Cheating Death (5 page)

Whatever the reason, hospitals and doctors in the United States have been slow to adopt the treatment. Medivance, which makes
the most widely used therapeutic cooling pads, says that just a few hundred U.S. hospitals—of nearly six thousand total—have
even installed the necessary equipment.
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This sluggish response is especially bewildering, considering the lifesaving success that’s taken place in institutions that
do adopt the use of cooling. Just one example: after making hypothermia a standard protocol in 2006, the Virginia Commonwealth
University Medical Center reported that the death rate for cardiac arrest patients was cut in half.
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As I researched this book, I was incredulous that this lifesaving treatment could be ignored by so many. As I described it
to my friends and colleagues, they thought it was outrageous. What was the reason? Dr. Raina Merchant, a physician and researcher
at the Center for Resuscitation Science, tried to explain. Merchant has conducted a number of studies and surveys, talking
to hospitals and doctors about their use of hypothermia and other therapies.
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She is thirty-one years old, an accomplished physician, but she looks almost like an undergraduate—petite, with studious
glasses and often a neat black dress. She is African American, which stands out in the world of leading emergency physicians
and cardiologists. I started right into it: why don’t more doctors use hypothermia, when the evidence seems to show it’s a
lifesaver? “At first, we used to think it was because it wasn’t in the guidelines,” she said. “But now, since 2005, we have
that.”
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By this Merchant was talking about the modest recommendation from the American Heart Association.

You might think it costs too much, but according to Merchant, that’s not the problem, either. When I take nonphysicians to
an ICU and show them the hypothermia equipment, they are always a bit surprised. I think they imagine futuristic ice tubs
with bluish solutions coursing through the patient’s bloodstream. The truth is, hypothermia is not especially high tech. Doctors
pump cool saline through a patient’s veins or wrap cold solution-filled pads around the torso and extremities. Picture the
opposite of a hot water bottle.

To be fair, the box used to cool and pump the iced slurry solution costs about $25,000. But even if $25,000 sounds like a
lot of money, when compared to therapies like dialysis, it’s cheap. Cost-benefit studies showed the box would actually save
money. Merchant told me, “If you cool even one patient and avoid complications, you save more than the cost of dozens of boxes.
It’s cheaper to cool than not to cool.” And even the box isn’t absolutely necessary. Ice bags will do the trick, although
it’s harder to control the temperature. According to Lance Becker, for years, heart surgeons in Russia would pack a patient’s
chest cavity with ice until it was cold enough to stop the heart. Fritz Sterz, the Austrian physician who pioneered the use
of hypothermia in Europe, tells of a case where he used bags of frozen vegetables from a grocery freezer to cool a patient
who had collapsed in a grocery aisle.

In other words, it is a recommended, rather cost-effective therapy. I had to ask: “What am I missing here?” In Merchant’s
view, the biggest hurdle to widespread use of hypothermia is a psychological one. Her colleague in the University of Pennsylvania
emergency department, Dr. Ben Abella, explained, “It’s a paradigm shift. We’re using this for people whose eyes are yellow,
they’re not moving, and you’re telling doctors to cool these people for twenty-four hours—then warm them up for a day, then
take them to the cath lab. You’re doing all these things for people who look dead, sound dead, and act dead. It’s asking a
lot.”

Abella sees a parallel to the resistance that met the first groundbreaking chemotherapy treatments in the 1930s. At that time,
cancer was a truly hopeless diagnosis, and many doctors were defeatist about it. “There was a certain sense of ‘everyone is
going to die, so why waste all this money and time?’ ” he said.

It may be that lack of hope leads to inertia and apathy, but as I dug deeper, I found even more reasons therapeutic hypothermia
has been slow to catch on. Here’s one that will probably make you angry: using hypothermia might be inexpensive and effective,
but it isn’t nearly as simple as rolling out a new miracle drug. In this case, being inexpensive is not necessarily an asset,
but a potential liability. For example, let’s say you’ve invented this new medication. You run studies comparing the new pill
to a placebo, publish the results, and then—assuming it works—you send the sales team to tell physicians about it. If they’re
convinced, the doctors start writing prescriptions. There is no doubt money to be made.

