by Sanjay Gupta
Copyright
Copyright © 2009 by Sanjay Gupta, MD
All rights reserved. Except as permitted under the U.S. Copyright Act of 1976, no part of this publication may be reproduced, distributed, or transmitted in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.
Wellness Central
Hachette Book Group
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First eBook Edition: October 2009
ISBN: 978-0-446-55876-1
For those living at the edge of a new frontier, working tirelessly to push forward the line between life and death. And for Sage, Sky and Soleil, the reasons I cheat death every day. They know it is not about eternal life, but about an extraordinary life.
Contents
Copyright
Prologue
CHAPTER ONE: Ice Doctors
CHAPTER TWO: A Heart-Stopping Moment
CHAPTER THREE: Suspend Disbelief
CHAPTER FOUR: Beyond Death
CHAPTER FIVE: What Lies Beneath
CHAPTER SIX: Cheating Death in the Womb
CHAPTER SEVEN: What Is a Miracle?
CHAPTER EIGHT: Another Day
Notes
Acknowledgments
About the Author
Prologue
I don’t want to achieve immortality through my work.
I want to achieve it through not dying.
—Woody Allen
I’M GOING TO let you in on a little secret: When the heart stops beating, it’s not the end. In fact, you might say that your troubles have only just begun. As it turns out, life and death is not a black-and-white issue. There is a gray zone—a faint no-man’s-land where you are neither truly dead nor actually alive. In order to control it, in order to cheat death, we have to first better understand it.
THE LAST THING Zeyad Barazanji remembers is the silence. 1 Thirty seconds earlier, he had been watching election returns on CNN, his head turned up from the treadmill, where he was huffing and puffing through his daily afternoon workout. His attention had drifted from the television to the sound of his own pounding feet, the whir of the machine, and his rasping breath as he strained to match his usual pace. That Tuesday, it felt like he was running uphill, and Barazanji cut it short, turning off the machine after only twenty minutes of jogging. A retired literature professor, Barazanji was in a bustling gym near his home in the Spuyten Duyvil section of the Bronx, surrounded by the banter of his neighbors and the clanking of weights. But then, nothing. Silence.
He doesn’t remember what happened next, only what people told him later. One woman will never forget it. One minute she was working out, and the next there was a blur in the corner of her eye. The wiry, older man with the white undershirt and headband crumpled in a heap at the foot of the adjacent treadmill. At least a dozen people saw him go down. Two called 911 from their cell phones. An athletic trainer, the gym’s manager, Juan Echevarria, grabbed the automatic defibrillator off the wall and rushed to Barazanji’s side.
Elbowing the crowd aside, Echevarria kneeled and placed the defibrillator’s electrodes on Barazanji’s chest. Upon getting a signal from the device, he sent a shock into the chest of the unconscious man. Two successive bursts of electricity—200 joules apiece—shook the crumpled body. Each jolt ran through the beaded sweat on Barazanji’s chest, through the breastbone, and into his still heart, shocking the muscle into a contraction. Another contraction followed, and then another. As the trainer held his breath, Barazanji’s heart caught a beat of its own. The heartbeat was back. The line between life and death had shifted just enough.
The professor groaned and remained senseless, but his heart was once again sending weak pulses of blood through his sixty-three-year-old arteries. About four minutes later, a team of emergency medical technicians raced across the basketball court, stretcher in hand, to Barazanji’s side. Two minutes later, a breathing tube was down his throat, he was on the stretcher, and the paramedics were sweeping toward the exit.
WE’RE USED TO thinking about dying in stark terms: dead or alive. You’re here and then you’re gone. In our imagination, this is how the moment of death plays out: The villain or hero or soldier gasping last words, stretching out a hand… until his eyes roll back in his head and we know it’s all over. Or the cancer patient surrounded by family. A light flickers behind her eyes and then goes out. You’ve read it in a thousand stories, seen it in a thousand movies, a hundred episodes of ER. The alarm sounds. The monitor flatlines. Time of death, 2:15 a.m.
