Lance Becker: Back From the Dead

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LANCE BECKER’S CELL phone rang at two in the morning.

“Lance!” screamed the woman on the other end of the line. “You have to help us!”

The woman was his cousin, Lynn Rossman. She was in the emergency room at Parkview Medical Center in Pueblo, Colorado. Her husband, Mike, had just died.

Lynn and Mike had flown in from California for her brother-in-law’s 60th birthday party. They’d just stepped off the dance floor and sat down at their table when Lynn felt Mike nuzzling her in the arm. She thought he was being cute. But when she turned around, she watched his body fall backwards toward the floor. He wasn’t breathing. Mike was in cardiac arrest.

“Mike!” she yelled as her sister Donna, an ER doctor, sprang from her chair and immediately began pounding his chest with compressions to get some blood flowing through his heart to his brain. A nurse from a nearby table started mouth-to-mouth. As Lynn waited for the paramedics to arrive, she watched her husband’s face turn blue. Then bluer. She looked at her watch; four minutes had passed. As a psychologist, she knew what that meant — after four minutes without oxygen, the brain starts to die. She wondered: How much brain damage will there be? Even though Mike wasn’t dying. At this point, Mike was already dead.

Four and a half more minutes passed. The paramedics arrived, shocked Mike’s heart with the defibrillator paddles. Once. Twice. Nothing. Usually they stop at two, but Donna demanded they try again. They did. And there it was: a pulse.

The ambulance sped to the nearest hospital, where Donna worked. As soon as the gurney pushed through the ER doors, a team of doctors and nurses surrounded it, including Donna. The attending on duty turned to his colleague, still dressed in her party clothes.

“I think we should freeze his brain,” he said.

“No,” Donna answered. “We should freeze his whole body.”

The trouble was, they didn’t know how.

The doctors in Pueblo had only heard about “therapeutic hypothermia” a few weeks before, when Donna had passed copies of a Newsweek article about it around their ER. The only reason Donna had read it was because the article was about her cousin, and the radical “cooling” he was doing at the University of Pennsylvania to help victims of sudden cardiac arrest, the number one cause of death in the United States. Ninety-five percent of people who show up at the hospital with cardiac arrest die from it. Of the very few who survive, almost all — 98 percent — suffer permanent brain damage. Cooling the body changed those stats, the article explained.

The Penn physician who was bringing people back from the dead was Lance Becker.

“Lance!” Lynn yelled over the phone. “Mike just had a cardiac arrest! We’re telling them they have to cool him, but they’ve never done it!” Becker knew what the ER docs were thinking: We see guys like this all the time; they never survive. And they were right. Becker had seen hundreds of cases like that himself — patients in their 50s and 60s and 70s who were resuscitated on the way to the hospital, but then continued to arrest in the ER, over and over, until they died. If they lived, they were vegetables.

But Becker now knew how to stop it.

He calmly talked the ER doc through Penn’s protocol for cooling — reducing the body’s temp to 91 degrees for 24 hours. The hospital didn’t have the high-tech “cooling suit” Penn wraps around a patient’s torso and limbs, so the nurses packed Mike’s body in Ziploc baggies filled with ice. Just like at Penn, they gave him a sedative, and a drug so he wouldn’t shiver. They pumped chilled saline through his veins. And then they waited.

And Lynn waited, staring at her husband as he lay on his hospital bed in a coma, encased in ice, with tubes poking out of his body. After 24 hours, the nurses started to warm him slowly, taking away the ice, decreasing the drugs, carefully prodding him to wake up. No one knew if Mike was even still in there, if his brain would actually work. Finally, his eyes opened.

“Do you know who I am?” Lynn asked him.

“Yes,” he said. “This is the strangest hotel room I’ve ever been in.”

A joke. That was all Lynn needed to know that Mike was still there. She started to cry.

Lance Becker, though, is frustrated by this story. Yes, it has a happy ending. Yes, that ending is a direct result of the work at the Center for Resuscitation Science at Penn, which he runs. But here’s Becker’s problem:

Mike Rossman was lucky.

That’s all.

He was lucky that he collapsed in a roomful of people instead of in his house, alone. Lucky that among those people, there were doctors and nurses who gave him good CPR. Lucky that one of those doctors was his sister-in-law, who had just read about cooling, that some of the ER doctors at the hospital had heard about it, that they were willing to try a procedure they’d never done. Lucky that his wife not only knew the single most knowledgeable physician in the field of therapeutic hypothermia, but had his phone number.

