Although his eyes were closed and there was no obvious indication that a spirit flickered behind them, the rest of his body
had been the site of a raging battle for several hours. Barazanji’s skull had a hairline crack where his head had struck the
side of the treadmill from which he fell. Between that blow and the lack of oxygen from his cardiac arrest, the cells and
tissues of his body were bruised and swelling in agitated response—most alarmingly, in his brain.
For Raoua Barazanji,
12
it was terrifying. Her husband lay as if asleep, pale machines and tubing bristling, it seemed, from every inch of skin.
She could read the concern on the faces of the doctors who stopped by his bedside. Dr. Stephan Mayer had started Barazanji
on the non-FDA approved hypothermia. Cooling pads were wrapped around Barazanji’s arms and legs, and he was strapped into
what looked like a padded vest—each compartment filled with cold liquid, cooling the fire that raged in every tissue of his
body. Old cells would need to heal; new ones would need to grow. It would take energy and time. The cooling would help buy
that time.
Mayer had promised Raoua and the patient’s niece that he would try everything, but even Mayer was not optimistic. Like many
patients whose brain goes without oxygen for an extended period of time, Barazanji’s brain was being rattled by seizures.
It was frightening to watch the normally calm professor’s body being wracked by uncontrollable shakes. Soon these seizures
were coming every few minutes. It was quickly becoming a life-threatening condition called status epilepticus.
Status epilepticus is the uncontrolled firing of neurons in the brain. Our nervous system is made of neurons, forming the
grid that carries all the information that our brains send out and receive, whether it’s working out a math equation, telling
a finger muscle to start wiggling, or feeling pain when that finger is pricked. The signals are transmitted across synapses,
minute gaps between the neurons. An electrical charge causes the release of chemicals that bridge the gap. To function, neurons
require a brief period of rest to recharge the supply of chemicals. In a brain gripped by seizures, that rest never comes.
Unchecked, the condition is a death spiral. A brain that’s continually seizing is constantly burning fuel, burning energy.
As a rule of thumb, if status epilepticus continues for more than an hour, neurons start to die and the patient with them.
To stop the electrical frenzy, to keep the brain circuits from burning themselves out, the Columbia physicians gave Barazanji
a massive dose of the sedative propofol. Over the course of an hour, the brain waves on the EEG monitor turned from a spiking,
storm-driven sea to shorter, gently rolling swells. Barazanji was in a deep, medically induced coma. As Dr. Mayer, the chief
neurologist, explained it to Raoua, sedation along with the cold was just like wrapping the brain in cotton to let it heal.
The neurons would have a chance to rest, a chance to recharge and recover. Or so they hoped.
I
T WAS ON
this same floor, five years earlier, that Mayer met the patient who forced him to rethink his whole approach to neurointensive
care. Mayer first heard about Mark Ragucci when he got a call from Ragucci’s wife, Laura. A doctor like her husband, she crisply
laid out the situation. Mark had already been in a coma for more than two weeks at another New York hospital. The physicians
there, she said, were “laying the crepe,” as doctors sometimes say about cases deemed hopeless. The family wasn’t happy. They
wanted to give Mark every possible chance of survival. Moved by the strength of the request, Mayer agreed to take a look.
“We did something in our unit that we never ordinarily do,” said Mayer. “Usually, we only transfer patients from other hospitals
if we think there’s something we could do to help them that they can’t get at their present hospital.” Mayer paused. “In this
case, we really didn’t think we had anything to offer.”
Although he agreed to take the case, Mayer privately agreed with the assessment of the other neurologists. He too thought
that if Ragucci somehow made it out of the hospital, he would live out his days in a futile, eyes-open coma. Beyond the grim
clinical picture, Ragucci’s MRI images were the clincher. A healthy brain scanned by MRI looks like a symmetrical sculpture
of grays and black. On Ragucci’s scan, there were half a dozen large white blotches scattered around the picture. Two of them
lay just two inches behind his eyes, the largest about the size of a quarter. Ragucci had holes all over his brain. Each white
blotch was dead tissue, the cells burst open, destroyed by a lack of oxygen. For a neurologist, the writing was on the wall.
The patient would not survive without never-ending artificial respiration and a feeding tube. Not a life that anyone would
want.