By contrast, a single doctor, no matter how motivated, can’t just start writing prescriptions for hypothermia. He or she has
to convince a hospital to buy the equipment; it might not be terribly expensive as medical equipment goes, but it’s enough
that a purchasing committee needs to get involved. It gets even more complicated. A cardiac arrest patient is as likely to
be treated as a neurology patient as a cardiology patient, and in either case, he or she almost certainly starts in the emergency
department. All three of those departments have to not only agree that hypothermia is useful, they have to agree on where
to get the money to buy the gear. Then they have to figure out a protocol for identifying patients who would be helped by
the treatment—and train people to do it properly. This would be hard enough in a single hospital department; with two or three
departments involved, it can be a bit like herding cats. Even a good idea, without the millions of dollars that are often
backing a new drug, has a hard time getting off the ground. There is a sometimes ugly underbelly of medical progress, and
this is just one example of it.

On the Penn Medicine website, Becker and his colleagues have posted the hypothermia protocols from more than two dozen medical
centers.
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There’s no special qualification; someone just has to be willing to e-mail their institution’s guidelines. Since setting
up the website, the Center for Resuscitation Science has received thousands of e-mails from hospitals who want to set up their
own hypothermia programs. The hope is that by making the details easily and publicly available, Becker and his team will inspire
others to start—and will take away the excuse that hypothermia programs are all too complicated.

Raina Merchant found that the most common reason hospitals start using hypothermia is because there’s a doctor or even a nurse
who knows about hypothermia and talks it up among their colleagues. If there’s no local champion, no one gets cooled. Like
a lot of things in medicine, it boils down to word of mouth, the squeaky wheel. Simply put, despite all the technology and
years of studies, hypothermia still needs champions like Stephan Mayer.

At Columbia, when it comes to hypothermia, it’s full speed ahead. After receiving the midnight call from Nobl Barazangi, Mayer
called the hospital that was treating her uncle and arranged a transfer. Thirty minutes later, Zeyad Barazanji was in Mayer’s
ICU, being strapped to the cooling pads and blankets.
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His temperature was falling. Mayer could only hope that it would hold down the chaos bubbling up in the professor’s wounded,
oxygen-deprived brain cells.

Watching over Barazanji was a nurse, Mary Grace Savage, who had her own story to tell. That spring, her husband, a senior
official with the New York Fire Department, suffered a cardiac arrest at his gym in Brooklyn. Two fellow firefighters performed
CPR to get his heart going again, but he was still unconscious when he was taken to the local hospital. When Savage found
out, she had him transferred to Columbia immediately. She believes that if it had been just another hour or two longer, he
might not have made it. As it is, he was out of the hospital in eight days and back at work within six months.
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As these success stories start to percolate, the tide has lately been turning. In early 2009, the New York Fire Department
announced bold new plans to cool cardiac arrest patients in the field, and to only take them to hospitals that practice cooling.
“The plan is to make therapeutic hypothermia the first thing out of the bag, right after defibrillation,” says FDNY Medical
Director John Freese. “Once we get the breathing tube and an IV placed, we’ll just give everyone two liters of cooled saline.”
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In preparation, Freese has had to identify which hospitals are able to efficiently cool patients coming in from the field.
After all, it would make no sense to cool a cardiac arrest victim in their home, only to let them warm up thirty minutes later
when they reach the hospital. The process has not been tension free. There was shouting at one meeting, when the head of a
major hospital group said he didn’t want to publicly compare survival rates at different hospitals—it might embarrass someone.
Similar efforts are underway in Arizona, Wisconsin, and Seattle.

Lance Becker insists that doubters are missing the forest for the trees; whatever side effects exist are minimal in contrast
to the life-preserving power of cold. “No matter which direction you go, whether you’re conservative or aggressive, we know
it will save people’s lives,” said Becker. “How many lives have been lost, because we delayed implementing this for a year
or two? I have to think that we’ve lost lives, because we’ve failed to move aggressively.”

