DAVE DAVIES, host:
This is FRESH AIR. I'm Dave Davies, senior writer for the Philadelphia Daily News, filling in for Terry Gross.
If a relative has been in a deep coma for months, how do you know when it's time to let go? When a team of emergency room doctors and nurses work to revive a heart-attack victim, at what point do they give up and declare the patient dead?
My guest, Sanjay Gupta, says those questions are getting harder to answer as new medical treatments enable doctors to save and revive patients whose hearts have stopped beating for long periods of time or who've seemed brain dead for weeks. Gupta is a practicing neurosurgeon and associate chief of neurosurgery at Grady Memorial Hospital and an assistant professor at Emory University Hospital in Atlanta. He's also a medical journalist. He's a columnist for Time Magazine and chief medical correspondent for CNN. His new book is "Cheating Death: The Doctors and Medical Miracles that Are Saving Lives Against All Odds."
Well, Sanjay Gupta, welcome to FRESH AIR. I thought we'd begin with this remarkable story that you tell early in the book of this Norwegian skier who takes a plunge in the mountains and gets trapped in freezing water for something like two hours and manages somehow to recover. How?
Dr. SANJAY GUPTA (Associate Chief of Neurosurgery, Grady Memorial Hospital; Author, "Cheating Death: The Doctors and Medical Miracles that Are Saving Lives Against All Odds"): It is a remarkable story, even for someone like me who's been studying this for a couple of years, who's had the opportunity to travel around the world and talk to the foremost researchers in hypothermia, in extreme survival. This story is sort of the pinnacle of even that. This was a woman who has, I guess, the dubious honor of being the coldest-ever human being who subsequently went on to live. This is a woman who was declared dead in a hospital in Tromso, Norway, and now is a practicing physician at that same hospital.
She was found after she fell into a stream, a sort of frozen stream on a very cold place, and this is Tromso, Norway, which is north of the Arctic Circle in one of the northern-more points of Norway. What we know now is that she struggled for around 30 minutes or so. She was probably getting pockets of air, which is why she could last that long. And then she just stopped, and by the time they got her out of that frozen stream, she was dead. She had no spontaneous respiration. She had no spontaneous heartbeat. She had no blood pressure. Her pupils were dilated, indicating that her brain had become swollen. She was dead, and it was at this point that I think that a critical decision was made. The decision was to go ahead and leave her cold. The idea was that this cold could somehow be protective. It could somehow stimulate an almost hibernation-like reflex in the body. We know that there was no oxygen traveling through the body, but because she was cold, the body wasn't really demanding oxygen, either.
DAVIES: How cold was she? How cold was her body?
Dr. GUPTA: She was 13.7 degrees Celsius, so right around 55 degrees or so. And again, that's the coldest recorded temperature of someone actually surviving, someone surviving.
DAVIES: And how long did they decide to leave her in this hypothermic state?
Dr. GUPTA: Several hours. They did not warm her up at the scene, which is what often happens, even with blankets, and then warm saline and things like that. And they did not warm her up right away when she finally got to the hospital. They waited a few hours and then slowly, very slowly started to re-warm her using these temperature gradients, so just a few degrees at a time.
DAVIES: And what happened?
Dr. GUPTA: What happened is that, you know, they got her in there, and they realized that, you know, she really had no heartbeat. And sometimes you can't tell in the field, you know, it's tough to check a pulse, but now they have - they're doing an echocardiogram, directly looking at her heart, and she really has no heartbeat. So now they're very concerned, and they say we're going to slowly start to re-warm her, and we're also not going to give her any extra IV fluids.
One thing they learned is that when you start to go into this hibernation-like state from cold, from hypothermia, all your blood vessels become very leaky. They just leak fluid. So if you give a lot of fluid, that fluid starts to leak, and if it leaks into the brain or into the lungs, that can cause death.
So they gave no fluids, slowly re-warmed her, and then there was just this great moment where all of the sudden the heart, which was doing nothing - you had true, what's known asystole, that flat line on EKG, and all of a sudden it started to come back. And it was a magical moment as they described it to me when I was visiting them in Tromso, but I think they were still concerned that her brain had gone for too long without oxygen. How could the body tolerate this? But as I said, you know, she slowly recovered. At first, she was paralyzed, almost, in her entire body from lack of oxygen to her brain, but over a period of time, she continued to recover, finished her medical school, which she was a medical student at the time, and is now a doctor in that same hospital.
