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
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.
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