The ambulance delivered Ragucci to Columbia the week after Christmas. Bad as the prognosis was, it can be hard to make long-term
predictions about brain-damaged patients—at least, in the first few weeks of their condition. That meant there might be a
tiny sliver of hope. Mayer told me, “When he got to Columbia, on exam he was brain-dead. His EEG was flatline. But we had
no idea how much of that was irreversible brain damage and how much was the anesthesia.” To get a better sense of things,
Mayer wanted to take more MRI scans. But when Ragucci’s mother and wife heard that Mayer was booking the imaging suite, they
confronted him: no more MRIs. If the scan looked hopeless—and they suspected it would—it would take away any shred of motivation
that doctors had to keep treating him.
“They said, ‘We know what you’re going to see. It’s going to be bad. And then you’re going to use it as some kind of ammunition
to argue that we should withdraw care, and we’re not going to do it,’ ” Mayer says. He shrugged and told them he would do
his best.
T
HE REST OF
the story can speak for itself—literally. My team met Ragucci six years later in an ornate, borrowed conference room at the
Rusk Institute in New York City, one of the premier rehab hospitals in the country. Outside, patients shamble down the cheerfully
shabby hallways, but Mark Ragucci isn’t one of them. He was once, but today he’s a doctor in a beige suit and a crisp white
physician’s coat. As a rehab specialist, he helps to restore the minds and bodies of patients facing long-term recoveries—anything
from broken legs to paralyzing strokes. When he’s with a patient, he talks to them constantly, guiding them earnestly and
gently, even those who supposedly can’t hear a thing.
Dr. Ragucci tells his story in a soft, almost apologetic voice, but I can see the same kind of stubbornness that his family
showed the doctors at Columbia. By his own account, he was always that way. A wrestler in high school, Ragucci brought a wrestler’s
intensity to his studies at the University of Illinois, where he earned his undergraduate degree and then finished his medical
degree at the College of Osteopathic Medicine. He met his wife Laura in medical school, where she was training to become a
pediatrician. By the fall of 1997, they were engaged to be married and doing their respective internships at Cook County Hospital
in Chicago. But then, about halfway through his training, Ragucci got a shock. He learned he had a congenital heart condition.
Ragucci has told the story often enough that he can recount it in sharp detail, as if giving a clinical presentation: “I had
my first aortic dissection on January 2, 1998.” He says the date with a note of defiance, maybe a remnant of the frustration
of the coma patient he was, struggling to hold a thought in his head, or maybe it’s just the preciseness of his medical training.
In any case, the trouble started with a stabbing pain in his chest, as Ragucci was working out at the gym, fighting through
a bout of insomnia between long hospital shifts.
Internship is the most demanding year that physicians will ever experience, and it was no different for Ragucci. Cook County,
which in 2002 was renamed John H. Stroger, Jr. Hospital of Cook County, is iconic enough to have served as the model for television’s
ER.
Large public hospitals are perfect medical training grounds, because they bring in patients with every variety of serious
illness and injury, and most of the patients are poor—they have no choice but to endure the probing of medical students and
new doctors. Of course, the training is well supervised. Hospitals like Cook County are elite training grounds as well as
public medical facilities, and many of its senior physicians are professors at Rush Medical College.
The stress was intense. Ragucci says he regularly worked more than ninety hours a week, often staying awake nearly two days
straight. As if that weren’t hard enough, Ragucci had insomnia. The day his heart troubles began, he found himself sitting
alone in his Oak Park apartment, after a twenty-four-hour shift followed by several hours of paperwork. “I was postcall, and
I hadn’t slept in about thirty-two hours. [Laura] was on call at the hospital. I couldn’t sleep. So around three or four in
the afternoon, I decided to go to the gym,” said Ragucci.
But it was no relief. Struggling against a heavy weight, he felt a pain deep inside his chest. “I was twenty-seven years old
at the time, and my first thought was, ‘what the hell would I be having a heart attack for?’ ” recalls Ragucci. “So I waited
about forty-five minutes in the locker room until the pain went away. Then I went home. I know that’s probably not the smartest
thing to do,” said Ragucci.
