Cheating Death (19 page)

So Laura and her in-laws went looking for a second opinion. Ragucci said, “My wife called various ICUs, and someone told her
there are two places you want to go. So she tried them both, and Columbia was the first place to call back.”

It’s the day after I’ve heard Ragucci tell his story, and Mayer is conducting rounds in Columbia’s neurointensive care unit.
A wiry bundle of nervous energy, he walks fast and talks fast, and when he and his herd of young doctors move to a new patient’s
room, it’s hard to keep pace while simultaneously avoiding the crush of doctors, nurses, students, and visitors all pushing
in the opposite direction.

Today, the nine white coats are talking about an elderly Chinese woman lying comatose in room 3, her head swathed in bandages.
She was brought to Columbia after being hit by a car. Making matters worse, there were problems getting a breathing tube in,
and the woman’s brain was starved of oxygen for several minutes. Since arriving in the neurointensive care unit, she’s had
part of her skull removed to relieve the pressure, but she’s been slammed with one severe infection after the other, so much
that one doctor describes her as a human bacteria culture.

Mayer strides to the head of the inclined hospital bed, a dozen students and medical residents crowding in to watch. Leaning
in, he begins yelling in a voice so loud that it makes the nonphysicians in the back of the crowd jump. “Li! Li!” (To be precise,
he was yelling something a bit different—we’ve changed the name to protect the woman’s privacy.)

Gripping Li’s shoulders, Mayer shakes her back and forth with a vigor that is disconcerting. Li’s head flops back and forth,
but her expression doesn’t change, unlike the slack-jawed expressions of the medical students who look on intently. Mayer
pulls up Li’s eyelids and shouts her name again to no response. “No directed gaze,” he mutters, almost to himself. Next, he
lifts up her arm and pinches as hard as he can on two of Mrs. Li’s fingernails. She grimaces slightly, and Mayer gently lays
her arm back at her side.

“She’s better than I remember,” he says, satisfied. Mayer has seen a glimpse of life, which is all he needs to keep pushing
as hard as possible. It’s all relative: unresponsive as she seems, it’s a tiny bit better than the day before. I could tell
Mayer isn’t the type of doctor to give up easily.

New York-Presbyterian Hospital/Columbia University Medical Center sits on a high bluff on the edge of the Washington Heights
neighborhood. It’s less than a mile from the George Washington Bridge, and on one end of the neurointensive care unit, there’s
a picture window over-looking the graceful towers of the bridge. From other windows you can see the chop of waves in the Hudson
and the green-topped cliffs on the New Jersey side of the river. As a first-time visitor walks around the unit, there’s an
impression of serenity. It’s like a well-run day care center at nap time. Nurses smile, doctors talk quietly among themselves.

Despite the brightness of the rooms, there’s an eerie feeling here. There’s no bedside chatter, no obvious sign that until
recently the men and women in these rooms were walking, talk-ing, smiling… fathers, mothers, aunts, brothers. Almost everyone
has their eyes closed, and most are hooked up to an alarming array of wires and tubes. Almost everyone looks small, surrounded
by the towering machinery. Nearly all are unconscious, many with mouths agape. And that’s when a darker thought strikes: this
is a tomb. Many of the people we’re looking at now will never make it out alive, and many of the rest will leave with their
mind imprisoned in a barely working body.

In many rooms there are family members sitting at the bedside, holding a limp hand, speaking words that no one but a reporter
can hear. In 2001, it was Mark Ragucci’s parents in those chairs and his wife, imploring doctors to do everything and raging
at the chief neurologist to not give in to his own deep doubts.

When morning rounds are over, Mayer takes a breath and talks about the patient who landed in his unit the day after Christmas
in 2001. “Mark Ragucci was a case that really opened my eyes. Up to then, I mostly bought into what they tell you in the neurology
textbooks, that there’s nothing we can do for these patients,” said Mayer.

In all likelihood, thought Mayer, he would monitor Ragucci for a few days and end up telling the family the same bad news.
“I was looking at it like an act of compassion,” not a medical challenge, he says. “Let’s give the family some peace of mind.
We’ll probably end up finding the same terrible things and tell the family the same message, but at least they’ll have the
peace of mind to know that they went the extra mile. They tried everything.”

