Nobody is cold and dead is the golden rule of emergency doctors, even though many forget it or even don’t know it. But if on 20 May 1999 Dr Mats Gilbert of the University Hospital in Tromso, Norway, considered the world’s most northerly populated city, had lifted his arms from his 29-year-old patient just because her heart had stopped two and a half hours earlier, Anna Bagenholm would be dead today. So she skis, saves lives in the mountains and works as a radiologist in the hospital where she was brought back from the dead.
The slender Swedish woman had no desire to become a textbook example of the world’s most hypothermic person ever rescued from the clutches of death, and she expected nothing of the sort when, after completing her medical studies and her compulsory hospital work, she left her native Sweden for the ice-cold north of Norway.
She was lured to Narvik not by a tempting job offer, but by mountains covered in ice and snow. The extreme skier could not have asked for a better place to live: when she wasn’t working in the hospital, she skied the most exposed slopes and enjoyed the white powder immensely.
On the evening of 20 May 1999, she and her colleagues Marie Falkenberg and Torvind Naesheim strapped on skis. First she was hurled up the ridge of the mountain, then down an icy waterfall. Torvind Naesheim was the first to go. He had no problems. Anna followed him down the slope. She also did well.
Then, suddenly, her skis slipped off. She started braking. Her ski hit a rock and she fell. She fell on her back but was not injured. She would have been fine if she had not accidentally hit her head on a hole in the ice.
Trapped under ice
The time was 20.30, but it was still bright in the beautiful Norwegian north. Spring was approaching and the snow was slowly melting. It was about 15 degrees and Anna and her friends were skiing more or less on ice. The streams, which in some places were already flowing underneath, were bubbling vigorously. Anna was now crawling into one of them through a hole in the ice.
Her clothes got wet and heavy, dragging her under the ice. She could do nothing as the current sucked her deeper and deeper, until only her skis and bindings were left sticking out of the hole.
Her two friends hurriedly rushed up to her. They grabbed her by one leg each and tried to pull her out into the open. It didn’t work. She was stuck somewhere. The minutes ticked by like seconds. Anna was lucky to be lying on her back in the stream, so that the water did not cover her nose or mouth, but the water was freezing. It was clear to Marie and Torvind that Anna’s body would not last long in it.
They called for help. Anna was lucky again to have had an accident this year. Three years earlier, there was no mobile signal in that area and no one could be called from there, but now Torvind Naesheim could at least call the rescuers.
As he was a doctor, he typed in the hospital’s number, but had to be transferred elsewhere and it was a short while before Police Lieutenant Bard Mikkalsen took the call. “It was immediately clear to me that it was serious,” he recalled of the call, in which Torvind also mentioned to him that it was hypothermia. In northern Norway, this word means that the rescue team must carry “artificial lungs” or a lung-breathing machine.
Torvind went on to describe to Mikkalsen where they were, in a “down by that rock down there” kind of way, because there were no electronic devices that could pinpoint the exact location of the crash at that time. Then they both just hoped that they had a good understanding, because the mountain ranges in northern Norway are so vast that the rescuers could easily have missed the trio.
Bard Mikkalsen sent two teams: Ketil Singstad and his boys skied down from the top, while another team slowly climbed from the base. Mikkalsen also called Bodo, a town about 320 kilometres from Narvik. The nearest rescue helicopter was in Bodo, but it was already in the air and on its way to pick up a baby who needed to be urgently transported to hospital.
“I told the dispatcher: ‘You have to send the helicopter here. You have one minute to decide. Call me back. Time is running out.” Once again, Anna was lucky. The dispatcher was drowning once, and that’s when a helicopter rescue saved his life, so he diverted the helicopter in mid-air and sent it to pick Anna up.
This gave her 45 minutes, as the other helicopter would have flown that much longer. He had to take off from an even more distant place, but now he went to pick up the baby and got him to the hospital in time.
While the men were deciding which helicopter would go where, Marie Falkenberg and Torvind Naesheim were still holding one of Anna’s legs each. Forty minutes after she slipped under the ice, it seemed that they were holding only the body. Anna’s body was still. She was no longer breathing. Her heart stopped.
