Extreme Medicine (27 page)

Today history recognizes this as having been an important feat of exploration, a necessary step toward still greater feats of naval discovery. But to Magellan's crew and the people who lived and worked in the Spanish port into which the
Victoria
limped at the start of the sixteenth century, it could hardly have seemed so.

—

I
N RETELLING THE STORY
of twentieth-century medicine, we often superimpose a narrative of steady progress, when in truth physicians, surgeons, and scientists did little more than stumble ahead, as all explorers do, solving and creating problems as they went.

Both Charles Bailey and Dwight Harken endured many failures in the early days of closed-heart surgery, resulting in the deaths of a very large percentage of their first cohort of patients. These first efforts at heart surgery were viewed as bizarre and extreme forms of intervention. So too was Archibald McIndoe's practice of subjecting disfigured airmen to dozens of operations, waltzing squares of flesh across their bodies in the hope of reconstructing something of their faces. Bjørn Ibsen only narrowly convinced his colleagues of the value of artificial ventilation in addressing the devastating effects of poliomyelitis.

Faced either with the scars of the Battle of Britain or the suffocating death of the polio epidemics, both McIndoe and Ibsen could have safely chosen to do nothing. In both cases, the threats addressed by their innovation were rapidly neutralized by other means. Aircraft, even combat aircraft, became immeasurably safer through improved engineering. Polio was addressed effectively with programs of vaccination. Within twenty years of the Copenhagen epidemic that gave rise to the world's first intensive-care units, the specter of this paralyzing illness had all but disappeared from developed countries, and today polio is very nearly eradicated from the world at large.

But the intensive-care units that Bjørn Ibsen labored to create were soon repurposed to treat all sufferers of critical illness—within three decades, we could artificially support lungs, hearts, kidneys, and even the gut. And intensive care came to underpin the heroic feats of surgery that we have come to expect in the modern age, Dallas Wiens and his transplanted face among them.

Plastic surgery also underwent something of a transformation. The devastation and disfiguration wrought by fires became thankfully rarer over the course of the last hundred years. Its ravages have been replaced by the invasion of cancer. And it is here that the art of plastic surgery, forged in the fire of war, now finds itself most keenly applied. None of these destinations was arrived at through careful planning. But when you strike out into new territory, you rarely know what you're going to discover.

Together, dozens of discrete events in the history of modern medicine came together to ensure Anna Bågenholm's survival. From flying ambulances and cardiac-bypass circuits to intensive-care units and reconstructive surgeries, all of it eventually became a continuous chain of survival that took a young doctor from death beneath the ice of a frozen river in Norway to resuscitation and survival in a hospital in Tromsø. Anna's survival was one of the unintended consequences of the exploration of earlier epochs. In part, that answers the question of why we should explore at all. To be able to explore, we must continue to survive. But the reverse is also true. To survive, we must explore.

We advance in science, medicine, and exploration in fits and starts. There is no real plan—at least not one that anyone has ever stuck to for very long. We happen upon our discoveries largely by accident, making the most of them as and when they arise. We meet disaster in the same way. We explore simply because we must. And that is what makes us human.

There are many without whom this book would not have been possible. Foremost among them: Will Francis for chasing me for so many years to write something and his opposite number in the United States, P. J. Mark, for his sterling efforts in making this transatlantic version happen. I owe a debt of gratitude to Virginia Smith, my editor at Penguin Press, chiefly for her patience, but also for insight, comments, and suggestions that have hugely improved the text. As well as providing first-class editorial input, she and Kaitlyn Flynn have been my tutors in the strange language of American English. I must thank Kaitlyn also for her fantastic attention to detail and for her role in polishing up the final versions of the text.

I must finally say a huge thank-you to the many people who have helped me along the way. It occurred to me that author and evolutionary biochemist Nick Lane, having bashed the idea of the importance of mitochondria and bioenergetics into my head over beers in the Jeremy Bentham pub, played a more important role than perhaps he knew. And I'm particularly grateful to those who read, commented, and corrected, among them Mike Herd, Adam Rutherford, Mark Paul, Viki Mitchell, and Neil Nixon. And none of this could have happened without Sue Rider, who is always there trying to manage the chaos that is the rest of my life.

Perhaps the biggest sacrifice was made by my wife, Dee, and our boys, who have given up weekends, evenings, and holidays for too long to let me get to the end of this. Special thanks to the Wellcome Trust, the BBC, and particularly to my colleagues and friends at University College London Hospital for allowing me to continue to explore and of course to my parents for encouraging me to do so in the first place.