DAVIES: The subject that you discuss after this remarkable story really involves the use of hypothermia, chilling a body as a therapy, and if I understand what you're saying, that in many acute cases where someone has a heart attack or a severe trauma and looks as if, you know, they're going to die or maybe actually stop breathing, that deliberately lowering the body temperature can be - I don't want to use the word miraculous, but a remarkable therapy, right?
Dr. GUPTA: It really can, and you know, with this particular skier, obviously it wasn't intentional, but in some ways it was actually almost a perfectly executed form of hypothermia. The way her body chilled, at the rate that it chilled, they were able to piece that together, actually worked very much in her favor. They figured that out in retrospect. But every day, hospitals use hypothermia, for example when people are having certain types of open-heart procedures, having certain types of brain procedures, it is used. The idea is that, look, we know for a period of time, we're going to put the body in a state where it can't deliver. It can't do what it's supposed to do, at least the heart can't pump oxygenated blood throughout the body.
So we have a couple of choices here. One is - one of those choices is to reduce the demands of the body. Oh, not enough oxygen there? Well, let's make it so the body doesn't need as much oxygen. And that's sort of where hypothermia, among other things, sort of comes in.
DAVIES: Now, is this a technique that can be used by paramedics as they arrive in, you know, at medical emergencies around the country? Are they starting to use hypothermia as a therapy?
Dr. GUPTA: There's great literature on this now. If you're walking down the street, and you see someone have a sudden cardiac arrest, their chances of survival is very much related to a couple of different things.
One is if someone helps them. That greatly improves their chance of survival as you might imagine, a bystander, but also this idea of hypothermia. So paramedics now, in addition to having their medication bag and their medication bag and their defibrillators, and several cities now around the country are carrying these ice chests filled with cold saline, ice-cold saline, and as part of their therapy, right in the field, is to immediately start infusing this ice-cold saline to start to bring the temperature down.
So when you think about things like hypothermia, what you're really doing more than anything else is stealing away some time from death. You know, death and life are sort of battling it out at this point in some critical situation, perhaps after a cardiac arrest, and what you're saying is, you know, if we could only have a few more minutes, if we could only have a few more hours, the body's going to be able to recover from this. So let's buy a few more hours using something like hypothermia. That's one way to do it.
DAVIES: You also write that one thing that emergency medical personnel have learned is that you actually get better results when administering CPR if you leave out the mouth-to-mouth resuscitation. Why?
Dr. GUPTA: I found this to be one of the most fascinating things that I've really covered for a few different reasons. If I can back up for one second and just say that if you, you know, ask people, if they see someone, you know, collapse in front of them on the street, would they help? And most people will say yes in poll after poll, but that doesn't seem to translate to what actually happens.
People seem to not help as much as they say they'd like to. What we know is if someone has a sudden cardiac arrest and there's no bystander help, their chance of survival is around three percent. If someone helps, just jumps in and helps, that survival rate can go up by four to 500 percent, so a significant improvement.
When they ask people: Why wouldn't they help, what was the concern? And the concern really seemed to be more about mouth-to-mouth resuscitation. They were concerned A, that they didn't know how to do it, or they just didn't feel comfortable doing mouth-to-mouth resuscitation.
So these researchers say okay, well, let's sort of think about this and figure out models. Can we just create a chest-compression-only model, and if so, how would it work, and how effective would it be? And cutting to the chase here, after years of research, they figured out not only was it as effective as cardiopulmonary resuscitation where you're giving breaths, they found it was actually more effective.
And the reason is pretty simple. The reason is that if someone has a sudden cardiac arrest, they probably have a fair amount of oxygen already in their blood. After all, they were just breathing. So the oxygen is there. The key now, more than anything else, is to get that oxygenated blood moving through the body. So just call 911, push on the chest 100 times a minute and don't stop for anything. That seems to be the key. Move that oxygenated blood throughout the body, and then when the paramedics get there, you know, they continue the process until they get to the hospital.
DAVIES: Dr. Sanjay Gupta's new book is called "Cheating Death: The Doctors and Medical Miracles that Are Saving Lives Against All Odds." We'll talk more after a break. This is FRESH AIR.
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DAVIES: If you're just joining us, our guest is Dr. Sanjay Gupta. He is a neurosurgeon and medical journalist. He's written a new book about the line between life and death and medical efforts to reverse the effects of dying called "Cheating Death."