Shortly afterwards, the first rescue team reached her. The rescuers tied a rope around Anna’s legs and tried to pull her to the surface, but they were also unsuccessful. They should have made a hole in the ice, but a snow shovel and a small saw were no match for the thick ice.
Once again, they had no choice but to wait, this time for the team that was fighting its way towards them from the foot of the mountain. Its members had brought with them a garden spade that was rounded at the top. They finally used it to break through the ice, just below where Anna had got stuck.
Now they slowly loosened the rope wrapped around her legs so that her body slid down to the bottom hole. There, they trapped the head and pulled Anna out into the open 80 minutes after she had ducked under the ice. Her skin was blue and her heart had not beaten for 40 minutes, but her two doctor friends did not give up.
Absolutely dead
Just two weeks earlier, she and Anna had attended a mountain rescue course. Since all three of them were in the mountains all the time and were doctors by profession, it seemed the most practical thing to do was to become mountain rescuers. So they had practised with mountaineers, police officers and firefighters what to do in extreme situations, and now they were practising live on Anna what they had previously learnt together in theory.
They immediately started to resuscitate her. They relentlessly pressed her chest with their hands and pumped air into her mouth. Although manual resuscitation is exhausting and there was little hope of survival, they persevered until the helicopter arrived.
Inside, the paramedic continued his work, although the ECG he hooked Anna up to showed a straight line, as straight as if he had drawn it with a ruler. Anna’s body showed no signs of life when they finally landed on the roof of Tromso University Hospital and the head of the emergency department, Dr Met Gilbert, jumped into the helicopter.
He got the details from the boys, looked at Anna and assessed her condition: ‘Her pupils are completely dilated. She is ashen, flaxen white. Wet. When I touch her skin, it is icy cold. She looks absolutely dead.”
Her body temperature was 13.7 degrees Celsius. For a normal person, that would mean she could hardly be more dead, but for the head of the emergency room in a town high in the icy Norwegian north, it meant she still had a chance. He immediately decided, “We’re not going to declare her dead until she’s warm and dead!” He jumped on the bed where she had been transferred from the helicopter and continued to massage her heart.
Anna’s heart had not beating for more than two hours, but it was crystal clear to Dr Gilbert: the cold that had stopped her heart was now her ally. It is true that no one had ever been revived who had been chilled to only 13.7 degrees Celsius, but this did not stop Dr Gilbert, nor was he disconcerted by the fact that he had no idea what state Anna’s brain was in.
Her friends started resuscitating her 40 minutes after her heart stopped beating. They forced blood to circulate through her body by pressing hard on her chest, and made air move in and out of her lungs by blowing air into her mouth. Both of these things should have kept the blood flowing to the brain, even if not ideally.
Have they been sufficiently oxygenated? Anna had another lucky accident. She cooled slowly in the water, while she was still breathing. Her brain was already hypothermic when her heart stopped, and hypothermic brains need much less oxygen to function than those that function in a body with a normal body temperature of 37 degrees Celsius.
As they rushed to the operating room with Anna on the bed, Dr Gilbert and his colleagues thought only of how to warm her up as quickly as possible without harming her body too much. It was clear to them that the heated operating theatre and the heat wraps they had surrounded her with would not be enough, so they hooked her up to the extracorporeal circulation, or ECC, normally used in open-heart surgery. Anna’s blood flowed through the machine, warmed up in it and returned warm to her body.
Her body temperature was slowly rising. Dr Gilbert and his colleagues watched the scene on the screen. The ultrasound showed nothing. The minutes ticked by, but her heart was still. It had been 2 hours and 45 minutes since Anna’s heart stopped.
“It was completely motionless. No movement. I only saw a few tiny vibrations, but no heartbeat. Then it suddenly contracted,” Dr Gilbert later recalled. And it contracted again. It started to beat.
“I had to control myself not to start crying because it was really very moving,” he admitted. “My heart started pounding, we were all excited: ‘Yes! Yes! My heart is beating! It’s coming back!'”
Why did you save me?
After 2 hours and 45 minutes, Anna has returned from the dead, but now her fight has only just begun. First, she had to undergo a quick operation. As they tried to revive her at any cost, the blood vessel behind her collarbone on the right side of her chest was damaged. Now she could bleed to death, so they had to quickly open her up, find the damaged vein and stop the bleeding.