Although this book covers a century of change in the world of exploration and medicine, it isn't constructed as a historical treatise any more than it is intended to be a textbook of medicine for aspirant physicians.

The narratives within are stories that I was aware of but didn't really know. They are there to provide an insight into the incredible things that we are able to do in medicine and exploration today and the ways in which we arrived at this point.

But they are a starting point rather than a destination. For those wanting to explore further, I've included the references below, which were used as source material but whose details it was not always possible to discuss in the depth they deserve.

ICE

I met Anna and Torvind while making a
Horizon
documentary for the BBC. Anna's case is one that has become the stuff of legend among the medical fraternity, one that we have often used to illustrate the fact that in the face of hypothermia, it is worth persisting with efforts at resuscitation. But I had never in all of that time referred to the original
Lancet
publication. Torvind and Anna were good enough to come to London and lecture at a seminar I had organized at the Royal Society of Medicine in 2011. There they told their story in its full detail, and it is upon that account—and our conversation during the drenching on the way to dinner afterward—that the substance of the material in this chapter is based.

My thanks also to the Dezhbod family for permission to include their story and for talking with me about it. Esmail has recovered well from his surgery and has returned to work. His eldest daughter is at college and hoping to go to medical school upon graduation.

It is worth noting that cardiac-arrest survival rates have improved significantly in the fifteen years since I first graduated from medical school. I'm hugely grateful to Dr. Jerry Nolan, consultant anesthetist and chairman of the Resuscitation Council (UK) for answering numerous queries. Changes in treatment protocols and new techniques, including therapeutic hypothermia, have brought significant benefits. And while survival following cardiac arrest remains the exception rather than the rule, junior doctors today thankfully have far less cause for pessimism.

Berdowski, Jocelyn, et al. “Global Incidences of Out-of-Hospital Cardiac Arrest and Survival Rates: Systematic Review of 67 Prospective Studies.”
Resuscitation
81 (2010): 1479–87.

Boutilier, Robert G. “Mechanisms of Cell Survival in Hypoxia and Hypothermia.”
Journal of Experimental Biology
204, no. 18 (September 2001): 3171–81.

Gilbert, Mads, et al. “Resuscitation from Accidental Hypothermia of 13.7 Degrees C. with Circulatory Arrest.”
Lancet
355, no. 9201 (January 2000): 375–76.

Haman, François. “Shivering in the Cold: From Mechanisms of Fuel Selection to Survival.”
Journal of Applied Physiology
100, no. 5 (May 2006): 1702–8.

Lane, Nick.
Power, Sex, Suicide: Mitochondria and the Meaning of Life
. New York: Oxford University Press, 2006.

———, and William F. Martin. “The Energetics of Genome Complexity.”
Nature
467, no. 7318 (October 2010): 929–34.

Larson, Edward J.
An Empire of Ice: Scott, Shackleton, and the Heroic Age of Antarctic Science
. New Haven, CT: Yale University Press, 2012.

Mallet, Mark L. “Pathophysiology of Accidental Hypothermia.”
QJM
95, no. 12 (December 2002): 775–85.

Nolan, Jerry.
Advanced Life Support
, 5th ed
.
London: Resuscitation Council (UK), 2006.

Scott, Robert Falcon.
Journals: Captain Scott's Last Expedition
, 2d ed., ed. Max Jones. Oxford, UK: Oxford University Press, 2008.


Solomon, Susan.
The Coldest March: Scott's Fatal Antarctic Expedition
. New Haven, CT: Yale University Press, 2001.


———, and Charles R. Stearns. “On the Role of the Weather in the Deaths of R. F. Scott and His Companions.”
Proceedings of the National Academy of Sciences of the United States of America
96, no. 23 (November 1999): 13012–16.


Swinton, William E. “Edward Wilson: Scott's Final Antarctic Companion,” Physicians as Explorers series.
Canadian Medical Association Journal
117, no. 8 (October 1977): 61–63, 74.

