Extreme Medicine

How Exploration Transformed Medicine in the Twentieth Century

by Kevin, M.d. Fong

Extreme Medicine

Hardcover, 294 pages, Penguin Group USA, List Price: $27.95 | purchase

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Extreme Medicine
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How Exploration Transformed Medicine in the Twentieth Century
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Kevin, M.d. Fong

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An anesthesiologist and NASA adviser explores how pioneering doctors and scientists have built on findings about the body's response to extreme environments and physical challenges to develop such medical innovations as open-heart surgery, skin grafts, and trauma care.

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NPR stories about Extreme Medicine

Most of us have never been submerged under more than a few feet underwater. But just a few meters down, the water compresses the tissues of your body so that you become more dense. At that point, "You're more likely to sink than float," says Dr. Kevin Fong. iStockphoto.com hide caption

itoggle caption iStockphoto.com

Note: Book excerpts are provided by the publisher and may contain language some find offensive.

Excerpt: Extreme Medicine

INTRODUCTION

Later this century a small crew of people will find themselves spiraling toward Mars from deep space, on their way to becoming the first human beings to set foot on the surface of the Red Planet. They will have crossed hundreds of millions of interplanetary miles in the process, traveling farther from Earth than anyone in the history of their species. They will have left their home planet behind, launching through the sky on a rocket-propelled journey of breathtaking violence, slipping the narrow layer of atmosphere smeared around Earth that supports human life. They will have lived inside a machine for many months, a speck set in sharp relief against the void of space, having endured a journey of hazards unparalleled in the field of exploration.

It sounds like a preposterous endeavor. But when it comes to exploration, we have come a long way in a short time. A century ago, there was still white space on the maps of the world, places that remained unexplored. Cartographers at the turn of the twentieth century still referred to the landmass of snow and ice to the south as the "supposed" continent of Antarctica. They were able to illustrate its coastline in only vague detail.

Through advances in science, engineering, and technology, we have moved forward at a breakneck pace—such that today we talk of the surface of Mars in much the same way that we might have discussed the unknown southern continent of Antarctica only a century ago. We arrived at this incredible peak of human exploration by coming to know the limits of human physiology and then cloaking it in increasingly sophisticated systems of artificial life support. In large part, we can successfully protect our fragile form from the extremes that the physical world has to offer.

As we conquered the physical world in the twentieth century, we mastered the terrain of the body as well. Programs of public health brought vaccination and better sanitation. With antibiotics these advances greatly increased our expectations of life and longevity. But on this foundation we mounted even more ambitious assaults against disease and injury. We specialized, mastered the technique of anesthesia, learned to operate safely upon the human heart, developed new systems of trauma care, dared to transplant organs, and discovered how to manipulate the immune system. We went on to create the new specialty of intensive-care medicine, a platform from which today we launch our most ambitious surgeries and medical interventions. These are but a few of the innovations that combined to create our audacious modern survival.

These twin pursuits of the last hundred years, exploration and medicine, have changed the course of human life—and death. They also profoundly informed each other. It's not so much that we drew direct lessons from our endeavors in hostile environments. Rather, because of our exploration of the physical world, we came to accept that the extremes of illness and injury could not be overcome without almost total reliance upon artifice of science and technology. Often it took years of research to perfect that artifice. In the twentieth century our exploration of the limits of the human body and those of the physical world revolutionized the way we saw ourselves and the lengths to which we were prepared to go to protect human life.

In retelling the story of how we arrived at this point in medicine, we usually relate an abbreviated history, a tale of steady progress across the century. But when considered more closely, the events that led to these innovations tell a different tale. The path to progress in medicine looks less like the plodding inductive advance of science and more like the haphazard endeavor of exploration. To fully appreciate either, we must see both in parallel.

Seeing medicine through the lens of exploration, and vice versa, is something I have forced myself to do. I have spent my adult life engaged in both pursuits and in trying to reconcile one with the other. I majored in astrophysics at University College London before going on to study medicine. Toward the end of my medical studies, I was accepted onto a student training rotation in aerospace medicine at NASA's Johnson Space Center in Houston.

It was the realization of a long-held ambition and a way to indulge my childhood fascination with human spaceflight. I found excuses to go back to Houston as often as I could, gaining far more from the experience than NASA ever gained from me. I led a double life shuttling between Houston and the hospital wards. I'd leave a punishing on-call stretch in a UK hospital to fly across the Atlantic and sit in on a meeting where people talked, straight-faced, about how NASA might best get people to Mars.

I used to feel guilty about indulging my space-age passion for exploration when there appeared to be so many questions to address in the field of terrestrial medicine. But later, as I specialized in intensive-care medicine, I began to understand what we were up against in trying to treat the extremes of illness and disease. Despite the advanced patient monitors and life-support machines, despite the endless reams of information we gathered and the perpetual vigilance, when confronted by the challenge of critical illness, we often failed miserably. I began to wonder which was the more ridiculous pursuit: standing at the end of a bed, tilting at the windmills of critical illness, or staring down telescopes at destinations that lay waiting to be explored.

