by Sanjay Gupta
The scars are still there, figuratively and literally. To remove one of the tumors, doctors had to cut out part of Matt’s vocal cords. His voice is raspy and so high it almost squeaks. But somehow, after three years doing battle with cancer, Matt picked up at almost the same place he left off. He returned to college, graduating from Saginaw Valley State University, near his home, with close to a 4.0 grade point average. Then he made it back to Ann Arbor, where he picked up a degree in electrical engineering. Today he designs software for General Electric and marvels at what was almost his fate.
Whether or not you believe in divine intervention, even some hard-core scientists and cancer specialists see real value in positive thinking, which Matthew almost always maintained. On the most basic level, research tells us that a positive attitude goes along with a stronger immune system; one study even found that people who meditated or prayed were more resistant to a flu virus that was blown into their noses. Beyond that, I believe strongly that the will to live is real. This may just be that a person who decides to fight his disease is more aggressive in seeking care. Any doctor will tell you that the most difficult, complaining patients are usually the ones who do best. Think of Mark Ragucci. Or it may be that someone healthy enough to fight is just more physically resilient.
Many people lump all this together as “the biology of hope.” David Gorski, the skeptic, isn’t sold. “I don’t reject it out of hand, but I don’t think the current state of research supports it.” On the other hand, Dr. Henry Friedman—as serious a scientist as there is—says there is no question: hope is a lifesaver. Even if he’s not sure how it works.
Friedman told me, “I think the real message is that if you enter with a philosophy that cancer patients will die—well, then they die. But if you go all out to help them, an ever-increasing number survive.”
A skeptic would say that the prayers for and by Matthew Pfenninger didn’t really work. After all, the tumors came back again and again. If he got better, it’s because he had state-of-the-art treatment at Duke. But even in that select group of patients, quite a few don’t make it. We’ll never know why Matt was one of the lucky ones. His faith is stronger than ever, but at the same time, the illness left him with a sense of unease, as if the ground beneath him had shifted. He struggles to put the feeling into words, then tells me, “I haven’t figured it all out yet. It’s been years and years, and I haven’t figured out what it meant to my life. But I think there’s a lot more to God and to Jesus than meets the eye.”
Jack Pfenninger says there are still times he finds himself consumed with what was lost. “I’m still so angry about it. I ask Matt, ‘What do your friends think of all those scars?’ You had to give up the Fulbright scholarship—you lost your youth—aren’t you angry?’ And he tells me, ‘No, I’m the luckiest guy in the world. I walk and talk, I feed myself, I play music [Matt is an amateur guitarist and songwriter], and I’m an engineer. If you weren’t a doctor and hadn’t noticed the problem with my eyes, I’d be dead.’ ” To this, Jack Pfenninger adds, “I’m a scientist. I don’t understand why he was healed. He should have been dead. Who saved him? God? I don’t know.”
Whether we’re a doctor or a patient, we tend to think that life and death are somehow under our control, and to an extent, they are. That’s why we go to the doctor in the first place, to help us heal. That’s what motivates doctors like Henry Friedman and the other medical mavericks we’ve seen in these pages. They push the boundaries of our knowledge. They try and shift that line in the sand between life and death, saving many lives in the process. But as good as our science becomes, there may always be something else—beyond that science—that allows someone to recover and heal when all hope is lost. I have learned that while we can never truly vanquish death, there will always be countless stories about how we cheated it.
CHAPTER EIGHT
Another Day
Lateat scintillula forsan. (A small spark may perhaps lie concealed.)
—motto of the Royal Humane Society
WHEN WE LEFT Zeyad Barazanji, he was lying in a medically induced coma. He had survived a cardiac arrest, nearly four minutes of clinical death, and a hairline fracture in his skull, but he was still deep in the woods. Doctors at New York-Presbyterian Hospital/Columbia University Medical Center had cooled his entire body with special pads to try and minimize the swelling and inflammation. The procedure typically takes about three days—then you wait. But here it was, a week later, and the pads were back on. This time the goal was to cool the fevers that were boiling Barazanji’s system.