FIRE

Hundreds of servicemen were injured and then treated by the staff of the Queen Victoria Hospital in East Grinstead during the Second World War, and thousands have been treated there since. Tom Gleave's story is but one among hundreds of the same era, though as the first and only chief guinea pig and one of the founding members of the Guinea Pig Club, his seemed well worth retelling. The events of the air battle that led to his injuries have been told several times: in a television documentary made for what was Thames Television (
The Guinea Pig Club,
directed by Robert Fleming), in interviews for radio documentaries, and in his own book, published in 1941 and titled
I Had a Row with a German
after his first words to his wife when she saw his disfigurement and asked what had happened to him. The accounts vary a little from retelling to retelling, possibly because the original source—Gleave's own book originally published anonymously during the war and vetted by the Ministry of Information—modified details to avoid giving away secrets about the Hurricane's vulnerabilities. I have done my best to piece the different strands together. To get a proper sense of just how flimsy and flammable the Hurricane's fuselage was, I visited Hawker Restorations in Suffolk and saw a handful of reconstructed Hurricanes—one of which had been flown by Gleave in combat.

I am grateful for the assistance of Tom Cochrane and Bob Marchant, respectively honorary surgeon and honorary secretary to the Guinea Pig Club, for their wisdom and recollections. Mr. Cochrane rightly points out that Archibald McIndoe stood on the shoulders of the giants who preceded him, notably those of his cousin Harold Gillies, whose pioneering work in the field of plastic surgery is more fully described in the 1920s textbook
Plastic Surgery of the Face,
authored by Gillies himself.

My thanks also to Tom Edrich and Bohdan Pomahač for taking the time to talk with me at length about Dallas Wiens's difficult surgery and for reviewing the written material.

Battle, Richard. “Plastic Surgery in the Two World Wars and in the Years Between.”
Journal of the Royal Society of Medicine
71, no. 11 (November 1978): 844–48.

Bishop, Edward.
McIndoes's Army: The Story of the Guinea Pig Club and Its Indomitable Members.
London: Grub Street, 2001.


Fleming, Robert, director.
The Guinea-Pig Club
. London: Thames Television, 2011.


Geomelas, Menedimos, et al. “‘The Maestro': A Pioneering Plastic Surgeon—Sir Archibald McIndoe and His Innovating Work on Patients with Burn Injury During the Second World War.”
Journal of Burn Care and Research
32, no. 3 (May–June 2011): 363–68.

Gillies, Harold D.
Plastic Surgery of the Face
. Oxford, UK: Henry Frowde, Oxford University Press, 1920.


Gleave, Tom.
I Had a Row with a German
. London: Macmillan, 1941.


“The Hurricane Unveiled,”
Flight,
May 12, 1938, p. 467.

Jackson, Douglas MacG. “Burns: McIndoe's Contribution and Subsequent Advances,” McIndoe Lecture, 1978.
Annals of the Royal College of Surgeons of England
61, no. 5 (September 1979): 335–40.


McKinstry, Leo.
Hurricane: Victor of the Battle of Britain.
London: John Murray, 2010.


Matthews, David N. “A Tribute to the Services of Sir Archibald McIndoe to Plastic Surgery.”
Annals of the Royal College of Surgeons of England
41, no. 5 (November 1967): 403–12.


Mayhew, Emily R.
The Reconstruction of Warriors: Archibald McIndoe, the Royal Air Force, and the Guinea Pig Club.
Barnsley, UK: Frontline Books, 2010.

Morgan, Brian, and Margaret Wright.
Essentials of Plastic and Reconstructive Surgery.
London: Faber & Faber, 1986.

Mosley, Leonard.
Faces from the Fire: The Biography of Sir Archibald McIndoe.
London: Weidenfeld & Nicolson, 1962.

Page, G.
Shot Down in Flames: A WW2 Fighter Pilot's Remarkable Take of Survival.
London: Grub Street, 1999. 


Penn, Jack. “The Reminiscences of a Plastic Surgeon During the Second World War.”
Annals of Plastic Surgery
1, no. 1 (January 1978): 105–15.


Pomahač, Bohdan. “Establishing a Composite Tissue Allotransplantation Program.”
Journal of Reconstructive Microsurgery
28, no. 1 (January 2012): 3–6.

———, et al. “Donor Facial Composite Allograft Recovery Operation: Cleveland and Boston Experiences.”
Plastic and Reconstructive Surgery
129, no. 3 (March 2012): 461–67.

———, et al. “Restoration of Facial Form and Function After Severe Disfigurement from Burn Injury by a Composite Facial Allograft.”
American Journal of Transplantation
11, no. 2 (February 2011): 386–93.

———, et al. “Vascular Considerations in Composite Midfacial Allotransplantation.”
Plastic and Reconstructive Surgery
125, no. 2 (February 2010): 517–22.

———, Jesús Rodrigo Diaz-Siso, and Ericka M. Bueno. “Evolution of Indications for Facial Transplantation.”
Journal of Plastic, Reconstructive & Aesthetic Surgery
64, no. 11 (November 2011): 1410–16.

