Cheating Death (6 page)

She told my team she never despaired, even in the darkest days when she was still paralyzed in intensive care. “As a doctor,
I understood a lot of things that were happening. I knew there was no spinal cord damage. I just waited to see what would
happen. I focused on slowly getting better, trying do to the things I could. I never thought about not going back to work.”

Gilbert maintains that the rescue was no miracle: “It’s the simple things, not the complicated things.” Success came not from
any high-tech solution, but from fifteen years of hard work and intuition honed by trial and error. “It was the whole system,
from the way we interact with local resources to the way we include the hospital at the end,” said Gilbert. “We’d had mistakes
with other patients. We nearly succeeded, but lost them. By the time Anna came in, we’d adjusted some of the treatment… .
The team on call that very night was a very well-geared team, tightly woven, with a strong spirit and optimism.”

Bagenholm still goes hiking and skiing on a near daily basis. She and Gilbert are friends. In fact, the day he finally shared
the full details of Bagenholm’s case, he had just spent the weekend with her and a close friend, skiing on the same slopes
that sparked the frustration and inspiration for his most famous rescue.

And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his
hands: and stretched himself upon the child; and the flesh of the child waxed warm.

—2 Kings 4:34,
KJV

M
IKE MERTZ WAS
driving home, an hour after finishing his run as a school bus driver in Glendale, Arizona. He told me he doesn’t remember
why he didn’t come straight home from work that day. He thinks that maybe he went for a jog. A trim fifty-nine years old,
Mertz enjoyed a two- or three-mile run several days a week. Maybe he was looking for a cheaper gas station than the one on
his usual route or was just trying to avoid taking his Saturn over a nasty set of new speed bumps. Whatever the reason, whatever
route he wandered, it brought Mertz not to the usual entrance of his townhome complex, but the back driveway.
¹
The change in routine may have saved his life.

Corey Ash, a UPS driver, was making deliveries that Wednesday afternoon, when he heard a terrible engine noise. Thinking the
sound was underneath his own hood, he pulled over. Hopping out, Ash immediately realized that it was coming from a Saturn
almost directly across the street.

It was an accident scene. The small silver car was piled up against a palm tree, the engine revving at top speed. The only
thing keeping it in place was a stucco wall a few feet from the tree; the car was wedged between the two. Racing over, Ash
could see that the driver had his eyes closed and seemed to be unconscious. The driver’s foot was wedged against the accelerator.
Ignoring the chance that the car might break free and crush him, Ash reached across the slumped body and turned off the ignition.
He dragged Mertz out of the car and laid him on the ground. After dialing 911, Ash started CPR the way he’d learned during
an Air National Guard training exercise just two months before.

As he listened to the ambulance siren, racing up the road from Glendale Fire Station 154 barely a mile away, Ash began to
pump hard on Mertz’ chest. Studies show that when a bystander jumps in, the chances of survival in a cardiac arrest case increase
exponentially. Even though it may not seem like you are accomplishing much, simply pushing the heart and circulating the blood
can make a tremendous difference. Mertz had that going for him, but he was also fortunate to have collapsed in Glendale. Paramedics
there are at the forefront of a revolution in emergency care. With a few simple measures—going against the grain of the medical
establishment—they have found that they can radically improve the odds of surviving a cardiac arrest.

The fire engine pulled up with a screech, and a brawny firefighter named Ruben Florez jumped to the curb. As fellow firefighters
scrambled down, Florez thumped an urgent rhythm on Mertz’ chest, two hundred compressions over two minutes, before a medic
stepped in and delivered an electric shock from the paddles of a defibrillator.

Then came another two hundred compressions, then shock, two hundred compressions, then shock. Finally, after six hundred thumps
and three defibrillator shocks, a weak pulse returned. Mertz was back from the dead. At no point was mouth-to-mouth resuscitation
performed, and at no point did Mike Mertz get a breath. Surprisingly, that may be the
real reason
he survived.

