Scuba accident survivor: I'm here because "hero" husband did not stop CPR
Bill Greenberg was not going to stop CPR.
Forty minutes after his wife Hilary had been found at the bottom of the sea with her scuba breathing regulator removed during a family trip to Costa Rica, a physician who specializes in cosmetic medicine continued to perform cardiopulmonary resuscitation on his unresponsive wife.
"I sort of went into rescue mode," Bill told CBSNews.com in his Scarsdale, N.Y., home. "If I had freaked out, who knows what the outcome would have been?"
And nearly one year after the ill-fated trip with her husband and their three boys, Hilary is on a mission to tell whoever she meets to learn CPR -- because it could help save a life, just like her husband had saved hers.
"I feel like I'm a miracle because my hero is sitting next to me," said Hilary, 49, who like her husband was a physician, trained in internal medicine, before she started working in mortality assessment for life insurance.
When the Greenbergs went on vacation, a dive was often on the agenda. Bill, 51, had been diving since he was about 15 years old, and estimates he's been on over 100 dives. After marrying Hilary, the two went diving on their honeymoon and his wife also got hooked after immersing herself among the colorful fish, coral and breathtaking views of wildlife like eels and sharks.
The two kept up their hobby as they started a family, and as their three boys got older, they also wanted to join in the fun. When their youngest turned 11 and was old enough to get his junior scuba certification, the Greenbergs and their two other sons, ages 13 and 15, took off for Costa Rica for family vacation on April 6, 2012.
Bill had dove in Costa Rica several times and had a good friend living in the area who would join the group, so the family figured the picturesque Catalina Islands off Guanacaste Province provided the perfect setting for the boys' first chance to dive in open water.
On Saturday morning, the family boarded a boat together with other divers where they soon split into groups with the kids taking off for training with one instructor and Bill, Hilary and the more advanced divers in a second group with a divemaster.
Their first dive that morning went off without a hitch outside of a few small currents. Afterwards, the divers met up back on the boat to unwind before the next dive that afternoon. For the next dive, the adults would go deeper, 35-feet below the water's surface.
"We were probably the most advanced divers in the group so it was going to be an easy dive," said Bill.
By the time the couple would leave the water, their lives would be forever changed.
The second dive
The divemaster had told the group he expected currents deep underwater, and warned them to go with the current if they got caught up in one. The group of six divers, including a divemaster, got in a single-file line where they moved along the rock formations beneath the islands: Bill was fifth in the group, Hilary sixth.
One of the last things Hilary remembers is giving Bill the OK sign following their descent. Bill explains that soon after, the divemaster warned that a strong underwater wave, or "surge" was coming. Hilary described it as feeling like terrible shoving.
"In my mind I'm thinking 'oh my God what is this?' recalled Hilary. "And that's the last thing I remember."
Bill said the force was so strong that the group couldn't fight it, and could only move along with the underwater wave as it took them about 40 feet forward. When he turned around, Bill discovered not everyone in the group had been carried with the surge.
"I look behind me and I don't see Hilary," he said. "She's not there where she's supposed to be."
Bill then signaled the divemaster, who went back about 30 feet toward the start of the surge while the remaining group clung to the rock formation flanked by a coral reef, as the continuing surge swayed them back and forth. Bill anxiously watched four minutes tick off his dive watch, worrying whether it was time to get back to the surface where groups typically gather after an aborted dive. None of the other divers had seen Hilary pass them, and the divemaster soon came back and told them to move forward another 20 feet, past the rock formation. All of a sudden out of the corner of his eye, Bill spotted his wife sitting on the bottom of the sea floor with her regulator out of her mouth. She had cuts on her arms and legs; the surge may have thrown her into the coral, knocking out the apparatus.
"I'm freaking out, I mean, I couldn't believe this, she looked...I just couldn't believe it," Bill recounted. He feared his wife had drowned.