He couldn’t feel a thing. The usually nimble brain, the mind of a professional translator who could understand four languages, was utterly quiet. To quell the constant seizures that rippled through Barazanji’s brain and kept it from healing, the doctors put their patient on heavy doses of powerful sedatives. They had driven him into what’s known as a medically induced coma. All they could do was wait. He had arrived November 7. Now, it was November 18. 1
It was hardest on Raoua Barazanji. Born in Syria, like her husband, she had met him in the Bronx fourteen years before and married him a few months later—on New Year’s Day in 1992. She was his second wife, and they had no children, though Zeyad had a grown daughter from his previous marriage. He was everything to Raoua. By day and most nights, she kept a vigil by the bedside, her gaze shifting from the sunlight pouring through the windows to the mass of tubes and wires that were propping up her husband, figuratively and maybe even literally. When she left these days, it was home to the Bronx, where she spent most of her time calling relatives with updates. She tried to keep up her spirits by cooking some of Zeyad’s favorite Syrian dishes.
She would go to bed, the smells of dinner still hovering in the air, then wake and ride the subway across the bridge to Manhattan to her husband’s side. The mornings were usually easier, surrounded by friends, some from as far away as Damascus. When Raoua was alone, the frustration could be too much. She would find herself standing over the bed, shouting, “Wake up! Open your eyes!” Sometimes he would open his eyes. The first time he did, Dr. Mayer, the head of the neurointensive care unit, was surprised. But he said it happens that way sometimes. They would keep their fingers crossed. Raoua would tell herself that she could see Zeyad’s chin jutting out, the way it did when he was feeling stubborn. He couldn’t move, but he was sending out a message: I’m not going anywhere.
On the nineteenth of November, friends and family were putting on their coats and getting ready to leave Zeyad’s bedside. They asked Raoua where they might try to grab a bite to eat downtown, when there came a voice from the bed. Something about “the Village.” Raoua and the two friends turned and stared. The voice was coming from underneath all those wires; it really was. The words didn’t quite make sense, but there was her husband, awake, playing the gracious host. There were a few bumps after that—another fever, a bad case of shingles—but twenty days later, Barazanji was out of the hospital. He looked like a skeleton. He’d lost more than 65 pounds off his 185-pound frame. But he was alive. He had cheated death.
There’s no simple answer as to why Zeyad Barazanji cheated death when so many others who suffer cardiac arrests don’t make it. The truth is, most don’t make it. But, Barazanji had been fortunate in many ways. There was that quick response of bystanders and paramedics and the help from his niece who steered him to state-of-the-art treatment. Dr. Stephan Mayer, who puts so much faith in therapeutic hypothermia and the growing specialty of neurointensive care, thinks cooling was a crucial component. An unavoidable comparison was the young man in the room literally next to Barazanji. He had arrived the same day, but only after lingering nearly three weeks in another hospital, without being cooled. He died just a few days after Barazanji walked out of the hospital. 2 There but for the grace of God…
Barazanji’s friends like to joke about his stubbornness. Barazanji told me, “I don’t remember it, but my wife says I pulled aside one of the doctors or nurses and told them, ‘Listen,
I am not an easy patient. I am too demanding.’ ” As you may have gathered, I do believe there’s something tangible about the will to live, a certain inner strength. Whatever it was, something stopped the hourglass before it ran out. Barazanji was dying—he was clinically dead—but then the clock was reset.
IN THIS AND other cases, the line in the sand is shifting, reflecting the excitement of new technology and also the uncertainty that comes with it. I once thought death was inalterable, but Dr. Lance Becker, the director of the Center for Resuscitation Science at the University of Pennsylvania School of Medicine, says medical advances have changed its very definition. “The language of death will always contain one of two words that should bother everyone,” says Becker. “ ‘Irreversible’ or ‘permanent.’ That’s kind of funny, because if you think about it, ‘irreversible’ and ‘permanent’ are only words you can use in retrospect.”