It only takes a few minutes for life to slip away. Without a heartbeat, circulation slows to a halt. Blood no longer flows to your brain or any other organ. It takes just a couple of minutes before everything goes dim, and you’re blissfully unaware of the catastrophe unfolding inside your body. Starved of blood, the first organ to suffer is the brain, which in happier times consumes about 20 percent of all oxygen the body takes in, though it constitutes just 2 percent of our body mass. After ten seconds without oxygen, the brain’s function slows. Without oxygen or signals from the brain, other organs break down as well. Diaphragm muscles no longer contract and release to bring in air. The kidneys stop filtering blood. At the same time, an elaborate chain of chemical reactions triggers a breakdown in cells throughout the body.
This is the process of dying. Whether because of a car accident, a blockage in an artery, or a tumor somewhere in your body, it is generally understood that when the heart stops beating, life has ended. I have seen this play out more times than I care to remember. The first time, I was a third-year medical student at the University of Michigan. The patient was not much older than I was. I remember the call coming over the emergency radio: “Twenty-three-year-old unrestrained driver in an MVA [motor vehicle accident], found with the windshield starred and steering wheel bent.” Even then, I knew those details were important; it takes a lot of force to bend a steering wheel with your chest or smash a windshield with your head. I remember the trauma surgeons, neurosurgeons and orthopedic surgeons descending on this young man. They attempted to replace blood, stop bleeding and relieve pressure in his brain. It was a whirlwind of activity until… his heart stopped. And then everything else stopped, too. Everyone knew that was the end. After all, that’s what we were taught in medical school and throughout our training. But what if it doesn’t have to be that way? What if there were a way to give that twenty-three-year-old man and millions like him just a little more time, to shift the line between life and death? Ever since I watched that young man die, I have pondered that very question: can we move the line?
SURROUNDED BY FRIENDS and family in his Bronx apartment, Zeyad Barazanji told me his story of cheating death in a warm, friendly way. Barazanji, a translator and retired Columbia professor, immigrated here from Syria back in the 1970s. His two-bedroom apartment was filled with artwork and mementos from a lifetime of traveling between New York and the Middle East. A delicious smell was in the air; his wife Raoua was whipping up a feast of Syrian delicacies and dinner was almost ready. I leaned in to listen over the buzz of activity and clinking glasses in the kitchen. We were interrupted more than once as Barazanji got up to answer the door, clapping friends on the back and hanging their coats.
It was hard to believe that this man, so full of life, was dead not long ago, but that’s exactly what happened. His heart pumped no blood, his brain sent no signals, he thought no thoughts. Make no mistake—this is death. But
maybe not the way we tend to think about it.
For all that’s been said about immediate death—“I’m sorry, she was killed instantly”—in truth, there’s no such thing. As a doctor, I can assure you that when the heart stops beating, it’s not the end. Death is not a single event, but a process that may be interrupted, even reversed. And here’s the exciting part—at any point during this process, the course of what seems inevitable can be changed. That is precisely what we are going to explore in this book: the possibility of cheating death.
As the ambulance screeched away from the curb in front of Bally’s Total Fitness, Barazanji was in the gray zone—not dead but not quite fully alive, either. Millions of cells in his heart were already dead, suffocated by a lack of blood flow. It was too soon to say whether the damage was enough to cause a broader failure, similar to the collapse of a wall from which termites have taken one too many nibbles. It was also too soon to say if a significant number of brain cells—cells which had been nourished by a constant diet of oxygen for more than sixty-three years—had starved in those first precious minutes. There was no way to know just yet if the march toward death might be reversed.