Mayer was taken aback by the family’s decision not to get another MRI, but for the next several days, his team went all out,
trying to help their supposedly hopeless patient. Hypothermia has been shown to protect the brain from injury, so Mayer cooled
Ragucci’s body with special pads. An injured brain loses the ability to control blood pressure, resulting in dangerous swings,
so Mayer’s team checked the reading every few hours and adjusted Ragucci’s level of blood pressure medication. Ragucci had
pneumonia, so he got massive doses of antibiotics, as well. An experimental system was hooked up to continually monitor his
brain for seizures that might not be evident to the naked eye.

Mayer was encouraged when the seizures didn’t return, even after he had weaned Ragucci off the sedatives. Still, he showed
no sign of responsiveness. Ragucci was only alive because of the breathing tube down his throat and the feeding tube implanted
in his stomach. Each morning, Mayer and his residents would push, pull, and prod their patient, looking for a response. Mayer
would scream out his name: “Mark! Mark!” (He generally uses a patient’s first name because, he says, they’re more likely to
respond.)

For a long time, there was nothing. But then a funny thing happened. Something astonishing. The young physician, while still
in a coma, started getting better. He grimaced when Mayer dug a fingernail into his palm. He uttered a faint grunt when Mayer
shook him by the shoulders. Even as he recovered, Ragucci displayed signs of a devastating condition known as man-in-a-barrel
syndrome. That is where the legs start to spontaneously move, but the midbody and arms are frozen in place. Still, it was
something.

“It sounds small, but he showed small degrees of gradual improvement, from one day to the next, maybe two days later,” Mayer
told me. “What we’ve learned is that the most important sign you can see is early improvement. Even if it’s as subtle as a
patient starting to look over in your direction when you yell at them or reach up with a hand. Because once a patient shows
you they’re on a recovery trajectory, that means a healing process is in motion, and we don’t know where it stops.”

Within three weeks, the breathing and feeding tubes were out, and Ragucci was well enough to leave the hospital. Mayer was
amazed, but he cautioned against expecting more. “I told [Mark’s wife Laura], ‘More likely than not, he’s going to end up
in a nursing home for the rest of his life. I guarantee you, he will never work again,’ ” Mayer said, leaning back and crossing
his arms as a giant smile crept across his face. “And I was wrong.”

A
YEAR LATER IN
late 2002, Mayer was sitting in his office when a young man walked through the door, his arms held awkwardly, his hands twisted
and held rigid. It was Mark Ragucci. “I almost fell out of my chair,” Mayer told me. “And the first thing he said was, ‘My
hands don’t work.’ ” It was enough to nearly bring tears to Mayer’s eyes.

Despite the incredible strides he had made, Ragucci was frustrated. No surprise here—any doctor will tell you that the most
difficult patients are often the ones who do best. Stubborn Ragucci had an innate refusal to accept anything but total success.
That’s not to say he wasn’t thankful. He knew he’d dodged a bullet. He confided to us that his greatest relief was being able
to walk again. It’s easy to see why—he’s constantly moving, so much that it’s unimaginable to think of him in a wheelchair.

It’s hard to say how many people might benefit from aggressive treatment, like what Ragucci got at Columbia. According to
the Mohonk Report, drafted by a congressionally sponsored task force of brain-injury specialists, about 35,000 Americans are
in a persistent vegetative state and another 280,000 in a minimally conscious state. It’s clear that many of those diagnoses
are inaccurate, but at the same time, patients like Ragucci—or Terry Wallis—are still exceedingly rare.

But they happen, and when they do, they tend to make news. One remarkable example is the story of Donald Herbert, a firefighter
in Buffalo, who woke up from a coma after ten years and then slipped back.
¹³
Dr. Nicholas Schiff had examined Herbert, and when I asked Schiff about it, he said Herbert’s recovery might have been triggered
by a medication he took for Parkinson’s disease. A similar case involved George Melendez, a young man in Houston, who was
comatose for five years after a car accident that left him underwater for ten minutes. One night, after taking an Ambien sleeping
pill, he paradoxically woke up and started giving one-word answers to his mother’s questions. Schiff told me that medication
may have played a role in the recovery of Terry Wallis, too. About eighteen months before he began talking again, he’d been
started on an antidepressant. One of his caregivers had thought he looked teary eyed, so doctors thought they’d try an SSRI.