Springing into action, Bill began to lift his wife toward the surface with help from the divemaster. Hilary was not breathing and CPR was almost impossible on the surface of the water, so Bill tried to get air to Hilary while the divemaster yelled for the boat -- which now rested more than 400 feet away. He estimates more than seven minutes had passed from the group losing Hilary to the time she got to the surface of the water. Another three minutes passed as the boat made its way to the troubled divers. Once they got her on the dive boat, Bill confirmed his fears: Hilary was not breathing and didn't have a pulse.
"All I can think of is, 'we've just got to do CPR'," said Bill.
He started compressions and breathing using a now-outdated method of repeating 15 compressions followed by two breaths. The American Heart Association currently recommends a fast compression-only approach, suggesting rescuers pump to the tune of the Bee Gees' 1970s disco hit "Stayin' Alive." Others soon helped with compressions as Bill continued to get air into Hilary's lungs, but the physician worried as no water would come out of her mouth when he turned his wife to her side. Her pulse and breathing had yet to return.
"I just keep thinking I've got to bring her back. She's my buddy, got to bring her back," he recounted. "I'm not going to let her die."
More time passed as the dive boat awaited a rescue vessel from almost 500 feet away. Hilary's pupils were fixed and dilated. She was blue, Bill recounted. Others on the boat began to urge him to stop because the CPR wasn't working, but he wouldn't have it. Thoughts raced through his head that if she did recover, she might be a vegetable, but Bill refused to give up, clinging to the hope that Hilary was just healthy moments ago before the dive, so he might be able to bring her back. More than 20 minutes into the ordeal, Bill and Hilary's kids got back to the boat where they saw their father frantically performing CPR on their mom.
Thirty minutes since Hilary had first vanished, the small rescue boat full of emergency technicians finally reached the divers. The rescuers had no equipment other than an oxygen tank and mask, according to Bill, who, fraught with exhaustion, turned his wife over to them. As they began to perform compressions, however, Bill says he soon noticed the mask was leaking air and oxygen was going into Hilary's stomach instead of her lungs. With a language barrier, Bill felt he had no choice but to push the technicians out of the way, where he started doing mouth to mouth again.
"I didn't want to fool around with this mask," he said.
He'd continue another 10 minutes as the boat made its way back to shore where it would be met by EMS workers who had more advanced equipment, like a defibrillator. More than 40 minutes had passed since Bill last saw Hilary conscious, and during most of that time he had performed CPR. Bill himself remembers during his medical training that he had never performed CPR for more than 20 minutes, but his resolve was unshakeable.
Once on shore, emergency crews hooked up the defibrillator and found a very weak heartbeat. While she still wasn't breathing on her own, that was the first positive sign for Bill -- that his wife's heart had hopefully started beating at some point while he was performing CPR, but it may have been too faint for him to notice. Bill joined Hilary for a 45-minute ambulance ride to a small hospital that had equipment required to conduct tests and to keep Hilary stable. Still soaking in his wetsuit, Bill diverted his efforts to calling the Divers Alert Network to arrange for his wife's evacuation and treatment back in the United States. Their children would arrive about an hour later.
Hilary's lab tests showed she was stable, but she was in a coma and completely unresponsive. A Learjet organized by the network transported the whole family to Delray Medical Center in Delray, Fla., where they arrived by 2 a.m. ET. Neurologists at the hospital ran tests but said it was too early to tell the extent of her damage. Bill told their worried children the family has to be lucky, but in the back of his mind he knew of the possible outcomes his wife faced.
"She was alive, her heart was beating, but we just didn't know anything as far as her brain function, what was going to happen," he said. "What was going through my head was, 'Did I do the right thing?'"
Road to recovery
Hilary remained unresponsive seven days after arriving at Delray and Bill returned back to New York with the kids. Family members flew to Florida to lend a hand. During her hospitalization at Delray, Hilary had shown some more movements, according to Bill, but none of them appeared purposeful. Their kids wondered if their mom could even hear them. After 10 days at Delray, Hilary was transported to Columbia University Medical Center in New York City.
She was stabilized, breathing on her own, her organs functioning -- everything else had come back "online" so-to-speak, except her brain.