Over time, I came to realize that the two halves of my life had more in common with each other than I had previously imagined. When you look back at the events that shaped much of modern medicine in the twentieth century, at times you can't help but be amazed at the capacity of that discipline to innovate and overcome. The mechanization of war and society provided new and terrible ways to inflict injury and propagate disease. In parallel—through aircraft and land ambulances—it also provided the means to attend patients and casualties with an immediacy never before seen, leaving doctors to confront extremes of physiology they had hitherto never witnessed.

Together these advances conspired to create challenges so great as to appear, to the vast majority, to be insurmountable. But there were, nevertheless, always a few brave souls willing to part with convention; willing simply to try. I learned from these stories about how we arrived at this point, with such inflated expectations of life and survival, that while our medical pioneers weren't concerned with geographical conquest, they were very much in the business of exploration.

Extreme Medicine is a book about life: its fragility, its fractal beauty, and its resilience. It is about a century during which our expectations of life transformed beyond all recognition, when we took what was routinely fatal and made it survivable. With heart transplants, intensive care, trauma surgery, and state-of-the-art life support, this exploration of the human body was no less extreme than our forays in the physical world.

The theme of rapid advance, using technology and science to surround our physiology like a cocoon, runs through all of the stories in this book. Each chapter of the book focuses on one of the modern limits of survivability—the extremes of cold, heat, critical illness, traumatic injury, disease, war, vacuum, and finally old age. Juxtaposed with the explorations of physical extremes is a litany of extraordinary medical advances. Avant-garde medicine is fundamentally changing our ideas about how our bodies work and of the nature of the boundary between life and death.

Human physiology is as fascinating as it is complex and, within the limits of a physical environment that can support it, extraordinarily resilient. But the way we've extended our reach—to the edge of the Earth and beyond into outer space—through the artificial systems we have built to augment our biology is equally breathtaking. It is this enhanced understanding of human physiology, and our new ability to protect it, that has in the past hundred years allowed us to extend our reach as an exploratory species and simultaneously look within to the edges of our own lives.

This book begins with "Ice," a chapter that revisits Robert Falcon Scott's ill-fated expedition to the South Pole in 1912 and considers how we came to understand the threat of hypothermia and later turn it to our advantage. Our twenty-first-century capabilities in exploration and our expectations of survival would have surely looked like the stuff of pure fantasy to Scott.

"Fire" tells the story of how in the decades that followed the Wright brothers' inaugural flight, we took to the sky in remarkable aircraft, made it a field of battle, and paid the price in human suffering. This tale, of how the modern medical specialty of reconstructive plastic surgery was forged in the cockpit fires of World War II fighter aircraft, is emblematic of our difficult relationship with novel technologies. Balancing the new capabilities that they bring against the harms that they expose us to has always been the challenge. By mitigating the consequences of those advances, progress elsewhere is made.

"Hearts," the third chapter of this book, follows some of the pioneers who sought to explore a continent that at the start of the twentieth century stood as unknown and fraught with risk as Antarctica had. This continent was not a geographical destination but instead a location to be found deep in the human body: the territory of the human heart. The road to the first scheduled heart operations was anything but straightforward, and before the final conquest, the edges of that territory were repeatedly probed—and retreated from—in much the same way that Scott and his predecessors had explored the South Polar region.

Mass motor transport transformed the pace at which our lives were led, routinely exposing great swathes of the population to kinetic energies they had hitherto never experienced. This created new mechanisms of injury and—simultaneously—the means to deliver health care with an immediacy never before witnessed. The chapters "Trauma,"

"Intensive Care," and "Water" together discuss the nature of this challenge and how it was met with innovation. Creating state-of-the-art medical systems pushed the boundaries of medicine and pushed us to the limits of our own physiology.

The final chapters of the book, "Orbit" and "Mars," return us to the field of exploration proper and attempt to give an appreciation of the massive obstacles that lie between us and the future exploration of space. Much of the advance that we have made in medicine in the twentieth century has come through wrapping fragile human physiology in concentric layers of artificial life support and allowing it to be projected into extremes that we were never before able to survive.

This strategy, of using technology to go beyond the human body's innate ability to adapt and survive, is common to our exploration in medicine and in the physical world, including outer space. "Final Frontiers" looks at the progress of a century as experienced firsthand by centenarian James Hudson—a man who was born when maps of the globe still included territories uncharted and who lived long enough to see the world talk of exploring Mars the way they might have talked about the exploration of Antarctica when he was a boy.

Extreme Medicine is a book about medicine but also about exploration in its broadest sense—and about how, by probing the very limits of our biology, we may ultimately return with a better appreciation of precisely how our bodies work, of what life is, and what it means to be human.