“If she hadn’t called, he’d be dead,” Becker says. “We have to get to a point where cooling is standard.” In all ambulances. In all emergency rooms. In all hospitals. But it’s not. Yet.

And that’s why Becker can’t sleep at night, why he stays in his office on South 31st Street sometimes until 2:30 in the morning. He’s certain that because of him, because he isn’t working fast enough, people who shouldn’t be are dying.

IT’S NOT AN easy job, changing what death means.

Well, that’s not exactly true. The hard part isn’t pushing the boundary between life and death. Becker’s already doing that. That standard four-minute time limit during which you can be dead and still be brought back? Becker thinks it’s now more like 15 minutes, maybe even 30.
“Thirty minutes would mean that every ambulance could get to a scene and bring somebody back to the hospital and they would have a chance of being alive,” says Becker, 55, dressed in scrubs as he picks at french fries during lunch. “That’s a revolution.”

For him, the hard part is convincing other people — other doctors and nurses and EMTs and cardiologists and neurologists and hospital administrators — that death doesn’t mean what they learned in their med school textbooks: 10 minutes without oxygen equals gone. Death isn’t so black-and-white anymore, which explains why Penn’s Center for Bioethics is working with Becker’s team.

“This is hugely complicated,” says center director Art Caplan. “We’re taking an area that has been relatively settled — how long a brain can live without oxygen, what to do in an emergency with a cardiac arrest patient, what’s futile — and shaking that all up.” Caplan foresees lots of issues (who gets cooled? Who doesn’t? Who decides?), but the biggest is this: rethinking the protocols about when to pronounce people dead if technology like cooling is available. “It’s a game changer,” he says.

The rules of the old game, accepted as fact and printed in medical textbooks until only a few years ago, were that when it came to cardiac arrest, the survival rate for patients whose hearts suddenly stopped pumping was 18 percent. But that’s not what Becker was seeing while working in the ER at Michael Reese Hospital in Chicago in the 1980s. Way more cardiac-arrest patients were dying. So many, in fact, that he decided to study the numbers officially. He found that the percentage of survivors in Chicago wasn’t 18. It was only 1.8. These findings jump-started Becker’s career, landing him his first publication in the prestigious New England Journal of Medicine in 1993.

But Becker couldn’t enjoy it. At almost exactly the same time, his father suffered cardiac arrest and died. Becker wasn’t at his bedside. If I’d been there, he wondered then, could I have saved him? He still wonders, every single day … Could I have saved him?

“I knew there had to be a better way to treat cardiac arrest patients than what we were doing,” Becker says. Back then, he was doing what every doctor in America had been doing for decades, following the steps from the Advanced Cardiac Life Support course: CPR, defibrillator, IVs, breathing tubes, drugs like epinephrine.

So he began to study that process. Under a microscope, he deprived heart cells of oxygen for an hour and then gave them oxygen again, mimicking what happens when a cardiac-arrest patient’s heart is suddenly restarted. What he discovered blew him away. Adding oxygen wasn’t like pumping fuel into a car’s empty gas tank. It was more like pouring fuel on a fire. The abrupt flood of oxygen made the cells die even faster.
The cells were already in death mode, he says, sending the message to the rest of the body: “You’re now meant to die! It’s time to die!” During later experiments, he left some cells at room temperature, outside of the 98.6-degree incubator. They were cooler. And most stopped dying. They stopped sending the message and rested, taking the time to gradually heal. In more ways than one, those cells chilled out. No one’s entirely sure how, exactly, cooling works, but Becker thinks this might be the linchpin — getting those suicidal cells to chill.

It wasn’t that Lance Becker invented cooling; Hippocrates suggested packing patients in snow back in 450 B.C. But legitimate experiments in medical hypothermia didn’t start until well into the 20th century, in the same place where, nearly seven decades later, such studies would become the cornerstone for a center focused on -resuscitation — Philadelphia. In 1938, Temple University neurosurgeon (and, interestingly, Penn med school grad) Temple Fay refrigerated patients to control the growth of cancer. But he abandoned his work when Nazis began using his data for experiments in concentration camps.