The practice of medicine is changing constantly. The innovation isn’t always for the better—ask one of the women who took
thalidomide in the 1960s to ward off morning sickness. And innovation is never easy—most of the first heart transplant patients
died within hours or days of their transplant. But the next round of transplants went better, and then better, and today thousands
of heart transplant patients live rich lives because of the bold pioneers of the 1950s and 1960s and their brave subjects.
What I have learned is that this cycle—desperation, desperate measure, apparent miracle, insight, common practice—shifts the
line in the sand. That’s how medicine moves forward. When Mads Gilbert saw his lifeless, near-frozen patient, what if he had
thrown his hands in the air, and said, “We’ve done all we can do”? Would he have been unreasonable?

Hypothermia is no antidote to death, no cure for cardiac arrest. What it does is buy time. Today, minutes, or hours, but some
scientists have more dramatic goals. The European Space Agency, the counterpart to NASA, reportedly has studied extreme hypothermia—cryonics—as
a way to preserve astronauts for distant journeys through the solar system, trips too long to bring sufficient food or water.
Some people say extended preservation using extreme cold could someday be part of routine medical care. The British futurist
Aubrey de Grey, whose scientific foundation is seeking ways to radically increase longevity, predicts that in the future virtually
any ailment will be reversible, anything short of total physical destruction.
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The trick is to somehow preserve our bodies until such technology exists. Grey says cryonics is an extremely promising technique:
“This is not bringing people back from the dead. This is a form of critical care.”

Cryonics is already starting to find its way into the lay public. At least two private companies, including the Arizona-based
Alcor Life Extension Foundation, are already using cryonics to preserve paying customers at extremely low temperatures. Alcor
says that its process—called vitrification—uses organ preservation fluid that enables rapid cooling without creating ice crystals
that would damage individual cells. The bodies are stored in gleaming metal tanks at the bottom of a bubbling pool of liquid
nitrogen; it looks like water, but it’s no hot tub: the temperature is minus-196 degrees Celsius. Despite a price tag of $150,000
(with a bargain rate of $80,000 for neuropreservation—i.e., just having your head frozen), Alcor says it has already chilled
more than eighty people and signed up nearly nine hundred members to follow in their footsteps.
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Lest it be seen as an out-of-reach luxury, Alcor Executive Director Jennifer Chapman notes that most customers pay using
proceeds of their life insurance.

According to Alcor’s website, cryonic preservation needs to begin within fifteen minutes of the heart stopping, and ideally
within just a minute or two. Otherwise, too much damage is done to cells in the process of death. Along those same lines,
Mads Gilbert believes it was the suddenness of Anna Bagenholm’s plunge through the ice that may have saved her. “If you’re
suffocated while you’re still warm, it’s like hanging or drowning,” he explains. “You can probably forget it.”

That pessimism largely stems from an experience Gilbert had in 1989, helping to rescue Norwegian soldiers trapped in an avalanche
during NATO’s winter training exercise: thirty-one troops were trapped; sixteen of them died—most from hypothermia, as their
body temperature
slowly
dropped inside their snowy prison. It is true that as the body cools, every organ needs less oxygen. But when that cooling
process is dragged out, it means an extended time where oxygen demand is high, even as supply—the ability to breathe—stays
low. That means irreversible damage. Had the soldiers fallen into frozen water causing a sudden and dramatic drop in body
temperature, says Gilbert, it could have turned out differently. “If you fall in through the ice, you’re cool before you even
stop breathing,” he said. “That’s Anna.”

Bagenholm herself remembers nothing of the accident, only waking up to find herself in critical care. In an interview a year
later, she said she’s as surprised as anyone to still be here. “When you’re a patient, you’re not thinking you are going to
die. You think, I’m going to make it,” said Bagenholm. “But as a medical person, I think it’s amazing that I’m alive.”
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