———, and Julian Joseph Pribaz. “Facial Composite Tissue Allograft.”
Journal of Craniofacial Surgery
23, no. 1 (January 2012): 265–67.

Proksch, Ehrhardt, Johanna M. Brandner, and Jens-Michael Jensen. “The Skin: An Indispensable Barrier.”
Experimental Dermatology
17, no. 12 (December 2008): 1063–72.

Scripko, Patricia D., and David M. Greer. “An Update on Brain Death Criteria.”
Neurologist
17, no. 5 (September 2011): 237–40.

Taylor, G. Ian, and J. H. Palmer. “The Vascular Territories (Angiosomes) of the Body: Experimental Study and Clinical Applications.”
British Journal of Plastic Surgery
40, no. 2 (March 1987): 113–41.

Wallace, Antony F. “The Early Development of Pedicle Flaps.”
Journal of the Royal Society of Medicine
71, no. 11 (November 1978): 834–38.

HEART

The staff of the British Library was particularly patient with me while I researched this chapter. The case of Grey Turner's wounded soldier was detailed in a case report for the
Lancet
in 1940, with a more formal treatise on the subject of gunshot wounds of the heart in 1941 for the
British Medical Journal
. His lecture to surgeons preparing for service during the First World War predates these publications by some twenty-three years.

I was very fortunate to be able to speak with Dr. Alden Harken, son of Dwight Harken and also a successful cardiothoracic surgeon. His recollections of the early days of cardiac surgery and the rivalries his father had to contend with were particularly colorful, and I am very grateful for the time he was able to spare.

Chaikhouni, Amer. “The Magnificent Century of Cardiothoracic Surgery.”
Heart Views
11, no. 1 (March 2010): 31–37.

Cooley, Denton. “In Memoriam: Dwight Emary Harken.”
Texas Heart Institute Journal
20, no. 4 (Autumn 1993): 250–51.

Ellis, Lawrence, and Dwight Harken. “Mitral Stenosis, Clinico-Physiologic Correlations, with Particular Reference to Surgical Intervention.”
Transactions of the American Clinical and Climatological Association
60 (1948): 59–70.


Fye, W. Bruce. “Ernest Henry Starling, His Law and Its Growing Significance in the Practice of Medicine.”
Circulation
68, no. 5 (November 1983): 1145–48.

Gonzalez-Lavin, Lorenzo. “Charles P. Bailey and Dwight E. Harken—The Dawn of the Modern Era of Mitral Valve Surgery.”
Annals of Thoracic Surgery
53, no. 5 (May 1992): 916–19.


Grey Turner, George. “A Bullet in the Heart for 23 Years.”
Lancet
236, no. 6112 (October 1940): 487–89.

———. “A Clinical Lecture on the Importance of General Principles in Military Surgery.”
British Medical Journal
1, no. 2881 (Mar. 18, 1916): 401–7.


———. “Gunshot Wounds of the Chest (Correspondence).”
British Medical Journal
1, no. 3043 (April 26, 1919): 530–31.


———. “Gunshot Wounds of the Heart.”
British Medical Journal
1, no. 4198 (June 21, 1941): 938–41.


Hadfield, Charles F. “Anaesthetic Explosions.”
British Medical Journal
2, no. 4779 (August 9, 1952): 332–34.


Harken, Dwight E. “One Surgeon Looks at Human Heart Transplantation.”
Chest
54, no. 4 (October 1968): 349–52. Also see: Glenn S. Tillotson, “Introduction: Transplantation and Philosophy.”
Chest
136, no. 5 suppl. (November 2009): e24.

———, and Warren J. Taylor. “Diseases of the Cardiovascular System (Surgical).”
Annual Review of Medicine
10, no. 1 (February 1, 1959): 93–126.


Harned, Calvin W. “Some Practical Suggestions Concerning the Use of Alkoform as an Anesthetic Agent.”
Current Researches in Anesthesia & Analgesia
6, no. 6 (December 1927): 285–91.


Hoyt, David B. “Blood and War—Lest We Forget.”
Journal of the American College of Surgeons
209, no. 6 (December 2009): 681–86.


Katz, Arnold M. “Ernest Henry Starling, His Predecessors, and the ‘Law of the Heart.'”
Circulation
106, no. 23 (December 3, 2002): 2986–92.


McCawley, E. L. “Management of Cardiac Arrhythmias During Anaesthesia.”
Canadian Anaesthetists' Society Journal
2, no. 2 (April 1955): 137–41.