In reality, survival from cardiac arrest outside the hospital is rare. Until very recently, Arizona was in line with the rest
of the country—only about 2 percent of the victims pulled through without long-term damage.
²
But in 2005, cities around Arizona began doing something new. It went against the guidelines of the American Medical Association
and the teaching practices of major medical schools and hospitals. This new method didn’t look like the CPR that had been
taught in every YMCA, firehouse, school, and church ever since the 1970s. In short, it was a radical experiment.

The experiment sprang from two lines of thinking: animal studies aimed at modifying CPR technique and a public health effort
to train more people in CPR. If your heart gives out while you’re walking down the street, the number-one thing that can save
your life is to have a bystander who is not only trained in CPR, but willing to help. Unfortunately, such help is rare. Published
studies put the rate of bystander CPR at around 20 percent.
³
If you dig deep, the number really has nothing to do with the lack of desire. Instead, study after study shows people are
apprehensive about putting their mouth on someone else’s and maybe catching an infection from someone who’s on the ground
dying.

Now, the reluctance can be overcome. In Seattle, which has run massive training programs and public education campaigns since
the 1970s, the rate of CPR assistance from bystanders is close to 50 percent.
⁴
That one fact gets much of the credit for the city’s high survival rate from cardiac arrest. In recent years, a driving goal
of the American Heart Association has been to encourage more members of the public to jump in and help. But how? There was
simply no getting around mouth-to-mouth resuscitation. Or was there?

Cardiologist Dr. Gordon Ewy, and his team at the Sarver Heart Center in Tucson, had been doing CPR experiments for more than
twenty years. Their focus was to try to understand the role that artificial breathing plays in emergency resuscitation, and
for more than a decade, much to the consternation of the powers that be, Ewy had argued that breathing was nearly irrelevant.

Ewy is cantankerous and opinionated, and he’s sure those opinions are right. In other words, he’s like a lot of heavyweights
in academic medicine. In professional stature, Ewy is decidedly a heavyweight, even if his office is thousands of miles from
any ivy-covered wall. After graduating from the University of Kansas, he completed a medical residency at Georgetown. After
finishing his training in Washington, D.C., in 1971, Ewy headed west to help launch the University of Arizona’s new teaching
hospital in Tucson. He’s run the cardiology department since 1990, which makes him the longest-serving chief of cardiology
in the United States.
⁵

Ewy first got interested in CPR research as a way to fine-tune guidelines for the public. For years, studies have shown that
people are much more willing to do a simplified version of CPR—if you tell them to stick with chest compressions and don’t
worry about the mouth-to-mouth part. To Ewy, that itself was more than enough reason to support a change in guidelines. But
as he took a closer look at the data, to make sure a modified technique would still be reasonably effective, Ewy started to
notice something else, something strange. The survival rates for people getting chest compressions alone weren’t only as good
as people getting full AHA-approved CPR, they were better. Almost by accident, the public health campaign had stumbled onto
a medical discovery.

To understand Ewy’s theory about CPR, you have to know about the three-phase model of cardiac arrest, developed by our friend
Dr. Lance Becker from the University of Pennsylvania’s Center for Resuscitation Science and Myron Weisfeldt of Johns Hopkins
University.
⁶
The three distinct phases are electrical, circulatory, and metabolic. The first lasts approximately four minutes, during
which time the heart still pulsates with its own electrical energy, even as it fails to generate a coherent, blood-pumping
rhythm. The ensuing circulatory phase lasts from approximately four minutes after cardiac arrest until the ten-minute mark.
Whatever oxygen was present in the blood has been consumed, and without oxygen, the heart can no longer generate electrical
energy. The absence of oxygen also triggers dangerous chemical reactions throughout the body, as cells turn to sources of
stored energy. At a certain point—about ten minutes after cardiac arrest, assuming there is no intervention—the cascade of
cell-killing chemical reactions reaches a crescendo. This marks the third step toward death, the metabolic phase. It’s during
this time that cell death begins in earnest.

