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. Doctors
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.
Hibernation seems to be caused by different factors, depending on the animal, but cold weather is a common trigger. Take ground
squirrels, for example. As soon as temperatures dip below freezing on a regular basis, ground squirrels go into a near-complete
torpor. Their heart rate, usually around two hundred beats per minute, slows to less than ten. The squirrel’s body temperature
will drop from a warm-blooded 37 degrees Celsius to just one or two degrees above the outside temperature. They stay in that
state, using just a bare minimum of energy, for at least six months.
5
True, humans aren’t squirrels, but believe it or not, we have some of the same adaptive ability. For example, immersion in
cold water triggers something called the mammalian diving reflex. You could think of it as throwing the body into a state
of semi-hibernation. Blood flow is shunted from the extremities to the heart and lungs, breathing slows, and the heart and
brain use less than half of the oxygen they normally require. Survival time is stretched out.
B
AGENHOLM COULDN’T HAVE
known it at the time, but as the helicopter prepared to land, her life was about to intersect with a doctor who in one way
or another had been preparing for this moment all his professional life. The director of emergency services at the University
Hospital in Tromso was Dr. Mads Gilbert. Like his patient, Gilbert is a daredevil, a risk taker, enjoying off-piste skiing
and trekking through the wilderness. He loves action; he loves riding the emergency helicopters that serve as ambulances for
much of the far-flung, mountainous stretch of coastal Norway that surrounds his home base. In fact he had taken off in the
rescue chopper to treat Bagenholm in the field, and only turned back when he learned that a larger, better-equipped helicopter
was closer to the scene.
Gilbert spends his vacation time in places like Burma and Kurdistan, teaching emergency medical techniques to people who don’t
live anywhere near a hospital and doctors who have to treat battlefield wounds with only the barest medical kits. He had a
brush with worldwide fame in 2008, during Israel’s offensive in the Gaza Strip. Gilbert was interviewed inside a Gaza hospital,
where he helped to treat wounded fighters and civilians. He accused Israel of deliberately killing civilians and in turn was
denounced by conservative critics who called him a “Hamas apologist” and a “shill for terrorism.”
6
In other words, Gilbert is not a man who shies from controversy, whether the debate is over politics or medicine. That was
true long before he started turning up in global hot spots. Some might consider his risk taking dangerous, even reckless,
but in Bagenholm’s case, it was exactly what she needed. Many other doctors would have given up, and for good reason. Taking
stock of his new patient, Gilbert told me he knew that she didn’t look good. “I saw this very, very athletic young girl. But
she looked like a corpse.” By the time Anna Bagenholm was wheeled into the operating room, she had been clinically dead for
three hours.
When I first read about the Bagenholm case, I imagined a daring physician, attempting extravagant new measures on behalf of
his beautiful, hopeless patient. I imagined only sheer desperation would drive someone to that brink of attempting the impossible.
As it turns out, only some of this is true. The effort to save Bagenholm did in fact stem from desperation, but it was not
so much a matter of luck as careful guesswork and experience.
Before the Bagenholm rescue, Gilbert says his team had made at least fifteen previous attempts to resuscitate patients with
no pulse and severe accidental hypothermia.
7
They were fishermen or skiers or hikers who had fallen in the sea or through ice, or gotten trapped under snow, or simply
become drunk and lost in the woods until they nearly froze to death. When I asked Gilbert how many of those patients had survived,
he looked away for a second and then replied thoughtfully, “We hadn’t succeeded with a single survivor, but we were getting
closer and closer.” He told me, “In fact, the person just before Anna was in some ways an even more dramatic story.”
Just a few months earlier, Gilbert had flown a risky helicopter mission to the scene of an avalanche that had buried another
skier, a young university student. The student and a companion had set off the avalanche while telemarking down a pristine
snowfield near the base of Ullstinden, a popular ski mountain just north of Tromso. The student’s companion managed to avoid
the collapse and made it down to the road to seek help. In the meantime, two young skiers who had seen the accident from above
made it down to the scene and began to dig.
Gilbert’s rescue chopper arrived within the hour, but the side of the valley was too steep for it to land, so the helicopter
touched down on a ridge several hundred yards above. Gilbert, a nurse, and a local police officer clambered down the side
of the valley. By the time they reached the victim, only his ski pole and one of his arms were visible. It took some time
to set him free and then start CPR. A long time had passed; perhaps too long.
The situation was dire. The young man had no pulse, and they would have to wait for a rescue; the snow was too deep and unstable
to carry out the victim on a pallet. For three hours in the bitter mountainside cold, Gilbert’s team pressed ahead with resuscitation
efforts. While Gilbert adjusted the breathing tube and pumped the young man’s chest, a colleague lit the emergency stove from
the camping set and boiled tea to keep them warm. The patient, on the other hand, was kept cold. Every five minutes, the team
members would switch places.
When the helicopter was finally able to land, they got the unconscious student up the steep mountainside on a sledge, stumbling
through the dark while shivering at the thought of another avalanche. Once on board, they continued CPR, all the while taking
care not to raise the patient’s temperature. Only after arriving at the hospital did they hook him to a bypass machine to
warm him up. Miraculously, the student’s heart regained a beat. What’s more, his kidneys and lungs had started to function,
and his pupils once again shrank in response to light, a sign that his brain was not irreparably damaged. “We were so completely
excited,” recalls Gilbert. “Very, very, very excited. We thought, ‘We finally did it!’ ”
The young man continued to do well for about two days, but then he took a sudden turn for the worse. In a matter of hours,
his brain was crushed by an overload of fluid. In the cramped space of his skull, the pressure was too much, and he died.
Gilbert and his team were devastated. They had been so close to a miraculous success, only to have it end the way others had.
“I was crazy. I just thought, what did we do wrong? Why were we unable to prevent swelling of the brain?” he said.
As they did after every intensive effort, his team gathered to compare notes on similar cases. Looking back at fifteen similar
cases, Gilbert saw that edema, or swelling, was a common problem; the young man had survived longer, but he was not the first
to suffer fatal brain swelling after getting back a heartbeat. Gilbert suspected that these half-frozen patients were particularly
susceptible. For one thing, hypothermia essentially acts as a blood thinner, so the patients were prone to internal bleeding.
But something else was happening that was even more critical. These patients had all suffered cardiac arrest due to hypothermia
or been partially suffocated by avalanches or submerged under ice. One way or another, their brains and bodies had been starved
of oxygen.
This is where it gets a little tricky and maybe counterintuitive. In effect, these patients were probably all suffering from
varying degrees of something known as reperfusion injury. Reperfusion injury is the name for the damage that takes place when
oxygen is reintroduced to oxygen-starved tissue. Normally, reintroducing oxygen is good, but with reperfusion injury it seems
to set off a complex chain of damaging chemical reactions. The exact mechanism isn’t clear, but Gilbert says that cell membranes
throughout the body tend to become more permeable—in other words, they start to
leak fluid
—and that is the major cause of swelling.