Hilary was lying in intensive care at the hospital, still unresponsive, but appeared to be in discomfort. She had broken six ribs while Bill and others performed CPR and was sedated with painkillers while she healed. After three days at Columbia, she was transferred to Burke Rehabilitation Center in White Plains, N.Y., where she was taken off the medication and was monitored by doctors looking for signs of brain activity.
Then, while driving to meet Hilary at Burke the day after she was admitted, Bill received a frantic phone call from his sister.
"Bill, you got to get there right away, Hilary is talking up a storm. You can't believe this," Bill recalled her saying.
He stepped on the gas and when he arrived at Burke, what he saw shocked him.
Hilary was alert, indeed "talking up a storm" in a laughing, jovial mood, he said. Most of the words she was saying were unintelligible, he added, but her mood was positive and she was more awake than she'd been since the incident happened nearly two weeks earlier.
"This was like a major, major breakthrough," Bill said. "Everybody was just amazed, I mean. it was a miracle. From way she was, it was like night and day. It was like waking up"
Dr. Mark Herceg, director of neuropsychology at Burke, describes Hilary during her early days at Burke as being confused, at times nonsensical, saying strange expressions like "I'm totally excellente" or "it's wonderful to meet you" in animated, inappropriate ways. One of the biggest hurdles to overcome in those early stages, he said, was that she had no idea anything had happened to her.
"She had absolutely no awareness that she sustained a brain injury," Herceg told CBSNews.com.
Hilary suffered what's called an anoxic brain injury, Herceg explained. That means the brain was deprived of oxygen for up to five minutes, which caused cells to die off. These injuries are more common from carbon monoxide poisonings or heart attacks that deprive the brain of oxygen, he said, not scuba accidents.
During her stay at Burke, Hilary would keep referring to herself as a doctor, seeing physicians in white coats and trying to involve herself in the conversation. She thought she was in a lockdown unit, according to Herceg, and would frequently ask to leave. She wasn't eating and at one point ripped out her feeding tube, which Hilary concedes probably did not thrill the staff. Friends would have to help feed her during her therapy sessions.
Herceg said one of the most important parts of a person's rehabilitation from a brain injury is to get the person aware of the injury. That's because the brain has to be slowed down and not overtaxed, so patients and doctors can find ways to tap into the brain and allow it to communicate with parts of the body experiencing deficits. That's what makes rehabbing from a brain injury more unusual than recovering from a knee injury or hip replacement, where there a finite measures of improvement.
To help her become more aware, doctors and rehab specialists gave her a strategy of following basic instructions and telling Hilary to think each time before she spoke, in order to allow her brain to slow down.
Hilary said it took her days just to figure out how to use a spoon, and then would take her even longer to learn to place the spoon in her oatmeal and eventually bring it to her mouth. She couldn't even remember the days of the week or five fruits when asked, she said, but as her inpatient stay progressed, more and more would come back. Throughout, visitors would come see Hilary but by the next day, she would forget who was there -- including her husband, who came every day.
"That was like being in Groundhog Day," said Bill, comparing her daily forgetfulness to the 1994 movie in which the protagonist wakes up each day to find its February 2nd, and nothing from the previous day had any impact. Eventually Hilary posted a sign-in sheet to track her visitors.
Strangely, she was able to speak French and Spanish to others at the facility. As more and more kept coming back online and the layers of the injury peeled back, Herceg diagnosed the anoxia in Hilary's frontal lobe. The frontal lobe is the most advanced area of the brain that controls thinking, planning, sequencing ability, interpersonal emotional regulation; is essentially controls for higher level reasoning skills and abilities, according to Herceg.
She would improve every day, working with her therapists at Burke until she was discharged six weeks after she arrived on May 18. Her rehab, however, was far from over.
Hilary would continue speech and occupational therapy as an outpatient, asking many questions and taking detailed notes throughout. By July, her long-term memory started to come back. Bill's sister recorded a list of every family member's birthday and would quiz Hilary. She still had to be monitored almost 24 hours a day and needed help around her house, in the early months from a live-in caregiver, and Bill. Friends and family also volunteered their time.
