bad news.
This time he said that scar tissue around the original valve repair was expanding, the way a garden hose starts to bulge around a tiny puncture. It could only be fixed by replacing the valve with a mechanical one. It was elective surgery technically, but as the cardiologist made clear, it was not really a choice. “They call it a semielective procedure,” says Ragucci, “but what that means is that you have to do it or you’re going to die.”
By then, he was living in New York City, finishing his training in the specialty of rehab medicine. Though serious, the second open-heart surgery was supposed to be routine. The rate of serious complications for valve replacement surgery is only about one in fifty, and few of those complications are life threatening. Routine preoperative tests, leading up to the surgery, found nothing unusual. But there are no guarantees in medicine, and Ragucci fell on the wrong side of the odds.
“I still don’t know what happened. No one does,” Ragucci told me. “I figured I’d be home for the holidays.” The operation was performed December 3, 2001. At first everything was routine, but then it wasn’t, and all hell broke loose. Something caused Ragucci’s blood pressure to drop precipitously, and the surgeons struggled to maintain the pressure. The surgery dragged on, close to twelve hours. Then Ragucci began to seize. In the recovery room, it was clear that something was wrong. The seizures steadily grew in intensity. Soon, a new one was coming every two to three minutes—status epilepticus, just like Zeyad Barazanji. An MRI scan revealed devastating injuries on both sides of Ragucci’s brain.
He languished in intensive care for twenty-three days. Doctors were only able to knock out the seizures by using medication that put Ragucci into a deep coma. Each time they lowered the dose, the seizures returned. His brain was, in effect, cooking itself. By the week after Christmas, the prognosis was bleak. The family kept pressing for updates, asking if there was any sign of improvement, but after a while, the doctors could no longer hide their impatience. One exasperated physician said that they were making the ordeal more painful for themselves, looking for hope where there was none. What Laura needed to do, the doctor told her gravely, was to think seriously about taking her husband off life support. The game was over. Even if her husband’s condition stabilized, the doctor said, he would be a vegetable his whole life. Another neurologist told her the same thing. There was no way her husband could recover any meaningful function. He was better off dead.
So Laura and her in-laws went looking for a second opinion. Ragucci said, “My wife called various ICUs, and someone told her there are two places you want to go. So she tried them both, and Columbia was the first place to call back.”
It’s the day after I’ve heard Ragucci tell his story, and Mayer is conducting rounds in Columbia’s neurointensive care unit. A wiry bundle of nervous energy, he walks fast and talks fast, and when he and his herd of young doctors move to a new patient’s room, it’s hard to keep pace while simultaneously avoiding the crush of doctors, nurses, students, and visitors all pushing in the opposite direction.
Today, the nine white coats are talking about an elderly Chinese woman lying comatose in room 3, her head swathed in bandages. She was brought to Columbia after being hit by a car. Making matters worse, there were problems getting a breathing tube in, and the woman’s brain was starved of oxygen for several minutes. Since arriving in the neurointensive care unit, she’s had part of her skull removed to relieve the pressure, but she’s been slammed with one severe infection after the other, so much that one doctor describes her as a human bacteria culture.
Mayer strides to the head of the inclined hospital bed, a dozen students and medical residents crowding in to watch. Leaning in, he begins yelling in a voice so loud that it makes the nonphysicians in the back of the crowd jump. “Li! Li!” (To be precise, he was yelling something a bit different—we’ve changed the name to protect the woman’s privacy.)
Gripping Li’s shoulders, Mayer shakes her back and forth with a vigor that is disconcerting. Li’s head flops back and forth, but her expression doesn’t change, unlike the slack-jawed expressions of the medical students who look on intently. Mayer pulls up Li’s eyelids and shouts her name again to no response. “No directed gaze,” he mutters, almost to himself. Next, he lifts up her arm and pinches as hard as he can on two of Mrs. Li’s fingernails. She grimaces slightly, and Mayer gently lays her arm back at her side.
“She’s better than I remember,” he says, satisfied. Mayer has seen a glimpse of life, which is all he needs to keep pushing as hard as possible. It’s all relative: unresponsive as she seems, it’s a tiny bit better than the day before. I could tell Mayer isn’t the type of doctor to give up easily.