Ever since, researchers and physicians like Becker had been testing hypothermia as a treatment for brain injury — in mice, in rats, in pigs. But it wasn’t until 2002, when the New England Journal of Medicine published the results of two clinical trials on humans in Europe and Australia, that the procedure got some cred. There had been miraculous anecdotes floating around — one about an Australian man who collapsed from cardiac arrest in a grocery store and was kept cool with bags of frozen french fries, another about a Norwegian skier who fell into a freezing river, had her heart stop, and ended up without brain damage despite being without oxygen for at least an hour. But the trials in NEJM proved that cooled cardiac arrest patients did better neurologically than non-cooled patients. Hypothermia drastically improved survival rates.

So Becker finally felt confident enough to cool a cardiac arrest patient. The guy was an ideal candidate for hypothermia — he had just died. When the ambulance arrived at the ER at the University of Chicago’s hospital, Becker and the nurses began filling baggies with ice. They packed his body with them, then transferred him — baggies and all — to the critical care unit.

When Becker went to check on him a few hours later, the ice packs were gone. Becker knew immediately what had gone wrong: He hadn’t explained to the CCU staff what he was doing. In order for this to work, he had to have everyone on board: the critical care staff, the cardiologists, the neurologists, every single nurse on every single shift. Without it, this was what would happen.

The baggies had dripped water all over the floor. So the CCU had taken away the ice. By the time Becker got there, the patient was running a fever. He never recovered.

Standing in the CCU, Becker said to himself, “You failed.”

SIX YEARS LATER, in November 2008, it seemed like the entire staff at HUP was waiting to see what would happen when Chris Brooks woke up.
ER doc Benjamin Abella, who’d been monitoring Chris since he was life-flighted from Aria hospital in Langhorne that morning, knew the case was complicated. Abella was Robin to Lance Becker’s Batman at the Center for Resuscitation Science; both men had moved their families to Philadelphia in 2006 to get the lab up and running. In two years, they’d created the largest, most advanced, most cross-disciplined hospital-wide resuscitation program in the country. In their lab, scientists tested deep into mitochondria, epidemiologists studied data, physicians experimented in a mini surgical suite made for rat-size patients, engineers built bizarre equipment. They consulted with physicians across the Penn system — from pediatric surgeons to neurologists. By the time Chris Brooks was helicoptered in, they’d already cooled nearly 50 cardiac arrest patients.

But Chris Brooks was unusual. He’d been “down” — without oxygen — for at least 45 minutes, so severe brain damage was likely. Proper cooling hadn’t started until he got to Penn, about 12 hours after he first arrested. Plus, no one could figure out why he’d gone into cardiac arrest. He hadn’t had a heart attack. He didn’t have coronary disease. He wasn’t a smoker or out of shape.

Nurse Dana Bower started the sedatives and other meds through IVs, and wrapped Chris’s torso and limbs in the “cooling suit,” which works like a giant, flexible ice pack, with a thermostat attached to control the temperature of the water flowing inside it. He already had a breathing tube. All he needed was for the doctor to come and start the thick IV of chilled saline in his neck and groin. Then Chris’s father walked into the hospital room. When Bower turned to greet him, she instantly broke into tears.

“It’s not the nurse in me that’s crying,” she explained. “It’s the mom.”

Chris Brooks was just 22 years old.

He’d been out bowling with friends the night before, back from East Stroudsburg University for the weekend. After driving a friend home, he pulled into his parents’ driveway at 2:30, then lay down on the couch in his parents’ living room. His mom, Joan, was asleep on the loveseat. Chris started snoring. Loudly.

“Christopher, knock it off,” Joan said. He kept snoring. She sat up. “Christopher, wake up!” she screamed. Nothing. His father, Joe, woke up, and his parents pulled Chris onto the floor, yelling, splashing water on his face. Nothing. He had stopped breathing.

Joe called 911. Following instructions from the emergency dispatch operator, Joe passed the phone to Joan and then got on his knees, straddling his son’s torso, pushing repeatedly on his son’s chest, just the way he’d seen it done on House.

“Come on, Chris!” Joan cried out as she held the phone.

“Look out front,” Joe yelled, sweating from all the compressions. Joan ran to the door just as a police car and an ambulance sped onto the street. The EMTs took over. They shocked Chris once. Twice.