One of the more fascinating parts of this book involves brain death. You know, we've come to regard death as less a function of the heart stopping its beats than when the brain ceases to function. And you describe some treatments that have shown some remarkable results in reversing these, you know, persistent vegetative states that some patients are in. Give us an example of a case that illustrates some of these, you know, some of these new treatments.
Dr. GUPTA: Yeah, what we sort of realize is that this idea that the brain is really dead, you know, looking at an EEG, for example, which measures electrical activity of the brain and seeing it as silent or not having any activity, may be not that good of a measure after all, or even showing low blood flow to the brain or no blood flow to the brain, may be not a very good measure. There's a few stories in here that I think really gave me a lot to think about when I heard them and then researched them and then validated them, where patients could describe with surprising accuracy exactly what was happening around them and to them at a time when doctors thought that they were brain dead.
The hypothermia, which we talked about earlier, was something that seemed to make a difference with patients who we thought were brain dead and subsequently made a recovery. Putting the brain to sleep again, with the combination of cold and some medications, really seemed to make a difference.
DAVIES: Just to - we're talking about cases where someone has had a severe head injury or perhaps a heart attack and have lost blood flow to the brain, and their brains appear not to be functioning. You're saying that in cases like this, where it appears there is no hope, and this person lying in the bed, maybe on a ventilator, is never going to come back, we're never going to see them, there are cases where interventions have actually produced a reversal of these? And you said one of them is hypothermia? I mean, they chill the body, chill the brain? How does that work?
Dr. GUPTA: Yeah, that's exactly right. They chill the brain, and it works in a sort of amazingly simple way. I mean, they literally take ice packs and wrap it around the person's body. They use cold saline, injecting it into the bloodstream, and they sort of put the brain into a deep chill. That's essentially what they're doing. And with that, they're hoping for two things. One is that the brain will repair itself, if there was some sort of traumatic injury during that time, but also they're sort of turning the brain off for a while. You know, they know that the brain doesn't like even a small amount of time without getting lots of nutrient-rich blood bathing it, and if you, you know, turn it off, it doesn't really need that blood anymore. So those are sort of the two basic principles of that.
But I think, you know, this idea that there are patients that we say okay, they're brain dead, and in the United States that means they're dead. In different countries, it means different things, but we use brain death as a criteria here in the United States. And then I go talk to these patients. I've looked through their charts. They were declared brain dead. It was written in their chart as such. And here they are, sitting up talking to me. Hypothermia probably played a role. Medications probably played a role, but I think the larger message to me, and what I really spent the last couple years thinking about was we don't really know when to give up. And we really don't know what dead really means. We thought we did, but here this guy is talking to me, and you know, a bunch of people with crisp, white coats and hundreds of years of medical experience combined all urged this man's wife to pull the plug because they didn't think he'd ever recover, and here he is talking to me. What is dead? That's what I kept sort of stumbling upon and trying to figure out.
DAVIES: Yeah, I mean, that really has very profound implications. I mean, anyone who is lying there and appears to be gone, I mean, you know, if their body is in shape, but the brain isn't functioning, how would you know when to ever give up treatment?
Dr. GUPTA: And that was a really difficult thing for me to tangle with in the book because I'm not trying to malign doctors or certainly indict anybody. That's not the purpose at all, and obviously, there are lots of patients who really won't recover. I think for the most part, the system works well, but there are patients who do make these really astounding recoveries, and the question - you could just call them a miracle or an outlier or say, you know, we don't know and chalk it up to that, or you could say let's really dissect down why this person lived and is functioning so well when so many others wouldn't. What is it about them? Is it about them, or is it about the techniques, or you know, what were all those micro pieces that came together to create this remarkable recovery?
DAVIES: And do you feel like, you know - you're a neuroscientist. I mean, are folks getting a better handle on what's happening and how they can tell when someone will recover and when they won't?
Dr. GUPTA: They're starting to get a better handle on it, but I think that there's - you know, as often happens in medicine, with some more answers come a lot more questions. This idea that people's brains continue to work and continue to process things, even at a time when we think it doesn't or that we even think that it's dead, really I think in many ways is blowing the lid off of what we know about neuroscience.