If you ask Mark Roth, the scientist who’s been putting animals into suspended animation, whether death has taken place, he’ll say something similar. “I don’t know. How long did you wait?”
This might sound like pointless wordplay, but it has a direct impact on clinical practice, on the care of real patients. Becker estimates that he’s pronounced about a thousand people dead over the course of his twenty-five-year medical career. Like other doctors, he has to fumble along the best he can. According to Becker, here’s how it usually happens at the Center for Resuscitation Science: “You’re working, doing everything you can. The guy doesn’t have a pulse. You don’t have another drug. You sit there, and say to one of the residents, ‘Okay, hand me the chart; let me see if something else is going on.’ You read the chart. Then you start asking people on the team: ‘Can you think of anything else to do? Can you?’ And when no one else has any ideas, we call it.” Time of death, 2:15 a.m.
Can you really define death as the moment that doctors quit? “Yes, that’s what I believe,” says Becker. You can say to yourself that he must be exaggerating, that doctors don’t really argue about death like that—but as my team did research for this book, we ran across all sorts of examples where the line in the sand was not clear at all.
Some of them are pretty bizarre. We heard about a case in Haiti, involving a man named Clairvius Narcisse, who died in a Port-au-Prince hospital in 1962 of what his doctors described as malnutrition. 3 He—or at least someone—was buried in the local cemetery. But in 1980, a sick, elderly man appeared in Narcisse’s village claiming to be Narcisse. His sister and several other family members immediately recognized him. What happened in the eighteen years in between remains unclear, but Narcisse and his family claim he was drugged and kept as a slave on a distant sugar plantation. He said he escaped after the plantation’s owner died and the poison wore off.
Chalk it up to the curse of the zombie. In Haitian folklore, a witch doctor can gain control of a victim’s mind with black magic and keep him or her in a state between life and death—as an undead. Far-fetched as it may seem, a Canadian ethnobotanist and anthropologist named Wade Davis claims to have found some real evidence—not of black magic, but of something equally strange. In the 1980s, Davis spent time in Haiti, where he befriended voodoo priests who gave him—he claims—a “zombie powder,” which he tested in a Washington, D.C., laboratory. (He later detailed the experience in two books, The Serpent and the Rainbow and Passage of Darkness.) According to Davis, the powder’s key ingredient was tetrodotoxin, the same substance found in the lethal puffer fish. The victim ingesting the powder would be immobilized with a near-lethal dose; as it began to wear off, the zombie would be aware of his or her surroundings yet unable to move. Supposedly, victims like Clairvius Narcisse could then be enslaved for years, kept in a fog or trance with drugs like scolopamine, atropine, and hyoscyamine, the chemicals found in hallucinogenic plants like Datura or nightshade. The zombies look dead, were pronounced dead, and yet are here are among the living.
The details of Davis’ work are controversial, 4 but there’s a natural fascination with stories like these, and it often shows up in popular culture—and not just in horror movies about zombies and the undead. Back in the early nineteenth century, catalogs and fashionable stores sold an array of coffins equipped with features such as air hoses, glass lids, and ropes that could be tied to bells at the graveyard surface. The most famous “bell” coffin was known as the Bateson Life Revival Device. From today’s vantage point, it looks like paranoia, but the craze stemmed from a new medical advance: the emergence of rudimentary mouth-to-mouth resuscitation and defibrillation techniques. Then, as now, the public was fascinated by a handful of tales about patients literally brought back from the dead. I should point out that there is no documented case of one of these “safety coffins” actually being put to good use, but there are documented cases right here in the modern United States, of patients who were taken to the morgue and put in the freezer before they woke up and started calling for help. 5
AS FASCINATING AS I find these stories, the true scientific advances of people like Mark Roth and Lance Becker are something I find even more exciting. They remind us that for all the progress we’ve made, we’ve still only scratched the surface when it comes to cheating death. Some branches of medicine are able to manipulate death so easily, it barely raises an eyebrow. At the Center for Resuscitation Science alone, twenty to thirty patients have their hearts intentionally stopped each day, when they have an internal defibrillator implanted. It only lasts a few seconds, but those few seconds are indistinguishable from the first few seconds of a cardiac arrest like the one that almost killed Zeyad Barazanji. As long as the clock has barely started ticking, it’s no big deal to bring you back from the dead.
