Sunday, November 18, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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CURRENT BOOKS
Miraculous Medical Tales

Brien A. Seeley, MD

Extreme Medicine: How Exploration Transformed Medicine in the Twentieth Century,
Kevin Fong, MD, 304 pages, Penguin (2014).

It’s amazing what a body can stand.
   —Third-year resident observation

My fath
er-in-law, the late Dr. Lyle Powell Jr., taught me the axiom that “to best understand something complex, one should examine its extremes.” This examination not only clarifies the thing’s limits; it reveals what inner workings impose those limits. That revelation is precisely the result when this axiom is applied to human physiology by Dr. Kevin Fong in his engaging new book, Extreme Medicine.

Fong’s book provides the reader with a fascinating tour of the emergence of modern medicine from a brutish past in which war, disaster, epidemics and the perils of exploration all pressed pioneering physicians to try new things. Fong is a master storyteller, and his prose delivers a captivating and punchy mix that is part Discovery Channel and part Rod Serling. His writing style bespeaks of British formality, impeccably correct and at times reminding one of a dialogue in Downton Abbey. His medical training in London gives much of the book the tone of a lecture by an emeritus professor. Yet his tales have a dramatic and personalized intimacy, both from his own experiences and those of real historical figures. These stories are thrilling. They put the reader right there, as if personally confronting the acute, life-threatening medical problem and having to make the daring decisions about what should be done.

Extreme Medicine will reward both lay readers and those in the medical profession. For physicians, this book will summon again the awe and “aha” that we felt at the new insights into human physiology that were bestowed upon us during our medical training. When Fong recounts the frantic, midnight rush to respond to a code blue crash-cart experience, he instantly transports the physician reader back to those breathtaking codes that we attended as interns, where some of those insights were etched into us.

Time and again, Fong removes the reader from the immediate crisis to the comfort of a crystal-clear, academic retelling of the underlying physiology that pertains. This technique is quite effective, and it intensifies our appreciation for the importance of the miraculous cellular and molecular workings of human physiology. As such, this book will improve every physician who reads it.

Fong was born and raised in the UK. He has an ideal résumé for writing this book, with degrees in both astrophysics and medicine from University College London (UCL) as well as a degree in astronautics and space engineering from Cranfield University. He worked with NASA at the Johnson Space Center, as well as serving as medical officer for deep-sea diving expeditions. He completed training as an anesthesiologist and now teaches as honorary senior lecturer in physiology at UCL.

Fong begins Extreme Medicine with a thoughtful description of what life really is, deconstructing it as an active, organized storing of potential energy as charged ions are corralled behind a cell membrane, and then the periodic release of that energy when those ions cross the membrane with purposeful effect. This struggle against entropy, this straining to postpone collapse into equilibrium, is what makes us us, he says. Such a fundamental definition of life exemplifies the depth that Fong applies to his other explanations in the book.

Fong vividly sets the scene in each of a series of cases in which the intrepid doctors of yore are forced to solve terrible medical problems by trial and error. What emerges from the ways in which pioneering doctors deal with freezing, drowning, burning, dismemberment, shock and weightlessness are discoveries that make modern medicine the miraculous thing it is today. Each case is told with dramatic detail, such as that of Tom Gleave, an RAF fighter pilot in World War II whose Hawker Hurricane, when struck by machine gun fire from a German bomber, catches fire and inflicts Gleave with severe burns before he can bail out. The following excerpt conveys Fong’s writing talents and the intensity of his subject:

     Gleave glanced down. Flames were pushing into the right side of the cockpit from below; the fuel tank buried in the root of his starboard wing was alight. He rocked the Hurricane hard and slipped it sideways in the vain hope that this would somehow quell the fire. But the flames only grew fiercer, wrapping around his feet and climbing to reach his shoulders. Plywood and fabric burst rapidly into flames around him, accelerated by fuel from the breached tanks. In a few short seconds, the center of Gleave’s cockpit had become the head of a blowtorch. The aluminum sheet in which the dials of his control panel were set began to melt. But he was far too high to ditch the aircraft; there was nothing he could do but attempt to bail out.

Fong goes on to describe Gleave’s miraculous survival and arduous recovery after extensive, pioneering plastic surgery, including breakthrough techniques in preserving graft vascularity. He includes other examples of burn therapy and reconstruction that exemplify the enormous medical progress driven by injuries in war and industrial accidents.

In another passage, Fong’s description of the skin bespeaks his reverence for human physiology:

     Together the epidermis and dermis form a waterproof but breathable layer. They have pores that are small enough to prevent ingress of water droplets but large enough to let molecules of water vapor out. Gore-Tex clothing attempts to do the same thing, but as a breathable and waterproof barrier, it achieves only the very palest imitation of skin. But it is the sensory array that is perhaps the skin’s most remarkable feature. Able to resolve point contacts little more than a millimeter apart, it’s capable not only of registering heat and cold, but also of differentiating between a lover’s caress and the pain from a needle tip.

Fong also describes in chilling detail how a woman skier in Norway survives without a heartbeat for over 90 minutes while suffering extreme hypothermia. The woman’s ordeal from her fall into a frozen stream, to her helicopter rescue and hospital treatment, are a tribute to the extremes that a body can stand and to the miracles that can be wrought by modern intensive care and anesthesia.

In the chapters
devoted to trauma and intensive care, Fong conveys the impressive capabilities of modern emergency medicine and how it can respond to bombings, plane crashes and other acute trauma through actual events that he experienced as an ER doc.

Fong’s tour of physiologic limits visits every organ and sensory system and explains for each how the daring lifesaving decisions of pioneering physicians led to today’s breakthrough therapies. Along the way, he touches on the evolution of trauma and intensive-care units, elaborate plastic surgery (including a complete face transplant), hypothermic- and micro-surgery, emergency thoracotomies for gunshot wounds, heart-lung bypass machines, organ transplantation, the bizarre and forbidding physiological adversities of space travel, a centenarian’s extreme aging, and the creepiness of SARS.

Extreme Medicine is also available as an audio book, a 6-CD set elegantly narrated by the very British Jonathan Cowley. The audio book can be enjoyed by busy physicians while driving a car.

I highly recommend this book to anyone who wants to better understand the body in which they live. ::

Dr. Seeley, a Santa Rosa ophthalmologist, serves on the SCMA Editorial Board.

Email: cafe400@sonic.net

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