New York-Presbyterian Hospital/Columbia University Medical Center sits on a high bluff on the edge of the Washington Heights neighborhood. It’s less than a mile from the George Washington Bridge, and on one end of the neurointensive care unit, there’s a picture window over-looking the graceful towers of the bridge. From other windows you can see the chop of waves in the Hudson and the green-topped cliffs on the New Jersey side of the river. As a first-time visitor walks around the unit, there’s an impression of seren
ity. It’s like a well-run day care center at nap time. Nurses smile, doctors talk quietly among themselves.
Despite the brightness of the rooms, there’s an eerie feeling here. There’s no bedside chatter, no obvious sign that until recently the men and women in these rooms were walking, talk-ing, smiling… fathers, mothers, aunts, brothers. Almost everyone has their eyes closed, and most are hooked up to an alarming array of wires and tubes. Almost everyone looks small, surrounded by the towering machinery. Nearly all are unconscious, many with mouths agape. And that’s when a darker thought strikes: this is a tomb. Many of the people we’re looking at now will never make it out alive, and many of the rest will leave with their mind imprisoned in a barely working body.
In many rooms there are family members sitting at the bedside, holding a limp hand, speaking words that no one but a reporter can hear. In 2001, it was Mark Ragucci’s parents in those chairs and his wife, imploring doctors to do everything and raging at the chief neurologist to not give in to his own deep doubts.
When morning rounds are over, Mayer takes a breath and talks about the patient who landed in his unit the day after Christmas in 2001. “Mark Ragucci was a case that really opened my eyes. Up to then, I mostly bought into what they tell you in the neurology textbooks, that there’s nothing we can do for these patients,” said Mayer.
In all likelihood, thought Mayer, he would monitor Ragucci for a few days and end up telling the family the same bad news. “I was looking at it like an act of compassion,” not a medical challenge, he says. “Let’s give the family some peace of mind. We’ll probably end up finding the same terrible things and tell the family the same message, but at least they’ll have the peace of mind to know that they went the extra mile. They tried everything.”
Mayer was taken aback by the family’s decision not to get another MRI, but for the next several days, his team went all out, trying to help their supposedly hopeless patient. Hypothermia has been shown to protect the brain from injury, so Mayer cooled Ragucci’s body with special pads. An injured brain loses the ability to control blood pressure, resulting in dangerous swings, so Mayer’s team checked the reading every few hours and adjusted Ragucci’s level of blood pressure medication. Ragucci had pneumonia, so he got massive doses of antibiotics, as well. An experimental system was hooked up to continually monitor his brain for seizures that might not be evident to the naked eye.
Mayer was encouraged when the seizures didn’t return, even after he had weaned Ragucci off the sedatives. Still, he showed no sign of responsiveness. Ragucci was only alive because of the breathing tube down his throat and the feeding tube implanted in his stomach. Each morning, Mayer and his residents would push, pull, and prod their patient, looking for a response. Mayer would scream out his name: “Mark! Mark!” (He generally uses a patient’s first name because, he says, they’re more likely to respond.)
For a long time, there was nothing. But then a funny thing happened. Something astonishing. The young physician, while still in a coma, started getting better. He grimaced when Mayer dug a fingernail into his palm. He uttered a faint grunt when Mayer shook him by the shoulders. Even as he recovered, Ragucci displayed signs of a devastating condition known as man-in-a-barrel syndrome. That is where the legs start to spontaneously move, but the midbody and arms are frozen in place. Still, it was something.
“It sounds small, but he showed small degrees of gradual improvement, from one day to the next, maybe two days later,” Mayer told me. “What we’ve learned is that the most important sign you can see is early improvement. Even if it’s as subtle as a patient starting to look over in your direction when you yell at them or reach up with a hand. Because once a patient shows you they’re on a recovery trajectory, that means a healing process is in motion, and we don’t know where it stops.”
Within three weeks, the breathing and feeding tubes were out, and Ragucci was well enough to leave the hospital. Mayer was amazed, but he cautioned against expecting more. “I told [Mark’s wife Laura], ‘More likely than not, he’s going to end up in a nursing home for the rest of his life. I guarantee you, he will never work again,’ ” Mayer said, leaning back and crossing his arms as a giant smile crept across his face. “And I was wrong.”
A YEAR LATER IN late 2002, Mayer was sitting in his office when a young man walked through the door, his arms held awkwardly, his hands twisted and held rigid. It was Mark Ragucci. “I almost fell out of my chair,” Mayer told me. “And the first thing he said was, ‘My hands don’t work.’ ” It was enough to nearly bring tears to Mayer’s eyes.