Barazanji could easily be you or me, our father or mother. In a sense, what happened to Barazanji is extraordinary, but in another sense, it happens to us all eventually. It’s been said that life is a terminal condition, that nothing lasts forever, and the minute we’re born, we start the long process of our end. I think everyone, at one point or another, has probably wondered: does it really have to be that way? When we explore the story of Barazanji, we’re exploring the chances of cheating death—for you or me.
What you’re holding in your hands is a medical thriller that explores an exciting and fast-moving realm of science. In these pages, we’ll take you to the thin line that separates life and death, along with the doctors who struggle to keep their patients on the right side of the line. We will also explore that border through the eyes and ears of people who have found themselves straddling it, and we’ll introduce you to scientists who are taking on incredible challenges. These determined pioneers are true optimists who believe that even if we don’t yet have all the answers, we may find them.
From womb to deathbed, we’ll see the myriad ways that modern science is changing our understanding of life and death. You’ll see that neither the starting nor the finish line is written in stone; they are written in sand, shifting with each new wave of medical understanding and technology. In our journey to understand death—and to find a way to stave it off—we’re going to explore the gray no-man’s-land between this life and whatever lies beyond it.
Before we tell what happened to Barazanji, we’re going to introduce you to another explorer, a woman who has been to the no-man’s-land and lived to tell the tale. She arrived there by accident, on a faraway mountainside, in a world where people are used to working and playing in bitter cold and near darkness. That mountainside is the first stop on our remarkable journey.
CHAPTER ONE
Ice Doctors
She presented all the ordinary appearances of death. The face assumed the usual pinched and sunken outline. The lips were of the usual marble pallor. The eyes were lusterless. There was no warmth. Pulsation had ceased.
—Edgar Allan Poe, “The Premature Burial”
IN MAY 1999, a twenty-nine-year-old medical resident, Anna Bagenholm, was skiing with two friends near Narvik in northern Norway. They were colleagues as well as friends. All three were training at nearby Narvik Hospital, a small community hospital. Torvind Næsheim was working toward becoming an anesthesiologist, who handles the duties of an emergency physician in Norway. Marie Falkenberg hoped to be a pediatric surgeon. 1
Bagenholm was studying to become an orthopedic surgeon. An experienced backcountry skier, she had chosen to work in Narvik in part because of the spectacular mountains where she could ski nearly year-round. That fateful day, she and her friends had hiked about 30 minutes into an off-piste area, a place they had come many times before. They soon were making their way down a gully carved by a stream, now frozen and coated with a thin layer of snow. Largely hidden from the sun, the spot was known as the Mørkhåla, or black hole.
The details of the accident were wiped from Bagenholm’s memory by the months that followed, but somehow she fell and found herself sliding on her back. To her friends, it looked at first like a run-of-the mill tumble, but when they came closer, they could see that Bagenholm had broken partly through some ice and was trapped.
She was wedged headfirst between rocks and an overhanging shelf of ice that capped the stream rushing over her head. From what Falkenberg and Næsheim could tell, Bagenholm was in an air pocket, because she was still moving. There was no time to lose. They tried to tug her free, each hanging on to a leg, but the current pulled back and the cold made it difficult to keep a firm grip. After seven minutes they gave up and used a cell phone to call for help. The dispatcher at Narvik, a colleague, told them help was on the way, but it was a difficult wait, watching as Bagenholm’s struggles grew weaker and then ceased. It had been forty minutes since her head plunged through the ice.
By then, fellow skiers and friends were on the scene. Nearly forty minutes after that, at 7:39 p.m., another friend arrived with a steel garden shovel. Along with Næsheim and Falkenberg, they cut a hole through thick ice a short ways downstream, attached a rope to Bagenholm’s leg and dragged her underwater to the new hole, where they pulled her from the water.
Photos taken at the scene show a lifeless body, the pallor of its blue skin broken only by some dull purple welts and the pale oxygen lines. Bagenholm was soaking wet and by traditional measures, clinically dead. Næsheim and Falkenberg were experienced in backcountry medicine and weren’t ready to give up. They immediately commenced CPR. A few minutes later, a second medical team arrived by helicopter. The chopper hovered above while a rescuer dropped down, secured Bagenholm’s airway and strapped her to a backboard so she could be winched up to the helicopter. By 7:56 p.m., she was en route to the University of North Norway Hospital in Tromso, about 150 miles away.