From Extreme Medicine: How Exploration Transformed Medicine in the Twentieth Century by Kevin Fong. Copyright 2014 Kevin Fong. Excerpted by permission of Penguin Press.

Excerpt: 'Extreme Medicine'

Later this century a small crew of people will find themselves spiraling toward Mars from deep space, on their way to becoming the first human beings to set foot on the surface of the Red Planet. They will have crossed hundreds of millions of interplanetary miles in the process, traveling farther from Earth than anyone in the history of their species. They will have left their home planet behind, launching through the sky on a rocket-propelled journey of breathtaking violence, slipping the narrow layer of atmosphere smeared around Earth that supports human life. They will have lived inside a machine for many months, a speck set in sharp relief against the void of space, having endured a journey of hazards unparalleled in the field of exploration.

It sounds like a preposterous endeavor. But when it comes to exploration, we have come a long way in a short time. A century ago, there was still white space on the maps of the world, places that remained unexplored. Cartographers at the turn of the twentieth century still referred to the landmass of snow and ice to the south as the "supposed" continent of Antarctica. They were able to illustrate its coastline in only vague detail.

Through advances in science, engineering, and technology, we have moved forward at a breakneck pace — such that today we talk of the surface of Mars in much the same way that we might have discussed the unknown southern continent of Antarctica only a century ago. We arrived at this incredible peak of human exploration by coming to know the limits of human physiology and then cloaking it in increasingly sophisticated systems of artificial life support. In large part, we can successfully protect our fragile form from the extremes that the physical world has to offer.

As we conquered the physical world in the twentieth century, we mastered the terrain of the body as well. Programs of public health brought vaccination and better sanitation. With antibiotics these advances greatly increased our expectations of life and longevity. But on this foundation we mounted even more ambitious assaults against disease and injury. We specialized, mastered the technique of anesthesia, learned to operate safely upon the human heart, developed new systems of trauma care, dared to transplant organs, and discovered how to manipulate the immune system. We went on to create the new specialty of intensive-care medicine, a platform from which today we launch our most ambitious surgeries and medical interventions. These are but a few of the innovations that combined to create our audacious modern survival.

These twin pursuits of the last hundred years, exploration and medicine, have changed the course of human life — and death. They also profoundly informed each other. It's not so much that we drew direct lessons from our endeavors in hostile environments. Rather, because of our exploration of the physical world, we came to accept that the extremes of illness and injury could not be overcome without almost total reliance upon artifice of science and technology. Often it took years of research to perfect that artifice. In the twentieth century our exploration of the limits of the human body and those of the physical world revolutionized the way we saw ourselves and the lengths to which we were prepared to go to protect human life.

In retelling the story of how we arrived at this point in medicine, we usually relate an abbreviated history, a tale of steady progress across the century. But when considered more closely, the events that led to these innovations tell a different tale. The path to progress in medicine looks less like the plodding inductive advance of science and more like the haphazard endeavor of exploration. To fully appreciate either, we must see both in parallel.

Seeing medicine through the lens of exploration, and vice versa, is something I have forced myself to do. I have spent my adult life engaged in both pursuits and in trying to reconcile one with the other. I majored in astrophysics at University College London before going on to study medicine. Toward the end of my medical studies, I was accepted onto a student training rotation in aerospace medicine at NASA's Johnson Space Center in Houston.

It was the realization of a long-held ambition and a way to indulge my childhood fascination with human spaceflight. I found excuses to go back to Houston as often as I could, gaining far more from the experience than NASA ever gained from me. I led a double life shuttling between Houston and the hospital wards. I'd leave a punishing on-call stretch in a UK hospital to fly across the Atlantic and sit in on a meeting where people talked, straight-faced, about how NASA might best get people to Mars.

I used to feel guilty about indulging my space-age passion for exploration when there appeared to be so many questions to address in the field of terrestrial medicine. But later, as I specialized in intensive-care medicine, I began to understand what we were up against in trying to treat the extremes of illness and disease. Despite the advanced patient monitors and life-support machines, despite the endless reams of information we gathered and the perpetual vigilance, when confronted by the challenge of critical illness, we often failed miserably. I began to wonder which was the more ridiculous pursuit: standing at the end of a bed, tilting at the windmills of critical illness, or staring down telescopes at destinations that lay waiting to be explored.

Over time, I came to realize that the two halves of my life had more in common with each other than I had previously imagined. When you look back at the events that shaped much of modern medicine in the twentieth century, at times you can't help but be amazed at the capacity of that discipline to innovate and overcome. The mechanization of war and society provided new and terrible ways to inflict injury and propagate disease. In parallel — through aircraft and land ambulances — it also provided the means to attend patients and casualties with an immediacy never before seen, leaving doctors to confront extremes of physiology they had hitherto never witnessed.

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