“No response,” a paramedic said. Just that night at dinner, Chris had downed two big glasses of milk as he told his mom what he planned to do with his life: graduate with a degree in business and finance, buy a car, buy a house in two years. No response. Joe began to sob. The medic pulled out a syringe of epinephrine and plunged it into Chris’s chest. Another shock. A heartbeat. Finally.
The docs in the ER at Aria knew they should cool Chris, but they didn’t have the right equipment, or any official protocol to follow. So they packed him in bags of ice. The next morning, Saturday, Chris was transferred to Penn.

As they waited the eight hours it takes for the body to cool to 91 degrees, Chris’s family tried to pinpoint exactly when he got home from bowling. His sister Melissa thumbed through the texts on his cell. The last text he’d received was from the friend he’d dropped off the night before. “Oh, you must be so tired,” she wrote. Chris had texted back one word: “Dead.”

All day Sunday, friends and family came by. Joan knew why staffers let so many people stay in the waiting rooms, the hallways: They didn’t think Chris would make it.

Twenty-four hours passed. Chris’s heart and brain had rested. The cooling hopefully had halted the “death mode” and all the nasty chemicals released into his bloodstream as a result. The time had come to warm him. Chris’s family sat around his bed, holding onto his hands. Dr. Abella was there, worrying as he always did at this moment. Would Chris still be in there?

“If you can hear us, squeeze our hands,” Joan said. “Squeeze our hands.” Melissa thought she felt a hint of pressure. Chris’s mouth twitched a little. His eyes fluttered.

“Can you hear us, Chris?” a nurse asked. “If you can hear us, give us a thumbs-up, Chris. Chris!”

Chris didn’t give them a thumbs-up.

He gave them two.

From then on, he was known throughout the hospital as “The Miracle Kid.”

Chris knows he’s a miracle, and not just because his mom reminds him 48 times a day. “I mean, I’m happy that I’m alive, obviously,” he says.

But Chris isn’t the typical cardiac arrest survivor — the 60-year-old guy who leaves the hospital vowing to change his life, to walk on that treadmill four days a week, to eat more whole grains. Chris is now 23. A year ago, he was totally athletic, totally pushing limits, totally invincible. And now, he isn’t. For a while, he couldn’t lift heavy things or run too fast or too long. Now, no contact sports.

“I’m kind of pissed off,” he admits. “This is something I now have to deal with. And it sucks.” For one thing, there’s a defibrillator implanted in his chest — not everyone gets one, and the big old bump it makes — because the docs still don’t know what caused the arrest and don’t want to risk it happening again. So he needs to get DNA tests to try and figure it out, but the tests cost up to $20,000, and since he just graduated from college, he’s not on his dad’s insurance anymore.

But then he looks up at the photo of him in his college graduation cap and gown, propped on the mantle in his parents’ house. He remembers sitting with the other graduates in the auditorium when the dean called the name of a student who had died. Her parents walked up the stairs. When the mother took the diploma in her hand, she started to cry. Chris realized it could have been his parents making that walk.

“When I saw that,” he says, “I was like, Oh my God.”

Chris knows he was lucky. He says it a lot: “I’m lucky. I’m lucky.” And that’s exactly why Becker doesn’t just sprint on weekends when he runs through the Wissahickon with his daughter, who just started at Penn’s med school. He sprints through the halls of Penn’s Translational Research Lab, too.
“I get to talk to people who were dead,” Becker says. “That’s what keeps me going.” When he was flying out West to see Mike Rossman, his cousin’s husband, for the first time since he’d died in Pueblo, Becker felt nervous, wondering what to say. He came up with something clever, but when he saw Rossman and how rosy his cheeks were and how pink his skin was from all the blood flowing through him, he forgot all of it. Instead, he grabbed Rossman by the shoulders and whispered, “It’s really good to see you.”

But Becker’s not telling the truth about what motivates him. Not entirely. Sure, he loves to tell the good-luck stories. Like Chris Brooks. Like the six-month-old from Chester who went limp in his father’s arms, and ended up happy and healthy and saying “Dada” at his first birthday. Like the woman who came into the ER just a few days ago, arresting, clinically dead, and nine months pregnant. They saved the baby. The mother, so far, was doing well, breathing on her own, wiggling her fingers and toes.