As they soared through the darkening sky, the rescuers took turns pumping Bagenholm’s chest, using the desperate rhythm of CPR. The young physician still showed no sign of life. She had no breath, no pulse. A thermometer revealed that her core body temperature was just 56 degrees Fahrenheit.
Stick your foot in a bucket of 56-degree water, and in less than a minute, it will start to hurt. If you jump into water that is 56 degrees Fahrenheit, it will suck the breath out of you. Stay in the water for ten minutes, and you’ll be suffering from hypothermia. Bagenholm had been in the water for more than an hour, and she was in the air, in the rescue chopper, for another hour and fourteen minutes.
There was only one real glimmer of hope. There’s a saying in medicine that no one is dead until they are warm and dead. Bagenholm would not be warm for a long, long time. The rescue team knew that the very cold that was killing this young woman could end up saving her, too. They knew they had science on their side, as long as they could be patient. Instead of throwing blankets on Bagenholm and infusing warm IV fluid, they sat back, and waited.
The idea that cold might improve the chance of survival was truly discovered by accident, but it’s a lesson that’s driven home on a regular basis. Some recent examples: In the spring of 2008, a forty-three-year-old British woman named Mandy Evans survived after falling off a mountainous footpath and ending up in a near-freezing river; she lay there nine hours before rescuers found her. Her body temperature had fallen to 77 degrees Fahrenheit. In 2001, a Canadian toddler survived a night when her body temperature dropped to less than 58 degrees Fahrenheit. She had slipped out the front door of her home on a midwinter night, and then couldn’t get the door back open. She was found the next morning and rushed to the hospital; she eventually made a full recovery. 2
As these examples make obvious, under certain conditions the body can dramatically modify its requirements for survival. Do
ctors have long explored ways to make use of this lifesaving principle. Therapeutic hypothermia was first used in the 1940s and 1950s, when pioneering heart surgeons like Walt Lillehei started using hypothermia to extend their time in the operating room. Prior to the 1940s, most open-heart surgeries were thought to be impossible, because anything more than a very simple repair could not be completed in the few minutes that the heart—and brain—might survive without oxygen. By chilling a patient’s blood, Lillehei found that he could buy precious minutes. A heart that only lasted ten minutes at room temperature could survive an hour when it was cooled to 20 degrees Celsius. 3
There’s no easy answer as to how or why hypothermia really works. The first person I thought to ask was Dr. Lance Becker, an emergency physician and researcher who runs the Center for Resuscitation Science at the University of Pennsylvania School of Medicine. Becker says the hypothermia procedure is still mysterious. “We’re pretty sure it doesn’t work on just one mechanism. I’ve looked at twenty or thirty ideas [in the lab] that have been postulated, but the truth is, nobody knows [just why or how it helps].”
What does seem clear is that as a medical therapy, hypothermia buys time. I explain it this way: Chest compressions and artificial respiration provide oxygen that the body needs, but hypothermia slows the body down. That in turn reduces the need for oxygen, so the body can last longer on what’s already there.
Studies show that every 1 degree (Celsius) drop in body temperature will lower cellular metabolism by roughly 5 to 7 percent. 4 Becker’s best guess is that this reduced metabolism also slows the chemical reactions that are triggered by oxygen deprivation and which prove so damaging to cells. There’s no doubt this is complicated. Hibernation is a good example of cold going hand in hand with lower metabolism; mammals who hibernate can survive, even thrive, for long periods of time at far below their usual body temperature. In these animals, cold doesn’t just slow metabolism the way it thickens a jar of molasses. Rather, it triggers a whole set of biochemical changes.