The model helps explain why some interventions do work. During the electrical phase, defibrillation is highly effective; after
that, not so much. That’s because defibrillation doesn’t restore electricity to the heart; it just resets the rhythm. For
it to work, the heart needs to have enough energy present to resume beating once given the chance, like a car battery with
enough juice to still take a jump. No matter how hard you try, you can’t restart a completely dead battery.

When you perform CPR, you are in effect sending oxygenated blood to the heart tissue—sort of like kindling to catch the electrical
flame of a defibrillator. In traditional CPR, bystanders and paramedics alike are trained to start by checking to see that
the airway is clear and to alternate compressions with rescue breaths—mouth to mouth. Paramedics are trained to insert a breathing
tube, as well. The artificial breaths are supposed to add oxygen to the blood, and chest compressions are meant to circulate
that oxygen. What Ewy realized is that some of that effort might be wasted. From the three-phase model, we see that when breathing
ceases, for several minutes there is still a good amount of oxygen sitting in the bloodstream. The human body stores far more
oxygen than we are generally aware of, and that oxygen lingers for some time after we’ve actually stopped breathing. Therein
lies an important lesson that turns conventional CPR on its head: maybe, just maybe, those artificial breaths aren’t necessary.

The thing is, in order to help, that oxygen has to circulate in the blood. If your heart has stopped, the oxygen can only
circulate if someone pumps the heart artificially, by compressing the chest. When you pause to give an artificial breath,
you’re not pressing on the chest. The same goes for inserting a breathing tube, a sometimes awkward process that usually takes
anywhere from twenty to thirty seconds.
⁷
Even after administering a shock, you’re supposed to wait and read the heart rhythm, to see if the shock has worked—and try
again, if needed. All these extra steps, says Ewy, waste time. Precious time that has cost too many lives.

You don’t need the three-phase model to understand that time is at a desperate premium after cardiac arrest. Every second
is critical. According to the American Heart Association, for every minute that goes by without someone attempting CPR or
defibrillation, the odds of survival decrease by 7 to 10 percent.
⁸
If ten minutes go by, survival is a long shot. Delay means more than just a lower chance of survival. Every moment without
oxygen increases the chance of brain damage should the victim survive. The heart itself is also at risk; as cardiologists
like to say, “Time is muscle,” heart muscle. Even if a patient survives with brain function nearly intact, extra minutes without
oxygen means more dead heart tissue, increasing the severity of cardiovascular disease and the risk of a future heart attack.

In Ewy’s view, getting blood and oxygen moving—-compressing the chest—is virtually the only thing that matters. In theory,
all the extra steps and equipment are lifesaving, but Ewy felt they could just as easily be distractions. In fact, when the
city of Seattle initially put defibrillators on their ambulances, survival rates for cardiac arrest actually went down.
⁹
It’s not because defibrillators are a bad idea, just the opposite. But anything that slows down the process of CPR poses
a new challenge. “If you stop for anything, it’s a disaster,” Ewy likes to say.

With a mix of admiration and exasperation, Dr. Ben Abella, who works with Becker as research director at the Center for Resuscitation
Science, calls Ewy a zealot for chest compressions. It’s an accurate description. The takeaway message from Ewy is if you
see someone fall to the ground after a cardiac arrest, just start pushing on the chest as fast as you can. To emphasize the
goal of preserving full brain function, he dubbed the method CCR, for cardio-cerebral resuscitation.

In the lab, the Sarver team, led by Ewy and cardiologist Dr. Karl Kern, did controlled experiments with animals. In 1993,
they compared research subjects who received only chest compressions during resuscitation from cardiac arrest to subjects
who received artificial breaths along with the compressions. The animals who got only compressions didn’t just do as well,
they did better.
¹⁰
After publishing those startling findings, the team kept plugging along. Between 1993 and 2002, they conducted six more studies
with pigs, comparing CCR (chest compressions only) to CPR with artificial breaths. They all found the same thing: the breaths
provided no extra benefit.
¹¹