by Sanjay Gupta
Gilbert helped develop this emergency curriculum, which is called the Village University. It’s already made a big impact. One of Gilbert’s first projects was in northern Iraq; another was in Cambodia, where forty-year-old landmines take a tremendous toll in the rural countryside. In these two far-apart regions, the fatality rate from landmine injuries fell from 40 percent to just 15 percent, after two intensive training sessions of twelve to fifteen days each, under Gilbert’s direction. 10 There was no medical breakthrough, no high-tech drug for the battlefield. Gilbert and his colleagues simply taught the farmers and village leaders how to properly stabilize a wound and helped them develop transportation networks—mostly by motorbike—to speed the delivery of victims to formal medical care.
He’s set up similar village universities in Burma and Angola with similar success. Gilbert says, “It’s the simple things, not the sophisticated things. We saved all these lives just by working with what you’d call barefoot doctors, training in basic techniques that are usually reserved for academic doctors, at least in our part of the world.”
It’s a lesson being learned here as well. In the field of emergency care, Lance Becker says the biggest change on the horizon is a breaking of walls between traditional specialties. To use therapeutic hypothermia on a patient isn’t technically complicated, but it takes a lot of coordination. Everyone from the emergency room staff to the cardiology team to surgeons to neurointensive specialists all need to be on board. That’s a problem, says Becker. “Right now, we have an organ mentality. There’s been this two hundred–year period, where cardiologists take care of the heart, and pulmonologists handle the lungs, and kidneys are for the nephrologists, and on and on. It’s like the blind man looking at various parts of the elephant.”
We now know that death is a complicated thing. Actual death doesn’t happen in just one organ at a time. It’s almost always a system-wide breakdown, a cascade of unfortunate events, unfolding inside every cell. “We need an integrated systems approach,” says Becker. “And I predict we’ll see that change within ten years. I’m hopeful, because there’s a coming together of a lot of this science. There will be some unifying kinds of therapies. But we’re not there yet.”
The psychologist and author Robert Kastenbaum has written quite a bit about the concept that death doesn’t happen in a moment but rather unfolds over time. At any point, it just might be stopped, it just might be cheated. Although it may be cutting-edge science, Kastenbaum says it harkens back to older beliefs:
Historical tradition… has often conceived death as a process that takes some time and is subject to irregularities. This process view has characterized belief systems throughout much of the world and remains influential in the twenty-first century. Islamic doctrine, for example, holds that death is the separation of the soul from the body, and that death is not complete as long as the spirit continues to reside in any part of the body. 11
None of the exciting medical changes that we’ve come across will ever give us total control over death. They won’t eliminate the sense of awe and mystery that stalks our notions of death. And I have a feeling they will never answer some of the nagging questions that confront every patient with a life-threatening illness or the doctors who care for them.
When a patient is lying close to death—Mark Ragucci, for instance—the family hopes for a miracle. But what, exactly, does that mean? In the sometimes faceless, technologically driven world of advanced medicine, doctors tend to be uncomfortable about discussing just how much uncertainty remains in what they do. Doctors are said to “practice.” The implication is they don’t quite have it down. And it’s true.
What makes for a miracle can only be understood through the filter of our current knowledge and our own expectations and hopes. One of the most remarkable people we came across while writing this book was David Bailey, the software salesman turned musician, who fought off a deadly brain tumor with the help of experimental treatments at the Preston Robert Tisch Brain Tumor Center. He was given six months to live. When my team first met him, it had been twelve years cancer free. But the week we were finishing the first draft of the book, we got this e-mail:
“… Don’t know if you heard, but long story short I spent the last week at Duke for a semi-emergency brain surgery (#3) to remove an 8cm fluid filled cyst and an odd tumor that is now being biopsied.
Home now, feeling much better. getting used to the train track on the side of my face. :-) Let me know if there’s anything I can do—and have a great thanksgiving.—lots to be thankful for(!)