There was a great story of a woman in England who was, you know, essentially considered to be in a persistent vegetative state. And they put this woman in what's known as a functional MRI scanner. That's a scanner that measures the activity of brain. It shows where certain parts of the brain are lighting up, and as you'd expect when they first did this MRI scan, there was nothing lighting up. This woman was in a persistent vegetative state. Then the doctors, the researchers in this case, decided to ask her a few questions, and one of the questions they asked her was about tennis. They knew that she liked to play tennis. So they said to her - again, this woman who to the world was doing nothing. She was, you know, just lying there. They said imagine playing tennis. What would you do? How would you hold the ball? How would you hold the racquet? What would you do exactly?
And they saw something that I think probably stunned them into silence, and that is that the motor areas of the brain started to light up. This woman, who they thought couldn't hear a thing, was doing nothing, she was imagining playing tennis because they asked her to do it. The motor areas, the exact area that you'd expect to light up, was doing just that, and I think that we're just starting to learn more and more about what the brain is capable of doing, even when we think it's doing nothing.
DAVIES: Right. That also meant that she was hearing and comprehending what they were telling her when she could do nothing in response.
Dr. GUPTA: Yeah, that's exactly right, which shows an executive level of function of the brain. When I delved into it, and I talked to these researchers specifically about it, they said look, you know, you go around to any place in the world and look at these diagnoses, persistent vegetative state, you know, coma, all that sort of stuff, you go to nursing homes where elderly people are given this diagnosis, and you'll find that about a third of the time, the diagnosis is wrong.
I mean, inherent within the definition of persistent vegetative state is some idea of permanence, this idea that it's persistent, but in fact, these patients can recover. We don't know why for sure, and we don't know exactly how, but they can. I think these terms are probably terms that we shouldn't be using because we don't know exactly what's persistent or permanent by any means.
DAVIES: Do you speak to patients differently now that you know some may be hearing you that you didn't think weren't?
Dr. GUPTA: Yes, I do, and it's been a conscious decision really over the last several months because I needed to convince myself. You know, I wasn't cynical about whether this could be happening, but I was a bit skeptical. And I started to read a lot about this, and more than reading the scientific literature, which I, you know, spent a lot of time doing, just talking to these patients and really convincing myself that look, this wasn't by chance. Some of the stories - it just couldn't be. I mean, someone remembering exactly where a doctor placed his glasses when he was thought to be brain dead. They couldn't find his glasses. When he finally recovers, he says: I know where my glasses are. They're over here. How could he have known that? You know, the only way he could've known that is if he was actually processing things at the time that the doctor in a rush, sort of, hid those.
So after I convinced myself, I do talk to patients now who otherwise would be considered either in a persistent vegetative state or having a really, really low coma scale, meaning that, you know, they're not interacting or able to process anything as far as we know. I behave differently around them now.
DAVIES: I can't let you go without asking you what it feels like not to be the nation's surgeon general.
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DAVIES: You were - you know, it was widely reported that President Obama spoke to you about becoming surgeon general earlier this year.
Dr. GUPTA: Right.
DAVIES: And it was reported you looked as if you might be taking it, and in the end, you said, you know, the demands of your professional life and a desire to be with your family kept you from serving. Do you look back and wonder what you might be doing? I mean, you know, never has health care been a more - you know, more of a public issue than it is today.
Dr. GUPTA: Yeah, well, you know, I'm a big fan of public service. I have been a public servant before. I've worked at the White House. You know, I don't live in the world of regrets by any means, and for me, this was a very personal decision. You know, I have three young children. I would've been a commuting dad for a few years.
One of the things that I didn't realize as I was going into the process was that the surgeon general cannot practice surgery anymore. You know, I'm 39 years old. I thought that, you know, if I didn't practice for four years or eight years - depending on what happens with President Obama - then I wouldn't be going back to being a neurosurgeon, and I just didn't think it was the right thing for me. I like being a doctor. I like taking care of patients, and sure, you know, there's sometimes a little bit of wistfulness, but I don't think there's any regrets about it. This was a personal decision, and you know, my family and - we're very happy with it.
DAVIES: Well, Sanjay Gupta, thanks so much for spending some time with us.
Dr. GUPTA: It was a lot of fun. Thanks for having me.
DAVIES: Sanjay Gupta is a neurosurgeon at Grady Memorial Hospital in Atlanta. He's also a columnist for Time Magazine and chief medical correspondent for CNN. His new book is "Cheating Death: Doctors and Medical Miracles that are Saving Lives Against All Odds." I'm Dave Davies, and this is FRESH AIR.
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