We don’t how it worked in any of these recoveries, or near recoveries, but the fact that medication may have played a role
is a reminder that the amazing qualities of the mind are built on a physiological foundation. Mind
is
matter. The goal of scientists like Schiff is to understand that physiology, so that someday these patients won’t require
a desperately rare stroke of luck to reclaim their lives.

How do these death-defying recoveries from coma happen at all? Brain imaging technology provides a few clues, offering a glimpse
of what may lie beneath the placid surface of a supposedly vegetative patient. Dr. Adrian Owen, a neuroscientist at the University
of Cambridge, did an experiment with a twenty-three-year-old woman who was diagnosed as being in a vegetative state after
a car accident. For five months, up to the time that Owen saw her, she remained totally unresponsive. You could poke her,
shake her, and scream her name—nothing. But Owen wondered if the problem might be primarily one of communication; in other
words, whether the woman might be forming thoughts but unable to tell anyone about them.

To test this idea, his team used functional magnetic resonance imaging (fMRI) to monitor the woman’s brain while he played
back a series of carefully spoken sentences. The fMRI detects blood flow to various regions of the brain, which serves as
a marker of activity. When Owen played certain sentences, like “There was milk and sugar in his coffee,” the parts of the
woman’s brain associated with speech comprehension lit up. By way of comparison, Owen also took fMRI readings while playing
back white noise. During these interludes, the speech centers were inactive—just what you’d expect in a healthy person.

Owen also played back more complex sentences, where the meaning of a word depends on the words that follow it. For example,
“The creak came from a beam in the ceiling.” When he did this, the response in the speech center was even stronger. Clearly,
the woman’s brain was “thinking,” even if she showed no outward sign of it.

And there was more. The speech fMRI findings weren’t conclusive evidence of consciousness; Owen knew that people sometimes
process language even while not consciously aware of it—for example, under partial anesthesia or when they’re asleep. To further
test the level of consciousness, Owen asked the unconscious woman to imagine playing tennis, something she had enjoyed before
her accident. During the imaginary game, the fMRI detected activity in a part of the brain known as the supplementary motor
area, the same activity seen in healthy volunteers actually watching a ball being bounced back and forth across the net. That
cinched it. Somehow, while she was totally unable to communicate, this particular woman was not completely out of it, not
at all.
¹⁴

The most striking research, still in its infancy, involves a look at what happens to the brains of comatose patients over
time. In 2006, after Terry Wallis awoke from his coma at age thirty-nine, his family allowed Schiff to peer inside Wallis’
brain, using PET scans and diffusion tensor imaging. The frontal cortex, the region where most higher order thinking takes
place, was full of dead areas. But remarkably, Schiff found that Wallis had grown new brain connections, working around the
dead spots to connect relatively undamaged areas. There were also highly unusual brain structures developed in the rear part
of the brain. When doctors scanned Wallis again, eighteen months later, the changes were even more pronounced. Schiff calls
the findings “amazing.”

You see, those changes are supposed to be impossible. When Schiff was getting started in neurology, he was taught that when
it comes to brain injuries, “what’s done is done.” I was taught the same thing. Since brain cells don’t regenerate when they
die, it was thought that a brain injury had no chance of healing. No sensible physician would dare to cross that line in the
sand, to believe otherwise, but it turns out the brain has a surprising innate ability to cheat death.

Based on a growing body of research, Schiff says that doctors need to throw out virtually everything they’ve been taught about
the brain’s ability to recuperate. To me, this relatively new field is just as exciting as the advances that might give people
an extra few hours to survive a cardiac arrest. It’s certainly just as meaningful—when Terry Wallis or Mark Ragucci beats
the odds to awake from a devastating brain injury, it’s no exaggeration to say they’ve been reborn.