The Mom Who Died Twice

On a warm Wednesday in August 2010, just after midnight, obstetrician Cathy Cowal was walking through the fluorescent-lit halls of Mississauga’s Trillium Health Centre when an announcement over the PA system stopped her mid-stride. Nurses were calling for an anesthetist in Room 2, where a woman named Niolys Garcia was in labour. The announcement was puzzling. Cowal had seen Garcia moments before and the expectant mother had been doing fine. Why are they calling anesthesia? Cowal wondered. She doubled back to find out.

After 19 years of delivering babies, Cowal had seen just about everything. The miracle of life was a normal day’s work, something she handled with the same casual competence as a dentist filling a cavity. When Cowal entered the room, however, she was stunned. Garcia’s husband, Ariel Collazo, and her 20-year-old daughter from a previous marriage, Siurlin, were at the foot of the bed, wild-eyed and panicked. Garcia-the elegant dark-haired 41-year-old who seemed fine minutes earlier-was splayed out, convulsing and quickly turning blue.

Cowal hustled the family out of the room and called a Code Blue-the signal that a patient needs resuscitation-bringing staff running from across the hospital. While another doctor pumped oxygen into Garcia’s lungs, Cowal monitored the baby’s heart rate. His pulse was steady, but with every passing second it was growing weaker. Not only was the child in danger but it was impossible to properly ventilate Garcia with the baby applying so much pressure on her diaphragm. To save the mother, they needed to deliver the son. Now.

In the waiting room, Garcia’s husband was distraught. Collazo wasn’t used to feeling so helpless. He was someone who seized control. As a teenager he’d left his native Cuba to explore the jungles of Guinea-Bissau. In his 30s he’d left again, this time for wintry Canada, where he built his own shipping business through industriousness and sheer pluck. Collazo first met Garcia when he washed dishes at a Cuban restaurant she owned in Toronto. How rare is it to find someone who’s both beautiful and hard-working? he asked himself. Collazo knew he had to win her over.

A few years later they were married and ready to start a family, but Garcia couldn’t get pregnant. Though doctors said both of them were perfectly healthy, nothing seemed to work. Garcia took fertility drugs and tried in vitro fertilization. Finally, after three years, a pregnancy test came back positive. The couple was crushed when Garcia miscarried after several months. They decided not to try again-the ordeal had been too heartbreaking. Then, amazingly, only three months later and without any planning, Garcia was pregnant again with a baby they called Jacob. Garcia wasn’t religious, but even she agreed: He was their private blessing.

Now Collazo paced the hospital floor, too afraid to even consider that he might not only lose his child but the love of his life as well.

The baby’s pulse flashed on a monitor next to Garcia’s bed; the rate was dropping, the beeps coming further apart. Cowal looked at her patient and weighed her options. With Garcia unconscious and unable to push, a vaginal birth was risky. A Caesarean section was safer, but with all the preparation required it wasn’t the fastest option, and Cowal knew there wasn’t much time.

Cowal took a calculated risk-with Garcia fully dilated, she decided on a vacuum-assisted birth, using suction to pull out the baby. While staff continued to fill Garcia’s lungs with air, Cowal attached a suction cup to Jacob’s head. The baby was already beginning to suffer from a lack of oxygen. He was limp, making everything more difficult, but Cowal was patient.

The delivery was over in moments. By 1:08 a.m., 11 minutes after the Code Blue alert, Jacob was out. He was flat and slightly blue, lacking the firm tone of a healthy newborn, but a quick blood test reassured Cowal that his oxygen levels were fine. His brain functions would turn out to be perfectly normal. She had been fast enough.

Cowal directed her attention to the mother. In the rush to deliver Jacob, the doctors hadn’t been able to answer a basic question: What had caused Garcia’s lungs to stop working in the first place? Was it a stroke? A reaction to the morphine? Following the delivery, Garcia had needed some routine stitches. Now Cowal noticed dark pools of blood forming around each stitch. Cowal looked at Garcia’s arms. Blood was trickling out of the areas where doctors had inserted intravenous tubes. Alarmed, Cowal pulled aside Garcia’s hospital gown. Her stomach was covered in tiny purple bruises where the nurses had massaged her. Something was terribly wrong. Wherever there was the smallest nick or cut, blood was flowing-a deep, dark red that refused to clot. That’s when it clicked. Cowal was dealing with something she’d never seen before.

No one understands exactly what causes amniotic fluid embolisms, but everyone knows just how deadly they are. During labour, amniotic fluid can enter the mother’s bloodstream through a small tear in the uterus, creating a catastrophic allergic reaction. It’s like flipping the “off” switch on the body’s most basic functions. The lungs stop working. The heart shuts down. Blood stops clotting. It’s a condition so rare most obstetricians will never see a case in their entire careers. Before Garcia, Trillium Health Centre had treated only two amniotic fluid embolisms in the last several years. Both mothers had died.

Mere minutes after giving birth, Garcia’s heart stopped beating. Doctors sounded their second Code Blue of the night and requested backup-Dr. Chris O’Connor, the critical-care physician on call, and Garcia’s obstetrician, Dr. Dalip Bhangu. In all her years Cowal had never lost a patient, but a dark thought kept echoing through her mind: This is going to be my first.