The life of a woman who had just been pulled from the grip of death was fought for several hours before her condition was stable enough to be moved to intensive care. There, the effects of hypothermia caused her kidneys to fail and then her metabolism to shut down. When she opened her eyes for the first time three weeks later, she was paralysed from the neck down.
It was so horrible that she nagged her friends why they had rescued her in the first place. At the time, she cared very little that she had not suffered any brain damage. “Her brain had time to cool completely before her heart stopped. When it did, they were so cold that the brain cells needed extremely little oxygen, so they could survive for a very long time,” explained one of her doctors.
Anna spent two months in intensive care and was immobile for a year. There was nothing wrong with her spinal cord. She was paralysed because the cold had affected her nerves so badly, but it also meant that she had a chance of recovery.
After two years, she was able to leave her job, and it was six years before her nerves were finally repaired, although she did not regain the feeling she used to have in her arms and had to give up her specialisation in surgery. Instead, she chose radiology and took a job at the hospital where her life was saved.
Her husband, Torvind Naesheim, the friend she was skiing with on that fateful day, also works there as an anaesthetist. During the years of recovery, they grew closer and fell in love. Today, they are both part of the rescue team. “Three things are important in emergency medicine: never give up, never give in, never give up. Because there is always hope,” says Naesheim.
His wife is living proof. He has no memory of the accident. She knows that she fell, that she was lying in a coffin of ice, slowly fading away, and that she learned about it from other people’s stories. “You know when you have a computer and you’re typing on it and then suddenly the power goes out? Everything is still on the hard drive, but nothing is on the screen anymore. Well, that’s how it is for me. Everything I saved is still there, but the things that happened that day are gone. I still don’t remember anything.” Her first subsequent memory is from the hospital, when she woke up again.
Returning to the living was no spiritual rebirth for her and opened no doors to life’s great insights. “I’m obviously more practical,” she says, but perhaps she had always lived the way she wanted to, so she didn’t need the proximity of death to open her eyes.
The garden shovel used to break the ice still hangs from the tree near the stream where her heart stopped, a reminder that it is never too late to help. The map on which the helicopter pilot, after a rough description of the area, marked the place where he would find Anna is now hers. A memory. Her accident has become a reminder.
In its aftermath, Norway changed quite a few rules. Today, a rescue helicopter could reach her in a few minutes, because the Swedes could be called to help, and nearby neighbours could cross the border without complications. In 1999, Anna had to wait for a Norwegian helicopter because one from a neighbouring country was not allowed to cross the border without permission. Thanks to Anna, a bureaucratic obstacle that cost people their lives was removed.
It has also led doctors to take a closer look at hypothermia. At the time, Anna was still the record holder, having been resuscitated after her heart was still for 2 hours and 45 minutes. In 2010, she lost the unwanted record. That was when a seven-year-old Swedish girl, Stella, was pulled out of the water. Her heart was still for 5½ hours before she came back to life.
Well, she didn’t hold the record for long either, because along came John Arve Johansen, who survived a seven-hour cardiac arrest while under constant resuscitation. No more manual pressure was applied to their chests. It was done by Lucas, or a chest pressing device. After Anna’s accident, at least one Norwegian rescue helicopter was also equipped with it.
Anna, who still hasn’t forgotten what it’s like to be a victim of hypothermia, uses it in her work as a paramedic. “I was paralysed from the neck down and couldn’t move.” At the time, she was eternally sorry that her friends had rescued her. “I was afraid of an empty life without dignity. Now I am extremely lucky to be alive and I would like to apologise,” she said years later, reflecting on why she survived. “It was no miracle. It was physiology. The miracle is that we have learned that people like me can be saved.”
The miracle that isn’t
Scientists still don’t know exactly why some people come back from an apparent icy death and others don’t. They also don’t know much about how the body works during hypothermia, but in principle, the first signs of mild hypothermia are when the body temperature drops to 35 degrees Celsius. This is when a person starts to shiver. The shivering is uncontrollable because it is an attempt to warm the body.
