May 20, 1999. Northern Norway, just outside Narvik. The sun hung low but bright in the late spring sky, the kind of endless Arctic daylight that makes you forget winter ever existed. Anna Bågenholm, 29, a sharp, adventurous radiology resident from Sweden, was out skiing with her two colleagues and friends—Torvind Næsheim and Marie Falkenberg. They’d skied these slopes before; it was their escape from long hospital shifts.

“Race you to the bottom!” Anna shouted over her shoulder, laughing as she pushed off, carving smooth turns down the crisp snow. The air bit sharp, but the speed felt alive.

Torvind grinned back. “You’re on—but don’t blame me when you eat my snow!”

She was flying, feeling invincible… until her ski edge caught a hidden patch of ice under the fresh powder. In an instant, control vanished. She tumbled hard, sliding headfirst toward a frozen mountain stream.

“Anna!” Marie yelled, digging her poles in to stop.

The ice cracked like a gunshot. Anna plunged through, head and torso sucked into the raging meltwater beneath an 8-inch-thick sheet. The hole sealed above her. Gone.

Torvind and Marie skidded to the spot, hearts pounding. “Anna! Oh God—Anna!” Marie dropped to her knees, clawing at the ice. Torvind joined, pounding with fists and poles.

“She’s under there—pull her skis!” Torvind gasped, grabbing the tips still protruding. They yanked, but the current had her pinned upside down, dragging her deeper under the solid layer.

Seven minutes in, Marie fumbled for her phone. “We need help—now!” she screamed to the dispatcher. Police lieutenant Bård Mikalsen took the call and sprang into action, scrambling teams from top and bottom of the mountain. He even badgered a Sea King helicopter already en route for a sick child: “Turn it around—this is life or death!”

Down below the ice, Anna was terrifyingly awake. The water wasn’t just cold—it burned like fire at first, then turned to crushing numbness. Upside down, head submerged, she thrashed wildly, pounding the unyielding ceiling above.

Air—I need air, she thought, panic screaming in her mind. Her medical training flashed: Four minutes to unconsciousness. Brain damage soon after.

Then—miraculously—her searching hand found a tiny air pocket between ice and rock. Barely enough to press her face into. She gasped, wedged her body there, clinging to jagged stones with freezing fingers.

Hold on. They’re coming. Torvind… Marie… they know I’m here.

Forty agonizing minutes. Breathing in shallow, desperate sips. The cold stole everything: strength, feeling, then her heartbeat. Her body shut down. Clinically dead.

Above, rescuers arrived in a frenzy. Ketil Singstad led the team from the top, skiing like mad. “Tie a rope to her legs—pull!” he ordered. Nothing. Shovels scraped uselessly against thick ice.

“Get a better tool—a pointed spade!” someone shouted from below.

Chainsaws roared. Finally, a hole. They hauled her limp, gray body out after 80 minutes submerged.

Ketil stared down. “I thought we were pulling a friend… dead… out of the water.”

No pulse. No breath. Pupils fixed. Core temperature: 13.7°C (56.7°F)—the lowest ever survived.

They started CPR anyway. Helicopter to University Hospital of North Norway in Tromsø.

In the ER, Dr. Mads Gilbert took charge. He’d seen harsh Arctic cases before. Some doctors shook their heads. “She’s been without oxygen too long. Brain’s gone.”

Gilbert held firm. “No. Remember the rule: You’re not dead until you’re warm and dead.”

He explained later: “Her body cooled completely before the heart stopped. The brain was so cold—it needed almost no oxygen. Cells just… waited.”

They hooked her to a cardiopulmonary bypass machine—warming her blood outside the body, degree by slow degree, pumping it back oxygenated and warm.

Hours dragged. Monitors flat.

A nurse whispered, “It’s hopeless…”

“Keep going,” Gilbert urged. “Warm and dead. That’s when we stop.”

Nine hours after her heart stopped—nine hours of mechanical life support—a flicker. Then a beat. Weak, but there.

“We couldn’t believe it,” a team member recalled.

Days in coma. Then her eyes fluttered open.

Weeks later: “Where… am I?” Her first words.

Scans, tests—memory sharp, speech clear, mind untouched. Only frostbite scarred her hands and feet, needing months of rehab.

Her case hit The Lancet, rewrote textbooks, pushed therapeutic hypothermia worldwide—cooling patients deliberately to protect brains during cardiac arrest.

Anna? She finished her residency. Became Dr. Anna Bågenholm, radiologist. And chose to work at that very hospital in Tromsø—the one where she’d arrived as a corpse.

She walks those halls now, passing the bypass machines that rebooted her life. Colleagues who saved her nod hello.

One day, a young doctor asked, “Doesn’t it feel strange? Working here after… everything?”