David
The cancer was back. That wasn’t how the story was supposed to go. It doesn’t make it any less of a miracle that Bailey lived twelve cancer-free years with an illness that kills most people in a few months. But it’s still a gut punch for all the doctors he has encountered and the friends that Bailey has made on his incredible journey. At the time of this writing, he was back at Duke for another round of monoclonal antibody therapy—the same experimental treatment that saved him all those years ago, now refined, we hope, to be even better.
When someone dies of illness, we say they died of natural causes. But it’s just as natural that we fight it. We cling to life like a drowning man clings to a life raft. Life is the only thing we know.
In Zeyad Barazanji’s living room, we could see the sun getting low, as the hum of conversation grew louder in the living room and mouthwatering smells wafted out from the kitchen. Barazanji gestured to the door and said he wanted to show us something. We walked down the stairs, a spring in his sixty-eight-year-old steps, out the back door and onto the sidewalk. We strolled in the warm late summer afternoon, a block down the steep winding hill, tracing the edge of a park where dog lovers walked and the voices of children rang out on a playground. Barazanji pointed out what he said was the oldest building in Riverdale, and from there it was another half block along the promenade, overlooking Henry Hudson Park. We stopped at the top of the next staircase, broken stone steps leading down into the park. This was his favorite spot, he said, where he walked during his rehab, where he came when he wanted to watch the trains heading up to Connecticut, the boats on the Hudson, the sunset beyond. He closed his eyes. Death was nowhere to be seen.
Notes
PROLOGUE
1. The story of Zeyad Barazanji is based on interviews with the author and his team, and on this article: “Return of the Ice Age: Therapeutic Hypothermia in Emergency and Critical Care,” P&S (in-house journal for the College of Physicians & Surgeons of Columbia University) vol. 27, no. 3 (Fall 2007).
CHAPTER ONE: ICE DOCTORS
1. Unless otherwise noted, information on the Anna Bagenholm case comes from three sources: interviews conducted by the author and his team with Mads Gilbert and Anna Bagenholm; and “Resuscitation from accidental hypothermia of 13.7°C with circulatory arrest” by Mads Gilbert and others, from The Lancet 355, no. 9201 (2000): 375–76.
2. The cases of Mandy Evans and Canadian toddler Erika Nordby were widely described in contemporary news reports.
3. The experiments of Walt Lillehei and the University of Minnesota produced historically important scientific research that was vital in the development of cardiac surgery, transplant surgery, and other specialties. A gripping account for lay readers is included in Donald McRae’s book Every Second Counts.
4. L. P. Kammersgaard and others, “Admission body temperature predicts long-term mortality after acute stroke,” Stroke 33 (July 2002): 1759.
5. Matt Andrews, PhD, of the University of Minnesota, in interview with the author’s team. Another source of wisdom on ground squirrels is Hannah Carey, PhD, of the University of Wisconsin.
6. For a few days, Gilbert was a favorite target of conservative websites in the United States and Great Britain. Two examples can be seen at http://confederateyankee.mu.nu/archives/280821.php and http://www.hurryupharry.org/2009/01/07/mads-gilbert-doctor-pundit-shill-for-terrorism/. As an interesting side note, CNN was criticized for showing video
of Gilbert in a Palestinian hospital, assisting with CPR on a boy in a manner that several critics described as fake. CNN pulled the video from circulation to give me a chance to observe it and assess the veracity of the resuscitation effort. To me it was clear that the effort was real, though futile, in that the badly wounded patient was beyond the point of no return.
7. All accounts of earlier efforts at the University Hospital of North Norway to resuscitate severely hypothermic patients are based primarily on the recollections of Dr. Mads Gilbert.
8. Dr. Nobl Barazangi is the daughter of Zeyad’s brother, who spells the family name differently.
9. Several psychiatrists confirmed that cold sheets were widely used in psychiatric hospitals in the first part of the twentieth century. Dr. Julie Holland of NYU suggested another reason they may have been effective; she pointed out research by Temple Grandin, PhD, showing that simply being held tightly can have a calming effect, in particular lowering the respiratory rate. Being wrapped tightly would presumably do the same. The cold—depressing temperature and metabolism—would magnify the effect.