If not, the body continues to cool until it is moderately hypothermic at around 32 degrees Celsius. At that point, the skin is pale, the lips are bluish and speech is slurred. If a person still has no chance to warm up and his body temperature drops to 27.8 degrees Celsius, he is in the zone of severe hypothermia. If the circumstances remain unchanged, his heart starts beating more and more slowly until it finally stops and he dies.
Sometimes he was pronounced dead as soon as his heart stopped beating and his body temperature was 20 degrees Celsius or less. The doctors did not think he could survive, but they did not bother with him. Since Anna survived hypothermia to 13.7 degrees Celsius, the limit at which they still deal with a hypothermic person has been lowered considerably.
In hypothermia, the line between life and death is not as clear as it is at normal body temperature, when doctors declare a person dead if their heart still has not recovered after 20 minutes of resuscitation. A fairly hypothermic person can be “dead” for several hours and will come back to life, it is just important that he is well hypothermic before his heart stops.
The cold protects the brain because it slows down cell metabolism so much that the brain and organs can survive on a fraction of the oxygen they otherwise need to function. Metabolism slows down by 5 to 7 per cent with every degree that the body drops. “Imagine that oxygen is petrol. If you drive 90 kilometres per hour, you use more fuel than if you drive 30 kilometres per hour. The same is true for the body. Hypothermia naturally slows down blood flow, lowers metabolism and the body uses less oxygen,” explained Dr Torkjel Tveita from Tromso University Hospital.
If a body is cooled to 25 degrees Celsius, but someone is tending to revive it to keep the blood circulating, oxygen circulates normally through the body. “As long as the lungs are getting oxygen and the body is pumping blood, there is hope,” says Dr Tveita, but he also makes the point that any chill below 30 degrees Celsius is dangerous.
Of course, not all hypothermic people survive. Those who say goodbye after being warmed usually die from brain damage caused by lack of oxygen. They can also die several days later in intensive care because several of their internal organs fail at once. However, the hearts of those who leave hospital alive usually make a full recovery.
The Fatal Tree
24-year-old Christine’s heart is also. A few years ago, she went with six friends to a cabin in the Canadian Rockies. On the last day of March, she decided to set off alone at around 2am on a 35-kilometre hiking trail. The trailhead was about 11 kilometres from the hut.
Her friends had a little more sleep and then headed out into the snow themselves at around 9am. Not far away, about 500 metres from the hut, they saw a daypack. It was Christine’s. It was lying by a tree. Then they saw footprints and, shortly afterwards, heard moaning. They followed the sound.
He led them to Christine’s head, because it was the only thing that caught the eye. The body was hidden in a snow hole that had formed around the low branches of a tree and was wedged in the snow. Christine gasped for air. Her eyes were wide open. She did not even blink. Her friends tried to pull her out, but she was stuck. They could not move her.
They tried and tried, but by the time they succeeded, Christine had been stuck in the snow for about seven hours. She was unconscious and severely hypothermic. She could no longer feel her heart beating. One of her friends, a former volunteer rescuer, covered her with a sleeping bag and started to resuscitate her, while another ran into the hut and called for help.
The paramedics arrived only two hours later, and it took another two and a half hours to get to hospital. When Christine arrived, her body temperature was 16.6 degrees Celsius. In the past, doctors would have calmly pronounced her dead, but now that they knew the case of Anna Bagenholm, they resumed resuscitation.
Christine was lucky enough to be brought to a hospital equipped with an Extracorporeal Membrane Oxygenation (ECMO) machine, which takes over the work of the lungs and heart. It sucks the blood out of the body, filters it, heats it, oxygenates it and puts it back in.
While the device is not new, having long been used in the treatment of babies and open-heart surgery, it has only been a welcome ally in the fight against hypothermia in many hospitals for a short time. In some places, they still do not know that they can use it for this purpose, but in the hospital where Christine was brought, they knew her power.
They put their young patient on ECMO and tried to shock her heart while her body was warmed up. They immediately felt a pulse. They resumed CPR and a few hours later Christine woke up.
Soon enough, she was able to concentrate enough to follow simple commands, such as nodding her head. On the third day, all the devices that had helped her survive were turned off, and by 2am, the nurse could hear her singing.