While nurses performed chest compressions, the doctors sent a series of drugs through Garcia’s intravenous tubes to try to kick-start her heart and thicken her blood. Her heart began beating again, but the bleeding wouldn’t stop. Garcia’s body was a conduit, the blood pouring out as quickly as it could be pumped back in. Bhangu and Cowal decided the best way to stop the flow was to remove the primary site of the bleeding. At 3 a.m. Bhangu performed an emergency hysterectomy.

Garcia seemed to stabilize. As the sun came up, Cowal was sure the worst was over. When she left the hospital at 9 a.m., O’Connor told her he was optimistic. “You know, I think she’s going to do fine,” he said. The team had managed to bring Garcia back from the dead.

Later that morning, Dr. Gopal Bhat-nagar, a cardiac surgeon and the hospital’s chief of staff, was in the intensive care unit reviewing some X-rays when an anesthetist named Dr. Brian Nishimura came rushing in to ask for advice. One of Nishimura’s patients had just had a second cardiac arrest. It was Garcia. The doctors tried everything, but no matter what they did, they couldn’t get her heart pumping again. Bhatnagar said he would have a look.

When he arrived at the medical-surgical ICU, the scene was one of organized chaos. Doctors and nurses surrounded Garcia, simultaneously trying to replenish her blood, fill her lungs and pump her heart. She didn’t look good. The smell of blood permeated the room. Garcia’s legs were as white as soap from the lack of circulation, and her entire body was swollen, the skin taut and mottled. Most distressingly, her pupils were dilated and fixed, a telltale sign that there was no brain activity. Bhatnagar did the grim arithmetic in his head. Three or four minutes without oxygen and brain cells begin to die. After 20 minutes of CPR, the odds of survival are slim. When Bhatnagar arrived, nurses had already been performing CPR on Garcia for over an hour, longer than most of them had ever worked on an unresponsive patient.

At what point do you stop? thought Bhatnagar. Still, Garcia was young and she’d been healthy when she’d entered the hospital. More than that, she was a new mother with a baby who depended on her.

“Let’s get her into the OR,” said Bhatnagar. He decided to put Garcia on a heart-lung machine, an instrument that pumps oxygen into a patient’s blood and then sends it coursing through the body. It was a desperate decision. The machine is generally used only in heart surgeries, and the chances of a patient bleeding to death are high while undergoing an invasive heart surgery when blood isn’t clotting. Bhatnagar knew it was well beyond a long shot, but he wanted to be able to tell Collazo they had done everything humanly possible for his wife.

As soon as Bhatnagar made the call, everyone leaped into action. A doctor working on a patient in the operating room finished his surgery quickly and cleared out. Nurses prepped the room in record time. Security emptied the halls, leading the team of nearly 30 medical staff, who jogged beside Garcia’s bed, trailing five IV poles behind them.

Bhatnagar anxiously watched the preparations as he went over the game plan. Once in the operating room, however, he felt perfectly calm. He had done this hundreds of times. It was all muscle memory now. With one fluid motion, Bhatnagar sliced his scalpel through Garcia’s chest until he felt the familiar resistance of the breastbone. He took an air-powered saw and cut the bone in half, then stuck the retractor in and ratcheted the whole thing open-like using a car jack. Garcia’s chest was butterflied, exposing her heart, which was swollen to the size of a big grapefruit and completely still.

Carefully, Bhatnagar connected tubes to Garcia’s heart, feeding her blood into the heart-lung machine. The whirring desk-size contraption pumped oxygen into the blood, cooled it to try to prevent the cell death that can lead to brain damage and sent it back through her body. With the machine temporarily doing Garcia’s vital work, Bhatnagar began looking for the cause of cardiac arrest. He suspected a blood clot had travelled up her body and settled in her heart, clogging everything. The normal procedure would be to cut open the artery, look for the clot and try to suck it out, but Bhatnagar felt Garcia was in too delicate a state to try that. If he couldn’t stitch up the artery, that would be the end. Instead, Bhatnagar reached into her chest and took hold of her lungs. They were like wet sponges. The surgeon gently squeezed them, hoping the blood he was manually pumping through her body would push out the clot.

By now Garcia had been without a pulse for an hour and a half. The doctors had done everything possible. As they slowly warmed her blood back to a normal body temperature, all they could do was watch. Minutes passed without any movement. Then they saw it-a weak contraction of the heart, a faint but steady rhythm.

Collazo didn’t leave the hospital for a week, camping out in the waiting room with Siurlin and a rotating group of friends and relatives. Jacob stayed in the nursery, a giant among the tiny premature babies. Garcia remained unconscious, but each day the doctors delivered a tiny morsel of good news. Her heart and lungs were recovering. Although her liver had failed, she’d successfully completed three rounds of dialysis.

A week later, they decided to wake Garcia up. The doctors warned Collazo there was a good chance she would have some kind of brain damage. As the drugs used to keep Garcia sedated slowly wore off, she groggily came to. When she looked around, the first thing she saw was the picture of baby Jacob the nurses had taped to the wall.

Today, mother and son are happy and healthy. Garcia uses a cane because of complications from the lack of circulation in her feet, but she’s improving every day.

She remembers going into labour and checking into the hospital that evening, but after that it’s all a blank. Collazo has filled her in on the details: doctors who kept going when it made sense to stop, nurses who looked after Jacob so Collazo could be with his wife. When the little family visited the hospital a few months later to thank the staff, they were mobbed by doctors and nurses. Garcia didn’t recognize half of them, but they all knew her. She was the woman who had come back from the dead. Twice.