Anna smiled faintly. “It feels right. I know what it’s like on the other side. Now I help pull others back.”

Eighty minutes trapped. Forty without a heartbeat. Frozen so deep death paused.

But as they say in the cold North: You’re not dead until you’re warm and dead.

Anna came back whole. And she came back to fight.

Therapeutic Hypothermia Techniques (Targeted Temperature Management)

Therapeutic hypothermia, now more commonly referred to as targeted temperature management (TTM), is a medical intervention used to protect the brain and improve outcomes after events like cardiac arrest or neonatal hypoxic-ischemic encephalopathy (HIE). It works by lowering body temperature to reduce metabolic rate, oxygen demand, inflammation, and cell death in the brain. The technique gained prominence from cases like Anna Bågenholm’s extreme accidental hypothermia survival, which highlighted how profound cooling can “pause” damaging processes.

Current Indications and Guidelines (as of 2025)

• Post-Cardiac Arrest in Adults: Major trials (e.g., TTM2 in 2021) showed no clear benefit of deep hypothermia (32–34°C) over preventing fever (target ≤37.5°C). Current guidelines from AHA, ILCOR, and ESICM emphasize actively preventing fever rather than mandatory deep cooling. TTM involves continuously monitoring and controlling temperature to avoid hyperthermia, with targets often 36–37.5°C. Deep cooling (32–34°C) may still be considered in select cases (e.g., non-shockable rhythms per HYPERION trial), but normothermia with fever prevention is standard for most comatose survivors.
• Neonatal HIE: Whole-body cooling to 33–34°C for 72 hours remains the gold standard for term infants with moderate-to-severe encephalopathy, followed by slow rewarming. It’s initiated within 6 hours of birth.
• Duration: Typically 24–72 hours of cooling/maintenance, then gradual rewarming (0.2–0.5°C per hour) to avoid rebound issues.

Main Cooling Techniques

Techniques fall into three categories: conventional (simple), surface (external), and intravascular (internal). Choice depends on resources, patient stability, and speed needed. Advanced devices often include feedback systems for precise control.

1. Conventional Methods (Simple, Low-Cost Induction):

• Cold intravenous fluids: Rapid infusion of 30–40 mL/kg ice-cold (4°C) saline or Ringer’s lactate. Quick (drops temperature 1–2°C fast) and feasible pre-hospital.
• Ice packs/gel packs: Applied to groin, axillae, neck, and torso.
• Fans with misting or evaporative cooling.
• Pros: Inexpensive, quick start. Cons: Labor-intensive, risk of overcooling, poor maintenance.

1. Surface Cooling (External Devices – Most Common):

• Cooling blankets/pads: Adhesive hydrogel pads (e.g., Arctic Sun) or water-circulating blankets that automatically adjust via feedback from core temperature probes.
• Convective air systems: Forced cold air over the body.
• Immersion or convective-immersion: Rarely used clinically due to practicality.
• Pros: Non-invasive, good precision with automated systems. Cons: Slower induction than intravascular.

1. Intravascular (Endovascular) Cooling:

• Catheters inserted into a large vein (e.g., femoral) with circulating cold fluid (e.g., CoolGard system).
• Pros: Fastest, most precise maintenance (least temperature deviation), effective even in obese patients. Cons: Invasive (risk of infection, thrombosis), requires expertise.

1. Emerging/Adjunct Methods:

• Transnasal evaporative cooling: Nasal prongs delivering coolant mist for rapid brain-specific cooling (prehospital use).
• Esophageal devices: Experimental for precise control.
• Extracorporeal (e.g., via ECMO): For severe cases.

Technique Induction Speed Precision/Maintenance Invasiveness Cost/Availability Cold IV Fluids + Ice Packs Fast Low Low Low Surface Pads/Blankets Moderate High (with feedback) Low Moderate Intravascular Catheter Fast Very High High High

Practical Steps in TTM

1. Initiation: Start as soon as possible post-event. Use sedation/paralysis to prevent shivering (increases metabolism).
2. Monitoring: Core temperature via esophageal probe, bladder catheter, or pulmonary artery (gold standard). Avoid overcooling below target.
3. Maintenance: 24–72 hours at target.
4. Rewarming: Slow (0.2–0.5°C/hour) to prevent seizures or rebound hyperthermia.
5. Side Effects Management: Bradycardia, arrhythmias (rare below 30°C), infections, electrolyte shifts, coagulopathy.

TTM has evolved from aggressive cooling to precise temperature control, inspired by survival stories like Anna’s. It requires a multidisciplinary team and is most effective when integrated into comprehensive post-arrest or neonatal care. Always follow local protocols, as guidelines continue to refine based on ongoing trials (e.g., ICECAP).