Despite the incredible strides he had made, Ragucci was frustrated. No surprise here—any doctor will tell you that the most difficult patients are often the ones who do best. Stubborn Ragucci had an innate refusal to accept anything but total success. That’s not to say he wasn’t thankful. He knew he’d dodged a bullet. He confided to us that his greatest relief was being able to walk again. It’s easy to see why—he’s constantly moving, so much that it’s unimaginable to think of him in a wheelchair.
It’s hard to say how many people might benefit from aggressive treatment, like what Ragucci got at Columbia. According to the Mohonk Report, drafted by a congressionally sponsored task force of brain-injury specialists, about 35,000 Americans are in a persistent vegetative state and another 280,000 in a minimally conscious state. It’s clear that many of those diagnoses are inaccurate, but at the same time, patients like Ragucci—or Terry Wallis—are still exceedingly rare.
But they happen, and when they do, they tend to make news. One remarkable example is the story of Donald Herbert, a firefighter in Buffalo, who woke up from a coma after ten years and then slipped back. 13 Dr. Nicholas Schiff had examined Herbert, and when I asked Schiff about it, he said Herbert’s recovery might have been triggered by a medication he took for Parkinson’s disease. A similar case involved George Melendez, a young man in Houston, who was comatose for five years after a car accident that left him underwater for ten minutes. One night, after taking an Ambien sleeping pill, he paradoxically woke up and started giving one-word answers to his mother’s questions. Schiff told me that medication may have played a role in the recovery of Terry Wallis, too. About eighteen months before he began talking again, he’d been started on an antidepressant. One of his caregivers had thought he looked teary eyed, so doctors thought they’d try an SSRI.
We don’t how it worked in any of these recoveries, or near recoveries, but the fact that medication may have played a role is a reminder that the amazing qualities of the mind are built on a physiological foundation. Mind is matter. The goal of scientists like Schiff is to understand that physiology, so that someday these patients won’t require a desperately rare stroke of luck to reclaim their lives.
How do these death-defying recoveries from coma happen at all? Brain imaging technology provides a few clues, offering a glimpse of what may lie beneath the placid surface of a supposedly vegetative patient. Dr. Adrian Owen, a neuroscientist at the University of Cambridge, did an experiment with a twenty-three-year-old woman who was diagnosed as being in a vegetative state after a car accident. For five months, up to the time that Owen saw her, she remained totally unresponsive. You could poke her, shake her, and scream her name—nothing. But Owen wondered if the problem might be primarily one of communication; in other words, whether the woman might be forming thoughts but unable to tell anyone about them.
To test this idea, his team used functional magnetic resonance imaging (fMRI) to monitor the woman’s brain while he played back a series of carefully spoken sentences. The fMRI detects blood flow to various regions of the brain, which serves as a marker of activity. When Owen played certain sentences, like “There was milk and sugar in his coffee,” the parts of the woman’s brain associated with speech comprehension lit up. By way of comparison, Owen also took fMRI readings while playing back white noise. During these interludes, the speech centers were inactive—just what you’d expect in a healthy person.
Owe
n also played back more complex sentences, where the meaning of a word depends on the words that follow it. For example, “The creak came from a beam in the ceiling.” When he did this, the response in the speech center was even stronger. Clearly, the woman’s brain was “thinking,” even if she showed no outward sign of it.
And there was more. The speech fMRI findings weren’t conclusive evidence of consciousness; Owen knew that people sometimes process language even while not consciously aware of it—for example, under partial anesthesia or when they’re asleep. To further test the level of consciousness, Owen asked the unconscious woman to imagine playing tennis, something she had enjoyed before her accident. During the imaginary game, the fMRI detected activity in a part of the brain known as the supplementary motor area, the same activity seen in healthy volunteers actually watching a ball being bounced back and forth across the net. That cinched it. Somehow, while she was totally unable to communicate, this particular woman was not completely out of it, not at all. 14
The most striking research, still in its infancy, involves a look at what happens to the brains of comatose patients over time. In 2006, after Terry Wallis awoke from his coma at age thirty-nine, his family allowed Schiff to peer inside Wallis’ brain, using PET scans and diffusion tensor imaging. The frontal cortex, the region where most higher order thinking takes place, was full of dead areas. But remarkably, Schiff found that Wallis had grown new brain connections, working around the dead spots to connect relatively undamaged areas. There were also highly unusual brain structures developed in the rear part of the brain. When doctors scanned Wallis again, eighteen months later, the changes were even more pronounced. Schiff calls the findings “amazing.”