She'd vigilantly complete her homework from therapy, which ranged from short-term memory tests to complex math problems and brain teasers that many people with full frontal-lobe capacity would have trouble with. In January, Hilary relayed an estimate from her doctors that she was about "90 percent recovered."
Herceg explained that an important milestone when recovering from a brain injury is the one-year marker -- in this case, April 2013. That's when most of the recovery will have occurred. The challenges that lie ahead for her, he said, are her abilities to problem-solve on her own and sequence information, problems that are magnified when she's in a social situation and is trying to figure out what to say, the tone of how to say it. He said she is aware of this and it's really frustrating for her, but she attacks these challenges like she has approached the rest of her rehab.
Her recovery won't stop after the year-mark, though it may slow down, Herceg said. By then he's hoping for that "a-ha" moment where Hilary is better able to generalize what she learned throughout rehab in less structured environments.
"That's one of the key components we hope will happen," said Herceg.
Hilary herself has a goal to get back to work, and has been studying for re-certification. Herceg is also optimistic she will be able to return.
With the approach she's used to get through rehabilitation, Hilary is also on another mission: To make sure everyone she meets knows CPR. She jokes how her sons are embarrassed when she'll approach anyone, including the local mechanic, to make sure they know CPR.
"The course is only three hours," she tells them.
A medical miracle?
While no one may ever know what exactly went on in Hilary's body to get her to the point of near recovery after not breathing or having a measurable pulse for over 40 minutes, research suggests several factors may have worked in her favor -- starting with the CPR.
Dr. Zachary D. Goldberger, assistant professor of medicine and cardiology at the University of Washington School of Medicine, in Seattle, told CBSNews.com that a cardiac arrest occurs when a person becomes unresponsive, stops breathing and no longer has a pulse. It is often an unexpected event, and when that happens, blood flow effectively stops.
"With CPR, we're trying to externally pump the heart to enable blood circulation," explained Goldberger, who has no involvement in Hilary's care.
He led a study in a September 2012 issue of The Lancet that looked at hospitalized patients, and found extending CPR for longer amounts of time could potentially save more lives. Traditionally, doctors have believed the longer it takes to bring someone back, the worst chances they had for survival. Although his study found that most patients were revived early, there were still some who benefited from longer efforts. In addition, the study found patients who were resuscitated for longer periods of time had similar neurologic outcomes as those given CPR for shorter periods, meaning they were not more impaired.
Goldberger, however, is quick to point out his study was conducted in a hospital setting, and the findings can't be generalized to those who suffer cardiac arrest outside of one, like Hilary. His study also did not look at a specific amount of time to extend CPR, which he calls a decision that relies on careful clinical judgment. However, he said Bill's efforts likely helped.
"Her recovery is remarkable, and it's a success story. Being young, and the fact that she got a long duration of effective CPR probably played a role in her recovery," he said.
Bill adds that because Hilary was in the water colder than her body temperature, hypothermia may have bought her extra time. Doctors sometimes induce hypothermia therapeutically for patient in cardiac arrest, and Medscape reports that has a "major impact on long-term neurologically intact survival and may prove to be one of the most important clinical advancements in the science of resuscitation."
Hilary also thinks a higher power helped the CPR, and tears up thinking of the support and prayers she received from across the world during her recovery.
Herceg said the CPR could have helped Hilary's case immensely, in that the sooner a person can get oxygen after an anoxic brain injury, the better. Without the CPR, she may not be here today. But other factors were also working in her favor, he said.
Since Hilary was already intelligent and educated as a physician, she had a stronger foundation and skill-set to aid her recovery, according to her doctor. The intense therapy she received as an inpatient and her willingness to continue being an active participant in her recovery as an outpatient also played favorably, he added. And without the strong support of her friends and family, especially Bill, Herceg said Hilary would not be where she is today. Anything she needed, whether it was extra time in rehab, more of a certain therapy, or getting the word out to her friends on how to help, Bill was there to handle it.
"He made sure nothing stood in the way," Herceg said of Bill. "I think the fact that he was a physician played a big role in his understanding of what needed to be done medically. But, I think it's just the relationship he has with his wife that is priceless on so many levels."