Two weeks later, Christine was discharged from hospital. She made a full recovery because her brain had not suffered any damage.
Urban hypothermia is set to increase
Deaths from hypothermia are relatively few around the world, but interestingly, most of them are not in the far north, or in the coldest parts of the world. The number of deaths in central and eastern Europe is not insignificant.
In the future, doctors warn, there will be more and more of them in cities. Climate change is likely to make winters harsher and harsher, and social cuts will make people existentially weaker, leaving many exposed to the cold without adequate shelter.
There is also little in-depth research on hypothermia, apart from the ethically acceptable one carried out by the Nazis during the Second World War, when they soaked camp in freezing water for hours to see how long German pilots could survive in the icy North Sea after being shot down by the Allies. They then concluded that a man could not survive more than an hour or two in the cold sea.
At Dachau, Dr Sigmund Rascher gathered 300 camp inmates, systematically cooled them and measured how their bodies reacted to the extreme cold. He conscientiously recorded their heart rate, muscle control and body temperature, and also noted how long it took before they lost consciousness. He usually left them in the ice water until their body temperature dropped to 25 degrees Celsius or less.
Between 80 and 90 prisoners died during the study. Dr Rascher was not bothered by this, but the noise was getting on his nerves, so he asked to move his laboratory from Dachau to Auschwitz, because there would be more space and the campers would not be so disruptive. Their cries of pain during the cooling process disturbed his concentration.
No one knows whether 25-year-old Jason also screamed when he was freezing to death. When his father, Don, found him lying in the snow by the side of the road, he was already “blue. His face showed no signs of life. I checked his heartbeat. I checked the heartbeat. I couldn’t detect anything.”
He had taken his son to a party the night before, and now he was dead. He had been lying in minus 5 degrees Celsius for at least 12 hours. The father called the paramedics. They found no sign of life. Someone had covered the body with a white sheet. Others called the morgue inspector. The police started investigating the suspicious death. Don telephoned his wife with the terrible news: their son was dead.
But the paramedic from the field still called an ambulance to the nearest hospital. He explained to the emergency doctor Gerald Coleman that a 25-year-old man had been found lying in the snow. That he was unresponsive, that he had no heartbeat and that the thermometer used to measure the temperature in his ear could not measure his body temperature at all. All the signs indicate that he has been dead for quite some time, he concluded.
But in Dr Coleman’s mind, a warning message rang out: to be dead, you have to be warm! He told the paramedic that, given the boy’s age and the fact that he was hypothermic, he dared not pronounce him dead. He quickly calculated that Jason had been lying at minus 5 degrees Celsius for at least 10 hours and said to the paramedic, almost apologetically, “The effort will probably be in vain, but we have to do the best we can. Right?”
The paramedic started CPR and there were 15 people waiting at the hospital to resuscitate Jason. One of the nurses later recalled that his limbs were as hard as concrete. They massaged Jason’s heart and pumped air into his lungs, but it was not enough.
They had to put him on ECMO, but their hospital didn’t have it. Jason was flown by helicopter to another one, even though there was a storm raging outside. During the flight, they kept pressing on his chest and blowing air into him, even though there were only two seats for two people in the helicopter.
When Jason’s blood was finally warmed, oxygenated and the thermometer read 30 degrees Celsius, his heart woke up again in the early evening. Everyone was overjoyed, but no one knew what was wrong with the boy’s brain. In theory, brain cells should start to die four minutes after being deprived of oxygen, but with hypothermia the rules of the game are different.
When he came out of the coma two weeks later, Jason didn’t know where he was, but he was responsive. His brain took it well, certainly better than his arms and legs. He had to cut off all his toes and the calcaneus of his hands because of frostbite, but this is a negligible price to pay for survival.
But he also stayed alive because one doctor remembered that a man must be warm to be dead. In the hands of any other doctor, Jason with a body temperature below 20 degrees Celsius would have been considered dead and died.
“The most important thing is not to declare a person dead in the open. If possible, start resuscitating him, take him to hospital, put him on ECMO and keep him warm with everything you have. Do not take your hands off him. Even if it looks like he won’t survive, you have to keep going until it’s really over,” survivor Anna Bagenholm repeats tirelessly today.