“Once I got home, I called my mom—that’s what you do in these kinds of situations.” He paused to smile. “She said to call
911.” It was January, and Chicago was digging out from a blizzard; still, Ragucci decided to walk to the hospital. He tells
us he climbed over snowbanks higher than his head to reach the emergency room entrance. He found it inconceivable that he
could be anything but healthy. “Going over the snow, I remember thinking, ‘Hey, I’m fine,’ ” he said.
But inside, an EKG test was abnormal enough to alarm the attending physician. The next test, an echocardiogram, or “echo,”
uses ultrasound to detect abnormalities in the heart’s structure. Ragucci recalls a growing sense of dread as he waited for
the news—a feeling that was soon justified by the results.
“I don’t really know how to read an echocardiogram, but I could see that wasn’t good at all,” recalls Ragucci. “My aortic
valve was floppy.” The aortic valve separates the left ventricle, the chamber where blood first enters the heart, from the
aorta, the exit chamber. Many patients with the condition show no symptoms or just a bit of fatigue. Many live happily without
ever knowing that something is amiss, but if the valve is more deformed, it can cause irregular heart rhythms or even sudden
death. Ragucci’s test results were so alarming, the cardiologist at Cook County recommended immediate surgery.
Ragucci is not prone to outer turmoil or emotional displays. He doesn’t smile much. His curly hair is cropped short and graying
at the temples, and though he looks to be in excellent physical condition, his serious aspect comes across as older than his
thirty-six years. Even as he described what was probably the most frightening day of his life, his tone was flat, almost clinical.
“I think I’d just stressed my body too much,” he said. Between lack of sleep, the rigors of medical training, and his insomniac
gym workout, he had literally pushed himself to the brink of death. Of course, while many people keep crazy hours, Ragucci
had something else working against him, genetic susceptibility. An uncle had died suddenly in his mid-thirties, presumably
of heart trouble, although no autopsy was performed and the cause of death was never determined.
Fortunately, the open-heart surgery was a success, and Ragucci returned to work just six weeks later. Driven as ever, he pushed
ahead with his medical training. He made no concessions to his new status as a heart patient, except for regular checkups
by a cardiologist. It was nearly four years later when that cardiologist once again gave him bad news.
This time he said that scar tissue around the original valve repair was expanding, the way a garden hose starts to bulge around
a tiny puncture. It could only be fixed by replacing the valve with a mechanical one. It was elective surgery technically,
but as the cardiologist made clear, it was not really a choice. “They call it a semielective procedure,” says Ragucci, “but
what that means is that you have to do it or you’re going to die.”
By then, he was living in New York City, finishing his training in the specialty of rehab medicine. Though serious, the second
open-heart surgery was supposed to be routine. The rate of serious complications for valve replacement surgery is only about
one in fifty, and few of those complications are life threatening. Routine preoperative tests, leading up to the surgery,
found nothing unusual. But there are no guarantees in medicine, and Ragucci fell on the wrong side of the odds.
“I still don’t know what happened. No one does,” Ragucci told me. “I figured I’d be home for the holidays.” The operation
was performed December 3, 2001. At first everything was routine, but then it wasn’t, and all hell broke loose. Something caused
Ragucci’s blood pressure to drop precipitously, and the surgeons struggled to maintain the pressure. The surgery dragged on,
close to twelve hours. Then Ragucci began to seize. In the recovery room, it was clear that something was wrong. The seizures
steadily grew in intensity. Soon, a new one was coming every two to three minutes—status epilepticus, just like Zeyad Barazanji.
An MRI scan revealed devastating injuries on both sides of Ragucci’s brain.
He languished in intensive care for twenty-three days. Doctors were only able to knock out the seizures by using medication
that put Ragucci into a deep coma. Each time they lowered the dose, the seizures returned. His brain was, in effect, cooking
itself. By the week after Christmas, the prognosis was bleak. The family kept pressing for updates, asking if there was any
sign of improvement, but after a while, the doctors could no longer hide their impatience. One exasperated physician said
that they were making the ordeal more painful for themselves, looking for hope where there was none. What Laura needed to
do, the doctor told her gravely, was to think seriously about taking her husband off life support. The game was over. Even
if her husband’s condition stabilized, the doctor said, he would be a vegetable his whole life. Another neurologist told her
the same thing. There was no way her husband could recover any meaningful function. He was better off dead.