“At time zero, survival is fabulous,” Becker says. “It’s pretty good up to five minutes. But if we could extend that window to thirty minutes, it would save 200,000 people a year.” From seconds to minutes to hours and days, with interventions like therapeutic hypothermia and possibly hydrogen sulfide. How far can it go? At Alcor, the cryogenics foundation, they’ve had nearly a thousand customers willing to pay $150,000 apiece to have themselves put into a deep freeze, to await some as-of-yet-unknown medical miracle. They’re betting their inheritance that by the time they’re unfrozen, doctors will know how to fix any damage that the process may have caused.
The military is pushing hard to find better methods of trauma care, and by extension, ways to extend the clock. Another frontier, as they say, is outer space. If we humans ever get around to traveling beyond our solar system, we’ll need an effective means of suspended animation. Otherwise, even traveling at the speed of light, any astronaut would die long before reaching his destination.
There are special challenges when it comes to this realm of research. We’re talking about life and death, not good skin care—the stakes could not be higher. Especially in the United States, this makes it difficult to obtain approval for major studies, where a new treatment is tested against a control group that gets the standard treatment or even no treatment at all. Ethics councils and review boards play an important function, helping patients avoid unnecessary risks, but there also are risks to sticking with the status quo. Look at what happened with therapeutic hypothermia. Despite its immense promise, the treatment ran into a catch-22—one government agency said there wasn’t enough evidence to approve its use, but no one could get more evidence because another agency said it was already obvious that the treatment works and that it would be unethical to withhold it. 6
Research on emergency care can provide critical insight by challenging conventional wisdom. Here’s one example: Since the 1970s, it’s been standard of care to treat cardiac arrest by giving a shot of epinephrine—adrenaline—along with any CPR and defibrillation. But doctors in Norway just finished a study that lasted five years, with more than a thousand patients, comparing the survival of patients who received epinephrine during their cardiac arrest with patients who did not. There was no difference in survival. 7 The standard treatment didn’t help at all.
A few months before those results were announced, a popular television reporter, an investigative journalist named Tarjei Leer-Salvesen, got wind of the study and did an expose. He called the study a “lottery,” where lifesaving treatment was withheld from half the patients. 8 There was such an uproar the study was cut short.
You can see the problem. When we challenge conventional wisdom, we may find that treatments we’ve taken for granted—like traditional CPR—aren’t terribly effective, and we may find newer approaches that work better. In the example from Norway, it turns out the lifesaving treatment, epinephrine, wasn’t really lifesaving at all, and if the study had been cut off sooner, no one ever would have known. Dr. Kjetil Sunde, one of the authors, was still furious when my team met him a few months later. He told us, “People only think you’re a good practitioner if you give a lot of drugs. If you just cure him with traditional doctor’s wisdom, they think you’re bad.”
In fact, what I’ve seen again and again while writing this book is that simple treatment can indeed be the best lifesaving method when it comes to emergency care. Therapeutic hypothermia is decidedly low tech. You can produce the effect using bags of ice. The biggest breakthrough in emergency resuscitation of the past thirty years is a new version of CPR that involves nothing more than pressing the victim’s chest firmly and rapidly.
Speed and simplicity are a mantra for Dr. Mads Gilbert, the daring physician who saved Anna Bagenholm from the frozen stream where she spent two hours underwater. Gilbert spends a lot of his time as far away as you can get from the frozen fjords of Norway. He makes several trips a year to developing countries, bringing basic supplies to strapped physicians (as in Gaza) or teaching basic emergency medical techniques to laypeople in places that are out of the reach of emergency medical technicians. 9