10. Stephan Mayer in interview with the author’s team.
11. I covered Richardson’s death for CNN. Her injury, known as an epidural hematoma, is generally fatal unless surgery is performed within a few hours of the injury.
12. Donald W. Benson, “The use of hypothermia after cardiac arrest,” Anesthesia & Analgesia 38, no. 6 (1959): 423–28.
13. Suad A. Niazi and F. John Lewis, “Profound hypothermia in man,” Annals of Surgery 147, no. 2 (February 1958): 264–66.
14. Benson, “Hypothermia after cardiac arrest.”
15. Mayer, interview.
16. Stefan Schwab et al, “Feasibility and Safety of Moderate Hypothermia After Massive Hemispheric Infarction,” Stroke 32, no. 6 (June 2009): 2033–2035
17. Andrea Zeiner et al, “Mild resuscitative hypothermia to improve neurological outcome after cardiac arrest: a clinical feasibility trial,” Stroke 31, no. 1 (January 2000): 86–94.
18. “Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest,” The New England Journal of Medicine 346, no. 8 (February 2002): 549–56.
19. “2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care,” Circulation 112, no. 24 (December 2005): IV-136–IV-138.
20. U.S. Food and Drug Administration, Center for Devices and Radiological Health, Circulatory System Devices Panel, minutes of meeting on September 21, 2004.
21. U.S. FDA, CDRH, minutes from meeting on September 21, 2004.
22. Carmelo Graffagnino, MD, Duke University, in interview with the author’s team.
23. Edna Kaplan, Medivance spokeswoman, in interview with author’s team.
24. Marcus Ong and others, “Controlled therapeutic hypothermia post-cardiac arrest compared to standard intensive care unit therapy,” presentation to the 2006 Society for Academic Emergency Medicine.
25. Raina M. Merchant and others, “Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest,” Critical Care Medicine 34, no. 7 (July 2006): 1935–1940.
26. Raina Merchant in interview with the author and his team.
27. http://www.med.upenn.edu/resuscitation/hypothermia/protocols.shtml
28. Zeyad Barazanji’s medical records.
29. Mary Grace Savage in interview with the author. Her husband, Patrick Savage, is a deputy chief with the FDNY; a detailed timeline of his rescue was laid out in the New York Daily News on July 3, 2007.
30. John Freese in interview with the author’s team.
31. I came to know the work of Audrey de Grey while researching my previous book, Chasing Life. Among other things, I had dinner at the home of his research assistant, Michael Rae, who is practicing another radical longevity strategy: a diet of severe calorie restriction.
32. Jennifer Chapman in interview with author’s team.
33. CBS’s The Early Show, February 3, 2000.
CHAPTER TWO: A HEART-STOPPING MOMENT
1. Unless otherwise noted, information on the Mike Mertz case comes from interviews conducted by the author’s team with Mike Mertz, Corey Ash, and Chuck Montgomery, Glendale Fire Chief.
2. Bentley J. Bobrow, “Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest,” Journal of the American Medical Association 299, no. 10 (March 2008): 1158–1165.
3. Benjamin S. Abella, “Reducing barriers for implementation of bystander-initiated cardiopulmonary resuscitation,” AHA Scientific Statement, Circulation, published online January 14, 2008.
4. U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality, http://www.innovations.ahrq.gov/content.aspx?id=1737.
5. Gordon Ewy in interview with the author’s team.
6. Myron L. Weisfeldt and Lance B. Becker, “Resuscitation after cardiac arrest: a 3-phase time-sensitive model,” Journal of the American Medical Association 288, no. 23 (December 2002): 3035–3038.
7. Ewy, interview.
8. American Heart Association, “About sudden death and cardiac arrest,” http://www.americanheart.org/presenter.jhtml?identifier=604.