“She would have been dead at almost every other hospital in the country,” Becker says. And that is what keeps him going. The bad-luck stories. He gets e-mails from people all over the U.S., people who took their father to an emergency room and were told that he was “too old” to be cooled, people who were sure doctors “pulled the plug” too soon because they didn’t know they could grab some ice and, maybe, bring a patient back. When he heard the reports last year about Tim Russert dying, about the failed resuscitation efforts, Becker wondered: Could he have been saved?

Only a quarter of emergency room docs in the United States have ever cooled a cardiac arrest patient. The procedure has been endorsed by the American Heart Association, but some doctors remain wary, worried that there haven’t been enough studies in humans. (Generally, in order to study someone, a doc needs the patient’s consent, which is tough to get when the patient arrives at a hospital … well … dead.) When Becker appeared as “the cooling guy” on Charlie Rose as part of a panel of superstar heart disease experts, one of his fellow panelists pretty much slammed the door on the discussion. “I have to admit I’m a skeptic about cooling,” said Steven Nissen, not only chair of the department of cardiovascular medicine at the Cleveland Clinic, but also one of Time magazine’s 2007 “most influential people in the world.” “I’m not at all convinced that we’re there yet.”
The doctors who think it’s risky aren’t wrong — cooling a patient too much or for too long might actually cause cardiac arrest. When Mike Rossman was flown from Pueblo to San Francisco for open-heart surgery to unblock his arteries, the cardiac surgeon was incensed when he found out Rossman had been cooled.

“They could have killed him,” the surgeon said.

“No,” Rossman’s wife answered. “He was already dead.”

Becker knows that advances in medicine tend to stumble forward, which is clearly not his speed. But 50 years ago, cancer was just cancer, and everyone who got it died from it. Becker points to just 10 years ago, when premature babies who were born weighing less than two pounds frequently died. Now, they don’t.

In the midst of change, though, chance is all there is. “Right now, it’s pretty much all luck,” Becker says. “If you end up in the wrong hospital, you might not make it.”

LANCE BECKER’S NEW favorite thing is a “slurry.” It’s the technical name for a crazy solution, a saline-and-ice-water slushy that can be pumped directly into a patient’s IV. It cools the body to 91 degrees several hours faster than it can be done now.

He points to a boxy metal contraption in the center’s lab. One of the engineers built the slurry-making machine — part mini fridge, part margarita mixer — which, as is, is way too big. But they’ll keep tweaking and tinkering until it’s small enough to fit in an ambulance. Because that’s the point.

The earlier the cooling starts, the better. Seventy-five percent of cardiac arrests happen outside of a hospital. But only 100 of the 24,000 emergency medical companies in the country now have the means to cool a patient in an ambulance; none of them are in Philly. If having a slurry machine on the bus doesn’t freak out EMTs enough, using it means completely changing how they do their jobs. Doctors think it might be even better to start cooling before the EMT restarts the heart. Before the defibrillator. Before the epinephrine.

“We have to revise what we think we know,” Becker says. And perhaps Becker needs to follow his own advice.

One Saturday morning last summer, a neighbor knocked on the door of Becker’s house in Powelton Village. “Did you hear about Lawrence?” the neighbor asked, referring to a man who lived down the street. “They’re saying you saved him.”

“I don’t know what you’re talking about,” Becker replied. “I haven’t even seen him.”

“They’re saying that they used your technique on him.”

The day before, Lawrence suffered cardiac arrest in his office in West Philly. The paramedics took him to Presbyterian. When they brought him into the ER, he was in terrible shape. The docs couldn’t keep his blood pressure up. He arrested again. And again. The staff thought he would die right there.

But just the month before, the ER at Presby had adopted Becker’s cooling protocol. They had the suit. They had the saline. They were ready. Lawrence was the second patient they had ever cooled. For the cardiologist on duty, Lawrence was the first. And Lawrence recovered. Slowly. Steadily. But he recovered.

Lawrence wasn’t brought to Becker’s hospital. He didn’t have Becker’s cell-phone number. He didn’t even need it. Becker says, right now, it’s only luck. But Lawrence wasn’t one of the lucky ones. He just got the standard treatment — a second chance.

 

Source URL: https://www.phillymag.com/news/2009/11/24/lance-becker-back-from-the-dead/