9. Leonard Cobb et al, “Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation,” Journal of the American Medical Association 281, no. 13 (April 1999); 1182–1188.
10. Gordon A. Ewy, “Cardiocerebral resuscitation: the new cardiopulmonary resuscitation,” Circulation 111, no. 16 (April 2005): 2134–2142.
11. Gordon A. Ewy, “Continuous-chest-compression cardiopulmonary resuscitation for cardiac arrest,” Circulation 116, no. 25 (December 2007): 2894–2896.
12. Ewy, interview.
13. Mike Kellum in interview with the author’s team.
14. Mercy Health System website, http://www.mercyhealthsystem.org/body.cfm?id=7
15. Kellum, interview.
16. M. Kellum, K. Kennedy, and G. Ewy, “Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest,” The American Journal of Medicine 119, no. 4 (2006): 335–340.
17. Mike Kellum and others, “Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest,” Annals of Emergency Medicine 52, no. 3 (September 2008): 244–252.
18. Bentley Bobrow in interview with the author’s team.
19. We spent time with several paramedics in Glendale during the writing of this book; all recalled intense initial skepticism about Bobrow’s approach. Perhaps the most interesting story came from paramedic Crystal Sorenson. A day before he visited her firehouse, she had performed a highly unusual resuscitation on a dog belonging to her son’s girlfriend. The dog had apparently collapsed with no heartbeat, due to an allergic reaction to a bee sting. While Sorenson dug through the house for a shot of epinephrine, her son, on her instructions, pressed on the dog’s chest, but—as you might imagine—gave no rescue breaths. Despite more than ten minutes with his heart stopped, after receiving the shot of epinephrine, the dog revived with no obvious long-lasting ill effects. With that experience fresh in her mind when Bobrow gave his presentation, Sorenson was more receptive than most to the new protocol.
20. Bobrow, “Minimally interrupted cardiac resuscitation.”
21. Taku Iwami, “Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest,” Circulation 116, no. 25 (December 2007): 2900–2907.
22. I found another simple but successful intervention in an unlikely spot. Perhaps no public place on earth is so closely watched as the gaming floor of a Las Vegas casino. Security cameras hang in every conceivable location. In the mid-1990s, Dr. Terence Valenzuela of the University of Arizona realized that the cameras—and the people watching them—could do more than scan for drunks, card cheats and criminals. Valenzuela and colleagues convinced thirty-two casinos to ins
tall automated defibrillators in all public areas, trained the security guards to use them, and taught them basic CPR. Over the next two and a half years, 105 casino patrons suffered what doctors would consider a “survivable” cardiac arrest. More than half the victims lived to walk out of the hospital, at least ten times better than the typical survival rate. To this day, the safest place to have your heart give out is probably the floor of a Las Vegas casino. (As detailed in The New England Journal of Medicine 343, no. 17 (2000): 1206–1209.)
23. R. Dunne and others, “Outcomes from out-of-hospital cardiac arrest in Detroit,” Resuscitation 72, no. 1 (2007): 59–65.
24. Graham Nichol and others, “Regional variation in out-of-hospital cardiac arrest incidence and outcome,” Journal of the American Medical Association 300, no. 12 (September 2008): 1423–1431.
25. Graham Nichol, director of emergency care at the University of Washington Harborview Center for prehospital care in Seattle, in interview with the author’s team.
CHAPTER THREE: SUSPEND DISBELIEF
1. This estimate is based on the following: the LC-50 (concentration that would kill half the people exposed to it) for hydrogen sulfide is 800 parts per million. That can be converted to 0.8 grams per liter. Fanciful as it may be, one could thus say that 0.8 grams of H2S could kill approximately half the people exposed to it; therefore an ounce of H2S could kill approximately 18 people. This experiment will not be conducted any time soon.
2. This is based on standard material data safety sheets; these are two examples: www.mathesongas.com/pdfs/msds/MAT11210.pdf and http://avogadro.chem.iastate.edu/MSDS/hydrogen_sulfide.pdf
